Reversed Gore Excluder conformable main body as a conduit between branched stent graft limb, common iliac artery, and renal artery.

Renal artery access might not always be achieved due to anatomical reasons during the deployment of a branched stent graft in thoracoabdominal or juxtarenal abdominal aortic aneurysms. Renal perfusion is maintained through the aneurysm sac until the iliac limbs are deployed. To preserve renal perfusion, a branched iliac limb would be needed. Such limbs with a side branch, a narrow (12-14 mm) proximal end, and a wide (16-20 mm) distal end are not commercially available. Due to the nature of their deployment mechanism, Gore Excluder distal limbs (W.L. Gore & Associates) have been used outside the instructions for use in reversed position. A traditional Gore Excluder main body can be reversed; however, the smallest proximal diameter is 23 mm, which could be too large to be deployed in a typically 16- to 18-mm common iliac artery. However, the smallest Gore Excluder Conformable endoprosthesis (W.L. Gore & Associates, Inc) main body is 20 mm in diameter, and the distal limb is 14.5 mm. This allows for a perfect fit when deployed in reversed position between an 11-mm unibody limb (Cook Medical Inc) and the common iliac artery, resulting in access to the renal artery from the side branch. We used a Gore Excluder Conformable main body graft in two such cases successfully. In these two patients, the iliac limbs and renal artery have stayed patent during a follow-up of 24 and 3 months. A Gore Excluder Conformable graft can be deployed in reversed position, using it as a conduit between the branched stent graft limb, common iliac artery, and renal artery.

Arm vein conduit vs prosthetic graft in infrainguinal revascularization for critical leg ischemia.

BACKGROUND: One-piece great saphenous vein (GSV) is the conduit of choice in infrainguinal revascularizations for critical limb ischemia (CLI). Unfortunately, adequate length of usable GSV is not always available. Despite inferior patency rates compared with GSV, prosthetic and arm vein conduits are generally considered usable. The purpose of this study was to compare the outcome of infrainguinal arm vein and prosthetic bypass. MATERIAL AND METHODS: We retrospectively reviewed 290 consecutive infrainguinal bypasses for CLI using arm vein conduit (n = 130) or prosthetic graft (n = 160) during January 2000 and December 2006 at our institution. The groups were compared for risk factors, indication for surgery, and runoff score. Survival, leg salvage, and patency rates were calculated with the Kaplan-Meier method. RESULTS: Median surveillance time was 35 months (range 0-118 months). The age, gender, and usual risk factors were similar in arm vein and prosthetic groups, except cerebrovascular disease that was more common in the prosthetic group (P = .011). Indication for surgery was CLI. In the arm vein group, more than two-thirds (70.2%) of the procedures were for ischemic ulcer or gangrene, whereas in the prosthetic group the main indication was ischemic rest pain (51.3%). When the outcome of femoropopliteal bypasses was analyzed, the difference between groups was not statistically significant. However, in infrapopliteal revascularizations primary patency, assisted primary patency, and secondary patency rates at 3 years were significantly better in the arm vein group: 28.3% (SE +/- 6.3%) vs 9.6% (SE +/- 8.1%) (P = .031), 56.8% (SE +/- 6.6%) vs 10.4% (SE +/- 8.7%) (P = .000), and 57.4% (SE +/- 6.6) vs 11.2% (SE +/- 9.3%) (P = .000), respectively. Leg salvage and survival at 3 years were 75.0% (SE +/- 4.9%) vs 57.1% (SE +/- 8.8%) (P = .005) and 58.8% (SE +/- 5.1%) vs 39.5% (SE +/- 7.7%) (P = .007), respectively. CONCLUSION: Arm vein conduits, even when spliced, are superior to prosthetic grafts in terms of midterm assisted primary patency, secondary patency, and leg salvage in infrapopliteal bypasses for CLI.

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.

The consequences of an outbreak of multidrug-resistant Pseudomonas aeruginosa among patients treated for critical leg ischemia.

OBJECTIVE: This retrospective matched case-control study evaluated the consequences of multidrug-resistant Pseudomonas aeruginosa (MDR Pa) in critical leg ischemia (CLI) patients treated with infrainguinal bypass surgery (IBS). METHODS: An outbreak of MDR Pa occurred on our vascular surgical ward during a 13-month period. Bacteria cultures positive for MDR Pa were obtained from 129 patients, and 64 CLI patients treated with IBS formed the study group. A control group of 64 was retrospectively matched from MDR Pa-negative patients treated with IBS in the same unit according to sex, age, presence of diabetes, Fontaine class, graft material, and site of the distal anastomosis. The most frequent sites of initial positive MDR Pa culture were the incisional wound in 30 (47%) and ischemic ulcer in 23 (36%). Median time between the positive MDR Pa-culture and IBS was 14 days (range, 56 days pre-IBS to 246 days post-IBS). Graft patency, survival, leg salvage, and amputation-free survival were assessed. RESULTS: One-year amputation-free survival (+/- standard error) was 52% +/- 6% in the MDR Pa group vs 75% +/- 5% in the control group (P = .02). Five-year amputation-free survival was 29% +/- 6% in the MDR Pa group and 32% +/- 6% in the control group (P = .144). For MDR Pa and control groups, the 1-year survival was 69% +/- 6% and 82% +/- 5% (P = .063), respectively, and 5-year survival was 36% +/- 6% and 36% +/- 6% (P = .302), respectively. For the MDR Pa and control groups, leg salvage was 79% +/- 5% and 92% +/- 4% at 1 year (P = .078) and 73% +/- 7% and 87% +/- 5% at 5 years (P = .126), respectively. The overall secondary patency rate at 1 year was 72% +/- 7% in the MDR Pa group vs 81% +/- 6% in the control group (P = .149). Local wound surgery was more frequent in MDR Pa patients than in controls (P = .002). CONCLUSIONS: The MDR Pa outbreak was associated with a decreased short-term amputation-free survival after IBS for CLI in patients with positive MDR Pa culture. The potential risks of MDR Pa should be seriously considered whenever a positive culture is obtained in a vascular patient with CLI.

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.

The influence of the characteristics of ischemic tissue lesions on ulcer healing time after infrainguinal bypass for critical leg ischemia.

OBJECTIVE: Ulcer healing is a seldom reported outcome in studies of critical leg ischemia (CLI). The aim of this study was to analyze local factors affecting ulcer healing time after infrainguinal bypass surgery (IBS) for CLI Fontaine IV. METHODS: In this prospective single center cohort study, 110 patients (113 legs) undergoing IBS due to CLI with ischemic tissue defects during year 2006 were followed prospectively for 1 year after the bypass. Ulcer location, duration, presence of gangrene, and the University of Texas wound classification (UTWCS) were determined at presentation. Healing time of the ischemic tissue defects, leg salvage, patency, and survival were calculated. The characteristics of the ischemic tissue lesions and patient comorbidities were analyzed to determine risk factors for adverse outcome. RESULTS: Complete ulcer healing (+/-SE) was achieved in 74% +/- 5% of the legs 12 months after IBS. Median ulcer healing time was 186 days (range, 11 to >365 days). Leg salvage, secondary patency, and survival at 12 months were 87% +/- 3%, 82% +/- 4%, and 76% +/- 5%, respectively. Amputation-free survival with healed ulcers was attained in 55% at 12 months. Ischemic tissue lesions located in the mid- and hindfoot had significantly prolonged ulcer healing time (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.1 to 0.9, P = .044). None of the UTWCS classes predicted either ulcer healing time or leg salvage. Median ulcer duration before IBS was 68 days, range, 6 to 1154 days. Ulcer duration did not correlate with ulcer healing time (Spearman r = 0.138, P = .267). Ischemic ulcers with gangrene were not associated with prolonged ulcer healing time (P = .353). CONCLUSION: The location of the ischemic tissue lesions influences ulcer healing time. According to our study UTWCS can be used as descriptive classification of ischemic ulcers but it does not predict the ulcer healing time or leg salvage after infrainguinal bypass surgery.

Decrease of mortality of ruptured abdominal aortic aneurysm after centralization and in-hospital quality improvement of vascular service.

Our aim was to determine whether organizational changes could improve the outcome after ruptured abdominal aortic aneurysm (RAAA). Regional centralization and quality improvement in the in-hospital chain of treatment of RAAA included strengthening of the emergency preparedness and better availability of postoperative intensive care. During the reorganization, all patients with RAAA were admitted to Helsinki University Central Hospital (HUCH) from Helsinki and Uusimaa district. RAAA patients in the hospital district of Helsinki and Uusimaa between 1996 and 2004 were identified. The study period was divided into three periods: I, control; II, change; and III, present. Of the total of 626 patients with RAAA, 352 (56%) were admitted to the HUCH, of whom 315 (90%) underwent surgery. During the study period, population-based mortality decreased from 77% to 56% (P < 0.001) and 90-day mortality, from 54% to 28% (P = 0.002). Operative 30-day mortality was 19% during the third period and lower than previously (P = 0.001). Our results seem to argue in favor of centralization of emergency vascular services with adequate manpower and operative expertise in the first line and with availability of closed-unit postoperative critical care to achieve better results as these measures were associated with a positive impact on survival.