Optimizing the diagnostic approach of functional popliteal artery entrapment syndrome.

OBJECTIVE: Functional popliteal artery entrapment syndrome (fPAES) is an underdiagnosed and undertreated etiology of atypical claudication. Symptoms of fPAES include deep posterior muscle cramping and pain with exercise and, unlike anatomic PAES, there are seldom vascular complications. Common noninvasive diagnostic modalities include ankle-brachial index, arterial duplex Doppler ultrasound (DUS) examination, and cross-sectional imaging such as magnetic resonance angiography (MRA). Entrapment can be difficult to reproduce during diagnostic testing, requiring provocative maneuvers. Because we believed different provocative maneuvers provide different diagnostic efficacy, we sought to optimize our diagnostic approach to fPAES. METHODS: We performed a retrospective review of patients before and after optimizing our noninvasive imaging protocol comparing patients with fPAES versus other atypical claudicants with chronic compartment syndrome. RESULTS: Arterial DUS examination and exercise ankle-brachial index were important components of our protocol with a significant decrease in systolic posterior tibial blood pressure of -14 mm Hg after exercise, whereas nonentrapment release patients had an overall increase of 8 mm Hg (P = .006). Arterial DUS examination of the distal PA with forced plantarflexion demonstrated a trend toward an increase in the measured velocity ratio, especially in the middle and distal PA. MRA with stressed plantar flexion findings were positive in 6 of 11 patients with fPAES, with false negatives likely owing to patients' inability to maintain a provocative position for the duration of the MRA. CONCLUSIONS: Diagnosing fPAES is challenging owing to a lack of standardized diagnostic testing and provocative maneuvers. Different maneuvers demonstrated varying diagnostic yields for fPAES. Exercise ABIs were the most reliable vascular laboratory test to detect changes attributable to fPAES and to distinguish it from chronic compartment syndrome. Segmental PA DUS examination seems to be promising as a means of detecting PA impingement. Stress positional MRA effectively demonstrates anatomic PAES, but has a false-negative rate for fPAES.

Chronic compartment syndrome secondary to venous hypertension: fasciectomy for symptom relief.

Chronic compartment syndrome (CCS) from venous hypertension following lower leg deep venous thrombosis or severe venous insufficiency is rare and often difficult to diagnose. Although ileocaval stenting and thrombolysis have improved claudication symptoms related to outflow venous disease, chronic calf claudication from distal vein thrombosis and venous insufficiency have historically been managed with rest, compression, and elevation. Often, conservative options give inadequate symptom relief and active individuals are rarely compliant. We report the presentation, workup, and treatment with fasciectomy for lower leg CCS secondary to venous hypertension. Fasciotomy and fasciectomy have been used for atypical claudication secondary to classic overuse CCS with symptom relief for many individuals. This case illustrates the recognition of claudication induced by CCS secondary to venous insufficiency and an approach to treatment with fasciectomy with a promising outcome.

The social media: its impact on a vascular surgery practice.

OBJECTIVES: Social media has revolutionized interpersonal communication and has become a commonly used public informational resource. This study evaluates the impact of intranet informatics on a specialty practice of vascular surgery. METHODS: Referral patterns for patients with chronic compartment syndrome (CCS) and popliteal entrapment syndrome (PAES) between 2008 and 2011 were analyzed. Demographics included referral source (physicians, nonphysicians), media resource, and case volume change. RESULTS: Prior to 2008, referrals came from local or regional sports medicine practices (100%). Since 2008 this pattern has changed; local/regional (80%), national (15%), and international (5%). Physician referrals dropped from 97% to 70%, and nonphysician referrals increased from 3% to 30%. Both CCS procedures and PAES procedures increased as remote geographic and public referrals increased. Referral change was associated with social media searches using applications such as PubMed and Google. CONCLUSION: Social media is an evolving source of medical information and patient referrals which physicians should cautiously embrace.

Foot claudication with plantar flexion as a result of dorsalis pedis artery impingement in an Irish dancer.

Dorsalis pedis artery impingement is an extremely rare cause of foot claudication, with a single case reported in the literature. In this report, we describe the case of a 17-year-old female Irish dancer who presented with intermittent bilateral foot pain and discoloration during active plantar flexion.

Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm.

BACKGROUND: The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA). METHODS: A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage (≥10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis. RESULTS: One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P < .03) for patients transfused at a PRBC:FFP ratio ≤2:1 (HIGH FFP group) compared with those transfused at a ratio of >2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2-14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004). CONCLUSION: For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients.

Impact of intraoperative arteriography on limb salvage for traumatic popliteal artery injury.

BACKGROUND: Time to revascularization is speculated to be a major determinant of limb salvage for traumatic popliteal injuries. The purpose of this study was to determine whether location of diagnostic arteriography affected outcome. METHODS: From 1996 to 2006, patients with popliteal injuries were identified from our trauma database. Additional data were extracted from chart review. Amputation rates for those undergoing arteriography performed in radiology (ARAD) versus the operating room (AOR) were compared. RESULTS: In 35 patients 36 limbs were treated, with 94% resulting from blunt mechanisms. The mean age was 37 years (11-69 years), 81% were men, and the mean Injury Severity Score was 15. The average mangled extremity severity scores (MESS) was 6 +/- 2. Follow-up was available in 97% patients with a median of 14 months. Overall amputation rate was 16.7% (6 of 36). Extremities with MESS <8 had 93% limb salvage, and MESS > or =8 had 55% limb salvage. ARAD (n = 10) and AOR (n = 15) groups were equivalent with regard to age, mechanism, Injury Severity Score, MESS, time to presentation, associated injuries, and fasciotomy rate. The median time from emergency room arrival to operating room was shorter (125 minutes vs. 214 minutes; p < 0.05) and salvage rate was higher (100% vs. 70%; p = 0.05) in the AOR group compared with the ARAD group. CONCLUSION: For popliteal artery injuries, diagnostic arteriography in the operating room reduces the likelihood of amputation by decreasing time to initiating repair and thereby limiting limb ischemia. Salvage is possible in the most severely injured extremities with rapid transport to the operating room.

Functional popliteal artery entrapment syndrome: A poorly understood and often missed diagnosis that is frequently mistreated.

OBJECTIVES: Functional popliteal artery entrapment syndrome (FPAES) is an uncommon overuse injury in young physically active adults manifest by neuromuscular symptoms (gastroc/soleus cramping, plantar paresthesias). It is commonly confused with chronic recurrent exertional compartment syndrome (CRECS). This study evaluated the diagnostic testing, mechanism of injury, and treatment differences between FPAES and CRECS. METHODS: Between 1987 and 2007, 854 patients (557 women, 297 men; mean age, 28.5 years) were surgically treated for the diagnosis of CRECS or FPAES, or both. Compartment pressures were measured in all patients who had anterior lateral or posterior superficial calf symptoms (normal pressure or=25 mm Hg), and fasciectomy was performed for CRECS under local anesthesia (anterior lateral, 508; posterior superficial, 191; distal deep posterior, 101). The result of stress plethysmography was positive in 139 (18%), but they were asymptomatic. Forty-three patients (27 women, 16 men; mean age, 26.6 years) had positive stress plethysmography, appropriate FPAES symptoms, and normal compartment pressures. MRA/MRI in all 43 demonstrated normal musculotendinous anatomy and lateral neurovascular compression with plantar flexion. Under general anesthesia, all had excision of the soleal band, with relief from symptoms. In 19 of the 43 FPAES patients (44%), CRECS releases were done before or after FPAES surgery. Follow-up ranged from 12 to 240 months. CONCLUSION: FPAES and CRECS occur in the same population with similar symptoms but require different treatment.

Outcomes after endarterectomy for chronic mesenteric ischemia.

OBJECTIVES: A retrospective study was performed to identify optimal factors affecting outcomes after open revascularization for chronic mesenteric ischemia. METHODS: All patients who underwent open surgery for chronic mesenteric ischemia from 1987 to 2006 were reviewed. Patients with acute mesenteric ischemia or median arcuate ligament syndrome were excluded. Mortality, recurrent stenosis, and symptomatic recurrence were analyzed using logistic regression, and univariate and multivariate analysis. RESULTS: We identified 80 patients (69% women, 31% men). Mean age was 64 years (range, 31-86 years). Acute-on-chronic symptoms were present in 26%. Presenting symptoms included postprandial pain (91%), weight loss (69%), and food fear and diarrhea (25%). Preoperative imaging demonstrated severe (>70%) stenosis of the superior mesenteric artery in 75 patients (24 occluded), the celiac axis in 63 (20 occluded), and the inferior mesenteric artery in 53 (20 occluded). Multivessel disease was present in 72 patients (90%), and 40 (50%) underwent multivessel reconstruction. Revascularization was achieved by endarterectomy in 37 patients, mesenteric bypass in 29, and combined procedures in 14. Concurrent aortic reconstruction was required in 13 patients (16%). Three hospital deaths occurred (3.8%). Mean follow-up was 3.8 years (range, 0-17.2 years). One- and 5-year survival was 92.2% and 64.5%. Mortality was associated with age (P = .019) and renal insufficiency (P = .007), but not by clinical presentation. Symptom-free survival was 89.7% and 82.1% at 1 and 5 years, respectively. Symptoms requiring reintervention occurred in nine patients (11%) at a mean of 29 months (range, 5-127 months). Multivariate analysis showed that freedom from recurrent symptoms correlated with endarterectomy for revascularization (5.2% vs 27.6%; hazard ratio, 0.20; 95% confidence interval, 0.04-0.92; P = .02). CONCLUSION: For open surgical candidates, endarterectomy appears to provide the most durable long-term symptom relief in patients with chronic mesenteric ischemia.

Product line development: a strategy for clinical success in academic centers.

OBJECTIVE: Academic medical centers, which have traditionally been relatively inefficient, have increasing difficulty in meeting the missions of patient care, teaching, and research in a progressively competitive medical marketplace. One strategy for improved efficiency in patient care while keeping quality high is utilization of a product line matrix. This study addresses the outcome of utilizing a product line strategy consisting of 3 service lines during the past 5 years at the University of Wisconsin Hospital and Clinics (UWHC). METHODS: Service lines in heart and vascular surgery, oncology, and pediatrics have been organized since 2001, and report directly to hospital leadership as a product line. Service line leadership consists of a combination of medical leaders plus representatives of hospital administration, and service lines are allowed direct access to resources for program development, marketing, and resource allocation. Measurements of patient numbers, market share, length of stay, net margin, and patient satisfaction have been gathered and compared with the preproduct line era. RESULTS: In the 3 service lines, UWHC has seen variable but steady growth in patient numbers, enhanced market share, positive net margins, and improved patient satisfaction during the period of measurement. During this same period, the insurance milieu has resulted in consistent downward pressure on reimbursement, which has been offset by improved patient care efficiency as measured by length of stay, enhanced preferred provider status, and gains in market share. Scorecard measures of quality are also being developed and show enhanced teaching and research opportunities for students and trainees as well as improved Press Ganey patient satisfaction scores. CONCLUSIONS: At UWHC, the development of a product line matrix consisting of 3 service lines has resulted in more patient care efficiency, enhanced patient satisfaction, improved margin for the hospital, and enlargement of teaching and research opportunities. The key to successful implementation of the product line concept is a close working relationship between the hospital administration and service line medical leadership.

Effectiveness of intensive medical therapy in type B aortic dissection: a single-center experience.

OBJECTIVE: Although the mainstay of managing acute descending thoracic aortic dissection (ADTAD) remains medical, certain patients will require emergency surgery for complications of rupture or ischemia. This study evaluates factors that affect outcome and determines which patients previously treated surgically would have been eligible for endovascular repair. METHODS: A single-institution retrospective study was conducted of patients who presented with clinical signs of ADTAD that was confirmed by magnetic resonance angiography (MRA) or computed tomography (CT). All patients were admitted to the intensive care unit (ICU) and medically managed to maintain systolic blood pressure<120 mm Hg and heart rate<70 beats/min. Two treatment groups were identified: group 1 received medical treatment only; group 2 received medical treatment plus emergency surgery. Patient demographic and clinical data were correlated with 30-day group mortality and morbidity and need for emergency surgery. The MRA and CT scan images of group 2 were retrospectively reviewed to determine if currently available endovascular treatment could have been done. The Fisher exact test was used to compare between the groups, and P<.05 was considered significant. RESULTS: Between 1991 and 2005, 83 patients (55 men) were treated for ADTAD. The mean age was 67 years (range, 38 to 85). Sixty-eight patients (82%) had hypertension, three (3.6%) had Marfan syndrome, and 51 (62%) were smokers. Twenty-five (32%) of the patients were receiving beta-blocker therapy before the onset of their symptoms. Back pain was the most common initial symptom (72.2%). Emergency surgery was required in 19 patients (23%): 12 for rupture or impending rupture, four for mesenteric ischemia, and three for lower extremity ischemia. The need for emergency surgery was significantly higher in smokers (P=.03), in patients>70 years old (P=.035), and in patients who were not receiving beta-blocker therapy before the onset of symptoms (P=.023). The combined overall morbidity rate was 33%, and the mortality rate was 9.6%. Morbidity in group 2 was 64% and significantly higher than the 23% in group 1 (P=.00227). The mortality rate was also higher in group 2 at 31.5% compared with group 1 at 1.6% (P=.0004). Factors affecting the overall mortality included age>70 years (P=.057), previous abdominal aortic aneurysm repair (P=.018), tobacco use (P=.039), and the presence of leg pain at initial presentation (P=.013). As determined from the review of radiologic data, 11 of 13 patients with scans available for review in group 2 could have been treated with currently available endovascular grafts. CONCLUSIONS: Intensive medical therapies are effective in preventing early mortality associated with ADTAD. Predictably, the need for emergency surgery carries a high morbidity and mortality rate. Most patients in this series requiring emergency surgery could have been candidates for endovascular therapy had it been available.

Clinical utility of time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance angiography for infrageniculate arterial occlusive disease.

OBJECTIVE: The diagnostic accuracy of magnetic resonance angiography (MRA) in the infrapopliteal arterial segment is not well defined. This study evaluated the clinical utility and diagnostic accuracy of time-resolved imaging of contrast kinetics (TRICKS) MRA compared with digital subtraction contrast angiography (DSA) in planning for percutaneous interventions of popliteal and infrapopliteal arterial occlusive disease. METHODS: Patients who underwent percutaneous lower extremity interventions for popliteal or tibial occlusive disease were identified for this study. Preprocedural TRICKS MRA was performed with 1.5 Tesla (GE Healthcare, Waukesha, Wis) magnetic resonance imaging scanners with a flexible peripheral vascular coil, using the TRICKS technique with gadodiamide injection. DSA was performed using standard techniques in angiography suite with a 15-inch image intensifier. DSA was considered the gold standard. The MRA and DSA were then evaluated in a blinded fashion by a radiologist and a vascular surgeon. The popliteal artery and tibioperoneal trunk were evaluated separately, and the tibial arteries were divided into proximal, mid, and distal segments. Each segment was interpreted as normal (0% to 49% stenosis), stenotic (50% to 99% stenosis), or occluded (100%). Lesion morphology was classified according to the TransAtlantic Inter-Society Consensus (TASC). We calculated concordance between the imaging studies and the sensitivity and specificity of MRA. The clinical utility of MRA was also assessed in terms of identifying arterial access site as well as predicting technical success of the percutaneous treatment. RESULTS: Comparisons were done on 150 arterial segments in 30 limbs of 27 patients. When evaluated by TASC classification, TRICKS MRA correlated with DSA in 83% of the popliteal and in 88% of the infrapopliteal segments. MRA correctly identified significant disease of the popliteal artery with a sensitivity of 94% and a specificity of 92%, and of the tibial arteries with a sensitivity of 100% and specificity of 84%. When used to evaluate for stenosis vs occlusion, MRA interpretation agreed with DSA 90% of the time. Disagreement occurred in 15 arterial segments, most commonly in distal tibioperoneal arteries. MRA misdiagnosed occlusion for stenosis in 11 of 15 segments, and stenosis for occlusion in four of 15 segments. Arterial access was accurately planned based on preprocedural MRA findings in 29 of 30 patients. MRA predicted technical success 83% of the time. Five technical failures were due to inability to cross arterial occlusions, all accurately identified by MRA. CONCLUSION: TRICKS MRA is an accurate method of evaluating patients for popliteal and infrapopliteal arterial occlusive disease and can be used for planning percutaneous interventions.

Cardiovascular service line development: what is it, who benefits and is it worthwhile?

This article describes the creation and function of a cardiovascular service line in a university healthcare-based system. In 2001, an organizational structure (service line) was created to establish accountability between vascular surgeons, cardiologists and hospital administrators. The purpose of this merger was to provide focused, efficient care of cardiovascular patients at a reduced cost. Performance measures included clinical volume change, market share, length of stay, patient satisfaction and hospital margins. Between 2000 and 2006, annual patient volumes increased from 28,140 to 38,182 patients per year (36% increase). Endovascular case volumes increased from 730 to 1591 per year. Between 2003 and 2006, the average length of stay dropped from 7.7 to 5.5 days. Hospital margins increased from an average of 2.8 to 8%. This service line has improved efficiency and care of heart and vascular patients with decreased length of stay and hospital cost.

Absence of buttock claudication following stent-graft coverage of the hypogastric artery without coil embolization in endovascular aneurysm repair.

PURPOSE: To evaluate the safety and efficacy of stent-graft coverage of the hypogastric artery origin without coil embolization during endovascular treatment of aortoiliac or iliac aneurysms. METHODS: A retrospective study was conducted of patients who underwent endovascular aneurysm repair with endograft coverage of the hypogastric artery between September 2001 and September 2005. Among the 88 patients who underwent EVAR during the study period, 21 patients (19 men; mean age 77+/-6 years, range 67-86) had unilateral hypogastric artery coverage without coil embolization. Aneurysmal arteries included 11 aortoiliac, 8 isolated common iliac arteries (CIA), and 2 isolated hypogastric arteries. Preoperative AAA size was a mean 57 mm (range 46-73), and mean CIA aneurysm diameter was 36 mm (range 17-50). All covered hypogastric arteries were patent prior to the procedure. The stent-grafts implanted were 10 Excluder, 10 AneuRx, and 1 Zenith. Clinical outcome focused on mortality and morbidity, including the occurrence and duration of new-onset buttock claudication, which was further correlated with superior gluteal and profunda femoris artery patency. RESULTS: Immediate seal was achieved in all patients. Mean follow-up was 16 months (range 1-54). No type I endoleaks developed from the aortic or external iliac artery, and no type II endoleaks were found from the origin of the hypogastric artery. New-onset buttock claudication occurred in 2 (9.5%) patients, but resolved in both within 4 months. No additional secondary procedures, aneurysm rupture, or aneurysm-related death occurred. CONCLUSION: Stent-graft coverage of the orifice of the hypogastric artery without coil embolization is a safe and effective adjunct during the treatment of aortoiliac or iliac aneurysm, with a low incidence of buttock claudication.

Vertebral artery embolic protection via ipsilateral brachial approach during left subclavian artery angioplasty and stenting--a case report.

The purpose of this report is to explore angioplasty and stenting with cerebral embolic protection as a salvage procedure for a compromised carotid-subclavian bypass in the presence of antegrade vertebral artery flow. A 76-year-old woman with a carotid-subclavian bypass presented with graft infection. Failure of medical therapy to treat the infection prompted surgical removal of the graft. The native subclavian artery was still patent, but a severe complex proximal stenosis was present with antegrade flow into the left vertebral artery. Angioplasty and stenting of the subclavian artery was performed with cerebral protection achieved by positioning a FilterWire EX in the left vertebral artery via the left brachial artery approach. Deployment of a filter device in the vertebral artery via the brachial or radial approach can provide embolic protection without interfering with the subclavian artery stenting. The successful treatment of the subclavian artery enabled the complete removal of the infected graft without need for major vascular reconstruction.

Limb-salvage angioplasty in vascular surgery practice.

OBJECTIVE: To assess outcomes of percutaneous infrainguinal arterial angioplasty for treatment of chronic limb-threatening ischemia (CLI) in poor surgical candidates. METHODS: A retrospective clinical analysis of 67 consecutively treated patients (76 limbs) with CLI over a 33-month period was performed. Patients were considered poor surgical candidates because of absent distal target vessels (31 limbs), severe comorbid conditions (36 limbs), or lack of an autologous vein for distal bypass (9 limbs). Limb salvage was defined as preservation of a functional foot without the need for a prosthesis. Technical success was defined as the ability to percutaneously recanalize the arterial segment with less than 30% residual stenosis. Clinical success was healing of ulcers or minor amputation sites, resolving rest pain, or avoiding a major amputation. Successful technical and clinical outcomes were correlated with patient demographics, clinical presentation, and TransAtlantic Inter-Society Consensus arterial lesion characteristics by using the Fisher exact test. RESULTS: Seventy-six limbs were treated for rest pain (n = 12), gangrene (n = 22), or nonhealing ulcers (n = 42). There were 40 men and 27 women. The mean age was 70 years (range, 36-94 years). Lesions were located in tibial (n = 55), popliteal (n = 6), and superficial femoral (n = 15) arteries. Arterial recanalization and limb salvage was achieved in 64 (83.5%) limbs. Technical failure (n = 12) correlated with TransAtlantic Inter-Society Consensus D lesions ( P = .009) and the presence of occlusion ( P = .027). Clinical failure (major amputation, n = 12) correlated with the presence of gangrene ( P = .032) or the combination of diabetes, arterial occlusion, and gangrene ( P = .018). The single variables of age, sex, diabetes, and renal failure did not adversely affect outcomes. There was one mortality (myocardial infarction), and there were two major morbidities (femoral artery pseudoaneurysm and sepsis). CONCLUSIONS: Peripheral arterial angioplasty should be considered as an alternative to primary amputation in selected patients with CLI who are poor candidates for traditional surgical bypass.

Endovascular aortic repair or minimal incision aortic surgery: Which procedure to choose for treatment of high-risk aneurysms?

BACKGROUND: This study evaluates use of endovascular aortic repair (EVAR) and minimal incision aortic surgery (MIAS) for treatment of high-risk patients with infrarenal aneurysms. METHODS: A retrospective review of patients treated with EVAR or MIAS between 2000 and 2002 was performed. High-risk criteria included age older than 80 years, creatinine level greater than 3.0 mg/dL, recent myocardial infarction, congestive heart failure, severe chronic obstructive pulmonary disease, hostile abdomen, or morbid obesity (body mass index greater than 30). Patient demographics, duration of stay, morbidity, and mortality were compared. Exclusionary criteria for EVAR treatment included neck less than 1.5 cm or greater than 26 mm in diameter, densely calcified iliac arteries less than 6 mm, or creatinine level greater than 3.0 mg/dL. Exclusionary criteria for MIAS included pararenal abdominal aortic aneurysm, aneurysm greater than 10 cm, and morbid obesity. RESULTS: Eighty-four patients were treated (61 EVAR, 23 MIAS). Average age for EVAR was 74 years and 72 years for MIAS. Average aneurysm size was 6 cm for both. American Society of Anesthesiologists score was 3.1 for EVAR and 3.0 for MIAS patients. Thirty-two of 61 EVAR patients (52%) had 2 risk factors, and 12 of 61 (20%) had 3 risk factors. Seven of 23 MIAS patients (30%) had 2 risk factors, and 7 had more than 3 risk factors (30%). There were 2 EVAR deaths (3%) from multiorgan failure and 1 MIAS death (4%) from myocardial infarction. Average duration of stay was 5.1 days for both EVAR and MIAS. Thirty-day morbidity was 18% for EVAR and 17% for MIAS patients. CONCLUSIONS: EVAR and MIAS are comparable for the treatment of high-risk aneurysm patients.

Chronic abdominal pain and upper gastrointestinal bleeding due to duodenal perforation caused by migrated inferior vena cava filter--a case report.

The authors describe an unusual case of a 41-year-old man presenting with chronic abdominal pain and gastrointestinal bleeding caused by a migrated inferior vena cava filter eroding into the duodenum.

Is coil embolization of hypogastric artery necessary during endovascular treatment of aortoiliac aneurysms?

The aim of this study was to evaluate the safety and efficacy of stent graft coverage of hypogastric artery in the management of aortoiliac aneurysms. Between January 2000 and December 2002, 98 patients underwent endovascular repair of aortoiliac aneurysms (EVAR). Of these, 24 (24.5%) required occlusion of one hypogastric artery to facilitate the endovascular repair. Based on the method of hypogastric artery occlusion, patients were divided in to two groups. Group A (13/24 = 54%) underwent standard coil embolization followed by hypogastric artery orifice coverage whereas group B (11/24 = 46) underwent hypogastric artery orifice coverage without coil embolization. Post-EVAR computed tomographic angiography (CTA) was used to determine occurrence of endoleaks from the hypogastric artery orifice and patency of superior gluteal artery in both groups. These findings were further correlated with presence or absence of gluteal claudication. There was no difference in age (p < 0.38) or iliac aneurysm size (p < 0.3). In group A (13 patients), occlusion of superior gluteal artery was seen in 6 (46%). Four of six (66%) patients developed severe gluteal claudication. Patients in group A were likely to require more than one intervention (p < 0.00036). No patients in group B developed occlusion of the superior gluteal artery (p < 0.04) or gluteal claudication (p < 0.046). No endoleaks were seen from the origins of hypogastric artery in either group. The follow-up period ranged from 2 to 35 months. Hypogastric artery orifice coverage without coil embolization effectively prevented retrograde endoleak without the occurrence of disabling gluteal claudication. Coil embolization of the hypogastric artery may be unnecessary during treatment of aortoiliac aneurysm.