EVAR deployment in anatomically challenging necks outside the IFU.

OBJECTIVE: Treatment of abdominal aortic aneurysms with high-risk anatomy (neck length <10-15 mm, neck angle >60°) using commercially available devices has become increasingly common with expanding institutional experience. We examined whether placement of approved devices in short angled necks provides acceptable durability at early and intermediate time points. METHODS: A total of 218 patients (197 men, 21 women) at a single academic center underwent endovascular aneurysm repair (EVAR) with a commercially available device between January 2004 and December 2007. Available medical records, pre- and postoperative imaging, and clinical follow-up were retrospectively reviewed. Patients were divided into those with suitable anatomy (instructions for use, IFU) for EVAR and those with high-risk anatomic aneurysm characteristics (non-IFU). RESULTS: IFU (n = 143) patients underwent repair with Excluder (40%), AneuRx (34%), and Zenith (26%) devices, whereas non-IFU (n = 75) were preferentially treated with Zenith (57%) over Excluder (25%) and AneuRx (17%). Demographics and medical comorbidities between the groups were similar. Operative mortality was 1.4% (2.1% IFU, 0% non-IFU) with mean follow-up of 35 months (range 12-72). Non-IFU patients tended to have larger sac diameters (46.7% ≥60 mm) with shorter (30.7% ≤10 mm), conical (49.3%), and more angled (68% >60°) necks (all p < .05 compared with IFU patients). Operative characteristics revealed that the non-IFU patients were more likely to be treated utilizing suprarenal fixation devices, to require placement of proximal cuffs (13.3% vs. 2.1%, p = .003), and needed increased fluoroscopy time (31 vs. 25 minutes, p = .02). Contrast dose was similar between groups (IFU = 118 mL, non-IFU = 119 mL, p = .95). There were no early or late surgical conversions. Rates of migration, endoleak, need for reintervention, sac regression, and freedom from aneurysm-related death were similar between the groups (p > .05). CONCLUSIONS: EVAR may be performed safely in high-risk patients with unfavorable neck anatomy using particular commercially available endografts. In our experience, the preferential use of active suprarenal fixation and aggressive use of proximal cuffs is associated with optimal results in these settings. Mid-term outcomes are comparable with those achieved in patients with suitable anatomy using a similar range of EVAR devices. Careful and mandatory long-term follow-up will be necessary to confirm the benefit of treating these high-risk anatomic patients.

Nature of the renal injury following total renal ischemia in man.

The effects of total renal ischemia (TRI) of 15-87 min duration due to suprarenal clamping of the aorta were studied in 15 mannitol-treated patients undergoing abdominal aortic surgery. 15 patients undergoing similar surgery but requiring only infrarenal clamping served as controls. 1-2 h following TRI, GFR was reduced to only 39% of that in controls, 23 +/- 5 vs. 59 +/- 7 ml/min (P less than 0.001). This could not be ascribed to impaired renal plasma flow (RPF), which was mildly reduced to 331 +/- 71 and was not different from the value in controls, 407 +/- 66 ml/min. However, impaired PAH extraction (43 +/- 7%) and isosthenuria, not present in controls, suggest a primary role for tubular injury in lowering GFR at this time. 24 h following TRI, the GFR remained depressed below controls, 45 +/- 8 vs. 84 +/- 8 ml/min (P less than 0.005), while the transglomerular sieving of neutral dextrans was significantly enhanced (radius interval, 24-40 A). A theoretical analysis of transcapillary solute exchange revealed that these findings could be largely explained by a selective reduction of either RPF (-61%) or of transmembrane hydraulic pressure difference (-18%) below control values. Alternately, a combination of these two factors with changes of smaller magnitude could explain the findings. In contrast, a selective increase in oncotic pressure or decrease of the glomerular ultrafiltration coefficient could be excluded as a cause of hypofiltration 24 h after TRI. These observations lead us to suggest that the transient azotemia observed following TRI is due to a self-limited injury to the nephron that is identical to that seen in overt and sustained forms of acute renal failure.

Intra-arterial embolization in the management of arteriovenous malformations.

Eighteen patients with arteriovenous malformations (AVM's) involving the extremities, pelvis, or head are reported and their treatment is discussed. Our experience has led us to the following conclusions: (1) careful selective angiography is mandatory to delineate the vascular anatomy, extent, and major afferent vessels supplying the AVM; (2) ligation of afferent vessels to an AVM never is indicated; (3) intra-arterial embolization (IAE) can be used prior to surgical removal of extensive but resectable AVM's; (4) IAE may be employed for symptom control of inoperable AVM's.

Rupture of the left kidney following renosplenic shunt.

Kidney rupture following division of the left renal vein during portal decompression is presented. A review of the renal venous anatomy is described and a possible explanation of this ususual occurrence is offered.

Autogenous tissue reconstruction in the management of infected prosthetic grafts.

Infection is the most dreaded complication associated with implantation of a prosthetic arterial graft. Although remote bypass followed by complete removal of the infected prosthesis has proven to be a satisfactory method of treatment, in certain instances remote bypass alone is not feasible and other modes of surgical treatment must be employed. This report describes the use of autogenous reconstructions within the infected field, including endarterectomy and replacement of the infected graft with arterial or venous autografts in 24 patients. The key approach in these patients was (1) accurate preoperative assessment of the extent of graft infection, (2) aggressive surgical efforts to remove all infected prosthetic material, and (3) autogenous reconstructions within the infected field to supply critical vascular beds. Three patients died, for a mortality rate of 13%. There were no strokes and only two amputations. Suture lines involving autogenous tissue healed, even when in an infected field. In the aortofemoral group, preservation of aortic continuity is very desirable, when possible. We believe that these techniques provide the maximal potential for salvage of life and limb in the management of this dreaded vascular complication.

Retroperitoneal approach for portasystemic decompression.

A left retroperitoneal approach has been developed and used to perform a renal-splenic shunt for portal decompression in seven patients with massive variceal hemorrhage. In each patient, at least one intra-abdominal finding contraindicated a conventional transperitoneal portasystemic shunt. Retroperitoneal approach avoided possible complications and permitted successful portal decompression with cessation of bleeding in each instance. These results support the use of this technique when it is necessary to avoid the peritoneal cavity in a patient requiring portasystemic decompression.

Institutional peer review can reduce the risk and cost of carotid endarterectomy.

HYPOTHESIS: Surgeon-directed institutional peer review, associated with positive physician feedback, can decrease the morbidity and mortality rates associated with carotid endarterectomy. DESIGN: Case series. SETTING: Tertiary care university teaching hospital. PATIENTS/INTERVENTIONS: All patients undergoing carotid endarterectomy at our institution during a 5-year period ending August 1998. RESULTS: Stroke rate decreased from 3.8% (1993-1994) to 0% (1997-1998). The mortality rate decreased from 2.8% (1993-1994) to 0% (1997-1998). Length of stay decreased from 4.7 days (1993-1994) to 2.6 days (1997-1998). The total cost decreased from $13,344 (1993-1994) to $9548 (1997-1998). CONCLUSIONS: An objective, confidential peer review process that provides ongoing feedback of performance to surgeons and documents that performance in relationship with that of peers seems to be effective in reducing the morbidity and mortality rate associated with carotid endarterectomy. In addition, the review process lowered the hospital cost of performing carotid endarterectomy.

The carotid "string" sign. Differential diagnosis and management.

Seventeen patients with arteriographic findings consistent with the carotid "string" sign are presented. Five separate clinicopathologic categories were present, and each required special consideration for proper management. The arteriographic findings alone were insufficient to allow categorization or to predict intraoperative findings. Special emphasis is placed on the importance of examining the apparently occluded carotid artery for signs of the carotid string sign which, if found, indicates continued patency. Familiarity with the broad spectrum of clinicopathologic entities associated with the carotid string sign facilitates management of these often complicated problems.

Renosplenic shunt for control of esophageal variceal hemorrhage.

The left renal vein was used to perform a renosplenic (38 patients) or an adrenosplenic (5 patients) shunt in forty-three patients with esophageal variceal hemorrhage. All patients were successfully decompressed without recurrence of variceal bleeding in the postoperative period. One shunt thrombosed six months postoperatively and one kidney was removed because of venous hypertension and spontaneous rupture two days postoperatively. Overall mortality was 16 per cent, including a 22 per cent mortality in the emergency group.

Video angioscopy as an alternative to intraoperative arteriography.

Improved technology has made available the technique of video angioscopy. When applied routinely, it can provide a high yield of important technical detail in a graphically precise and easily applicable manner, at the time of a great variety of vascular reconstructions, and complications are rare. Although not entirely replacing intraoperative arteriography, its multiple attractive characteristics make it substantially more useful in many circumstances. Familiarity with the technique will enable vascular surgeons to more rapidly utilize new methods of therapy, such as lasers, as well as improve already existing ones.

Endoaneurysmorrhaphy for visceral artery aneurysms.

The clinical histories and surgical management of two patients with mycotic aneurysms involving the hepatic and superior mesenteric arteries are presented. Endoaneurysmorrhaphy was used to successfully manage these patients. This technic permits the preservation of maximum blood flow to the abdominal viscera. The clinical features and surgical technic are discussed.

Unusual problems of abdominal aortic aneurysms.

Complications other than rupture occurred in 12 per cent of 254 patients operated on for an infrarenal abdominal aortic aneurysm. The unusual problems encountered included aortocaval fistula, inflammatory aneurysm, aortoenteric fistula, aortic thrombosis, peripheral embolization, and retropsoas rupture. The clinical manifestations and management of these lesions are discussed.

Planned approach to the management of malignant invasion of the carotid artery.

A planned approach to the evaluation and management of patients with tumor involvement of the cervical carotid artery is presented. Preoperative arteriography and determination of carotid back-pressure permitted a rational approach in these high risk patients. One patient found to have an extremely low carotid back-pressure was advised not to undergo carotid resection. Six patients with satisfactory carotid back-pressure tolerated carotid resection and reconstruction.

Continuous ambulatory peritoneal dialysis. Technique of catheter insertion and management of associated surgical complications.

Fifty-seven patients initiated continuous ambulatory peritoneal dialysis. All patients were generally pleased with this form of dialysis and particularly enjoyed the greater mobility and decreased dietary restriction. Complications associated with continuous ambulatory peritoneal dialysis include peritonitis, pericatheter infection, catheter malfunction, dialysate leak, and hernias of the abdominal wall.

Visceral artery syndromes and reconstructions.

Acute and chronic visceral ischemia are now well recognized clinical entities and extensive progress has been made in both the evaluation and treatment of patients with these lesions. The visceral vessels and the nature of their collateral pathways can also be of critical importance when dealing with other intra-abdominal pathology. Poor anastomotic healing, or the formation of strictures and intestinal fistulas may result when the mesenteric circulation is slowly compromised. Hence, it is imperative that the visceral arteries, their lesions, and their collateral pathways be understood by all surgeons operating in the abdominal cavity.

The treatment of the expectant mother with deep venous thrombosis.

Experience with 12 expectant mothers with DVT from 1978 to 1983 supports heparin therapy. After early experience with four patients with various doses of intravenous and subcutaneous mini-heparin both in and out of the hospital, we have selected a program of outpatient, self-administered adjusted subcutaneous heparin. There has been no maternal or fetal mortality. There have been no serious bleeding or post-phlebitic complications, although two patients have had flare-ups of superficial phlebitis during the follow-up over the last four-and-a-half years. There have been three subsequent pregnancies, two of which were first trimester miscarriages and one uneventful term delivery of a normal infant.

Renovascular hypertension.

In summary, renovascular surgery has evolved during the past 20 years to become a highly efficacious therapeutic modality provided proper patient selection is practiced. Surgical techniques are now well established, and with the advent of ex vivo techniques practically any extraparenchymal renal artery lesion may be repaired. At present, much investigative work is in progress in an attempt to develop better means of selecting patients who will benefit from renovascular surgery. The newer modifications of renal vein renin assays may permit better patient selection. Many factors must be weighted when considering medical versus surgical management of hypertension. Paramount among these must be the quality of life of the patient. The inconstancy of pressure control and the frequency of undesirable side effects in the more extreme medical regimens are the primary disadvantages of nonsurgial management. An aggressive surgical approach appears to be warranted in selected patients with atherosclerosis and in almost all patients with fibromuscular dysplasia.

Lymphoscintigraphy in the diagnosis of lymphatic leak after surgical repair of femoral artery injury.

PURPOSE: Technetium-99m-labeled sulfur colloid lymphoscintigraphy is useful to evaluate lower extremity lymphatic circulation in cases of possible lymphedema and to reveal abnormal lymphatic collections. Groin lymphatic fistulas and lymphoceles are known complications of peripheral vascular surgical procedures. The authors describe a patient with ascites that developed into right lower extremity swelling after surgical repair of a femoral artery injury. Even after surgical ligation of multiple lymphatic channels, the patient continued to have lymphorrhea. It was unclear whether this was attributable to a persistent lymphatic leak or an ascitic leak from a postsurgical defect resulting in an abnormal connection with the peritoneal cavity. METHODS: Lymphoscintigraphy of the lower extremities was performed using Tc-99m sulfur colloid. Images were obtained at several intervals after injection of the radiotracer. Images were also acquired after the wound packing was removed. RESULTS: The images revealed an accumulation of radiotracer in the right groin, confirming the lower extremity lymphatic origin of the collection. CONCLUSIONS: Lymphoscintigraphy is useful to evaluate the origin of serous collections in the groin, a region in which lymphatic complications of vascular surgery are not uncommon.