Early and midterm outcomes after endovascular treatment of degenerative aneurysms of the descending thoracic aorta: a Finnish multicenter study.

PURPOSE: To evaluate results of endovascular stent-graft placement for aneurysms of the descending aorta in 3 Finnish university hospitals during 1998-2010. METHODS: Among 158 consecutive patients treated with stent-graft placement for disease of the descending thoracic aorta, all 69 patients (58 men; mean age 71.7 years, range 54-90) with an aneurysm were included in the analysis. Medical records, radiological images, and national death records were collected and analyzed on an intention-to-treat basis. RESULTS: The 30-day mortality rate was 3.7% in 54 elective patients and 46.7% in 15 urgently treated acute patients. The paraparesis rate was 4.3%, and the major stroke rate was 4.3% after the operation. There were 4 aneurysm ruptures, all in the urgent group, two of whom had access failure. The other two died despite seemingly good initial results. The mean follow-up was 34.8±29 months. Two late ruptures occurred in patients who were lost to follow-up. In all, 12 type I (10 early, 2 late) and 1 late type III endoleaks were encountered in the observation period. CONCLUSION: Based on our findings, endovascular treatment of aneurysms of the descending aorta is relatively safe. To reduce the risk of postoperative complications, optimal preoperative imaging is mandatory. Postoperative regular imaging controls are indicated for early detection and prompt treatment of late type I or III endoleaks and to reduce the risk of late ruptures.

[Interventional radiology of the liver and bile ducts]. / Maksan ja sappiteiden toimenpideradiologia.

Procedures of the liver and bile ducts performed under imaging guidance are directed to hepatic blood vessels, bile ducts or alterations of the liver parenchyma. Most of them are associated with the treatment of malignant tumors or complications caused by them. Embolization can be applied to treat tumors and hemorrhages caused by traumas or tumors. Vascular procedures are also applied to the treatment of portal hypertension as well as occlusions of the hepatic and portal veins. Tissue specimens of the liver and its focal changes, effusions associated with bile ducts, and intrahepatic abscesses are most commonly also channeled under imaging guidance.

Risk prediction in patients undergoing elective endovascular repair of an abdominal aortic aneurysm.

OBJECTIVES: The aim of this study was to retrospectively evaluate three risk scoring methods in predicting outcome after elective endovascular repair of an abdominal aortic aneurysm. DESIGN: A Zenith stent graft was employed in 205 patients during years 2001-2005. RESULTS: The 30-day postoperative mortality rate was 2.9%. Receiver operating characteristics (ROC) curve analysis showed that the Glasgow aneurysm score (GAS) (AUC: 0.843, p=0.004) and the Giles' score (AUC 0.815, p=0.009) had a rather large area under the curve in predicting 30-day mortality rate. The modified Leiden score was much less accurate (AUC: 0.594). The best cut-off value for the GAS in predicting 30-day mortality was 90 (0.6% vs. 17.9%, p<0.0001). Patients with a GAS > or = 90 had a 4-year survival rate of 56.8%, whereas it was 78.5% among those with a lower GAS (p = 0.001). The best cut-off value for the Giles' score was 11 (1.3% vs. 8.3%, p<0.0001). Patients with a Giles' score > or = 11 had a 4-year survival rate of 63.9%, whereas it was 79.0% among those with a lower score (p = 0.016). CONCLUSIONS: The GAS and Giles' risk scoring methods are good predictors of poor immediate and late outcome after EVAR.

Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.

The purpose of this study was to report our experience in treating type II endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. Two hundred eighteen patients underwent EVAR with a Zenith stent-graft from January 2000 to December 2005. During a follow-up period of 4.5 + or - 2.3 years, solely type II endoleak was detected in 47 patients (22%), and 14 of them underwent secondary interventions to correct this condition. Ten patients had transarterial embolization, and four patients had translumbar/transabdominal embolization. The embolization materials used were coils, thrombin, gelatin, Onyx (ethylene-vinyl alcohol copolymer), and glue. Disappearance of the endoleak without enlargement of the aneurysm sac after the first secondary intervention was achieved in only five of these patients (5/13). One patient without surveillance imaging was excluded from analyses of clinical success. After additional interventions in four patients and the spontaneous disappearance of type II endoleak in two patients, overall clinical success was achieved in eight patients (8/12). One patient did not have surveillance imaging after the second secondary intervention. Clinical success after the first secondary intervention was achieved in two patients (2/9) in the transarterial embolization group and three patients (3/4) in the translumbar embolization group. The results of secondary interventions for type II endoleak are unsatisfactory. Although the small number of patients included in this study prevents reliable comparisons between groups, the results seem to favor direct translumbar embolization in comparison to transarterial embolization.

[Emergency problems in vascular surgery]. / Päivystysongelmat verisuonikirurgiassa.

The most typical emergency patient of vascular surgery is suffering from urgent lower limb ischemia, potentially threatening the viability of the limb. Life-threatening conditions requiring immediate treatment include rupture of the abdominal aorta as well as septicemia associated with necrosis of a neuropathic-ischemic leg of the diabetic patient. Stenosis of the carotid artery requires an emergency operation, if in spite of antithrombotic medication the patient exhibits persistent transient symptoms of paresis or attacks of blindness. Vascular injury should be suspected and a vascular surgeon consulted in limb injuries, if the pulse cannot be conclusively felt distally.

Finnish multicenter study on the midterm results of use of the Zenith stent-graft in the treatment of an abdominal aortic aneurysm.

PURPOSE: To assess the midterm results of endovascular repair of abdominal aneurysm (AAA) with a Zenith stent-graft. MATERIALS AND METHODS: Between January 2001 and December 2005, a Zenith stent-graft was employed for endovascular repair of an infrarenal AAA in 206 patients. The mean patient age (+/-standard deviation) was 73.2 years +/- 7.3. Bifurcated grafts were used in 196 patients (96.1%), aortouni-iliac grafts were used in seven patients (3.4%), and a tubular graft was used in one patient (0.5%). The mean follow-up period was 2.4 years +/- 1.7. RESULTS: The 30-day mortality rate was 2.9%. The overall survival rates at 1-, 3-, and 5-year follow-up were 93.3%, 78.7%, and 64.5%, respectively. None of the patients died of AAA rupture. The primary and assisted technical success rates 1 week after endovascular aneurysm repair were 82.0% and 90.3%. The primary clinical success rates at the 1-, 3-, and 5-year follow-up were 90.6%, 85.6%, and 83.5%. Twenty-seven patients (13.1%) underwent a secondary intervention during the study period. CONCLUSIONS: An 83% rate of freedom from repeat vascular intervention over a period of 5 years as well as an absence of structural failures or aneurysm ruptures demonstrates that a Zenith stent-graft is associated with good midterm results.

Outcome of symptomatic, unruptured abdominal aortic aneurysms after endovascular repair with the Zenith stent-graft system.

OBJECTIVE: Symptomatic abdominal aortic aneurysms (AAA) account for up to 20% of patients with unruptured AAA undergoing open repair. This condition is associated with an average postoperative mortality rate after open repair of about 16%. The aim of this study was to evaluate the outcome of a consecutive series of patients who underwent endovascular repair for symptomatic, unruptured AAA. MATERIAL AND METHODS: From January 2000 to October 2006, 14 patients underwent endovascular repair of intact AAA within 15 days since admission for AAA-related symptoms. In these patients, a Zenith stent-graft (Cook Incorporated, Bloomington, IN, USA) was deployed at the Oulu University Hospital, Kuopio University Hospital and Helsinki University Hospital, Finland. RESULTS: Stent-grafting was not successful in one patient because of access failure. The procedure was immediately converted to open repair and an aortobifemoral bypass with a Dacron prosthesis was performed. In the remaining 13 patients, bifurcated Zenith stent-grafts were deployed. After the procedure, type II endoleak was observed in three patients. The mean follow-up time was 1.9+/-1.4 years. The 2-year survival rate was 69%. The survival freedom from secondary procedure was 71% as one patient underwent stent-grafting for a distal type I endoleak 5 months after the procedure. Another patient underwent femoro-femoral cross-over bypass surgery because of right limb graft thrombosis which occurred 9 months after the procedure. CONCLUSIONS: These preliminary results suggest that endovascular repair of symptomatic, unruptured AAA is feasible and can be associated with a favourable outcome despite a very high operative risk.

Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis.

BACKGROUND: In patients with chronic pancreatitis, an actively bleeding pseudoaneurysm can be life-threatening. Angioembolization is an attractive alternative to often complex operative management, and its feasibility was assessed in a retrospective analysis. METHODS: During 1993-2005, 33 patients (27 males, median age 51 years) with bleeding pancreatic pseudoaneurysms underwent urgent angiographic evaluation followed by angioembolization if possible. Angioembolization was performed in 23 patients, whereas 10 patients required hemostatic surgery, including 6 distal pancreatectomies and 3 vessel ligations. RESULTS: Between 1993 and 2005 33 out of 745 patients (4.4%) admitted for chronic pancreatitis had bleeding pancreatic pseudoaneurysms. The proportion of bleeders out of the total number of hospital admissions for chronic pancreatitis was 33 out of 1,892 (1.7%). The overall success rate of angioembolization was 22 out of 33 (67%) including 3 patients requiring re-embolization for recurrent bleeding. The success rate was 16 out of 20 (80%) when the pseudocyst was in the head of the pancreas, and only 50% when the splenic artery was the source of bleeding. Four of the 5 cases with free bleeding into the peritoneal cavity required operative intervention. The overall mortality and morbidity rates were 2 out of 33 (6%) and 7 out of 33 (21%) respectively, with no significant differences between embolized and operated patients. Angioembolization was associated with a significantly lower need for total blood transfusions and length of hospital stay. During the years 2000-2005, the overall success rate of angioembolization was 95%. CONCLUSIONS: All hemodynamically stable patients with chronic pancreatitis and bleeding pseudoaneurysms should undergo prompt initial angiographic evaluation and embolization if possible. Repeated angioembolization is feasible in patients with recurrent bleeding, whether initially embolized or operated. Patients with unsuccessful embolization should undergo emergency hemostatic surgery with ligation of the bleeding vessel in the head of the pancreas and distal resection in patients bleeding from the splenic artery or its branch. The combination of angioembolization and later endoscopic drainage of the pseudocyst via endoscopic retrograde cholangiopancreatography (ERCP) is effective in the majority of the cases of pseudoaneurysms in chronic pancreatitis.

Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.

OBJECTIVE: The aim of this study was to assess the outcome of infrapopliteal bypass when an adjuvant arteriovenous (AV) fistula was reconstructed as means of rescue as a result of poor runoff. The design was a retrospective multicenter case-control study. METHODS: Seventy-seven infrapopliteal vein bypasses required an adjuvant AV fistula among 1813 patients operated on for critical leg ischemia in 3 vascular centers between 1996 and 2003. The mean age was 74 years (range, 39-90 years). A total of 70% of the patients had diabetes, and 24% had undergone previous vascular surgery. In 25% of the bypasses, the distal anastomosis was in a crural artery, in 55% it was in the dorsal pedal artery, and in 20% it was in a plantar artery. An adjuvant AV fistula was reconstructed in all cases because of poor intraoperative arterial status, intraoperative angiography, or low intraoperative flow. A control group was retrieved that matched the study group according to the recipient artery and runoff score. RESULTS: The primary and secondary patency were 61% and 75%, respectively, at 1 year in the AV fistula group and 57% and 71% in the control group. The 3-year patency rates were 49% and 62% for the AV fistula group and 46% and 71% for the control group, respectively. There was a 76% leg-salvage rate at 3 years in the study group, compared with 87% in the control group. There were no major complications related to the AV fistula. Intraoperative flow was increased from a median of 20 mL/min to 115 mL/min by the AV fistula (P = .003). The graft flow was significantly higher in the AV fistula group than in the control group (P = .001). CONCLUSIONS: The adjuvant AV fistula increased graft flow significantly in a poor-outflow venous bypass. In this extreme patient group, acceptable patency and leg salvage was achieved without adverse effects. Despite this, the AV fistula did not improve the outcome.

Infrainguinal endovascular and bypass surgery for critical leg ischemia in patients on long-term dialysis.

Lower limb revascularization has been shown to be worthwhile for treatment of critical leg ischemia in uremic patients, but poor results are expected in patients on long-term dialysis. We have retrospectively evaluated the results of a series of 21 consecutive patients on long-term dialysis who underwent 20 infrainguinal bypass graft and 5 endovascular procedures for critical leg ischemia to identify factors contraindicating any infrainguinal revascularization attempt in this patient population. At 2-year follow-up, the patency rate was 74%, leg salvage rate was 85%, and survival rate was 23%, whereas 23% of patients were alive with salvaged leg. Patients on hemodialysis achieved better survival outcome than patients on peritoneal dialysis (p = 0.02). Multivariate analysis showed that low serum level of albumin (p = 0.009; p = 0.005) and coronary artery disease (p = 0.0002; p = 0.001) had an adverse effect on the survival rate and on the rate of patients alive with salvaged leg, respectively. Patients without coronary artery disease achieved an alive-with-salvaged-leg rate at 1- and 2-year follow-up of 68% and 41%, respectively, whereas 12% of patients with coronary artery disease survived with salvaged leg after 1 year, but none of them survived with salvaged leg at 2-year follow-up (p = 0.003). In conclusion, infrainguinal revascularization for lower extremity ischemia in dialysis patients is hardly indicated in the presence of coronary artery disease and severe hypoalbuminemia.