Outcomes after Endovascular Stent Placement for Long-Segment Superficial Femoral Artery Lesions.

BACKGROUND: Endovascular intervention is commonly pursued as first-line management of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare metal stents (BMS), covered stents (CS), and drug-eluting stents (DES) for long-segment SFA lesions remain uncertain. METHODS: A retrospective cohort study identified patients with symptomatic SFA lesions measuring at least 15 cm in length who successfully received an endovascular stent (BMS, CS, or DES). The outcomes were patency, patient presentation upon stent occlusion, amputation-free survival (AFS), and all-cause mortality. Proportional hazards regressions and a multinomial logistic regression model were used to control for significant confounders. RESULTS: A total of 226 procedures were analyzed (BMS: 95 [42%]; CS: 74 [33%]; DES: 57 [25%]). There were no significant differences among the 3 stent types with respect to age, prevalence of either diabetes or end-stage renal disease, or smoking history. The median length of the SFA lesion varied across the cohorts (BMS: 28 cm [interquartile range, IQR 20-30]; CS: 26 cm [IQR 20-30]; DES: 20 cm [IQR 16-25]; P = 0.002). The unadjusted primary patency of BMS at 12, 24, and 48 month following index stent placement was 57%, 47%, and 44%, respectively. This is compared to 62%, 49%, and 42% for CS, and 81%, 66%, and 53% for DES, respectively (log-rank P = 0.044). In adjusted models, however, there were no significant differences in primary patency among the stent types. Compared to CS however, DES was associated with improved primary-assisted patency (hazard ratio [HR] for patency loss: 0.35, P = 0.008) and secondary patency (HR: 0.32, P = 0.011). Across the entire follow-up period, stent occlusions occurred in 38 (40%) BMS cases, 42 (57%) CS, and 11 (19%) DES (P < 0.001). Of these, acute limb ischemia (ALI) occurred in 2 (5%) BMS cases, 14 (33%) CS, and 1 (9%) DES (P = 0.010). After adjustment, the relative risk of presenting with ALI as opposed to claudication was 27 times greater among patients re-presenting with occluded CS compared to BMS (P = 0.020). There were no significant differences in AFS or all-cause mortality across the 3 cohorts. CONCLUSIONS: For long-segment SFA lesions, DES is associated with improved primary-assisted and secondary patency over long-term follow-up. In the event of stent occlusion, CS is associated with an increased risk of ALI.

Arteriovenous fistula maturation rate is not affected by ipsilateral tunneled dialysis catheter.

OBJECTIVE: The effect that ipsilateral tunneled dialysis catheters (TDC) have on arteriovenous fistula (AVF) maturation is unclear. We sought to define this association by comparing AVF maturation rates in patients with contralateral TDC with those with ipsilateral TDC. METHODS: A review of a prospectively maintained database including all AVF creation procedures between 2009 and 2016 was performed. All patients with a TDC in place at the time of AVF creation were included in this study. Clinical and functional maturation rates were compared in patients with contralateral vs ipsilateral dialysis catheters. Categorical variables were analyzed by a two-tailed Fisher's exact test. A P value of less than .05 was considered statistically significant. RESULTS: There were 187 patients who underwent fistula creation with a TDC in place during the study period. Of those, 137 patients had a contralateral TDC and 50 had an ipsilateral TDC. A greater proportion of contralateral patients were first-time dialysis access patients at the time of index AVF creation (67% vs 48%; P = .03). There was no difference in clinical (contralateral 73% vs ipsilateral 78%; P = .57) and functional (contralateral 64% vs ipsilateral 74%) maturation rates between the two groups. The rate of TDC removal after AVF maturation was also not different (contralateral 64% vs ipsilateral 72%; P = .30). There was also no statistical difference in the rates of thrombosis at less than 30 days, outflow stenosis, central stenosis, and steal syndrome. CONCLUSIONS: There was no association between TDC sidedness and AVF maturation or early failure in our cohort. Planning for AVF creation should not be influenced by attempts to avoid an ipsilateral TDC.

Ischemia-induced lower extremity neurologic impairment after fenestrated endovascular aneurysm repair.

OBJECTIVE: Placement of large sheaths in the iliac system during fenestrated endovascular aneurysm repair (FEVAR) leads to lower extremity (LE) ischemia that can be associated with serious neurologic complications. We sought to determine the effect of LE ischemic time on neurologic impairment after FEVAR. METHODS: Consecutive patients who underwent FEVAR at a single institution were analyzed. LE ischemic time was calculated from the time of large sheath (≥18F) insertion to the time of sheath removal from the iliac arteries that led to continuous LE ischemia. The primary outcome was neurologic impairment defined as any new sensory or motor deficit in either LE. Outcomes were analyzed using descriptive statistics and modeled with logistic regression with interaction terms. Each individual LE was used as a unit of analysis. RESULTS: We examined 101 patients (202 lower extremities) who underwent FEVAR over a 5-year period. The median LE ischemic time was 2.75 hours (range, 0.8-5.2 hours). Neurologic impairment developed in 18 extremities (9%). Of those, 12 (67%) developed mild sensory loss, 6 (33%) complete sensory loss, 4 (22%) loss of proprioception, and 2 (11%) motor dysfunction. Sensory deficit was permanent in four limbs (2%) and motor dysfunction in one limb (0.5%). In all other cases, the neurologic examination returned to baseline by postoperative day 15. Duration of LE ischemic time (odds ratio, 6.3; 95% confidence interval, 3.1-12.4; P < .001) and common iliac artery (CIA) stenosis to a lumen of 8 mm or less (odds ratio, 2.7; 95% confidence interval, 1.5-7.3; P = .002) were independent predictors for the development of neurologic impairment. An interaction term between LE ischemic time and CIA stenosis was statistically significant (P = .042), indicating that the presence of CIA stenosis modifies the effect of LE ischemic time. In those with CIA stenosis to a lumen of 8 mm or less, the risk of neurologic impairment increased rapidly after 2.5 hours of LE ischemia, and became nearly certain after 4 hours of ischemic time. By contrast, patients without CIA stenosis tolerated longer ischemic times and demonstrated a less steep increase in the risk for LE neurologic impairment. CONCLUSIONS: LE neurologic impairment after FEVAR is strongly associated with LE ischemic time and CIA occlusive disease to a lumen of 8 mm or less. Our data indicate that, when the LE ischemic time is expected to exceed 2.5 hours (in patients with CIA stenosis) or 3 hours (in patients without CIA stenosis), measures to ensure LE perfusion should be given consideration.

Retrograde transpopliteal access is safe and effective-it should be added to the vascular surgeon's portfolio.

BACKGROUND: The aim of the study was to review the outcomes of superficial femoral artery (SFA) interventions using a retrograde transpopliteal access approach after failed antegrade recanalization. METHODS: A database of patients undergoing endovascular treatment of the SFA between 2008 and 2011 was retrospectively queried, and those cases with transpopliteal artery retrograde access were analyzed. Time-dependent outcomes were determined by Kaplan-Meier survival analyses. RESULTS: A total of 16 patients (75% men; mean age 61 ± 9 years) underwent retrograde popliteal access after failed antegrade attempts. Patients had multiple cardiovascular comorbidities with a mean modified cardiac index score of 3.1 ± 1.8. The reason for intervention was lifestyle-limiting claudication in 67% of cases and critical ischemia in the remainder. Most of the lesions were Trans-Atlantic Inter-Society Consensus II C and D. Retrograde ultrasound-guided puncture of the popliteal artery was successful in all cases and there were no local site complications. Intervention was successful in 94% of cases. One uncomplicated perforation (7%) was encountered during attempted recanalization of the SFA in the thigh. There was no perioperative morbidity or 30-day mortality. The 30-day major adverse cardiovascular events rate was 6% but both 30-day major adverse limb events and the 30-day major amputation rate were 0%. There was a 40% increase in actual ankle-brachial index (ABI); 93% of patients achieved an ABI rise >0.15. On longer term follow-up, 2 patients developed restenosis and 1 an asymptomatic occlusion. Both restenosis patients required re-angioplasty. Two patients required expected toe amputations as a result of their presenting symptoms. The primary patency was 66 ± 9%, assisted patency 81 ± 9%, and secondary patency 87 ± 8% at 2 years. Limb salvage was 100%. Clinical efficacy was 63 ± 9% at 2 years. CONCLUSIONS: Ultrasound-guided retrograde transpopliteal access is a safe and successful technique, which extends the ability to perform endovascular interventions after failed antegrade approaches.

Prediction of Peripheral Artery Disease Prognosis Using Clinical and Inflammatory Biomarker Data.

Purpose: Inflammatory biomarkers associated with peripheral artery disease (PAD) have been examined separately; however, an algorithm that includes a panel of inflammatory proteins to inform prognosis of PAD could improve predictive accuracy. We developed predictive models for 2-year PAD-related major adverse limb events (MALE) using clinical/inflammatory biomarker data. Methods: We conducted a prognostic study using 2 phases (discovery/validation models). The discovery cohort included 100 PAD patients that were propensity-score matched to 100 non-PAD patients. The validation cohort included 365 patients with PAD and 144 patients without PAD (non-matched). Plasma concentrations of 29 inflammatory proteins were determined at recruitment and the cohorts were followed for 2 years. The outcome of interest was 2-year MALE (composite of major amputation, vascular intervention, or acute limb ischemia). A random forest model was trained with 10-fold cross-validation to predict 2-year MALE using the following input features: 1) clinical characteristics, 2) inflammatory biomarkers that were expressed differentially in PAD vs non-PAD patients, and 3) clinical characteristics and inflammatory biomarkers. Results: The model discovery cohort was well-matched on age, sex, and comorbidities. Of the 29 proteins tested, 5 were elevated in PAD vs non-PAD patients (MMP-7, MMP-10, IL-6, CCL2/MCP-1, and TFPI). For prognosis of 2-year MALE on the validation cohort, our model achieved AUROC 0.63 using clinical features alone and adding inflammatory biomarker levels improved performance to AUROC 0.84. Conclusion: Using clinical characteristics and inflammatory biomarker data, we developed an accurate predictive model for PAD prognosis.

Inflammatory biomarkers associated with peripheral artery disease (PAD) have been examined separately; however, an algorithm that includes an inflammatory protein panel to inform prognosis of PAD may improve predictive accuracy. We developed predictive models for 2-year major adverse limb events (MALE) using clinical characteristics (demographics, comorbidities, and medications) and a panel of 5 PAD-specific inflammatory biomarkers (MMP-7, MMP-10, IL-6, CCL2/MCP-1, and TFPI) that achieved excellent performance on an independent validation cohort (AUROC 0.84). The models developed through this study may support PAD risk-stratification and targeted management strategies.

Hybrid repair of type II thoracoabdominal aortic aneurysm using modified branch-first technique.

The hybrid modified branch-first technique has extended the feasibility of open thoracoabdominal aortic aneurysm (TAAA) repair in otherwise hostile aortic anatomy that is not entirely amenable for extent II open TAAA conventional repair or total endovascular repair. The modified branch-first open TAAA technique has been developed successfully at our center and has been used to treat extent III TAAAs with successful outcomes. By combining the modified technique with endovascular thoracic aortic repair, we have been able to successfully extend its use to more extensive extent II TAAAs. This could prove to be a useful technique in the armamentarium of aortic surgeons.

Clinical and Haemodynamic Effects of Arteriovenous Shunts in Patients with Heart Failure with Preserved Ejection Fraction.

The arteriovenous shunt (AVS) is the most commonly used vascular access in patients receiving regular haemodialysis. The AVS may have a significant haemodynamic impact on patients with heart failure. Many studies have sought to understand the effect of AVS creation or closure on heart structure and functions, most of which use non-invasive methods, such as echocardiography or cardiac MRI. Data are mainly focused on heart failure with reduced ejection fraction and there are limited data on heart failure with preserved ejection fraction. The presence of an AVS has a significant haemodynamic impact on the cardiovascular system and it is a common cause of high-output cardiac failure. Given that most studies to date use non-invasive methods, invasive assessment of the haemodynamic effects of the AVS using a right heart catheter may provide additional valuable information.

Prevalence of variant brachial-basilic vein anatomy and implications for vascular access planning.

OBJECTIVE: To describe and increase understanding of the brachial-basilic vein anatomy that could impact planning of long-term hemodialysis access procedures. METHODS: Preoperative vein mapping was conducted in a cross-sectional, observational study in end-stage renal disease patients from August 2005 to May 2010. "Traditional" anatomic description with basilic-brachial junction at the axillary level with paired brachial veins was classified as "Type 1." Junctions observed at the mid or lower portions of the upper arm with duplication of the brachial vein above that level were classified as "Type 2." Junctions at the mid and lower portions of the upper arm with no duplication of the brachial vein above that level were classified as "Type 3." RESULTS: Two hundred ninety patients (mean age, 56 ± 17 years; 52% men) were observed and 426 arms mapped (221 right, 205 left). The prevalence of variations in venous arm anatomy was as follows: Type 1: 66%; Type 2: 17%; and Type 3: 17%. CONCLUSIONS: This study underscores the need for heightened awareness of upper arm venous variations and advocates the regular use of preoperative ultrasound imaging. We propose that recognition of Type 3 anatomy may have implications in access algorithm and planning.

Transhepatic hemodialysis catheters: functional outcome and comparison between early and late failure.

PURPOSE: To describe the authors' experience with transhepatic placement of catheters, highlighting early and late complications, and to determine if this procedure is a viable option in patients in whom central venous occlusions present a significant challenge. MATERIALS AND METHODS: The records of all the patients who underwent placement of transhepatic hemodialysis from January 2003 to October 2008 were retrospectively reviewed. Selected patients were dialysis-dependent, having undergone multiple access procedures and revisions. Kaplan-Meier analysis was used to estimate primary and secondary patency. RESULTS: Twenty-two patients (mean age 42 years, range 22-70 years, 59% women) underwent a total of 127 transhepatic catheter placements at 24 transhepatic access sites; technical success was achieved in all cases. There were no hepatic injuries (bleeding or fistula formation). There were 105 exchanges in 14 patients, with a mean of 7.5 exchanges, a median of 5 exchanges (range 1-18 exchanges), and a catheter migration rate of 0.39 per 100 catheter-days. The sepsis rate was 0.22 per 100 catheter-days, and the catheter thrombosis rate was 0.18 per 100 catheter-days. The mean cumulative catheter duration in situ was 506.2 days, and the mean time catheter in situ was 87.7 days. The mean total access site interval was 1,046 catheter-days (range of 423-1,413 catheter-days). CONCLUSIONS: Transhepatic hemodialysis catheter placement is associated with low rates of morbidity. In this series, transhepatic catheters provided the possibility of long-term functionality, despite associated high rates of catheter-related maintenance, provides a potentially viable access for patients with exhausted access options.

Outcomes before and after initiation of an acute aortic treatment center.

BACKGROUND: Acute aortic syndromes remain life-threatening. Time is of the essence, as mortality rises with increasing time after the acute episode. The aim of this report is to show changes in practice and outcomes after the establishment of an acute aortic treatment center (AATC) to expedite the care of acute aortic syndromes in a major metropolitan area with the belief that "door to intervention time under 90 minutes" reduces mortality and morbidity from acute aortic disease. METHODS: A database of patients admitted with acute aortic disease (Type A and B aortic dissections, acute thoraco-abdominal aortic aneurysms, acute and ruptured abdominal aortic aneurysms) for 1 year prior to initiation (2007) and 1 year after initiation of the pathway (AATC) in 2008 was developed. Comorbidities were scored according to Society of Vascular Surgery criteria. Anatomic and functional outcomes were determined and categorized by Society of Vascular Surgery reporting criteria. Multivariate analysis was performed for categorical outcomes and Cox proportional hazard analyses for time-dependent outcomes. RESULTS: Six hundred twenty-one patients reported with aortic disease to the cardiovascular services; 306 patients were considered to have acute disease. When compared with the year before the AATC was instituted, there was a 30% increase in the total number of admissions and a 25% increase in acute pathology after setting up the AATC (P = .02). There was a two-fold increase in thoracic aortic dissections admitted to the service. Initiation of the treatment pathway resulted in a highly significant 64% reduction in time to definitive therapy (526 ± 557 vs 187 ± 258 minutes, mean ± SD pre-AATC vs AATC; P = .0001). Comorbidity scores were equivalent between the two cohorts. Despite the increase in acuity, mortality (4% vs 6%) and morbidity (41% vs 45%) rates were unchanged, and there was a significant decrease in intensive care unit length of stay (5 vs 4 days, pre-AATC cohort vs the AATC cohort), but total hospital length of stay (11 vs 10 days) was unchanged. There was no correlation between deaths within 30 days and length of stay in the intensive care unit. CONCLUSION: Establishment of a multidisciplinary AATC pathway was associated with a 30% increase in volume, 64% reduction in time to definitive treatment, improved throughput with reduced intensive care unit time, and maintained clinical efficacy despite an increase in acute admissions. These results suggest the concept be further evaluated.

Hybrid thoracic endovascular aortic repair: pushing the envelope.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) can be limited by inadequate proximal and distal landing zones. Debranching or hybrid TEVAR has emerged as an important modality to expand landing zones and facilitate TEVAR. We report a single-center experience with hybrid TEVAR. METHODS: We retrospectively reviewed all patients with thoracic aortic disease who received a TEVAR between February 2005 and October 2008. RESULTS: Forty-two patients underwent a hybrid procedure (mean age 68 +/- 13 years; 55% men). All patients were denied open surgery due to preoperative comorbidities or low physiologic reserve; 62% had a history of coronary artery disease, 67% had chronic obstructive pulmonary disease, 61% had undergone prior aortic surgery, and 90% had an American Society of Anesthesiology score of 4 and above. The average Society for Vascular Surgery comorbidity score was 12 +/- 2 with a range of 9 to 14. Fifty-five percent of cases were symptomatic on presentation and 83% were done emergently. Seventy-six percent underwent debranching of the aortic arch, 17% of the visceral vessels, and 7% required both. Primary technical success was achieved in all cases and of these, 43% were staged. The 30-day mortality was 5%. Myocardial infarction developed in 5%, respiratory failure in 31%, cerebrovascular accident (stroke or transient ischemic attack) in 19%, and spinal cord ischemia with ensuant paraplegia occurred in 5% of patients. Fifty-eight percent of patients were discharged home, 11% required rehabilitation, and 29% were transferred to a skilled nursing facility. There was a significant association between visceral vessel debranching and both spinal cord ischemia (P = .004) and gastrointestinal complications (P = .005). On the other hand, there was no difference between staged and non-staged hybrid procedures. CONCLUSIONS: Hybrid procedures can successfully extend the range of patients suitable for a subsequent TEVAR. These procedures are associated with higher complication rates than isolated infrarenal or thoracic endovascular repair, but given the medical and anatomical complexity of these patients, the current results are quite encouraging.

Spontaneous regression of an abdominal aortic aneurysm in an immunocompromised patient.

Spontaneous aneurysmal regression is a rare event, having been observed only in association with arteritides or immunosuppression following solid-organ transplantation. In particular, the spontaneous regression of an aortic aneurysm, to our knowledge, has never been documented. We report a case of a 46-year-old, HIV-positive, African-American man who developed an asymptomatic juxtarenal abdominal aortic aneurysm, which significantly regressed over a 6-month period in the absence of arteritides or systemic immunosuppressive therapy. This case describes the spontaneous regression of an inflammatory AAA in an HIV-positive patient. Further studies will be required to determine if this was an isolated occurrence or if it occurs with any frequency in specific patient populations.

Thoracic endovascular aortic repair for type B aortic dissection.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has emerged as an acceptable off-label treatment modality for aortic dissection. We report our experience in endovascular treatment of this disease with an emphasis on defining the patterns of morbidity. METHODS: We retrospectively reviewed all (n = 90) patients with thoracic aortic disease who received a TEVAR between February 2005 and December 2007. Aortic dissection was the indication in 23 (26%) patients (48% acute, 52% chronic; Stanford A 17%, Stanford B 83%). For the purposes of this report, we concentrated on the type B dissection (17 patients). Eighty-two percent of the patients were symptomatic on presentation, and 56% of cases were performed either urgently or emergently. RESULTS: Technical success was achieved in 100% of cases, with an average operative time of 178 + or - 119 min. Forty-seven percent required a left subclavian bypass. Thirty-day mortality was 5.5% and morbidity was 12%. Postoperative complications included respiratory failure in 28% of cases, gastrointestinal symptoms in 11%, and cerebrovascular symptoms in 5.5%. No renal failure occurred. While cerebrospinal fluid drain was used in 35% of cases, transient spinal cord ischemia was observed in 5.5%. Average length of stay was 13 + or - 12 days; 63% of patients were discharged home, 12% required rehabilitation, and 25% were discharged to a skilled nursing facility. There was no association between outcome and mode of presentation or anatomic extent. CONCLUSION: Aortic dissection remains a challenging clinical entity, and the advent of TEVAR has improved outcomes but still carries considerable morbidity, with distinct patterns between mode of presentation and anatomic extent.

Yolk sac tumor of the ovary in a young girl with tuberous sclerosis: A case report and review of the literature.

•We reported the first tuberous sclerosis patient with an ovarian yolk sac tumor.•Although angiomyolipoma is a common benign tumor in TS patients, abdominal malignancies must be considered.

End-stage renal disease and limb salvage.

The prevalence of peripheral arterial disease and both traditional and nontraditional vascular risk factors are more common in patients with end-stage renal disease who are undergoing hemodialysis than the general population. Patients undergoing hemodialysis may also be at risk for peripheral arterial disease via nonvascular risk factors and the hemodialysis treatment itself. Unfortunately, because peripheral arterial disease and its risk factors in hemodialysis patients have not been thoroughly ascertained, evaluation of potential treatments has been limited. Given the high potential of morbidity and impaired quality-of-life related to peripheral arterial disease in patients with end-stage renal disease, additional studies are needed to evaluate both quality of life and potential screening for peripheral arterial disease, its risk factors, and treatments to identify areas for improvement in this vulnerable population.

A computational fluid dynamics study pre- and post-stent graft placement in an acute type B aortic dissection.

PURPOSE: To demonstrate the capability of computational fluid dynamics (CFD) for quantifying hemodynamic forces pretreatment/posttreatment in type B aortic dissection (TB-AD). METHODS: From CFD simulations initialized with dynamic magnetic resonance image data, wall shear stress (WSS) and dynamic pressure (dynP) changes post endovascular treatment were quantified. RESULTS: After 1 year follow-up, thoracic aortic segment was completely remodeled, and persistent, nonthrombosed false lumen in the abdominal aorta was noted. Pretreatment, large WSS (>5 Pa) and dynP (>80 Pa) occurred at entrance tear and a stenotic region in the true lumen (TL). Posttreatment, WSS was lower than 3.3 Pa and dynP was lower than 55 Pa in TL, except at proximal end of the stent graft and at reentrance tear. Two focal locations of high dynP existed within the stent graft. CONCLUSIONS: Computational fluid dynamics may provide quantitative assessment of hemodynamic wall forces in TB-AD potentially of interest for follow-up examinations.

An image processing algorithm for the in-vivo quantification and visualization of septum motion in type III B - aortic dissections with cine magnetic resonance imaging.

Currently, there is no method to predict outcome of endovascular treatment (EVAR) of type III B aortic dissections (TB-AD). A new image processing algorithm is presented for quantifying IS displacement from cine 2D phase contrast magnetic resonance images (2D pcMRI) towards a new classification of TB-AD based on IS mobility. Bulk motion of the true aortic lumen (tAB) center (ALC), maximum, minimum and average displacement of the boundary points composing the IS and tAB excluding the IS were quantified at two locations in one patient. Correlations of the ALC motion and the averaged temporal displacement AD(t) of IS and tAB excluding IS with the aortic flow waveform were calculated. Range of ALC motion was similar in both locations (average 0.56 mm, max 1.37 mm) and correlated with the aortic flow waveform in the abdominal aorta but not the thoracic aorta. Range of displacement of the IS was from 1.27 mm to -1.64 mm (average 0.09 + or - 0.07 mm) in the thoracic aorta, and from 0.38 mm to -3.38 mm (average 0.42 + or - 0.23 mm) in the abdominal aorta. tAB motion excluding the IS was 1.21 mm to 0.84 mm (thoracic, average 0.13 + or - 0.07 mm) and 0.52 mm to -1.88 mm (abdominal, average 0.37 + or - 0.11 mm). AD(t) for IS and tAB excluding the IS both correlated with aortic flow in the abdominal aorta only.