Endovascular repair of an abdominal aortic aneurysm in a patient with stenosis of bilateral common iliac artery stents.

BACKGROUND: The explosion in endovascular interventions for peripheral vascular disease has resulted in procedures being used by a multitude of specialties. Nonvascular surgeons performing these interventions can create scenarios that may make future vascular interventions difficult. In this article, we present a case report illustrating this point. METHODS: A 68-year-old man with severe chronic obstructive pulmonary disease, coronary artery disease with prior myocardial infarction, and multiple abdominal operations presented with an abdominal aortic aneurysm. In our opinion, this patient was at a prohibitive operative risk for open repair. Review of his imaging results revealed a 6.7-cm infrarenal aneurysm with bilateral common iliac artery (CIA) stents (right: 8 mm; left: 6 mm) and 6-mm self-expanding stents extending from the right external iliac artery through the common femoral artery. A Cook Zenith Renu (30 × 108 mm) graft (Cook Medical Inc., Bloomington, IN) was advanced after serial dilation and balloon angioplasty of the stenotic right CIA stent. Left brachial access was used for arteriographic imaging. The left common femoral artery was accessed and the left CIA was coil-embolized to prevent backbleeding. A femoro-femoral artery crossover bypass was then performed after segmental resection of the right common femoral artery stent. RESULTS: The patient tolerated the procedure well and was discharged home on postoperative day 3. Subsequent postoperative computed tomography arteriogram after 1 month showed palpable pulses and no evidence of endoleak with flow in the femoro-femoral graft on clinical exam. CONCLUSIONS: This case demonstrates an endovascular intervention which limited the potential options available for aneurysm repair. Similar problems may become increasingly common as more providers offer endovascular interventions, thus emphasizing the importance of a collaborative approach to the patient with complex aorto-iliac occlusive disease and abdominal aortic aneurysm. It is the duty of the vascular surgeon to offer his vital expertise and leadership in the care of these patients.

Treatment of Nonreconstructable Critical Limb Ischemia With Ischemic Wounds Utilizing a Noninvasive Intermittent Pneumatic Compression Device Monitored With Fluorescence Angiography.

INTRODUCTION: Critical limb ischemia (CLI) is a leading cause of lower extremity amputation. When CLI is identified, revascularization should be performed if possible. When options for revascularization do not exist, use of a noninvasive intermittent pneumatic compression device (NPCD) can be considered. OBJECTIVE: Presented here are 2 cases of patients with nonreconstructable CLI at risk for limb loss who were serially assessed with indocyanine green fluorescence angiography (ICGFA) to determine the effects of NPCD use on local tissue perfusion. MATERIALS AND METHODS: Both patients were treated with the NPCD for 1 hour, 3 times per day, for 4 weeks. Serial ICGFA utilizing a ICGFA device was performed at various time points to monitor the effects of NPCD use on tissue perfusion. RESULTS: The treatment of both patients with serial ICGFA provided limited objective evidence of increased local tissue perfusion which expedited wound resolution. CONCLUSIONS: Larger randomized control trials of this modality of perfusion assessment and NPCD use are recommended.

A quality improvement project to improve inferior vena cava filter retrieval.

OBJECTIVE: Poor retrieval rates for retrievable inferior vena cava filters (R-IVCFs) have been reported throughout the literature, with poor follow-up a common cause. In 2009, we reported a retrieval rate of 18% despite an initial follow-up rate of 85%. Use of a registry has been shown to improve retrieval rates. As a quality improvement project, in May 2012, the vascular surgery fellowship implemented a reiterative registry to track R-IVCFs placed at Walter Reed National Military Medical Center to improve retrieval rates. We report the results in 125 patients after 38 months. METHODS: Patients receiving an R-IVCF were entered into a registry. All patients were reviewed monthly using an electronic health record. When there was no longer an indication for the R-IVCF, the patient was scheduled for an outpatient appointment with a vascular surgeon followed by retrieval. Rates of retrieval, technical success, dwell time, indication, complications, and demographics were collected. RESULTS: There were 125 R-IVCFs placed between May 2012 and June 2015; 52 filters were placed for therapeutic and 73 for prophylactic indications. Our follow-up rate improved to 94%. A total of 79 filters were retrieved (63% absolute retrieval rate). Excluding patients who died before retrieval and patients with a permanent indication, 77% of filters were retrieved. The average dwell time was 101.5 days (7-460 days), and 63% of successful R-IVCF retrievals were within 3 months of placement. Technical success for retrieval was 92%. There were two major complications from retrievals (1.5% of retrievals). CONCLUSIONS: The creation of an R-IVCF registry promoted ongoing follow-up with patients. In our earlier experience, retrieval rates were poor despite a high follow-up rate. The use of a reiterative registry improved our retrieval rate by 45% and increased our follow-up rate to 94%. These results emphasize the importance of repetitive follow-up for R-IVCFs. Despite a follow-up rate >90%, around a third of R-IVCFs were not retrieved.

Management of a catecholamine-secreting paraganglioma requiring aortic reconstruction.

INTRODUCTION: Retroperitoneal paragangliomas are rare extraadrenal pheochromocytomas that can involve major vascular structures. RESULTS AND DISCUSSION: A case of periaortic catecholamine-secreting paraganglioma was reviewed and literature search performed to summarize the current surgical management of this disease process. CONCLUSION: Resection for cure of retroperitoneal paragangliomas with vascular reconstruction can be performed with acceptable morbidity and mortality with the use of current vascular techniques.