Low-profile versus standard-profile multibranched thoracoabdominal aortic stent grafts.

OBJECTIVE: This study compared midterm results using low-profile stent grafts (LPSGs; 18F) and standard-profile stent grafts (SPSGs; 22F-24F) for endovascular pararenal and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: From July 2005 to March 2015, 134 asymptomatic patients underwent endovascular repair of a pararenal or TAAA using multibranched aortic stent grafts. In March 2011, we started using a LPSG with nitinol stents and thin-walled polyester fabric. Prospectively collected data on operative repair, complications, and outcomes were compared between the two groups. RESULTS: LPSGs were used in 37 patients (8 women [21.6%]; mean ± standard deviation age, 72.5 ± 8 years) and SPSGs in 97 patients (25 [26%] women; mean age, 73 ± 8 years). Medical comorbidities, aneurysm size, and aneurysm extent were similar in the LPSG and SPSG groups. Mean follow-up time was longer in the SPSG group (3.1 ± 2 years) than in the LPSG group (1.3 ± 0.9 years; P < .001). Operative time, renal failure, stroke, myocardial infarction, and perioperative death were not significantly different between the two groups (P > .05). Aneurysm-related death, rupture, stent graft migration, type I or III endoleaks, aneurysm enlargement >5 mm, branch vessel occlusion, and reintervention rates were similar between the two groups (P > .05). However, the combined outcome of conduit use or access artery injury occurred at a lower rate in the LPSG group than in the SPSG group (16% vs 36%; P = .03). Women experienced significantly higher rates of conduit use and access artery injury than men after repair with SPSGs (64% vs 26%, respectively; P = .001) but similar rates after repair with the LPSG (25% vs 14%, respectively; P = .45). CONCLUSIONS: LPSGs had similar safety profile and midterm outcomes compared with the SPSGs for treatment of pararenal and TAAA. The substitution of LPSGs for SPSGs lowered the number of patients who required conduit insertion to avoid access artery injury, especially in women, thereby reducing an otherwise striking gender difference.

Standard off-the-shelf versus custom-made multibranched thoracoabdominal aortic stent grafts.

OBJECTIVE: The complex aortic branch anatomy in thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs) presents a challenge for endovascular repair. The multibranched endovascular device has durable midterm results with use of a custom branch stent graft (CSG) configuration. The midterm results with use of the standard branch stent graft (SSG) configuration are unknown, but it has the advantage of off-the-shelf technology. The goal of this study was to compare the midterm outcomes of CSG and SSG multibranched endovascular devices. METHODS: From July 2005 to September 2014, 133 patients underwent elective endovascular repair of TAAA and PRAA in a prospective trial. Beginning in December 2008, SSGs were used in those with suitable anatomy. RESULTS: Fifty patients (mean age, 71 ± 7 years; 11 women [22%]) were treated using SSGs, and 83 patients (mean age, 74 ± 9 years; 22 women [26.5%]) underwent repair using CSGs. The SSG and CSG groups were similar with regard to aneurysm size, aneurysm extent, and medical comorbidities, with the sole exception of lung disease, which was more common in the SSG group. All stent grafts were deployed as intended, with no conversions to open repair. Mean ± standard deviation follow-up (days) was 694 ± 525 for the SSG group and 942 ± 764 for the CSG group (P = .045). There were no significant differences in aneurysm-related death, renal failure requiring dialysis, stroke, endoleak, visceral or renal branch occlusion, lower extremity weakness, or reintervention (P > .05 for each). The volume of contrast material was significantly lower in those with SSGs compared with CSGs (P = .016), but there were no significant differences in operative or fluoroscopy times. Time to treatment (days from consent to surgery) was significantly lower in SSG patients compared with CSG patients (P = .01). CONCLUSIONS: For patients with suitable anatomy, the use of SSGs for TAAA and PRAA repair results in significantly shorter wait times to surgery and is as safe, effective, and durable in the midterm compared with CSGs.

Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts.

OBJECTIVE: We conducted our study to describe the incidence, presentation, management, risk factors, and outcomes of lower extremity weakness (LEW) after elective endovascular aneurysm repair with multibranched thoracoabdominal stent grafts. METHODS: Excluding symptomatic patients and those with aortic dissection, between July 2005 and October 2013, 116 patients with aortic aneurysms were treated in a prospective, single-center trial of multibranched endovascular aneurysm repair. LEW that resolved within 30 days of operation was classified as transient. Persistent LEW was defined as inability to walk or stand 30 days after surgery. Perioperative spinal cord protection measures included bypass as needed to maintain flow to the subclavian and internal iliac arteries, cerebrospinal fluid drainage, and permissive hypertension. RESULTS: Postoperative LEW occurred in 24 of 116 patients (20.6%). In 15 (12.9%), LEW was transient with full recovery. Nine patients (7.7%) had persistent LEW, three with paraparesis and six with paraplegia. Five of 24 patients (21%) awoke from anesthesia with LEW. Symptoms of LEW developed within 72 hours of operation in 14 of 24 (58%). Late-onset LEW (≥72 hours postoperatively) always occurred in the presence of a precipitating hypotensive event (5 of 24; 21%). Univariate analysis showed no association between LEW and Crawford type, staged repair, aneurysm extent, or postoperative endoleak. Baseline glomerular filtration rate <30 mL/min/1.73 m(2) (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.2-14.6; P = .03), fluoroscopy time >190 minutes (OR, 3.6; 95% CI, 1.0-12.7; P = .04), and sustained hypotension (OR, 2.9; 95% CI, 1.1-7.7; P = .04) were identified as independent risk factors for LEW in multivariate analysis. CONCLUSIONS: Most episodes of LEW after multibranched endovascular aneurysm repair are transient and do not occur in the operating room. Adjunctive strategies to maintain spinal perfusion, including cerebrospinal fluid drainage and permissive hypertension, may help prevent permanent LEW.

Assessing the anatomic applicability of the multibranched endovascular repair of thoracoabdominal aortic aneurysm technique.

BACKGROUND: Multibranched endovascular aneurysm repair (MBEVAR) has the potential to lower the morbidity and mortality rates of thoracoabdominal aneurysm repair, but the applicability of the technique is unknown. Our aim was to estimate the prevalence of anatomic suitability for MBEVAR. METHODS: Retrospective review of patients referred for a prospective trial of MBEVAR between November 2005 and July 2012. Anatomic suitability was assessed on three-dimensional computed tomography scan reconstructions according to the current criteria for a custom-made stent graft or a fixed, off-the-shelf stent graft in both standard (22F) and low-profile (18F) delivery systems. RESULTS: A total of 250 contrast-enhanced computed tomography scans were reviewed, 49 of which were excluded due to inadequate aneurysm size. Of 201 candidates for repair, 149 (74%) were men and 86 (43%) had Crawford classification type IV/paravisceral aneurysms; 109 (58%) were anatomically suitable for a single-stage repair with a custom-made, low-profile stent graft. Another 58 (29%) could have been made suitable for MBEVAR with an adjunct procedure, including angiogram with visceral or renal artery stenting (n = 23), carotid-subclavian bypass (n = 5), or iliac bypass for device insertion (n = 17), or to preserve internal iliac artery flow because of an iliac aneurysm (n = 9), or dissection (n = 8). There was no association between suitability and gender, aneurysm diameter, or type. However, women were significantly more likely to need a conduit or low-profile device (P = .003). Patients with type B aortic dissections were significantly less likely to have anatomy suitable for repair (P = .035) and more likely to require a multistage repair. Thirty-four patients would have been unsuitable for repair because of renal artery anatomy (n = 14), visceral artery anatomy (n = 4), lack of a proximal landing zone due to an arch aneurysm (n = 7), or inadequate access arteries (n = 9). The low-profile device increased the number of patients who would have been suitable for a single-stage repair by 16. The off-the-shelf graft has the advantage of a faster assessment-to-treatment time, but only 64 patients would have been suitable for a single-stage repair and another 30 could have been made suitable with an adjunct procedure. CONCLUSIONS: Most patients would have been suitable or could have been made suitable for a thoracoabdominal stent graft using current anatomic criteria. The applicability of MBEVAR will continue to change as the experience with the technique grows and devices evolve, as evidenced by the potential reduction in iliac bypasses after the introduction of a low-profile device and the ability to treat symptomatic or urgent patients with the off-the-shelf device.

Impact of supplemental training programs on improving medical students' confidence in providing diabetes self-management education and support.

BACKGROUND/PURPOSE: The purpose of this study was to evaluate the effectiveness of supplemental diabetes-related training modalities and volunteer activities in increasing first-year medical students' knowledge/comfort in providing diabetes self-management education and support (DSMES) to patients. METHODS: A group of medical students developed supplemental diabetes-related training/volunteer programs. The training modalities included an optional 7-session interprofessionally taught Diabetes Enrichment Elective and a 3-hour endocrinologist-led training session intended to prepare students for involvement in an inpatient DSMES volunteer program. The volunteer program provided the students with the opportunity to provide DSMES to patients with diabetes admitted to an academic medical center. Those participating in any of the stated programs were compared to those with no such training regarding confidence in providing DSMES using an optional online survey. The results were analyzed by using Mann-Whitney U test and descriptive analyses. RESULTS: A total of 18 first-year medical students responded to the optional survey with a response rate of ~30% (10 of 33) among participants in any training/volunteer program. First-year medical students who attended any of the offered optional programs had statistically significant higher comfort level in 4 of the 6 areas assessed regarding providing DSMES compared with those with no such training (p<0.05), with medium to large effect size (r=0.48-0.59). CONCLUSION: This study suggests that the supplemental preclerkship diabetes-specific training modalities/volunteer programs can provide benefit in providing medical students with practical knowledge while improving their confidence in providing DSMES to patients with diabetes.