The Effect of Patient Oral Intake Status on Abdominal Aortic Ultrasound Visualization.

BACKGROUND: The standard abdominal aortic duplex ultrasound protocol requires fasting for 8-12 hours prior to examination in attempt to reduce bowel gas and improve visualization. Such practice results in frequent testing delays and patient non-compliance. The aim of this study was to determine whether fasting improves visualization of the abdominal aorta in patients undergoing duplex ultrasound or influences diagnostic properties. METHODS: This was a prospective, randomized, double-blind imaging trail at a single institution. Ninety patients were randomized to one of three dietary groups, including NPO, clear liquids or control (regular diet). Diagnostic ultrasound examinations were performed by accredited Registered Vascular Technologists who remained blinded to the patients' diet. Sonographers commented on the presence of limited visualization in the study based on their ability to accurately measure aortic diameter. Examination results were randomly assigned to interpreting physicians who were also blinded to the patients' diet. Following interpretation, the reading physician was asked to comment whether they had sufficient information for a conclusive diagnostic interpretation. RESULTS: All ultrasound studies were deemed diagnostic by the interpreting physician regardless of the patients' dietary status. Limited visualization was reported in 19 of the 90 study patients (21.1%) with no significant difference existing between the dietary groups (P = 0.344). The NPO group contained the most patients with studies deemed to have limited visualization. CONCLUSION: Oral intake status did not affect visualization of the abdominal aorta or the rate of diagnostic studies in patients undergoing DUS at a single center. These results suggest that dietary restrictions prior to DUS evaluation of the abdominal aorta is unnecessary.

Shear rate is a better marker of symptomatic ischemic cerebrovascular events than velocity or diameter in severe carotid artery stenosis.

OBJECTIVE: This study was designed to test the hypothesis that the high shear rate of flow in the area of carotid stenosis is associated with the incidence of ischemic symptoms in patients with a high degree of carotid stenosis. METHODS: This is a case-control study of patients with >70% stenosis of the internal carotid artery (ICA) identified by duplex ultrasound in an Intersocietal Accreditation Commission-accredited laboratory during 1 year. Symptomatic patients were included in the study group, and asymptomatic patients served as controls. Shear rates were calculated from high-resolution ultrasound images. Descriptive statistics and univariate and multivariate analysis were performed to account for confounding factors. Receiver operating characteristic curves were used to compare diagnostic values of shear rate, velocities, and diameters of the ICA. RESULTS: The study included 308 patients (55.5% male; mean age, 73 ± 10 years); 209 of them were asymptomatic and 99 were symptomatic. The mean shear rate was 7930 s-1 for asymptomatic and 9338 s-1 for symptomatic patients. Receiver operating characteristic curve identified a cutoff value of 8000 s-1 to differentiate between symptomatic and asymptomatic patients; 92% of asymptomatic patients and 8.0% of symptomatic patients had a shear rate of <8000 s-1 compared with 48.5% asymptomatic and 51.5% symptomatic who had a shear rate ≥8000 s-1. Patients who had a shear rate higher than this cutoff value were 12 times more likely to be symptomatic than those with a shear rate <8000 s-1 (odds ratio, 12.1; 95% confidence interval, 6.12-24.09). Sensitivity and specificity were 84.8% and 61.2%, respectively. CONCLUSIONS: In patients with >70% ICA stenosis, the shear rate is associated with the prevalence of symptomatic cerebrovascular ischemic events. A shear rate of 8000 s-1 and above may be used as a predictor for having symptomatic cerebrovascular ischemic events. Further validation as well as further study of the pathologic mechanism connecting the high shear rate and ischemic cerebrovascular events is needed.

Timing of Hospital-acquired Venous Thromboembolism and Its Relationship with Venous Thromboembolism Prevention Measures in Immobile Patients.

BACKGROUND: The aim of this study is to describe the timing of venous thromboembolism (VTE) diagnosis in patients with cerebral or spinal trauma and stroke and describe the relationships between VTE prophylaxis and timing of VTE diagnosis at a community hospital. METHODS: Retrospective cohort observational study over a span of 10 years from 2006 to 2016 was conducted. RESULTS: Lower extremity ultrasound surveillance identified 138 patients who developed VTE during their hospital stay (mean age 62 years, 61.6% males). Mechanical prophylaxis was used in 79.7% and pharmacologic prophylaxis in 78.3% of patients. The average time of admission to administration of mechanical prophylaxis was 1.92 and 7.7 days for pharmacologic prophylaxis. In patients who received pharmacologic prophylaxis within 2 days, 51.5% of all VTE events occurred during the first week, 73.5% by the second week, and 91.2% by the third week of the hospital stay. In patients who started pharmacologic prophylaxis after 2 days in the hospital, 85% of all VTE events occurred within the first week and 90% within 10 days of the hospital stay (P < 0.001). The timing of initiation of mechanical prophylaxis did not influence the timing of VTE events. CONCLUSIONS: In immobilized patients with stroke, traumatic brain injury, or spinal cord injury, VTE screening should be performed at different schedules based on the timing of initiation of pharmacologic prophylaxis. In patients who did not start prophylaxis during the first 2 days of admission to the hospital, the majority of the VTE events occurred during the first 10 days.

Emergent carotid endarterectomy versus stenting in acute stroke patients with tandem occlusion.

OBJECTIVE: Acute stroke due to tandem cervical internal carotid artery (ICA) and intracranial large-vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. In this study, we report our institutional outcomes with two approaches: emergent carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: Patients with tandem ICA-ILVO were identified in a prospective mechanical thrombectomy (MT) database between July 2012 and April 2016. Patients had a concomitant complete ICA origin occlusion and occlusion of the intracranial ICA or M1 or M2 middle cerebral artery segment. Baseline characteristics, procedural data, and treatment times were reviewed. End points included good recanalization of both ICA and ILVO, symptomatic intracerebral hemorrhage (defined by clinical decline of >4 points on the National Institutes of Health Stroke Scale), and functional outcome at 90 days. RESULTS: Forty-five patients had tandem ICA-ILVO occlusion; 27 patients underwent emergent CAS and 12 patients underwent emergent CEA after MT. Successful Thrombolysis in Cerebral Infarction grade 2B/3 recanalization was achieved in 92% of the CEA and 96% of the CAS patients (P = .53). Three CAS patients (11%) and none of the CEA patients had symptomatic intracerebral hemorrhage (P = .54). At 90 days, 75% (9/12) of the CEA patients were functionally independent compared with 70% (19/27) in the CAS group (P = 1.0). No deaths were noted in the CEA group compared with five (18.5%) in the CAS arm (P = .30). CONCLUSIONS: Our study indicates that early recanalization with MT followed by emergent CEA is safe and feasible, which suggests that both CAS and CEA should be considered in the emergent treatment of patients with tandem occlusion.

Transport of enterococci and F+ coliphage through the saturated zone of the beach aquifer.

Coastal groundwater has been implicated as a source of microbial pollution to recreational beaches. However, there is little work investigating the transport of fecal microbes through beach aquifers where waters of variable salinity are present. In this study, the potential for fecal indicator organisms enterococci (ENT) and F+ coliphage to be transported through marine beach aquifers was investigated. Native sediment and groundwaters were collected from the fresh and saline sections of the subterranean estuary at three beaches along the California coast where coastal communities utilize septic systems for wastewater treatment. Groundwaters were seeded with sewage and removal of F+ coliphage and ENT by the sediments during saturated flow was tested in laboratory column experiments. Removal varied significantly between beach and organism. F+ coliphage was removed to a greater extent than ENT, and removal was greater in saline sediments and groundwater than fresh. At one of the three beaches, a field experiment was conducted to investigate the attenuation of F+ coliphage and ENT down gradient of a septic leach field. ENT were detected up to 24 m from the leach field. The column study and field observations together suggest ENT can be mobile within native aquifer sediments and groundwater under certain conditions.

Impacts of beach wrack removal via grooming on surf zone water quality.

Fecal indicator bacteria (FIB) are used to assess the microbial water quality of recreational waters. Increasingly, nonfecal sources of FIB have been implicated as causes of poor microbial water quality in the coastal environment. These sources are challenging to quantify and difficult to remediate. The present study investigates one nonfecal FIB source, beach wrack (decaying aquatic plants), and its impacts on water quality along the Central California coast. The prevalence of FIB on wrack was studied using a multibeach survey, collecting wrack throughout Central California. The impacts of beach grooming, to remove wrack, were investigated at Cowell Beach in Santa Cruz, California using a long-term survey (two summers, one with and one without grooming) and a 48 h survey during the first ever intensive grooming event. FIB were prevalent on wrack but highly variable spatially and temporally along the nine beaches sampled in Central California. Beach grooming was generally associated with either no change or a slight increase in coastal FIB concentrations and increases in surf zone turbidity and silicate, phosphate, and dissolved inorganic nitrogen concentrations. The findings suggest that beach grooming for wrack removal is not justified as a microbial pollution remediation strategy.

A coupled modeling and molecular biology approach to microbial source tracking at Cowell Beach, Santa Cruz, CA, United States.

Consistently high levels of bacterial indicators of fecal pollution rank Cowell Beach as the most polluted beach in California. High levels of fecal indicator bacteria (FIB), E. coli and enterococci, are measured throughout the summer, resulting in beach advisories with social and economic consequences. The source of FIB, however, is unknown. Speculations have been made that the wrack accumulating on the beach is a major source of FIB to the surf zone. The present study uses spatial and temporal sampling coupled with process-modeling to investigate potential FIB sources and the relative contributions of those sources. Temporal sampling showed consistently high FIB concentrations in the surf zone, sand, and wrack at Cowell Beach, and ruled out the storm drain, the river, the harbor, and the adjacent wharf as the sources of the high concentrations observed in the surf zone. Spatial sampling confirmed that the source of FIB to the beach is terrestrial rather than marine. Modeling results showed two dominant FIB sources to the surf zone: sand for enterococci and groundwater for E. coli. FIB from wrack represented a minor contribution to bacterial levels in the water. Molecular source tracking methods indicate the FIB at the beach is of human and bird origin. The microbial source tracking (MST) approach presented here provides a framework for future efforts.

Mobilization and transport of naturally occurring enterococci in beach sands subject to transient infiltration of seawater.

This study explores the transport of enterococci (ENT) from naturally contaminated beach sands to the groundwater table via infiltrating seawater using field, laboratory, and modeling experiments. ENT were readily mobilized and transported through the unsaturated zone during infiltration events in both the field and laboratory column experiments. Detachment mechanisms were investigated using a modified version of HYDRUS-1D. Three models for detachment kinetics were tested. Detachment kinetics that are first order with respect to the rate of change in the water content and attached surface bacterial concentrations were found to provide a best fit between predicted and observed data. From these experimental and model results we conclude that detachment mechanisms associated with the rapid increases in pore water content such as air-water interface scouring and thin film expansion are likely drivers of ENT mobilization in the investigated system. These findings suggest that through-beach transport of ENT may be an important pathway through which ENT from beach sands are transported to beach groundwater where they may be discharged to coastal waters via submarine groundwater discharge.

The clinical significance of ultra-high D-dimer levels.

OBJECTIVE: Plasma D-dimer levels >5000 ng/mL are encountered in a number of conditions other than venous thromboembolism (VTE). Recent studies have used plasma D-dimer levels as a prognostic indicator for coronavirus disease 2019 (COVID-19) infection. The implications of abnormal levels are less clear for patients diagnosed with COVID-19 with a baseline elevation in plasma D-dimer levels. In the present study, we reviewed the occurrence of plasma D-dimer levels >5000 ng/mL and investigated the clinical significance of this finding before the onset of the COVID-19 pandemic. METHODS: Inpatient records for a 4-year period were screened for laboratory results of plasma D-dimer levels >5000 ng/mL. The patient data were reviewed for the clinical identifiers commonly associated with elevated plasma D-dimer levels, including VTE, cancer, sepsis, pneumonia, other infection, bleeding, and trauma. The patients were then categorized into groups stratified by the plasma D-dimer level to allow for comparisons between the various clinical diagnoses. RESULTS: A total of 671 patients were included in the present study. VTE was the most common diagnosis for patients with a plasma D-dimer level >5000 ng/mL, followed by cancer and pneumonia. Multiple clinical diagnoses were present in 61% of the patients. No clear cause for the ultra-high plasma D-dimer level could be identified in 11.3% of the patients. Among the patients lacking a clinical diagnosis at discharge, mortality was 24% in the 5000- to 10,000-ng/mL group, 28.6% in the 10,000- to 15,000-ng/mL group, and 75% in the >15,000-ng/mL group. CONCLUSIONS: VTE, cancer, and pneumonia were frequently present when ultra-high plasma D-dimer levels were encountered, and mortality was high when the levels were >15,000 ng/mL. The results from our study from a pre-COVID-19 patient population suggest that ultra-high plasma D-dimer levels indicate the presence of severe underlying disease. This should be considered when using the plasma D-dimer level as a screening tool or prognostic indicator for COVID-19 infection.

Sources and fate of Salmonella and fecal indicator bacteria in an urban creek.

This research aimed to understand the sources and fate of Salmonella and fecal bacteria in urban surface waters. An urban creek (San Pedro Creek, California, USA) that had unusually high levels of Salmonella and fecal bacteria relative to other nearby waterbodies was chosen as a model field site. State of the art microbiological methods were used in concert with modeling to investigate Salmonella and fecal bacteria sources, and determine field-relevant dark inactivation and photoinactivation rates. Three along-creek surveys that spanned reaches adjacent to both urban and forested land covers were conducted to measure Salmonella, enterococci, Escherichia coli, and horse- and human-specific Bacteroidales. Salmonella were detected adjacent to and downstream of urban land cover, but not adjacent to forested land cover. No human or horse-specific Bacteroidales fecal markers were detected implicating other urban animal sources of bacteria. Two locations along the creek where Salmonella was consistently detected were sampled hourly for 25 hours and a mass-balance model was applied to determine field-relevant light and dark inactivation rates for Salmonella, enterococci, and E. coli. Sunlight inactivation did not appear to be important in modulating concentrations of Salmonella, but was important in modulating both enterococci and E. coli concentrations. Dark inactivation was important for all three organisms. This is the first study to quantitatively examine the fate of Salmonella within an urban surface water. Although the work is carried out at a single site, the methodologies are extendable to source tracking in other waterbodies. Additionally, the rate constants determined through the modeling will be useful for modeling these organisms in other surface waters, and represent useful benchmarks for comparison to laboratory-derived inactivation rates.

Interface pressure changes under compression bandages during period of wearing.

BACKGROUND: The aim of the present study was to investigate the changes in pressure over time under three different compression bandages and compare the temporal patterns of pressure changes among them. METHODS: The 4-hour changes in interface pressure were investigated in 10 volunteers with no venous disease or leg swelling. In 20 patients with venous ulcers, the change in interface pressure was measured after 4 hours, 1 day, and 7 days of bandage wearing. The three bandages tested were the Smart Sleeve compression system (SSB; Carolon, Rural Hall, NC), Coban 2 (C2; 3M, St Paul, Minn), and Profore Lite (PL; Smith & Nephew, London, United Kingdom). Pressure measurements were performed using the PicoPress transducer (Microlab, Padua, Italy) and the Juzo Pressure Monitor (Juzo, Cuyahoga Falls, Ohio). RESULTS: In the 10 volunteers, the mean pressure loss during the first 4 hours under the SSB, C2, and PL were 4.5, 3.7, and 6.6 mm Hg, respectively. No significant differences were seen in the pressure loss among the three bandages, whether in the supine (P = .59) or standing (P = .47) position. In the 20 patients with venous ulcers, the pressure had decreased gradually over 7 days under the C2 bandages. For the SSB and PL bandages, however, the interface pressure was relatively stable during the first day but decreased significantly afterward. The mean pressure loss during the 7 days was 4.7, 7.7, and 8.6 mm Hg for the SSB, PL, and C2, respectively (P = .017). Only the SSB maintained a desirable mean pressure >30.0 mm Hg on the seventh day in the patients with venous ulcers. CONCLUSIONS: The interface pressure had decreased over time under all three studied bandages. However, the temporal pattern of the pressure changes varied among the different bandages. Therefore, monitoring the interface pressure, allowing for adjustment or changes of the bandage at an accurate point, is essential to maintain a desirable interface pressure during compression therapy.

Decay of sewage-sourced microbial source tracking markers and fecal indicator bacteria in marine waters.

The decay of sewage-sourced enterococci, Escherichia coli, three human-associated microbial source tracking (MST) markers, Salmonella, Campylobacter, and norovirus GII was measured in situ in coastal, marine waters. Experiments examined the effects of sunlight intensity and season on decay. Seawater was seeded with untreated sewage, placed into permeable dialysis bags, and deployed in the coastal ocean near the water surface, and at 18 cm, and 99 cm depths, to vary solar intensity, during winter and summer seasons. Microbial decay was modeled using a log-linear or shoulder log-linear decay model. Pathogen levels were too low in sewage to obtain kinetic parameters. Human-associated MST markers all decayed with approximately the same rate constant (k âˆ¼ 1.5 d-1) in all experimental treatments, suggesting markers could be detectable up to ∼6 days after a raw sewage spill. E. coli and enterococci (culturable and molecular marker) k significantly varied with season and depth; enterococci decayed faster at shallow depths and during the summer, while E. coli decayed faster at shallow depths and during the winter. Rate constants for MST markers and culturable FIB diverged except at the deepest depth in the water column potentially complicating the use of MST marker concentrations to allocate sources of FIB contamination.

Cilostazol May Improve Maturation Rates and Durability of Vascular Access for Hemodialysis.

Cilostazol is effective in controlling pathophysiological pathways similar or identical to those involved in nonmaturation and failure of the arteriovenous access. This case-control study examined whether cilostazol would improve maturation rates and durability of vascular access for hemodialysis. The treatment group included 33 patients who received cilostazol for ≥30 days prior to creation of a dialysis access and continued with cilostazol therapy for ≥60 days after surgery. The matched (gender, age, race, diabetes, and the year of surgery) control group included 116 patients who underwent the same procedure but did not receive cilostazol prior to and at least 3 months after surgery. Primary outcomes were maturation and, for those that matured, time of functioning access, defined as the time from the first use to irreparable failure of the access. Secondary outcomes were time to maturation, complications, and time to first complication. Study group patients were 3.8 times more likely to experience fistula maturation compared to the controls (88% vs 66%, RR = 3.8, 95% confidence interval: 1.3-11.6, P = .016). Fewer patients in the study group had complications (76% vs 92%, P = .025), and the time from construction of the fistula to the first complication was longer (345.6 ± 441 days vs 198.3 ± 185.0 days, P = .025). Time to maturation was similar in both groups (119.3 ± 62.9 days vs 100.2 ± 61.7 days, P = .2). However, once matured, time to failure was significantly longer in the treatment group (903.7 ± 543.6 vs 381.6 ± 317.2 days, P = .001). Multivariate analysis confirmed that the likelihood of maturation was significantly higher in the treatment group patients. These results suggest that dialysis access patients may benefit from preoperative and postoperative cilostazol therapy. If confirmed by a randomized trial, this treatment will have a major beneficial impact on patients dependent on a well-functioning access for their hemodialysis.

Risk and Representation in Research Ethics: The NunatuKavut Experience.

This article examines Canadian policy governing the ethics of research involving Indigenous communities. Academics and community members collaborated in research to examine how best to apply the Tri-Council Policy Statement guidelines in a community with complex and multiple political and cultural jurisdictions. We examined issues of NunatuKavut (Southern Inuit) authority and representation in relation to governance of research in a context where community identity is complex and shifting, and new provincial legislation mandates centralized ethics review. We describe the politics of risk--the ways in which collective identity and research risks are co-constructed. Our case study illustrates that collective consent to research must emphasize shifting identity construction in relation to the particular risks and benefits invoked by the research question, to ascertain with which groups or individuals the negotiation of risk should take place in the first place. We conclude by describing a necessary re-imagining of policy governing research ethics involving Indigenous communities.

Factors related to short length of stay after carotid endarterectomy.

In the past decade, expected in-hospital length of stay (LOS) after carotid endarterectomy (CEA) has decreased from 4 days to 1. Long LOS is associated with known complications and factors affecting severity of the patient's condition. Factors affecting an intermediate stay of 2 to 4 days need further clarification. The vascular registry at Jobst Vascular Center includes data on manifestation of disease; cardiovascular history; operation and discharge dates; surgeon; surgical details such as patching, shunting, and completion arteriography; and complications. Univariate chi-square and ANOVA and multivariate logistic regression were applied to analyze 635 CEAs performed in 1998, 1999, and 2000. Statistical significance was at a p value less than 0.05 (two-sided). Overall morbidity rate was 8.2% with three (0.5%) in-hospital neurologic complications and one death for a 0.16% mortality rate. Fifty-eight percent of the patients were discharged in 1 day. Patients staying 1 day were 3 years younger. Female gender and prior cerebrovascular accident were factors extending LOS to 2 and 3 days. History of angina, heart failure, valve disease, and vein patch or no patch contributed to LOS of 3 or 4 days. Completion arteriography had an association with LOS of 2 days. The relative percentage of patients with complications increased with LOS. No significant relationship was found for symptoms, smoking, myocardial infarction, atrial fibrillation, cardiac revascularization, or surgeon. Insulin-treated diabetes mellitus, cardiac risk factors, cerebrovascular accident, and vein patch or no patch correlated with prolonged hospitalization. Factors were identified that may alter a clinical pathway designed for discharge 1 day after CEA. Focused management of patients with cardiac and cerebrovascular accident history or requiring vein patch and a better understanding of CEA in women may further increase the percentage of patients discharged 1 day after CEA.

Characterization of fecal concentrations in human and other animal sources by physical, culture-based, and quantitative real-time PCR methods.

The characteristics of fecal sources, and the ways in which they are measured, can profoundly influence the interpretation of which sources are contaminating a body of water. Although feces from various hosts are known to differ in mass and composition, it is not well understood how those differences compare across fecal sources and how differences depend on characterization methods. This study investigated how nine different fecal characterization methods provide different measures of fecal concentration in water, and how results varied across twelve different fecal pollution sources. Sources investigated included chicken, cow, deer, dog, goose, gull, horse, human, pig, pigeon, septage and sewage. A composite fecal slurry was prepared for each source by mixing feces from 6 to 22 individual samples with artificial freshwater. Fecal concentrations were estimated by physical (wet fecal mass added and total DNA mass extracted), culture-based (Escherichia coli and enterococci by membrane filtration and defined substrate), and quantitative real-time PCR (Bacteroidales, E. coli, and enterococci) characterization methods. The characteristics of each composite fecal slurry and the relationships between physical, culture-based and qPCR-based characteristics varied within and among different fecal sources. An in silico exercise was performed to assess how different characterization methods can impact identification of the dominant fecal pollution source in a mixed source sample. A comparison of simulated 10:90 mixtures based on enterococci by defined substrate predicted a source reversal in 27% of all possible combinations, while mixtures based on E. coli membrane filtration resulted in a reversal 29% of the time. This potential for disagreement in minor or dominant source identification based on different methods of measurement represents an important challenge for water quality managers and researchers.

Distal internal iliac artery embolization: a procedure to avoid.

OBJECTIVES: Internal iliac artery (IIA) coil embolization as an adjunct to endovascular stent grafting (ESG) is common practice for treating abdominal aortic aneurysm (AAA) in patients with a substantially enlarged common iliac artery requiring extension of the stent-graft limb into the external iliac artery. The literature describing pelvic ischemia in association with IIA coil embolization contains conflicting reports of symptom severity. We studied IIA occlusion outcome as a function of coil placement in the IIA. METHODS: From August 1997 to March 2002, 20 patients with AAA underwent ESG with unilateral IIA coil embolization. Coils were placed proximal to the first branch of the IIA in 8 patients and distal to the first branch in 12 patients. Symptoms of pelvic ischemia and mid-term outcome were studied. RESULTS: Patients included 18 men and 2 women with mean age of 70(1/2) years (range, 53-86 years). Mean diameter of AAA was 54.4 mm (range, 38-80 mm), and of common iliac artery was 24.2 mm (range, 15-48 mm). Ten patients (50%) had new onset of symptoms of pelvic ischemia after endograft procedures: 1 of 8 patients (13%) with proximal IIA embolization had buttock claudication, and 9 of 12 patients (75%) with distal IIA embolization had pelvic ischemic symptoms, including buttock claudication in 8 and impotence in 1 (P =.02, Fisher exact test). No colonic ischemia occurred in this series. At 12-month follow-up, 4 patients with distal IIA embolization were symptom-free. At further follow-up to 24 months, 4 patients remained significantly limited with symptoms of claudication. CONCLUSIONS: A significantly higher incidence of symptoms of pelvic ischemia occurred with more distal placement of coils for IIA embolization. Failure to control for extent of coil placement may account for the apparently conflicting results in published studies. IIA coil embolization should be performed as proximal as possible to prevent interference with pelvic collateral circulation.

Bell-bottom aortoiliac endografts: an alternative that preserves pelvic blood flow.

OBJECTIVE: Dilated common iliac arteries that complicate aortic aneurysm stent grafting usually have been managed with endograft extension across the iliac artery bifurcation with internal iliac artery (IIA) occlusion. We studied 25 patients with significant common iliac artery (CIA) dilation treated with two methods: endograft extension across the iliac bifurcation or a new approach with a flared cuff within the CIA that preserves the IIA. METHODS: Of 86 patients with abdominal aortic aneurysm (AAA) who underwent bifurcated endovascular stent grafting (ESG), 25 (29.1%) had at least one dilated CIA. Two treatment groups had different methods of management of iliac artery dilation. Group 1 underwent ESG with straight extension across the iliac bifurcation and IIA coil embolization before the ESG procedure (n = 2) or simultaneously with ESG (n = 8). Group 2 underwent ESG with flared distal cuff (AneuRx, Medtronic AVE, Santa Rosa, Calif) contained within the CIA, the so-called "bell-bottom" procedure, thus preserving the IIA (n = 15). Iliac artery dimensions, operating room time, fluoroscopy time, and postoperative complications were prospectively gathered. RESULTS: Two women and 23 men had mean diameters of AAA of 56.6 mm (range, 38 to 98 mm) and of CIA of 21.4 mm (range, 15 to 48 mm). The diameters of CIA treated with device extension into external iliac artery after IIA coil embolization in group 1 and with the bell-bottom procedure in group 2 were not different (mean CIA diameter, 19.9 mm; range, 15 to 26 mm; and mean, 19.1 mm; range, 15 to 24 mm; respectively). However, significantly lower operating room and catheter procedure times were found in group 2 compared with group 1 (137 versus 192 minutes; 58 versus 106 minutes; P =.02 and.02, respectively). No periprocedural type I endoleaks were found in either group. Nine patients in group 2 also had a second contralateral CIA aneurysm, and five patients (mean CIA diameter, 33.0 mm; range, 22 to 48 mm) underwent treatment with extension across the iliac artery bifurcation and IIA occlusion. Use of the bell-bottom procedure on the other side allowed preservation of one IIA. Four cases (mean diameter, 19.3 mm) also underwent contralateral bell-bottom procedure. Two of these group 2 patients had complications, with severe buttock claudication in one and distal embolism necessitating limb salvage bypass after preoperative coil embolization of the IIA in another. CONCLUSION: Significant CIA ectasia or small aneurysm is often associated with AAA. In such cases, the bell-bottom procedure that preserves IIA circulation is a new alternative to the common practice of placement of endograft extensions across the iliac artery bifurcation in patients with at least one CIA diameter of less than 26 mm. Additional benefits include reduced total procedure time. Early technical success appears to justify continued use. However, long-term evaluation is necessary to determine durability because the risk of rupture as the result of potential expansion of the excluded iliac artery or late failure is unknown.