Incidental Findings in Trauma Patients: How Big is the Challenge?

INTRODUCTION: The purpose of this study was to examine the prevalence of incidental findings (IFs) identified during workup of trauma patients and the effectiveness with which they were documented and communicated. MATERIALS AND METHODS: We performed a retrospective analysis of all trauma patients ≥15 y of age in 2018, who underwent at least one computed tomography scan. Patients' Electronic Medical Record was reviewed for the presence of IFs. IFs were classified in three categories: category 1, which includes highly significant findings requiring attention during hospitalization; category 2, which warrants attention in an outpatient basis; and category 3, which includes nonsignificant findings that require no follow-up. RESULTS: 836 patients were identified, of which 582 had at least one IF. Of the patients with IFs; 14 (2.4%) were category 1, 138 (23.7%) were category 2, and 569 (97.8%) met category 3 criteria. All category 1 patients received appropriate documentation of their IFs. Of patients with category 2 findings, only 13% had documentation of the IFs. Patients with IFs had longer length of stay (P: 0.04) and lower probability of being discharged to home (P < 0.01) compared to patients with no IFs. Only 12.5% of the patients admitted to trauma surgery service received an outpatient follow-up. CONCLUSIONS: There was timely documentation and intervention for all patients with category 1 IFs. However, 87% of patients with category 2 IFs had inadequate documentation of the IF and outpatient follow-up. Outpatient follow-up of IFs poses a challenge for trauma patients partially due to their discharge disposition.

Hemoglobin A1c as a measure of disease severity and outcome in limb threatening ischemia.

BACKGROUND: Diabetes mellitus is a known risk factor in the development of peripheral vascular disease. Hemoglobin A1c (HbA1c) has been used by clinicians as a means to measure short to intermediate term glucose control in diabetics. Trials evaluating tight glucose control using HbA1c measurements have recently been conducted for several medical conditions. The goal of this study is to determine if the level of hemoglobin A1c has any effect on disease severity in diabetic patients with limb threatening ischemia. METHODS: A retrospective review of all patients presenting with limb threatening ischemia between January 1 and December 31, 2007 was conducted. All patients underwent conventional arteriography prior to intervention. Of 148 patients, 73 were diabetics with a hemoglobin A1c level performed within 3 mo of presentation. Patients were placed into high (>7) and low (<7) hemoglobin A1c groups and data was collected on type of presentation, comorbidities, anatomic level of disease, tibial artery patency, need for amputation, contralateral disease, need for an open versus an endovascular procedure, and freedom from intervention. Fisher's exact t-test was used to compare the two groups. A P value <0.05 was considered statistically significant. RESULTS: Thirty-six patients had HbA1c levels above 7.0 and 37 had levels below 7.0 (mean 7.64 ± 2.04, range 5.1-14.7). There were no statistically significant differences in the two groups in comorbities, average age, initial gangrene at presentation, aspirin or statin use, or smoking status. Patients in the high group were more likely to have had a previous attempt at revascularization (23 versus 11, P = 0.0049). There was no difference in the presence of contralateral disease (7 versus 4, P = 0.3447) or in the number of patent tibial vessels. Patients with low HbA1c levels were more likely to have the peroneal artery affected (17 versus 8, P = 0.048). In addition, TASC II classifications of iliac and femoral popliteal disease was similar between the two groups. Freedom from intervention is depicted graphically by life table analysis. CONCLUSION: Glucose control measured by hemoglobin A1c does not appear to affect severity of disease or need for reintervention in diabetics with limb threatening ischemia. This suggests other factors related to diabetes may play a role in peripheral vascular disease. Larger, prospective studies are needed to assess the affect of glucose control in limb threatening ischemia.

Is the length of follow-up evaluation in published reports on the treatment of infrainguinal occlusive disease decreasing?

BACKGROUND: There is increasing pressure for the rapid development and implementation of new techniques and procedures. This study examined whether or not there has been a trend toward increasingly short follow-up times for studies evaluating the treatment of lower-extremity occlusive disease. METHODS: A search was performed of PubMed using the term "femoropopliteal occlusive disease" from 1976 to 2006. Reports describing the open and/or endovascular treatment of femoropopliteal occlusive disease were classified according to the number of patients, method of treatment, and follow-up time. RESULTS: A total of 103 of the 435 reports met the inclusion criteria. Average follow-up times from 1976 to 1986 were a mean of 43.3 months and a median of 38.8 months, from 1986 to 1996 were a mean of 32.4 months and a median of 16.9 months, from 1996 to 2006 were a mean of 22.6 months and a median of 16.5 months. CONCLUSIONS: The number of reports on femoropopliteal occlusive disease treatment has increased. The length of follow-up period was 2- to 3-fold longer for reports on open procedures compared with those on endovascular procedures. Whether length of follow-up evaluation and reporting intervals should be standardized warrants further investigation.

Proportion of patients with critical limb ischemia who require an open surgical procedure in a center favoring endovascular treatment.

Endovascular interventions have gained widespread acceptance as primary and secondary treatments for critical lower extremity ischemia (CLI), and many believe there is little need for open bypasses for CLI. Despite this, some patients presenting with CLI require traditional lower extremity bypass procedures at some point for successful limb salvage. To determine the proportion of patients requiring an open procedure, we reviewed our 1-year experience with CLI patients at a center committed to endovascular approaches whenever possible. We reviewed all patients presenting with CLI from January 1, 2007 to December 31, 2007. CLI was defined as ischemic rest pain, nonhealing ulceration, or gangrene for which a major amputation was imminently required. All patients underwent duplex and conventional angiography before intervention. Endovascular treatments were favored as primary, secondary, or tertiary treatments, if possible. If these failed or were impossible, standard lower extremity bypasses were performed. One hundred and forty-eight patients presented with primary, secondary, or tertiary CLI over this 1-year period. Of these, 63 (42%) were treated successfully with an endovascular intervention, and 69 (47%) required standard lower extremity bypass, and 16 (11%) required a combined endovascular and open procedure (i.e., hybrid procedure). Of these 148 patients, 46 (31%) were presenting with secondary, tertiary, or more CLI after failed previous (1-5) procedures. Despite the initial enthusiasm that the majority of patients presenting with CLI may be treated with endovascular procedures, there exists a significant cohort of patients that will ultimately require standard open surgical procedures.

Incidence and characteristics of venous thromboembolic disease during pregnancy and the postnatal period: a contemporary series.

BACKGROUND: To evaluate the incidence and characteristics of venous thromboembolic events (VTE) associated with pregnancy in a contemporary patient series. METHODS: We performed a retrospective review of 33,311 deliveries between June 2003 and June 2008. Patients with objective documentation of a VTE during pregnancy or the 3-month postnatal period were identified from hospital discharge International Classification of Disease Codes edition 9 codes. Diagnosis of deep venous thrombosis (DVT) was largely made by a Duplex ultrasound, whereas pulmonary embolism (PE) was diagnosed by a computerized tomographic angiography (CTA). RESULTS: Of 33,311 deliveries during the study period, 74 patients (0.22%) had a VTE. There were 40 incidents of DVT (0.12%) and 37 of PE (0.11%). DVT involved the iliac veins (6), the femoral or popliteal veins (16), the infrapopliteal veins (17), and the axillary vein (1). Most (57.5%) of the DVTs involved the left lower extremity. Thirty-eight (51.6%) of the VTEs occurred in the postnatal period, and of those 33 (87%) occurred within 1 week of delivery. Most of the postnatal VTEs (68%) were seen in patients who underwent a cesarean section. Among patients with VTE during pregnancy, there were 28% in the first trimester, 25% in the second, and 47% in the third. Events were distributed among maternal age groups as follows: 26% aged 13-24, 50% aged 25-34, and 24% aged 35-54. Of the 35 patients tested for a hypercoagulable disorder, 12 were found to have a positive test result. Five (6.8%) of these 74 patients had a prior history of VTE, with two having a hypercoagulable disorder. In addition, 45 of the 74 patients were on oral contraceptive therapy or received hormonal stimulation therapy before pregnancy. Patients with a VTE during pregnancy were treated with low molecular weight or unfractionated heparin. Most postnatal patients were treated with subcutaneous low molecular weight heparin and coumadin. Six inferior vena cava filters were placed in patients with bleeding complications as a result of anticoagulation. There were no deaths during the study period. CONCLUSIONS: Comparing our results with historic controls (DVT: 0.04-0.14% and PE: 0.003-0.04%), the incidence of DVT in pregnancy has not changed significantly. We note, however, that the incidence of pulmonary embolus in our series is higher than previously reported. CTA has been used for the diagnosis of PE since the past decade. The increase in the rate of PE in the current series may be because of the higher sensitivity of CTA when compared with previous diagnostic modalities.

Long-term outcome of inferior vena cava filter placement in patients undergoing gastric bypass.

BACKGROUND: It has been well established that inferior vena cava (IVC) filter placement at the time of open gastric bypass (OGB) surgery in patients with a body mass index of more than 55 kg/m(2) reduces both the pulmonary embolism rate and the perioperative mortality. However, little is known about the long-term effects of IVC filter placement in this particular group of patients. METHODS: Over an 8-year period, a total of 571 morbid obese patients underwent OGB procedures, and 58 (10%) of them required placement of an IVC filter before their procedure. All IVC filters were placed percutaneously through a femoral vein approach using a portable OEC fluoroscope. Types of IVC filters used in our study included the TrapEase (n = 35), Simon-Nitinol (n = 9), Greenfield (n = 2), and Bard Recovery (n = 12). RESULTS: Of the 58 patients who required an IVC placement, 56 remained free of any thromboembolic phenomena over the 8-year period (range, 1-8 years). The remaining two patients developed deep venous thrombosis. One patient was successfully treated with intravenous heparin and a 6-month course of Coumadin. She had complete resolution of her deep venous thrombosis and was incidentally noted to have a prothrombin 20210 gene mutation. The other patient, who had multiple gastric bypass complications, could not be successfully treated with intravenous heparin and thus progressed on to complete IVC thrombosis. She developed phlegmasia cerulea dolens and required bilateral above-the-knee amputations. She subsequently died 3 months after her procedures. CONCLUSION: It appears that IVC filter placement at the time of OGB surgery is a relatively benign intervention with a maximal benefit. A note of caution should be exerted for those obese patients who have a hypercoagulable disorder and for those who have complications related to the gastric bypass. An aggressive posture, which may consist of immediate anticoagulation after their procedures (only when it is deemed safe), should be advocated in this small sub-group of morbid obese patients.

Experience with a modified composite sequential bypass technique for limb-threatening ischemia.

BACKGROUND: Composite sequential femoro-popliteal-distal bypass is a valuable option for treatment of critical limb ischemia when autogenous vein is limited and an isolated popliteal or distal arterial segment exists. We report a modified technique for composite sequential bypass and the results with its use over a 14-year period. METHODS: Twenty-five modified composite sequential bypass procedures were performed on 24 patients to treat gangrene, ischemic ulceration, and severe rest pain. Vein grafts were anastomosed from blind popliteal or blind distal arterial segments above-knee (7) or below-knee (18) to a distal outflow vessel including the below-knee popliteal (1), posterior tibial (5), anterior tibial (7), or peroneal (12) artery. Polytetrafluoroethylene bypass grafts were then placed from a suitable inflow artery to the proximal hood of the vein graft. RESULTS: Cumulative primary patency rates were 80% at 3 years, and 65% at 5 years. The limb-salvage rate was 85% at 4 years. Occlusion of the prosthetic segment with a patent distal vein segment was recognized in two patients who presented with less severe recurrent ischemia. Limb-salvage in these patients was achieved by a secondary prosthetic graft to the patent vein graft. CONCLUSION: Our modified configuration of the prosthetic-vein anastomosis for composite sequential bypass is an alternative to the conventional procedure and may help preserve vein graft patency should the polytetrafluoroethylene graft thrombose.

Endovascular management of multiple arteriovenous fistulae following failed laser-assisted pacemaker lead extraction.

A woman presented for evaluation of new-onset left arm edema after failed laser-assisted pacemaker lead extraction. Initial workup demonstrated a left subclavian artery to vein arteriovenous fistula (AVF). She underwent repair of the AVF with placement of a covered stent in the subclavian artery, however, her symptoms did not completely resolve. Investigation revealed a left common carotid artery to left innominate vein AVF, which was repaired by deploying a covered stent retrograde into the left common carotid artery. Her symptoms subsequently resolved. Multiple iatrogenic AVF can be repaired endovascularly, however, a high degree of suspicion for multiple injuries should be maintained.

Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.

BACKGROUND: Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial. OBJECTIVE: To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers. METHODS: Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR). RESULTS: Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients. CONCLUSION: These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed.

Perimalleolar and pedal thromboembolectomy and bypasses to treat distal embolization during aortoiliac aneurysm repairs.

OBJECTIVES: Lower extremity embolization occurs during aortoiliac aneurysm repair and may require major amputation when distal arteries are occluded. Because nonoperative treatments are often ineffective, we evaluated an aggressive operative approach. METHODS: In the past 11 years, we performed 328 endovascular and 350 open aortoiliac aneurysm repairs. Excluding cases of embolization to iliac, femoral, popliteal, and more proximal tibial vessels, which were treated in a standard fashion, foot ischemia severe enough to produce cadaveric, pregangrenous, or gangrenous skin changes occurred from more distal embolization after seven endovascular and three open aortoiliac aneurysm repairs. Six of these 10 patients underwent thromboembolectomies of both their dorsalis pedis and perimalleolar posterior tibial arteries < or =4 hours of their original operation. In the other four patients, treatment was delayed 7 to 10 days. Because of progressive foot ischemia, arteriography was performed. From these results, four bypasses (3 autologous vein, 1 polytetrafluoroethylene graft) were performed to the transverse metatarsal arch, dorsalis pedis, perimalleolar peroneal artery, or perimalleolar anterior tibial artery. RESULTS: Patency and limb-salvage rates for both thromboembolectomy and bypass procedures were 100% at a mean follow-up of 3.0 years (range, 5 months-8 years). CONCLUSIONS: Perimalleolar and foot artery thromboembolectomy and bypasses to arteries as distal as the metatarsal arch can be effective treatment for distal embolization from aortoiliac aneurysm repair. Even when cadaveric, pregangrenous, or gangrenous lesions are present, distal arteriography and operative treatment (thromboembolectomy or bypass) may be indicated to successfully salvage the foot.

Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas.

Prosthetic graft seromas is a rare complication that has been traditionally managed with open methods using partial graft replacement and open drainage. We report the first two cases of hemodialysis graft seromas successfully treated with a covered stent. Both patients underwent arteriovenous graft placement from the brachial artery to the axillary vein using a standard wall, tapered 4 to 7 mm polytetrafluoroethylene graft, but developed a seroma at the arterial end of the graft. Unsuccessful attempts were made to treat these seromas with percutaneous and open drainage. In both patients, an 8 mm x 50 mm Wallgraft (Boston Scientific, Natick, Mass) was retrogradely deployed "bareback" at the arterial end of the graft allowing for complete resolution of the graft seromas.

Incidence and significance of nonaneurysmal-related computed tomography scan findings in patients undergoing endovascular aortic aneurysm repair.

OBJECTIVE: This study examined the frequency and nature of incidental findings seen on computed tomography (CT) scans during preoperative and postoperative follow-up in patients undergoing endovascular aortic aneurysm repair (EVAR). METHODS: Between January 1, 2000, and March 1, 2006, 176 consecutive patients who underwent EVAR at our institution were retrospectively reviewed. Patients were included in the study if all preoperative and postoperative surveillance CT scans were performed at our institution. Eighty-two patients, 26 women (32%) and 56 men (68%), met this criterion. Their mean age was 76 years (range, 51-103 years). Official CT scan reports were reviewed. Findings were considered primary incidental if they were noted on preoperative CT scans and secondary incidental if they appeared on surveillance CT scans but not on the preoperative study. Primary and secondary incidental findings were considered either benign (eg, gallstones, diverticulosis) or clinically significant if they warranted further workup (eg, suspicious masses or changes suggestive of malignancy, internal or diaphragmatic hernias, and diverticulitis). The median follow-up was 29 months (range, 3-60 months). Each incidental finding was counted only once, on the first scan in which it appeared. RESULTS: Of the 82 patients, 73 (89%) had at least one primary incidental finding, and 14 (19%) of these were clinically significant. Secondary incidental findings, many of which were clinically significant, continued to appear throughout the follow-up period. The most common clinically significant primary incidental finding was the presence of a lung mass (n = 4). The most common clinically significant secondary incidental findings were lung mass (n = 6), liver mass (n = 6), and pancreas mass (n = 3). There was a significant difference in the proportion of men to women in the group with clinically significant incidental findings vs the group without clinically significant incidental findings (P = .03959). Differences between the groups with respect to age or aneurysm size were not significant. CONCLUSION: CT scans yielded surprisingly large numbers of both primary and secondary incidental findings, many of which were clinically significant. Primary incidental findings were more common than secondary incidental findings; however, clinically significant findings were found at a consistent rate throughout the study period.

Endovascular aortic repair should be the gold standard for ruptured AAAs, and all vascular surgeons should be prepared to perform them.

When ruptured abdominal aortic aneurysms (AAAs) are not treated, they cause death. In addition, ruptured abdominal aortic aneurysms (RAAAs) have high mortality (35%-70%) and morbidity rates when treated by standard open surgical methods. These high perioperative mortality and morbidity rates have not been substantially reduced despite the introduction of many improvements in open operative technique or perioperative care. Endovascular approaches to treat AAAs introduced in the early 1990s provided an opportunity to substantially alter treatment outcomes when rupture occurred. This article details how these endovascular approaches, which include endovascular stented grafts, can be applied to the treatment of RAAAs, and what advantages these new catheter-based approaches to treatment offer.

The incidence of pulmonary embolism in open versus laparoscopic gastric bypass.

Obesity independently increases the risk of pulmonary embolism (PE). We compare a superobese population (body mass index [BMI] > 55 kg/m(2)) undergoing open gastric bypasses (OGBs) with a similarly matched group of laparoscopic gastric bypasses (LGB) to see if the incidence of PE differs. We included all patients undergoing OGB (n = 193, average BMI = 51 kg/m(2)) at our institution by a single surgeon between July 1999 and April 2001. Thirty-one patients were superobese (BMI > 55 kg/m(2)). LGB was started at our institution in April 2001. Since that time 213 patients (average BMI = 52 kg/m(2)) have undergone the procedure. One hundred and nine patients were superobese. Pre- and postoperative prophylaxis included sequential compression stockings and subcutaneous heparin. Postoperatively, patients who developed signs of hypoxia, tachypnea, or tachycardia underwent a chest X-ray and spiral computed tomography. In addition, all patients who expired in the 30-day postoperative period underwent postmortem examination. Data were analyzed using the chi-squared test. In the OGB group, four patients (2.1%) developed PE. All occurred in superobese patients with a BMI > 55 kg/m(2). Three were fatal PEs and one was nonfatal. None of these patients had a prior history of deep vein thrombosis, PE, venous stasis disease, or pulmonary hypertension. In the LGB group, one patient (0.9%) had a nonfatal PE. This patient had a history of deep vein thrombosis. The incidence of PE was statistically higher in the superobese OGB group (P < 0.01). Despite the theoretical hindrance to venous return and vena caval compression observed with pneumoperitoneum, fewer PEs occurred in the laparoscopic group. Our data, however, suggest that patients with a BMI > 55 kg/m(2) might be at an increased risk for PE independent of operative approach.

Histologic and duplex comparison of the perclose and angio-seal percutaneous closure devices.

The intravascular and extravascular effects of percutaneous closure devices have not been well studied. We assessed the performance and healing characteristics in dogs of two devices approved by the US Food and Drug Administration. Nine adult male dogs were anesthesized prior to percutaneous access of both femoral arteries with a 6F sheath. All dogs were systemically heparinized to an activated clotting time (ACT) > 250 seconds. Duplex sonography was performed preoperatively to measure vessel diameter and flow velocity. In each dog, one of two devices (Perclose, Abbot Laboratories, Abbott Park, IL or Angio-Seal, St. Jude Medical, St. Paul, MN) was randomly deployed into one of the two femoral arteries. The other device was deployed on the opposite side. Duplex sonography was repeated immediately after deployment and 28 days later to measure changes in vessel diameter and flow velocity. At 28 days, angiography was performed on both femoral arteries before they were removed for histologic evaluation. The time required to excise each vessel reflected the degree of scarring. Hemostasis time for the Angio-Seal device far surpassed the Perclose device (39 +/- 7 vs 0 minutes; p < .05). Vessel narrowing was observed only at 28 days after deployment of the Angio-Seal device (p < .05). Extensive extravascular scarring was observed with the Angio-Seal device, which resulted in a longer femoral artery dissection time and greater periadventitial scar thickness compared with the Perclose device (p < .05). When compared with the Perclose suture closure device, the Angio-Seal collagen plug closure device prolonged hemostasis time and produced greater vessel narrowing and periadventitial inflammation (extravascular scarring) in a canine model at 4 weeks.

Experience with inferior vena cava filter placement in patients undergoing open gastric bypass procedures.

OBJECTIVE: Patients undergoing open gastric bypass (OGB) for morbid obesity are at significant risk for pulmonary embolism (PE) despite the use of subcutaneous heparin injections and sequential compression devices. Prophylactic preoperative inferior vena cava (IVC) filter placement may reduce this risk. We report our experience with simultaneous IVC filter placement and OGB in an operating room setting. METHODS: From July 1999 to April 2001, 193 patients (group 1) underwent OGB. Eight patients had prophylactic intraoperative IVC filters placed for deep vein thrombosis, PE, or pulmonary hypertension. From May 2001 to January 2003, 181 patients (group 2) underwent OGB. There were 33 IVC filters placed for body mass index (BMI) greater than 55 kg/m2 in addition to the above-mentioned criteria. To confirm observations made in group 1 and 2 patients, from July 2003 to May 2005, 197 patients (group 3) underwent OGB, and patients with a BMI greater than 55 kg/m2 (n = 35) were offered IVC filter placement. Group 3A (n = 17) consented to IVC filter placement, and group 3B (n = 18) did not. RESULTS: Fifty-eight IVC filters were placed (100% technical success rate) with an increase in operating room time of 20 +/- 5 minutes. In group 1, the eight patients with IVC filters had a BMI greater than 55 kg/m2. There were four PEs (3 fatal and 1 nonfatal) in the other 185 patients, all which occurred in patients with BMIs greater than 55 kg/m2. In group 2, there were no PEs. The perioperative PE rate in these patients was reduced from 13% (4/31; 95% confidence interval [CI], 1.1%-25.7%) to 0% (0/33; 95% CI, 0%-8.7%). Perioperative mortality was reduced from 10% (3/31; 95% CI, 0%-20.0%) to 0% (0/33; 95% CI, 0%-8.7%). There were no pulmonary emboli or deaths related to PE in group 3A patients. Group 3B patients had a 28% PE rate (two fatal and three nonfatal) and an 11% PE-related death rate. None of the remaining patients in group 3 had a PE. CONCLUSIONS: Intraoperative IVC filter placement for the prevention of PE in morbidly obese patients undergoing OGB is feasible. We observed a significant reduction in the perioperative PE rate when a BMI greater than 55 kg/m2 was used as an indication for IVC filter placement despite the use of subcutaneous heparin injections and sequential compression devices.

Absence of proximal neck dilatation and graft migration after endovascular aneurysm repair with balloon-expandable stent-based endografts.

OBJECTIVE: Proximal neck dilatation (PND) and/or endograft migration with the subsequent development of type I endoleak is a significant cause of late endograft failure after endovascular abdominal aortic aneurysm repair (EVAR). Although there are numerous reports examining PND in patients receiving endografts that use self-expanding stents (SES) for proximal fixation, there are no such reports for patients treated with endografts that use balloon-expanding stents (BES). The purpose of this study was to investigate PND and endograft migration after EVAR with BES endografts. METHODS: We retrospectively reviewed all charts and all serial computed tomographic scans available for patients who underwent EVAR with a BES endograft (surgeon-made, aortounifemoral polytetrafluoroethylene graft with a proximal Palmaz stent) between August 1997 and October 2002. Only patients with longer than a 12-month follow-up were analyzed. Neck diameter was measured at the level of the lowest renal artery and at 5 mm below it. PND was defined as neck enlargement of 2.5 mm or more. To assess endograft migration, the distance between the superior mesenteric artery and the cranial end of the BES was measured. Stent migration was defined as a change of 5 mm or more. RESULTS: A total of 77 patients received this device during the study period. The technical success rate was 99%. The 1-, 3-, and 5-year survival was 66%, 48%, and 29.5%, respectively. Complete serial computed tomographic scans were available in 41 of the 48 patients who survived 12 months or longer after the operation. The mean follow-up period for these patients was 31 months (range, 12-66 months). The maximum aneurysm diameter was either unchanged or decreased in 35 patients (85%). The immediate postoperative proximal neck diameter was 19 to 29 mm (median, 24 mm). This was unchanged at the latest follow-up. None of the patients had significant PND. The cranial end of the BES was located in the area between 14 mm proximal and 36 mm distal to the superior mesenteric artery (median, 6 mm). None of the patients developed significant endograft migration. CONCLUSIONS: Neither PND nor endograft migration was observed with the BES endograft. The nature of the SES may be responsible for the observed neck dilatation and device migration after EVAR with SES endografts. This study suggests that BES may be a better fixation method for EVAR.