ann vasc surg 2012;26(1)

Ann Vasc surg 2012; 26(1)Originals

1.Ann Vasc Surg. 2012 Jan;26(1):102-6. doi: 10.1016/j.avsg.2011.10.002.

Results of staged carotid endarterectomy and coronary artery bypass graft in patients with severe carotid and coronary disease.

Santos A, Washington C, Rahbar R, Benckart D, Muluk S.

Source

Allegheny General Hospital, The Gerald McGinnis Cardiovascular Institute, Pittsburgh, PA 15212, USA. [email protected]

Abstract

BACKGROUND:

To evaluate our experience with staged carotid endarterectomy (CEA) followed by coronary artery bypass grafting (CABG) within the perioperative period for patients with severe carotid and coronary artery disease.

METHODS:

From 1998 to August of 2010, 40 patients who were referred for isolated coronary surgery were found to have significant carotid disease. All patients underwent CEA followed by subsequent CABG within 30 days of the CEA. Severe carotid stenosis was defined as >70%.

RESULTS:

Average patient age was 65.5 ± 10.6 years and 32 (80%) were male. Severe carotid stenosis was unilateral in 37 of the patients, bilateral in 3, and asymptomatic in 37. Patients underwent CEA with either patch angioplasty or eversion technique. General anesthesia with selective shunting was used in all cases. There were zero deaths, zero strokes, and one myocardial infarction (MI) (2.5%) immediately after CEA. After CEA, CABG was performed within 30 days. The average interval between procedures was 6.87 days. There were two (5.0%) deaths, one from MI and the other from multisystem organ failure. There were two strokes (5.0%), with one having permanent effects. The perioperative mortality, stroke, and MI rates after both operations were 5.0%, 5.0%, and 5.0%, respectively.

CONCLUSIONS:

Staging of CEA followed by CABG in the immediate perioperative period may be an acceptable approach to patients with severe carotid and coronary disease. Despite the presence of known severe coronary disease, the performance of CEA under general anesthesia as the initial procedure was well tolerated. We propose that this strategy

may be a possible option for patients who present with severe disease in both coronary and carotid distributions. The results of our study, though based on a limited cohort, suggest that this approach of staged CEA-CABG within the perioperative period <30 days is reasonable.

Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

PMID:22176880[PubMed - indexed for MEDLINE]

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Sex-related differences in embolic potential during carotid angioplasty and stenting.

Spyris CT, Vouyouka AG, Tadros RO, Chung C, Marin ML, Faries PL.

Source

Department of Vascular Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.

Abstract

BACKGROUND:

Carotid angioplasty and stenting (CAS) is an alternative to carotid endarterectomy. CAS outcomes and risk factors affecting postoperative complications in women are not well defined. We sought to determine the effect of sex on particle size captured by embolic protection devices, comorbidities influencing embolization, and results after CAS.

METHODS:

Embolic debris from 188 consecutively collected carotid embolic protection devices were analyzed using photomicroscopy and imaging software. Patient comorbidities, preoperative cerebrovascular symptoms, and perioperative outcomes (cerebrovascular accident, myocardial infarction, mortality) were examined.

RESULTS:

The mean age was 71.0 years (56.4% males). Men (M) were more likely than women (W) to be smokers (M: 70.4% vs. W: 55.6%, p = 0.046) and have coronary artery disease (M: 65.7% vs. W: 48.1%, p = 0.02). Symptomatic (S) patients had larger mean particle size compared with asymptomatic (AS) patients (S: 469.9 ± 416.4 μm vs. AS: 316.1 ± 241.1 μm, p = 0.01). On subgroup analysis, a larger mean particle size was observed in symptomatic woman compared with asymptomatic women (S: 461.5 ±

http://linkinghub.elsevier.com/retrieve/pii/S0890-5096(11)00477-8

348.1 μm vs. AS: 281.4 ± 209.4 μm, p = 0.02). In men, a trend toward a larger mean particle size in symptomatic patients did not reach statistical significance (S: 475.8 ± 462.9 μm vs. AS: 351.2 ± 262.4 μm, p = 0.08).

CONCLUSIONS:

Preoperative cerebrovascular symptoms are associated with a greater mean particle size in symptomatic women compared with asymptomatic women. This difference in mean particle size was not observed in men. These results provide evidence that may help in better selection of CAS patients, but the impact of an increased mean particle size in symptomatic women during carotid stenting requires further investigation.



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Cost impact of extension cuff utilization during endovascular aneurysm repair.

Chandra V, Greenberg JI, Al-Khatib WK, Harris EJ, Dalman RL, Lee JT.

Source

Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA 94305, USA.

Abstract

BACKGROUND:

Modular stent-graft systems for endovascular aneurysm repair (EVAR) most often require two to three components, depending on the device. Differences in path lengths and availability of main body systems often require additional extensions for appropriate aneurysm exclusion. These additional devices usually result in added expenses and can affect the financial viability of an EVAR program within a hospital. The purpose of this study was to analyze the use of extensions during EVAR, focusing on incidence, clinical impact, and financial impact, as well as determining the associated cost differences between two- and three-component EVAR device systems.

METHODS:

We reviewed available clinical data, images, and follow-up of 218 patients (203 males and 15 females, mean age: 74 ± 9 years) who underwent elective EVAR at a single


academic center from 2004 to 2007. Patients were divided into two groups: patients undergoing EVAR using the standard number of pieces, that is, no extensions used (group A, n = 98), and those needing proximal or distal extensions during the index procedure (group B, n = 120).

RESULTS:

Both groups were similar in terms of demographics; preoperative characteristics, including aneurysm morphology; as well as intraoperative, postoperative, and midterm outcomes. Overall, 30-day operative mortality was 1.4%, with a mean follow-up of 24 months. Group A patients underwent repair with two-piece modular devices 41% of the time and three-piece systems 59% of the time, whereas group B patients underwent repair with two-piece modular systems 82% of the time and three-piece modular systems 18% of the time. The number of additional extensions per patient ranged from one to four (median: one piece). There was a 30% cost increase in overall mean device-related cost when using extensions versus the standard number of pieces (group A: $13,220 vs. group B: $17,107, p < 0.01).

CONCLUSIONS:

Clinical midterm aneurysm-related outcomes after EVAR in patients who required additional extensions was comparable with those treated with the standard number of pieces. An increased number of extensions led to increased costs and could have potentially been minimized with appropriate preoperative planning or device selection. Consideration should be made toward per-case pricing instead of per-piece pricing to further improve cost efficiency without compromising long-term patient outcomes.



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Open repair of vertebral artery: a 7-year single-center report.

Ramirez CA, Febrer G, Gaudric J, Abou-Taam S, Beloucif K, Chiche L, Koskas F.

Source

Department of Vascular Surgery, Groupe Hospitalier Pitié Salpêtrière, Paris, France. [email protected]

Abstract

BACKGROUND:

http://linkinghub.elsevier.com/retrieve/pii/S0890-5096(11)00478-X

To report the long-term results of proximal and distal VA open repairs.

METHODS:

From January 2002 to December 2009, 74 cases of VA open repair were performed (73 patients, 41 men; mean age, 66.5 ± 15.2 years). Symptoms of vertebrobasilar insufficiency were present in 61 cases (82.4%). Forty-seven have had a proximal VA repair, and 27, a distal one. Bypass grafting using a saphenous vein graft was performed in 21 cases (28.3%). Direct transposition was used in 48 (64.8%), mostly into the common carotid artery.

RESULTS:

Mean duration of follow-up was 39.5 ± 31.3 months. A stroke was present in three patients (4.1%), two hemispheric (2.7%) and one vertebrobasilar (1.3%), which turned lethal. The two hemispheric strokes occurred in the subgroup of 35 procedures combined with a carotid artery reconstruction. A transient Horner syndrome was found in 16 cases (21.6%), and a transient vocal palsy, in six (8.1%). Early postoperative occlusion occurred in two cases (2.7%). A total of seven (9.4%) patients died during follow-up, one from a stroke. Cumulative Kaplan-Meier survival rate was 90.7 ± 4.8% at 3 years and 77.3 ± 12.2% at 6 years. Assessment of late patency was obtained in 54 (84.3%) of 64 survivals by duplex scanning (70.3%) or angiography (10.9%). Significant vertebrobasilar symptom-free rate was 87.7 ± 9.2% at 6 years. Primary patency rate was 94.8 ± 3.8% at 3 years and 90.8 ± 9.4% at 6 years.

CONCLUSIONS:

VA open repair provides excellent long-term results. Patients with combined carotid and VA reconstruction are at higher risk of postoperative stroke than patients undergoing isolated repair of the VA.



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Predicting functional status following amputation after lower extremity bypass.

Suckow BD, Goodney PP, Cambria RA, Bertges DJ, Eldrup-Jorgensen J, Indes JE, Schanzer A, Stone DH, Kraiss LW, Cronenwett JL; Vascular Study Group of New England.

Source


Division of Vascular Surgery, University of Utah Hospital, University of Utah School of Medicine, Salt Lake City, UT 84132, USA. [email protected]

Abstract

BACKGROUND:

Some patients who undergo lower extremity bypass (LEB) for critical limb ischemia ultimately require amputation. The functional outcome achieved by these patients after amputation is not well known. Therefore, we sought to characterize the functional outcome of patients who undergo amputation after LEB, and to describe the pre- and perioperative factors associated with independent ambulation at home after lower extremity amputation.

METHODS:

Within a cohort of 3,198 patients who underwent an LEB between January, 2003 and December, 2008, we studied 436 patients who subsequently received an above-knee (AK), below-knee (BK), or minor (forefoot or toe) ipsilateral or contralateral amputation. Our main outcome measure consisted of a "good functional outcome," defined as living at home and ambulating independently. We calculated univariate and multivariate associations among patient characteristics and our main outcome measure, as well as overall survival.

RESULTS:

Of the 436 patients who underwent amputation within the first year following LEB, 224 of 436 (51.4%) had a minor amputation, 105 of 436 (24.1%) had a BK amputation, and 107 of 436 (24.5%) had an AK amputation. The majority of AK (75 of 107, 72.8%) and BK amputations (72 of 105, 70.6%) occurred in the setting of bypass graft thrombosis, whereas nearly all minor amputations (200 of 224, 89.7%) occurred with a patent bypass graft. By life-table analysis at 1 year, we found that the proportion of surviving patients with a good functional outcome varied by the presence and extent of amputation (proportion surviving with good functional outcome = 88% no amputation, 81% minor amputation, 55% BK amputation, and 45% AK amputation, p = 0.001). Among those analyzed at long-term follow-up, survival was slightly lower for those who had a minor amputation when compared with those who did not receive an amputation after LEB (81 vs. 88%, p = 0.02). Survival among major amputation patients did not significantly differ compared with no amputation (BK amputation 87%, p = 0.14, AK amputation 89%, p = 0.27); however, this part of the analysis was limited by its sample size (n = 212). In multivariable analysis, we found that the patients most likely to remain ambulatory and live independently despite undergoing a lower extremity amputation were those living at home preoperatively (hazard ratio [HR]: 6.8, 95% confidence interval [CI]: 0.94-49, p = 0.058) and those with preoperative statin use (HR: 1.6, 95% CI: 1.2-2.1, p = 0.003), whereas the presence of several comorbidities identified patients less likely to achieve a good functional outcome: coronary disease (HR: 0.6, 95% CI: 0.5-0.9, p = 0.003), dialysis (HR: 0.5, 95% CI: 0.3-0.9, p = 0.02), and congestive heart failure (HR: 0.5, 95% CI: 0.3-0.8, p = 0.005).

CONCLUSIONS:

A postoperative amputation at any level impacts functional outcomes following LEB surgery, and the extent of amputation is directly related to the effect on functional outcome. It is possible, based on preoperative patient characteristics, to identify

patients undergoing LEB who are most or least likely to achieve good functional outcomes even if a major amputation is ultimately required. These findings may assist in patient education and surgical decision making in patients who are poor candidates for lower extremity bypass.

Published by Elsevier Inc.


PMCID:PMC3339378

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Thoracic endovascular repair (TEVAR) in the management of aortic arch pathology.

Murphy EH, Stanley GA, Ilves M, Knowles M, Dimaio JM, Jessen ME, Arko FR 3rd.

Source

Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9157, USA.

Abstract

BACKGROUND:

Conventional repair of aortic arch pathology is associated with significant mortality and stroke rates of 6-20% and 12%, respectively. Because endografting has excellent results for descending thoracic aortic disease, extension of thoracic endovascular repair (TEVAR) to the arch is a consideration.

METHODS:

Records of patients with aortic arch pathology treated with TEVAR were reviewed. Branch vessels were (1) covered without revascularization, (2) surgically bypassed, (3) stented, or (4) fenestrated. Technical success was defined both by accurate endograft deployment with disease exclusion and by target vessel revascularization. Patient postoperative outcomes, complications, and follow-up are reported.

RESULTS:

Between March 2006 and January 2010, 58 patients with arch pathology were treated with TEVAR. Indications included aneurysm (n = 19, 32.8%), dissection (type A: n = 3, 5.2%; type B: n = 18, 31.0%), transection (n = 8, 13.8%), pseudoaneurysm (n = 6,


http://www.ncbi.nlm.nih.gov/pmc/articles/pmid/22176876/

10.3%), or other (n = 4, 6.9%). Pathology was zone 0 (n = 1, 1.7%), zone 1 (n = 10, 17.2%), zone 2 (n = 45, 77.6%), or zone 3 (n = 2, 3.4%). Interventions were emergent in 44.8% and elective in 55.2%. The left subclavian (LSA) was covered in all and revascularized (n = 23, 39.7%) via bypass (n = 13, 22.4%), stenting (n = 4, 6.9%), or fenestration (n = 6, 10.3%). The carotid was revascularized (n = 11, 19.0%) with bypass (n = 7, 12.1%) or stenting (n = 4, 6.9%). One patient (1.7%) underwent innominate revascularization with a homemade branched endograft. Technical success was 100% for endograft deployment and 97.1% for revascularization. Thirty-day mortality was 3.4% (2 of 58). ICU and hospital stays were 5.8 ± 6.8 (range: 0-34; median 4) and 10.9 ± 8.0 (range: 1-40; median: 9) days, respectively. Morbidities included renal failure (n = 3, 5.2%), respiratory (n = 2, 3.4%), myocardial infarction (n = 1, 1.7%), stroke (n = 6, 10.3%), and spinal cord ischemia (SCI) (n = 2, 3.4%). SCI (p < 0.001), but not stroke (p = 0.33), was associated with LSA sacrifice. Stroke was associated with underlying pathology and graft selection (p = 0.01). During follow-up of 10.6 ± 9.1 (range: 0-43) months, 17 patients (29.3%) required 20 reinterventions for endoleak (n = 8, 13.8%), disease extension (n = 5, 8.6%), steal (n = 4, 6.9%), or other reasons (n = 3, 5.2%). Dissection patients had a higher rate of reintervention (p = 0.01). All patients with steal had LSA sacrifice and were left-hand dominant.

CONCLUSIONS:

TEVAR can effectively treat aortic arch pathology in high-risk patients with low morbidity and mortality. TEVAR and branch vessel revascularization techniques may be extended to the more proximal arch without increased complications compared with patients with subclavian only involvement. Stroke remains the most significant drawback of arch interventions. Indications for intervention, graft selection, and revascularization choices may all affect outcome. LSA sacrifice is associated with increased SCI and may predispose left-handed patients to symptomatic weakness.


Comment in

How to perform aortic arch debranching in the hybrid procedure applied to the thoracic aorta: total or partial? [Ann Vasc Surg. 2012]


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Increasing complexity in the open surgical repair of abdominal aortic aneurysms.

Barshes NR, McPhee J, Ozaki CK, Nguyen LL, Menard MT, Gravereaux E, Belkin M.


Source

Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02215, USA.

Abstract

BACKGROUND:

Patient selection and techniques for the operative management of abdominal aortic aneurysms (AAAs) continue to evolve. We sought to examine trends in open surgical repair (OSR) over a 15-year period in which endovascular aneurysm repair (EVAR) has become increasingly prevalent.

METHODS:

Patients undergoing elective repair of infra- and pararenal AAAs were identified through our center's prospective vascular surgery registry during two time periods: 1995 to 2004 (era 1) and 2004 to 2010 (era 2). Data collected included comorbidities, demographics, and operative characteristics.

RESULTS:

A total of 1,188 elective AAAs were repaired during the study period, including 828 (70%) OSRs and 360 (30%) EVARs. The proportion of OSRs requiring suprarenal cross-clamping increased from 14.2% during era 1 to approximately 50% by the end of era 2. Compared with era 1, increases were seen in the unadjusted mortality rates during era 2 for OSR with infrarenal clamping (from 0.62% to 1.73%) and OSR with suprarenal clamping (from 1.22% to 3.98%); after adjusting for other variables, however, no significant temporal trends were seen. Similarly, no significant change in major complication rate was seen after adjusting for other factors. The incidence of major comorbidities among the OSR group was largely unchanged between the two eras.

CONCLUSIONS:

OSR of AAAs has become increasingly complex, with the increased utilization of EVAR. Despite this complexity, risk-adjusted outcomes may remain good in high-volume centers.



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8.


Ann Vasc Surg. 2012 Jan;26(1):46-54. doi: 10.1016/j.avsg.2011.08.008. Epub 2011 Nov 12.

Preoperative inpatient hospitalization and risk of perioperative infection following elective vascular procedures.

deFreitas DJ, Kasirajan K, Ricotta JJ 2nd, Veeraswamy RK, Corriere MA.

Source

Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, GA 30322, USA.

Abstract

BACKGROUND:

Health care-associated infections are not uncommon after elective vascular surgery and can negatively impact mortality rates and hospital resource utilization. Identification of modifiable risk factors for perioperative infection is critical for efforts aimed toward reducing their incidence. We evaluated the associations between preoperative inpatient hospitalization and perioperative surgical site infection (SSI), pneumonia, and urinary tract infection (UTI) following elective vascular surgery procedures.

METHODS:

Vascular procedures were identified from the 2005 to 2008 American College of Surgeons National Safety Quality Improvement Participant User Data File by using primary Current Procedural Terminology (CPT) codes. Perioperative infections were evaluated as outcomes based on three categories: SSI, pneumonia, and UTI. Patients admitted ≥1 day before operation were considered inpatients before surgery. Associations between preoperative inpatient hospitalization and perioperative SSI, pneumonia, and UTI were evaluated using the Cochran-Armitage trend test and multivariable logistic regression.

RESULTS:

In total 40,669 elective vascular procedures were identified, of which 7,514 (18.5%) were preoperative inpatients. Patients with preoperative inpatient hospitalization had a greater frequency of age >80 years and dependent functional status and also had higher rates of several comorbid conditions, including congestive heart failure, severe chronic obstructive pulmonary disease, >10% weight loss over the past 6 months, history of bleeding disorder, and current smoker within 1 year, than patients admitted on the same day of their procedure. The overall rates of SSI, pneumonia, and UTI were 3.2%, 1.9%, and 1.4%, respectively. Patients with preoperative inpatient hospitalization had higher 30-day incidence of SSI (4.5 vs. 2.9%), pneumonia (3.1 vs. 1.6%), and UTI (2.3 vs. 1.2%). In multivariable models including preoperative risk factors, preoperative inpatient hospitalization was associated with increased 30-day risk of SSI (odds ratio [OR], 1.21; 95% confidence interval [CI]: 1.06-1.39; p = 0.0066), pneumonia (OR, 1.64; 95% CI: 1.39-1.94; p < 0.0001), and UTI (OR, 1.46; 95% CI: 1.20-1.77; p < 0.0001).

CONCLUSION:

Preoperative inpatient hospitalization is associated with higher rates of perioperative SSI, pneumonia, and UTI in patients undergoing elective vascular surgery procedures. Avoidance of unnecessary preoperative hospitalization has potential to reduce rates of perioperative infection, but additional research is needed to develop evidence-based management strategies when hospitalization before elective procedures is necessary.



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9.Ann Vasc Surg. 2012 Jan;26(1):141-8. doi: 10.1016/j.avsg.2011.03.019. Epub 2011 Nov 1.

Funnel technique for EVAR: "a way out" for abdominal aortic aneurysms with ectatic proximal necks.

Ronsivalle S, Faresin F, Franz F, Rettore C, Zanchetta M, Zonta L.

Source

Department of Cardiovascular Disease, Vascular and Endovascular Surgery and Angiology, Cittadella Hospital, Cittadella, Padua, Italy. [email protected]

Abstract

BACKGROUND:

To describe an endovascular technique for proximal stent-graft fixation in patients with an abdominal aortic aneurysm and an ectatic aortic neck.

METHODS:

We describe a method in which using currently available devices in a hybrid assembly offers another option for circumventing the limitations of problematic proximal fixation.

CONCLUSIONS:

Through four examples, we illustrate the feasibility of placing a straight endograft as proximal extension of a bifurcated or aorto-uni-iliac graft in patients with a dilated proximal aortic neck. It appears secure and effective, with no type I endoleak or migration over a midterm follow-up.


PMID:


22050882[PubMed - indexed for MEDLINE]

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10.Ann Vasc Surg. 2012 Jan;26(1):34-9. doi: 10.1016/j.avsg.2011.07.003. Epub 2011 Oct 22.

ViPS (Viabahn Padova Sutureless) technique: preliminary results in the treatment of peripheral arterial disease.

Ferretto L, Piazza M, Bonvini S, Battocchio P, Grego F, Ricotta JJ.

Source

Clinic of Vascular and Endovascular Surgery, Padova University, School of Medicine, Padova, Italy.

Abstract

BACKGROUND:

To describe early results of a novel technique (ViPS, Viabahn Padova Sutureless) that connects a vascular prosthetic graft to a target artery in a sutureless fashion.

METHODS:

A consecutive series of five patients with peripheral arterial occlusive disease (Rutherford class IV and V) underwent six ViPS procedures (one bilateral) for limb revascularization. Angiography in all cases demonstrated complete superficial femoral artery (SFA) occlusion with reconstitution of a circumferentially calcified above-knee popliteal artery. Ultrasonography revealed no adequate vein for autogenous bypass creation. In all cases, a previous attempt of SFA endovascular recanalization was unsuccessful. A Viabahn (W.L. Gore, Flagstaff, AZ) endoprosthesis was partially deployed, and its proximal end was sutured to a polytetrafluoroethylene graft. After surgical exposure, the circumferentially calcified popliteal artery, which could not be safely sutured, was transected and the undeployed distal portion of the Viabahn was inserted into the popliteal artery supported by a stiff guidewire. The distal portion of the Viabahn graft was then deployed 2.5 cm into the popliteal artery with optimal apposition. The proximal end of the polytetrafluoroethylene graft was then sutured to the common femoral artery. The distal portion of the Viabahn was ballooned to ensure apposition with the popliteal artery.

RESULTS:

The mean time for surgical modification of the device was 6.6 minutes with a mean time for ViPS anastomosis deployment of 7 seconds. Mean operative time for ViPS procedure was 61 minutes (range: 48-74). Completion angiogram in all cases demonstrated a patent graft with no sign of dissection. The patients' symptoms resolved in all cases, with complete ulcer healing occurring in five patients within 3


weeks. Follow-up imaging (mean = 2.6 months, range: 1-5) with eco-color-Doppler and computed tomography angiogram demonstrated a patent graft with no loss of device integrity in all cases.

CONCLUSION:

The ViPS technique is simple, easily performed, and provides an alternative for bypass creation, particularly in cases where challenging arterial anastomoses are required. Furthermore, this technique has the potential to reduce operative time and is accomplished using common commercially available devices.

Copyright © 2012 Annals of Vascular Surgery Inc. All rights reserved.


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11.Ann Vasc Surg. 2012 Jan;26(1):40-5. doi: 10.1016/j.avsg.2011.07.005. Epub 2011 Oct 1.

Does a contralateral carotid occlusion adversely impact carotid artery stenting outcomes?

Keldahl ML, Park MS, Garcia-Toca M, Wang CH, Kibbe MR, Rodriguez HE, Morasch MD, Eskandari MK.

Source

Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.

Abstract

BACKGROUND:

Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood.

METHODS:

A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as


well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years).

RESULTS:

Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant).

CONCLUSION:

A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.



PMCID:PMC3242852[Available on 2013/1/1]

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12.Ann Vasc Surg. 2012 Jan;26(1):25-33. doi: 10.1016/j.avsg.2011.05.028. Epub 2011 Sep 23.

Endovascular procedures in patients with Ehlers-Danlos syndrome: a review of clinical outcomes and iatrogenic complications.

Lum YW, Brooke BS, Arnaoutakis GJ, Williams TK, Black JH 3rd.

Source

Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287-8611, USA.

Abstract

BACKGROUND:


Ehlers-Danlos syndrome (EDS) is a hereditary connective tissue disorder caused by mutations in genes involved with collagen matrix formation that results in weakened blood vessels. Endovascular therapy on patients with EDS is fraught with concerns of vessel dissection and access site complications. We describe the technical and clinical outcomes of patients with EDS who have undergone a range of endovascular procedures.

METHODS:

Patients with EDS undergoing endovascular procedures at a single-institution academic center between 1994 and 2010 were retrospectively reviewed. Perioperative data, including details of the procedure, hospital course, complications, and in-hospital mortality, were evaluated using nonparametric tests.

RESULTS:

In all, 26 patients (8 with classic EDS, 15 with hypermobile EDS, and 3 with vascular EDS) who underwent 48 endovascular procedures (5 diagnostic, 43 interventional; 13 arterial, 35 venous) were identified. The indications for endovascular therapy included pelvic venous varices, visceral aneurysms/pseudoaneurysms, visceral/peripheral occlusive disease, coronary artery disease, and others. Median length of hospital stay was 2 days (range: 0-21 days). The rate of perioperative vascular injury and access site complications was low (2%), and it was not found to be associated with the type of vascular access technique, arterial versus venous procedures, target vessel site, sheath size, or method of closure (all: p > 0.1). Median follow-up period was 7.5 years. There were no late complications from the initial endovascular procedure.

CONCLUSIONS:

Certain endovascular procedures for patients with EDS can be safely performed with a low rate of dissections and access site complications. However, some indications (particularly aortic interventions) still remain to be determined.



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13.Ann Vasc Surg. 2012 Jan;26(1):110-24. doi: 10.1016/j.avsg.2011.05.017. Epub 2011 Sep 15.

Endovascular management of acute limb ischemia.

Hynes BG, Margey RJ, Ruggiero N 2nd, Kiernan TJ, Rosenfield K, Jaff MR.

Source


Section of Vascular Medicine and Intervention, Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA.

Abstract

Despite major advances in pharmacologic and endovascular therapies, acute limb ischemia (ALI) continues to result in significant morbidity and mortality. The incidence of ALI may be as high as 13-17 cases per 100,000 people per year, with mortality rates approaching 18% in some series. This review will address the contemporary endovascular management of ALI encompassing pharmacologic and percutaneous interventional treatment strategies.



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14.Ann Vasc Surg. 2012 Jan;26(1):18-24. doi: 10.1016/j.avsg.2011.05.026. Epub 2011 Aug 31.

Massive and submassive pulmonary embolism: experience with an algorithm for catheter-directed mechanical thrombectomy.

Nassiri N, Jain A, McPhee D, Mina B, Rosen RJ, Giangola G, Carroccio A, Green RM.

Source

Department of Surgery, Division of Vascular & Endovascular Surgery, The Heart & Vascular Institute of New York, Lenox Hill Hospital, New York, NY 10075, USA. [email protected]

Abstract

BACKGROUND:

The role of catheter-directed mechanical thrombectomy (CDMT) for the treatment of massive pulmonary embolism (MPE) and submassive pulmonary embolism (SMPE) is not clearly defined. We report our experience with an algorithm for CDMT as a primary treatment in patients with MPE and SMPE.

METHODS:

We retrospectively reviewed our experience in treating MPE and SMPE in consecutive patients over a 2-year period (2008-2010). Patients with computed tomography


angiography evidence of saddle, main branch, or ≥2 lobar pulmonary emboli in the setting of hypoxia, tachycardia, echocardiographic right heart strain, and/or cardiogenic shock underwent AngioJet CDMT, with or without adjunctive thrombolytic power-pulse spray. Outcomes, including angiographic success, clinical improvement, complications, and survival to discharge, were evaluated.

RESULTS:

Fifteen patients (8 men, 7 women; 14 SMPE, 1 SMPE) with a mean age of 59 years (range: 35-90 years) were treated for heart strain (100%), tachycardia (67%), hypoxia (67%), and cardiogenic shock (7%). Ten patients (67%) also received Alteplase power-pulse spray. Resolution of symptoms and improvement in heart strain were achieved in all patients. There were no in-hospital mortalities. Complications occurred in 3 patients (20%), including 2 patients with acute tubular necrosis and 1 patient with an intraoperative cardiac arrest. Average hospitalization was 9 days (range: 4-26 days). All patients were discharged on full anticoagulation. None required supplemental oxygen at discharge.

CONCLUSION:

CDMT as primary treatment of MPE and SMPE has a high rate of technical and clinical success in a high-risk patient population. Experience and strict patient selection criteria may improve therapeutic outcomes.


Comment in

Thrombolytic treatment of pulmonary embolism via catheter. [Ann Vasc Surg. 2012]


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15.Ann Vasc Surg. 2012 Jan;26(1):1-9. doi: 10.1016/j.avsg.2011.04.003. Epub 2011 Jul 20.

Recruiting strategies for potential 0+5 vascular residency applicants.

Illig KA, Kalata E, Reed A, Glass C, Gillespie DL.

Source

Department of Surgery, Division of Vascular Surgery, The University of Rochester Medical Center, Rochester, NY 14642, USA. [email protected]


Abstract

BACKGROUND:

The 0+5 integrated vascular residency training pathway was established in 2006 to allow for trainee-focused training culminating in vascular surgery certification only. An early concern was whether enough medical students could be recruited directly into a vascular internship without the exposure that a general surgery residency provides. We hypothesized that programs that send a large percentage of their general surgical graduates to vascular fellowships have models that can be adapted to medical student recruitment.

METHODS:

Opinions and practices were sought from program directors through survey and from trainees taking the Vascular Surgery In-Training Examination.

RESULTS:

Eight programs were identified that sent 20% or more of their residents to vascular fellowships over the past 5 years (projecting a mean of 1.6 residents entering vascular fellowships in 2011). Almost all such programs have a formal mentoring system in place that match mentors to residents by interest, and almost all send residents to academic meetings before their senior year. Seventy-five percent of such programs have formal vascular lecture exposure to the first and second year medical student classes, offer clinical shadowing experiences, and have time on the vascular service during the MS3 clerkship; 83% offer a third- or fourth-year elective in vascular surgery. Vascular Surgery In-Training Examination responses were collected from 156 fellows and 13 "0+5" residents. Although fellows had initially been attracted to vascular surgery by the technical aspects of the field learned during residency (43%), the most important factor initially attracting medical students was an interested mentor (46%). However, the most important factor for both residents and students in making a final decision was the technical aspects of the field (66% and 63%, respectively).

CONCLUSIONS:

Although residents are automatically exposed to the field during residency, students can only be exposed to vascular surgery if a conscious effort is made by interested educators. Programs that send a high proportion of students and residents into vascular surgery tend to have planned exposure at the MS1 and MS2 levels, formal clinical rotations in place at the MS3 and MS4 levels, and pay personal attention to those who display interest. A guide is presented to help specifically plan these steps. Successful recruiting of students into a 0+5 integrated training program requires specific planning and action.



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16.Ann Vasc Surg. 2012 Jan;26(1):125-40. doi: 10.1016/j.avsg.2011.02.025. Epub 2011 May 31.

Open and endovascular management of concomitant severe carotid and coronary artery disease: tabular review of the literature .

Venkatachalam S, Gray BH, Shishehbor MH.

Source

Department of Medicine, Cleveland Clinic, Cleveland, OH 44195, USA.


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Ann Vasc surg 2012; 26(1)Case Reports

1.Ann Vasc Surg. 2012 Jan;26(1):109.e7-11. doi: 10.1016/j.avsg.2011.07.015.

Resection of intracaval leiomyomatosis using abdominal approach and venovenous bypass.

Schindler N, Babrowski T, DeSai T, Alexander JC.

Source

NorthShore University HealthSystem and University of Chicago Pritzker School of Medicine, Department of Surgery, Skokie, IL 60077, USA. [email protected]

Abstract

BACKGROUND:

Intravenous leiomyomatosis is the venous involvement of a histologically benign uterine tumor. This uncommon tumor can present contemporaneously with the primary uterine tumor or in a delayed fashion. Tumor extends up the venous system, via the iliac or ovarian veins, and can involve portions or all of the inferior vena cava and can extend into the heart as well. Complete resection of this tumor is the therapeutic goal. Previous reports have described the use of combined thoracic and abdominal approaches, cardiopulmonary bypass, circulatory arrest, and a single report of an entirely abdominal approach to resection without bypass.

METHODS AND RESULTS:

We present a review of the existing literature describing surgical intervention for intravenous leiomyomatosis and describe two cases of tumor extending up the intra-abdominal vena cava. Using venovenous bypass without need for thoracotomy, we were able to resect both tumors with minimal blood loss and no hemodynamic instability.

CONCLUSIONS:

We suggest that venovenous bypass is an excellent tool in resection of these tumors and should be considered for many cases in lieu of full cardiopulmonary bypass or circulatory arrest.


PMID:22176883

[PubMed - indexed for MEDLINE] Related citations


Preservation of hypogastric artery blood flow during endovascular aneurysm repair of an abdominal aortic aneurysm with bilateral common and internal iliac artery involvement: utilization of off-the-shelf stent-graft components.

Riesenman PJ, Ricotta JJ 2nd, Veeraswamy RK.

Source

Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, GA 30322, USA.

Abstract

A 72-year-old male presented with a 7.4-cm abdominal aortic aneurysm with bilateral common and internal iliac involvement. To maintain pelvic perfusion, preservation of the patient's left hypogastric artery (HA) was pursued. Two weeks after right HA embolization, endovascular repair of the patient's aneurysms was performed using a branched endograft approach. A 22-mm main body bifurcated endograft was unsheathed and the proximal covered stent was removed. The contralateral gate was preloaded with a wire and catheter. The device was resheathed and placed in the left common iliac artery. The preloaded wire in the contralateral gate was snared from the right side, establishing through-and-through femoral access. A contralateral femoral sheath was advanced up and over the aortic bifurcation from the right side into the contralateral gate of the bifurcated endograft. The repair was bridged to the left HA using a balloon-expandable stent-graft, followed by standard endovascular abdominal aortic aneurysm repair. Completion angiography demonstrated exclusion of patient's aneurysms, without evidence of endoleak, and maintenance of pelvic blood flow through the left HA. The patient recovered without complication and was discharged home on postoperative day 4. This technique illustrates the technical feasibility of using a preloaded commercially available endograft to preserve HA blood flow and maintain pelvic perfusion during endovascular aortic aneurysm repair.



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Chronic mesenteric ischemia in a 26-year-old man: multivessel median arcuate ligament compression syndrome.

Doyle AJ, Chandra A.

Source

Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA.

Abstract

BACKGROUND:

Chronic mesenteric ischemia (CMI) is a rare diagnosis for patients in their third decade of life. Other conditions can mimic the signs and symptoms of CMI, including median arcuate ligament syndrome (MALS), primary arteritides, and congenital anomalies. Here, we present the case of a 26-year-old man who presented with CMI and multivessel mesenteric occlusive disease.

METHODS:

A 26-year-old man presented with a 6-month history of 40-pound weight loss, postprandial abdominal pain, and food fear. His physical examination showed a scaphoid abdomen with no tenderness. Findings from laboratory evaluation were normal. Computed tomography angiogram revealed celiac artery (CA) occlusion and >80% superior mesenteric artery (SMA) stenosis, with a large marginal artery of Drummond supplying collateral circulation.

RESULTS:

A retroperitoneal exposure of the perivisceral aorta was performed. Surgical exposure revealed compression of both CA and SMA by the MAL. The total distance of caudal arterial displacement was >3 cm. Both the CA and SMA were chronically stenotic/occluded secondary to this compression. After division of the MAL, a retrograde aortoceliac and aortomesenteric bypass was performed for mesenteric revascularization. The patient recovered uneventfully and was discharged home on the third day after surgery tolerating a full diet.

CONCLUSIONS:

MALS is a pathologic entity that can affect more than the CA. This case demonstrates multivessel, mesenteric arterial insufficiency secondary to MALS sufficient to promote IMA collateralization of the SMA circulation. In young patients with CMI, multivessel MALS must be considered. In addition to MAL release, arterial revascularization may be necessary owing to stenoses from chronic compression.



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4.Ann Vasc Surg. 2012 Jan;26(1):108.e1-4. doi: 10.1016/j.avsg.2011.07.004. Epub 2011 Sep 23.

Contained ruptured paravisceral aortic aneurysm related to immunoglobulin G4 aortitis.

Trinidad-Hernandez M, Duncan AA.

Source

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN 55906, USA. [email protected]

Abstract

BACKGROUND:

To describe a case of autoimmune inflammatory abdominal aortic aneurysm (AAA) associated with rupture.

METHODS:

A 63-year-old woman presented with 5 days of abdominal pain, malaise, fever, and chills after 6 months of debilitating back pain with a 3-kg weight loss. On examination, she was shown to have a tender palpable pulsatile abdominal mass. Computed tomographic angiography revealed a multilobulated paravisceral AAA (5.5 cm in maximal diameter) and bilateral popliteal aneurysms. The appearance of the aneurysms was indicative of primary aortic infection. Laboratory examinations demonstrated a white blood cell (WBC) count of 12.3×10(9)/L, erythrocyte sedimentation rate of 131 mm/hr, normal antinuclear antibody level, and C-reactive protein level of 211 mg/L. Nuclear WBC scan showed no uptake of tracer around the aorta. Blood and urine cultures were negative. Because of the AAA size and symptoms, open repair was expedited. The operation was performed through a transabdominal midline incision with a mediovisceral rotation. Extensive retroperitoneal inflammation extending into the paravisceral aorta was encountered. Supraceliac clamping was possible. The aorta was replaced from the level of the superior mesenteric artery to the aortic bifurcation with a 16-mm rifampin-soaked graft with reimplantation of the left renal artery. Cultures and biopsies were done.

RESULTS:

Histology demonstrated vessel wall rupture, adventitial fibrosis and inflammatory cell infiltration, obliterative phlebitis, lymphoid follicles, perineural inflammation, and immunoglobulin G4 (IgG4) plasma cell infiltration, consistent with a contained ruptured


aneurysm associated with IgG4 periaortitis. The patient had a long postoperative course with prolonged intubation and renal failure requiring hemodialysis, which resolved 8 weeks postoperatively. Immunosuppression was paramount for her improvement.

CONCLUSION:

IgG4-related inflammatory AAAs are rare; this is the first report of one with a contained rupture. The patient's symptoms, the unusual appearance on computed tomography, the presence of popliteal aneurysms in a woman, and the normal WBC scan were indicative of an inflammatory etiology. Tissue biopsy was critical to obtain histological diagnosis and direct treatment.



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5.Ann Vasc Surg. 2012 Jan;26(1):107.e1-4. doi: 10.1016/j.avsg.2011.05.027. Epub 2011 Aug 26.

Duodenal obstruction from mesenteric stents mimicking SMA syndrome.

Lum YW, Bone C, McKown J, Black JH 3rd.

Source

Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, Baltimore, Maryland 21287-8611, USA.

Abstract

BACKGROUND:

Superior mesenteric artery (SMA) syndrome is a rare condition, which results in compression of the third portion of the duodenum by a narrow-angled SMA against the aorta. We report a case of a patient treated for chronic mesenteric ischemia, who developed an SMA-like syndrome as a result of the compression of the duodenum between an SMA stent and an inferior mesenteric artery (IMA) stent.


A 44-year-old woman with chronic mesenteric ischemia had previously been treated with multiple endovascular stents. She re-presented with persistent abdominal pain and weight loss. Findings from the angiogram performed revealed an occluded celiac artery


and an SMA. Mesenteric perfusion was maintained by the IMA with poor collateralization to the celiac circulation. At the time of surgical exploration, there were no suitable target sites for a traditional aortomesenteric bypass because of the extensive length of prior stenting. A renohepatic bypass with reversed saphenous vein was performed to improve the celiac circulation. Postoperatively, she continued to have persistent abdominal pain associated with nausea and vomiting. An upper gastrointestinal study was performed that revealed severe partial obstruction of the third portion of her duodenum. On re-reviewing her preoperative computed tomography scan of the abdomen, it was more apparent that the duodenum was constricted between the SMA and IMA stents that had been previously placed. She underwent re-exploration, and a side-to-side duodenojejunostomy was performed. Subsequent study of the upper gastrointestinal showed resolution of the obstruction.

CONCLUSION:

To our knowledge, this is the first report of duodenal obstruction caused as a result of the complications caused by multiple stent placements, which gave an impression of SMA-like syndrome.



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6.Ann Vasc Surg. 2012 Jan;26(1):107.e5-10. doi: 10.1016/j.avsg.2011.06.005. Epub 2011 Aug 11.

Endovascular repair of bilateral iliac artery aneurysms in a patient with Loeys-Dietz syndrome.

Casey K, Zayed M, Greenberg JI, Dalman RL, Lee JT.

Source

Division of Vascular and Endovascular Surgery, Stanford University Medical Center, Stanford, CA 94305, USA.

Abstract

BACKGROUND:

Loeys-Dietz syndrome (LDS) is a rare congenital connective tissue disorder (CTD) caused by mutations in the gene encoding for transforming growth factor-β receptors I and II. This recently described syndrome is characterized by aortic aneurysms and dissections, arterial tortuosity, and spontaneous organ perforation. The technical


feasibility of endovascular interventions, particularly endovascular aneurysm repair (EVAR), in CTDs is relatively unknown.


A 38-year-old man presented with asymptomatic bilateral common iliac artery aneurysms measuring 5.3 cm on the right and 4.3 cm on the left. The patient had an extensive surgical and medical history, including a recently repaired Stanford type-A aortic dissection, total colectomy with end ileostomy for a colonic perforation, splenectomy for rupture, and cirrhosis secondary to chronic hepatitis C. The patient's CTD, multiple abdominal surgeries performed in the past, and ileostomy made him a poor candidate for open repair. We elected to offer him a complex endovascular repair and hoped to preserve his pelvic circulation by using "double-barrel" configuration of stent-grafts in the right iliac artery system. Successful deployment of the devices and repair of femoral access allowed routine discharge on postoperative day 2. At 6-month follow-up, the patient's pelvic circulation has been maintained, the aneurysms are excluded without endoleak, and sac regression has been shown.

CONCLUSION:

LDS is a rare connective tissue disorder characterized by vascular aneurysms and arterial tortuosity. When vascular reconstruction is necessary, open techniques are often preferred given the lack of data on endovascular procedures. In the present case, we report the first successful abdominal EVAR in a high-risk patient with LDS, providing excellent short-term results.



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