In-hospital outcomes of endovascular versus surgical revascularization for chronic total occlusion in peripheral artery disease.

BACKGROUND: The outcome of endovascular intervention (EVI) compared vs. surgical revascularization in patients with peripheral artery disease (PAD) due to chronic total occlusion (CTO) is unknown. METHODS: Using the National Inpatient Sample database between 2007 and 2014, we identified all PAD patients with CTO who had limb revascularization. Multivariate analysis was performed to estimate the odds of in-hospital mortality and adverse outcomes between both groups. RESULTS: A total of 168,420 patients who had peripheral CTO and underwent limb revascularization were identified. 99,279 underwent EVI, and 69,141 underwent surgical revascularization. The patients who underwent EVI were younger, more likely to be women and African American, and less likely to be white (p < 0.001 for all). EVI was associated with lower in-hospital mortality (1.2% vs 1.7%, adjusted odds ratio [aOR]: 0.54; 95% confidence interval [CI] 0.50-0.59). The EVI group had higher vascular complications, major bleeding, acute kidney injury (AKI), and major amputation compared with surgical revascularization. A subgroup analysis on patients with critical limb ischemia showed lower mortality in the EVI group (1.4% vs. 1.9, aOR 0.56; 95% CI 0.50-0.63). Although there was no difference in the incidence of AKI or major amputation between the two groups, the EVI group had higher vascular complication rates and major bleeding events. CONCLUSION: EVI in PAD with CTO is associated with lower in-hospital mortality, likely due to the procedure's less-invasive nature; however, it is associated with higher postprocedural complications likely due to the CTO's complexity.

Ex Vivo Reconstruction and Autotransplantation for Hilar Renal Artery Aneurysms in Patients with Congenital Anomalies.

Renal artery aneurysms (RAAs) are an uncommon finding but are more often associated with other congenital disorders. The complex (hilar) RAAs constitute a subset of RAAs that present a therapeutic dilemma for the vascular surgeon because of their anatomic location. This dilemma worsens when hilar RAAs occur with a solitary kidney where organ preservation is vital. Ex vivo reconstruction with autotransplantation is especially suitable for hilar RAAs, even when they are associated with a solitary kidney. We report 2 of such cases of RAAs with a solitary kidney in patients with pertinent congenital anomalies. In 1 case, the hilar RAA was associated with a significant accessory renal artery, whereas in the other case, the hilar RAA was associated with a significant connective tissue disorder. Ex vivo reconstruction and autotransplantation was successful in both cases; however, treatment modalities had to be adapted to the patient's unique conditions.

Hyperbaric oxygen decreases intimal thickness and area after carotid artery balloon injury in a rat model.

BACKGROUND: Clinical studies have suggested a benefit for hyperbaric oxygen (HBO) treatment in decreasing symptomatic restenosis after coronary angioplasty. We hypothesize that HBO treatment will decrease hyperplastic intimal area after arterial balloon injury in a rat. METHODS: Fifty-four male Sprague-Dawley rats (Charles River Laboratories, Wilmington, MA) were randomly assigned either to room air (n = 27) or a treatment group (n = 27) receiving HBO treatment (2 hyperbaric treatments of 100% oxygen at 2 bars for 90 min). A 2F balloon-tipped catheter was used to injure the right common carotid arteries, which were harvested at 7, 14, and 28 days. Postinjury intimal thickness and area were measured from hematoxylin-eosin-stained specimens at each time point. Computer-assisted histomorphometry was used to calculate maximal intimal thickness, relative intimal thickness (ratio of intimal to intimal plus medial thickness), intimal area, and the intimal to medial area ratio. RESULTS: There was a 42.3% reduction in maximal intimal thickness (P = 0.0012) and a 36.5% reduction in intimal area (P = 0.0337) at day 28 in the HBO-treated group (mean ± standard error [SE], 0.0425 ± 0.0054 mm for maximal thickness and 0.065 ± 0.0056 mm(2) for area) when compared to the normoxic group (0.0737 ± 0.004 mm for maximal thickness and 0.0413 ± 0.0074 mm(2) for area). The relative intimal thickness also showed a 28.3% reduction at day 28 in the HBO-treated group (ratio of 0.38 ± 0.0329) compared to the normoxic group (ratio of 0.53 ± 0.0141; P = 0.0065). CONCLUSIONS: Our results indicate that HBO treatment decreases maximal intimal thickness and intimal area of the carotid artery after balloon injury. This could have significant clinical implications on the increasing number of endovascular interventions in vascular surgery and cardiology.

Medical student career survey--vascular surgery awareness initiative.

BACKGROUND: The objectives of this survey were to identify medical students' general knowledge of vascular surgery as a career choice on entrance to medical school, and how student perspectives change during their exposure to clinical disciplines. Furthermore, we sought to determine which factors may influence the choice of a particular career path, and to apply this knowledge to improve the recruitment process of medical students into the specialty of vascular surgery. METHODS: A one-time anonymous questionnaire consisting of 21 open and multiple-choice questions was distributed to first- (MS1), second- (MS2), and third-year (MS3) medical students at a large single-campus medical school. Responses were collected and subjected to analysis. RESULTS: Three hundred thirty-eight medical students responded to the survey (110 MS1, 126 MS2, and 102 MS3). Two hundred thirty-six MS1 and MS2 students had no clinical exposure to vascular surgery. Of 102 MS3 students having completed a general surgery rotation, 38 had exposure to vascular surgery. Of MS1 and MS2 students, 49% would consider vascular surgery. An additional 19% were willing to consider vascular surgery if the length of training was reduced. Twenty-six percent of the clinical students rotated on a vascular surgery service during their clinical general surgery rotation, of which 78% reported a positive experience. Only 26% (10 of 38) still considered vascular surgery as a career at the MS3 level. Thirty-four percent of students would consider vascular surgery if the training was reduced from 7 to 5 years. However, only 5% of MS1 and MS2 (11 of 236) and 9% of MS3 (9 of 102) students were aware of the 0 + 5 training program. As students advanced in medical school, lifestyle (31% MS1 vs. 63% MS3, P < 0.001) and length of training (19% MS1 and 2 vs. 34% MS3, P < 0.001) became a more critical factor in their career choice decision making. CONCLUSIONS: Medical students have minimal knowledge of vascular surgery on entry to medical school; however, many are willing to consider vascular surgery as a career. Lack of exposure in the first 2 years of medical school and lifestyle considerations may be deterrents for students to choosing vascular surgery as a career. To improve the recruitment process, focused education and interaction with preclinical medical students are needed.

Interventions for mesenteric vasculitis.

OBJECTIVE: This study reviewed the outcomes of open and endovascular revascularization for mesenteric vasculitis (MV). METHODS: We reviewed the clinical data of all patients who underwent revascularization for occlusive MV from 1984 to 2008. Patients treated for aneurysms or mucosal bleeding without ischemic symptoms were excluded. End points were early mortality and morbidity, survival, freedom from mesenteric symptoms, and patency. Outcomes of open reconstructions were compared with the results of 163 patients who underwent open operations for atherosclerotic disease. RESULTS: There were 15 patients (13 females, 2 males) with a mean age of 38 years (range, 15-66 years). Etiologies were Takayasu's arteritis in 7, polyarteritis nodosa in 4, indeterminate in 3, and giant cell arteritis in 1. The celiac axis was affected in 13, superior mesenteric artery (SMA) in 13, renal arteries in 8, and the aorta in 4. Seven patients had active disease, and eight were in remission. Nine (60%) presented with symptomatic chronic (n = 8) and acute (n = 1) mesenteric ischemia. Six patients with asymptomatic disease underwent mesenteric revascularization during other aortic-based operations. Fourteen patients (93%) had 10 mesenteric bypasses (8 aortic based; 2 iliac), three had aortoplasties, of which two had mesenteric patch angioplasties, and one underwent arcuate ligament release with patch angioplasty. One patient (7%) underwent percutaneous transluminal angioplasty of SMA stenosis. There were no early deaths. Early complications occurred in three patients (20%) after open reconstruction, including gastrointestinal hemorrhage, ileus with re-exploration, and superior mesenteric vein thrombosis. Median follow-up was 22 months. One graft thrombosis in a patient with active disease was treated with redo bypass 74 months after aorta-celiac-SMA bypass. All patients were alive at 10 years, with similar expected survival compared with the general population (P = .69). Compared with patients with atherosclerotic disease, open reconstructions for MV had similar freedom from mesenteric symptoms (83% vs 75%, P = .80) and similar primary graft patency (83% vs 84%, P = .9). CONCLUSION: Mesenteric vasculitis is a rare manifestation of Takayasu arteritis, polyarteritis nodosa, indeterminate, or giant cell arteritis. Open revascularization is durable and effective when needed.

Revascularization for failed carotid artery stenting in a patient with a rare vertebral artery anomaly.

There is a growing cohort of patients requiring complex revascularization for failed carotid artery stenting. This revascularization can be complex in patients with coexisting supra-aortic vascular anomalies. Aberrant origin of the vertebral artery (VA) is an example of such an anomaly. Although VA anomalies are rare, their occurrence is of significant importance in endovascular and open vascular procedures. We report a case of a 78-year-old man with rare VA anomaly, whose left internal carotid artery ostium was inadvertently covered during a carotid artery stenting procedure. We discuss the carotid artery revascularization in this patient as well as the relevant literature.

Patency of the Viabahn stent graft for the treatment of outflow stenosis in hemodialysis grafts.

BACKGROUND: To evaluate arteriovenous graft patency when failing grafts are treated with Viabahn covered stents vs percutaneous angioplasty (PTA) alone. METHODS: A retrospective review of all patients that underwent endovascular interventions for failing grafts at a single institution between January 2010 and July 2013 was performed. Forty-four patients were identified who were treated with PTA alone (11) and with Viabahn stent grafts (33) for stenoses in the venous to graft anastomoses. Patient demographics, procedural success, and intraoperative complications were recorded as well as graft patency at 3, 6, and 12 months. Graft patency was reviewed and compared with PTA alone. RESULTS: There was no statistically significant difference between the 2 groups regarding gender, frequency of diabetes, hypertension, coronary artery disease, or peripheral arterial disease. Primary technical success defined as residual stenosis 10% or less was achieved in 100% of the cases. Follow-up was determined by flow velocities during dialysis and ultrasound imaging in the vascular laboratory. At 12 months 87.8% (29/33) grafts with stents were functional vs 36.4% (4/11) of those with PTA alone. Primary patency of the stent group was 61%, 52%, and 42% at 3, 6, and 12 months respectively vs the PTA group 64%, 45%, and 9%. CONCLUSIONS: Grafts treated with Viabahn covered stents for outflow stenosis have a superior patency to PTA alone, 12 months after treatment; although earlier post treatment results are comparable.

Endovascular repair of a ruptured giant popliteal artery aneurysm.

This report presents the first reported case of an endovascular repair of a ruptured giant popliteal artery aneurysm. The patient, an 86-year-old man, presented emergently with a free rupture of a 7-cm left popliteal artery aneurysm and a large hematoma in his left thigh of approximately 20 cm in diameter. The patient was considered to be at high risk for open surgery and therefore underwent endovascular repair of his ruptured popliteal artery aneurysm using two 8 mm x 15 mm Viabahn endografts. At one month follow-up, the large hematoma in the left thigh had completely resolved, the patient was ambulating without pain or difficulty and had palpable pedal pulses on physical examination. One year following the procedure, the endografts remained patent without endoleak.