One-year results of the INSIGHT study on endovascular treatment of abdominal aortic aneurysms.

OBJECTIVE: Endovascular repair of abdominal aortic aneurysms (AAAs) using the INCRAFT AAA Stent Graft System was safe and effective in regulatory approval studies. We herein report on the 1-year results of a real-world clinical study. METHODS: The INSIGHT study is a multi-center, prospective, open label, post-approval study conducted to continually evaluate the safety and performance of the INCRAFT System. Between 2015 and 2016, 150 consecutive patients with AAA at 23 centers in Europe were treated with the device in routine clinical practice. The primary endpoint was freedom from major adverse events (MAEs), namely death, myocardial infarction, cerebrovascular accident, and renal failure, within 30 days of the index procedure. End point data were assessed by a core laboratory. The secondary end points included technical success at the conclusion of the procedure and clinical success. RESULTS: All 150 patients studied (mean age, 73.6 ± 8.0 years; 89.3% men) met the primary end point without MAEs at 30-day follow-up. Technical success was achieved in 99.3% of patients without stent fractures at 30 days. Among the 146 patients eligible for 1-year follow-up, the MAE rate was 8.2% (ie, 12 patients suffered 13 MAEs: cerebrovascular accident in 8, myocardial infarction in 1, and 4 died, resulting in a 2.7% all-cause mortality rate). There were no reports of new onset renal failure requiring dialysis. Only 2.7% of patients had type I endoleak, and no type III endoleaks were identified through 1 year. The rate of clinical success at 1 year was 91.8%. CONCLUSIONS: The 1-year results of this multicenter real-world study underscore the safety and effectiveness of endovascular treatment of AAA with the INCRAFT System in routine clinical practice.

Nationwide Study to Predict Colonic Ischemia after Abdominal Aortic Aneurysm Repair in The Netherlands.

BACKGROUND: Colonic ischemia remains a severe complication after abdominal aortic aneurysm (AAA) repair and is associated with a high mortality. With open repair being one of the main risk factors of colonic ischemia, deciding between endovascular or open aneurysm repair should be based on tailor-made medicine. This study aims to identify high-risk patients of colonic ischemia, a risk that can be taken into account while deciding on AAA treatment strategy. METHODS: A nationwide population-based cohort study of 9,433 patients who underwent an AAA operation between 2014 and 2016 was conducted. Potential risk factors were determined by reviewing prior studies and univariate analysis. With logistic regression analysis, independent predictors of intestinal ischemia were established. These variables were used to form a prediction model. RESULTS: Intestinal ischemia occurred in 267 patients (2.8%). Occurrence of intestinal ischemia was seen significantly more in open repair versus endovascular aneurysm repair (7.6% vs. 0.9%; P < 0.001). This difference remained significant after stratification by urgency of the procedure, in both intact open (4.2% vs. 0.4%; P < 0.001) and ruptured open repair (15.0% vs. 6.2%); P < 0.001). Rupture of the AAA was the most important predictor of developing intestinal ischemia (odds ratio [OR], 5.9, 95% confidence interval [CI] 4.4-8.0), followed by having a suprarenal AAA (OR 3.4; CI 1.1-10.6). Associated procedural factors were open repair (OR 2.8; 95% CI 1.9-4.2), blood loss >1L (OR 3.6; 95% CI 1.7-7.5), and prolonged operating time (OR 2.0; 95% CI 1.4-2.8). Patient characteristics included having peripheral arterial disease (OR 2.4; 95% CI 1.3-4.4), female gender (OR 1.7; 95% CI 1.2-2.4), renal insufficiency (OR 1.7; 1.3-2.2), and pulmonary history (OR 1.6; 95% CI 1.2-2.2). Age <68 years proved to be a protective factor (OR 0.5; 95% CI 0.4-0.8). Associated mortality was higher in patients with intestinal ischemia versus patients without (50.6% vs. 5.1%, P < 0.001). Each predictor was given a score between 1 and 4. Patients with a score of ≥10 proved to be at high risk. A prediction model with an excellent AUC = 0.873 (95% CI 0.855-0.892) could be formed. CONCLUSIONS: One of the main risk factors is open repair. Several other risk factors can contribute to developing colonic ischemia after AAA repair. The proposed prediction model can be used to identify patients at high risk for developing colonic ischemia. With the current trend in AAA repair leaning toward open repair for better long-term results, our prediction model allows a better informed decision can be made in AAA treatment strategy.

Chimney Technique to Preserve Visceral Flow in a Coral Reef Aorta.

The coral reef aorta (CRA) is a rare phenomenon of extreme calcification in the juxtarenal and suprarenal aorta. Open revascularization has an overall in-hospital mortality rate of 13%. We present a patient with a suprarenal CRA with colon ischemia. She has an extensive past medical history of percutaneous transluminal angioplasty and stenting of the celiac trunk (CT) and superior mesenteric artery (SMA). The computed tomography angiography showed a CRA of the suprarenal aorta with occlusion of the CT stent and near occlusion of the SMA stent. Our case illustrates that the CRA in the suprarenal part of the aorta can be treated well by chimney graft procedure, although owing to lack of long-term follow-up, it might be reserved for high-risk candidates for (thoraco)abdominal aortic surgery.

Validation of randomized controlled trial-derived models for the prediction of postintervention outcomes in chronic limb-threatening ischemia.

BACKGROUND: Chronic limb-threatening ischemia (CLTI) represents the most severe form of peripheral artery disease and has a large impact on quality of life, morbidity, and mortality. Interventions are aimed at improving tissue perfusion and averting amputation and secondary cardiovascular complications with an optimal risk-benefit ratio. Several prediction models regarding postprocedural outcomes in CLTI patients have been developed on the basis of randomized controlled trials to improve clinical decision-making. We aimed to determine model performance in predicting clinical outcomes in selected CLTI cohorts. METHODS: This study validated the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL), Finland National Vascular registry (FINNVASC), and Prevention of Infrainguinal Vein Graft Failure (PREVENT III) models in data sets from a peripheral artery disease registry study (Athero-Express) and two randomized controlled trials of CLTI in The Netherlands, Rejuvenating Endothelial Progenitor Cells via Transcutaneous Intra-arterial Supplementation (JUVENTAS) and Percutaneous Transluminal Angioplasty and Drug-eluting Stents for Infrapopliteal Lesions in Critical Limb Ischemia (PADI). Receiver operating characteristic (ROC) curve analysis was used to calculate their predictive capacity. The primary outcome was amputation-free survival (AFS); secondary outcomes were all-cause mortality and amputation at 12 months after intervention. RESULTS: The BASIL and PREVENT III models showed predictive values regarding postintervention mortality in the JUVENTAS cohort with an area under the ROC curve (AUC) of 81% and 70%, respectively. Prediction of AFS was poor to fair (AUC, 0.60-0.71) for all models in each population, with the highest predictive value of 71% for the BASIL model in the JUVENTAS population. The FINNVASC model showed the highest predictive value regarding amputation risk in the PADI population with AUC of 78% at 12 months. CONCLUSIONS: In general, all models performed poor to fair in predicting mortality and amputation. Because the BASIL model performed best in predicting AFS, we propose use of the BASIL model to aid in the clinical decision-making process in CLTI. However, improvements in performance have to be made for any of these models to be of real additional value in clinical practice.

Endovascular Revascularization of a Chronic Occluded Aortobifemoral Bypass.

Bilateral limb occlusion after aortobifemoral (ABF) prosthesis occurs in 1-3% patients. Multiple remedial choices are known in literature to manage a bilateral occluded ABF such as "redo" ABF bypass, axillobifemoral bypass, endovascular recanalization of the native aortoiliac system, and thrombectomy. We present a patient with an occluded ABF bypass since 2001. A new minimal invasive treatment strategy was performed by traversing the occluded limbs with aortic re-entry using stiff Terumo wires. To make way for safe passing of the stents, kissing balloon angioplasty was performed of the entire ABF bypass. Kissing Viabahn (W. L. Gore & Associates, Flagstaff, AZ) balloon-expandable stents were placed in the proximal part of the ABF bypass and extended with a Viabahn self-expandable stent (standard Viabahn). This option should be added to the known multiple remedial choices in case of bilateral limb occlusion of an ABF.

Severe Infrarenal Atheroma Load in Open Aortic Aneurysm Repair Is Not a Risk Factor for Postoperative Acute Kidney Injury.

BACKGROUND: Acute kidney injury (AKI) after open aortic repair is subject to multiple patient- and operation-related variables. Hostile neck morphology in open aneurysm repair is thought to contribute to this AKI risk postoperatively. The aim of this study was to evaluate if large neck atheroma is a possible risk factor in the postoperative development of AKI. METHODS: Retrospectively 137 patients were evaluated for neck atheroma and AKI incidence. Atheroma load measurements were performed by 2 different techniques. Results were compared, and secondly a univariate analysis was performed for multiple additional risk factors regarding AKI occurrence. RESULTS: Significant (>30%) neck atheroma was not associated with a higher risk for developing AKI (odds ratio [OR]: 1.81; 95% confidence intervals: 0.74-4.44). Overall incidence of AKI based upon Acute Kidney Injury Network criteria was 19.7%. In univariate analysis coronary artery disease and the presence of a renal artery stenosis were both significantly associated with AKI (OR: 2.38, 3.31, respectively) as well as the use of B-blockers and angiotensin converting enzyme inhibitors (OR 3.05, 2.48, respectively). CONCLUSIONS: Cross-clamping in case of significant neck atheroma during open aortic aneurysm repair is not associated with increased risk of AKI. Defining high-risk patients based on additional risk factors must be a part of preoperative patient selection.

Safety and effectiveness of selective carotid angioplasty prior to cardiac surgery: a single-centre matched case-control study.

OBJECTIVES: Reducing the rate of postoperative stroke after cardiac surgery remains challenging, especially in patients with occlusive cerebrovascular disease. Angioplasty in all patients with high-grade carotid artery stenosis has not been shown to be effective in reducing the post-surgical stroke rate. In this study, we present the initial results of a different approach using selective carotid angioplasty only in patients with poor intracranial collaterals. METHODS: We conducted a single-centre study to assess the safety of this procedure. The postangioplasty complication rate of the study group was compared to that of patients who were scheduled for symptomatic carotid artery angioplasty. To determine the effectiveness of this procedure, the post-cardiac surgery complication rate of the study group was compared with that of the matched case controls. RESULTS: Twenty-two patients were treated with selective carotid angioplasty without developing persistent major neurological complications. All patients except 1 patient subsequently underwent surgery without developing persistent major neurological disabilities. Two patients died of cardiogenic shock within 30 days. CONCLUSIONS: Selective carotid angioplasty prior to cardiac surgery in patients with a presumed high risk of stroke was relatively safe and effective in this study group. Although this strategy does not prevent stroke in these high-risk patients, data suggest that this approach shifts the postoperative type of stroke from a severe haemodynamic stroke towards a minor embolic stroke with favourable neurological outcomes. Larger studies are needed to determine whether this strategy can effectively eliminate the occurrence of haemodynamic stroke after cardiac surgery.

High and immeasurable ankle-brachial index as predictor of poor amputation-free survival in critical limb ischemia.

OBJECTIVE: The objective of this study was to assess the prognostic value of a high or immeasurable ankle-brachial index (ABI) at baseline for major amputation and amputation-free survival (AFS) in patients with critical limb ischemia (CLI). METHODS: Data from two recent trials in patients with CLI and proven infrapopliteal arterial obstructive disease were pooled. Patients were allocated to the low (<0.7), intermediate (0.7-1.4), or high (>1.4)/immeasurable ABI subgroup. Major amputation and AFS rates were compared. Hazard ratios for major amputation and death were calculated. The net reclassification improvement of incorporating high/immeasurable ABI in the Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III) prediction model was derived. RESULTS: There were 146 patients (56.2%) who had a low ABI, 81 patients (31.2%) who had an intermediate ABI, and 33 patients (12.7%) who had a high/immeasurable ABI at baseline. Patients with high/immeasurable ABI showed higher 5-year major amputation (52.1%) and lower 5-year AFS (5.0%) rates than the intermediate (25.5% and 41.6%, respectively) and low ABI patients (23.5% and 46.9%, respectively; both P < .001). This same trend was observed in subgroup analysis of diabetics and nondiabetics. Adjusted hazard ratio of high/immeasurable ABI for major amputation/death risk was 2.93 (P < .001). Adding a high/immeasurable ABI as model factor to the PREVENT III model yielded a net reclassification index of 0.38 (P < .0001). CONCLUSIONS: A high/immeasurable ABI in patients with CLI and infrapopliteal arterial obstructive disease is an independent risk factor of major amputation and of poor AFS, in both diabetics and nondiabetics. Incorporating high/immeasurable ABI in the PREVENT III prediction model improves its performance.

Determinants of Acute Kidney Injury and Renal Function Decline After Endovascular Abdominal Aortic Aneurysm Repair.

OBJECTIVE/BACKGROUND: Endovascular aneurysm repair (EVAR) may be associated with renal injury and more insight is needed into potential risk factors. The aim was to identify clinical, anatomical, and peri-procedural parameters as potential risk factors for the occurrence of acute kidney injury (AKI) and to evaluate chronic kidney disease (CKD) after EVAR. METHODS: A cohort of 212 consecutive patients who underwent elective EVAR for abdominal aortic aneurysm from January 2009 to October 2016 was included. A subgroup of 149 patients with 2 years follow-up was compared with a set of 135 non-operated aneurysm patients with smaller aneurysms (similar cardiovascular risk profile) to assess CKD. Primary outcomes were AKI (Acute Kidney Injury Network criteria) and CKD measured by estimated glomerular filtration rate (Kidney Disease Improving Global Outcomes guidelines). For AKI, candidate risk factors were identified by univariate and multivariate logistic regression analysis; for chronic renal function decline, risk factors were identified using Cox regression analysis. RESULTS: AKI occurred in 30 patients (15%). On multivariate analysis, the use of angiotensin II blocker (odds ratio [OR] 4.08, 95% confidence interval [CI] 1.38-12.07) and peri-operative complications (OR 3.12, 95% CI 1.20-8.10) were independent risk factors for AKI, whereas statin use was a protective factor (OR 0.19, 95% CI 0.07-0.52). EVAR resulted in a significant increase (23.5%) in the occurrence of CKD compared with the control group (6.7%; p <.001). On univariate and multivariate Cox regression the risk factors: aortic neck diameter (per mm increase) (hazard ratio [HR] 1.13, 95% CI 1.02-1.25), renal artery stenosis >50% (HR 2.24, 95% CI 1.05-4.79), and the occurrence of AKI (HR 2.19, 95% CI 0.99-4.85) were significant predictors of CKD. CONCLUSION: This study identified use of angiotensin II blockers and peri-operative complications as risk factors for AKI. In addition, the problem of renal function decline after EVAR is highlighted, which indicates that prolonged protective measures (e.g., in those patients at high risk) over time are needed to improve patient outcomes.

Impact of the Haga Braincare Strategy on the burden of haemodynamic and embolic strokes related to cardiac surgery.

OBJECTIVES: This study prospectively evaluates the impact of the Haga Braincare Strategy (HBS) on the occurrence of haemodynamic and embolic stroke in a cohort of patients who underwent coronay artery bypass grafting (CABG), valve replacement of a combination of both types of surgery between 2012 and 2015 at the Haga Teaching Hospitals. METHODS: The HBS is a dual strategy based on a preoperative vascular work-up of the cerebral circulation by transcranial Doppler and a perioperative monitoring of the cerebral circulation by cerebral oximetry. Duplex of the carotid arteries and/or computed tomography angiography prior to surgery was performed in high-risk patients. Patients with severe carotid artery stenosis were scheduled for carotid angioplasty prior to surgery or waived from surgery. RESULTS: A total of 1065 patients were included. Poor cerebral haemodynamics were identified by transcranial Doppler in 2.1% of patients (n = 22). Based on the HBS, 3 patients were waived from surgery, 4 received preoperative carotid angioplasty followed by cardiac surgery and the remaining patients were operated while being monitored with bilateral cerebral oximetry sensors. In all, 2.2% of the study group experienced a stroke (n = 23), of which none were classified as haemodynamic. Most of the remaining presumed embolic strokes showed a minor to moderate stroke severity. CONCLUSIONS: In this single-centre prospective follow-up study, surveillance of cerebral perfusion by the HBS eliminated the occurrence of haemodynamic stroke while most of the residual strokes had a good to favourable prognosis.

Antegrade Ureteral Stenting is a Good Alternative for the Retrograde Approach.

BACKGROUND/AIMS: Double J (JJ) stents for treating obstructive ureteral pathology are generally inserted through a retrograde route with cystoscopic guidance. Antegrade percutaneous insertion using fluoroscopy can be performed alternatively but is less known. Indications, success rate and complications of antegrade ureteral stenting were evaluated. METHODS: Data of consecutive patients in which antegrade ureteral stenting was performed were retrospectively analysed using the radiology information system and patient records. Patient characteristics, details of the antegrade JJ stent insertion procedure and registered complications were collected. Furthermore, it was investigated if prior to the antegrade procedure a retrograde attempt for JJ stent insertion was performed. RESULTS: Total 130 attempts for antegrade JJ stent insertion were performed in 100 patients. A percutaneous nephrostomy catheter had already been placed in the majority of kidneys (n = 109) for initial treatment of hydronephrosis. Most prevelant indication for a JJ stent was obstructive ureteral pathology due to malignancy (n = 63). A JJ stent was successfully inserted in 125 of 130 procedures. In 21 cases, previous retrograde ureteral stenting had failed but, subsequent antegrade ureteral stenting was successful. There were 8 procedure related complications; 6 infections, 1 false tract and 1 malposition. CONCLUSION: Antegrade percutaneous insertion of a JJ stent is a good alternative for retrograde insertion.

Percutaneous Transluminal Angioplasty and Drug-Eluting Stents for Infrapopliteal Lesions in Critical Limb Ischemia (PADI) Trial.

BACKGROUND: Endovascular infrapopliteal treatment of patients with critical limb ischemia using percutaneous transluminal angioplasty (PTA) and bail-out bare metal stenting (BMS) is hampered by restenosis. In interventional cardiology, drug-eluting stents (DES) have shown better patency rates and are standard practice nowadays. An investigator-initiated, multicenter, randomized trial was conducted to assess whether DES also improve patency and clinical outcome of infrapopliteal lesions. METHODS AND RESULTS: Adults with critical limb ischemia (Rutherford category ≥4) and infrapopliteal lesions were randomized to receive PTA±BMS or DES with paclitaxel. Primary end point was 6-month primary binary patency of treated lesions, defined as ≤50% stenosis on computed tomographic angiography. Stenosis >50%, retreatment, major amputation, and critical limb ischemia-related death were regarded as treatment failure. Severity of failure was assessed with an ordinal score, ranging from vessel stenosis through occlusion to the clinical failures. Seventy-four limbs (73 patients) were treated with DES and 66 limbs (64 patients) received PTA±BMS. Six-month patency rates were 48.0% for DES and 35.1% for PTA±BMS (P=0.096) in the modified-intention-to-treat and 51.9% and 35.1% (P=0.037) in the per-protocol analysis. The ordinal score showed significantly worse treatment failure for PTA±BMS versus DES (P=0.041). The observed major amputation rate remained lower in the DES group until 2 years post-treatment, with a trend toward significance (P=0.066). Less minor amputations occurred after DES until 6 months post-treatment (P=0.03). CONCLUSIONS: In patients with critical limb ischemia caused by infrapopliteal lesions, DES provide better 6-month patency rates and less amputations after 6 and 12 months compared with PTA±BMS. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00471289.

Endovascular treatment in patients with acute ischemic stroke and apparent occlusion of the extracranial internal carotid artery on CTA.

BACKGROUND: Intra-arterial treatment is gaining importance in acute ischemic stroke, but its role in patients with apparent occlusion of the extracranial internal carotid artery (ICA) on computed tomographic angiography (CTA) is inconclusive. OBJECTIVE: To review retrospectively the results of intra-arterial treatment in patients with stroke and apparent extracranial ICA occlusion. METHODS: In more than 3000 patients with stroke admitted to our institution during 2008-2013, and the subgroup with suboptimal results after intravenous thrombolysis (IVT), CTA showed the absence of contrast in the extracranial ICA in 16 patients. Angiography showed true occlusion of the extracranial ICA in 10 and pseudo-occlusion in 6 patients. Treatment was considered technically successful when Thrombolysis in Cerebral Infarction scale (TICI) scores improved to 2 or 3 and clinically successful when the National Institutes of Health Stroke Scale (NIHSS) improved by at least 10 points or a NIHSS score of 0 or 1 was found at discharge. RESULTS: Recanalization was achieved in 5 of 6 patients with pseudo-occlusions and in 6 of 10 patients with true occlusion of the extracranial ICA. Favorable clinical outcomes were seen in 3 of 6 patients with pseudo-occlusions and in 4 of 10 patients with true occlusions. Four patients died, and in these patients infarction of >15% of the affected hemisphere had been seen on admission CT. CONCLUSIONS: In cases of acute stroke and apparent occlusion of the extracranial ICA, intra-arterial treatment should be considered, especially when IVT fails and <15% of the hemisphere is infarcted on CT. Endovascular treatment may be beneficial especially in pseudo-occlusions but also in true occlusions of the extracranial ICA.

[When peripheral drips fail: favourable experience with peripherally-inserted central venous catheters]. / Wanneer perifere infusen falen: goede ervaringen met perifeer ingebrachte centraalveneuze katheters.

OBJECTIVE: Evaluation of the technical success rate, insertion complications and patient survival when peripherally-inserted central venous catheters (PICCs) are used in oncologic patients and patients with severe infections in whom it was not possible to place a peripheral drip. DESIGN: Retrospective cohort study. METHOD: Patient records and the radiological computer system RADOS were searched and analysed for data regarding patients, variables at the time of PICC insertion, indwelling time and the reasons for PICC removal. RESULTS: During the period 1 September 2000 - 30 June 2007, 68 patients underwent 101 attempts for PICC placement. Ninety-one (91%) procedures were successful in 64 patients. There were 2 (2%) periprocedural complications; local haematoma (n=1) and palpitations (n=1). At the time of data analysis 14 (15%) PICCs were still in situ. Forty-five (50%) had been removed electively after a mean period of 114 (range: 10-446) days. Thirty-two (35%) PICCs had been removed prematurely after a mean period of 67 (range: 7-266) days. Reasons for premature removal were infection (n=14, 15%), migration (n=10, 11%), dislocation (n=4, 4%), clinical thromboses (n=2, 2%) and occlusion (n=2, 2%). CONCLUSION: PICCs appear to be a good alternative in oncologic patients and patients with infections in whom peripheral drip insertion is not possible. The technical success rate of PICCs was high and was associated with a low periprocedural complication rate. The percentage of prematurely removed catheters seems acceptable, in part because these catheters were removed after a mean period of 2 months.

Update on PADI trial: percutaneous transluminal angioplasty and drug-eluting stents for infrapopliteal lesions in critical limb ischemia.

The Percutaneous transluminal Angioplasty and Drug eluting stents for Infrapopliteal lesions in critical limb ischemia (PADI) trial is a prospective, multicenter, randomized, controlled, double-arm study investigating the safety and efficacy of primary paclitaxel-eluting stent implantation vs primary percutaneous transluminal angioplasty (PTA) in infrapopliteal lesions in critical limb ischemia (CLI). PTA with provisional "bailout" stent implantation is currently an accepted treatment for arterial obstructions in CLI, including those in below-the-knee arteries. A drawback compared to open bypass surgery is the relatively high restenosis rate. One proposed method to reduce restenosis is the use of drug-eluting stents (DES), as these have shown good results in the coronary bed. Primary DES implantation for focal obstructions in infrapopliteal arteries in CLI potentially reduces restenosis compared to PTA alone and may subsequently prolong effect of treatment, allowing for better wound healing, and preventing recurrence of symptoms. In this article, we report on rationale, design, and progress of the PADI trial, which investigates the safety and efficacy of a paclitaxel-eluting stent system compared to PTA with provisional bare metal stent implantation.

Metastases in supraclavicular lymph nodes in lung cancer: assessment with palpation, US, and CT.

PURPOSE: To compare ultrasonography (US), computed tomography (CT), and palpation for diagnosing supraclavicular lung cancer metastases and to assess the effect of proved metastases on TNM stage and diagnostic work-up. MATERIALS AND METHODS: One hundred seventeen consecutive patients (91 men and 26 women; mean age, 64.0 years) underwent palpation, US, and CT of supraclavicular regions and chest and upper abdominal CT. Fine-needle aspiration cytologic (FNAC) analysis was performed in patients with nodes with a short-axis diameter of 5 mm or greater; cytologic diagnosis was used as the standard of reference. Sensitivities of palpation, US, and CT were compared with McNemar testing. Relationship between size and palpability of nodes with metastasis was evaluated with logistic regression. RESULTS: Supraclavicular metastases were diagnosed cytologically in 30 (26%) of 117 patients: eight (31%) of 26 patients with small cell lung cancer (SCLC) and 22 (24%) of 91 patients with non-small cell lung cancer (NSCLC). Sensitivities of US (1.00; 30 of 30 patients) and CT (0.83; 25 of 30 patients) for detection of metastases were significantly higher (P <.001 and P =.001, respectively) than that of palpation (0.33; 10 of 30 patients). Palpable nodes with metastasis (mean diameter, 25.2 mm) were significantly larger than nonpalpable nodes with metastasis (mean diameter, 13.7 mm) (P =.002). To have a 50% chance of being palpable, nodes with metastasis had to have a diameter of at least 22.3 mm. TNM stage was changed in three of 91 patients with NSCLC, and further invasive diagnostic procedures were prevented in 11 of such patients because it was proved that nonpalpable nodes had metastases. CONCLUSION: Supraclavicular lung cancer metastases were cytologically proved in 26% of patients. Nodes with metastasis were only palpable when markedly enlarged. US tripled the sensitivity of palpation for detection of metastases. Results of US and US-guided FNAC analysis can change the work-up in patients with lung cancer.

Endovascular aneurysm repair with a bifurcated endovascular graft at a primary referral center: influence of experience, age, gender, and aneurysm size on suitability.

OBJECTIVE: The purpose of this study was to assess the suitability for endovascular repair of abdominal aortic aneurysm (EVAR) in an unselected patient population. PATIENTS AND METHODS: Between February 1999 and May 2002 all consecutive patients with a nonemergent abdominal aortic aneurysm (AAA) were prospectively examined with contrast material-enhanced spiral computed tomography (CT). Those patients probably suitable for EVAR on the basis of CT findings underwent calibrated angiography. A panel of radiologists and vascular surgeons reviewed the clinical data and vascular anatomy, and decided on the appropriateness of EVAR with the bifurcated Zenith AAA endovascular graft. RESULTS: One hundred seven patients were included. Fifty-six patients (52%) had one or more contraindications for EVAR. Unsuitability was most frequently (88%) related to the proximal neck. Inadequate neck length was the most common specific reason. Inadequate iliac anatomy was the reason for unsuitability in 59% of patients. The rate of unsuitability decreased from 61% during the first half of the study to 40% during the second half (P =.03) Unsuitability was equal between men and women. Age and maximum diameter did not differ between candidates and noncandidates. CONCLUSION: Almost half (48%) of patients with an infrarenal AAA referred to a primary referral center are suitable for EVAR with the bifurcated Zenith AAA endovascular graft. Neck anatomy was the most frequent reason for rejection. Rate of suitability increased over time, probably as a result of increasing experience. Suitability was not influenced by gender, age, or aneurysm size.