RevCore thrombectomy system for treatment of chronic left external and common iliac vein stent occlusion.

In recent years, deep venous stenting has increasingly become a treatment strategy for post-thrombotic syndrome. Stent thrombosis can occur, resulting in symptom recurrence despite medical therapy, and there are few options available for durable stent patency restoration. We present a case of a 50-year-old male with prior iliocaval reconstruction that experienced recurrent left lower extremity swelling secondary to occlusion of left external iliac and common iliac vein stents during follow-up. Mechanical thrombectomy with the RevCore System and angioplasty was performed. One month later, the patient demonstrated widely patent bilateral iliac vein stents and complete symptomatic resolution. The RevCore System is a feasible alternative for treatment of chronic in-stent thrombosis.

Superior mesenteric artery aneurysm endovascular repair.

Superior mesenteric artery aneurysms are rare and associated with high mortality rates in cases of rupture. Current Society for Vascular Surgery guidelines recommend treatment of all superior mesenteric artery aneurysms regardless of size. A 53-year-old woman who was admitted for abdominal pain was found with a 14-cm, ruptured superior mesenteric artery branch aneurysm. Endovascular approach was performed with microvascular plug embolization of a feeding branch and aneurysm sac exclusion with a stent graft. Four months later, the patient demonstrated a 21% regression of the aneurysm and stent patency. Thus, timely diagnosis and treatment of superior mesenteric artery aneurysms with endovascular techniques can reduce potential complications.

Endovascular reconstruction of aortic bifurcation for aortic pseudoaneurysm in a pediatric trauma patient.

Endovascular treatment options for vascular injury in pediatric patients are quite limited owing to concerns regarding long-term durability and the lack of devices suitable for the pediatric anatomy. However, in rare circumstances, open surgical therapy will not be an option, and patients will require unconventional endovascular solutions for lifesaving or limb-saving therapies. In the present report, we describe an endovascular treatment of a pediatric patient for whom initial surgical management of a blunt abdominal aortic injury had failed, with subsequent development of an aortic pseudoaneurysm. A 10-year-old girl had presented after a high-speed motor vehicle accident with a seatbelt sign. Multiple abdominal injuries were identified, including blunt aortic injury, significant devitalization of the small bowel, colonic perforation with fecal contamination, multiple lumbar spine fractures, and pulmonary contusions. The patient developed bilateral lower extremity ischemia from the aortic injury and had initially undergone open repair. One month later, the patient had developed a pseudoaneurysm of the aorta near the aortic bifurcation. Because of the hostile abdomen and ensuing short gut syndrome, the pseudoaneurysm was managed using endovascular techniques. The limb of an Excluder internal iliac branch endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ) was used as the endograft. The aortic bifurcation was raised and reconstructed using four Viabahn self-expanding stents (W.L. Gore & Associates). The completion angiogram showed complete resolution of the pseudoaneurysm. The follow-up computed tomography angiogram showed widely patent stent grafts with complete resolution of the pseudoaneurysm. Endovascular management of traumatic vascular injuries in pediatric patients is feasible. The likelihood of reintervention in the future is high with patient growth. However, it is a viable option in lifesaving or limb-saving situations in which open repair is high risk.

The sequential catheterization amid progressive endograft deployment technique for fenestrated endovascular aortic aneurysm repair.

Fenestrated endovascular aneurysm repair (FEVAR) is an alternative to open repair of complex aortic aneurysms. Despite promising short-term results, the technical complexities of this procedure remain a considerable challenge. The risk of technical failure with loss of visceral or renal arteries is ubiquitous even in the most experienced hands, and thus many patients with unfavorable anatomy are frequently denied FEVAR. We have adopted a new technique for FEVAR that involves retrograde brachial artery access and stepwise deployment of the endograft during target vessel catheterization, overcoming many anatomic limitations encountered from a transfemoral approach. This technique, termed sequential catheterization amid progressive endograft deployment, has become our preferred approach for FEVAR and is described in this article. Of note, currently available Food and Drug Administration-approved fenestrated endografts may not be amenable to sequential catheterization amid progressive endograft deployment as this technique requires preloaded wires incorporated into the endografts.

Upper extremity access for fenestrated endovascular aortic aneurysm repair is not associated with increased morbidity.

OBJECTIVE: Fenestrated endovascular aortic aneurysm repair (FEVAR) is an alternative to open repair in patients with complex abdominal aortic aneurysms who are neither fit nor suitable for standard open or endovascular repair. Chimney and snorkel grafts are other endovascular alternatives but frequently require bilateral upper extremity access that has been associated with a 3% to 10% risk of stroke. However, upper extremity access is also frequently required for FEVAR because of the caudal orientation of the visceral vessels. The purpose of this study was to assess the use of upper extremity access for FEVAR and the associated morbidity. METHODS: During a 5-year period, 148 patients underwent FEVAR, and upper extremity access for FEVAR was used in 98 (66%). Outcomes were compared between those who underwent upper extremity access and those who underwent femoral access alone. The primary end point was a cerebrovascular accident or transient ischemic attack, and the secondary end point was local access site complications. The mean number of fenestrated vessels was 3.07 ± 0.81 (median, 3) for a total of 457 vessels stented. Percutaneous upper extremity access was used in 12 patients (12%) and open access in 86 (88%). All patients who required a sheath size >7F underwent high brachial open access, with the exception of one patient who underwent percutaneous axillary access with a 12F sheath. The mean sheath size was 10.59F ± 2.51F (median, 12F), which was advanced into the descending thoracic aorta, allowing multiple wire and catheter exchanges. RESULTS: One hemorrhagic stroke (one of 98 [1%]) occurred in the upper extremity access group, and one ischemic stroke (one of 54 [2%]) occurred in the femoral-only access group (P = .67). The stroke in the upper extremity access group occurred 5 days after FEVAR and was related to uncontrolled hypertension, whereas the stroke in the femoral group occurred on postoperative day 3. Neither patient had signs or symptoms of a stroke immediately after FEVAR. The right upper extremity was accessed six times without a stroke (0%) compared with the left being accessed 92 times with one stroke (1%; P = .8). Four patients (4%) had local complications related to upper extremity access. One (1%) required exploration for an expanding hematoma after manual compression for a 7F sheath, one (1%) required exploration for hematoma and neurologic symptoms after open access for a 12F sheath, and two patients (2%) with small hematomas did not require intervention. Two (two of 12 [17%]) of these complications were in the percutaneous access group, which were significantly more frequent than in the open group (two of 86 [2%]; P = .02). CONCLUSIONS: Upper extremity access appears to be a safe and feasible approach for patients undergoing FEVAR. Open exposure in the upper extremity may be safer than percutaneous access during FEVAR. Unlike chimney and snorkel grafts, upper extremity access during FEVAR is not associated with an increased risk of stroke, despite the need for multiple visceral vessel stenting.

Cough-induced transient ischemic attack treated with revascularization of the external carotid artery.

A 65-year-old man presented with right arm and face weakness associated with severe coughing fits. A computed tomography angiogram revealed an occlusion of the left common and internal carotid arteries and an incomplete circle of Willis. An arch angiogram demonstrated reconstitution of the left external carotid artery, which collateralized with the intracranial left internal carotid artery. The patient underwent left subclavian-to-external carotid artery bypass with reversed saphenous vein, with complete resolution of symptoms over 1 year of follow-up. Cough-induced hemispheric transient ischemic attack is a rarely described hemodynamic phenomenon that can be managed with revascularization of the external carotid artery in select patients.

Low rates of complications for carotid artery stenting are associated with a high clinician volume of carotid artery stenting and aortic endografting but not with a high volume of percutaneous coronary interventions.

OBJECTIVE: Prior studies have demonstrated improved clinical outcomes for surgeons with a high-volume experience with certain open vascular operations. A high-volume experience with carotid artery stenting (CAS) improves clinical outcomes. Moreover, it is not known whether experience with other endovascular procedures, including percutaneous coronary interventions (PCIs), is an adequate substitute for experience with CAS. The goal of this study was to quantify the effect of increasing clinician volume of CAS, endovascular aneurysm repair (EVAR), and thoracic endovascular aortic aneurysm repair (TEVAR), and PCI on the outcomes for CAS. METHODS: The Nationwide Inpatient Sample was analyzed to identify patients undergoing CAS for the years 2005 to 2009. Clinicians were stratified into tertiles of low-volume, medium-volume, and high-volume groups by annual volume of CAS, EVAR/TEVAR, and PCI. Multiple logistic regression analyses were used to examine the relationship between clinician volume and a composite outcome of the in-hospital stroke and death rate after CAS. RESULTS: Between 2005 and 2009, 56,374 elective CAS procedures were performed nationwide, with a crude in-hospital stroke and death rate of 3.22%. A median of nine CAS procedures (interquartile range, 3-20) were performed annually per clinician. As expected, stroke and death rates for CAS decreased with increasing volume of CAS performed by a clinician (low-volume vs medium-volume vs high-volume: 4.43% vs 2.89% vs 2.27%; P = .0001). Similar patterns were noted between clinicians' volume of EVAR/TEVAR (low-volume vs medium-volume vs high-volume: 4.58% vs 3.18% vs 2.16%; P = .0023). In contrast, increasing PCI volume was not associated with decreased stroke and death rates after CAS (low-volume vs medium-volume vs high-volume: 2.99% vs 3.18% vs 3.55%; P = .35). After adjusting for patient and hospital characteristics, clinician volume of CAS (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.94; P = .003) and EVAR/TEVAR (OR, 0.85; 95% CI, 0.75-0.97; P = .020) remained significant predictors of stroke and death after CAS, whereas increasing clinician volume of PCI was associated with significantly increasing likelihood of stroke or death after CAS (OR, 1.025; 95% CI, 1.004-1.047; P = .019). CONCLUSIONS: The stroke and death rate for CAS to treat carotid stenosis is inversely affected by the number of CAS and EVAR/TEVAR procedures performed by a clinician. In contrast, a high-volume experience with PCI is not associated with improved outcomes after CAS.