Pre-existing Systolic Dysfunction is the Most Powerful Predictor of Failed Arteriovenous Fistula Maturation.

BACKGROUND: Patients requiring hemodialysis access creation often have significant comorbid conditions, which may impact access maturation. Underlying cardiac dysfunction likely plays an important role in the maturation of arteriovenous fistulae (AVF). The effect of specific parameters of cardiac function on successful AVF creation has not previously been explored. METHODS: A retrospective chart analysis of patients undergoing first-time AVF creation at a single center from 2011 to 2018 was performed. Patients with a transthoracic echocardiogram within the 12 months prior to surgery were included. Standard demographic and perioperative variables were collected, in addition to echocardiographic and vascular mapping data. The primary outcome was access maturation, defined as the use of the access site for hemodialysis at 3, 6, and 12 months after surgery. RESULTS: A total of 121 patients met inclusion criteria with a cumulative AVF maturation rate of 57% (69/121) in this select population. Patients with pre-existing systolic cardiac dysfunction were more than 5 times less likely to see their AVF mature by one year postsurgery (OR = 0.17, P = 0.018). Preoperative venous diameter, access site location, and the type of fistula did not differ significantly between patients with and without systolic dysfunction. Selection of the cephalic vein as the venous anastomosis and diastolic dysfunction (≥ Grade 2) were also associated with lower rates of access maturation, although these associations were less robust. CONCLUSIONS: Systolic cardiac dysfunction is the most important nonmodifiable variable associated with failed AVF maturation. Patients requiring hemodialysis with significant pre-existing cardiac dysfunction may not be appropriate for permanent access creation, and long-term catheter use should be seriously considered as an alternative.

Rationale and design of a smartphone-enabled, home-based exercise program in patients with symptomatic peripheral arterial disease: The smart step randomized trial.

BACKGROUND: Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first-line therapy, although patient adoption remains low. Home-based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low-resource settings, remains unknown. METHODS: Smart Step is a pilot randomized trial of smartphone-enabled HBET vs walking advice in patients with symptomatic PAD in an inner-city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone-based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6-minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year. RESULTS: A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants. CONCLUSIONS: The potential significance of this trial will be to provide preliminary evidence of a home-based, "mobile-first" approach for delivering a structured exercise rehabilitation program. Smartphone-enabled HBET can be potentially more accessible than center-based programs, and if proven effective, may have a potential widespread public health benefit.

Surgical Intervention for Peripheral Artery Disease Does Not Improve Patient Compliance with Recommended Medical Therapy.

BACKGROUND: Nonadherence to smoking abstinence, antiplatelet therapy, and statin therapy in patients with peripheral artery disease (PAD) is associated with worse long-term outcomes. We hypothesized that patients who underwent invasive revascularization procedures would be more likely to adhere to these therapies than patients who were managed medically. METHODS: Prospective survey-based interviews pertaining to medication and behavioral compliance of patients with symptomatic PAD were performed. Specifically, adherence to smoking cessation, antiplatelet therapy, and antilipid therapy was evaluated. A retrospective review of the electronic medical record was then performed to obtain procedural data and divide patients into medically managed or surgically managed (open revascularization, percutaneous revascularization, amputation) cohorts. RESULTS: One hundred patients met criteria for inclusion and took part in the study. Overall, 62% were nonsmokers, and 59.1% of those with a history of smoking had quit; 66.7% were adherent to statin therapy; and 72.7% were adherent to antiplatelet therapy. Among patients treated with or without surgery, respectively, there was no difference in regards to rates of smoking abstinence (64.8% vs. 55.2%, P = 0.37), successful smoking cessation (61.5% vs. 53.6%, P = 0.51), antiplatelet adherence (73.9% vs. 74.1%, P = 0.99), or statin adherence (65.2% vs. 70.4%, P = 0.24). Major amputation was also not associated with adherence to these therapies. CONCLUSIONS: Surgical revascularization does not influence the likelihood of adherence to smoking abstinence, smoking cessation, antiplatelet therapy, or statin therapy in patients with symptomatic PAD. Patients should be counseled regarding revascularization options with the understanding that their likelihood of medical treatment compliance will be unaffected by any proposed intervention.

Hemodialysis Vascular Access: Rising Costs as a Surrogate Marker for Patency and Function of Arteriovenous Fistulas.

BACKGROUND: Establishment and maintenance of vascular access for hemodialysis is life-sustaining for patients needing renal-replacement therapy. Arteriovenous fistulas (AVFs) are the preferred type of access, but the costs associated with creation and maintenance are poorly characterized, especially with respect to patient characteristics. METHODS: A prospectively maintained registry has been established at The Mount Sinai Hospital for patients undergoing access procedures since 2007. We studied 163 patients undergoing successfully placed and cannulated AVFs as their first permanent ipsilateral access and for whom 3-year follow-up was available, including 18 patients with failed contralateral AVFs. Records were analyzed for institutional inpatient and outpatient procedures related to access maturation, imaging, catheter-related procedures, and revisions. We determined hospital costs for 3 AVF locations, assessing the contribution of various factors to variation in costs and patency. RESULTS: The median first-year cost of patent AVFs was $8,662, with $4,754 attributable to initial creation. For fistulas remaining patent for at least 3 years, median cumulative 36-month costs were $11,639, with $1,343 attributable to imaging and $10,478 to creation and interventions. Fistulas with patent lifetimes of 19-30 months (3.7%) had median cumulative costs of $26,035. Those with patent lifetimes of 6 months or shorter (6.7%) had median cumulative costs of $17,526. Right-sided fistulas were associated with 41% higher 1-year costs and 38% higher 3-year costs when compared with left-sided fistulas. Human Immunodeficiency Virus (HIV) status and prior history of complex contralateral access were also associated with higher 1-year and 3-year costs. CONCLUSIONS: Hemodialysis access maintenance contributes significantly to the healthcare burden of renal disease. Our data suggest that particular patient characteristics factor into patency and costs. Short-term mounting costs associated with AVF maintenance may portend poor long-term patency. Rising healthcare costs cannot be easily controlled without understanding the clinical factors driving them.

Inflow stenosis as a contributing factor in the etiology of AV access-induced ischemic steal.

OBJECTIVE: To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS). METHODS: A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, preoperative angiographic imaging and interventions performed were analyzed. RESULTS: A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography (14) and computed tomography angiography (3). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation (3), ligation (1) and angioplasty/stenting (1). CONCLUSION: In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete preoperative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.

Peripheral arterial disease in women.

Peripheral arterial disease (PAD) affects a significant portion of the United States population, and much research has been conducted on identifying populations at risk for PAD, evaluating appropriate diagnostic modalities for PAD, studying the effect of risk factor reduction on PAD progression, and determining the best method of treatment for symptomatic PAD. However, most PAD research and clinical trials have focused on whole populations, or populations consisting mostly of men. Little data exist with respect to PAD in women. The goal of this review is to highlight what is known about gender-related differences for PAD.

Chronic kidney disease and dialysis access in women.

Chronic kidney disease currently affects one in nine Americans and over 500,000 have progressed to failure requiring kidney replacement therapy, with nearly 45% being women. Clinical Practice Guidelines have been developed in an effort to synthesize the latest literature, particularly randomized controlled trials, to assist clinical decision making. Women have different levels of kidney function than men at the same level of serum creatinine and may also lose kidney function over time more slowly than men. Although the arteriovenous fistulae have long been recognized as the preferred access for hemodialysis, women are less likely to initiate dialysis with an arteriovenous fistula in place. In addition, the female sex is regarded as a risk factor for access failure as well for complications such as steal. This article reviews treatment of women with chronic kidney disease, focusing on the difficulties they are perceived to have with dialysis access.

Experience of HeRO dialysis graft placement in a challenging population.

OBJECTIVE: To assess the outcomes of the hemodialysis reliable outflow (HeRO) device in a subset of hemodialysis access-challenged patients with central venous obstruction. METHODS: Retrospective analysis of a series of patients in 2 centers who underwent placement of the HeRO device between September 2009 and November 2010. Patients' demographics, access history, HeRO patency, and number of reinterventions were analyzed. RESULTS: Eleven patients underwent 12 HeRO implantations. The average duration of dialysis prior to HeRO placement was 5.55 ± 3.64 years. Primary and secondary patencies at 6 months and 1 year were 36.4% and 54.5% and 9.1% and 45.5%, respectively. CONCLUSIONS: In the end-stage renal disease population with central venous occlusive disease, the HeRO device offers the best long-term dialysis option when an arteriovenous fistula or graft is not possible. Close follow-up and subsequent aggressive interventions can prolong the use of the HeRO and avoid the last resort of dialysis catheters.

Carotid artery pseudo-occlusion: does end-diastolic velocity suggest need for treatment?

OBJECTIVE: We reviewed our institution's experience with carotid artery pseudo-occlusion (CAPO), to investigate whether internal carotid artery (ICA) end-diastolic velocity (EDV) as measured by duplex ultrasonography, was a predictor of need for further intervention. METHODS: From February 2003 to January 2008, 7478 patients underwent duplex ultrasonographic evaluation of their carotid arteries. Diagnosis of CAPO included the appearance of a narrow flow jet (string sign) on power doppler images, low velocities in the ICA and additional criteria listed below. RESULTS: Ten patients (0.13%) were identified as having a CAPO. All patients were asymptomatic and had an EDV<78 cm/s. Occlusion or functional occlusion was identified in nine patients on contrast imaging studies. Eight of these patients were treated medically without neurologic complication on follow-up. Two patients were treated with interventions and were asymptomatic at follow up. The mean follow up for the entire group was 12 months. CONCLUSIONS: Although this is a low volume study, there is evidence to suggest that asymptomatic patients with low EDV in the setting of carotid artery pseudo-occlusion found of duplex, may be safely managed medically.

Endovascular stent-graft repair of failed endovascular abdominal aortic aneurysm repair.

Despite high initial technical success, the long-term durability of endovascular abdominal aortic aneurysm repair (EVAR) continues to be a concern. Following EVAR, patients can experience endoleaks, device migration, device fractures, or aneurysm growth that may require intervention. The purpose of this study was to review all patients treated with secondary endovascular devices at our institution for failed EVAR procedures. Over an 8-year period, 988 patients underwent EVAR, of whom 42 (4.3%) required secondary interventions involving placement of additional endovascular devices. Data regarding patient characteristics, aneurysm size, initial device type, time until failure, failure etiology, secondary interventions, and outcomes were reviewed. The mean time from initial operation until second operation was 34.1 months. Failures included type I endoleaks in 38 patients (90.5%), type III endoleaks in two patients (4.8%), and enlarging aneurysms without definite endoleaks in two patients (4.8%). The overall technical success rate for secondary repair was 92.9% (39/42). Perioperative complications occurred in nine patients (21.4%), including wound complications (n = 6), cerebrovascular accident (CVA) (n = 1), foot drop (n = 1), and death (n = 1). Mean follow-up following secondary repair was 16.4 months (range 1-50). Eighty-six percent of patients treated with aortouni-iliac devices had successful repairs compared to 45% of patients treated with proximal cuffs. Ten patients (23.8%) had persistent or recurrent type I or type III endoleaks following revision. Of these, four had tertiary interventions, including two patients who had additional devices placed. Failures following EVAR occur in a small but significant number of patients. When anatomically possible, endovascular revision offers a safe means of treating these failures. Aortouni-iliac devices appear to offer a more durable repair than the proximal cuff for treatment of proximal type I endoleaks. Midterm results indicate that these patients may require additional procedures but have a low rate of aneurysm-related mortality. Longer-term follow-up is necessary to determine the durability of these endovascular revisions.

Endovascular treatment of visceral artery aneurysms.

Visceral artery aneurysms, although uncommon, can present with life-threatening hemorrhage. The increasing use of imaging studies has allowed for earlier identification and intervention of these aneurysms, thus avoiding the high morbidity and mortality associated with rupture. The treatment options for visceral artery aneurysms range from conventional open surgical repair to minimally invasive techniques using covered stents or embolization materials. Anatomic features and patient selection determine which treatment option would result in the most durable treatment and outcome. This article reviews our experience with the endovascular treatment of visceral artery aneurysms.

Management of aneurysms involving branches of the celiac and superior mesenteric arteries: a comparison of surgical and endovascular therapy.

OBJECTIVE: Aneurysms involving branches of the superior mesenteric and celiac arteries are uncommon and require proper management to prevent rupture and death. This study compares surgical and endovascular treatment of these aneurysms and analyzes outcome. METHODS: Patients at the Mount Sinai Medical Center in New York who were treated for aneurysms in the branches of the celiac artery and superior mesenteric artery were identified through a search of the institution's medical records and endovascular database. Patient demographics, history, clinical presentation, aneurysm characteristics, treatments, and follow-up outcome were retrospectively recorded. Significant differences between patients treated by surgical or endovascular therapy were determined by using Student's t test and chi2 analysis. RESULTS: Between January 1, 1991, and July 1, 2005, 59 patients with 61 aneurysms were treated at a single institution. Twenty-four patients had surgical repair, and 35 underwent endovascular treatment, which included coil embolization and stent-graft therapy. Splenic (28) and hepatic (22) artery aneurysms predominated. Eighty-nine percent of splenic artery aneurysms were true aneurysms and were treated by endovascular and surgical procedures in near equal numbers (14 and 11, respectively). Pseudoaneurysms were significantly more likely to be treated by endovascular means (P < .01). The technical success rate of endovascular treatment for aneurysms was 89%, and failures were successfully treated by repeat coil embolization in all patients who presented for retreatment. Patients treated by endovascular techniques had a significantly higher incidence of malignancy than patients treated with open surgical techniques (P = .03). Furthermore, patients treated by endovascular means had a shorter in-hospital length of stay (2.4 vs 6.6 days, P < .001). CONCLUSION: Endovascular management of visceral aneurysms is an effective means of treating aneurysms involving branches of the celiac and superior mesenteric arteries and is particularly useful in patients with comorbidities, including cancer. It is associated with a decreased length of stay in the elective setting, and failure of primary treatment can often be successfully managed percutaneously.

Experience with endovascular abdominal aortic aneurysm repair in nonagenarians.

PURPOSE: To report a single-institution experience with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in nonagenarians. METHODS: A retrospective review was performed of all patients >90 years old undergoing EVAR over an 8-year period at a major academic medical center. The patient population was investigated for the presence of various comorbidities, initial aneurysm size, successful aneurysm exclusion, perioperative complications, disposition, endoleaks, secondary interventions, and overall survival. RESULTS: EVAR was performed in 18 male nonagenarians (mean age 92.4 years, range 90- 95). Mean aneurysm diameter was 7.3 cm (range 5.5-9.8). The cohort had an average of 3.2 comorbid conditions. Sixteen patients were treated electively, while 2 patients underwent emergent repair for contained rupture and bleeding aortoenteric fistula, respectively. Immediate technical success was 100%. Perioperative local/vascular complications occurred in 4 (22%) patients. Perioperative systemic complications occurred in 3 (17%) patients. There were 2 (11%) perioperative (<30 days) deaths. Three (17%) patients required secondary interventions. Mean survival in patients who expired during the follow-up period beyond the first 30 days was 34 months (range 8-78). Mean survival in 8 patients who are still alive is 17.4 months (range 9-39). CONCLUSION: Endovascular AAA repair in nonagenarians is associated with a high rate of technical success and relatively low morbidity rate. Survival times following successful hospital discharge are significant. Suitable patients over 90 years of age may benefit from an endovascular AAA repair.

Successful endovascular treatment of bleeding aortoenteric fistula: a case report.

Aortoenteric fistula (AEF) is an infrequent but disastrous complication of open abdominal aortic repair. Left untreated, it has a 100% fatality rate. The traditional approaches to the repair of secondary AEF (SAEF) are associated with average mortality rates of 21-59% and numerous major complications. Here, we report a case of acute gastrointestinal bleeding due to SAEF, successfully treated with endovascular stent graft repair. At 1-year follow-up, the patient was doing well without any signs of recurrent fistula. Endovascular treatment of AEF provides another treatment option that may be particularly valuable in patients whose comorbidities would preclude open repair.

Incidence and distribution of lower extremity deep vein thrombosis in rehabilitation patients: implications for screening.

Patients admitted to in-patient rehabilitation programs have an increased risk for developing deep venous thrombosis (DVT). However, the utility of screening for lower extremity DVT using duplex ultrasound in this high-risk population is not well characterized. The purpose of this study is to identify whether or not screening lower-extremity duplex exams are indicated in this high-risk population. Screening lower extremity duplex exams were performed on all patients admitted to the rehabilitation center at Mt. Sinai Hospital over a 3-year period. Charts were reviewed for patient age, gender, diagnosis, date of screening and follow-up duplex exams, presence and location of venous thrombosis at each duplex exam, history of anticoagulation, and medical DVT prophylaxis. The presence of DVT at screening, the location of DVT along the lower extremity, and the outcome of calf DVT were analyzed in terms of gender, underlying diagnosis, and history of DVT prophylaxis. Lower extremity DVT was detected in 34% of patients. Twenty-three percent of patients had isolated calf vein thrombosis. Men were more likely than women to have DVT. Calf DVTs progressed in 3% of patients over an average follow-up of 2 weeks. The presence of DVT, its location along the lower extremity, and the outcome of calf vein DVT had no significant relationship to underlying diagnosis or history of prophylaxis. Screening duplex exams to detect lower extremity DVT in rehabilitation patients is useful. Screening altered management in 26% of patients, prompting either anticoagulation or repeat duplex exam.

Abdominal aortic aneurysm sac shrinkage after endovascular aneurysm repair: correlation with chronic sac pressure measurement.

OBJECTIVES: Abdominal aortic aneurysm (AAA) sac shrinkage after endovascular aneurysm repair (EVAR) is considered to be evidence of clinical success. Exclusion of the sac from systemic pressure is the likely cause of shrinkage. We report our continuing clinical experience with the use of a permanently implantable, ultrasound-activated remote pressure transducer to measure intrasac pressure and its correlation with changes in sac diameter over time. METHODS: Over a 22-month period, 21 patients underwent EVAR of an infrarenal AAA with implantation of an ultrasound-activated remote pressure transducer fixed to the outside of the stent-graft and exposed to the excluded aortic sac. Intrasac pressures were measured directly with an intravascular catheter and by the remote sensor at the time of stent-graft deployment. Follow-up sac pressures were measured by remote sensor and compared with systemic arterial pressure at every follow-up visit. Mean follow-up was 11.4 +/- 5.0 months (range, 1 to 26 months). Twenty patients had follow-up of > or =6 months. Mean pressure index (MPI) was calculated as the ratio of mean sac pressure to mean systemic pressure. RESULTS: Pressures could be obtained at all visits in 15 of the 21 patients. Fourteen of these 15 patients had follow-up of at least 6 months. Aneurysm sac shrinkage of >5 mm was seen in seven (50%) of these 14 patients. No aneurysm enlargement was observed in any patient. The MPI was significantly lower in patients with sac shrinkage at 6 months and at final follow-up. CONCLUSIONS: Endovascular aneurysm repair results in marked reduction of sac pressure in most patients. Patients with aneurysm shrinkage after EVAR have significantly lower MPI; however, the absence of sac shrinkage does not imply persistent pressurization of the sac. Further clinical follow-up will delineate the role of long-term sac pressure monitoring in surveillance after EVAR.

Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage "elephant trunk" repair.

Reconstruction of aortic arch and descending thoracic aortic aneurysms (TAAs) is technically challenging and associated with significant morbidity and mortality. We report our experience with extensive TAAs using a two-stage "elephant trunk" repair, with the second stage completed using an endovascular stent graft (ESG). Over 6 years, 111 patients underwent ESG treatment of TAAs at Mount Sinai Medical Center. Twelve of these patients were referred for ESG placement for the second stage of elephant trunk reconstruction because comorbidities placed them at high risk of open surgical repair. Our database was analyzed for technical and clinical success and perioperative complications. The mean follow-up was 11.8 months (range 1-64 months). Twelve patients (five women and seven men) with a mean age of 69 +/- 10 years underwent repair of their distal aortic arch and descending TAAs. These aneurysms included nine atherosclerotic aneurysms, one pseudoaneurysm, and two penetrating atherosclerotic ulcers. Three patients were symptomatic. Stent graft repair was technically successful in 91.7% or 11 of 12 patients. Excessive aortic arch tortuosity resulted in failure to deploy a stent graft in one patient. An antegrade approach through the open elephant trunk was used in two patients with severe iliac occlusive disease. Endoleaks (type 2) were identified in two patients with no aneurysm expansion; however, a 14 mm expansion over 1 year occurred in a patient with no identifiable endoleak. One early mortality occurred in a patient with a ruptured 6 cm infrarenal AAA after successful exclusion of the 8 cm TAA. Second-stage elephant trunk reconstruction of an extensive TAA using an ESG is effective in the short term. Its long-term durability remains to be determined.

First experience in human beings with a permanently implantable intrasac pressure transducer for monitoring endovascular repair of abdominal aortic aneurysms.

OBJECTIVES: Endovascular stent graft repair of abdominal aortic aneurysms (AAAs) prevents rupture by excluding the aneurysm sac from systemic arterial pressure. Current surveillance protocols after endovascular aneurysm repair (EVAR) follow secondary markers of sac pressurization, namely, endoleak and sac enlargement. We report the first clinical experience with the use of a permanently implantable, ultrasound-activated remote pressure transducer to measure intrasac pressure after EVAR. METHODS: Over 7 months, 14 patients underwent EVAR of an infrarenal abdominal aortic aneurysm with implantation of an ultrasound-activated remote pressure transducer fixed to the outside of the stent graft and exposed to the excluded aortic sac. Twelve patients received modular bifurcated stent grafts, and 2 patients received aortouniiliac devices. Intrasac pressures were measured directly with an intravascular catheter and by the remote sensor at stent-graft deployment. Follow-up sac pressures were measured with a remote sensor and correlated with systemic arterial pressure at every follow-up visit. Mean follow-up was 2.6 +/-1.9 months. RESULTS: Excellent concordance was found between catheter-derived and transducer-derived intrasac pressssure intraoperatively. Pulsatile waveforms were seen in all functioning transducers at each evaluation interval. One implant ceased to function at 2 months of follow-up. In 1 patient a type I endoleak was diagnosed on 1-month computed tomography (CT) scans; 3 type II endoleaks were observed. Those patients with complete exclusion of the aneurysm on CT scans had a significant difference in systemic and sac systolic pressures initially (P <.001) and at 1 month (P <.001). Initial sac diastolic pressures were higher than systemic diastolic pressures (P <.001). The ratio of systemic to sac systolic pressure increased over time in those patients with complete aneurysm exclusion ( P <.001). Four of 6 patients with no endoleak and greater than 1-month follow-up had diminution of sac systolic pressure to 40 mm Hg or less by 3 months. CONCLUSION: This is the first report of a totally implantable chronic pressure transducer to monitor the results of EVAR in human beings. Aneurysm exclusion leads to gradual diminution of sac pressure over several months. Additional clinical follow-up will be necessary to determine whether aneurysm sac pressure monitoring can replace CT in the long-term surveillance of patients after EVAR.

The role of aortic stent grafting in the treatment of atheromatous embolization syndrome: results after a mean of 15 months follow-up.

BACKGROUND: Endovascular stent-graft (ESG) repair of abdominal aortic aneurysm (AAA) has emerged as an alternative to open surgery. The role of ESG in patients with challenging medical and anatomic problems remains an area of general debate. This study reviews an experience with stent grafts to treat patients with AAA and atheromatous embolization syndrome (AES) presenting with chronic distal embolization (CDE). METHODS: Over a 5-year period 660 patients with AAA were treated with aortic stent grafts. Patients with AAA and ischemic ulcerations or toe gangrene due to CDE despite palpable foot pulses were investigated for successful aneurysm exclusion, resolution of ischemic symptoms, complications and survival. Follow-up averaged 15.3 +/- 14.9 months (range, 1 to 60 months). RESULTS: Nineteen patients had AAA and manifestations of CDE. The population (16 males/3 females) had a mean age of 79 +/- 7 years and mean aneurysm diameter of 5.5 cm. Renal insufficiency was present in 5/19 (26 %). Ischemia presented as ischemic ulcers (16/19 [84.2%]) or toe gangrene (3/19 [15.8%]). Stent grafts included 6 aortouniiliac and 13 bifurcated devices. Exclusion was achieved in all but 2 patients who had type II lumbar endoleaks. At 30-day postoperative follow-up, mortality was 0 % and resolution of CDE/ischemia was noted in 2 of 19 (10.5%) patients. Eight of 9 patients with follow-up of 1 year had complete resolution of their ischemic symptoms, with no recurrent manifestations of AES. Complications included progression of renal insufficiency over an 18-month period in 1 patient and an unstable expanding pararenal aortic neck in 1 patient. Foot ischemia persisted at 1 year in a patient with severe coexisting thoracic aortic disease despite successful AAA exclusion. Six (31.6%) patients died during a mean follow-up of 15.3 months from causes unrelated to their AAA. CONCLUSION: On the basis of this experience, stent-graft repair of AAA and CDE may be an effective strategy to prevent future embolization. Recognition of coexisting thoracic aortic disease is essential. ESG does not address the extremely high morbidity and mortality from cardiovascular causes in this population.

The role of surgical revascularization in the management of diabetic foot wounds.

Diabetic foot wounds affect an estimated 15% of all patients with diabetes. These wounds are typically multifactorial in origin. Neuropathy of the foot and impaired wound healing are frequently associated with peripheral arterial occlusive disease. These factors combine to contribute to the development of foot ulcers. Successful wound healing and limb salvage require prompt recognition and treatment. Assessment of arterial perfusion is imperative and may be accomplished by a combination of physical examination and noninvasive vascular laboratory studies. When associated with significant ischemia, diabetic foot ulcers require arterial revascularization to achieve wound healing.