Common Iliac Artery Aneurysm Repair with Hypogastric Preservation via Balloon-Expandable Covered Stents Using the Eyelet Technique-Iliac Branched Devices Still Inappropriate in Many Patients.

BACKGROUND: Common iliac artery aneurysms (CIAAs) are seen in 20-40% of patients with abdominal aortic aneurysms. Historically treated with sacrifice of the hypogastric artery, which can result in significant morbidity related to pelvic ischemia, new devices have made hypogastric artery preservation more feasible but are only applicable to a small subset of aneurysm anatomy. We sought to assess the safety and efficacy or a novel technique for hypogastric artery preservation applicable to a wider variety of patients with CIAAs. METHODS: We conducted a retrospective review of a prospectively maintained database of all patients with CIAAs treated with a novel endovascular technique at the UC San Diego Sulpizio Cardiovascular Center or the San Diego Veterans Affairs Hospital between March 2016 and December 2017. The endovascular technique involved stent placement in both the internal and external iliac arteries, with balloon expansion to minimize gutters between the endografts. Primary end points included technical success, limb patency, and presence of endoleaks (ELs). RESULTS: A total of 14 limbs (12 patients) were treated for CIAAs with 100% technical success and limb patency at an average of 6.8 months of follow-up. No patients experienced type I or type III ELs or evidence of pelvic ischemia. Two patients required reintervention, and one patient died of causes unrelated to the procedure. CONCLUSIONS: This technique was performed with excellent short- and mid-term safety in patients with varying aneurysm anatomy. The high rates of technical success and low rate pelvic ischemia represent improvement over conventional techniques that sacrifice the hypogastric artery and warrant further testing in a larger patient series with longer term follow-up.

Dialysis Access Hemorrhage: Access Rescue from a Surgical Emergency.

BACKGROUND: Hemorrhage from a dialysis access can be a life-threatening condition. This study details our experience using access rescue strategies, including in situ graft replacement, primary repair, or conversion to an autogenous fistula, coupled with treatment of central vein occlusion to maintain access usage in patients presenting with conduit hemorrhage. METHODS: During a 3-year period (2012-2014), 26 patients (14 women, 12 men) on chronic hemodialysis were treated for access conduit bleeding (n = 18) or life-threatening hemorrhage (n = 8), located in the upper extremity (n = 23) or thigh (n = 3). All patients had developed bleeding from a skin eschar/ulcer over a bovine (n = 9) or polytetrafluoroethylene (n = 9) bridge graft, or aneurysmal autogenous fistula (n = 8). A retrospective review of outcome relative to clinical signs, etiology of conduit bleeding (infection, wall erosion), and the type of rescue procedure(s) was performed. Duplex ultrasound testing was used to guide therapy based on the presence of aneurysmal degeneration, perigraft fluid, or access flow pattern indicative of venous outflow obstruction. RESULTS: One-half of the patients were taken emergently to the operating room for hemorrhage control or impending rupture of an infected false aneurysm, the remaining repaired on an urgent basis. In 18 patients, emergency room personnel attempted control of access site bleeding by suturing (n = 14) or tourniquet (n = 4). Dialysis access salvage was achieved in 22 (85%) of 26 patients by in situ conduit replacement using a rifampin-soaked polytetrafluoroethylene conduit (n = 19) or primary repair (n = 3). Two patients with sepsis and ruptured, infected false aneurysm were treated by ligation, and 2 patients with nonsalvable access had conversion to an autogenous fistula. One-third of rescued accesses (n = 7) had staged endovascular treatment of central vein stenosis. One patient died within 30 days. All dialysis access revisions remained patent and used for immediate dialysis (n = 5), within 4-5 weeks (n = 19), or after vein maturation (n = 2). One replaced graft was revised for infection. Positive blood or bleeding site cultures were obtained from 9 (45%) of 20 patients tested. CONCLUSIONS: Salvage of a functional dialysis access is possible in the majority of patients presenting with conduit hemorrhage. Loss of wall integrity, infection, and venous hypertension were etiologic factors. Application of in situ graft replacement strategies known to be effective in the treatment of graft infection should be considered in the management of this surgical emergency.

Computed Tomography Fractional Flow Reserve Can Identify Culprit Lesions in Aortoiliac Occlusive Disease Using Minimally Invasive Techniques.

BACKGROUND: Currently, the gold standard diagnostic examination for significant aortoiliac lesions is angiography. Fractional flow reserve (FFR) has a growing body of literature in coronary artery disease as a minimally invasive diagnostic procedure. Improvements in numerical hemodynamics have allowed for an accurate and minimally invasive approach to estimating FFR, utilizing cross-sectional imaging. We aim to demonstrate a similar approach to aortoiliac occlusive disease (AIOD). METHODS: A retrospective review evaluated 7 patients with claudication and cross-sectional imaging showing AIOD. FFR was subsequently measured during conventional angiogram with pull-back pressures in a retrograde fashion. To estimate computed tomography (CT) FFR, CT angiography (CTA) image data were analyzed using the SimVascular software suite to create a computational fluid dynamics model of the aortoiliac system. Inlet flow conditions were derived based on cardiac output, while 3-element Windkessel outlet boundary conditions were optimized to match the expected systolic and diastolic pressures, with outlet resistance distributed based on Murray's law. The data were evaluated with a Student's t-test and receiver operating characteristic curve. RESULTS: All patients had evidence of AIOD on CT and FFR was successfully measured during angiography. The modeled data were found to have high sensitivity and specificity between the measured and CT FFR (P = 0.986, area under the curve = 1). The average difference between the measured and calculated FFRs was 0.136, with a range from 0.03 to 0.30. CONCLUSIONS: CT FFR successfully identified aortoiliac lesions with significant pressure drops that were identified with angiographically measured FFR. CT FFR has the potential to provide a minimally invasive approach to identify flow-limiting stenosis for AIOD.

Congenital agenesis of inferior vena cava: a rare cause of unprovoked deep venous thrombosis.

Congenital anomalies of the inferior vena cava (IVC), although rare, are a risk factor for lower limb deep venous thrombosis (DVT). A 19-year-old male presented with a left flank and groin pain caused by iliofemoral venous thrombosis. Vascular imaging by computed tomography (CT) scanning and venography demonstrated agenesis of the IVC. Catheter-directed thrombolysis via a popliteal vein was attempted but did not alter the patency of the common femoral vein outflow collaterals into the retroperitoneal azygous venous system. The patient was anticoagulated using systemic heparin infusion and clinical symptoms resolved within 5 days. He was transitioned to oral Coumadin anticoagulation, and follow-up venous duplex testing demonstrated no infrainguinal DVT and phasic venous flow with respiration in the femoral vein indicating patent collateral veins. Anomalies of the IVC are present in 0.3-0.5% of otherwise healthy individuals. Agenesis of the IVC has an incidence of 0.0005-1% in the general population but is found in almost 5% of patients <30 years of age with unprovoked lower limb DVT. In adults, IVC agenesis anomaly can cause diagnostic problems in the paravertebral area because of the tumor-like appearance of the azygous venous collaterals on noncontrast CT imaging. In young adults presenting with unprovoked lower limb DVT, the presence of an IVC anomaly should be considered and evaluated for by venous duplex testing and if necessary CT venography.

Spinal cord ischemia occurring in association with induced hypotension for colonic surgery.

A 19-year-old woman underwent an ileoanal pull-through. Intraoperatively, deepening of anesthesia was associated with reduced bleeding. Therefore, induced hypotension, mean arterial blood pressure 50 to 55 mm Hg, was maintained for 2.5 hours. Postoperatively, the patient was paraplegic with spinal cord infarction on magnetic resonance imaging from T9 to the tip of the conus medullaris. The collateralization of the anterior spinal artery is very variable and it seems likely that in this individual induced hypotension was associated with inadequate blood flow in the distribution of the artery of Adamkiewicz.

Migration of vascular embolisation material from the intravascular space to surrounding interstitial tissues in arteriovenous malformations.

We present the case of a young man active duty in the military who initially presented with pelvic pain and fullness during sexual activity. Extensive workup showed a large pelvic arteriovenous malformation (AVM). He underwent over 10 interventional radiology procedures to embolise his AVM and suffered multiple postoperative complications resulting in exploratory laparotomies, bowel resections and ultimately a colostomy. Six years after his embolisation procedures, he was found on imaging to have gluteal fluid collections with metallic particles, presumed to be migrated Onyx from his angioembolisations as a result of non-target embolisation. Current literature does not document other instances of Onyx material migrating from an intravascular source to interstitial tissue.

Intervention after endovascular aneurysm repair: Endosalvage techniques including perigraft arterial sac embolization and endograft relining.

Endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysm (AAA). However, persistent AAA sac endoleak following EVAR can result in sac diameter increase requiring re-intervention in up to one-third of cases and even result in aneurysm rupture. In this case review, we summarize and detail endovascular re-interventions for each type of endoleak. We also detail specific options including stent-graft relining for indeterminate, Type III, and Type IV endoleaks and perigraft arterial sac embolization to induce thrombosis and resolve acute Type I, II, or III endoleaks. Endograft relining involves placement of a new stent-graft-elevating the bifurcation and extending the repair from renal artery to hypogastric arteries; perigraft arterial sac embolization involves placement of a catheter into the excluded sac from common femoral artery access, characterization of the inflow and outflow of the endoleak, and inducing cessation of the blood flow into the sac by the administration of thrombogenic material. Endoleaks range from low-pressure endoleaks, which can be safely monitored in a surveillance program to high-pressure endoleaks, which mandate intervention when associated with AAA sac diameter increase to protect from rupture. The evaluation of new devices and techniques to treat endoleak after EVAR remains an important issue in patient care after EVAR.

Incorporating robot-assisted prostatectomy at a Veterans Affairs hospital: outcomes.

PURPOSE: To evaluate a unique method of extended mentorship in robot-assisted laparoscopic prostatectomy (RALP) at VA San Diego Healthcare System (VASDHS). As novel robotic technologies diffuse into surgical practice, developing safe apprenticeships remains a challenge. PATIENTS AND METHODS: Between October 2008 and November 2010, 90 RALPs were prospectively divided into three phases: Proctored, Independent, and Instructor. During the first 30 Proctored cases, an experienced robotic surgeon from the affiliated university-based hospital mentored a robotic novice attending surgeon with previous open retropubic and laparoscopic experience. The novice surgeon gained proficiency during the next 30 Independent cases, then introduced increasing resident participation during the last Instructor 30 cases. Patient demographics, tumor characteristics, operative measures, and length of hospital stay were compared. Functional outcomes were assessed using the Sexual Health Inventory for Men and an incontinence questionnaire. We used independent t test, analysis of variance, Mann-Whitney U test, Fisher exact test, Kruskal-Wallis, and Pearson chi-square tests for comparison in these patient populations. RESULTS: All groups were similar in age, clinical T-stage, and D'Amico Risk Group. Preoperative prostate-specific antigen levels were significantly higher (P<0.001) and prostates were larger (P=0.044) in the middle Instructor Phase. The early Proctored Phase had the lowest Gleason scores and the lowest body mass indexes. Despite these differences favoring the Proctored Phase, immediate operative outcomes were similar with respect to safety, oncologic, and functional parameters. CONCLUSIONS: In the VASDHS cohort, RALPs were performed safely under the supervision of a newly proctored attending surgeon. Although longer follow-up could reveal subtle differences between groups, overall follow-up was similar to most existing studies. Extended mentorship by an experienced surgeon is a viable model for achieving proficiency in RALP in a setting such as a VA hospital affiliated with an academic hospital and increasing access to care for the veteran patient population.

Assessment and remedial clinical education of surgeons in California.

HYPOTHESIS: Assessment and remedial clinical education of practicing surgeons is feasible and possibly beneficial. DESIGN: Retrospective series. SETTING: Urban academic medical center. PARTICIPANTS: Licensed surgeons. INTERVENTIONS: Structured assessment and remedial clinical education based on resident-education models. MAIN OUTCOME MEASURES: Assessment and clinical education results. RESULTS: Forty-seven general, general/vascular, and colorectal surgeons were assessed by the University of California, San Diego, Physician Assessment and Clinical Education program in 2000 to 2010. Forty-six (98%) were male (mean [SD] age, 54 [11] years; range, 34-80 years). Thirty-three (70%) came from state medical board actions: 25 from California's disciplinary division, 2 from California's licensing division, 3 from other state boards, and 3 self-referred during other state board actions. Fourteen (30%) came from health care organizations: 8 from California hospitals, 3 from hospitals in other states, 2 self-referred during hospital proceedings, and 1 self-referred during a medical group investigation. Twenty-three (49%) underwent a 2-day assessment only, including a 1-hour mock oral board examination: 8 "passed" with no recommendations; 6, with minor recommendations; 6 had major recommendations; and 3 "failed." Twenty-four surgeons (51%) also completed 26 five-day clinical education programs, with 20 "passes," 1 minor recommendation, 3 major recommendations, and 2 "fails." CONCLUSION: A program of assessment and remedial clinical education of surgeons designed to meet the needs of one medical board is being used by nongovernmental organizations as well, and it seems to meet the needs of some individual surgeons. This type of program may play a role in the profession's self-regulation.

Endovascular repair of an aortopulmonary fistula via the axillary artery.

A 62-year-old man presented with several months of progressive hemoptysis. He has a history of aortobifemoral bypass and thoracofemoral bypass grafts, which were both removed due to infection. Evaluation with multiple imaging modalities revealed a descending thoracic aortic pseudoaneurysm around the retained Dacrontrade mark graft with bronchiectatic changes and consolidation of the adjacent left lower lobe. No evidence of direct arterial communication between the aorta and the bronchioles was ever demonstrated, but an aortopulmonary fistula was suspected. Endovascular repair with several Excluder aortic cuffs stacked in the thoracic aorta was successfully performed via the axillary artery. Exclusion of the pseudoaneurysm with no evidence of endoleak was noted on computed tomography 2 months postoperatively, at which time the patient reported complete resolution of his hemoptysis. To our knowledge, this is the first report of endovascular repair of an aortopulmonary fistula via the axillary artery.

Surgical management of acute complications and critical restenosis following carotid artery stenting.

Carotid artery angioplasty with stenting (CAS) is being increasingly used in the treatment of extracranial carotid artery stenosis. As in other catheter-based approaches to the treatment of arterial disease, surgical intervention may be required because of either acute complications or correct critical restenosis. We have reviewed our experience managing early complications and critical in-stent restenoses after CAS in a tertiary care university hospital and a Veterans Affairs Medical Center. During the last 5 years, 22 carotid arteries (21 patients) underwent CAS. One patient developed thrombosis and rupture of the carotid artery during stenting. Two other patients (3 arteries) developed critical restenosis within 12 months. Subsequent surgical reconstructions included an internal carotid artery (ICA)-to-external carotid artery (ECA) transposition and a common carotid artery (CCA)-to-ICA bypass with reversed saphenous vein (RSV). The patient who underwent CCA-to-ICA bypass later required subclavian-to-ICA bypass because of rapidly progressive intimal hyperplasia and subsequent occlusion of the CCA. The other patient has not had surgical repair because of his deteriorating condition and significant co-morbidities. During the same time period, two additional patients were referred from outside institutions specifically for surgical intervention after carotid stenting. One had delayed rupture of the carotid artery 1 day after stenting and underwent urgent surgical repair. Another patient had early, critical restenosis within the stent and underwent placement of a CCA-to-ICA interposition graft using RSV. Acute treatment failures after CAS can be successfully managed using standard surgical techniques. Patients who develop critical in-stent restenosis requiring surgical repair may need more challenging surgical reconstructions to maintain cerebral perfusion.

Surgical and endovascular treatment of lower extremity venous insufficiency.

Lower extremity venous insufficiency is a highly prevalent condition. Now it is understood that telangiectasias, reticular varicosities, and true varicose veins are physiologically similar and etiologically identical. The four main influences causing these abnormalities are heredity, female sex, gravitational hydrostatic forces, and hemodynamic muscular compartment pressure. There are clear indications and goals for intervention. A cornerstone in the treatment of venous insufficiency is elimination of sources of venous hypertension. One of these is the refluxing greater saphenous vein. Minimally invasive saphenous ablation can be achieved by radiofrequency energy and laser light energy. These new techniques eliminate the psychologic barrier to treatment caused by the term "stripping" and allow the objectives of surgery to be achieved with minimal invasion and quick recovery. Endovenous techniques show great promise. They provide minimal invasion, often under local anesthesia and intravenous sedation, thereby eliminating the need for general anesthesia. Objectives of venous insufficiency have been established and the endoluminal minimally invasive techniques developed in recent years appear to accomplish their goals.

Small-caliber mesothelial cell-layered polytetraflouroethylene vascular grafts in New Zealand white rabbits.

Reduction in the thrombogenicity of small-caliber synthetic vascular grafts by lining them with mesothelial cell has been suggested as a method to reduce thrombosis. The purpose of this research is to determine whether creation of a mesothelial lining on the inner surface of a synthetic vascular graft would improve the patency rate of a small-caliber vascular grafts. Carotid interposition grafting was performed using mesothelial-lined grafts (MLG) in 30 New Zealand rabbits and compared with similar carotid interposition grafts using non-mesothelial-lined grafts (NLG) on the contralateral side. The mesothelial lining was created by suturing a piece of harvested peritoneum with the visceral surface toward the lumen onto a 2-mm polytetraflouroethylene (PTFE) graft. Graft patency was studied by in vivo Dopler. In vitro evaluations were done with hematoxylin-eosin stains, broadband cytokeratin staining, and monoclonal antibodies for macrophages. Explanation of the grafts was done in terminal operation at 7, 14, and 21 days. The MLG showed progressive fibroblastic proliferation in direct proportion to the age of the graft, but this did not lead to graft occlusion. However, a significant number of NLG were not patent at each time period studied. We concluded that mesothelial cell lining of smallcaliber PTFE grafts could enhance the short-term patency more than using the PTFE without the mesothelial lining. The use of such hybrid small-caliber grafts has a potential for improving the patency of these artificial vascular graft substitutes.

Early experience using the Wallgraft in the management of distal microembolism from common iliac artery patholology.

Blue toe syndrome commonly occurs as a result of aneurysmal or atherosclerotic disease in the iliac arteries. Surgery, angioplasty, or intraarterial stent placement are the most common treatment options but the optimal management has not been defined. Here we report managing distal microembolization from iliac artery atherosclerosis associated with aneurysmal dilation with the Wallgraft Endoprosthesis, a self-expanding metallic stent covered with Dacron. Three common iliac arteries in two patients were treated using this device. A 79-year-old male presented with unilateral symptoms and an 83-year-old female with bilateral disease. Arteriography demonstrated complex plaque at the aortic bifurcation associated with aneurysmal dilation of the distal common iliac artery in both patients. This complex disease was successfully covered using the Wallgraft Endoprosthesis. Postoperatively the patients received aspirin, their toe lesions healed, and neither has had a recurrence after 16 months. Covered stents offer the theoretic advantage of completely excluding the diseased segment, preventing the escape of thrombus or plaque debris, and covering aneurysmal dilation in the artery.