Endovascular retrieval of a fractured Optease inferior vena cava filter using endobronchial forceps and intraoperative cone-beam computed tomography guidance.

Endovascular retrieval of fractured inferior vena cava (IVC) filters after the manufacturer recommended indwelling time can be challenging and require advanced retrieval techniques. We describe an endovascular retrieval technique of a fractured Optease IVC filter in a 57-year-old woman using endobronchial forceps and intraoperative cone-beam computed tomography guidance. Following incomplete filter retrieval, the location and orientation of fractured strut was confirmed by cone-beam computed tomography venography. The embedded filter fragment was then successfully removed using endobronchial forceps via a transjugular venous approach. In the present report, we highlight the additional value of intraoperative cross-sectional imaging, in conjunction with advanced endovascular techniques, for retrieval of challenging IVC filters.

"Octafen": A Noninvestigational Alternative Endograft Configuration for the Treatment of Thoracoabdominal Aortic Aneurysms.

PURPOSE: To demonstrate the feasibility of Octafen technique, a novel endovascular configuration for the treatment of thoracoabdominal aortic aneurysms (TAAA). TECHNIQUE: Two patients with complex TAAA and high surgical risk were treated with Octafen endograft configuration in a hybrid operating room with computed tomography (CT)-fluoroscopy image fusion guidance, using 3D-3D fusion techniques to facilitate procedural success. The procedure is a modification of the previously-described Octopus technique for endovascular repair of TAAA. The main advantage of this technique is the ability to use devices to repair a TAAA with the combination of off-the-shelf and noninvestigational custom-made devices. The devices used are readily available to most practicing vascular surgeons, which provides an alternative treatment in case of limited access to investigational devices, in time-sensitive cases, and in patients with limited functional capacity who cannot undergo open repair. In the modification described herein, we use a combination of standard bifurcated endovascular aneurysm repair (EVAR) devices (Excluder; W.L. Gore & Associates, Flagstaff, Arizona) in combination with a 2-vessel renal fenestrated device (Z-Fen; Cook Medical, Bloomington, Indiana). The article describes a step-by-step approach to this technique to elucidate pitfalls, benefits, and advantages. CONCLUSION: The Octafen technique might offer an alternative option for thoracoabdominal aneurysm treatment circumventing the need for access to custom-made, investigational devices. CLINICAL IMPACT: In this manuscript, we describe a technique for endovascular repair of thoraco-abdominal aortic aneurysms that involves the combination of off-the-shelf and non-investigational, custom-made devices. The 'Octafen' technique provides a treatment alternative in case of limited access to investigational devices and can be adjusted according to patient anatomy.

Laterality of deep white matter hyperintensities correlates with basilar artery bending and vertebral artery dominance.

AIM: To investigate whether vertebrobasilar geometry contributes to the presence, severity, and laterality of white matter hyperintensities (WMH). METHODS: We retrospectively reviewed 290 cerebral scans of patients who underwent time-of-flight and fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) between 2017 and 2018. WMH were counted, localized, and grouped according to laterality on the FLAIR sequence. A 3D mesh of the posterior circulation was reconstructed (with ITK SNAP software) and the morphology of the vertebrobasilar system analyzed with an in-house software written in Python. RESULTS: Patients were assigned into a group with WMH (n=204) and a group without WMH (n=86). The severity of WMH burden was mainly affected by age and hypertension, while the localization of the WMH (or laterality) was mainly affected by the vertebrobasilar system morphology. Basilar artery morphology only affected the parieto-occipital region significantly if both posterior communicating arteries were hypoplastic or absent. The dominant vertebral artery and basilar artery curve had an opposite directional relationship. CONCLUSIONS: An unequal vertebral artery flow is an important hemodynamic contributor to basilar bending. Increased basilar artery curvature and increased infratentorial WMH burden may signal inadequate blood flow and predict cerebrovascular events.

Medial claviculectomy for the treatment of recalcitrant central venous stenosis of hemodialysis patients.

OBJECTIVE: Outflow tract stenosis is the leading cause of hemodialysis access loss. Many lesions are highly resistant to endovascular treatment, necessitating open surgical intervention. We present our experience using medial claviculectomy for treatment of recalcitrant lesions at the thoracic outlet. METHODS: We retrospectively reviewed patients who underwent medial claviculectomy for dialysis-associated venous thoracic outlet syndrome at our institution between February 2013 and February 2018. Data collection included demographics, past medical history, access history, subsequent procedures, preoperative and postoperative brachial volume flows, and access use. RESULTS: We performed 25 medial claviculectomies in 25 patients with central venous stenosis. Four patients underwent concomitant central venous bypass and were excluded from this study. Twelve accesses were created at our institution; of these, the average access age was 41.6 months (±26.7 months). All patients previously underwent multiple angioplasty attempts to treat outflow stenosis and continued to have residual symptoms and poor fistula function. Medial claviculectomy with venolysis and angioplasty were performed to treat residual outflow stenosis at the level of the subclavian vein. Twenty-one patients had residual stenosis requiring angioplasty. Six patients had subclavian rupture requiring stent graft placement. All patients reported symptom improvement and immediate use of the fistula after medial claviculectomy. Nineteen (76%) patients reported complete resolution of symptoms after the procedure. Ultimately, eight (32%) ipsilateral arteriovenous accesses were lost, and six (24%) patients died in follow-up with patent, functional fistulas. Median length of follow-up was 17 months (interquartile range, 5-28 months). The 18-month primary patency and secondary patency with regard to subclavian vein interventions were 28% (95% confidence interval, 13.8%-56.1%) and 84% (95% confidence interval, 69.7%-100%), respectively. One patient required ligation for high-output cardiac failure. One patient had contralateral brachiocephalic jailing, which was corrected with kissing brachiocephalic stents. CONCLUSIONS: Medial claviculectomy is an effective treatment of recalcitrant central venous stenosis of the thoracic outlet. Balloon angioplasty or stent or stent graft placement is often necessary after extrinsic compression is alleviated and demonstrates acceptable secondary patency rates.

Intraoperative cone beam computed tomography-guided endovascular recanalization of an interrupted aorta.

A 42-year-old man sustained a stroke secondary to malignant hypertension and was found to have complete aortic interruption. We report a case of real-time image-guided endovascular repair to highlight the value of preprocedural planning and intraprocedural cone beam computed tomography. Two-dimensional fluoroscopy enhanced with three-dimensional landmarks from cone beam computed tomography was used to direct a Nykanen radiofrequency wire (Baylis Medical, Montreal, Quebec, Canada) through the interruption, avoiding critical adjacent structures. A covered Cheatham-Platinum stent (NuMED, Inc, Hopkinton, NY) was deployed successfully, recanalizing the thoracic aorta. The pressure gradient normalized, and the patient was discharged on postoperative day 1. At 10-month follow-up, the patient was on an antihypertensive regimen of two minimum-dose drugs.

Vitamin D deficiency is associated with mortality and adverse vascular access outcomes in patients with end-stage renal disease.

BACKGROUND: Plasma 25 hydroxycholecalciferol (vitamin D) deficiency has been associated with adverse cardiovascular outcomes in epidemiologic studies. Chronic kidney disease is associated with loss of 1α-hydroxylase and consequently vitamin D deficiency. We hypothesized that vitamin D deficiency was associated with increased mortality and increased vascular access failure in patients undergoing permanent vascular access for end-stage renal disease. METHODS: This retrospective cohort study analyzed 128 patients undergoing permanent vascular access surgery between 2003 and 2012 for whom concurrent plasma vitamin D levels were also available. Levels were considered deficient at <20 ng/mL. Multivariable analysis was used to determine the association between vitamin D and mortality and vascular access outcomes. RESULTS: The mean age was 66.7 years, 96.8% were male, 32.0% were African American, and 60.9% had diabetes mellitus. In the entire cohort, 55.5% were vitamin D-deficient, despite similar rates of repletion among the vitamin D-deficient and nondeficient groups. During a median follow-up of 2.73 years, there were 40 deaths (31%). Vitamin D-deficient patients tended to be younger (P = .01) and to have higher total cholesterol (P = .001) and lower albumin (P = .017) and calcium (P = .007) levels. Despite their younger age, mortality was significantly higher (P = .026) and vascular access failure was increased (P = .008) in the vitamin D-deficient group. Multivariate logistic regression analysis found vitamin D deficiency (odds ratio [OR], 3.64; 95% confidence interval [CI], 1.12-11.79; P = .031), hemodialysis through a central catheter (OR, 3.08; 95% CI, 1.04-9.12; P = .042), coronary artery disease (OR, 3.08; 95% CI, 1.06-8.94; P = .039), increased age (OR, 1.09; 95% CI, 1.03-1.15; P = .001), and albumin (OR, 0.27; 95% CI, 0.09-0.83; P = .023) remained independent predictors of mortality. Vitamin D deficiency (hazard ratio [HR], 2.34; 95% CI, 1.17-4.71; P = .02), a synthetic graft (HR, 3.50; 95% CI, 1.38-8.89; P = .009), and hyperlipidemia (HR, 0.42; 95% CI, 0.22-0.81; P = .01) were independent predictors of vascular access failure in a Cox proportional hazard model. CONCLUSIONS: Vitamin D deficiency is highly prevalent in patients undergoing vascular access procedures. Patients who are deficient in vitamin D have worse survival and worse vascular access outcomes. Further study is warranted to assess whether aggressive vitamin D repletion will improve outcomes in this population.