Suboptimal preventive practices in patients with carotid and peripheral vascular occlusive disease in a tertiary referral setting.

BACKGROUND: Effective strategies for the prevention of adverse vascular events in patients with atherosclerotic vascular disease include smoking cessation, platelet inhibition, antihypertensives, hypoglycaemic and cholesterol lowering agents. The current literature suggests that these practices are suboptimal in patients with peripheral vascular disease (PVD). This study aims to examine and compare the use of preventive therapy in patients admitted for interventions related to peripheral and carotid atherosclerotic occlusive disease. METHODS: All inpatients undergoing diagnostic or therapeutic procedures for occlusive disease of the lower limb and carotid artery at Royal Perth Hospital, Western Australia, between January 2000 and December 2000 were included in the study. Their medical charts were reviewed to measure the prevalence of the use of antithrombotic, antihypertensive and cholesterol-lowering therapies. RESULTS: Medical charts of 256 patients (97%) were reviewed during the study period. Carotid related procedures accounted for 26% of the sample. Overall, 80% were prescribed antithrombotic (antiplatelet or anticoagulation) therapy at the time of discharge. In the carotid group, 97% were on some form of antithrombotic therapy as opposed to 75% in the PVD group. Antihypertensive and cholesterol lowering therapies were used in 82% and 63%, respectively, of the carotid group vs 68% and 36% in the PVD group. Rates of preventive practices were lowest in the subgroup of PVD patients without a history of coronary or cerebrovascular disease. CONCLUSIONS: Preventive therapies are under utilized in patients with PVD. Effective strategies need to be developed to encourage the use of these adjunctive therapies in the long-term management of vascular patients.

Using bilateral iliac branch devices for endovascular iliac aneurysm repair.

INTRODUCTION: The endovascular repair of bilateral iliac aneurysms using bilateral Iliac Branch Devices (IBDs) has been infrequently performed and reported.We aim to describe this technique and report on the results of our case series. METHODS: Three different device designs are available. The procedural options include a totally transfemoral approach, or a combined transfemoral and brachial approach. Clinical records for patients who have had this procedure were reviewed. RESULTS: The indications for the technique include bilateral common iliac artery aneurysm repair, with or without concomitant abdominal aortic aneurysm repair. Considerations include the timing of main body endovascular aortic aneurysm repair (EVAR) device introduction, the use of a proximal access site and the type of IIA stent-graft that is used. Between 2007 and 2010, six patients had bilateral IBD implantation. All patients required an EVAR main body device in addition to bilateral IBDs. Eighty-three per cent were males, mean age was 73 years. Mean follow up was 15 months. Technical success was obtained in 100% of cases. There was one branch occlusion (8.3%). There were no type I endoleaks. One patient had a type II endoleak. CONCLUSIONS: Bilateral IBDs can be used safely and with excellent rates of technical success and branch patency in appropriately selected patients.

Treatment of infrarenal abdominal aortic aneurysms with oversized (36-mm) Zenith endografts.

PURPOSE: To evaluate the outcome of treating infrarenal abdominal aortic aneurysms with unfavorable necks using the 36-mm Zenith endograft. METHODS: The indication for use of the 36-mm endograft for infrarenal aortic aneurysm was a minimum 20-mm-long sealing zone and a diameter >28 mm at any point but <34 mm, varying more than 3 mm in contour. A series of 67 patients (64 men; mean age 76.2 years, range 59.5 to 88.3) who had been treated with the 36-mm endografts between June 1999 and February 2004 were assessed for medium-term outcomes. The patients were identified from the device planning records. Follow-up was carried out using chart review and direct patient contact. The indication for use of the endograft was checked with the aneurysm neck profile from the original planning diagrams. Cause of death was ascertained from the treating clinician, the medical record, or the State Death Registry. Outcome endpoints were proximal type I and type III endoleaks, migration, sac size change, and death. RESULTS: The mean diameter of the sealing zone was 31.9+/-1.6 mm within the 20-mm segment from the lowest renal artery. Stent-graft delivery was achieved in all 67 patients. Two (3%) patients died within 30 days from non-graft-related cardiorespiratory causes. Proximal type I endoleaks were identified in 3 (4.5%) patients: 2 during deployment and another at 9 days. The mean follow-up period for the 65 patients who survived 30 days was 26.9+/-12.6 months (range 2-66). Migration occurred in 1 patient with development of a type III endoleak and sac reperfusion due to separation of the graft body from the bare anchor stent owing to suture breakage. Forty-seven patients were alive at the last review. The aneurysm sac had contracted or was unchanged in 45 (96%) cases. Minor enlargements of the sac were observed in 2 patients. The re-intervention rate was 16.4% (11 patients). There was 1 conversion to open repair to treat perigraft sepsis. The aneurysm- and procedure-related mortality was 4.5%; no patient experienced rupture. All-cause mortality was 29.9% (20/67). CONCLUSION: Large caliber endografts such as the Zenith 36-mm are an alternative option to open surgery or fenestrated endografting for some infrarenal aneurysms.