Clinical Patterns, Predictors, and Results of Graft Limb Occlusion following Endovascular Aneurysm Repair.

BACKGROUND: To assess the incidence, clinical patterns, and outcomes of graft limb occlusion (GLO) following endovascular aneurysm repair (EVAR). METHODS: A retrospective study of patients undergoing EVAR from 2002 to 2017 at 2 mid-sized suburban teaching hospitals. The ipsilateral and contralateral aorto-common iliac artery (A-CIA) angle and common iliac artery-external iliac artery (CIA-EIA) angle were determined. The diameter of the EIA, graft extension to the EIA, and prior CIA stenting was recorded. RESULTS: Of the 373 patients who underwent EVAR, 319 were analyzed. 22 patients had 23 limbs with GLO (21 unilateral and 1 bilateral) with a mean follow-up of 9.1 ± 2.1 years. There were no statistically significant differences in mean age, gender, size of the abdominal aortic aneurysm, and risk factors of hypertension, coronary artery disease, diabetes mellitus, and chronic obstructive pulmonary disease in patients with and without GLO. There was no statistically significant difference in A-CIA and CIA-EIA angles. A smaller diameter EIA (6 mm or less), graft extension to EIA, and prior CIA stenting were significant predictors of GLO. Four limbs had GLO within 1 month of EVAR, only open thrombectomy was performed in 2 limbs, open thrombectomy with simultaneous axillo-femoral graft in 1 limb, and open thrombectomy with self-expandable stent placement in 1 limb. 12 limbs had GLO within 1-12 months treated with only open thrombectomy in 3 limbs, open thrombectomy with fasciotomy in 1 limb, open thrombectomy with graft extension to EIA in 1 limb, and crossover femoral-femoral graft performed in 3 limbs. Seven limbs had GLO within 1-5 years with a crossover femoral-femoral graft performed in 4 limbs and open thrombectomy with graft extension to EIA was performed in 1 limb. Six limbs with GLO following EVAR did not undergo any intervention. One patient had an above the knee amputation 3 years following occlusion of the axillo-femoral graft and 1 patient returned in 4 years with an increase in size of the excluded aneurysm leading to acute rupture and death. CONCLUSIONS: GLO leads to significant morbidity and mortality following EVAR. Predictors of GLO following EVAR include a small diameter EIA, prior CIA stenting and graft limb extension to the EIA.

Selective shunting for carotid endarterectomy in patients with recent stroke.

OBJECTIVE: Many surgeons favor routine shunting during carotid endarterectomy (CEA) in patients with recent stroke who otherwise prefer selective shunt placement for other indications of CEA. We analyzed the results of CEA in this group of patients with the strategy of selective shunting. METHODS: A retrospective review was performed of 59 patients (group A) undergoing CEA ≤8 weeks of a stroke (2000-2014) from two midsized teaching hospitals with stroke certification; of these, 38 patients had CEA ≤2 weeks and 21 other had CEA >2 weeks but <8 weeks. All patients sustained a middle cerebral artery stroke with ≥70% ipsilateral internal carotid artery stenosis. Cervical block anesthesia was used in 43 patients and general anesthesia in 16. During the same period, 1036 CEAs were performed for other indications (group B). All patients in group A were evaluated by stroke neurologist with a National Institutes of Health stroke scale score of 1 to 4 in 22 patients (minor stroke) and 5 to 15 in 37 patients (moderate stroke). A shunt was placed if neurologic changes (contralateral motor weakness, aphasia, loss of consciousness) occurred with the carotid cross-clamping or ischemic electroencephalogram changes under general anesthesia were observed. RESULTS: The study population consisted of 59 patients (36 males and 23 females) in group A with mean age of 70.5 ± 10.7 years. Carotid duplex imaging revealed contralateral internal carotid artery stenosis of <50% in 36 patients, 50% to 70% in 13, 71% to 99% in 9, and occlusion in 1. Ten patients (16.9%) required shunt placement, which was similar to the shunt in group B (11.8% for remote stroke, 10.2% for focal transient ischemic attack/monocular blindness, and 10.9% for asymptomatic carotid stenosis). Two patients in group A had perioperative stroke and died (3.4% stroke/mortality). There were no incidences of permanent cranial nerve palsy, myocardial infarction (MI), or hematoma requiring re-exploration in patients undergoing CEA in group A. Postoperative complications in group B included new neurologic deficits (postoperative stroke) in 16 (1.6%), MI in 2 (0.2%), permanent cranial nerve palsy in 3 (0.3%), and re-exploration for neck hematoma in 7 (0.7%). Six patients died after CEA in group B, for a combined stroke/death rate of 2.0%. Seizures after CEA for a recent stroke occurred in three patients (5.1%) in group A and in none in group B (P < .002). Postoperative complications (new neurologic deficits, MI, cranial nerve palsy, and re-exploration for neck hematoma) were similar in both groups (P > .05). CONCLUSIONS: Shunt requirement during CEA for acute stroke is similar to other indications of CEA. Patients undergoing CEA for recent stroke had similar incidence of postoperative new neurologic deficit/mortality, MI, and cranial nerve palsy compared with other indications of CEA but had a higher incidence of perioperative seizures.

Maldeployment of Celt ACD vascular closure device.

Vascular closure devices have become more popular in some clinical settings because they allow for quicker hemostasis and earlier ambulation. Although these devices have several benefits compared with manual compression, errors in deployment can result in a multitude of complications. We have presented two cases in which the Celt arterial closure device was maldeployed and caused significant patient morbidity.

Iatrogenic arterial injuries of spine and orthopedic operations.

OBJECTIVE: To describe the results of contemporary management of iatrogenic arterial injuries following spine and orthopedic operations. METHODS: Patients with major arterial injuries following spine and orthopedic operations in four teaching hospitals (Henry Ford Hospital, Detroit, Mich; Henry Ford Macomb Hospital, Clinton Township, Mich; St John Macomb Hospital, Warren, Mich; and St John Hospital, Detroit, Mich) over the last 10 years were studied. Data were collected on a continuous basis from vascular registries and analyzed retrospectively. RESULTS: Seventeen patients (8 spine, 9 orthopedic operations) had iatrogenic arterial injuries manifest as thrombosis or laceration with bleeding, pseudoaneurysm, or arteriovenous fistula. The majority of arterial lacerations with bleeding and pseudoaneurysms were treated with open surgical repair while the majority of thromboses and arteriovenous fistulae were treated with endovascular techniques. Fasciotomy was necessary in three of seven patients with arterial complications of knee and hip operations. There was no mortality or limb loss. Significant morbidity in the form of foot drop (1), iliac vein thrombosis (2), delayed ambulation due to hematoma and swelling of the lower extremity (2), and ischemic myonecrosis of calf muscles (1) occurred. Two patients launched legal action. CONCLUSION: Arterial injuries following orthopedic and spine operations can be successfully managed by both open and endovascular techniques. Significant morbidity and increased length of stay is common. Patient dissatisfaction with the complication and need for ensuing treatment can have significant medicolegal consequences.

Achenbach syndrome as a rare cause of painful, blue finger.

Paroxysmal finger hematoma, also known as Achenbach syndrome, is an underdiagnosed condition that causes apprehension in patients owing to the alarming appearance. It usually presents as a blue-purple discoloration of the volar aspect of one or more digits and can be associated with pain and paresthesia. This condition is benign and is usually self-limiting.

Results of 101 ruptured abdominal aortic aneurysm repairs from a single surgical practice.

UNLABELLED: Hypotheses The results of ruptured abdominal aortic aneurysm repairs from a solo community hospital-based practice are comparable to those reported from large university referral medical centers. Patients younger than 70 years, arriving in the emergency department with stable hemodynamics, and undergoing prompt operation have better outcome. DESIGN: A retrospective review from an ongoing vascular surgery registry. SETTING: Two midsized (300-bed) community hospitals. One hundred one consecutive patients with ruptured abdominal aortic aneurysms who were undergoing open surgical repair by a single surgeon (S.S.H.) during a 21-year period were reviewed. MAIN OUTCOME MEASURES: Operative mortality; cardiac, pulmonary, renal, and gastrointestinal complications; and coagulation abnormalities were recorded. Iatrogenic complications and length of hospital stay were noted. Preoperative and intraoperative factors affecting mortality were studied. RESULTS: Fifty-three patients survived ruptured abdominal aortic aneurysm repair (operative mortality, 47.5%). A favorable outcome was observed in patients (1). younger than 70 years, (2). with a hematocrit of more than 35% at presentation, and (3). with emergency department to operating room times of less than 120 minutes. Increasing experience of the surgeon did not result in improved survival. CONCLUSION: The results of ruptured abdominal aortic aneurysm repairs from community-based practice are comparable to those reported from university referral medical centers.

Results of endovascular therapy and aortobifemoral grafting for Transatlantic Inter-Society type C and D aortoiliac occlusive disease.

OBJECTIVE: The purpose of this study was to compare the outcomes of aortoiliac stenting (AIS) to those of aortobifemoral grafting (ABF) for patients with TransAtlantic Inter-Society Consensus (TASCII) C and D aortoiliac occlusive disease. METHODS: From 1998 to 2007, 32 patients underwent ABF and 40 patients underwent AIS. Kaplan-Meier estimates for patency were used. RESULTS: Patients undergoing AIS were older (66.6 years ABF vs 59.2 years AIS; P=.006). The ABF group had simultaneous profundoplasty (n = 8) and femoral-popliteal graft (n =1). Six patients had treatment for concomitant infrainguinal disease at the time of AIS. There was no mortality in either group. Average hospital stay in the ABF group was 7 +/- 2 days and 1 +/- 0.3 days for AIS (P = .0001). Pulmonary complications predominated in the ABF group (13%). Four patients in the AIS group (10%) developed intraprocedural complications. Primary patency at 48 months was 69 +/- .12% for AIS and 93 +/- .07% for ABF (P = .013). There was a significant increase in ankle-brachial indices after revascularization in both groups. CONCLUSIONS: TASC type C and D lesions can be treated with either ABF or AIS with satisfactory results. Compared with ABF, AIS is associated with decreased primary patency, decreased perioperative morbidity, and shorter hospital stay.

Prospective evaluation of electroencephalography, carotid artery stump pressure, and neurologic changes during 314 consecutive carotid endarterectomies performed in awake patients.

OBJECTIVE: This study attempted to correlate neurologic changes in awake patients undergoing carotid endarterectomy (CEA) under cervical block anesthesia (CBA) with electroencephalography (EEG) and measurement of carotid artery stump pressure (SP). METHODS: Continuous EEG and SP monitoring was measured prospectively in 314 consecutive patients undergoing CEA between April 1, 2003, and July 30, 2006, under CBA. Indications for CEA were asymptomatic 70% to 99% internal carotid artery stenosis in 242 (77.1%), transient ischemic attacks (including transient monocular blindness) in 45 (14.3%), and prior stroke in 27 (8.6%). Mean common carotid artery pressure before clamping, mean SP after carotid clamping, and intraarterial pressure were continuously monitored in all patients. An indwelling shunt was placed when neurologic events (contralateral motor weakness, aphasia, loss of consciousness, or seizures) occurred, regardless of SP or EEG changes. RESULTS: Shunt placement was necessary because of neurologic changes in 10% (32/314) of all CEAs performed under CBA. Only 3 patients (1.4%) of 216 required shunt placement if SP was 50 mm Hg or more, vs 29 (29.6%) of 98 if SP was less than 50 mm Hg (P < .00001; sensitivity, 29.8%; specificity, 98.6%). In patients with SP of 40 mm Hg or more, 7 (2.6%) of 270 required shunt placement, vs 25 (56.8%) of 44 if SP was less than 40 mm Hg (P < .00001; sensitivity, 56.8%; specificity, 97.4%). Ischemic EEG changes were observed in 19 (59.4%) of 32 patients (false-negative rate, 40.6%) requiring shunt placement under CBA. Three patients had false-positive EEG results and did not require shunt placement (false-positive rate, 1.0%). The perioperative stroke/death rate was 4 (1.2%) in 314. All strokes occurred after surgery and were unrelated to cerebral ischemia or lack of shunt placement. CONCLUSIONS: Ten percent of patients required a shunt placement during CEA under CBA. Shunt placement was necessary in 56.8% of patients with SP less than 40 mm Hg. EEG identified cerebral ischemia in only 59.4% of patients needing shunt placement, with a false-positive rate of 1.0% and a false-negative rate of 40.6%. Both SP and EEG as a guide to shunt placement have poor sensitivity. Intraoperative monitoring of the awake patients under regional anesthesia (CBA) is the most sensitive and specific method to identify patients requiring shunt placement.

Size and location of thrombus in intact and ruptured abdominal aortic aneurysms.

PURPOSE: This study compared the volume and morphology of intraluminal thrombus (ILT) in intact and ruptured abdominal aortic aneurysms (AAAs). METHODS: ILT volume in 67 intact AAAs and in 31 ruptured AAAs was assessed by using computed tomography (CT) angiography to measure the major and minor diameter of the outer wall and lumen of AAA as outlined by contrast at multiple sites. ILT thrombus morphology was recorded by AutoCAD 2000 software. Four equidistant images traced from the CT scan were recorded along the length of AAA. Thrombus volume was categorized as anterior-eccentric if the calculated area of thrombus was greater anteriorly, posterior-eccentric if greater posteriorly, eccentric-equal if the difference between the anterior and posterior thrombus was

Rupture of abdominal aortic aneurysm with tear of inferior vena cava in a patient with prior endograft.

We report a case of contained rupture of abdominal aortic aneurysm and tear of the inferior vena cava (IVC) 15 months after placement of an aortic endograft (ANEURX graft, Medtronic, Sunnyvale, Calif). A 63-year-old man with significant coronary artery disease underwent endograft exclusion of abdominal aortic aneurysm with Aneurx graft. The patient was seen with a rupture of the aortic aneurysm, probably caused by poor proximal fixation of the graft associated with separation of the left iliac extension limb from the main body of the graft. Angulated right iliac limb of the stent graft penetrated into the Ivc just above the common iliac junction and caused sealed perforation. Successful repair with aortobiiliac graft reconstruction after removal of the endograft was accomplished. The IVC laceration was repaired. Possible mechanisms of failure of endograft are discussed.

Relationship of residual intraluminal to intrathrombotic pressure in a closed aneurysmal sac.

PURPOSE: This study was undertaken to determine the relationship of residual intraluminal aneurysmal sac pressure (ILASP) to intrathrombic aneurysm sac pressure (ITASP) and to define the relationship between abdominal aorta aneurysm (AAA) size (anteroposterior or transverse diameter), volume of intraluminal thrombus, and residual ITASP. METHODS: We measured ILASP and ITASP after proximal aortic neck and distal iliac clamping by placing angiocatheters into the lumen and thrombus of an excluded aneurysm sac in 41 consecutive patients. Simultaneously, mean blood pressure was recorded and aneurysm sac pressure ratio was calculated. Changes in ILASP and ITASP after clamping of the inferior mesenteric artery were recorded. In addition, correlation between AAA size, volume of intraluminal thrombus in AAA, and residual ITASP was determined. RESULTS: Mean ILASP/blood pressure ratio was 0.40 (SD, 0.20). Mean ITASP/blood pressure ratio was 0.37 (SD, 0.23). There was a significant positive correlation of 0.47 between ITASP and ILASP (P =.002). Clamping of the inferior mesenteric artery resulted in markedly decreased ITASP in 2 patients (n = 40) and ILASP in 4 patients (n = 41). Each centimeter increase in AAA size resulted in a 47 mL increase in thrombus volume. CONCLUSION: Increased ILASP results in corresponding increase in ITASP, and increased AAA size is associated with increased thrombus volume. However, neither thrombus volume nor AAA size has any relationship to ITASP.