Midterm evaluation of perigraft arterial sac embolization in endovascular aneurysm repair.

OBJECTIVE: Management of clinically significant endoleaks (ELs) remains costly, time-consuming, and morbid. Unresolved ELs can result in rupture and mortality after endovascular aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) has been used to treat ELs diagnosed at the time of EVAR or during surveillance. METHODS: A retrospective review of prospectively maintained databases was conducted. The databases were compiled from two institutions between 2006 and 2016. PASE was performed for type I, type II, or type III EL with a thrombin, contrast medium, and Gelfoam (Pfizer, New York, NY) slurry prepared as previously described. PASE was administered either at the time of EVAR (primary) or during surveillance (secondary). Safety end points included nontarget embolization, defined as neurologic or enteric clinical sequelae from lumbar artery or visceral artery embolization, allergic reaction, peripheral embolization, or rupture. Efficacy end points included successful resolution of EL and cessation of aneurysm sac growth on computed tomography (CT) scans with contrast enhancement. RESULTS: A total of 66 patients included in the study were treated with PASE. Primary PASE was performed in 38 patients (58%) and secondary in 28 (42%). Within the total cohort, the average clinical and CT scan follow-up was 1.7 years (0.1-11.6 years). Four patients required open repair for residual high-pressure ELs (one type IIIB and three type I; 6%). Of the 95% of patients who did not require open conversion, aneurysm growth did not occur during the follow-up period. In the overall cohort, PASE was successful in 88% of type I EL and 73% of patients with type II EL. There was no evidence of recanalization after thrombosis of culprit vessel for EL. No patients suffered nontarget embolization, spinal ischemia, allergic reaction, post-EVAR rupture, or colonic ischemia. CONCLUSIONS: Primary and secondary PASE proved to be a safe, effective, and durable tool in sac management in conjunction with EVAR. Treating ELs during or after EVAR with PASE has minimized the incidence of EL on CT scan and halted aneurysm growth in our cohort. Further studies are needed to confirm the long-term durability of PASE in reducing secondary interventions after EVAR.

Blunt Traumatic Occlusion of the Common Iliac Artery Repaired With Segmental Excision and Internal Iliac Artery Patch Angioplasty.

Common iliac artery (CIA) occlusion as a result of blunt trauma is rare and seldom reported. This has been associated with pelvic fractures and other great vessel lesions. Management options include endovascular covered stent placement, open anatomic repair with autogenous conduit, or open extra-anatomic repair with prosthetic material. We report the case of a middle-aged male with a right CIA injury secondary to blunt trauma who underwent a successful repair using an internal iliac artery patch for injury to a 2 cm segment of CIA with peritoneal contamination. There is no definitively superior method to address CIA injuries in this setting reported in the literature. The use of the internal iliac artery as a patch can be regarded as an additional safe repair option when an autogenous repair is required for a large defect in the CIA as this can enable mobilization of the vessel for primary repair and offer a source for an autogenous patch.

Early vascular consultation in the setting of oncologic resections: benefit for patients and a continuing source of open vascular surgical training.

BACKGROUND: Oncologic surgeons have become more aggressive at tumor resections that often require complex open vascular interventions. Vascular surgeons may be consulted preoperatively to aid in these cases, or commonly called into the operating room for an urgent consult. These operations provide a challenge to the vascular surgeon and also an opportunity for open vascular surgical training of residents. We present our experience with vascular surgical interventions during oncologic resections. METHODS: A retrospective review of a prospectively maintained vascular registry was performed to identify patients undergoing vascular surgery in the setting of oncologic resections. Tumor histology, location, type of vascular intervention, vascular, and oncologic outcomes were recorded and reviewed. RESULTS: Over a 7-year period, 21 oncologic cases involving vascular surgeons were identified. Tumor types included sarcoma (9), adenocarcinoma (4), germ cell (4), paraganglioma (2), and others (2). Tumor locations included abdominal/pelvic (15), cervical (3), and extremity (3). Complete resection was achieved in 18 of the 19 patients; 2 patients underwent exploration alone for carcinomatosis. Vascular surgical procedures included bypass grafts in 7 patients, resection with primary repair in 5 patients, ligation/excision in 4 patients, and arterial mobilization in 3 patients. No major vascular complications occurred. Short-term patency rates were 100%. Survival rates following therapeutic resection were 90%, 80%, and 80% at 1, 3, and 5 years, respectively. Vascular surgeons were involved in the preoperative planning in 11 cases (52%). Patients with preoperative vascular consultation had significantly fewer vascular injuries, a nonsignificant trend toward lower blood loss, and a nonsignificant trend toward improved survival than those with urgent intraoperative vascular consultation. CONCLUSIONS: Vascular interventions can lead to favorable long-term outcomes during definitive oncologic resection of diverse tumor histologies and locations. Vascular surgeons must be prepared to participate, frequently urgently, in oncologic procedures. Standard open techniques employing all aspects of vascular exposures continue to be integral to vascular surgery training. Preoperative consultation between the oncologic and vascular surgeons may lead to improved outcomes.

Effects of prior abdominal surgery, obesity, and lumbar spine level on anterior retroperitoneal exposure of the lumbar spine.

OBJECTIVE: To evaluate the effects of prior abdominal surgery and obesity and the level of spine exposure on the technical aspects and complications of anterior retroperitoneal exposure of the lumbar spine (ARES). DESIGN: Retrospective review of prospective database. SETTING: Academic vascular surgery practice. PATIENTS: Patients undergoing ARES from 2001 to 2011. MAIN OUTCOME MEASURES: Influence of prior abdominal surgery, obesity, and level of exposure on time to spine exposure and incidence of vascular and perioperative complications. RESULTS: Four hundred seventy-six patients underwent ARES. Mean (SD) age was 47.7 (12.6) years; 46.6% had undergone prior abdominal surgery. Mean (SD) body mass index (BMI) was 28.3 (5.5); 61.6% of procedures included the L4-5 disk. Mean (SD) time to exposure was 70.0 (25.5) minutes. Vascular injury occurred in 23.3% (3.8% major). Perioperative complications occurred in 16.4% of cases. Prior abdominal surgery had no effect on time to exposure, vascular injury, and perioperative complications. A BMI of 30 or more had no effect on time to exposure compared with a lower BMI. A BMI of 30 or more led to higher rates of vascular injury (30.8% vs 19.7%; P = .007) and overall complications (21.4% vs 14.0%; P = .04). Exposures involving L4-5 led to increased time to exposure (77.0 vs 56.2 minutes; P < .001) and higher rates of vascular injury (29.7% vs 13.1%; P < .001) but had no effect on overall complications compared with exposures for other levels. CONCLUSION: Prior abdominal surgery should not be considered a contraindication to ARES. Caution is warranted in obese patients and exposures involving L4-5.