EndoAnchors Minimize Endoleaks in Chimney-Graft Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysms.

Juxtarenal abdominal aortic aneurysms (AAAs) are difficult to treat because they often have little or no proximal aortic neck. Patients with this complex anatomy are not usually candidates for an endovascular aneurysm repair (EVAR). Chimney-graft EVAR has been introduced, but type Ia endoleak is a typical risk. We have begun using EndoAnchors to determine whether this risk can be reduced. From July 2013 through July 2014, we used the chimney-graft EVAR technique in 5 patients whose juxtarenal AAAs had a short or no proximal aortic neck. During the procedure, we implanted EndoAnchors as needed. Postprocedurally, at 30 days, and through end of follow-up (duration, 11-18 mo), all patients had patent endografts without type Ia endoleak (our primary endpoint), visceral stent-graft thrombosis, or renal complications. One patient who received 4 chimney grafts had a postprocedural type II endoleak, which was treated with embolization. We found it feasible to use EndoAnchors with the chimney-graft technique to prevent type Ia endoleaks in the treatment of juxtarenal AAAs. Further studies are needed to validate this adjunctive technique and to determine its durability.

Preliminary results of adjunctive use of endoanchors in the treatment of short neck and pararenal abdominal aortic aneurysms.

OBJECTIVES: To present our initial experience with the use of EndoAnchors for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with little to no infrarenal landing zone. BACKGROUND: EndoAnchors have been reported to assist in the prevention and treatment of type 1a endoleaks in patients with hostile aortic necks who undergo EVAR. METHODS: Between July 2013 and July 2014, nine patients with AAAs and short proximal aortic necks (i.e., 0-10 mm in length) underwent EVAR. In five patients, utilization of the chimney graft technique was necessary. A mean of 2.5 (range 1-4) visceral vessels underwent chimney graft. The prophylactic use of EndoAnchors was utilized in all 9 patients. The decision to use the EndoAnchors was made in the preoperative planning phase. RESULTS: Technical success was achieved in 100% of cases. In two cases, type 1a endoleaks were noted before the deployment of any EndoAnchors. In both cases, a final angiogram depicted resolution of the type 1a endoleak after insertion of the EndoAnchors. Mean follow-up time was 8 months. At 30 days, 3 months, and 6 months, 100% of the endografts remained patent and free from type 1a endoleaks. No adverse renal complications or mortality was reported. CONCLUSIONS: EndoAnchors are an applicable adjunct to EVAR as treatment for short infrarenal neck and pararenal AAAs. Further investigations are needed to determine the durability of this novel application.

Innovative chimney-graft technique for endovascular repair of a pararenal abdominal aortic aneurysm.

After abdominal aortic aneurysm repair, progressive degeneration of the aneurysm can be challenging to treat. Multiple comorbidities and previous operations place such patients at high risk for repeat surgery. Endovascular repair is a possible alternative; however, challenging anatomy can push the limits of available technology. We describe the case of a 71-year-old man who presented with a 5.3-cm pararenal aneurysm 4 years after undergoing open abdominal aortic aneurysm repair. To avoid reoperation, we excluded the aneurysm by endovascular means, using visceral-artery stenting, a chimney-graft technique. Low-profile balloons on a monorail system enabled the rapid exchange of coronary wires via a buddy-wire technique. This novel approach facilitated stenting and simultaneous angioplasty of multiple visceral vessels and the abdominal aorta.

Most Coarctations, Recoarctations, and Coarctation-Related Aneurysms Should Be Treated Endovascularly.

For patients with coarctation of the aorta (CoA), surgical intervention results in an overall survival rate nearly twice that of medical management. Therefore, surgical correction of CoA has traditionally been warranted in the majority of patients, even though open repair entails its own complications. With the advent of endovascular technology, many interventionalists hoped that this approach would decrease the complications associated with open surgical repair of CoA. Nevertheless, there is still an ongoing debate about the merits of traditional open surgery versus endovascular therapy. In this review, we discuss the role of these two approaches for the management of CoA, recoarctation, and coarctation-related aneurysms.

The impact of preoperative statin therapy on open and endovascular abdominal aortic aneurysm repair outcomes.

OBJECTIVES: This study evaluated the utilization of preoperative statins and their impact on perioperative outcomes in patients undergoing open or endovascular aortic repair. METHODS: Patients ≥50 years of age with non-ruptured abdominal aortic aneurysm repair were identified in MedPAR files 2007-2008 utilizing ICD-9-CM codes. Preoperative statins use was identified using National Drug Codes in Part D. Chi-square test, multivariable logistic regression, Kaplan-Meier and Cox regression modeling were performed. RESULTS: In all, 19,323 patients were identified undergoing abdominal aortic aneurysm repair (14,602 endovascular aortic repair and 4721 open aortic repair); 9913 (50.3%) used statins before surgery. Bivariate analysis demonstrated lower rates of hospital, 30-, 90-day and 1-year mortality in patients with statins compared to those without statins after endovascular aortic repair (1.0% vs. 1.45%, p = 0.01; 1.51% vs. 2.3%, p = 0.0004; 3.05% vs. 4.66%, p < 0.0001; 7.91% vs. 11.56%, p < 0.0001, respectively). Multivariable logistic regression adjusting for age, gender, race, comorbidities and procedure demonstrated preoperative statins use was associated with a mortality reduction at 90-days postoperatively (odds ratio = 0.80; 95% CI 0.70-0.91, p = 0.0014) and 1-year postoperatively (odds ratio = 0.76; 95% CI 0.69-0.84, p = 0.0001). CONCLUSIONS: Only half of the patients undergoing abdominal aortic aneurysm repair were prescribed preoperative statins. After adjustment, statins were significantly associated with improved survival during 1 year after surgery and a decreased incidence of lower extremity embolic complications after endovascular aortic repair. These data support a beneficial role of statin use prior to surgery for patients undergoing abdominal aortic aneurysm repair. Further prospective studies are needed to assess the benefit of statins in the perioperative period after 365 days.

Clopidogrel and 1-year freedom from amputation after endovascular lower extremity revascularization in the Medicare population.

OBJECTIVE: To evaluate freedom from amputation in patients identified utilizing clopidogrel following their lower extremity endovascular revascularization (LER). METHODS: Patients, 65 years of age and older, undergoing LER were identified from Medicare Provider Analysis and Review and Carrier files utilizing International Classification of Diseases diagnosis and Current Procedural Terminology codes. Postprocedural use of clopidogrel was identified using the National Drug Code directory. Outcomes were evaluated. RESULTS: A total of 14 353 patients were identified: 5697 (39.7%) with claudication, 1467 (10.2%) with rest pain, and 7189 (50.1%) with ulceration/tissue loss. In all, 5416 (37.7%) patients were identified using clopidogrel after LER. Overall, patients initiated on clopidogrel had lower amputation rates at 30 days (10.34% vs 14.09%; P < .0001), 90 days (14.05% vs 18.71%; P < .0001), and 1 year (19.68% vs 24.06%; P < .0001). CONCLUSION: Utilization of clopidogrel after LER was associated with lower rates of amputation, yet only 38% of the Medicare population was identified as using clopidogrel. Patients with ulceration and tissue loss benefited the most with significantly greater freedom from amputation and overall survival.

Evaluation of readmission rates for carotid endarterectomy versus carotid artery stenting in the US Medicare population.

OBJECTIVE: We evaluated rates and identified predictors of readmission in the Medicare population after carotid endarterectomy (CEA) compared to carotid artery stenting (CAS). METHODS: MedPAR data (2005-2009) were used to select patients who underwent CEA or CAS (utilizing International Classification of Diseases, Ninth Revision, Clinical Modification codes). Readmission was evaluated using chi-square and multivariable logistic regression. RESULTS: A total of 235 247 carotid interventions were performed (211 118 CEA and 24 129 CAS). Readmission rates (%) for patients undergoing CEA and CAS, respectively, were 8.84 and 11.11 (30 days; P < .0001); 13.31 and 17.98 (60 days; P < .0001); and 16.86 and 22.68 (90 days; P < .0001). Patients aged >80 (odds ratio [OR] = 1.25; 95% confidence interval [CI] = 1.20-1.30) and patients with renal failure (OR = 1.6 95%; CI = 1.56-1.73), congestive heart failure (OR = 1.6; 95%CI = 1.57-1.73), diabetes (OR = 1.4; 95% CI 1.27-1.52), and CAS (OR = 1.2; 95%CI = 1.15-1.25) were more likely to be readmitted. CONCLUSIONS: Interventions for carotid artery disease had high overall readmission rates. After adjustment for comorbidities, utilization of less invasive techniques (CAS) did not result in lower readmission rates. Further evaluation is needed to determine strategies to reduce hospital readmission rates after carotid interventions.

Preoperative statins and limb salvage after lower extremity revascularization in the Medicare population.

BACKGROUND: Statins stabilize atherosclerotic plaque, decrease mortality after surgical procedures, and are linked to anti-inflammatory effects. The objective of this study was to evaluate preoperative administration of statins and longitudinal limb salvage after lower extremity endovascular revascularization and lower extremity open surgery. METHODS AND RESULTS: Patients were selected from 2007 to 2008 Medicare claims using the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes for claudication (N=8128), rest pain (N=3056), and ulceration/gangrene (N=11,770) and Current Procedural Terminology codes for endovascular revascularization (N=14,353) and open surgery (N=8601). Half (N=11,687) were identified as statin users before revascularization using Part D files. Amputations were identified using Current Procedural Terminology codes. Statin users compared with nonusers had lower amputation rates at 30 days (11.5% versus 14.4%; P<0.0001), 90 days (15.5% versus 19.3%; P<0.0001), and 1 year (20.9% versus 25.6%; P<0.0001). Survival analysis demonstrated improved limb salvage during 1 year for statin users compared with nonusers for the diagnosis of claudication (P=0.003), a similar trend for rest pain (P=0.061), and no improvement for ulceration/gangrene (P=0.65). CONCLUSIONS: Preoperative statins were associated with improved 1-year limb salvage after lower extremity revascularization. The strongest association was found for patients with the diagnosis of claudication. Statins seem to be underused among Medicare patients with peripheral artery disease. Further evaluation of the use of preoperative statins and the potential benefits for peripheral vascular interventions is warranted.

Longitudinal outcomes after tibioperoneal angioplasty alone compared to tibial stenting and atherectomy for critical limb ischemia.

OBJECTIVES: There are limited data available evaluating longitudinal outcomes after tibioperoneal angioplasty (TA) alone compared to adjunctive tibial procedures including stenting and atherectomy. METHODS: Using the Centers for Medicare & Medicaid Services inpatient claims (2005-2007), patients evaluated TA only, TA plus stent placement (TA + S), and TA plus atherectomy (TA + A). RESULTS: A total of 2080 patients with critical limb ischemia underwent percutaneous tibioperoneal intervention for the indication of ulceration. Procedures included TA (56.3%), TA + S (16.2%), and TA + A (27.5%). Rates of amputation were not statistically different between the groups at 30, 90, and 365 days after the intervention. Mean total hospital charges were TA ($35,867), TA + A ($41,698; P = .0004), and TA + S ($51,040; P < .0001). CONCLUSIONS: Patients undergoing TA alone compared to concomitant stenting or atherectomy for ulceration demonstrated no improvement in limb salvage. Future analysis of adjunctive tibioperoneal interventions is essential to temper cost, as they fail to improve long-term limb salvage.

Standardized laparoscopic simulation positively affects a student's surgical experience.

OBJECTIVE: The aim of the study was to determine whether a standardized orientation to basic laparoscopy makes a positive effect on the experience of third-year medical students. STUDY DESIGN: Fifty-three third-year medical students at the University of Missouri, Columbia were randomly divided into 2 groups during their clerkship orientation. Both groups received a 40-minute laparoscopic hands-on training simulation guided by instructors. However, only 1 group was given a 20-minute multimedia presentation on introduction to laparoscopy that covered equipment, set up, troubleshooting, and different methods of access into the abdomen. Both groups were given a preclerkship and postclerkship survey where students were asked to rate their experience, comfort, and interest in surgery on a 10-point Likert scale. RESULTS: Hundred percent of the students receiving the combined hands-on training simulation and the 20-minute presentation felt that the experience helped during their clerkship (p = 0.002) and 92% felt it had a positive effect (p = 0.501). In contrast, only 72% of the group that received the hands-on training simulation alone found it helpful (p = 0.029) and 86% thought it had a positive effect (p = 0.508). There was no statistical difference between either group with regard to their perceived comfort with assistance in the operating room and with laparoscopy. Neither experience had a statistical effect on a students' interest in surgery as a career. CONCLUSIONS: Our results demonstrate how a standardized orientation to basic laparoscopy can make a positive effect on a student's experience; however, it fails to transition into a student's interest in surgery as a profession or in their perceived comfort level in the operating room. Our study suggests that a student's surgical interest is highly variable and composed of multiple experiences that occur during their clerkship that ultimately affects their perception of surgery as a field and profession.

Endovascular versus open repair of popliteal artery aneurysms: outcomes in the US Medicare population.

OBJECTIVE: The management of popliteal artery aneurysms (PAAs) has undergone significant transition from open surgery to endovascular graft placement with few longitudinal data evaluating outcomes. METHODS: The Centers of Medicare & Medicaid Services Inpatient claims (2005-2007) were queried with a diagnosis of lower extremity artery aneurysm in association with elective Current Procedural Terminology codes for open (OPEN group) and endovascular (ENDO group) repair. RESULTS: A total of 2962 patients were identified. Endovascular interventions significantly increased over the time of the study (11.7% vs 23.6%, P < .0001). Overall complication rates for OPEN and ENDO groups did not differ significantly (11.3% vs 9.3%; P = .017). No differences in the 30- and 90-day mortality rates were found between OPEN versus ENDO groups. The ENDO group had greater 30- and 90-day reinterventions (4.6% vs 2.1%, P = .001 and 11.8% vs 7.4%, P = .0007, respectively). Length of stay (4.5 days vs 2.5 days, P < .0001) and charges ($43 180 vs $35 540, P < .0001) were greater for OPEN group. CONCLUSION: Despite a significant increase in the utilization of endovascular repair of PAAs, endovascular repair was associated with greater reinterventions over time and did not offer a mortality or cost benefit.

Matrix metalloproteinases and small artery remodeling.

Inward eutrophic remodeling is a common structural change found in small resistance arteries that has been associated with an increased risk for life threatening cardiovascular events, the number one cause of death in industrialized societies. Because inward eutrophic remodeling is the most prevalent small artery structural change found in hypertension, hypertensive animals are the most common in vivo models used to study this particular remodeling process. In vitro, the isolated artery, pressure myograph has also been used as a model to study the mechanisms responsible for the development of small artery remodeling. Compelling recent evidence indicates that the matrix metalloproteinases (MMPs), a family of endopeptidases whose primary function is the cleavage and degradation of extracellular matrix components, are involved in vasoconstriction and the pathogenesis of hypertension. In this review we provide an overview of the known and potential roles that MMPs have on vascular remodeling, paying particular attention to their role on the inward eutrophic remodeling process of small resistance arteries that occurs in hypertension.

Thoracic mural thrombi: a case series and literature review.

Thoracic mural thrombi (TMT) are rare but an important source of distal emboli. Treatment options are dynamic, ranging from open, endovascular to conservative therapies. We report two cases of TMT, one successfully treated with thoracic aortic endoluminal stent placement for visceral and peripheral embolization, the second treated conservatively for digital embolization secondary to TMT in the innominate artery.

Horseshoe kidney and inflammatory abdominal aortic aneurysm: a case report and literature review.

The combined presence of an inflammatory abdominal aortic aneurysm and a horseshoe kidney is a rare event with only one reported case in previously published data. We present a case of a horseshoe kidney with a concomitant 6-cm inflammatory abdominal aortic aneurysm and a 3.6-cm right iliac artery aneurysm repaired through a transperitoneal approach with aortoiliac reconstruction.