An Analysis of Cost-Effectiveness and Clinical Outcomes of a Comprehensive Aortic Service in a Tertiary Center over One Year.

BACKGROUND: Endovascular aortic repair (EVAR) is an established and attractive alternative to open surgical repair (OSR) of abdominal aortic aneurysms (AAA) due to its superior short-term safety profile. However, opinions are divided regarding its long-term cost-effectiveness. We compared the total yearly cost of running endovascular and OSR services in a single tertiary center to determine whether fenestrated EVAR (FEVAR) represents a clinically efficacious, affordable treatment option. METHODS: A single-center retrospective review was performed on 109 patients undergoing a procedure related to index or previous abdominal aortic repair, with 1 year follow-up. Data was collected from the National Vascular Registry and hospital records. The primary outcome was cost per quality-adjusted life year. Secondary outcomes included 30-day mortality and morbidity, reintervention rates, length of hospital stay, aneurysm, and all-cause mortality at 1 year for elective index procedures. RESULTS: The average cost per patient of all FEVAR was £16,041.53 (±8,857.54), £13,893.51 (±£21,425.25) for standard EVAR, and £15,357.22 (±£15,904.49) for OSR (FEVAR versus EVAR P = 0.55, FEVAR versus OSR P = 0.83, OSR versus EVAR P = 0.76). Of the secondary outcomes, significant findings included increased length of stay and respiratory morbidity for patients undergoing open versus endovascular repair. There was no significant difference in 30-day or 1-year mortality between groups. CONCLUSIONS: FEVAR, EVAR, and OSR all represent cost-effective options for aortic repair with similar outcomes. Our data highlights the potential for FEVAR to present a viable alternative to open repair, particularly in higher-risk groups, when performed in specialist centers.

Ten-year single-centre experience with type II endoleaks: Intervention versus observation.

Our objective was to determine the relative merits of intervention or observation of type II endoleaks (T2Ls). A retrospective analysis was performed on 386 infra-renal endovascular aneurysm repair (IR-EVAR) patients from 2006 to 2015. Annual surveillance imaging of patients undergoing EVAR at our centre were analysed, and all endoleaks were subjected to a multidisciplinary team meeting for consideration and treatment. In the 10-year time frame, 386 patients (79.5±8.7 years) underwent an IR-EVAR. Eighty-one patients (21.0%) developed a T2L and intervention was undertaken in 28 (34.6%): 17 (60.7%) were treated via a transarterial approach (TA) and 11 (39.3%) using the translumbar approach (TL). Fifty-three patients (65.4%) with T2Ls were managed conservatively. Patients who received T2L treatment had a greater proportion of recurrent T2Ls than patients who were conservatively managed ( p=0.032). T2Ls associated with aneurysmal growth were more resistant to treatment than those where there was no change or a decrease in aneurysm size during follow-up (0.033). There was no significant difference in the TA and TL approach with respect to endoleak repair success ( p=0.525). Treatment of a T2L did not confer a survival advantage compared to conservative management ( p=0.449) nor did the choice of either the TA or TL approach ( p=0.148). Our study suggests the development of a T2L associated with aneurysm growth may represent an aggressive phenotype that is resistant to treatment. However, this did not lead to an increased risk of mortality over follow-up. Neither a transarterial nor a translumbar approach to treating a T2L conferred superiority.

Open surgery for chronic dissection.

Chronic aortic dissection is one of the most challenging pathologies faced by aortic surgeons. The variety of presentations and the multiple comorbidities of the patients make treatment and follow-up a subject of much debate. Historical data is difficult to interpret because of the heterogeneity of the included populations, and the common tendency of authors to pool outcomes of thoracoabdominal aortic aneurysm repair secondary to degenerative pathology or connective tissue disorder with those who have an underlying dissection. As the endovascular treatment of chronic aortic dissection becomes more commonplace with the increasing use of branched and fenestrated technology, it will be important to have an historical "gold standard" to use as a comparator. This narrative review of the literature describes the challenges to interpretation of data and the available information published about chronic aortic dissection.

Retrograde Stenting Under Transmesenteric Angiographic Guidance of an Occluded Superior Mesenteric Vein to Treat Life-Threatening Hemorrhage.

Midgut carcinoid tumors (MCTs) are responsible for a range of mesenteric vascular complications and may rarely manifest with gastrointestinal (GI) hemorrhage. Endovascular approaches are particularly useful for this population, as surgery is often technically difficult. We report a case of life-threatening upper GI bleeding in a 50-year-old man previously diagnosed with an MCT in the small bowel mesentery. Computed tomography angiogram revealed an MCT obstructing the superior mesenteric vein (SMV) associated with multiple large collateral vessels. The patient underwent retrograde stenting of the obstructed SMV using a combined open and endovascular approach to successfully terminate the persistent GI bleeding.

Results of complex aortic stent grafting of abdominal aortic aneurysms stratified according to the proximal landing zone using the Society for Vascular Surgery classification.

BACKGROUND: Advances in endovascular technology have led to the successful treatment of complex abdominal aortic aneurysms. However, there is currently no consensus on what constitutes a juxtarenal, pararenal, or suprarenal aneurysm. There is emerging evidence that the extent of the aneurysm repair is associated with outcome. We compare the outcomes of 150 consecutive patients treated with a fenestrated or branched stent graft and present the data stratified according to the Society for Vascular Surgery classification based on proximal anatomic landing zones. METHODS: A prospectively collected database of consecutive patients undergoing fenestrated or branched stent graft insertion in a tertiary center between 2008 and 2013 was retrospectively analyzed. Aneurysms were subdivided into zones according to where the area of proximal seal could be achieved in relation to the visceral arteries. Zone 8 covers the renal arteries, zone 7 covers the superior mesenteric artery, and zone 6 covers the celiac axis. Patient demographics, operative variables, mortality, and major morbidity were analyzed by univariate and multivariate analysis to assess for differences between zones. RESULTS: During the study period, 150 patients were treated. There were 49 in zone 8, 76 in zone 7, and 25 in zone 6. Prior aortic surgery had been performed in 19 patients, which included 11 patients with previous endovascular aneurysm repairs. There was significantly increased blood loss (P < .001), operative time (P < .0001), total hospital stay (P = .018), and intensive care unit stay (P < .0001) as the zones ascended the aorta. There were 14 inpatient deaths recorded across all zones with a 30-day mortality rate of 8%. Logistic regression analysis for 30 day mortality showed a significant increase as the zones ascended (P = .007). Kaplan-Meier analysis showed that 5-year survival significantly deteriorated as the zones ascended (P = .039), with no significant difference in the freedom from reintervention curves between zones (P = .37). CONCLUSIONS: We have shown that the extent of the aneurysm repair as determined by the proximal sealing zone is associated with outcome. Mortality, operative duration, blood loss, and hospital stay all significantly increased as the zones ascended. These data also validate the use of the proposed new classification based on aortic anatomy.

Best evidence for medical therapy for carotid artery stenosis.

Carotid atheromatous disease is an important cause of stroke and represents a key target in stroke prevention. Randomized trials have shown the efficacy of carotid endarterectomy in secondary stroke prevention. Carotid stenting presents a less invasive alternative to surgical intervention. Advances in medical management, if compliance can be ensured, are leading to improvement in outcomes when implemented as sole therapy in the treatment of atherosclerotic carotid stenosis. This includes lifestyle modification, blood pressure control, and antiplatelet and statin therapy. Over the last 20 years, the annual rate of ipsilateral stroke associated with asymptomatic carotid stenosis has decreased from 2% to 4% to less than 1%. This is largely due to improvements in medical therapy. However, despite numerous trials and years of clinical research, the optimal management of symptomatic and asymptomatic carotid disease remains controversial. This article presents and summarizes the evidence supporting best medical treatment for carotid artery stenosis.

Temporary axillobifemoral bypass during fenestrated aortic aneurysm repair.

OBJECTIVE: Fenestrated endovascular aortic aneurysm repair (f-EVAR) of juxtarenal aneurysms requiring cannulation of the superior mesenteric artery and renal arteries is technically challenging, has a long operating time, and requires bilateral large-caliber sheath insertion into the femoral arteries. Consequently, the risk of lower limb ischemia and subsequent reperfusion injury is increased. We describe the use of an adjunct temporary axillobifemoral bypass graft (TABFBG) for f-EVAR and propose that it be used as a strategy to avoid ischemia-reperfusion injury in patients anticipated as being at increased risk. METHODS: Consecutive patients from a tertiary referral center undergoing f-EVAR, between October 2008 and August 2011, were retrospectively analyzed. Patients with lower limb arterial occlusive disease and those with difficult anatomy had an adjunct TABFBG. RESULTS: All patients presenting with a juxtarenal aortic aneurysm were treated endovascularly, regardless of aneurysm anatomy and technical difficulties. There were 37 patients without TABFBG (group 1) and 27 with TABFBG (group 2). No patients required open conversion. Sex and age were not significantly different between the groups. The median ankle-brachial pressure index was significantly higher in group 1 (P=.0001). The groups had similar median blood loss, percentage of target vessel cannulation, and median stay in the intensive therapy unit. Morbidities were similar in both groups. There were no significant differences in cardiac, renal, or respiratory complications between the groups. The 30-day mortality was 10.8% (n=4) in group 1 and 0% in group 2 (P=.046). CONCLUSIONS: Our series has demonstrated a significant reduction in mortality (10.8% absolute risk reduction) and no increase in morbidity with the use of a TABFBG for fenestrated grafts. This is likely a result of the reduction in ischemia and ischemia-reperfusion injury in these patients. We therefore recommend the use of TABFBG in patients with proximal severe stenotic or occlusive disease and those in whom an operative time of >4 hours is predicted (typically those for whom three or more target fenestrations is planned).

Mycotic internal carotid artery pseudoaneurysm secondary to Mycobacterium tuberculosis.

Mycobacterium tuberculosis is a rare causative agent for mycotic aneurysms of the extracranial carotid arteries. We describe a case of acute mycotic pseudoaneurysm and abscess in the right proximal internal carotid artery in close proximity to the carotid bifurcation, and subsequent management with antibiotic therapy, surgical debridement and resection with an end-to-end anastomosis.

A patient-specific multi-modality abdominal aortic aneurysm imaging phantom.

PURPOSE: Multimodality imaging of the vascular system is a rapidly growing area of innovation and research, which is increasing with awareness of the dangers of ionizing radiation. Phantom models that are applicable across multiple imaging modalities facilitate testing and comparisons in pre-clinical studies of new devices. Additionally, phantom models are of benefit to surgical trainees for gaining experience with new techniques. We propose a temperature-stable, high-fidelity method for creating complex abdominal aortic aneurysm phantoms that are compatible with both radiation-based, and ultrasound-based imaging modalities, using low cost materials. METHODS: Volumetric CT data of an abdominal aortic aneurysm were acquired. Regions of interest were segmented to form a model compatible with 3D printing. The novel phantom fabrication method comprised a hybrid approach of using 3D printing of water-soluble materials to create wall-less, patient-derived vascular structures embedded within tailored tissue-mimicking materials to create realistic surrounding tissues. A non-soluble 3-D printed spine was included to provide a radiological landmark. RESULTS: The phantom was found to provide realistic appearances with intravascular ultrasound, computed tomography and transcutaneous ultrasound. Furthermore, the utility of this phantom as a training model was demonstrated during a simulated endovascular aneurysm repair procedure with image fusion. CONCLUSION: With the hybrid fabrication method demonstrated here, complex multimodality imaging patient-derived vascular phantoms can be successfully fabricated. These have potential roles in the benchtop development of emerging imaging technologies, refinement of novel minimally invasive surgical techniques and as clinical training tools.

Plexin-B1 mutations in prostate cancer.

Semaphorins are a large class of secreted or membrane-associated proteins that act as chemotactic cues for cell movement via their transmembrane receptors, plexins. We hypothesized that the function of the semaphorin signaling pathway in the control of cell migration could be harnessed by cancer cells during invasion and metastasis. We now report 13 somatic missense mutations in the cytoplasmic domain of the Plexin-B1 gene. Mutations were found in 89% (8 of 9) of prostate cancer bone metastases, in 41% (7 of 17) of lymph node metastases, and in 46% (41 of 89) of primary cancers. Forty percent of prostate cancers contained the same mutation. Overexpression of the Plexin-B1 protein was found in the majority of primary tumors. The mutations hinder Rac and R-Ras binding and R-RasGAP activity, resulting in an increase in cell motility, invasion, adhesion, and lamellipodia extension. These results identify a key role for Plexin-B1 and the semaphorin signaling pathway it mediates in prostate cancer.

Temporary Perfusion Branches to Decrease Spinal Cord Ischemia in the Endovascular Treatment of Thoraco-Abdominal Aortic Aneurysms: Based on a Presentation at the 2013 VEITH Symposium, November 19-23, 2013 (New York, NY, USA).

BACKGROUND: Spinal cord ischemia (SCI) is one of the most feared complications following the repair of thoraco- abdominal aortic aneurysms (TAAA). Endovascular repair of TAAA is now possible with branched stent grafts, but spinal cord ischaemia rates are still unacceptably high. A number of techniques have been utilized to reduce these levels, however, SCI remains a challenge to endovascular repair of TAAA. The use of sac perfusion branches aims to reduce the incidence of this catastrophic complication. METHODS: A retrospective analysis of all patients undergoing branched endovascular aortic repair for all thoraco-abdominal aneurysms (TAAA) using custom made devices during January 2008 to August 2014. We describe a two staged technique in which perfusion of segmental vessels is maintained by a temporary endoleak through an open perfusion branch, incorporated within the branched stent graft, followed by a closure of this branch at a later date to complete exclusion of the aneurysm. RESULTS: Forty-seven patients underwent TAAA repair. Twenty-five (53%) had a two-stage procedure using either a sac perfusion branch or a target vessel to perfuse the sac. Nine patients (19.15%) suffered some form of SCI with eight patients having temporary SCI (lasting less than 72 hours) and one patient having permanent SCI. Of eight patients that had temporary spinal cord ischemia, all had a perfusion strategy. There was one case of permanent SCI (2.13%). CONCLUSION: Sac perfusion branches provide a safe method for preventing SCI, however this needs to be used in conjunction with controlling MAP and CSF drainage.

Successful stent graft repair of multiple thoracoabdominal mycotic aortic aneurysms in the presence of Kommerell diverticulum and complicated by aortoesophageal fistula.

We describe the management of a woman who presented with synchronous mycotic aortic aneurysms of the aortic arch in the presence of Kommerell diverticulum, the distal thoracic, and the juxtarenal aorta. A staged stent graft repair was undertaken due to rapid expansion of the aneurysms, which involved placement of multiple thoracic quadruple-fenestrated and infrarenal bifurcated stent grafts. Despite complications of an aortoesophageal fistula and transitory spinal cord ischemia, she has been managed successfully and is doing well at 36 months. This case illustrates that stent graft repair of mycotic aneurysms can offer a successful treatment option in selected patients.

A rare and potentially fatal cause of popliteal fossa swelling.

Popliteal vein aneurysms (PVAs) represent a rare form of venous aneurysm and necessitate prompt diagnosis and management due to their well-established role as a source of pulmonary emboli. Surgical repair is usually curative; we present the case of a 47-year-old woman with a recurrent PVA presenting as a soft popliteal fossa mass with associated sensory deficit affecting the right foot, 4 years after initial operative repair. Venous duplex imaging demonstrated a saccular aneurysm originating from the posterior wall of the right popliteal vein. In light of the long-term risk of potentially life-threatening pulmonary embolism, surgical repair was undertaken by tangential aneurysmectomy and long saphenous vein patch venoplasty. This case emphasises the importance of including PVA in the differential diagnosis of popliteal fossa swellings as well as the need for long-term follow-up to detect late recurrence with subsequent avoidance of the otherwise significant potential morbidity and mortality.

A new technique of branched stent graft treatment for ruptured thoracoabdominal aortic aneurysms.

Endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) using a branched stent graft is a technically challenging procedure. A 64-year-old man with multiple medical problems, including severe renal impairment, is presented with a ruptured type IV TAAA. He underwent emergency repair using an off-the-shelf branched stent graft and carbon dioxide as the exclusive contrast agent.

Paget-Schroetter syndrome: the importance of urgent referral and appropriate management.

The authors present the case of a young healthy male who was admitted with a case of acute primary subclavian vein thrombosis, otherwise known as Paget-Schroetter syndrome. The patient was successfully treated by catheter directed thrombolysis using a Trellis device and thoracic outlet decompression following prompt referral to the vascular team. The case highlights importance of early referral in the prevention of the long-term sequelae which can occur as a result of this rare condition.