Outcome Predictors in Civilian and Iatrogenic Arterial Trauma.

BACKGROUND: Our aim was to identify predictors of mortality and limb loss in iatrogenic and civilian arterial trauma. METHODS: Cases were identified by searching prospectively maintained registries. Multivariable logistic regression was used to identify independent outcome predictors. RESULTS: During the study period, 285 patients with arterial trauma were managed with endovascular (n = 20) or open (n = 265) repair. Iatrogenic injuries increased in frequency during the course of the study, from 23.9% during the first decade to 35.9 and 55.7% during the second and third decade, respectively (p < 0.001). Endovascular management increased in frequency during the course of the study, from 0% during the first decade to 5.1 and 11.1% during the second and third decade, respectively (p = 0.005). Mortality was 9.8%, and limb loss (in cases with injury of the aorta or limb arteries, n = 259) was 6.2%. Independent predictors of mortality included increased age (odds ratio, 95% confidence interval [OR, 95% CI] 1.05 (1.02-1.07), p < 0.001), blunt trauma (OR [95% CI] 4.8 (1.9-12.2), p = 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.25 (1.1-1.4), p = 0.001). Independent predictors of limb loss included the first half of the study period (OR [95% CI] 3.9 (1.1-14.1), p = 0.04), lower extremity arterial trauma (vs upper extremity, aortic, common or external iliac artery trauma, OR [95% CI] 8.3 (1.9-35.7), p = 0.004), bone fracture (OR [95% CI] 16.9 (4.7-62.5), p < 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.16 (1.02-1.33), p = 0.024). CONCLUSION: Increasingly iatrogenic in cause and managed by endovascular methods, arterial trauma remains a problem associated with significant mortality and limb loss. Identification of unfavourable outcome predictors may help clinicians involved with arterial trauma to escalate the level of care.

Snare Entrapment During EVAR Limb Cannulation Resulting in Open Conversion. A Rare Complication.

We present an unreported complication that occurred during an accidental loss of the ipsilateral limb's wire during EVAR. During an endovascular repair of an abdominal aortic aneurysm (EVAR), unintentional loss of the ipsilateral limb's wire during deployment and withdrawal of the endogaft's main body occurred. The snare's loops were entrapped while attempting to catch the wire through the limb. Multiple maneuvers were performed to detach the snare, but all were unsuccessful. We then performed a conversion to open repair. In conclusion, commercially available endografts should include standard radiopaque markers in the ipsilateral limb to facilitate retrograde cannulation. Retrieval via the snare should not be performed proximal to the gate of the limb.

Predictors of Operative Mortality of 928 Intact Aortoiliac Aneurysms.

BACKGROUND: The aim of this study is to identify preoperative and intraoperative factors associated with in-hospital mortality of intact abdominal aortoiliac aneurysm repair. METHODS: In this observational study, prospectively collected information included demographics, risk factors, comorbidities, aneurysm characteristics (including special aneurysm presentation, i.e., inflammatory, mycotic/infected, aortocaval fistula), investigations, and operative variables. Receiver operating characteristic) curve analysis of the Glasgow aneurysm score (GAS) and the Vascular Study Group of New England (VSGNE) score was performed in the subgroup of bland aneurysms undergoing isolated elective repair. RESULTS: A total of 928 cases with intact aortoiliac aneurysms had an elective (n = 882) or urgent (n = 46) repair, associated with an in-hospital mortality of 1.7% and 8.7%, respectively (P = 0.01). Open repair (n = 514) was a predictor of higher mortality (3.3% vs. 0.5% for endovascular aneurysm repair [EVAR], n = 414, odds ratio [OR] 7.1, P = 0.003), and so was the pre-EVAR era (4.8% vs. 1.3% in the EVAR era, OR 4.0, P = 0.004). Other significant predictors included the presence of abdominal/back pain (7.5% vs. 1.3%, OR = 6.0, P = 0.001), preoperative angiography (7% vs. 1.6%, OR = 4.5, P = 0.01), special aneurysm presentation (10.9% vs. 1.5%, OR = 8.1, P < 0.001), concomitant major procedures (19% vs. 1.7%, OR = 14.0, P < 0.001), serious intraoperative complications (9.1% vs. 1.5%, OR = 6.6, P = 0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, P < 0.001), and procedure duration (270 and 150 min for cases with and without mortality, respectively, P < 0.001). Open repair (OR = 4.5, P = 0.05), special aneurysm presentation (OR = 6.58, P = 0.001), and concomitant major procedures (OR = 14.3, P < 0.001) were independent predictors of higher mortality. ROC curve analysis for the GAS (P = 0.87) and VSGNE score (P = 0.10) failed to demonstrate statistical significance in the subgroup of bland aneurysms undergoing isolated elective repair. CONCLUSIONS: Our study has demonstrated independent risk factors for mortality, which should be considered when contemplating aortoiliac aneurysm repair. We failed to externally validate the GAS and VSGNE score.

Improved effectiveness of the repositionable GORE EXCLUDER AAA endoprosthesis featuring the C3 delivery system compared with the original GORE EXCLUDER AAA endoprosthesis for within the instructions for use treatment of aortoiliac aneurysms.

OBJECTIVE: To compare two endograft types, the original GORE EXCLUDER AAA endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) with the repositionable GORE EXCLUDER featuring the C3 delivery system, which allows repositioning of the proximal part of the graft to achieve accurate placement in relation to the renal arteries, in unselected patients with aortoiliac aneurysms. In a second nested, substudy we investigated the relative effect of the standard Gore and Gore Dryseal introducer sheaths on intraoperative transfusion needs. METHODS: We retrospectively analyzed prospectively collected information. The primary composite outcome measure was the intraoperative misdeployment or migration of the endograft's main body, proximally or distally to the renals (leading to technical failure or requiring either placement of aortic cuff extenders or conversion to open repair). Secondary outcome measures included the composite long-term event of rupture and/or type I/III endoleak. RESULTS: A total of 313 consecutive patients (303 males; median age, 73 years) had either an original GORE EXCLUDER device (n = 174) or the new device (n = 139) placed between 2004 and 2011 and 2011 and 2017, respectively, to treat an infrarenal aortoiliac aneurysm or an isolated common iliac artery aneurysm. The primary composite outcome measure occurred more often in patients who had the original GORE EXCLUDER device placed (10.9% vs 3.6% for the new device; odds ratio, 0.30; 95% confidence interval, 0.11-0.84; P = .016), confirmed by multivariate logistic regression analysis. This difference between the two groups was exclusively driven by distal misdeployment or migration of the endograft (10.3% vs 2.9% for the new device; P = .01), mostly requiring aortic extender placement. Intraoperative blood transfusion rates were lower in patients who had the GORE Dryseal introducer sheath used (1.1% vs 18.9% for the original GORE introducer sheath; OR, 0.05; 95% confidence interval, 0.006-0.35; P < .001). At a mean follow-up of 1.7 years (maximum, 13 years), 11 patients developed the composite event. On univariate Cox analysis, significant predictors included female gender (P = .003), absence of dyslipidemia (P = .023), the primary outcome measure (P = .006), and failure to cannulate (P = .009), but not device type or other variables. On multivariate Cox regression, female gender (hazard ratio, 37; P < .001), chronic obstructive pulmonary disease (hazard ratio, 3.99; P = .045), the primary outcome measure of the study (hazard ratio, 8.9; P = .002), and failure to cannulate (hazard ratio, 43; P = .003) were all independent predictors. CONCLUSIONS: Our study has demonstrated that the repositionable GORE EXCLUDER has important safety characteristics compared with the original device and equivalent long-term effectiveness. Additional benefit was obtained with the use of the Gore Dryseal introducer sheath.

Use of Drug-Coated Balloons in Dysfunctional Arteriovenous Dialysis Access Treatment: The Effect of Consecutive Treatments on Lesion Patency.

PURPOSE: A retrospective longitudinal analysis was performed to evaluate the outcome of consecutive treatments with drug-coated balloons (DCBs) in dysfunctional arteriovenous (AV) dialysis access (fistulae and grafts). MATERIALS AND METHODS: From January 2015 to December 2017, 339 DCBs were used in 257 procedures in 165 patients with dysfunctional accesses. Of these, 38 patients had ≥ 2 procedures and were included in the analysis. A total of 112 procedures were performed with 133 devices (22 patients treated twice, 4 treated 3 times, 7 treated 4 times, 2 treated 5 times, and 3 treated 6 times). Mean balloon diameter was 8.13 mm (min-max range, 3-12 mm) and length was 63.16 mm (min-max range, 40-150 mm). Primary outcome measures were safety and effectiveness based on the noninferiority hypothesis that the second treatment would be as effective as the first regarding postintervention primary patency (PIPP). Secondary outcome measures included independent factors that may influence outcomes. RESULTS: Mean lesion follow-up was 617 d (range, 175-1,100 d). Median PIPP durations were 216.5 d for the first intervention and 280 d for the second (P = .37; hazard ratio, 1.271; 95% confidence interval, 0.75-2.16). There was a significant difference in PIPP in favor of the second intervention when patients with only 2 interventions (22 of 38; 57.9%) were included (first intervention, 269 d; second intervention, 520 d; P = .03; hazard ratio, 2.354; 95% confidence interval, 1.087-5.098). CONCLUSIONS: There was no significant difference in PIPP between the first and second DCB procedures. Results suggest consistency in PIPP with the use of DCBs regardless of aging AV access.

Acute Effects of Graduated Elastic Compression Stockings in Patients with Symptomatic Varicose Veins: A Randomised Double Blind Placebo Controlled Trial.

OBJECTIVES: To investigate the effectiveness of graduated elastic compression stockings (GECS) below the knee in improving symptoms in patients with varicose veins in the absence of high quality evidence. METHODS: This was a randomised double blind placebo controlled trial. Thirty patients with no experience of elastic stockings, presenting with primary varicose veins causing calf pain or aching were randomised to a GECS (18-21 mmHg at the ankle level, n=15) or a placebo stocking (0 mmHg, n=15). Pain or aching of the index leg after 1 week was the primary outcome measure. In patients with bilateral varicose veins the leg with the most severe pain/aching was considered. Other defined symptoms were secondary outcome measures. All symptoms were scored on a visual analogue scale (VAS). RESULTS: The two study groups were well balanced at baseline. At the completion of the study after 1 week, GECS were more effective than placebo stockings in reducing pain or aching (VAS score 1.7±3.0 vs. 4.5±2.8 for placebo, p=.02), while non-significant trends were observed for some of the remaining symptoms of the index leg, including feeling of swelling (VAS score 0.9±1.9 vs. 3.3±3.5 for placebo), paraesthesiae (VAS score 0.2±0.6 vs. 2.1±3.1 for placebo), and the number of symptoms other than pain or aching (1.3±1.1 vs. 2.8±1.7 for placebo). Number needed to treat (95% CI) for a 50% or complete improvement of pain or aching in the index leg was 2 (95% CI 1.2-5.5) and 2 (95% CI 1.2-5.3), respectively. Mean daily use of the placebo stockings and GECS was 8.0 hours and 10.2 hours, respectively (p=.13). CONCLUSIONS: Among patients with varicose veins, GECS seem effective in ameliorating symptoms, particularly pain or aching, compared with placebo stockings after 1 week of use. Long-term studies are justified.