Initial Outcomes of the Gore TAG Thoracic Branch Endoprosthesis for Endovascular Repair of Blunt Thoracic Aortic Injury.

BACKGROUND: Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with an increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation. METHODS: Across 34 investigative sites, 9 patients with BTAI requiring LSA coverage were enrolled in a nonrandomized, prospective study of a single-branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion. RESULTS: This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up are planned. All participants had grade 3 BTAI. All procedures took place between 2018 and 2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 min (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to the purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection, or thrombosis) through 12 months of follow-up. CONCLUSIONS: Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for a definitive assessment of the device's safety and durability in traumatic aortic injuries.

One-year results with a low-profile endograft in subjects with thoracic aortic aneurysm and ulcer pathologies.

OBJECTIVE: The study objective was to evaluate the safety and effectiveness of the second-generation, low-profile RelayPro (Terumo Aortic) thoracic endograft for the treatment of descending thoracic aortic aneurysm or penetrating atherosclerotic ulcer. METHOD: A prospective, international, nonblinded, nonrandomized, pivotal trial analyzed a primary safety end point of major adverse events at 30 days (death, myocardial infarction, stroke, renal/respiratory failure, paralysis, bowel ischemia, procedural blood loss) and a primary effectiveness end point of treatment success at 1 year (technical success, patency, absence of aneurysm rupture, type I/III endoleaks, stent fractures, reinterventions, aneurysm expansion, and migration) compared with performance goals from the previous generation Relay pivotal study. The study was conducted in 36 centers in the United States and Japan and enrolled participants between 2017 and 2019. RESULTS: The study population of 110 patients had a median (interquartile range) age of 76 (70-81) years, 69 (62.7%) were male, and 43 (39.1%) were Asian. Patients were treated for 76 fusiform aneurysms (69%), 24 saccular aneurysms (22%), and 10 penetrating atherosclerotic ulcers (9%). Most patients (82.7%) were treated with a non-bare stent configuration. Technical success was 100%. The median (interquartile range) procedure time was 91 (64-131) minutes, and the deployment time was 16 (10-25) minutes. A total of 50 patients (73.5%) in the US cohort had percutaneous access, whereas centers in Japan used only surgical cutdown. The 30-day composite major adverse events rate was 6.4% (95% upper confidence interval, 11.6%; P = .0002): 2 strokes, 2 procedural blood losses greater than 1000 mL requiring transfusion, 2 paralysis events, and 1 renal failure. Primary effectiveness was 89.2% (lower 95% confidence interval, 81.8%; P = .0185). Nine subjects experienced 11 events (1 aneurysm expansion, 6 secondary interventions, and 4 type I endoleaks). There was no loss of stent-graft patency, no rupture, no fractures, and no migration. CONCLUSIONS: The low-profile RelayPro thoracic endograft met the study primary end points and demonstrated satisfactory 30-day safety and 1-year effectiveness for the treatment of patients with aneurysms of the descending thoracic aorta or penetrating atherosclerotic ulcers. Follow-up is ongoing to evaluate longer-term outcomes and durability.

Surgical management of an infected external iliac artery interposition graft with a bioengineered human acellular vessel.

Infection of prosthetic vascular grafts can manifest as pain, pseudoaneurysms, or arterial insufficiency in the leg. We present the case of a female patient with a medical history of a right external iliac artery endofibrosis, with a persistently infected synthetic iliofemoral bypass graft, which we replaced with a bioengineered human acellular vessel. At the 12-month follow-up visit, the clinical and radiologic studies demonstrated adequate human acellular vessel patency, with no signs of infection, stenosis, or pseudoaneurysm. Subsequent to the initiation of hormone therapy and cessation of antiplatelet therapy, the patient developed graft thrombosis. She continued to do well after restoration of patency with lytic therapy. At 22 months, secondary patency has been maintained with continued anticoagulation therapy, and the patient has remained asymptomatic.

Incidence of Acute and Chronic Renal Failure Following Branched Endovascular Repair of Complex Aortic Aneurysms.

BACKGROUND: The purpose of this study was to examine the incidence of acute kidney injury and chronic renal impairment following branched endovascular aneurysm repair (BEVAR) of complex thoracoabdominal aortic aneurysms (TAAA) using the Medtronic Valiant Thoracoabdominal Aortic Aneurysm stent graft system (MVM), the physician-modified Visceral Manifold, and Unitary Manifold stent graft systems. The objective was to report the acute and chronic renal function changes in patients following complex TAAA aneurysm repair. METHODS: This is an analysis of 139 patients undergoing branched endovascular repair for complex TAAAs between 2012 and 2020. Patient renal function was evaluated using serum creatinine and estimated glomerular filtration rate at baseline, 48 hr, discharge, 1 month, 6 months, and annually to 2 years. Patients on dialysis prior to the procedure were excluded from data analysis. RESULTS: A total of 139 patients (mean age 71.13; 64.7% male) treated for TAAA with BEVAR met inclusion criteria and were evaluated. A total of 530 visceral vessels were stented. A majority of patients (n = 131, 94.2%) underwent a single procedure while 8 required staged procedures. Thirty-day, 1-year and 2-year all-cause mortality rates were 5.8%, 25.2%, and 32.4%, respectively. Primary and secondary patency rates at a median follow-up of 26.9 months (95% CI; 21.1 - 32.7) were 96.2% and 97.5% for all vessels and 95.4% and 96.9% for renal arteries, respectively. Postoperative acute kidney injury (AKI) was identified in 22 (15.8%) patients. At discharge, 16 patients (11.6%) had an increase in CKD stage with 3 requiring permanent dialysis. Five additional patients required permanent dialysis over the 2-year follow-up period for a total of 8 (5.8%). Increasing age (HR = 1.0327, P= 0.0477), hemoglobin < 7 prior to procedure (HR = 2.4812, P= 0.0093), increasing maximum aortic diameter (HR = 1.0189, P= 0.0084), presence of AKI (HR = 2.0757, P= 0.0182), and increase in CKD stage (HR = 1.3520, P= 0.002) at discharge were significantly associated with decreased patient survival. CONCLUSIONS: Postoperative AKI and a chronic decline in renal function continue to be problematic in endovascular repair of complex aortic aneurysms. This study found that BEVAR using the manifold configuration resulted in immediate and mid-term renal function that is comparable to similar analyses of branched and/or fenestrated grafts.

Follow-up imaging of traumatic vertebral artery dissections is unnecessary in asymptomatic patients.

OBJECTIVE: Routine computed tomography (CT) imaging in trauma patients has led to increased recognition of blunt vertebral artery injuries (BVIs). We sought to determine the prevalence of strokes, injury progression, and need for intervention in patients with BVI. METHODS: Consecutive patients presenting with BVI during 2 years were identified from the institutional trauma registry. Inpatient records, imaging studies, and follow-up data were reviewed in detail from the electronic medical record. RESULTS: There were 76 BVIs identified in 70 patients (64% male; mean age, 47 ± 19 years); bilateral injuries occurred in 6 patients. Five patients who arrived at the hospital intubated had evidence of posterior circulation infarcts on admission CT, whereas one additional patient had evidence of a posterior circulation infarct attributed to complications of late spinal surgery. Four of the five patients with infarcts on admission CT survived to discharge, but only one had residual stroke symptoms. Minor (grade 1 or grade 2) injuries occurred in 25 (36%) patients; severe (grade 3 or grade 4) injuries occurred in 45 (64%). Twelve patients died of associated injuries (eight with severe BVI, four with minor BVI). Stepwise logistic regression analysis selected age (odds ratio, 1.14; confidence interval, 1.04-1.25; P < .001) and intubation on arrival (odds ratio, 450.4; confidence interval, 17.41-1645.51; P < .001) as independent predictors of hospital stroke and death. Of the 58 surviving to discharge, 31 (53%) returned for follow-up CT scans. Six of 10 (60%) patients with minor injuries had resolution or improvement compared with 3 of 21 (14%) with severe injuries (P = .027). One patient (10%) with a minor BVI and two patients (10%) with severe BVI had radiologic progression, but none were clinically significant. During a mean follow-up of 15 ± 13 months, none of the study patients had treatment (surgical or interventional) for BVI, and there were no delayed strokes. Only five patients in this series had vertebral pseudoaneurysms, which limits conclusions about this type of BVI. CONCLUSIONS: These data suggest that BVI-related strokes are present at the time of admission and do not have clinical sequelae. No late strokes occurred in this series, and no surgical or interventional treatments were required even in the presence of radiographic worsening. The relatively few cases of vertebral pseudoaneurysms in this series limit any conclusions about these specific lesions. However, these data indicate that follow-up imaging of nonaneurysmal BVI is not necessary in adults who are found to be asymptomatic on follow-up.

Critical ischemia and myonecrotic sepsis following scapulothoracic dissociation in the setting of apparent hand perfusion: A case report.

Scapulothoracic dissociation is a rare and devastating injury to the shoulder girdle. It is often caused by traction or severe blunt trauma injury to the upper extremity and is associated with both neurologic and vascular injuries. Scapulothoracic dissociation is a highly morbid and rare injury pattern that is often seen in conjunction with other traumatic injuries. The authors describe a case of scapulothoracic dissociation with associated complete brachial plexus injury and subclavian artery injury that was complicated by hypoperfusion, myonecrosis, and subsequent polymicrobial infection of the affected limb in the setting of a warm hand with brisk capillary refill. While capillary refill and hand warmth in the setting of a pulseless extremity have been used in previous cases of scapulothoracic dissociation as an indication for limb perfusion and nonoperative management, these markers cannot reliably be used to evaluate collateral circulation as exemplified in this case report. This case highlights multiple important aspects of the evaluation and management of scapulothoracic dissociation that orthopaedic surgeons and vascular surgeons should be familiar with and utilize when dealing with these challenging injuries. Level of Evidence: V.

Initial and intermediate-term treatment of the phantom thrombus (primary non-occlusive mural thrombus on normal arteries).

An embolic event originating from thrombus on an otherwise un-diseased or minimally diseased proximal artery (Phantom Thrombus) is a rare but significant clinical challenge. All patients from a single center with an imaging defined luminal thrombus with a focal mural attachment site on an artery were evaluated retrospectively. We excluded all patients with underlying anatomic abnormalities of the vessel at the attachment site. Six patients with a mean age of 62.5 years were identified over a 2.5-year period. All patients had completed treatment for or had a current diagnosis of malignancy and none were on antiplatelets or other anticoagulants. Four thrombi originated in the aorta proximal to the renal arteries and one originated distal. One thrombus was found in the common carotid artery and one was in an arterialized vein graft. Mean follow-up was 22 months. None of the patients underwent removal or exclusion of the embolic source. With systemic anticoagulation, four of the phantom thrombi were resolved on imaging within 8 weeks, one resolved after 72 weeks. One phantom thrombus reoccurred after 6 months on reduced anticoagulant dosing. There was one acute and one death in follow-up (26 months). One patient required a partial foot amputation secondary to tissue necrosis from the initial thromboembolic event. Arterial thrombi forming on otherwise normal vessels are a distinct clinical entity. In patients with a phantom thrombus, a strategy of therapeutic anticoagulation for management of the embolic source seems to be safe and effective over both the short and intermediate-term.

Does Management of True Aneurysms of Peripancreatic Arteries Require Repair of Associated Celiac Artery Stenosis?

BACKGROUND: True aneurysms of the gastroduodenal (GDA) and pancreaticoduodenal (PDA) arteries have been attributed to increased collateral flow due to tandem celiac artery stenosis or occlusion. Although GDA and PDA aneurysm exclusion is recommended because of the high reported risk of rupture, it remains uncertain whether simultaneous celiac artery reconstruction is necessary to preserve end-organ flow. STUDY DESIGN: We conducted a retrospective analysis of consecutive patients admitted from 1996 to 2015 with true aneurysms of the GDA or PDA. RESULTS: Twenty patients with true aneurysms of the PDA (n = 16) or GDA (n = 4) were identified. Mean age was 61.5 years (range 35 to 85 years) and 11 (55%) were women. Nine (45%) presented with rupture, 8 (40%) presented with pain, and 3 (15%) were asymptomatic. All 9 patients who presented with rupture had contained retroperitoneal hematomas, and none experienced rebleeding. Fifteen (75%) patients had an associated celiac artery >60% stenosis or occlusion, and 2 (10%) had both celiac and superior mesenteric artery stenoses. Thirteen (65%) patients underwent successful endovascular coiling, only 1 of which had a prophylactic celiac artery bypass. Three (15%) patients underwent open aneurysm exclusion and celiac bypass, and 4 (20%) others were observed. There were no aneurysm-related deaths in this series, and none of the patients who underwent coiling without celiac revascularization had hepatic ischemia or other mesenteric morbidity develop during a median follow-up of 6 months (maximum 200 months). CONCLUSIONS: Gastroduodenal artery and PDA aneurysms present most commonly with pain or bleeding, and all should be considered for repair, regardless of size. Aneurysm exclusion is safely and effectively achieved with endovascular coiling. Although associated celiac artery stenosis is found in the majority of cases, celiac revascularization might not be necessary.

Aortic arch involvement worsens the prognosis of type B aortic dissections.

OBJECTIVE: Medical management of acute aortic dissections limited to the descending thoracic aorta (AD-desc) is associated with acceptable outcomes. Uncertainty remains about whether acute type B aortic dissections involving the aortic arch (AD-arch) have an increased risk of retrograde extension into the ascending aorta or other dissection-related complications. This study compared outcomes of AD-arch with AD-desc managed medically. METHODS: Consecutive patients admitted from 2005 to 2014 with acute aortic dissections not involving the ascending aorta were retrospectively analyzed. Primary end points included dissection-related death and operative intervention. RESULTS: The study included 99 patients (63% men; mean age, 60 ± 14 years) with acute aortic dissections. Dissections were limited to the aorta distal to the left subclavian artery (AD-desc) in 79 patients (80%), and 20 (20%) had involvement of the left subclavian (n = 16), left common carotid (n = 1), or innominate (n = 3) arteries (AD-arch). Dissections ended proximal to the celiac artery in 30 patients (30%), between the celiac artery and aortic bifurcation in 36 (36%), and distal to the aortic bifurcation in 33 (33%). During medical management, further proximal extension into the arch occurred in two AD-arch patients and one AD-desc patient (P < .05), but proximal dissection into the ascending aorta occurred in only one AD-arch patient with Marfan disease. Compared with patients with AD-desc, those with AD-arch were younger (53 ± 12.5 vs 62 ± 16 years; P < .01) and had more frequent early interventions (40% vs 19%; P = .047), cardiac complications (35% vs 11%; P < .01), and neurologic events (25% vs 6%; P < .01). Seven AD-arch patients (35%) and nine AD-desc patients (11%) died of dissection-related causes (P < .01). Among survivors, late interventions were performed in four of eight AD-arch patients (50%) and in six of 58 AD-desc patients (10%; P = .02). Medical treatment without intervention was successful in four AD-arch patients (20%) and in 52 AD-desc patients (66%; P < .001). Multivariate logistic regression retained arch involvement as the sole predictor of dissection-related death (odds ratio, 4.2; 95% confidence interval, 1.3-13.4) and failure of medical treatment (odds ratio, 7.7; 95% confidence interval, 2.5-29). The distal extent of dissection had no bearing on outcome. CONCLUSIONS: AD-arch dissections are associated with a higher risk of cardiac and neurologic events, need for early intervention, and dissection-related death than AD-desc dissections. Because further proximal dissections into the ascending aorta were rare in this study, medical management appears to be safe as the initial treatment of AD-arch dissections. However, surgeons should be aware of the increased risk of complications and the potential need for urgent interventions in these patients.

A Regional Experience With Vascular Surgery Mock Oral Examinations.

INTRODUCTION: In 2006 the Southern Association for Vascular Surgery (SAVS) implemented a mock oral examination program to prepare trainees for the Vascular Surgery Certifying Examination (VCE). METHODS: Participating examinees and examiners were identified from SAVS Recorder records and contacted via e-mail with a request to participate in an anonymous online survey. Examinees were asked about passage on American Board of Surgery examinations and perceptions of the mock oral program. Examiners were asked for their perceptions of the examination, applicant performance, and perceived areas for training improvement. Board passage rates for the group and national comparison data were provided in a de-identified fashion by American Board of Surgery. RESULTS: From 2006 to 2014, 158 examinees and 86 examiners participated in the SAVS mock orals program. In all, 33% of examinees and 35% of examiners completed the anonymous survey. Of the examinees, 27 (60%) reported passage of the mock oral examination on their first attempt and 7 of 9 (78%) reported passage on the second attempt. Second year in training was significantly associated with passage of the mock oral (p = 0.002). Of the examinees questioned, 100% "would recommend" the SAVS mock oral examinations to future trainees. Of the responding examiners, 90% felt that the SAVS mock oral examinations were "comparable" to the VCE and 87% "strongly agreed" that the exercise was a valuable preparatory tool. Examiners identified "ability to describe technical aspects of open vascular techniques" and "management of complications associated with vascular disease processes and operations" as commonly displayed deficits among examinees (80% and 77%, respectively). In all, 115 examinee participants from the SAVS mock orals had taken the VCE between 2006 and 2014. Of them, 90 (78%) passed the VCE on their first attempt. During the same time interval, the national first-time pass rate for the VCE was 86%. CONCLUSIONS: Although participation in the SAVS mock orals was overwhelmingly assessed as a positive preparatory experience by examinees and examiners, no incremental advantage in VCE passage was observed. Explanations for the worse-than-average performance on the VCE are not clear but likely involve numerous factors, including participation bias. Importantly, examiners in the SAVS mock oral process felt that the exercise closely simulated the VCE and uniformly reported pervasive deficits in the areas of demonstrated understanding of open surgical techniques and management of complications. This investigation guides further examination of VCE simulation exercises to assist in guiding the use of educational resources at both institutional and professional society levels.

Outcome of the pivotal study of the Aptus endovascular abdominal aortic aneurysms repair system.

OBJECTIVE: Endovascular treatment of abdominal aortic aneurysm (AAA) is associated with benefits over open surgery, yet limitations remain with current endovascular devices. This study was performed to assess outcomes of AAA repair with the Aptus endograft and EndoAnchors (Aptus Endosystems, Sunnyvale, Calif). METHODS: This prospective, multicenter, single-arm investigational device exemption trial was conducted at 25 sites in the United States. A total of 155 patients were enrolled in the trial (mean age, 73 ± 8 years; male, 93.5%; mean AAA diameter, 53.6 ± 7.9 mm). The Aptus endograft is a two-component system: a multilumen, modular endograft with two docking limbs (Aptus Endograft System) and the Heli-FX Aortic Securement System comprising an electronically controlled applier (Heli-FX Applier) with helical EndoAnchors provided in a cassette and a deflectable sheath (Heli-FX Guide) designed for delivery of the applier to the target location for EndoAnchor implantation. The main eligibility criteria included proximal neck length of ≥12 mm, diameter of 19 to 29 mm, and infrarenal angulation of ≤60 degrees. The primary safety end point was freedom from major adverse events at 30 days, and the primary effectiveness end point was successful aneurysm treatment at 12 months. Thrombus-related events (TRE) were defined as limb occlusion or thromboembolism from the endograft. Subjects were observed for a median of 4.2 years, with imaging end points analyzed by a core laboratory and adverse events adjudicated by a clinical events committee. RESULTS: Among 155 enrolled subjects, 153 (98.7%) underwent successful implantation of the Aptus endograft and a median of five EndoAnchors; two subjects were converted to open surgical repair during the initial procedure. Overall, the primary safety and effectiveness end points were met in 98.1% and 97.4% of the subjects, respectively. Aneurysm-related mortality was 0.6%, with one postdischarge cardiac death 18 days after implantation. There were no AAA ruptures. There were no fractures of stents or EndoAnchors. There was one type I endoleak and one type III endoleak. Stent graft migration was noted in five subjects, none associated with sac enlargement, type I endoleak, or EndoAnchor dislocation from the endograft. AAA sac shrinkage of ≥5 mm at 1, 2, and 3 years was observed in 60.3%, 72.9%, and 81.7%, respectively. Sixty-one subjects (39.4%) experienced 113 TRE, associated with 80 reinterventions (in 58 subjects) unassociated with limb loss or death. A root cause analysis of TRE identified small, out-of-specification docking limbs with graft infolding and high local shear, resulting in thrombus formation within the endograft with subsequent distal embolization in some cases. CONCLUSIONS: Early results of the Aptus endograft trial met its safety and effectiveness end points; however, a high rate of TRE was observed because of manufacturing discrepancies. The findings confirm a low rate of type I and type III endoleaks, migration, and non-TRE reintervention with a high rate of aneurysm sac regression during midterm follow-up.

Natural history of grade I-II blunt traumatic aortic injury.

BACKGROUND: Endovascular aortic repair has revolutionized the management of traumatic blunt aortic injury (BAI). However, debate continues about the extent of injury requiring endovascular repair, particularly with regard to minimal aortic injury. Therefore, we conducted a retrospective observational analysis of our experience with these patients. METHODS: We retrospectively reviewed all BAI presenting to an academic level I trauma center over a 10-year period (2000-2010). Images were reviewed by a radiologist and graded according to Society for Vascular Surgery guidelines (grade I-IV). Demographics, injury severity, and outcomes were recorded. RESULTS: We identified 204 patients with BAI of the thoracic or abdominal aorta. Of these, 155 were deemed operative injuries at presentation, had grade III-IV injuries or aortic dissection, and were excluded from this analysis. The remaining 49 patients had 50 grade I-II injuries. We managed 46 grade I injuries (intimal tear or flap, 95%), and four grade II injuries (intramural hematoma, 5%) nonoperatively. Of these, 41 patients had follow-up imaging at a mean of 86 days postinjury and constitute our study cohort. Mean age was 41 years, and mean length of stay was 14 days. The majority (48 of 50, 96%) were thoracic aortic injuries and the remaining two (4%) were abdominal. On follow-up imaging, 23 of 43 (55%) had complete resolution of injury, 17 (40%) had no change in aortic injury, and two (5%) had progression of injury. Of the two patients with progression, one progressed from grade I to grade II and the other progressed from grade I to grade III (pseudoaneurysm). Mean time to progression was 16 days. Neither of the patients with injury progression required operative intervention or died during follow-up. CONCLUSIONS: Injury progression in grade I-II BAI is rare (~5%) and did not cause death in our study cohort. Given that progression to grade III injury is possible, follow-up with repeat aortic imaging is reasonable.

Skull base approach to carotid artery lesions: technique, indications, and outcomes.

Operative approaches to lesions of the carotid artery at the skull base are challenging and place multiple cranial nerves at risk. Herein, we describe a preauricular approach utilizing anterior dislocation of the temporomandibular joint with microscopic drill-out of the medial glenoid and Eustachian tube to identify and skeletonize the carotid artery in the foramen lacerum. The facial nerve remains undissected during this approach. Nine of 10 patients presented with aneurysm, six spontaneous and three following blunt trauma, and one patient presented with carotid artery rupture after penetrating trauma. Three of the patients presented with cranial nerve (CN) deficits that persisted. One patient was unevaluable preoperatively due to trauma but awoke with multiple CN deficits. Only one of nine evaluable patients suffered a new long-term CN deficit (XI). One patient had persistent temporomandibular joint dysfunction. All patients had long-term patency of the graft or anastamosis and no new neurologic symptoms were reported with a mean follow-up of 55 months. Open approaches to the carotid artery at the skull base are feasible and with careful anatomic dissection can be performed with minimal morbidity in most cases. We present full details and images of the operative approach.

Vacuum-pack temporary abdominal wound management with delayed-closure for the management of ruptured abdominal aortic aneurysm and other abdominal vascular catastrophes: absence of graft infection in long-term survivors.

Patients who undergo open repair of ruptured abdominal aortic aneurysms (rAAA) may require delayed abdominal wound closure to prevent the adverse consequences of intra-abdominal hypertension and abdominal compartment syndrome. However, surgeons may be reticent to use delayed abdominal closure techniques due to concern that such management may increase the risk of graft infection. We retrospectively reviewed our patient experience with rAAA and other vascular catastrophes in which vacuum-pack abdominal wound management with delayed closure was used between 2000 and 2007. Eighteen of 23 patients treated with delayed closure survived (78%). In five early deaths, graft infection was not clinically suspected. Sixteen of 20 rAAA patients survived, with abdominal wound closure achieved at a mean of 4 days. Mean follow up was 53 months, the longest among comparable series. Graft infection has not been encountered in this group. Our results suggest that the potential risk of graft infection should not outweigh the benefits of vacuum-pack temporary abdominal wound management with delayed closure in critically ill patients at high risk for intra-abdominal hypertension and abdominal compartment syndrome after major abdominal vascular procedures.

Carotid artery stenting for stenosis following cervical radiotherapy: report of early failure with associated stent fracture.

Experience with carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CE) for management of carotid stenosis continues to evolve. We report the case of a 64-year-old man who was treated with bilateral CAS for stenoses, which developed 7 years following thyroidectomy, neck dissection, and radiotherapy. Although long considered an ideal alternative to CE in this clinical setting, CAS in this case was complicated by multiple episodes of recurrent stenosis in his left carotid, managed by balloon angioplasty. Severe, early recurrence in his right carotid associated with a type III stent fracture was managed by CE. Close surveillance and intervention prevented neurologic morbidity. This case, combined with emerging published experience, argues for reappraisal of the general consensus that CAS is an ideal alternative to CE for radiotherapy-associated carotid stenoses.

Endovenous stent-assisted coil embolization for a symptomatic femoral vein aneurysm.

An 83-year old man presented with recurrent pulmonary embolism originating from a distal left superficial femoral vein aneurysm despite therapeutic anticoagulation. We treated the patient transluminally using the technique of stent-assisted coil embolization via percutaneous transpopliteal venous access. Follow-up by serial duplex ultrasonography and computer tomographic venography (CTV) demonstrated resolution of the aneurysm. Our case demonstrates that stent-assisted coil embolization may effectively exclude a saccular venous aneurysm and prevent recurrent pulmonary embolization.

Risk factors and angiographic technical considerations to guide carotid intervention.

Carotid angioplasty and stenting (CAS) with embolic protection is currently accepted as treatment for patients considered to be at high risk for carotid endarterectomy (CEA). The purpose of this study was (1) to determine what proportion of patients treated with CEA would be categorized as "high" risk by currently accepted criteria, (2) to characterize preoperative angiographic findings in patients with carotid stenosis, and (3) to determine the potential technical challenges of CAS in these patients. Consecutive patients who underwent CEA from January 1999 through August 2004 prior to introduction of CAS at our institution were identified. Demographics, indications, perioperative complications, and deaths were reviewed. Published guidelines defining high risk for CEA were applied, and preoperative angiograms were examined for technical limitations to CAS. Two hundred and seventy-nine CEAs were performed in 259 patients for asymptomatic carotid occlusive disease (57%), transient ischemic attacks (35%), or stroke (8%) during the study period. Of these, 35.5% (n = 99) would have met one or more high-risk criteria. Overall risks of perioperative stroke, myocardial infarction, and death were 1.1%, 2.2%, and 0.4% (n = 279), respectively, with a combined major complication rate of 3.3%. No difference in major complication rates was observed between standard-risk and high-risk patients. Preoperative angiograms were available for review in 83.5% of CEAs (n = 233). The distribution of aortic arch configurations included types I (3.5%), IIa (39.5%), IIb (54.5%), and III (1.3%). Aortic arch anomalies were observed in 15.5% (n = 35) of angiograms. There were 77.7% (n = 181) with one or more angiographic findings that would have increased the technical difficulty of CAS, but only 17.6% had relative angiographic contraindications to CAS. A significant proportion of patients with carotid stenosis previously managed with CEA would be categorized as high risk and considered potential candidates for CAS by currently accepted criteria. Based on preoperative angiography, technically challenging factors, some of which limit the ability to perform CAS, are common and should be anticipated when planning CAS.

Ischemic complications of percutaneous femoral artery catheterization.

Ischemic injuries following percutaneous femoral artery catheterization are uncommon but have been associated with vascular closure devices (VCDs). The purpose of this study was to retrospectively compare ischemic and hemorrhagic complications of femoral artery catheterization and to identify factors associated with ischemic injuries. The operative registries of the attending vascular surgeons at one academic and two community hospitals were retrospectively reviewed to identify all complications of femoral artery catheterization requiring operative intervention. Demographic, clinical, procedural, operative, and outcome data were compared between patients who sustained ischemic and hemorrhagic complications. From January 2001 to December 2006, 95 patients required operative management of complications related to femoral artery catheterization including 40 patients who experienced ischemic (group 1) and 55 patients who experienced hemorrhagic (group 2) complications. Compared to those sustaining hemorrhagic complications, ischemic complications were more frequently associated with younger age, smoking, VCD deployment, and, when controlling for VCD use, female gender. Time to presentation was also significantly longer in patients experiencing ischemic complications. Ischemic complications are increasingly recognized following femoral artery catheterization. Vascular surgeons should anticipate a new pattern of injury following femoral artery catheterization, one that often requires complex arterial reconstruction.