Mynx Vascular Closure Device in Arterial Endovascular Procedures.

BACKGROUND: Vascular closure devices have been used to achieve hemostasis of percutaneous access sites following endovascular procedures, with reported decreased time for arterial control as well as decreased time to ambulation. We sought to determine rates and risk factors of postoperative bleeding complications and failures using these devices from a single institution experienced in the use of vascular closure devices. METHODS: All patients undergoing arterial endovascular procedures with percutaneous access between March 2010 and October 2015 at a single institution were identified and analyzed (n = 894). Patients undergoing endovascular aneurysm repair, open access, venous procedures, or upper extremity access were excluded. Comparison groups were formed between those using the Mynxgrip® (Mynx), Angio-Seal™, Perclose® vascular closure devices and manual pressure (MP). Patient demographics, intraoperative data, and postoperative complications were compared. RESULTS: A total of 615 (69%) patients received Mynx, 165 other vascular closure devices (VCD) ([14%] Perclose, 44 [4%] Angio-Seal), and 114 (13%) MP. MP patients were more likely to be diagnostic angiogram with smaller sheaths, while VCD patients were more likely to be interventions with larger sheaths. Univariate analysis identified age, atrial fibrillation, intervention (as opposed to diagnostic), and sheath size >5F associated with postoperative bleeding (P < 0.05), and in backward, logistic regression analysis, sheath size, age, and renal failure were independent predictors of the same. CONCLUSIONS: Use of vascular closure devices has a low rate of bleeding complication, device failure, and need for operative repair. Bleeding is associated with increased age, interventional procedure, and end-stage renal disease. Mynx, Perclose, and Angio-Seal have similar rates of complications. Use of these devices are a safe option for groin vessel closure.

Nicotine Dependence and Willingness to Quit Smoking in Vascular Surgery Patients.

BACKGROUND: Smoking rates have declined; however, it remains the primary modifiable risk factor for vascular disease. While vascular surgeons often advise patients to quit, few provide assistance. We sought to understand patients' interest in quitting and determine factors that influence this willingness to quit. METHODS: Anonymous surveys were given to vascular surgery clinic patients in a single institution over a 5-month period. Demographic information, smoking status, cessation attempts, and barriers to quitting were obtained. Nicotine dependence was determined using the Fagerstrom Test, and willingness to quit was assessed using a contemplation ladder. Patient's willingness to quit was evaluated in relation to symptomatic status, previous/planned operation, and nicotine dependence levels. RESULTS: A total of 490 patients (92%) completed the survey with 109 (22%) current smokers, 195 (40%) former smokers, and 186 (38%) never smokers. Never smokers were more likely to be female and employed while smokers were more likely to be disabled. Although 51% of smokers displayed moderate/high nicotine dependence, 54% demonstrated willingness to consider quitting within 6 months. The primary barrier to cessation identified was previous failed attempt(s) to quit in 44%. Most (90%) had previously attempted quitting, 63% attempted 3 or more times, and the most common technique used was "quitting cold turkey". Fifty-nine percent of patients reported physicians' had offered assistance in cessation, but only 2% had been in a cessation program. There was no correlation between willingness to consider quitting and symptomatic status, previous/planned operation, or nicotine dependence. Smokers of less than 10 cigarettes/day had a lower nicotine dependence level (P = 0.0001) and higher willingness to consider quitting (P = 0.0015), as did those who had fewer failed prior attempts to quit and who did not believe it was too late to quit. CONCLUSIONS: Most of our vascular patients self-report as nonsmokers. Over half of those who smoke demonstrate willingness to consider quitting within 6 months, which is not dependent on nicotine dependence, previous/planned operation, or symptomatic status. Those who smoke less than 10 cigarettes per day, have fewer past failed attempts to quit, and believe that it is not too late to quit are more likely to consider quitting. Vascular surgeons should be more aware of previous quit attempts and patterns of smoking and be proactive in assisting patients in cessation attempts.

Contemporary Characteristics and Outcomes of Young Patients (Under 50 Years) Undergoing Open Carotid Artery Surgery.

BACKGROUND: Stroke is the second leading cause of death worldwide, with 10% of neurologic events occurring in adults aged 18-49 years. The incidence in this age group has risen over the last 2 decades (while falling in the aged), despite improved diagnostic capacity and greater ability to treat it medically and surgically. We are unaware of any modern data regarding the risk factors and outcomes after carotid artery surgery in this demographic. We sought to evaluate the contemporary characteristics and outcomes of young adults undergoing carotid surgery. METHODS: Retrospective analysis of patients aged 18-49 years who underwent carotid surgery from 2005 to 2015. We collected demographics, indications, and outcomes, comparing them to previously published series. RESULTS: Sixteen patients were with the mean age of 46 (41-49) years, and 44% were male. Most were Caucasian (88%) and smokers (94%), consuming 1.3 packs/day with a mean pack-year history of 32 years (10-100). Average body mass index was 29. The majority (81%) were symptomatic prior to surgery (69% of these were strokes). Complications after surgery were hyperperfusion (1) and one deep vein thrombosis. Compared to young patients treated from 1973 to 1990s, we found significantly more female patients (P < 0.001) and more strokes (P < 0.04) leading to the procedure, while smoking remained the most prevalent risk factor. CONCLUSIONS: Carotid artery surgery in young patients continues to be associated with symptomatic stenosis and smoking; however, compared to 2-4 decades ago it may be more common in young females, and following a stroke. This may be from an increased prevalence of female smoking and improved neuroimaging.

Risk of Acute Kidney Injury after Percutaneous Pharmacomechanical Thrombectomy Using AngioJet in Venous and Arterial Thrombosis.

BACKGROUND: Percutaneous mechanical thrombectomy is commonly used to treat acute thrombotic syndromes. AngioJet (AJ) forcibly sprays fibrinolytics to fragment and aspirate thrombus. It is known to cause hemolysis and gross hematuria, yet potential consequences to renal function after AJ remain unstudied. We sought to determine the risk of acute kidney injury (AKI) after AJ when compared with other lysis techniques. METHODS AND RESULTS: We retrospectively reviewed patients treated with thrombolysis over 5 years. We identified those treated with AJ or catheter-directed thrombolysis (CDT). Demographics, indications, procedures, and laboratory values within 3 days were recorded. AKI was defined as an increase >25% above the baseline creatinine within 72 hr of the procedure. IN total, 102 patients (52 AJ, 50 CDT) had no statistical difference in mean age (50 and 51), indication (arterial thrombosis 65% and 88%), or baseline creatinine (0.9 and 1.0 mg/dL), respectively. AKI occurred in 15 (29%) patients treated with AJ versus 4 (8%) of CDT (P = 0.007). Similar numbers of AJ and CDT patients underwent additional open surgical procedures (21% and 30%, respectively, P = not significant). Multivariable analysis demonstrated that the odds of AKI were only increased by AJ (odds ratio [OR] 8.2, 95% confidence interval [CI] 1.98-34.17, P = 0.004), open surgery (OR 5.4, 95% CI 1.43-20.17, P = 0.013), or a >10% drop in hematocrit (OR 4.0, 95% CI 1.15-14.25, P = 0.03). CONCLUSIONS: In our observational study, AJ is an independent risk factor for AKI. Concomitant open surgery and drop in hematocrit also raise the odds of AKI. Renal injury after AJ is under-reported in the literature, and may be related to hemolysis from the device.

High-Resolution CT Angiogram for Lower Extremity Vein Mapping.

High-resolution CT angiogram (CTA) has replaced traditional diagnostic angiography as the main preoperative imaging modality for vascular surgery patients. Although the use of CTA is increasing for arterial imaging, it has not been used routinely for vein mapping. The goal of this study was to evaluate the accuracy of CTA for venous anatomy and compare it to a standard venous duplex ultrasound (DUS). When the vein was used for bypass, the quality and size of the vein were evaluated in the operating room. As part of a preoperative workup before lower extremity revascularization, 16 patients underwent a CTA followed by a DUS. Although the CTA provided useful arterial anatomy, the greater saphenous vein (GSV) was also evaluated. In total, 22 GSV were evaluated in 11 patients. The vein diameter was measured by CTA at four locations: saphenofemoral junction, midthigh, knee joint, and midcalf region. Duplication or other anomalies were also noted, when present. These measurements were taken by an interventional radiologist independently and before the DUS. Routine vein mapping with diameter measurements were then performed with DUS in a vascular laboratory by registered vascular technicians. Measurements for each limb were then compared between CTA and DUS using linear regression (mean ± SD). There was no statistical difference in the diameter of the GSV when measured using a CT or a DUS at the standard points of measurements. Furthermore, the operative findings confirmed the CTA to be very accurate. There were four duplications in the GSV which were all seen on the CTA, whereas only two of these were identified by DUS. There was one vein found to be sclerotic and unusable by DUS that was not identified by CTA. CTA is as accurate as DUS for evaluation of superficial venous anatomy in the lower extremities. CTA can provide global anatomy and can be used as a one-stop imaging modality for both arterial and venous anatomy. However, sclerosis is not detected by CTA.

Unilateral inline replacement of infected aortofemoral graft limb with femoral vein.

OBJECTIVE: Aortic graft infection remains a formidable challenge for the vascular surgeon. Traditionally, reconstruction with a neoaortoiliac system (NAIS) involves removal of the entire synthetic graft with in situ reconstruction using femoral vein. Whereas the NAIS procedure is durable with excellent graft patency and a low reinfection rate, it can take up to 10 hours and result in a high perioperative complication rate with significant mortality. Not infrequently, the infection is limited to a single limb. In addition, the patient may be too frail to tolerate aortic clamping for a complete graft excision. Under such circumstances, complete excision of the aortofemoral bypass graft (AFBG) may not be indicated. It is hypothesized that local control of infection and limited reconstruction using femoral vein may be acceptable. The objective of this study was to examine the outcomes of all patients who underwent partial AFBG resection and in situ reconstruction with femoral vein. METHODS: A retrospective review of all AFBG infections from 2003 to 2015 treated at a tertiary care facility was undertaken. Patients who underwent unilateral partial graft excision with inline reconstruction using femoral vein at the distal (femoral) anastomosis were included. Complete excisions with bilateral revascularizations using any conduit or any extra-anatomic reconstructions were excluded. The primary end point was successful treatment of infection. Secondary end points were procedure-related mortality, graft patency, and perioperative complications. RESULTS: During a 12-year period, partial graft excision with bypass using the femoral vein was performed in 21 patients (24 limbs). Mean age was 61 ± 12 years. There were 13 men and 8 women. Mean follow-up was 53 ± 27 months. Successful treatment was achieved in 19 of 21 patients. The two treatment failures were due to persistent infection. One of these patients declined complete graft excision and is receiving lifelong suppressive antibiotic therapy. The other patient underwent complete graft excision and an NAIS reconstruction. There were no perioperative or procedure-related deaths. There were no major amputations, and primary graft patency was 92% at 72 months. The most common AFBG culture isolate was Staphylococcus species. Approximately one-third of cultures did not yield any growth. Patients underwent anywhere from 1 to 12 weeks of combined intravenous and oral antibiotic therapy. CONCLUSIONS: This limited series demonstrates excellent graft patency with a low persistent infection rate. Thus, in patients with localized graft infection, partial excision with preservation of the proximal synthetic graft is an acceptable alternative when patient factors preclude complete graft excision.

Outcomes after retroflexed gracilis muscle flap for vascular infections in the groin.

OBJECTIVE: Multiple catheterizations and procedures on the femoral arteries can increase the risk of infection and eventual destruction of the overlying skin and subcutaneous tissue. Without adequate tissue coverage, vascular structures are exposed and, thus, vulnerable to disruption. This can lead to loss of limb and/or life and carries a significant mortality. We hypothesized that gracilis muscle flap (GMF) was a reliable adjunct in providing healthy tissue coverage for a complex surgical problem. METHODS: Retrospective review of charts was performed on all patients who had undergone GMF for groin infections at a tertiary care medical center. RESULTS: From 1997 to 2012, GMF was performed in 68 limbs (64 patients) by vascular surgeons for infectious etiology to cover the common femoral artery. At the time the GMF was placed, the femoral artery had synthetic graft/patch in 14 limbs, whereas 54 limbs had procedures with autologous conduit. Complete healing was achieved in 58 (85%) limbs. Treatment was deemed not successful in 10 limbs where patients continued to have persistent infection. Six out of 10 limbs had anastomosis disruption requiring emergent ligation of the common femoral artery. Nine patients died during the perioperative period (30-day). There were a total of 13 amputations in 12 patients. Limb salvage was achieved in 55 limbs (81%). Univariate analysis suggested that patients that had revascularization procedures with synthetic graft had a higher complication rate compared with autologous/vein reconstruction (24% vs 5%; P = .021). This group also has a higher rate of persistent infection compared with the autologous group (24% vs 2%; P = .006). Patients older than 75 years at the time of GMF had a higher incidence of GMF-related complications (57% vs 5%; P = .04). Multivariate analysis confirmed that presence of prosthesis led to higher incidence treatment failures and muscle flap complications at the surgical site (odds ratio, 6.6; P = .04; and odds ratio, 13.3; P = .03, respectively). CONCLUSIONS: GMF is technically simple to perform and provides durable soft tissue coverage with a high rate of healing for complex groin wounds even in the presence of synthetic conduit.

Delayed management of Grade III blunt aortic injury: Series from a Level I trauma center.

BACKGROUND: Blunt aortic injuries (BAIs) are traditionally treated as surgical emergencies, with the majority of repairs performed in an urgent fashion within 24 hours, irrespective of the grade of aortic injury. These patients are often underresuscitated and often have multiple other trauma issues that need to be addressed. This study reviews a single center's experience comparing urgent (<24 hours) thoracic endovascular aneurysm repair (TEVAR) versus delayed (>24 hours) TEVAR for Grade III BAI. METHODS: All patients undergoing TEVAR for BAI at a single institution between March 2004 and March 2014 were reviewed (n = 43). Patients with Grade I, II, or IV aortic injuries as well as those who were repaired with an open procedure or who lacked preoperative imaging were excluded from the analysis. Demographics, intraoperative data, postoperative survival, and complications were compared. RESULTS: During this period, there were 43 patients with blunt thoracic aortic injury. There were 29 patients with Grade III or higher aortic injuries. Of these 29 patients, 1 declined surgery, 2 were repaired with an open procedure, 10 underwent urgent TEVAR, and 16 had initial observation. Of these 16, 13 underwent TEVAR in a delayed fashion (median, 9 days; range, 2-91 days), and 3 died of non-aortic-related pathology. Comparing the immediate repair group versus the delayed repair group, there were no significant demographic differences. Trauma classification scores were similar, although patients in the delayed group had a higher number of nonaortic injuries. The 30-day survival was similar between the two groups (9 of 10 vs. 12 of 16), with no mortalities caused by aortic pathology in either group. CONCLUSION: Watchful waiting may be permissible in patients with Grade III BAI with other associated multisystem trauma. This allows for a repair in a more controlled environment. LEVEL OF EVIDENCE: Therapeutic study, level V.

Management of noninfected prosthetic aortic bypass failures using femoral vein.

OBJECTIVE: The use of femoral-popliteal vein as a conduit to treat infected aortoiliac pathologies has been described extensively and is referred to as the neoaortoiliac system procedure. We examined our center's outcomes after using deep vein as a conduit for the salvage of failed aortofemoral prosthetic bypasses in patients without infection. METHODS: Procedures using femoral vein as conduit at the University of Arkansas for Medical Sciences between January 2005 and July 2013 were retrospectively reviewed (n = 110). Patients were excluded if the reconstruction was for infectious etiologies (n = 71) or for nonaortofemoral reconstructions (n = 31). Operative variables, complications, and patency rates were collected. RESULTS: Femoral vein was used to revascularize failed aortobifemoral bypasses in eight patients. Indications included rest pain (n = 7) and short-distance claudication (n = 1). Reconstructions identified two patients each with aortobifemoral bypass or aortofemoral bypass, and one patient each with aortofemoral bypass with femorofemoral bypass, aorotoiliac bypass, iliofemoral bypass with femorofemoral bypass, or ilioprofunda bypass. Mean follow up was 27.5 months. There were no major postoperative complications. Symptoms secondary to deep vein harvest (swelling/dermatitis) developed in three of eight patients. The average ankle-brachial index improved from 0.33 to 0.73 (P = .003), with a limb salvage rate of 100%. Kaplan-Meier analysis found primary patency was 70% at 1 year and 53% at 5 years, which improved to 100% and 75%, respectively, with secondary measures. CONCLUSIONS: Despite a need for secondary interventions and venous hypertension syndromes, deep vein offers good patency and excellent limb salvage after failed prosthetic aortoiliac bypasses.

Outcomes after arterial endovascular procedures performed in patients with an elevated international normalized ratio.

BACKGROUND: Patients treated with anticoagulants frequently require urgent vascular procedures and elevated prothrombin time/international normalized ratio (INR) is traditionally thought to increase access site bleeding complications after sheath removal. We aimed to determine the safety of percutaneous arterial procedures on patients with a high INR in the era of modern ultrasound-guided access and closure device use. METHODS: Patients undergoing arterial endovascular procedures at a single institution between October 2010 and November 2012 were reviewed (n = 1,333). We retrospectively analyzed all patients with an INR > 1.5. Venous procedures, lysis checks, and cases with no documented INR within 24 hr were excluded. Sixty-five patients with 91 punctures were identified. A comparison group was then generated from the last 91 patients intervened on with INR < 1.6. Demographics, intraoperative data, and postoperative complications were compared. RESULTS: The demographics were similar. More Coumadin use and higher INR were found in the study group (71/91 and 0/91, P = 0.001; 2.3 and 1.1 sec, P = 0.001, respectively), but there was more antiplatelet use in the control group (68/91 and 51/91, P = 0.01). Intraoperatively, the sheath sizes, protamine use, closure device use, ultrasound guidance, brachial access, and procedure types were not statistically different. Sheath sizes ranged from 4 to 22F in the study group and 4 to 20F in the control group. Paradoxically, heparin was administered more frequently in the study group (64/91 and 50/91, P = 0.046). Bleeding complications occurred more commonly in the study group (3/91 and 1/91, P = 0.62), but this failed to reach significance and the overall complication rate in both groups was low. CONCLUSIONS: Endovascular procedures may be performed safely with a low risk of bleeding complications in patients with an elevated INR. Ultrasound guidance and closure device use may allow these cases to be performed safely, but a larger series may be needed to confirm this.

Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts.

OBJECTIVE: Graft excision and neo-aortoiliac system (NAIS) reconstruction with large caliber, femoral popliteal vein (FPV) grafts have been reported as successful treatment of aortic graft infection (AGI) in several small series with limited follow-up. The goal of this study was to evaluate long-term outcomes in large cohort of consecutive patients treated with NAIS for AGI. METHODS: From 1990 to 2006, 187 patients (age: 63 +/- 10 years) with AGI were treated with in situ reconstructions using 336 FPV grafts. Data from a prospectively maintained data base were analyzed. RESULTS: NAIS reconstruction was performed for 144 infected aortofemoral bypasses, 21 infected aortic-iliac grafts, and 22 infected axillofemoral bypasses that had been placed to treat AGI. Polymicrobial cultures were present in 37% while 17% showed no growth. There were 55% gram positive, 32% gram negative, 13% anaerobic, and 18% fungal infections. The mean Society for Vascular Surgery run-off resistance score was 4.5 +/- 2.3. Concomitant infrainguinal bypass was necessary in 27 (14%) patients (32 limbs). Major amputations were performed in 14 (7.4%) patients. Out of 14 amputations, five patients had irreversible ischemia and in four, there was no conduit available. Graft disruption from reinfection occurred in 10 patients (5%). While 30-day mortality was 10%, procedure-related mortality was 14%. Independent risk factors for perioperative death on multivariate analysis were: preoperative sepsis (odds ratio [OR] 3.5) ASA class 4 (OR 2.9), Candida species (OR 3.4), Candida glabrata (OR 7.6), Klebsiella pneumoniae (OR 3.5), and Bacteroides fragilis (OR 4.1). Perioperative factors included use of platelets (OR 2.4), blood loss >3.0 liters (OR 9.5). Cumulative primary patency at 72 months was 81%; secondary/assisted primary patency was 91%. Limb salvage at 72 months was 89%. Five-year survival was 52%. CONCLUSIONS: These results compare favorably with other methods of treating AGI, especially in patients with multilevel occlusive disease. Principle advantages include acceptable perioperative mortality, low amputation rate, superior durability with excellent long-term patency, and freedom from secondary interventions and recurrent infections.

Definitive test to diagnose median arcuate ligament syndrome: injection of vasodilator during angiography.

The diagnosis of median arcuate ligament (MAL) syndrome and its correlation with symptoms has been controversial since the disease entity was described. The authors describe a technique that will identify patients who will benefit from intervention. Eight patients with isolated celiac artery compression from MAL were identified by the authors. Their technique involved selective cannulation of the superior mesenteric artery (SMA) and injection of a vasodilator during angiography. Symptom reproduction and loss of collateral filling of the celiac territory represented a positive test: 4 of the 8 patients had a positive test and underwent successful surgical treatment of the condition; 3 of them remained asymptomatic at follow-up; 1 patient continues to have mild abdominal discomfort. Of the 4 patients with a negative test, 2 were found to have other conditions causing their symptoms. Vasodilator injection into the SMA is a useful diagnostic test to identify patients with symptomatic MAL syndrome.

Staging the neoaortoiliac system: feasibility and short-term outcomes.

BACKGROUND: The neoaortoiliac system (NAIS) has gained popularity as a durable procedure for treating aortic graft infections. However, one of the disadvantages has been a long operation that can take up to 10 hours. The goal of this study was to assess the feasibility of staging the NAIS procedure with deep vein harvest a day before the aortofemoral bypass and evaluate if staging had any effect on graft patency or morbidity and mortality, or both. METHODS: We reviewed data for all the NAIS procedures performed for aortic graft infections at a tertiary care university hospital. The femoral popliteal veins of patients undergoing the staged NAIS were harvested a day in advance and left in situ. The next day patients underwent the prosthetic graft excision with reconstruction using the femoral popliteal veins. Patients with aortic occlusion on presentation were not candidates for vein harvest in advance and underwent a unilateral bypass with a subsequent femorofemoral bypass as a second stage. RESULTS: In the last 8 years, 26 patients (17 men, 9 women; mean age, 62.6 +/- 8.3 years) underwent the NAIS procedure for aortic graft infections. Mean follow-up was 15.7 months. Primary assisted graft patency was 100%. There were 11 patients in the staged group and 10 patients in the nonstaged group. All the staged patients underwent vein mobilization a day before excision of aortic prosthesis. Despite undergoing a separate procedure for vein harvesting at a different time, there was no difference in total operative time (12.0 +/- 1.8 vs 11.9 +/- 2.2 hours), operative blood loss (2.6 +/- 1.2 vs 3.4 +/- 2.4 L), and requirements for transfusion for blood products (6.7 +/- 3.7 vs 6.0 +/- 5.4 U) or crystalloid (11.3 +/- 3.1 vs 10.9 +/- 2.4 L) between the staged group and nonstaged groups. One amputation occurred in each group. The perioperative mortality was 18% for the staged group and 20% for nonstaged group. The 12-month survival was 72% for staged and 70% for nonstaged NAIS. No graft-related complications were observed from the preoperative vein harvest. CONCLUSION: The NAIS can be staged without compromising the efficacy of the procedure as evident by excellent long-term patency and control of the infection. By reducing the duration of the primary procedure, staging may be beneficial to both the patient and the surgeon.

Pseudoaneurysm: a review.

Pseudoaneurysms may arise from any artery in the human body. Most commonly found to involve the femoral artery after angiography, the presentation may vary from being clinically silent to a life-threatening emergency scenario. Recognition of this condition and treatment largely depend on the hemodynamic stability and anatomy of the pseudoaneurysm. Advances in treatment have enabled nonsurgical therapy in a significant number of cases. Ultrasound-guided thrombin injection is a fairly easy and effective treatment option. Other endovascular approaches, such as stent graft repair and coil embolization, are also available. Endovascular techniques play an important role in treating pseudoaneurysms arising from the aorta as a result of blunt trauma or previous aortic surgery. It is important to recognize the indications for surgery to avoid delay in the management of this potentially limb- or life-threatening condition.

Remote superficial femoral artery endarterectomy: early results for TASC D lesions in patients with severe ischemia.

Endovascular treatment for Transatlantic Inter-Society Consensus (TASC) D lesions of the superficial femoral artery has been disappointing. This has been attributed to a bulking atheromatous plaque. Debulking the superficial femoral artery allows for a larger lumen, whereas covering the lumen with an endograft provides in-line flow. We evaluated the intermediate results of remote superficial femoral artery endarterectomy with covered endograft placement in 18 patients. Patient demographic, vascular laboratory, and preoperative data were gathered retrospectively. The procedure was technically successful in all the patients. The mean age was 62.2 +/- 9.9 years. Ankle brachial index improved from 0.35 +/- 0.1 to 0.86 +/- 0.1. The cumulative 12-month primary patency was 42.2%, whereas assisted primary or secondary patency was 70.8%. Five endografts occluded within the 12 months. Two of those patients underwent subsequent femoral-to-below-knee bypass, whereas 2 had major amputations. Remote superficial femoral artery endarterectomy can be reasonably offered if an autogenous conduit is not available for revascularization of the superficial femoral artery.

Iliac conduit for deploying aortic endografts: an all-autogenous option.

Unfavorable iliac anatomy, such as small caliber or circumferential calcification, can cause problems during delivery of aortic endografts and lead to potential complications. An iliac artery conduit "chimney" has been used to deliver the large caliber endoprosthesis using a Dacron graft sewn onto the iliac bifurcation. An all-autogenous revascularization option allows for hypogastric bypass while limiting the use of synthetic graft.

Esophageal stent erosion into the common carotid artery.

A pseudoaneurysm of the common carotid artery was found with computed tomography in a 62-year-old woman with an esophageal stent that had eroded through her skin. The pseudoaneurysm was treated with a self-expanding nitinol stent; after massive hemoptysis, an endograft was placed on the pseudoaneurysm. The patient then underwent ligation of the left common carotid artery, proximal to the carotid bulb, and excision of the endograft and previously placed coils. The esophageal stent wires were so that they could no longer impinge the common carotid artery.

Techniques for managing complications of arterial closure devices.

According to data reported by the American Heart Association, more than 5 million diagnostic and therapeutic catheterizations are performed each year in the United States. The number of catheterizations has tripled since 1979. It has been estimated that complications related to the access site result in more than 75,000 surgical procedures annually. Thus, improved management of the access site itself is essential to achieve the greater goals of improved care and reduced cost. Manual compression directly over the site of arterial puncture usually results in adequate hemostasis but has several significant drawbacks. Manual compression is uncomfortable for the patient, is fatiguing and time-consuming for staff, and necessitates several hours of costly in-hospital observation. In addition, it may be ineffective in achieving hemostasis, especially in the setting of systemic anticoagulation or following the use of large-bore devices. Based on the perceived need for an improved method of managing the arterial access site following catheterization, various vascular sealing devices have been developed. There are at least 8 (and the number is increasing) hemostatic vascular closure devices that are currently approved by the FDA for access site closure after femoral arterial catheterization. The chief advantage attributed to vascular sealing devices is accelerated access site hemostasis, even in the setting of anticoagulation, leading to earlier ambulation and hospital discharge following arterial catheterization. The most important drawbacks related to vascular sealing devices include the cost of the devices and the possibility of increased access site complications. Despite the paucity of properly designed studies supporting their use, it is estimated that over one million vascular sealing devices are used annually in the United States, a number that has increased dramatically in the past 5 years.In this review, we present a brief description of the design and function of the most widely used devices, describe the most common mechanisms of failure, and recommend strategies for management of access site complications including hemorrhage, arterial obstruction, and infection.

Complex venous and arterial reconstruction with deep vein after pelvic exenterative surgery: a case report.

Effective local regional control for solid tumor malignancies is dependent upon prerequisite surgical excision with negative margins. Invasion of contiguous adjacent structures, particularly in anatomical spaces of limited size, may preclude the surgical goal of histologically negative margins. From a historical perspective, the invasion of vascular structures in the pelvis has proved to be a significant limitation in achieving local regional disease control with surgical resection. In recent years, advances in the field of vascular surgery have caused us to reassess the historical criteria of resectability when blood vessels are focally invaded by malignancy. En bloc resection of adjacent vessels has been reported primarily with head and neck extirpations and increasingly with hepatobiliary and pancreatic lesions. In many cases, where the local vasculature is invaded or impinged by the tumor, venous structures are often ligated while arteries are bypassed with an appropriate conduit. In pelvic exenterative surgery, significant morbidity from chronic limb edema and deep venous thrombosis may result from the ligation of larger veins. This is especially the case when multiple major venous structures such as the common and the external iliac vein, as well as the hypogastric vein, are all simultaneously interrupted. To the best of our knowledge, there is no prior report examining venous reconstruction using the femoral vein for pelvic exenterative surgery requiring major iliac artery and venous resection. Herein we describe a case of a complex vascular reconstruction after pelvic exenterative surgery in a patient with recurrent rectal cancer invading multiple adjacent contiguous structures, including the iliac vessels.