Use of retrievable filters in alternative common iliac vein location in high-risk surgical patients.

PURPOSE: To evaluate the use of retrievable filters placed in bilateral common iliac veins in high-risk surgical patients. MATERIALS AND METHODS: During the 4-year study period, 10 patients received bilateral common iliac vein placement of retrievable filters for pulmonary embolism (PE) prophylaxis. These patients were at risk for venous thromboembolism (VTE) but had no evidence of VTE at the time of filter placement. In nine patients undergoing bariatric surgery, placement of a filter in the inferior vena cava (IVC) was impossible because of megacava (defined as caval diameter ≥ 3.0 cm). In one patient who had planned dissection of an extensive retroperitoneal tumor, there was concern that IVC location of the filter would be prone to complications secondary to intraoperative manipulation. Filter placement and retrieval were evaluated. All patients were followed clinically until 4-6 weeks after filter retrieval. RESULTS: There were 20 filters placed in 10 attempts, 18 (nine patients) through the right internal jugular vein and 2 (one patient) through bilateral femoral veins. The mean (± standard deviation) dwell time of the filters was 40 days ± 10 (range 30-71 days). All filters were successfully removed. There were no procedural complications. No clinically evident PE was noted. CONCLUSIONS: Use of retrievable filters in the bilateral common iliac veins was found to be feasible and effective in preventing PE in patients with contraindications to filter placement in the IVC.

Mesenteric autotransplantation: an alternative technique for reoperation and bypass of the superior mesenteric artery.

Superior mesenteric artery (SMA) aneurysms represent a minority of visceral aneurysms but may result in lethal complications if left untreated. Options for treatment include aneurysmorraphy, bypass, ligation, or embolization. Here we present a case of a man with a history of celiac graft thrombosis who presents with a recurrent symptomatic SMA aneurysm. Given his compromised celiac axis, ligation was not an option. His SMA aneurysm was repaired with a PTFE patch. However, to secure longstanding blood flow to the small bowel in the event of graft thrombosis, the distal SMA pedicle was dissected free of the ileocolic vessels and anastomosed to the aorta. Follow-up studies demonstrated an occluded PTFE patch with a patent SMA autotransplant. This case depicts a novel approach to the surgical management of complex recurrent SMA aneurysms.

Is atherectomy the best first-line therapy for limb salvage in patients with critical limb ischemia?

OBJECTIVE: To determine the efficacy of atherectomy for limb salvage compared with open bypass in patients with critical limb ischemia. METHODS: Ninety-nine consecutive bypass and atherectomy procedures performed for critical limb ischemia between January 2003 and October 2006 were reviewed. RESULTS: A total of 99 cases involving TASC C (n = 43, 44%) and D (n = 56, 56%) lesions were treated with surgical bypass in 59 patients and atherectomy in 33 patients. Bypass and atherectomy achieved similar 1-year primary patency (64% vs 63%; P = .2). However, the 1-year limb salvage rate was greater in the bypass group (87% vs 69%; P = .004). In the tissue loss subgroup, there was a greater limb salvage rate for bypass patients versus atherectomy (79% vs 60%; P = .04). CONCLUSIONS: Patients with critical limb ischemia may do better with open bypass compared with atherectomy as first-line therapy for limb salvage.

Techniques used for difficult retrievals of the Günther Tulip inferior vena cava filter: experience in 32 patients.

PURPOSE: To retrospectively review experience with difficult retrievals of Günther Tulip filters (GTFs) in which various techniques were used. MATERIALS AND METHODS: From December 2004 to December 2006, 32 patients were referred to a single radiology department for GTF retrieval (25 women and seven men; mean age, 40 years; range, 21-60 y). All patients were evaluated, and 22 of these patients had undergone unsuccessful filter retrieval attempts elsewhere. In the remaining patients, significant tilt of the filter (n = 8) or difficult internal jugular vein access (n = 2) discouraged retrieval attempts. There were a total of 38 filters. Twenty-five patients had a filter in the infrarenal inferior vena cava (IVC). Among the remaining seven patients, six had bilateral iliac filters and one had a left iliac filter. Retrievals were performed via conventional technique-ie, by snaring the hook of the filter without additional maneuvers-or other techniques. RESULTS: Thirty-seven of 38 filters were successfully removed, for a success rate of 97%. Successful retrievals were performed with conventional (n = 4), catheter twist (n = 3), modified snare (n = 15), loop snare (n = 14), and balloon dilation (n = 1) techniques. The average dwell time for filters successfully removed was 58 days (range, 22-258 d). One failure occurred in a patient who had undergone unsuccessful retrieval previously. The hook of the filter and a displaced secondary strut, which had migrated superiorly, were incorporated into the IVC wall in this case. CONCLUSIONS: Additional maneuvers were useful in these difficult retrievals of GTFs that might not otherwise be retrievable with the conventional method.

Adrenocortical carcinoma invading the inferior vena cava: case report and literature review.

OBJECTIVE: To present the case of a man with a right-sided adrenocortical carcinoma that invaded the inferior vena cava and was managed by radical resection and vein patch repair. METHODS: We report the clinical, laboratory, imaging, and operative findings, and we highlight the pertinent features of this case. The literature is reviewed for the management of adrenocortical carcinoma in conjunction with inferior vena cava invasion. RESULTS: In a 34-year-old man with new-onset abdominal pain, abdominal imaging disclosed a large right adrenal mass with invasion into the inferior vena cava. Laboratory values revealed that the adrenal mass was likely nonfunctional. At surgical intervention with use of cardiopulmonary bypass, the mass was removed en bloc with the adrenal gland, right kidney, and the wall of the inferior vena cava, and the inferior vena cava was reconstructed with bovine pericardium. CONCLUSION: Despite direct invasion or extension of tumor thrombus into the inferior vena cava (or both), complete (R0) resection can be obtained. Thus, this scenario should not preclude attempted curative resection in patients with adrenal cancer.

Reappraisal of velocity criteria for carotid bulb/internal carotid artery stenosis utilizing high-resolution B-mode ultrasound validated with computed tomography angiography.

OBJECTIVE: Reliability of the most commonly used duplex ultrasound (DUS) velocity thresholds for internal carotid artery (ICA) stenosis has been questioned since these thresholds were developed using less precise methods to grade stenosis severity based on angiography. In this study, maximum percent diameter carotid bulb ICA stenosis (European Carotid Surgery Trial [ECST] method) was objectively measured using high resolution B-mode DUS validated with computed tomography angiography (CTA) and used to determine optimum velocity thresholds for > or =50% and > or =80% bulb internal carotid artery stenosis (ICA). METHODS: B-mode DUS and CTA images of 74 bulb ICA stenoses were compared to validate accuracy of the DUS measurements. In 337 mild, moderate, and severe bulb ICA stenoses (n = 232 patients), the minimal residual lumen and the maximum outer bulb/proximal ICA diameter were determined on longitudinal and transverse images. This in contrast to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method using normal distal ICA lumen diameter as the denominator. Severe calcified carotid segments and patients with contralateral occlusion were excluded. In each study, the highest peak systolic (PSV) and end-diastolic (EDV) velocities as well as ICA/common carotid artery (CCA) ratio were recorded. Using receiver operating characteristic (ROC) analysis, the optimum threshold for each hemodynamic parameter was determined to predict > or =50% (n = 281) and > or =80% (n = 62) bulb ICA stenosis. RESULTS: Patients mean age was 74 +/- 8 years; 49% females. Clinical risk factors for atherosclerosis included coronary artery disease (40%), diabetes mellitus (32%), hypertension (70%), smoking (34%), and hypercholesterolemia (49%). Thirty-three percent of carotid lesions (n = 110) presented with ischemic cerebrovascular symptoms and 67% (n = 227) were asymptomatic. There was an excellent agreement between B-mode DUS and CTA (r = 0.9, P = .002). The inter/intraobserver agreement (kappa) for B-mode imaging measurements were 0.8 and 0.9, respectively, and for CTA measurements 0.8 and 0.9, respectively. When both PSV of > or =155 cm/s and ICA/CCA ratio of > or =2 were combined for the detection of > or =50% bulb ICA stenosis, a positive predictive value (PPV) of 97% and an accuracy of 82% were obtained. For a > or =80% bulb ICA stenosis, an EDV of > or =140 cm/s, a PSV of > or =370 cm/s and an ICA/CCA ratio of > or =6 had acceptable probability values. CONCLUSION: Compared with established velocity thresholds commonly applied in practice, a substantially higher PSV (155 vs 125 cm/s) was more accurate for detecting > or =50% bulb/ICA stenosis. In combination, a PSV of > or =155 cm/s and an ICA/CCA ratio of > or =2 have excellent predictive value for this stenosis category. For > or =80% bulb ICA stenosis (NASCET 60% stenosis), an EDV of 140 cm/s, a PSV of > or =370 cm/s, and an ICA/CCA ratio of > or =6 are equally reliable and do not indicate any major change from the established criteria. Current DUS > or =50% bulb ICA stenosis criteria appear to overestimate carotid bifurcation disease and may predispose patients with asymptomatic carotid disease to untoward costly diagnostic imaging and intervention.

WITHDRAWN: Reappraisal of internal carotid artery stenosis velocity thresholds utilizing high-resolution B-mode ultrasound validated with computed tomography angiography (CTA).

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Use of retrievable compared to permanent inferior vena cava filters: a single-institution experience.

The purpose of this study was to review the use, safety, and efficacy of retrievable inferior vena cava (IVC) filters in their first 5 years of availability at our institution. Comparison was made with permanent filters placed in the same period. A retrospective review of IVC filter implantations was performed from September, 1999, to September, 2004, in our department. These included both retrievable and permanent filters. The Recovery nitinol and Günther tulip filters were used as retrievable filters. The frequency of retrievable filter used was calculated. Clinical data and technical data related to filter placement were reviewed. Outcomes, including pulmonary embolism, complications associated with placement, retrieval, or indwelling, were calculated. During the study period, 604 IVC filters were placed. Of these, 97 retrievable filters (16%) were placed in 96 patients. There were 53 Recovery filter and 44 Tulip filter insertions. Subjects were 59 women and 37 men; the mean age was 52 years, with a range of from 18 to 97 years. The placement of retrievable filters increased from 2% in year 1 to 32% in year 5 of the study period. The total implantation time for the permanent group was 145,450 days, with an average of 288 days (range, 33-1811 days). For the retrievable group, the total implantation time was 21,671 days, with an average of 226 days (range, 2-1217 days). Of 29 patients who returned for filter retrieval, the filter was successfully removed in 28. There were 14 of 14 successful Tulip filter retrievals and 14 of 15 successful Recovery filter retrievals. In one patient, after an indwelling period of 39 days, a Recovery nitinol filter could not be removed secondary to a large clot burden within the filter. For the filters that were removed, the mean dwell time was 50 days for the Tulip type and 20 days for the Recovery type. Over the follow-up period there was an overall PE incidence of 1.4% for the permanent group and 1% for the retrieval group. In conclusion, there was an increase in the use of retrievable filters over the study period and an overall increase in the total number of filters implanted. The increased use of these filters appeared to be due to expanded indications predicated by their retrievability. Placement and retrieval of these filters have a low risk of complications, and retrievable filters appeared effective, as there was low rate of clinically significant pulmonary embolism associated with these filters during their indwelling time.

Transperitoneal versus retroperitoneal suprarenal cross-clamping for repair of abdominal aortic aneurysm with a hostile infrarenal aortic neck.

Infrarenal abdominal aortic aneurysms (AAAs) with a hostile infrarenal aortic neck unfit for endovascular aneurysm repair (EVAR) are more likely to require open repair with suprarenal aortic cross-clamping. We compared the results of the transperitoneal versus retroperitoneal approaches for repair of infrarenal AAA requiring suprarenal cross-clamping and the relative frequency of such techniques after incorporating EVAR into our clinical practice. From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired. There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal) and 318 (67%) endovascular repairs. In 38 cases (24%) suprarenal cross-clamping was performed (47% transperitoneal and 53% retroperitoneal incisions) for a hostile infrarenal neck. A hostile aortic neck was defined as severe angulation (>60 degrees ), short neck (<15 mm), extensive calcification, or circumferential thrombus. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency. The median aneurysm size was 6.0 cm. A retrospective analysis was performed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. The results were determined for two time periods to assess whether open repair with suprarenal cross- clamping was being performed more frequently as a result of increased utilization of EVAR in the contemporary period. After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% to 39%, while the transperitoneal approach decreased from 81% to 61% (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002. There was no significant difference in age, sex, aneurysm size, or comorbidities between the trans- and retroperitoneal groups with suprarenal cross-clamping. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group. The transperitoneal approach was associated with significantly greater blood loss and longer suprarenal cross-clamp times (2,400 vs. 1,800 mL and 38.0 vs. 29.5 min; p = 0.03), but there were no significant differences in 30-day postoperative complications. In our 7 years' experience, there has been a gradual increase in the utilization of EVAR for infrarenal AAAs. At the same time, more infrarenal AAAs with hostile aortic necks requiring suprarenal aortic cross-clamping were encountered. In such instances, the retroperitoneal approach is safer, with less perioperative blood loss and shorter suprarenal cross-clamp time. This is likely attributed to better exposure of the suprarenal abdominal aorta, allowing a more secure proximal anastomosis.

Safety, feasibility, and outcome of retrievable vena cava filters in high-risk surgical patients.

OBJECTIVE: Retrievable vena cava filters (rVCFs) are being used frequently in the perioperative setting for preventing pulmonary embolism. The indications and safety profile for placement of preoperative retrievable vena cava filters (rVCFs) remains undefined, however. This study sought to determine the safety, feasibility, and outcome of rVCFs in bariatric surgery patients, who are known as a high-risk population for periprocedural deep vein thrombus (DVT) or pulmonary embolus, or both. METHODS: Between June 1, 2004, and October 1, 2005, protocols were developed and implemented at a tertiary referral hospital for placement of rVCFs in 59 consecutive high-risk patients undergoing laparoscopic gastric bypass or duodenal switch if they met any of the following criteria: body mass index >55 kg/m(2), hypercoagulable state, severe immobility, venous stasis, or previous history of DVT or pulmonary embolus. Using both Site-Rite (Bard Access Systems, Salt Lake City, Utah) ultrasound and fluoroscopy, Günther Tulip (Cook, Inc., Bloomington, Ind) rVCFs were placed immediately after general anesthesia, just preceding the bariatric procedure. The internal jugular vein was the preferred approach, followed by the femoral vein. Retrieval was performed after the fourth postoperative week. RESULTS: During a 16-month period, 60 rVCFs were placed in 61 attempts, 57 through the internal jugular vein and three through the femoral vein. Six patients refused the retrieval attempt. Of the remaining 54 rVCFs, the primary retrieval success was 90% (49/54), with all failures due to severe filter tilt. The secondary retrieval success was 100% (3/3). The two remaining patients refused secondary retrieval attempt. The mean +/- standard deviation dwell time of the rVCFs was 63 +/- 30 days. No procedure complications occurred in placement or retrieval. One patient developed a clinical pulmonary embolism with the filter in place while not receiving postoperative anticoagulation. No patients died. The mean body mass index of the patients was 61 +/- 10 kg/m(2). CONCLUSION: Placement and retrieval of retrievable vena cava filters in high-risk bariatric surgery patients is safe, feasible, and offers potential clinical benefit to patients requiring short-term protection from pulmonary embolism.