Outcomes Following Limb Crossing in Endovascular Aneurysm Repairs.

BACKGROUND: Crossing the limbs of the stent during endovascular aneurysm repair (EVAR) is often used to aid cannulation of the contralateral limb. This study assessed outcomes following the use of this technique. METHODS: Retrospective review of crossed (n = 43) and uncrossed (n = 269) EVARs was performed at a tertiary vascular center over 5 years. Primary end points were graft limb occlusion (GLO), endoleak, and sac expansion rates. Indications for limb crossing were also assessed. RESULTS: Two-year GLO (P = .34) and type 1 endoleak (P = .413) rates were similar between groups. Patients undergoing crossed EVAR experienced more type 2 endoleaks (P = .002) at 24 months but no increase in sac expansion rates was observed (P = .275). Thirty-day (P = .57) and late (P = .268) mortalities were similar between groups. The main indication for limb crossing was distal aortic angulation (48.8%). CONCLUSIONS: Crossed EVAR does not increase the risk of GLOs or clinically significant endoleaks. Further studies are needed to determine the effect on type 2 endoleak rates.

Endovascular treatment of the common femoral artery for limb ischemia.

OBJECTIVE: To determine the short- and mid-term outcomes of percutaneous endovascular common femoral artery (CFA) revascularization (eCFR) of the CFA. METHODS: A review of patients who underwent eCFR for limb ischemia between 2006 and 2012 was performed. Limb salvage, patient survival, survival free from reintervention, and survival free from amputation rates were determined. Median (range) follow-up was 28 (1-71) months. RESULTS: In all, 115 patients underwent 121 eCFR for CFA occlusion (n = 13) or stenosis (n = 108); 109 (90%) were technically successful and 7 (6%) had significant perioperative complications; access site hematoma (n = 2) and thromboembolism (n = 5). Thirty-day mortality and amputation rates were 2.5% and 0.8%, respectively. The 1- and 3-year limb salvage rates were 97% and 97%, respectively. The 1- and 3-year survival free from reintervention rates were 77% and 57%, respectively. The 1- and 3-year survival free from amputation rates were 84% and 70%, respectively. CONCLUSION: These novel data demonstrate that eCFR is a durable treatment for patients with limb ischemia associated with CFA disease.

Isolated percutaneous transluminal angioplasty of the profunda femoris artery for limb ischemia.

OBJECTIVE: To compare the outcome of endovascular profunda femoral artery revascularization (ePFR) with ePFR and concurrent endovascular femoropopliteal revascularization (eFPR). METHODS: A retrospective review of the consecutive patients with PFA and femoropopliteal vaso-occulsive disease who underwent ePFR or ePFR + eFPR for severe limb ischemia was performed. RESULTS: A total of 18 ePFRs and 26 ePFR + eFPRs were performed; 17 (94%) ePFRs and 22 (85%) ePFR + eFPRs were technically successful. The 12-month survival free from amputation and reintervention rates following isolated ePFR were 78% and 72%, respectively, and following ePFR + eFPR were 96% and 81%, respectively. There was no significant difference in the survival free from amputation (P = .4) or reintervention (P = .91) rates between the 2 groups. CONCLUSION: These contemporary data suggest isolated ePFRs and ePFR + eFPRs are associated with good and comparable early limb salvage rates.

Percutaneous ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms.

PURPOSE: To audit our experience with ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms. METHODS: A retrospective study of 85 consecutive patients undergoing percutaneous ultrasound-guided thrombin injection of post-catheterization femoral pseudoaneurysms during the period January 2002 to May 2007. RESULTS: Pseudoaneurysms had a mean maximum diameter of 3.3 cm (range 1.0-7.6 cm) and a mean neck width of 3.4mm (range 1.0-7.0mm). No statistically significant correlation existed between maximum diameter and neck width (Kendall's rank correlation tau b=-0.09, p=0.5). The median dose of thrombin injected was 425 U (range 100-1500 U). The procedure resulted in complete sac thrombosis in 81 (95%) patients. Seventy-nine pseudoaneurysms thrombosed immediately after one injection, whereas two required a second thrombin injection. There were no procedural complications. The maximum diameter of the pseudoaneurysm was predictive of procedural success (Wilcoxon's rank sum test, p=0.001) and of the 5 patients with a pseudoaneurysm measuring ≥6 cm, ultrasound-guided thrombin injection was unsuccessful in 4 (4/5 versus 0/80, p<0.0001, Fisher's exact test). Three of these necessitated implantation of a stent-graft, whereas one required repeated thrombin injection and coil placement. In contrast, the pseudoaneurysm neck width did not seem to relate to the success of the procedure. CONCLUSION: Percutaneous ultrasound-guided thrombin injection of is a quick, effective and safe treatment for iatrogenic femoral pseudoaneurysms. For larger pseudoaneurysms, although it is worth attempting more than one thrombin injection, endovascular repair may eventually be required.

Can surgeons assess CT suitability for endovascular repair (EVAR) in ruptured abdominal aortic aneurysm? Implications for a ruptured EVAR trial.

The purpose of this study was to determine whether surgeons without formal radiological training are able to assess suitability of patients with ruptured abdominal aortic aneurysms (AAA) for EVAR. The CT scans of 20 patients with AAA were reviewed under timed conditions by six vascular surgeons. Twenty minutes was allocated per scan. They were asked to determine if each aneurysm would be treatable by EVAR in the emergency setting and, if so, to measure for device selection. The results were then compared with those of a vascular radiologist. Six surgeons agreed on the suitability of endovascular repair in 45% of cases (95% CI, 23.1-68.5%; 9/20 scans; kappa = 0.41 [p = 0.01]) and concurred with the radiologist in eight of these. Individually, agreement ranged from 13 to 16 of the 20 scans, 65-80% between surgeons. The kappa value for agreement between all the surgeons and the radiologist was 0.47 (p = 0.01, moderate agreement). For the individual surgeons, this ranged from 0.3 to 0.6 (p = 0.01). In conclusion, while overall agreement was moderate between the surgeons and the radiologist, it is clear that if surgeons are to assess patients for ruptured EVAR in the future, focused training of surgical trainees is required.

Indwelling bowel management system as a cause of life-threatening rectal bleeding.

A 79-year-old male was transferred to the intensive care unit for postoperative respiratory support. An indwelling bowel management system was inserted for containment of noninfective diarrhoea. Following only 11 days of continual use the patient developed life-threatening rectal bleeding. Preoperative normal rectal mucosa and anatomy were documented. There was no evidence of postoperative coagulopathy. Mesenteric angiography identified bleeding from a branch of the superior rectal artery. Rectal mucosa pressure necrosis secondary to the indwelling Flexi-Seal® Fecal Management System was diagnosed. The patient required an 11-unit transfusion of packed red cells. Following intraarterial coil embolization of the superior rectal artery the bleeding abated. Indwelling bowel management systems are commonly used in immobile and critically ill patients with diarrhoea or faecal incontinence. This is the first report of this important complication in the literature.

Repair of ruptured abdominal aortic aneurysms by endovascular techniques.

Emergency EVR for ruptured AAA is now technically feasible, and several reports with small numbers have appeared in the literature from major centers suggesting that the results may be the same as or better than seen with open repair. The immediate priority is avoidance of over-resuscitation together with the rapid transfer of the patient to CT and then to the operating theater. Because of the learning curve involved, these cases should be attempted only by major centers that have extensive elective endovascular experience. The requirement for 24-hour availability of surgeons and radiologists trained in endovascular techniques places an enormous strain on vascular and radiologic staff and is achievable only in major centers with large teams of doctors. These issues raise important questions about the delivery of vascular services and whether all cases of ruptured aortic aneurysm should be transferred to major vascular centers. The operating theater staff and other support persons need training in endovascular techniques and in rapid deployment of an aortic occlusion balloon. A wide selection of devices, guidewires, and catheters must be immediately available in the operating theater. The ideal way to establish the role of EVR for ruptured AAA would be a randomized trial, but there might be logistic difficulties in recruiting sufficient numbers in major vascular centers, particularly as screening for AAA becomes more common and reduces the number of cases. There also are ethical issues as to whether these patients can give informed consent for involvement in such a trial. The alternative is for major centers to continue to develop their endovascular programs, to do more cases, and to compare the results with historical controls undergoing open repair.

Endovascular abdominal aortic aneurysm repair in the presence of a kidney transplant: therapeutic considerations.

Abdominal aortic aneurysm (AAA) repair in the presence of a kidney transplant can be extremely challenging, as it carries significant risks of renal ischemia. Endovascular repair is an attractive option, as it can be performed with little or no impairment of renal arterial flow. We describe the endovascular management of a recurrent AAA in a patient with a functioning renal transplant using a custom-made aorto-uni-iliac device. We discuss the planning and the potential problems of the technique.

Simultaneous superficial venous surgery and on-table subintimal angioplasty in the treatment of venous leg ulcers with arterial compromise.

PURPOSE: To determine the feasibility of synchronous superficial venous surgery and on-table subintimal angioplasty in the treatment of venous ulcers with arterial compromise. METHODS: Between January 1992 and December 2004, 9 patients (8 women; median age 83 years, range 72-92) underwent the synchronous procedure. No patient had deep venous reflux; 4 patients presented with rest pain and 2 were diabetic. Their medical records were retrospectively reviewed to gather data on clinical assessment, ankle-brachial index (ABI), lower limb arterial and venous duplex scans, and treatment variables. RESULTS: Angioplasty was technically successful (median ABI improvement 0.31, range 0.23-0.34) in all procedures, which lasted a median 85 minutes (range 60-160). The procedure was performed under general anesthesia in 7 patients, local in 1, and spinal in 1. Superficial venous surgery was performed first in 8 patients: 6 had great saphenous vein (GSV) ligation without stripping, followed by subintimal angioplasty, and 1 also had small saphenous vein (SSV) ligation. One patient underwent SSV ligation first, followed by angioplasty; another had GSV disconnection and stripping, followed by angioplasty. In 1 patient, angioplasty preceded GSV surgery. One patient required repeat angioplasty 1 week later for re-occlusion. All ulcers healed (median 4 months, range 1-36). Five patients died during a median 32-month follow-up (range 4-82) from unrelated causes; there was 1 ulcer recurrence at 3 years in a patient who declined further investigation and treatment. CONCLUSIONS: Simultaneous superficial venous surgery and on-table subintimal angioplasty is a safe and novel strategy in the management of a select subgroup of patients with venous ulcers and coexistent arterial compromise.

Combined laparoscopic and percutaneous treatment of a type II endoleak following endovascular abdominal aortic aneurysm repair.

We describe a novel approach in treating a persistent type II endoleak related to the inferior mesenteric artery (IMA) and the lower lumbar arteries. The endoleak failed to thrombose following percutaneous IMA coil embolization. We proceeded to one-stage laparoscopic IMA division and intra-sac thrombin injection under direct laparoscopic vision and fluroscopy. A CT scan at 1 and 7 months post-intervention showed no evidence of endoleak and the growth of the aneurysm was arrested. This combined laparoscopic and percutaneous approach may be a useful treatment option in the management of persistent complex type II endoleak. Its durability, however has yet to be defined.

Temporary endovascular control of a bleeding aortoenteric fistula by transcatheter coil embolization.

A 67-year-old man presented with gastrointestinal bleeding resulting from a fistula between the aortic stump and the fourth part of the duodenum 14 months after an axillobifemoral bypass, graft excision, and aortic stump closure for aortic graft infection. The patient initially refused any attempt at definitive surgical treatment so coil embolization of the aortic stump was performed via a brachial approach. Coil embolization may be a useful adjunct in the management of such difficult problems. This approach may buy time and allow careful planning of a definitive treatment or may serve as a palliative procedure in inoperable patients.

Suitability of ruptured AAA for endovascular repair.

PURPOSE: To determine the anatomical suitability and the range of endografts required to undertake an endovascular repair (EVR) program for ruptured abdominal aortic aneurysms. METHODS: The morphology of ruptured and nonruptured AAAs were compared by retrospective review of computed tomographic scans from 51 patients (47 men; mean age 76 years, range 55-90) with ruptured AAAs and 50 patients (37 men; mean age 74 years, range 57-75) with nonruptured AAAs. Three experienced clinicians reviewed the scans for EVR suitability based on a generic trimodular endograft with suprarenal fixation. Endograft oversizing was assumed to be 10% to 20%. RESULTS: Interobserver agreement was high, with a mean kappa of 0.78 (range 0.75-0.83, p<0.001). In all, 41% of ruptured and 68% of nonruptured AAAs were suitable for EVR (p=0.009). Ruptured AAAs had shorter mean neck lengths (17+/-12 versus 22+/-11 mm, p=0.031) and larger mean aneurysm diameters (75+/-15 versus 63+/-9 mm, p>0.001). Neck length and neck diameter were significantly correlated for ruptured AAAs (r=-0.34, p=0.018). The main contraindication to EVR was hostile neck morphology. A range of endografts with aortic components from 24 to 32 mm and iliac components from 12 to 22 mm would be required to stent 41% of ruptured AAAs. CONCLUSIONS: Ruptured AAAs are less suitable for EVR due to differing neck morphology. An EVR program for ruptured AAA requires an inventory of endografts with appropriate aortic and iliac components.

Clinical outcome of primary infrainguinal subintimal angioplasty in diabetic patients with critical lower limb ischemia.

PURPOSE: To evaluate the clinical outcome of subintimal angioplasty in diabetic patients with critical limb ischemia (CLI) compared to nondiabetics irrespective of the patency status of the treated arteries. METHODS: The records of 99 consecutive patients (53 men; median age 78.5 years, range 42-92) suffering from CLI who underwent primary infrainguinal subintimal angioplasty in 112 limbs within a 6-month period were studied retrospectively. A third of the patients (n=33) were diabetic. The technical success, perioperative morbidity/mortality, and clinical success were compared between the diabetic and nondiabetic patients. Kaplan-Meier life-table analysis was used to analyze clinical success, limb salvage, and survival for both groups. RESULTS: The overall technical success was 89% (81% in diabetics, 93% in nondiabetics, p=0.05). Perioperative morbidity was 8% (16.7% in diabetics, 3.9% in nondiabetics, p=0.03). The perioperative mortality was zero. The clinical success at 12, 24, and 36 months was 74%, 72%, and 65% in nondiabetics and 69%, 63%, and 54% in diabetics, respectively (p=0.17). The limb salvage rate at 36 months was 88% overall (90% in nondiabetics, 82% among diabetics, p=0.20). The 36-month survival rate was 61% in nondiabetics and 57% in diabetics (p=0.29). CONCLUSIONS: In terms of clinical outcome, infrainguinal subintimal angioplasty is almost equally effective in diabetics as in nondiabetics suffering from CLI.

Percutaneous transluminal angioplasty in the treatment of critical limb ischemia.

PURPOSE: To assess the role of percutaneous transluminal angioplasty (PTA) to treat critical limb ischemia (CLI) and to relate the changing experience with endovascular treatment of this condition in a major vascular unit. METHODS: A prospective study was performed involving 110 consecutive patients (57 women; mean age 76 years, range 57-99) undergoing balloon angioplasty for critical limb ischemia in 133 limbs. Outcome at 1 year was examined by case note review or questionnaire to determine survival, amputation-free survival, limb salvage, and CLI recurrence. RESULTS: Technical success was achieved in 105 (79%) of 133 limbs; the overall complication rate was 20% (3.8% major, 16.2% minor). The median follow-up was 15 months (minimum 12). The 12-month limb salvage rate by life-table analysis was 88%. Patients with an initially successful angioplasty had an extremely good outcome (95% 1-year limb salvage). In contrast, the 28 patients with failed angioplasty fared very poorly; a major amputation was required in 10, and death occurred in another 9, leaving only 9 survivors with limbs intact at 1 year. CONCLUSIONS: The results of this study justify the continuing use of PTA as first-line treatment for critical limb ischemia.

Early rupture of a partially treated abdominal aortic aneurysm: another endovascular lesson.

PURPOSE: To report early rupture of a partially treated abdominal aortic aneurysm. CASE REPORT: A 76-year-old man with a 6.4-cm abdominal aortic aneurysm had the main body of a bifurcated graft inserted into the aneurysm. However, it was not possible to cannulate the short cuff of the graft to deploy the contralateral limb, probably due to a proximal aortic stenosis compressing the stent-graft. The plan was for the patient to return on another date for a further attempt at recannulation; however, shortly after the patient was discharged, the aneurysm ruptured, necessitating conventional open repair, which the patient survived. CONCLUSIONS: Every effort should be made to complete endovascular treatment of abdominal aortic aneurysms at a single session.

Subintimal angioplasty of isolated infragenicular vessels in lower limb ischemia: long-term results.

PURPOSE: To assess the outcome of subintimal angioplasty in treating isolated infragenicular arterial disease in patients with severe lower limb ischemia. METHODS: A retrospective study reviewed 67 consecutive patients (39 men; mean age 76 years, range 41-96) who underwent infragenicular subintimal angioplasty between March 1997 and May 2000 for ischemia in 70 limbs. The median length of occlusion was 6 cm [corrected] (range 1-10) in the below-knee popliteal arteries, 4 cm [corrected] (range 1-4) in the tibioperoneal trunk, 21 cm [corrected] (range 1-35) in the anterior tibial artery, 10 (1-30) in the posterior tibial artery, and 5 (range 1-20) in the peroneal artery. RESULTS: The technical and clinical success rates were 86% and 80%, respectively. In the 10 (14%) patients with a technical failure, 3 underwent successful bypass, 4 had an amputation, 1 had a lumbar sympathectomy, and 2 were treated conservatively. Of the 4 (6%) limbs that did not achieve clinical success, 2 patients required femorodistal bypass and their ulcers improved; in the other 2, ulcerations did not heal completely. The cumulative limb salvage rate and freedom from critical limb ischemia (CLI) quantified by Kaplan-Meier life-table analysis were 94% and 84% at 36 months. Mortality rates were 19% at 1 year, 43% at 2 years, and 51% at 3 years. In a subgroup analysis, the rate of CLI was significantly lower in nondiabetics (4%) and than in diabetics (24%, p=0.02), but neither survival nor amputation rates were significantly different. CONCLUSIONS: Subintimal angioplasty is a safe and effective procedure for treating isolated crural vessels in patients with severe lower limb ischemia.

Arterial perforation during infrainguinal lower limb angioplasty does not worsen outcome: results from 1409 patients.

PURPOSE: To assess the prevalence and clinical significance of arterial perforation during lower limb angioplasty and determine the outcome of patients suffering this complication. METHODS: The radiology department records of 1409 patients (878 men; mean age 69.6 years) undergoing peripheral angioplasty in 1532 limbs between January 1996 and December 1998 were studied to identify patients with a perforated vessel. RESULTS: Fifty-two (3.7%) perforations occurred. Patients with a perforation were significantly older (median 74.8 years versus 69.6, p=0.03) and were more likely to be diabetic (p=0.01). The median age of a smoker with a perforation was 68 years versus 78 years for nonsmokers (p=0.02). Among the perforations, 29 resolved without intervention, 6 required temporary balloon occlusion, 15 were coil embolized, and 2 needed both balloon and coil treatment. Twenty-four (46%) of the 52 patients had a clinically successful angioplasty despite the perforation. No patient needed further urgent intervention. Seven patients underwent subsequent surgery to treat the underlying vascular disease that had prompted treatment initially; no one was treated for complications of the perforation. Due to the more extensive nature of the procedure, subintimal angioplasty was associated with an unsurprising increase in the rate of perforation (RR, 2.06; 95% CI, 1.19-3.56; p=0.01). In no case did the perforation prejudice the eventual outcome of the patient. CONCLUSIONS: Arterial perforation during angioplasty is more common in the elderly and in diabetics. The perforation itself does not influence the ultimate outcome of the case; rather, it is the underlying vascular pathology.

Long-term results of endovascular AAA repair using a homemade aortomonoiliac PTFE device.

PURPOSE: To assess the long-term results of a homemade aortomonoiliac polytetrafluoroethylene (PTFE) device used for endovascular abdominal aortic aneurysm (AAA) repair. METHODS: A vascular audit database was interrogated to identify 58 consecutive AAA patients (all men; median age 73 years, range 56-88) who underwent aortomonoiliac stent-graft repair. AAAs were eligible for endovascular treatment if the infrarenal neck was > or = 15 mm long and < or = 28 mm in diameter. RESULTS: Nine (15.5%) procedures failed, 8 during the procedure and 1 on the 7th postoperative day; 8(13.8%) patients were converted, but one was unfit for surgery. There was one intraprocedural stroke, and 3 (5.2%) patients died within 30 days. The primary success rate (no conversion or mortality) was 79.3%. Over a median follow-up of 45 months (range 23-80), there were 3 (5.2%) graft occlusions, 1 kink requiring stent implantation, and 1 expanding sac without identifiable endoleak. There were 11 (19.0%) endoleaks in 10 patients, 9 type I leaks (2 proximal) and 1 type II. One patient with a distal type I endoleak (treated) also exhibited a type III leak at 2 years, but the sac size had not increased. There was a 40% incidence of bilateral buttock claudication, which was serious in only 1 patient. The long-term survival rate by Kaplan-Meier life-table analysis was 57% at 4 years. CONCLUSIONS: Implantation of an aortomonoiliac PTFE device can be achieved with good primary success, and the stent-graft seems durable over the long term. Proximal type I endoleaks are rare, but distal endoleaks from the contralateral common iliac artery can be solved by using a different covered stent.