Abstracts of Current Literature

CLINICAL CARE

Johnson SG, Rogers K, Delate T, WittDM. Outcomes associated with com-bined antiplatelet and anticoagulanttherapy. Chest 2008; 133:948–954.

• BACKGROUND: The use of anti-platelet therapy in combination withoral anticoagulants remains controver-sial. The objective of this study was toestimate and compare the incidence ofadverse and coronary event rates be-tween patients receiving warfarin mono-therapy or warfarin and antiplateletcombination therapy. METHODS: Thiswas a retrospective, longitudinal, phar-macoepidemiologic analysis. Adult pa-tients receiving warfarin managed by ananticoagulation service who had docu-mented the use of antiplatelet agents (eg,aspirin, clopidogrel, and/or dipyridam-ole) [ie, the combination-therapy cohort]or their nonuse (ie, the monotherapy co-hort) were identified as of September 30,2005. Utilizing integrated, electronicmedical records, anticoagulation-relatedadverse events (eg, death, hemorrhage,or thrombosis) and coronary eventswere identified during a 6-month fol-low-up period (October 2005 throughMarch 2006). The proportions of eventswere compared between cohorts. Inde-pendent associations between the co-horts and the outcomes were assessedwith adjustment for potential confound-ing factors. RESULTS: Data from 2,560patients in the monotherapy cohort and1,623 patients in the combination-ther-apy cohort were analyzed. Patients inthe combination-therapy cohort weremore likely to have had anticoagulation-related hemorrhages (4.2% vs 2.0%, re-spectively; unadjusted p � 0.001) andcoronary events (0.9% vs 0.3%, respec-tively; p � 0.009), but not death (0.1% vs0.2%, respectively; unadjusted p �0.186) or thrombotic events (0.3% vs0.4%, respectively; unadjusted p �0.812). With adjustment, combined war-farin and antiplatelet use was indepen-dently associated with hemorrhagicevents (odds ratio [OR], 2.75; 95% confi-dence interval [CI], 1.44 to 5.28), but notwith coronary events (OR, 0.99; 95% CI,0.37 to 2.62). CONCLUSIONS: At thepopulation level, the hemorrhagic riskassociated with warfarin therapy com-bined with antiplatelet therapy appearsto outweigh the benefits. These findingssuggest that clinicians should carefully

consider the risks and benefits when rec-

1126

ommending combined antiplatelet ther-apy for patients receiving warfarin whodo not meet the evidence-based criteriafor such therapy.Authors’ Abstract

Allison MA, Hiatt WR, Hirsch AT,Coll JR, Criqui MH. A high ankle-brachial index is associated with in-creased cardiovascular disease mor-bidity and lower quality of life.J Amer Coll Cardiol 2008; 51:1292–1298.

• OBJECTIVES: The purpose of thisstudy is to determine if an ankle-brachialindex (ABI) �1.40 is associated with re-duced quality of life (QoL). BACK-GROUND: Ankle-brachial index values�1.40 have been associated with somecardiovascular disease (CVD) risk fac-tors and increased mortality, but the re-lationship to other disease morbiditysuch as reduced QoL has not been pre-viously evaluated. METHODS: ThePARTNERS (PAD Awareness, Risk andTreatment: New Resources for Survival)program was a national cross-sectionalstudy of 7,155 patients age �50 yearsrecruited from 350 primary care sites. Allsites performed the ABI using a Dopplerdevice and a standardized technique.RESULTS: A total of 296 subjects had anABI �1.40 in at least 1 leg, and 4,420 hadan ABI between 0.90 and 1.40. Diabetes,male gender, and waist circumferencewere positively associated with a highABI, and smoking and dyslipidemiawere inversely associated with a highABI. After adjustment for age, gender,and the traditional CVD risk factors, andaccounting for multiple comparisons,the high ABI group had significantlyhigher odds for foot ulcers (p � 0.005)and borderline associations with heartfailure, stroke, and neuropathy. Afterthe same adjustments and adjusting forpatients with other CVD, the high ABIgroup scored 2.0 points lower on thephysical component scale on the MedicalOutcomes Study Standard Form–36 and5.5 points lower on the Walking Impair-ment Questionnaire walking distancedomain (p � 0.05 for both). CONCLU-SION: Individuals with a high ABI havehigher odds for foot ulcers and neurop-athy, as well as lower scores on somephysical functioning QoL domains.Authors’ Abstract

Gaziano TA, Young CR, Fitzmaurice

G, Atwood S, Gaziano JM. Labora-

tory-based versus non-laboratory-based method for assessment of car-diovascular disease risk: the NHANESI Follow-up Study cohort. Lancet 2008;371:923–931.

• BACKGROUND: Around 80% of allcardiovascular deaths occur in developingcountries. Assessment of those patients athigh risk is an important strategy for pre-vention. Since developing countries havelimited resources for prevention strategiesthat require laboratory testing, we as-sessed if a risk prediction method that didnot require any laboratory tests could beas accurate as one requiring laboratoryinformation. METHODS: The NationalHealth and Nutrition Examination Survey(NHANES) was a prospective cohortstudy of 14 407 US participants aged be-tween 25–74 years at the time they werefirst examined (between 1971 and 1975).Our follow-up study population includedparticipants with complete information onthese surveys who did not report a historyof cardiovascular disease (myocardialinfarction, heart failure, stroke, angina)or cancer, yielding an analysis datasetN�6186. We compared how well eithermethod could predict first-time fatal andnon-fatal cardiovascular disease eventsin this cohort. For the laboratory-basedmodel, which required blood testing, weused standard risk factors to assess riskof cardiovascular disease: age, systolicblood pressure, smoking status, totalcholesterol, reported diabetes status, andcurrent treatment for hypertension. Forthe non-laboratory-based model, wesubstituted body-mass index for choles-terol. FINDINGS: In the cohort of 6186,there were 1529 first-time cardiovascularevents and 578 (38%) deaths due to car-diovascular disease over 21 years. Inwomen, the laboratory-based model wasuseful for predicting events, with a cstatistic of 0·829. The c statistic of thenon-laboratory-based model was 0·831.In men, the results were similar (0·784for the laboratory-based model and0·783 for the non-laboratory-basedmodel). Results were similar betweenthe laboratory-based and non-laborato-ry-based models in both men andwomen when restricted to fatal eventsonly. INTERPRETATION: A methodthat uses non-laboratory-based risk fac-tors predicted cardiovascular events asaccurately as one that relied on labora-tory-based values. This approach could

simplify risk assessment in situations

Abstracts • 1127Volume 19 Number 7

where laboratory testing is inconvenientor unavailableAuthors’ Abstract

L’Allier PL, Ducrocq G, Pranno N,and PREPAIR Study Investigators.Clopidogrel 600-mg double loadingdose achieves stronger platelet inhibi-tion than conventional regimens re-sults from the PREPAIR randomizedstudy. J Amer Coll Cardiol 2008; 51:1066–1072.

• OBJECTIVES: The objective of thisstudy was to compare the level of plate-let inhibition achieved by 3 different clo-pidogrel loading regimens in patientsundergoing elective angiography andpercutaneous coronary interventionwhen appropriate. BACKGROUND:Optimal platelet inhibition is a key ther-apeutic goal for patients undergoingpercutaneous coronary intervention. Al-though 600 mg has been described as themaximum absorbed dose when given asa single bolus, the effects of 2 bolusesgiven 24 h apart have not been de-scribed. METHODS: Patients (n � 148)were randomly assigned to one of 3 reg-imens: Group A, clopidogrel 300 mg theday before (�15 h) � 75 mg the morningof the procedure; Group B, clopidogrel600 mg the morning of the procedure(�2 h); and Group C, clopidogrel 600 mgthe day before (�15 h) and 600 mg themorning of the procedure (�2 h). Bloodsamples were obtained at baseline andimmediately before angiography. Peakand late platelet aggregation were mea-sured in platelet rich plasma, with re-searchers blinded to treatment alloca-tion. RESULTS: There was a consistentdifference favoring Group C in all aggre-gation parameters. Percent inhibition inGroups A, B, and C was 31.4%, 29.0%,and 49.5%, respectively, for peak aggre-gation (5 �mol/l adenosine diphos-phate; p � 0.0001) and 54.1%, 57.7%, and81.1%, respectively, for late aggregation(p � 0.0001). Similar striking reductionswere observed when 20 �mol/l adeno-sine diphosphate was used. All compar-isons between Group C and the other 2groups were statistically significant, andthose between Groups A and B were not.CONCLUSIONS: Clopidogrel 600-mgdouble bolus achieves greater platelet in-hibition than conventional single load-ing doses.Authors’ Abstract

NONINVASIVE VASCULARIMAGING – MRI

Neville C, House AA, Nguan CY, etal. Prospective comparison of mag-netic resonance angiography with se-

lective renal angiography for living

kidney donor assessment. Urology2008; 71:385–389.

• OBJECTIVES: For years, the refer-ence standard in the evaluation of livingdonor vascular anatomy has been selec-tive renal angiography (SRA). Because ofthe potential morbidity associated withSRA, we prospectively evaluated mag-netic resonance angiography (MRA) inthe assessment of renal donors. METH-ODS: All patients had SRA and 53 renalunits were prospectively evaluated byMRA. We used SRA supplemented byfindings at donor nephrectomy (DN) asour standard. We defined a positive testas the detection of any abnormality inthe number of renal arteries. RESULTS:Selective renal angiography yielded asensitivity of 86%, specificity of 95%,positive predictive value (PPV) of 75%,and negative predictive value (NPV) of97% compared with findings at DN.MRA had a sensitivity of 64%, 88% spec-ificity, 58% PPV, and 90% NPV. MRAcorrectly identified only 7 of 11 renalunits with accessory arteries. MRA alsoincorrectly identified 5 accessory arteriesnot present on SRA or DN. Two patientsdiagnosed with fibromuscular dysplasiaby SRA were missed using MRA. CON-CLUSIONS: We have shown that MRAis not capable of replacing SRA as thereference standard in renal donor imag-ing.Authors’ Abstract

ONCOLOGIC INTERVENTIONS

Weight CJ, Kaouk JH, Hegarty NJ, etal. Correlation of radiographic imag-ing and histopathology followingcryoablation and radio frequency ab-lation for renal tumors. J Urol 2008;179:1277–1283.

• PURPOSE: Followup after radiofrequency ablation and cryotherapy forsmall renal lesions lacks pathologicalanalysis. The definition of successful tu-mor ablation has been the absence ofcontrast enhancement on posttreatmentmagnetic resonance imaging or comput-erized tomography. We hypothesizedthat adding post-ablation kidney biopsywould help confirm treatment success.MATERIALS AND METHODS: FromApril 2002 to March 2006 a total of 109renal lesions in 88 patients were ablatedwith percutaneous radio frequency abla-tion and from September 1997 to January2006 a total of 192 lesions in 176 patientswere treated with laparoscopic cryoab-lation. Patients were followed with ra-diographic imaging and post-ablationbiopsy at 6 months. RESULTS: Radio-graphic success at 6 months was 85% (62

cases) and 90% (125) for radio frequency

ablation and cryoablation, respectively.At 6 months 134 lesions (45%) were bi-opsied and success in the radio fre-quency ablation cohort decreased to64.8% (24 cases), while cryoablation suc-cess remained high at 93.8% (91). Six of13 patients (46.2%) with a 6-month pos-itive biopsy after radio frequency abla-tion demonstrated no enhancement onposttreatment magnetic resonance imag-ing or computerized tomography. In pa-tients treated with cryoablation all posi-tive biopsies revealed posttreatmentenhancement on imaging just before bi-opsy. CONCLUSIONS: We observed apoor correlation between radiographicimaging and pathological analysis. Werecommend post-radio frequency abla-tion followup biopsy due to the sig-nificant risk of residual renal cell cancerwithout radiographic evidence, al-though to our knowledge the clinical sig-nificance of these viable cells remains tobe determined. In contrast, radiographicimages of renal lesions treated withcryotherapy appeared to correlate ade-quately with corresponding histopatho-logical findings in our series.Authors’ Abstract

Sergio A, Cristofori C, Cardin R, et al.Transcatheter arterial chemoemboliza-tion (TACE) in hepatocellular carci-noma (HCC): the role of angiogenesisand invasiveness. Amer J Gastroen-terol 2008; 103:914–921.

• OBJECTIVE: Although transcathe-ter arterial chemoembolization (TACE)is effective in hepatocellular carcinoma(HCC), it is not considered a curativeprocedure. Among the factors poten-tially interfering with its effectiveness isa hypothetical neoangiogenic reactiondue to ischemia. In our study, we eval-uated the changes in the levels of twoangiogenic factors (vascular endothelialgrowth factor [VEGF] and basic fibro-blast growth factor [b-FGF]) and one pa-rameter of invasiveness (urokinase-typeplasminogen activator [uPA]) in patientstreated with TACE. METHODS: Threeblood samples were provided from 71HCC patients undergoing TACE: beforeTACE (t0), after 3 days (t1), and after 4wk, when they had spiral computed to-mography (sCT) scanning (t2). The refer-ring radiologists blindly evaluated tu-mor burden and vascularization at t0and residual activity at t2. The choice ofTACE as treatment was based on theAmerican Association for the Study ofLiver Diseases (AASLD) guidelines. RE-SULTS: Complete response at sCT wasrecorded in 27% of patients; mean sur-vival was 35 months (confidence interval[CI] 31–40) and the 4-yr survival was

57%. VEGF levels were significantly cor-

1128 • Abstracts July 2008 JVIR

related with the number of nodes andwere higher in nonresponders at t2 (P �0.01); below-median VEGF levels pre-dicted a longer survival (P � 0.008). b-FGF correlated with VEGF, tumor size,vascularization, and residual activity,showing a borderline correlation withsurvival. uPA correlated with tumor sizeand VEGF. VEGF was singled out in theCox multivariate analysis as an indepen-dent predictor of survival. CONCLU-SIONS: When TACE is not totally effec-tive, it may induce a significantneoangiogenetic reaction, as suggestedby an increase in VEGF and b-FGF fol-lowing treatment; this affects patientsurvival. VEGF emerges as the most re-liable prognostic parameter, so it couldbe measured for judging TACE efficacy.Finally, antiangiogenic drugs may be in-dicated in TACE-treated HCC.Authors’ Abstract

Sangro B, Gil-Alzugaray B, RodríguezJ, et al. Liver disease induced byradioembolization of liver tumors. De-scription and possible risk factors.Cancer 2008; 112:1538–1546.

• BACKGROUND: To the authors’knowledge, liver damage after liver ra-dioembolization with yttrium90-labeledmicrospheres has never been studiedspecifically. METHODS: Using a com-plete set of data recorded prospectivelyamong all patients without previouschronic liver disease treated by radioem-bolization at the authors’ institutionfrom September 2003 to July 2006, pat-terns of liver damage were identifiedand possible risk factors were analyzed.RESULTS: In all, 20% of patients devel-oped a distinct clinical picture that ap-peared 4 to 8 weeks after treatment andwas characterized by jaundice and as-cites. Veno-occlusive disease was thehistologic hallmark observed in the mostsevere cases. This form of sinusoidal ob-struction syndrome was not observedamong patients who never received che-motherapy or in those in whom a singlehepatic lobe was treated. Relevant totreatment planning, a possible risk factorwas a higher treatment dose in relationto the targeted liver volume. A tran-sjugular intrahepatic stent shunt im-proved liver function in 2 patients withimpending liver failure, although 1 ofthem eventually died from it. CONCLU-SIONS: Radioembolization of liver tu-mors, particularly after antineoplasticchemotherapy, may result in an uncom-mon but potentially life-threateningform of hepatic sinusoidal obstructionsyndrome that presents clinically withjaundice and ascites.

Authors’ Abstract

PERIPHERAL ARTERIALINTERVENTIONS

Chaer RA, Barbato JE, Lin SC, ZenatiM, Kent KC, McKinsey JF. Isolatediliac artery aneurysms: A contempo-rary comparison of endovascular andopen repair. J Vasc Surg 2008; 47:708–713.

• OBJECTIVE: Iliac artery aneurysmsare rare but associated with significantmorbidity and mortality when ruptured.This study compares recent open andendovascular repairs of iliac aneurysmsat a single institution. METHODS: Pa-tients were identified and charts re-viewed using ICD-9 and CPT codes foriliac artery aneurysm and open or endo-vascular repair performed between Jan-uary 2000 and January 2006. Baselinecharacteristics, procedure-related vari-ables, and follow-up data were retro-spectively reviewed. RESULTS: A totalof 71 patients were treated with isolatediliac artery aneurysms. There were 19open and 52 endovascular repairs. Sevenpresented with acute ruptures and weretreated by open (4) or endovascular (3)repair. Preoperative comorbidities weresimilar between the two groups. Majorperioperative (30 day) complications in-cluded three deaths in the open groupfrom cardiovascular complications, allafter ruptured aneurysm repair, and onedeath in the endovascular group (afterrupture; one additional perioperativedeath occurred after 30 days due to co-lonic infarction) (P � NS). Postoperativecomplications were less frequent in theendovascular group, although this didnot reach statistical significance. Themortality was 50% in the open groupand 33% in the endovascular group forpatients presenting with a ruptured an-eurysm (P � NS). Transfusion require-ment was significantly higher in theopen group (47%) than in the endovas-cular group (6%) (P � .03). The meanfollow-up was 20 � 5 months in theopen group and 17 � 2 months in theendovascular group (P � NS). Long-term complications included two limbthromboses following repair with a bi-furcated stent graft that were treatedwith thrombolysis plus stenting or afem-fem bypass. Three endoleaks wereidentified on postop CT scans, all ofwhich were successfully managed withendovascular techniques. There were nopostoperative ruptures or aneurysm-re-lated death. The mean postoperativelength of stay was 5.2 � 2.3 days (open)and 1.3 � 1.0 days (endovascular) (P �.04). CONCLUSIONS: This is the firstlarge, case control study comparingopen vs endovascular repair of isolatediliac artery aneurysms. Endovascular re-

pair of iliac artery aneurysms is safe and

results in decreased length of stay, lowerrequirement for perioperative bloodtransfusion, and similar intermediateterm outcomes as open repair.Authors’ Abstract

PERIPHERAL ARTERIALINTERVENTIONS – STENTS

Ormiston JA, Serruys PW, Regar E, etal. A bioabsorbable everolimus-elut-ing coronary stent system for patientswith single de-novo coronary arterylesions (ABSORB): a prospectiveopen-label trial. Lancet 2008; 371:899–907.

• BACKGROUND: A fully bioab-sorbable drug-eluting coronary stentthat scaffolds the vessel wall whenneeded and then disappears once theacute recoil and constrictive remodellingprocesses have subsided has theoreticaladvantages. The bioasorbable everoli-mus-eluting stent (BVS) has a backboneof poly-L-lactic acid that provides thesupport and a coating of poly-D,L-lacticacid that contains and controls the re-lease of the antiproliferative agenteverolimus. We assessed the feasibilityand safety of this BVS stent. METHODS:In this prospective, open-label study weenrolled 30 patients who had either sta-ble, unstable, or silent ischaemia and asingle de-novo lesion that was suitablefor treatment with a single 3·0�12 mmor 3·0�18 mm stent. Patients were en-rolled from four academic hospitals inAuckland, Rotterdam, Krakow, and Ske-jby. The composite endpoint was cardiacdeath, myocardial infarction, and isch-aemia-driven target lesion revascularisa-tion. Angiographic endpoints wereavailable for 26 patients and intravascu-lar-ultrasound endpoints for 24 patients.Clinical endpoints were assessed in all30 patients at 6 and 12 months. In asubset of 13 patients, optical coherencetomography was undertaken at base-line and follow-up. Analysis was byintention to treat. This study is regis-tered with ClinicalTrials.gov, numberNCT00300131. FINDINGS: Proceduralsuccess was 100% (30/30 patients), anddevice success 94% (29/31 attempts atimplantation of the stent). At 1 year,the rate of major adverse cardiacevents was 3·3%, with only one patienthaving a non-Q wave myocardial in-farction and no target lesion revascu-larisations. No late stent thromboseswere recorded. At 6-month follow-up,the angiographic in-stent late loss was0·44 (0·35) mm and was mainly due toa mild reduction of the stent area(�11·8%) as measured by intravascularultrasound. The neointimal area wassmall (0·30 [SD 0·44] mm2), with a min-

imal area obstruction of 5·5%. INTER-

Abstracts • 1129Volume 19 Number 7

PRETATION: This study shows thefeasibility of implantation of the bioab-sorbable everolimus-eluting stent, withan acceptable in-stent late loss, mini-mal intrastent neointimal hyperplasia,and a low stent area obstruction.Authors’ Abstract

de la Torre-Hernández JM, Alfonso F,Hernández F, et al. Drug-elutingstent thrombosis results from the mul-ticenter Spanish Registry ESTROFA(Estudio ESpañol sobre TROmbosisde stents FArmacoactivos). J AmerColl Cardiol 2008; 51:986–990.

• OBJECTIVES: This study sought toassess the incidence, predictors, and out-come of drug-eluting stent (DES) throm-bosis in real-world clinical practice.BACKGROUND: The DES thrombosesin randomized trials could not be com-parable to those observed in clinicalpractice, frequently including off-labelindications. METHODS: We designed alarge-scale, nonindustry-linked multi-centered registry, with 20 centers inSpain. The participant centers providedfollow-up data for their patients treatedwith DES, reporting a detailed standard-ized form in the event of any angiogra-phy-documented DES-associated throm-bosis occurring. RESULTS: Of 23,500patients treated with DES, definite stentthrombosis (ST) developed in 301: 24acute, 125 subacute, and 152 late. Of thelate, 62 occurred �1 year (very late ST).The cumulative incidence was 2% at 3years. Antiplatelet treatment had beendiscontinued in 95 cases (31.6%). No dif-ferences in incidences were foundamong stent types. Independent predic-tors for subacute ST analyzed in a sub-group of 14,120 cases were diabetes, re-nal failure, acute coronary syndrome,ST-segment elevation myocardial infarc-tion, stent length, and left anterior de-scending artery stenting, and for late STwere ST-segment elevation myocardialinfarction, stenting in left anterior de-scending artery, and stent length. Mor-tality at 1-year follow-up was 16% andST recurrence 4.6%. Older age, left ven-tricular ejection fraction �45%, nonres-toration of Thrombolysis In MyocardialInfarction flow grade 3, and additionalstenting were independent predictorsfor mortality. CONCLUSIONS: The cu-mulative incidence of ST after DES im-plantation was 2% at 3 years. No differ-ences were found among stent types.Patient profiles differed between earlyand late ST. Short-term prognosis ispoor, especially when restoration of nor-mal flow fails.

Authors’ Abstract

PERIPHERAL ARTERIALINTERVENTIONS – STENT-GRAFTS

Bockler D, Kotelis D, Geisbusch P, etal. Hybrid procedures for thoracoab-dominal aortic aneurysms and chronicaortic dissections—A single center ex-perience in 28 patients. J Vasc Surg2008; 47:724–732.

• OBJECTIVE: We report our 6-yearexperience with the visceral hybrid pro-cedure for high-risk patients with thora-coabdominal aortic aneurysms (TAAA)and chronic expanding aortic dissections(CEAD). METHODS: Hybrid procedureincludes debranching of the visceral andrenal arteries followed by endovascularexclusion of the aneurysm. A series of 28patients (20 male, mean age 66 years)were treated between January 2001 andJuly 2007. Sixteen patients had TAAAstype I-III, one type IV, four thoracoab-dominal placque ruptures, and sevenpatients CEAD. Patients were treated forasymptomatic, symptomatic, and rup-tured aortic pathologies in 20, and 4 pa-tients, respectively. Two patients hadMarfan’s syndrome; 61% had previousinfrarenal aortic surgery. The infrarenalaorta was the distal landing zone in 70%.In elective cases, simultaneous approach(n � 9, group I) and staged approach (n� 11, group II) were performed. Meanfollow-up is 22 months (range 0.1-78).RESULTS: Primary technical successwas achieved in 89%. All stent graftswere implanted in the entire thoracoab-dominal aorta. Additionally, three pa-tients had previous complete arch vesselrevascularization. Left subclavian arterywas intentionally covered in three pa-tients (11%). Thirty-day mortality ratewas 14.3% (4/28). One patient had a rup-ture before the staged endovascular pro-cedure and died. Overall survival rate at3 years was 70%, in group I 80%, and ingroup II 60% (P � .234). Type I endoleakrate was 8%. Permanent paraplegia ratewas 11%. Three patients required long-term dialysis (11%). Peripheral graft oc-clusion rate was 11% at 30 days. Gutinfarction with consecutive bowel resec-tion occurred in two patients. There wasno significant difference between groupI and II regarding paraplegia and com-plications. CONCLUSIONS: Early re-sults of visceral hybrid repair for high-risk patients with complex and extendedTAAAs and CEADs are encouraging in aselected group of high risk patients inwhom open repair is hazardous andbranched endografts are not yet op-tional.Authors’ Abstract

Brown KE, Eskandari MK, Matsu-

mura JS, Rodriguez H, Morasch MD.

Short and midterm results with mini-mally invasive endovascular repair ofacute and chronic thoracic aortic pa-thology. J Vasc Surg 2008; 47:714–723.

• OBJECTIVES: Endovascular man-agement of both acute and chronic tho-racic aortic pathology has emerged as analternative to open surgery. We re-viewed our single center experience withendovascular devices for the treatmentof thoracic aortic pathology. METHODS:Between April 2000 and October 2007,116 thoracic aortic stent grafts wereplaced to treat a variety of acute orchronic thoracic aortic lesions. Thirty-five percent of the cases were performedemergently. Sixty-five percent of the pa-tients were male; the average age was63.9 years (range 20-93 years). Indica-tions for treatment were chronic degen-erative aneurysms (n � 70), traumaticaortic disruption (n � 20), complicateddissection, intramural hematoma, orpenetrating aortic ulcer (n � 14), pseu-doaneurysm (n � 10), and Diverticulumof Kommerell (n � 2). Arch vessel revas-cularization (n � 32) or mesenteric de-branching (n � 7) was performed in se-lect cases. Devices used were industry-approved thoracic aortic devices (n �80), aortic cuff extenders (n � 19), orcustom made by the surgeon (n � 17).RESULTS: The 30-day death, stroke andparaplegia/paresis rates were 5.2%,8.6%, and 2.6%, respectively. Arterial ac-cess complications requiring immediateoperative repair occurred at a rate of11.2% (n � 13). The endoleak rate requir-ing repeat intervention was 6.9% (n � 8).The delayed graft infection rate was5.2% (n � 6), with four of these casesresulting in death. The mean follow-upis 15 months (range 1-78 months). Com-puted tomography angiograms wereperformed at 1, 6, and 12 months follow-ing the index procedure, and yearlythereafter. CONCLUSIONS: Endovascu-lar therapy for acute and chronic tho-racic aortic pathology is a viable alterna-tive to open surgery with comparableoperative morbidity and mortality. Mid-term results suggest that endografts aredurable, but require more secondary in-terventions and imaging surveillancethan open reconstruction.Authors’ Abstract

PORTAL VEIN INTERVENTIONS

Yokoyama Y, Nagino M, Oda K, et al.Sex dimorphism in the outcome ofpreoperative right portal vein emboli-zation. Arch Surg 2008; 143:254–259.

• HYPOTHESIS: Although studiesindicate that patient sex modulates theprocess of hepatic regeneration, it re-mains unknown whether sex has a role

in the outcome of preoperative right por-

1130 • Abstracts July 2008 JVIR

tal vein embolization (PVE). We ana-lyzed the effects of patient sex on theoutcome of right PVE followed by majorhepatectomy. DESIGN: Retrospectivestudy. SETTING: Academic research.PATIENTS: Eighty-eight patients (42men and 46 women) who underwentpreoperative right PVE for bile duct car-cinoma were analyzed retrospectively.MAIN OUTCOME MEASURES: Thepercentage liver volume change, theplasma indocyanine green clearancerate, and the rate of postoperative he-patic failure were compared betweenmen and women. RESULTS: The mean(SD) volume of the nonembolized lobeafter PVE in women (323 [61] mL/m2)was statistically significantly greaterthan that in men (287 [61] mL/m2) (P�.008). The mean (SD) ratio of the non-embolized lobe to the total liver volumewas also statistically significantly greaterin women (45.8% [5.8%]) than in men(42.0% [5.9%]) (P �.003). The mean (SD)indocyanine green clearance rate of thefuture liver remnant was 0.075 [0.014] inwomen and 0.056 [0.011] in men (P�.001). The incidence of postoperativehepatic failure was higher in men (12 of42 [28.6%]) than in women (8 of 46[17.4%]) (P �.16). CONCLUSION: Theseresults indicate that sex dimorphism canbe present in the outcome of preopera-tive right PVE.Authors’ Abstract

THORACIC INTERVENTIONS

Pierucci P, Murphy J, Henderson KJ,Chyun DA, White RI. New defini-tion and natural history of patientswith diffuse pulmonary arteriovenousmalformations. Twenty-seven–yearexperience. Chest 2008; 133:653–661.

• BACKGROUND: Patients with dif-fuse pulmonary arteriovenous malfor-mations (PAVM), a small but importantsubset of the PAVM population, havesignificant morbidity and mortalityrates. METHODS: Thirty-six patients (21female and 15 male) with diffuse PAVMfrom a cohort of 821 consecutive patientswith PAVM were evaluated. DiffusePAVM were categorized angiographi-cally: involvement of one or more seg-mental pulmonary arteries in one orboth lungs. Hereditary hemorrhagic tel-angiectasia (HHT) status, gender, pres-ence or absence of large (� 3-mm diam-eter artery) focal PAVM, oxygensaturations, complications including he-moptysis, years of follow-up, and sur-vival were tabulated. RESULTS: HHTwas present in 29 of 36 patients (81%),and diffuse PAVM were more com-monly bilateral (26 of 36 patients, 72%)than unilateral (10 of 36 patients, 28%) [p

� 0.02]. Female gender was associated

with bilateral diffuse PAVM (19 of 26patients, 73%) [p � 0.01]. Focal PAVMwere present in both groups but morecommonly in patients with bilateral in-volvement (16 of 26 patients, 62%) [p �0.02]. Initial oxygen saturations (pulseoximetry, standing) of patients with uni-lateral and bilateral diffuse PAVM were87 � 7% and 79 � 8% (mean � SD),respectively (p � 0.02). The last or cur-rent values for patients with unilateraland bilateral involvement are 95 � 3%and 85 � 7%, respectively (p � 0.0001).Nine deaths occurred, and all were inpatients with bilateral involvement.Deaths were due to hemoptysis of bron-chial artery origin (n � 2), hemorrhagefrom duodenal ulcer (n � 1), spontane-ous liver necrosis (n � 3), brain hemor-rhage (n � 1), brain abscess (n � 1), andoperative death during attempted lungtransplant (n � 1). CONCLUSIONS: Pa-tients with diffuse PAVM are a high-riskgroup, and yearly follow-up is recom-mended.Authors’ Abstract

TRAUMA

Canaud L, Alric P, Branchereau P,Marty-Ané C, Berthet J-P. Lessonslearned from midterm follow-up ofendovascular repair for traumatic rup-ture of the aortic isthmus. J Vasc Surg2008; 47:733–738.

• OBJECTIVE: The aim of this studywas to evaluate the short- and midtermresults following endovascular repair ofa traumatic rupture of the aortic isth-mus. METHODS: Between January 2001and January 2007, 27 patients underwentendovascular repair for acute traumaticrupture of the aortic isthmus (8 women,19 men, mean age 40.2 � 16.7 years [19-78]). All patients underwent a computedtomography scan resulting in the preop-erative diagnosis of aortic disruptions.Twenty-one patients were treated withinthe first 5 days following diagnosis. Fol-low-up computed tomography scanswere performed at 1 week, at 3 and 6months, and annually thereafter. Themedian follow-up was 40 months. RE-SULTS: All endografts were successfullydeployed (Excluder-TAG [16], Talent[10], Zenith [2]). Three patients requiredcommon iliac artery access. The morbid-ity rate was 14.8%: two cases of inadver-tent coverage of supra-aortic trunks oc-curred peroperatively, a proximal type Iendoleak was successfully treated by aproximal implantation of a second en-dograft, and one collapse of an endograftwas successfully treated by open repairand explantation. No patient sufferedtransient or permanent paraplegia, cere-bral complication, endograft migration,

or secondary endoleak. The overall mor-

tality rate was 3.7%. CONCLUSIONS:Short and midterm results following en-dovascular treatment for traumatic rup-ture of the aortic isthmus favor the prop-osition of endovascular repair as thefirst-line treatment in hemodynamicallyunstable patients. In hemodynamicallystable patients, the preoperative mor-phological evaluations aim to assess aor-tic anatomy and thereby detect possibletechnical limitations (aortic diameter�20 mm, severe aortic isthmus angula-tion, short proximal aortic neck �20mm, conical aorta). In the presence ofany one of these technical restrictions,open surgical treatment should be dis-cussed to avoid major per- or postoper-ative complications related to endovas-cular repair. Further studies and long-term survival studies are mandatory todetermine the efficacy and durability ofthis technique.Authors’ Abstract

du Toit DF, Lambrechts AV, Stark H,Warren BL. Long-term results ofstent graft treatment of subclavian ar-tery injuries: Management of choicefor stable patients? J Vasc Surg 2008;47:739–743.

• BACKGROUND: The managementof penetrating subclavian artery injuriesposes a formidable surgical challenge.The feasibility of stent graft repair is al-ready established. General use of thismodality is not widely accepted due toconcerns regarding the long-term out-come in a generally young patient pop-ulation. We review our stent graft expe-rience to examine long-term outcomes.METHODS: All patients with penetrat-ing subclavian artery injuries were eval-uated for stent graft repair. Patients wereexcluded when hemodynamically unsta-ble or unsuitable on other clinical andangiographic grounds. Patients were fol-lowed prospectively for early (�30 days)and late (�30 days) complications. Clin-ical and telephone evaluation, Dopplerpressures, duplex Doppler, and angiog-raphy (when indicated), were used toasses patients at follow-up. Outcomeswere recorded as technical success ofprocedure, graft patency, arm claudica-tion, limb loss, the need for open surgi-cal repair, the presence or absence ofother complications, and death. RE-SULTS: Fifty-seven patients underwentstent graft treatment during the 10-yearperiod. Mean age was 34, and 91% weremen. There were 53 stab wounds andfour gunshot injuries. Pathology in-cluded false aneurysms (n � 42), arterio-venous fistula (n � 12), and three arterialocclusions. Early complications: One pa-tient (2%) had a femoral puncture siteinjury which was managed with open

surgical repair. One patient died early

Abstracts • 1131Volume 19 Number 7

due to multiple organ failure related toconcomitant injuries. Three patients (5%)presented with graft occlusion and non-limb threatening ischemia in the firstweek after treatment. All three patientswere managed successfully with a sec-ond endovascular intervention. Latecomplications: Twenty-five (44%) of the57 patients with subclavian artery inju-ries were followed-up with a mean du-ration of 48 months. Two patients diedas a result of fatal stab wounds monthsafter their first injuries. Five patients(20%) and three patients (12%) presentedwith angiographically significant steno-sis and occlusions, respectively. The ste-notic lesions were successfully managedwith endovascular intervention, and theoccluded lesions were managed conser-vatively. No patient experienced life orlimb loss or any incapacitating symp-toms at the end of the study period.There was no need for conversion toopen surgery. CONCLUSIONS: Thisstudy has reaffirmed the feasibility andsafety of stent graft repair in treatingstable patients with selected penetratingsubclavian artery injuries. The results ofthis study also confirmed acceptablelong-term follow-up without any limb or

life threatening complications. We con-

clude that endovascular repair should beconsidered the first choice of treatmentin stable patients with subclavian arteryinjuries.Authors’ Abstract

VENOUS INTERVENTIONS –THROMBOEMBOLIC DISEASE

Laporte S, Mismetti P, Décousus H, etal. Clinical predictors for fatal pul-monary embolism in 15 520 patientswith venous thromboembolism. Find-ings from the Registro Informatizadode la Enfermedad TromboEmbolicavenosa (RIETE) Registry. Circulation2008; 117:1711–1716.

• BACKGROUND: Clinical predic-tors for fatal pulmonary embolism (PE)in patients with venous thromboembo-lism have never been studied. METH-ODS AND RESULTS: Using data fromthe international prospective RegistroInformatizado de la Enfermedad Trom-boEmbolica venosa (RIETE) registryabout patients with objectively con-firmed symptomatic acute venousthromboembolism, we determined inde-pendent predictive factors for fatal PE.Between March 2001 and July 2006,

15 520 consecutive patients (mean

age�SD, 66.3�16.9 years; 49.7% men)with acute venous thromboembolismwere included. Symptomatic deep-veinthrombosis without symptomatic PEwas observed in 58.0% (n�9008) of pa-tients, symptomatic nonmassive PE in40.4% (n�6264), and symptomaticmassive PE in 1.6% (n�248). At 3months, the cumulative rates of overallmortality and fatal PE were 8.65% and1.68%, respectively. On multivariableanalysis, patients with symptomaticnonmassive PE at presentation exhib-ited a 5.42-fold higher risk of fatal PEcompared with patients with deep-vein thrombosis without symptomaticPE (P�0.001). The risk of fatal PE wasmultiplied by 17.5 in patients present-ing with a symptomatic massive PE.Other clinical factors independentlyassociated with an increased risk of fa-tal PE were immobilization for neuro-logical disease, age �75 years, and can-cer. CONCLUSIONS: PE remains apotentially fatal disease. The clinicalpredictors identified in the presentstudy should be included in any clini-cal risk stratification scheme to opti-mally adapt the treatment of PE to therisk of the fatal outcome.

Authors’ Abstract