Contemporary indications for open abdominal aortic aneurysm repair in the endovascular era.

OBJECTIVE: Despite the emergence of endovascular aneurysm repair (EVAR) as the most common approach to abdominal aortic aneurysm repair, open aneurysm repair (OAR) remains an important option. This study seeks to define the indications for OAR in the EVAR era and how these indicatioxns effect outcomes. METHODS: A retrospective cohort study was performed of all OAR at a single institution from 2004 to 2019. Preoperative computed tomography scans and operative records were assessed to determine the indication for OAR. These reasons were categorized into anatomical contraindications, systemic factors (connective tissue disorders, contraindication to contrast dye), and patient or surgeon preference (patients who were candidates for both EVAR and OAR). Perioperative and long-term outcomes were compared between the groups. RESULTS: We included 370 patients in the analysis; 71.6% (265/370) had at least one anatomic contraindication to EVAR and 36% had two or more contraindications. The most common anatomic contraindications were short aortic neck length (51.6%), inadequate distal seal zone (19.2%), and inadequate access vessels (15.7%). The major perioperative complication rate was 18.1% and the 30-day mortality was 3.0%. No single anatomic factor was identified as a predictor of perioperative complications. Sixty-one patients (16.5%) underwent OAR based on patient or surgeon preference; these patients were younger, had lower incidences of coronary artery disease and chronic obstructive pulmonary disease, and were less likely to require suprarenal cross-clamping compared with patients who had anatomic and/or systemic contraindications to EVAR. The patient or surgeon preference group had a lower incidence of perioperative major complications (8.2% vs 20.1%; P = .034), shorter length of stay (6 days vs 8 days; P < .001) and no 30-day mortalities. The multivariable adjusted risk for 15-year mortality was lower for patient or surgeon preference patients (adjusted hazard ratio, 0.44; 95% confidence interval, 0.24-0.80; P = .007) compared with those anatomic or systemic contraindications. CONCLUSIONS: Within a population of patients who did not meet instruction for use criteria for EVAR, no single anatomic contraindication was a marker for worse outcomes with OAR. Patients who were candidates for both aortic repair approaches but elected to undergo OAR owing to patient or surgeon preference have very low 30-day mortality and morbidity, and superior long-term survival rates compared with those patients who underwent OAR owing to anatomic and/or systemic contraindications to EVAR.

Emergency intraoperative vascular surgery consultations at a tertiary academic center.

OBJECTIVE: Vascular surgeons are frequently called on to provide emergency assistance to surgical colleagues. Whereas previous studies have included elective preoperative vascular consultations, we sought to characterize the breadth of assistance provided during unplanned intraoperative consultations at a single tertiary academic center. METHODS: We queried our institutional billing department during a 15-year period and reviewed the records (January 1, 2002-December 31, 2016) and identified unanticipated unplanned vascular surgery intraoperative consultations from all surgical services. Patients' demographics and comorbidities were recorded along with the consulting services, type of index operation, reasons for vascular consultation, regions of anatomic interventions, type of vascular interventions performed, and outcomes achieved. RESULTS: There were 419 emergency intraoperative consultations identified. Patients were 51% male, with an average age of 57 years and body mass index of 28.3 kg/m2. The most frequently consulting subspecialties included surgical oncology (n = 139 [33.2%]), cardiac surgery (n = 82 [19.6%]), and orthopedics (n = 44 [10.5%]). Index cases were elective/nonurgent (n = 324 [77.3%]), urgent (n = 27 [6.4%]), and emergent (n = 68 [16.2%]), with a majority involving tumor resection (n = 240 [57.3%]). The primary reasons for vascular consultation were revascularization (n = 213 [50.8%]), control of bleeding (n = 132 [31.5%]), assistance with dissection or exposure (n = 46 [11%]), embolic protection (n = 24 [5.7%]), and other (n = 4 [1.1%]). The primary blood vessel and anatomic field of intervention were categorized. Most cases (n = 264 [63%]) included preservation of blood flow, including primary arterial repair (n = 181 [43.2%]), patch angioplasty (n = 83 [19.8%]), bypass (n = 63 [15%]), and thrombectomy (n = 38 [9.1%]). Postoperative mean length of stay was 15 days, with 30-day and 1-year mortality of 7.2% and 26.5%. CONCLUSIONS: Vascular surgeons are called on to provide unplanned open surgical consultations for a wide variety of specialties over wide-ranging anatomic regions, employing a variety of skills and techniques. This study testifies to the essential services supplied to hospitals and our surgical colleagues along with the broad skills and training necessary for modern vascular surgeons.

High dose-rate brachytherapy for the treatment of lower extremity in-stent restenosis.

OBJECTIVE: Historically, edge stenosis and late thrombosis limited the effectiveness of adjunctive endovascular brachytherapy (EVBT) for in-stent restenosis (ISR) after percutaneous transluminal angioplasty (PTA) and stenting. We evaluated an updated protocol of PTA and EVBT for ISR among patients with lower extremity occlusive disease. METHODS: This is a retrospective, single-center review of patients treated with PTA and EVBT for ISR in the iliac and femoropopliteal segments between 2004 and 2012. A dose of 20 Gy was given at a depth of 0.5 mm beyond the radius of the largest PTA balloon using iridium 192, with at least 2-cm-long margins of radiation coverage proximal and distal to the injured area. Stents were assessed for patency by duplex ultrasound imaging at 1, 3, 6, 9, 12, and 18 months and then yearly. The primary end point was freedom from ≥50% restenosis in the treated segment at 6 months, 1 year, and 2 years. Patency data were estimated using the Kaplan-Meier method. Secondary end points were early and late thrombotic occlusion. RESULTS: Among 42 consecutive cases in 35 patients of EVBT for ISR in common or external iliac (9 [20.8%]) and superficial femoral or popliteal (33 [76.7%]) arteries, or both, 21 patients (50%) had claudication, asymptomatic hemodynamically significant stenoses were identified on duplex ultrasound imaging in 16 (38.1%), and 4 (9.8%) had critical limb ischemia. Mean treated length was 23.5 ± 12.3 cm over a mean duration of 16.1 ± 9.6 minutes. There was one technical failure (2.3%). Median post-EVBT follow-up time was 682 days (range, 1-2262 days). There were two (4.9%) and five (11.9%) cases of early and late thrombotic occlusions, respectively. There was one death, believed to be secondary to acute coronary syndrome. Primary, assisted primary, and secondary patency in the entire cohort was 75.2%, 89.1%, and 89.1%, respectively, at 1 year and 63.7%, 80.6%, and 85.6%, respectively, at 2 years. CONCLUSIONS: This contemporary protocol of PTA and adjunctive EVBT for lower extremity ISR, which is updated from those used in prior trials and includes a surveillance strategy that identifies at-risk stents for reintervention before occlusion, may be a promising treatment for lower extremity ISR at institutions where a close collaboration between vascular surgeons and radiation oncologists is feasible.

Endovascular longitudinal fenestration and stent graft placement for treatment of aneurysms developing after chronic type B aortic dissection.

The thickened intimal flap present in cases of chronic aortic dissection can present a challenge to attempts at endovascular stent graft treatment performed for subsequent aneurysmal degeneration by precluding adequate landing zones for the endograft and by constraining the endograft from full expansion. In this report we describe our technique and outcome for longitudinal endovascular fenestration of chronic aortic dissection flaps to facilitate endovascular stent graft treatment for thoracic aortic aneurysms developing after aortic dissection.

Contrast inhomogeneity in CT angiography of the abdominal aortic aneurysm.

BACKGROUND: If undetected, infrarenal Abdominal Aortic Aneurysm (AAA) growth can lead to rupture, a high-mortality complication. Some AAA patients exhibit inhomogeneous luminal contrast attenuation at first-pass CT angiography (CTA). This study assesses the association between this observation and aneurysm growth. METHODS: Sixty-seven consecutive pre-repair AAA CTAs were included in this retrospective study. The "Gravitational Gradient" (GG), defined as the ratio of the mean attenuation in a region-of-interest placed posteriorly to that in a region-of-interest placed anteriorly within the lumen of the aortic aneurysm on a single axial slice, and the maximum aneurysm diameter were measured from each CT data set. "AAA Contrast Inhomogeneity" was defined as the absolute value of the difference between the GG and 1.0. Univariate and multivariate logistic regression was used to assess the association of aneurysm growth >0.4 and >1.0 cm/year to AAA Contrast Inhomogeneity, aneurysm diameter, patient characteristics and cardiovascular co-morbidities. RESULTS: AAA Contrast Inhomogeneity was not correlated to aneurysm diameter (p = 0.325). In multivariable analysis that included initial aneurysm diameter and AAA Contrast Inhomogeneity, both factors were significantly associated with rapid aneurysm growth (initial diameter: p = 0.029 and 0.011, and, AAA Contrast Inhomogeneity: p = 0.045 and 0.048 for growth >0.4 cm/year and >1 cm/year respectively). CONCLUSIONS: AAA Contrast Inhomogeneity is a common observation in first-pass CTA. It is associated with rapid aneurysm growth, independent of aneurysm diameter.

Endovascular repair of diffuse atherosclerotic occlusive disease using stented grafts.

Minimally invasive techniques have greatly influenced the practice of surgery in the past two decades, especially the vascular surgical specialty. Current technological advances and refinements have allowed for the application of less invasive or percutaneous endovascular techniques to the treatment of arterial aneurysms and peripheral vascular occlusive disease. While balloon angioplasty and stenting for occlusive disease have proven successful in certain vascular beds (such as common iliac arteries), infrainguinal results are generally less impressive. This paper reviews the results of the application of covered stent-grafts to peripheral arterial occlusive disease, both at the aortoiliac and infrainguinal anatomical levels. The review includes the results of iliac artery stented graft placement utilizing a combined open surgical and endovascular technique at Mount Sinai Medical Center.

Abdominal aortic aneurysmorrhaphy and cholelithiasis in the era of endovascular surgery.

The incidence of acute cholecystitis complicating standard abdominal aortic aneurysm (AAA) repair has been reported between 0.3 and 18 per cent. This has prompted considerable debate regarding the management of cholelithiasis discovered incidentally during open aortic reconstruction. This study seeks to determine the incidence of cholelithiasis and acute cholecystitis after endovascular AAA repair and evaluate options for management. Between February 1996 and October 2001 492 patients underwent endovascular AAA repair. All the procedures were performed in the operating room under fluoroscopic guidance. Epidural (98.9%), local (0.5%), or general (1.7%) anesthesia was used during these cases. The incidence of cholelithiasis and acute cholecystitis was evaluated by CT scan and abdominal ultrasound. Serum measurements of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total and direct bilirubin, and amylase were performed and clinical assessment was conducted at 1, 6, and 12 months postoperatively and annually thereafter. The mean age of these patients was 76.6 years; 84% were male. Comorbid medical conditions were present in all patients (average 3.5 conditions/patient). Follow-up ranged from 2 to 35 months (mean 12.8 months). Endovascular stent graft deployment was successful in 486 of the 492 patients (98.8%). Six patients were converted to standard open repair because of inability to achieve successful endovascular aneurysm repair. The perioperative major morbidity rate was 14.9 per cent. Minor morbidity rate was 8.5 per cent. The perioperative mortality rate was 1.9 per cent. No deaths were related to biliary disease. Cholelithiasis was identified in 64 (13%) patients preoperatively. One of 64 patients with a prior Billroth II reconstruction for peptic ulcer disease developed jaundice 8 days after AAA repair as a result of choledocholithiasis that required surgical repair. One patient without gallstones developed acute acalculous cholecystitis on postoperative day 16 as determined on pathologic analysis of the gallbladder. A third patient who had gallstones identified on preoperative CT scan developed calculous cholecystitis 16 months after endovascular AAA repair. These two patients underwent uncomplicated laparoscopic cholecystectomy and recovered uneventfully. The incidence of postoperative symptomatic cholelithiasis is 1.6 per cent (one of 64). The incidence of postoperative acute cholecystitis was 0.2 per cent (one of 486) and was unrelated to the presence of gallstones. The incidence of delayed symptomatic cholelithiasis was 1.6 per cent (one of 64). Endovascular repair of AAA does not appear to predispose the patient to the development of symptomatic cholelithiasis during the perioperative period. Therefore a preoperative or intraoperative diagnosis of cholelithiasis does not necessitate cholecystectomy in the setting of planned endovascular AAA repair. Patients who develop cholecystitis after endovascular AAA repair may be effectively treated by standard laparoscopic techniques.

Recent advances in peripheral angioplasty and stenting.

Utilization of percutaneous interventions for arterial and venous occlusive lesions continue to increase. With the progression of the technology supporting these therapeutic measures, the results of these interventions may be expected to improve. In general, a comparison of techniques for revascularization demonstrates similar initial technical success rates for surgery and percutaneous transluminal angioplasty. Angioplasty is often associated with lower procedural morbidity and mortality rates. Conversely, surgery frequently provides greater long-term patency. Late failure of percutaneous therapies may often be treated successfully with reintervention, however. The continued accumulation of experience with PTA and stenting will ultimately define its role in the management of occlusive disease.

Treatment planning for peripheral arterial disease based on duplex ultrasonography and computed tomography angiography: consistency, confidence and the value of additional imaging.

BACKGROUND: Duplex ultrasonography (DUS) can be used for treatment planning for lower extremity peripheral arterial disease (PAD), but has not replaced contrast-enhanced imaging such as computed tomography angiography (CTA). We assessed DUS-based treatment planning for consistency, confidence, and the value of additional CTA among multinational surgeons. METHODS: Data from 12 patients with PAD were reviewed by 2 American vascular surgeons individually and 1 Dutch vascular department by consensus. Reviewers selected treatment based on DUS first and based on added CTA second. Agreement and consistency of treatment plans was assessed using kappa statistics (κ). Imaging quality and therapeutic confidence were scored (1-5) and assessed with t-tests. RESULTS: Of the 36 treatment plans formulated, additional CTA confirmed 27 (75%), changed 6 (17%), and supplemented 3 (8%) plans. The approach never changed when open revascularization was selected based on DUS (14 plans; 39%). Agreement between DUS- and CTA-based treatment planning was substantial, with a mean kappa (µκ) of 0.68, but agreement between reviewers was fair (µκ DUS, 0.24; µκ CTA, 0.23). CTA received greater average scores than DUS for quality (4.36 vs 3.29; P < .0001) and confidence (4.36 vs 3.26; P < .0001). Reviewers often expressed the need for additional imaging after DUS (mean, 63%). CONCLUSION: PAD treatment planning based on CTA was mostly consistent with DUS-based treatment plans, although CTA was still felt to be needed to increase confidence. This observation suggests that to promote greater use of less invasive DUS imaging, not only improvement of DUS quality but also improvement of clinician confidence is required.

Acute dissection of the descending aorta: a case report and review of the literature.

Cardiovascular disease is the leading cause of death worldwide. Acute aortic syndromes, which include aortic dissection, intramural hematoma, and penetrating aortic ulcer, represent the most morbid presentations of aortic disease and can be difficult to diagnose. Recent advances in imaging have allowed for more rapid and accurate diagnosis of acute aortic syndromes and the options for management are expanding. This case report and review presents the case of a 43-year-old man with acute type B aortic dissection who underwent two endovascular procedures for malperfusion syndrome. The review focuses on the presentation, diagnosis, medical management, and procedural options for acute dissection of the descending aorta.

Upper extremity composite tissue allotransplantation imaging.

OBJECTIVE: Upper extremity (UE) transplantation is the most commonly performed composite tissue allotransplantation worldwide. However, there is a lack of imaging standards for pre- and posttransplant evaluation. This study highlights the protocols and findings of UE allotransplantation toward standardization and implementation for clinical trials. METHODS: Multimodality imaging protocols for a unilateral hand transplant candidate and a bilateral mid-forearm level UE transplant recipient include radiography, computed tomography (CT), magnetic resonance (MR) imaging, catheter angiography, and vascular ultrasonography. Pre- and posttransplant findings, including dynamic CT and MR performed for assessment of motor activity of transplanted hands, are assessed, and image quality of vessels and bones on CT and MR evaluated. RESULTS: Preoperative imaging demonstrates extensive skeletal deformity and variation in vascular anatomy and vessel patency. Posttransplant images confirm bony union in anatomical alignment and patency of vascular anastomoses. Mild differences in rate of vascular enhancement and extent of vascular networks are noted between the 2 transplanted limbs. Dynamic CT and MR demonstrate a 15° to 30° range of motion at metacarpophalangeal joints and 90° to 110° at proximal interphalangeal joints of both transplanted hands at 8 months posttransplant. Image quality was slightly better for CT than for MR in the first subject, while MR was slightly better in the second subject. CONCLUSION: Advanced vascular and musculoskeletal imaging play an important role in surgical planning and can provide novel posttransplantation data to monitor the success of the procedure. Implementation of more standardized protocols should enable a more comprehensive assessment to evaluate the efficacy in clinical trials.

Comparative analysis of autogenous infrainguinal bypass grafts in African Americans and Caucasians: the association of race with graft function and limb salvage.

OBJECTIVE: African Americans (AAs) are at risk for developing diabetes mellitus and atherosclerosis. Whether race influences the results of infrainguinal arterial reconstruction is unclear. The purpose of this study was to compare the results of autogenous infrainguinal bypasses in AAs and Caucasians to determine the association of race with graft function and limb salvage. METHODS: This was a retrospective, comparative cohort study of AA and Caucasian patients who had undergone autogenous infrainguinal bypass surgery. Only single-limb bypasses in each patient cohort were considered in this analysis. In patients who had undergone bilateral lower limb bypasses, the first limb bypass was chosen as the index bypass procedure. RESULTS: From January 1985 to December 2003, 1459 autogenous infrainguinal bypasses were performed in 1459 patients for lower limb ischemia. Within this group, 89 AA patients/vein grafts formed the study cohort. The control group comprised 1370 Caucasian patients/vein grafts. Compared with the Caucasian cohort, AA patients were significantly younger (median age, 65 vs 70 years, respectively; P = .001) and predominantly female (57% vs 41%, respectively; P = .002). AA patients also had a higher prevalence of diabetes mellitus, hypertension, cerebrovascular disease, congestive heart failure, and dialysis-dependent renal failure. More AA than Caucasian patients presented with gangrene (34% vs 16%, respectively; P = .001), and more underwent bypass surgery for limb salvage indications (91% vs 81%, respectively; P = .01). The venous conduit used was predominantly the greater saphenous vein (AA, 83%; Caucasian, 85%), and the site of distal anastomosis was at the tibial/pedal level in 67% of AA and 61% of Caucasian patients. Overall morbidity (AA, 28%; Caucasian, 23%) and 30-day mortality (AA, 3%; Caucasian, 3%) were similar. Thirty-day graft failure was significantly greater in AAs than Caucasians (12% vs 5%, respectively; P = .003). The overall 5-year primary graft patency (+/-SE) was significantly worse in AA patients (AA, 52% +/- 6%; Caucasian, 67% +/- 2%; P = .009). The 5-year limb salvage rate (+/-SE) was also significantly worse in AA patients (AA, 81% +/- 5%; Caucasian, 90% +/- 1%; P = .04). With the Cox proportional hazard model, significant risk factors associated with primary graft failure were AA race, age younger than 65 years, female sex, secondary reconstructions, tibial bypasses, and critical limb ischemia. Significant risk factors associated with limb loss were age younger than 65 years, female sex, absence of coronary disease, presence of critical limb ischemia, and secondary reconstructions. CONCLUSIONS: Autogenous infrainguinal bypass surgery in AAs is associated with poorer primary graft patency and limb salvage rates compared with those of Caucasians. This may partially account for the higher rate of limb loss in AA patients with peripheral arterial occlusive disease.

Carotid stenting in the bovine arch.

We report our experience in stent-supported angioplasty of the left internal carotid artery in patients with anomalous origin of the left common carotid, the so-called bovine arch, in which the right brachiocephalic and left carotid share a common trunk from the aortic arch. The occurrence of the anatomic variant is discussed, and techniques of femoral, brachial, and radial approaches are described.

Congenital Vascular Anomalies.

Congenital vascular anomalies are rare. The cardiovascular specialist should nevertheless be aware of the more common types of vascular anomalies and understand the implications for patient treatment and the likelihood of associated morbidity. The presentation of congenital arteriovenous malformations can range from asymptomatic or cosmetic lesions, to those causing ischemia, ulceration, hemorrhage, or high-output congestive heart failure. Treatment of large, symptomatic arteriovenous malformations often requires catheter-directed embolization prior to the attempt at complete surgical excision. Later recurrence, due to collateral recruitment, is frequent. Graded compression stockings and leg elevation are the mainstays of treatment for the predominantly venous congenital vascular anomalies. Most congenital central venous disorders are clinically silent. An exception is the retrocaval ureter. Retroaortic left renal vein, circumaortic venous ring, and absent, left-sided or duplicated inferior vena cava are relevant when aortic or inferior vena cava procedures are planned. The treatment of the venous disorders is directed at prevention or management of symptoms. Persistent sciatic artery, popliteal entrapment syndrome, and aberrant right subclavian artery origin are congenital anomalies that are typically symptomatic at presentation. Because they mimic more common diseases, diagnosis is frequently delayed. Delay can result in significant morbidity for the patient. Failure to make the diagnosis of persistent sciatic artery and popliteal entrapment can result in critical limb ischemia and subsequent amputation. Unrecognized aberrant right subclavian artery origin associated with aneurysmal degeneration can rupture and result in death. The treatment options for large-vessel arterial anomalies are surgical, sometimes in combination with endovascular techniques.

An unusual cause of claudication.

We describe a case of a patient who presented with claudication 3 months following a coronary angiogram in which the femoral arterial puncture site had been closed with an AngioSeal. The lesion was found to be due to the anchor of the AngioSeal, which embolized during attempted percutaneous revascularization and had to be snared and retrieved to the level of the sheath in the left femoral artery and was then surgically removed.

Endovascular repair of thoracic aortic aneurysms: stent-graft fixation across the aortic arch vessels.

The close proximity of the arch vessels to the origin of many thoracic aortic aneurysms (TAA) may result in placement of the stent struts across the left subclavian or carotid ostia. The purpose of this study is to determine the incidence and impact of transaortic arch vessel fixation during thoracic aortic stent graft deployment for the treatment of descending TAA. From May 1997 to July 2000, 20 patients (10 men, 10 women, mean age 82 years) with descending TAA were treated in the operating room with endoluminally placed stent grafts secured proximally to the thoracic aorta with a long (15-mm) uncovered stent segment (Talent LPS). Pre- and post-operative angiograms and IV contrast-enhanced spiral CT scans were performed in all cases. Follow-up contrast CT scans were obtained at 1, 3, 6, and 12 months and yearly thereafter to assess the adequacy of repair and to determine stent position and arch vessel patency. We found that thoracic aortic endograft fixation across the left aortic arch vessels occurs frequently during device placement and is associated with no early morbidity. Long-term follow-up is necessary to ensure that there are no late sequelae.

Endovascular repair of abdominal aortic aneurysms: stent-graft fixation across the visceral arteries.

PURPOSE: Recent studies have suggested that transrenal artery fixation of endovascular stent-grafts is safe and may be a desirable means of reducing the risk of type I endoleaks, particularly those with short infrarenal necks. The close proximity of the superior mesenteric and celiac arteries to the renal arteries may commonly result in the placement of the stent struts across all the vessels of the visceral segment of the aorta. The purpose of this study was to determine the incidence and impact of transvisceral artery fixation during aortic stent-graft deployment for the treatment of abdominal aortic aneurysms (AAAs). METHODS: From January 1997 to June 1999, 192 patients (165 men, 27 women; mean age, 82 years) with AAAs were treated with an endovascular graft secured proximally to the aorta with a long (15 mm) uncovered stent segment (60 Parodi/Palmaz, 132 Talent-LPS). Preoperative and postoperative abdominal aortograms and intravenous contrast enhanced spiral computed tomography (CT) scans were performed. Follow-up CT scans were obtained at 3, 6, and 12 months and yearly thereafter as a means of determining stent position and visceral artery patency RESULTS: In 95 patients (49%), the uncovered stent was at or above the level of the superior mesenteric artery. In 23 patients (12%), the stent extended to the level of the celiac axis. In a mean follow-up period of 25 months (range, 6-44 months), serum creatinine levels remained stable, no stenoses or occlusions occurred in the celiac, superior mesenteric, or renal arteries, and no evidence of renal, hepatic, splenic, or intestinal infarction was present on contrast enhanced spiral CT scans. There were no type I endoleaks. CONCLUSION: Transvisceral fixation of the uncovered proximal aortic stent occurs frequently during deployment of devices designed for transrenal fixation and is associated with no early morbidity. Long-term follow-up is necessary to ensure that there are no late sequelae.