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A noninterventional management approach to endovascular coil migration into the sigmoid
colon - Corrected Proof
18 Nov 2013 12:00 am
A 75-year-old man underwent endovascular treatment of a right internal iliac artery (IIA) aneurysm by
placing coils in the distal IIA and occluding the inflow with a common iliac artery-to-external iliac artery stent
graft. Surveillance computed tomography angiography discovered migration of an endovascular coil from
the thrombosed right IIA into the sigmoid colon. Subsequent serial imaging demonstrated uncomplicated
extracorporeal passage of the coil. We review the relevant literature and treatment rationale.
A single-center experience of aneurysms in abdominal organ transplant recipients Corrected Proof
18 Nov 2013 12:00 am
Objective: The purpose of this study was to characterize the prevalence and natural history of aneurysms
among abdominal transplant recipients.Methods: This article is a retrospective review of adult patients who
underwent a kidney or liver transplant at a single center between February 23, 2000, and October 6, 2011.
Data were obtained by searching electronic medical records for documentation of arterial aneurysm.
Abdominal aortic aneurysms (AAAs) were included if they were ≥3.0 cm in diameter, and thoracic aortic
aneurysms were included if they had a diameter ≥3.75 cm. Additional data collected included recipient
demographics, transplant-specific data, and characteristics of the aneurysms.Results: There were 927 liver
transplant recipients, 2133 kidney transplant recipients, 23 liver-kidney transplant recipients, and 133
kidney-pancreas transplant recipients included in our study; 127 of these patients were identified to have
aneurysms (40 liver, 83 kidney, 3 liver-kidney, 1 kidney-pancreas). The overall prevalence of any aneurysm
was similar for liver and kidney recipients, but the distribution of aneurysm types was different for the two
groups. AAAs made up 29.6% of aneurysms in kidney transplant recipients and 11.4% of aneurysms in liver
transplant recipients (P = .02). Visceral aneurysms were 10-fold as common in liver transplant recipients
compared with kidney transplant recipients (47.7% of aneurysms vs 5.1% of aneurysms; P < .01). The
majority of visceral artery aneurysms involved the hepatic and splenic artery. For both liver and kidney
transplant recipients, most aneurysms occurred post-transplantation. All known aortic aneurysm ruptures
occurred post-transplantation (25% of AAAs in liver transplant patients and 22.2% of thoracic aortic
aneurysms in kidney transplant patients). There was a trend toward higher AAA expansion rates after
transplantation (0.58 ± 0.48 cm/y compared with 0.41 ± 0.16 cm/y).Conclusions: Compared with the general
population, aneurysms may be more common and may have an aggressive natural history in abdominal
transplant recipients. Furthermore, the types of aneurysms that affect liver and kidney transplant recipients
differ. Care teams should be aware of these risks and surveillance programs should be tailored
appropriately.
Acute bilateral renal artery chimney stent thrombosis after endovascular repair of a
juxtarenal abdominal aortic aneurysm - Corrected Proof
18 Nov 2013 12:00 am
The use of “chimney” stents to augment the proximal landing zone for endovascular aneurysm repair has
been increasingly reported. Despite mounting enthusiasm for this technique, the durability of this type of
repair and capability to preserve perfusion to target branches remains a paramount concern. Here, we
report management of a patient presenting with acute bilateral renal chimney stent thrombosis and a type Ia
endoleak.
Amplatzer vascular plug for occlusion or flow reduction of hemodialysis arteriovenous
access - Corrected Proof
07 Nov 2013 12:00 am
Objective: Use of the Amplatzer vascular plug (AVP; St. Jude Medical Inc, St. Paul, Minn) for percutaneous
occlusion of a hemodialysis arteriovenous access (AVA) is an emerging practice, and only a few reports by
radiologists have been published. We report here a multidisciplinary experience of this technique not only
for AVA occlusion but also for flow reduction in selected patients.Methods: This preliminary study includes a
series of 20 plugs of different generations (I, II, and IV) used in 19 hemodialysis patients (two children, 17
adults). Of these, 15 AVAs were autologous fistulas located at the elbow, 4 were autologous forearm
fistulas, and 1 was a brachial-basilic polytetrafluoroethylene graft. AVP deployment was through a 4F to 8F
sheath, with oversizing from 30% to 50% to reduce the risk of migration. AVA occlusion (n = 14), by placing
the AVP in the vein at its origin, was performed for central vein occlusion after unsuccessful percutaneous
recanalization (n = 4), high flow (n = 2), hand ischemia (n = 3), successful kidney transplant (n = 1), and
brachial-basilic or brachial-brachial fistula second-stage superficialization technical failure (n = 4).
Vein/polytetrafluoroethylene grafts were not removed. AVA flow reduction (n = 6), by placing the AVP in the
radial artery, was performed for well-tolerated high flow (n = 3) or high flow associated with distal ischemia
(n = 3). All patients underwent a postoperative evaluation at 6-month intervals that included a clinical
examination and duplex scan.Results: AVA occlusion or flow reduction was successfully achieved in all
patients. Ischemia persisted in one patient and a revascularization with a distal bypass was necessary.
Mean follow-up was 1.2 ± 0.8 years (range, 2 months-2.9 years). No plug migration, access
revascularization, or other complication was observed.Conclusions: The results of this short preliminary
study suggest that plug insertion for occlusion or for flow reduction in a hemodialysis AVA constitutes a
reasonable alternative to coil insertion or to open surgery in selected patients.
Aortic arch rupture after multiple multilayer stent treatment of a thoracoabdominal aneurysm
- Corrected Proof
07 Nov 2013 12:00 am
Despite the improvement in diagnostic and therapeutic strategies, the treatment of thoracoabdominal
aneurysms is still burdened with a high incidence of peri/postoperative morbidity and mortality. The
multilayer flow modulator is a new and promising technique for the treatment of such disease; however,
some limits are still evident. We report the case of a 76-year-old woman affected by a symptomatic
thoracoabdominal aneurysm treated with multiple Cardiatis multilayer flow modulators complicated by aortic
arch rupture on the fifth postoperative day, with subsequent patient death.
Comparison of open and endovascular treatment of acute mesenteric ischemia - Corrected
Proof
07 Nov 2013 12:00 am
Introduction: Acute mesenteric ischemia (AMI) is a commonly fatal result of inadequate bowel perfusion that
requires immediate evaluation by both vascular and general surgeons. Treatment often involves vascular
repair as well as bowel resection and the possible need for parenteral nutrition. Little data exist regarding
the rates of bowel resection following endovascular vs open repair of AMI.Methods: Using the National
Inpatient Sample database, admissions from 2005 through 2009 were identified according to International
Classification of Diseases, Ninth Revision codes correlating to both AMI (557.0) and subsequent vascular
intervention (39.26, 38.16, 38.06, 39.9, 99.10). Patients with a diagnosis of AMI but no intervention or
nonemergent admission status were excluded. Patient level data regarding age, gender, and comorbidities
were also examined. Outcome measures included mortality, length of stay, the need for bowel resection
(45.6, 45.71-9, 45.8), or infusion of total parenteral nutrition (TPN; 99.10) during the same hospitalization.
Statistical analysis was conducted by χ2 tests and Wilcoxon rank-sum comparisons.Results: Of 23,744
patients presenting with AMI, 4665 underwent interventional treatment from 2005 through 2009. Of these
patients, 57.1% were female, and the mean age was 70.5 years. A total of 679 patients underwent vascular
intervention; 514 (75.7%) underwent open surgery and 165 (24.3%) underwent endovascular treatment
overall during the study period. The proportion of patients undergoing endovascular repair increased from
11.9% of patients in 2005 to 30.0% in 2009. Severity of comorbidities, as measured by the Charlson index,
did not differ significantly between the treatment groups. Mortality was significantly more commonly
associated with open revascularization compared with endovascular intervention (39.3% vs 24.9%; P =
.01). Length of stay was also significantly longer in the patient group undergoing open revascularization
(12.9 vs 17.1 days; P = .006). During the study time period, 14.4% of patients undergoing endovascular
procedures required bowel resection compared with 33.4% for open revascularization (P < .001).
Endovascular repair was also less commonly associated with requirement for TPN support (13.7% vs
24.4%; P = .025).Conclusions: Endovascular intervention for AMI had increased significantly in the modern
era. Among AMI patients undergoing revascularization, endovascular treatment was associated with
decreased mortality and shorter length of stay. Furthermore, endovascular intervention was associated with
lower rates of bowel resection and need for TPN. Further research is warranted to determine if increased
use of endovascular repair could improve overall and gastrointestinal outcomes among patients requiring
vascular repair for AMI.
Decision analysis model of open repair versus endovascular treatment in patients with
asymptomatic popliteal artery aneurysms - Corrected Proof
18 Nov 2013 12:00 am
Objective: Repair is indicated of asymptomatic popliteal artery aneurysms (aPAAs) that are >2 cm.
Endovascular PAA repair with covered stents (stenting) is increasingly used. It is, however, unclear when
an endovascular approach is preferred to traditional open repair with great saphenous vein bypass (GSVB).
The goal of this study was to assess the treatment options for aPAAs using decision analysis.Methods: A
Markov model was developed and a hypothetic cohort of patients with aPAAs was analyzed. GSVB,
stenting, and nonoperative management with optimal medical treatment (OMT) were compared. Operative
mortality, patency rates, quality-of-life values, and costs were determined by comprehensive review of the
best available evidence. The main outcome was quality-adjusted life-years (QALYs). Secondary outcomes
were cost-effectiveness and number of reinterventions.Results: For a 65-year-old male patient with a 2.0cm aPAA and without significant comorbidities, probabilistic sensitivity analysis shows that intervention is
preferred over OMT (5.77 QALYs, 95% credibility interval [CI], 5.43-6.11; OMT). GSVB treatment for this
patient results in slightly higher QALYs than stent placement, with a predicted 8.43 QALYs (GSVB: 95% CI,
8.21-8.64) vs 8.07 QALYs (stenting: 95% CI, 7.84-8.29), a difference of 0.36 QALYs (95% CI, 0.14-0.58).
Furthermore, costs are higher for stenting ($40,464; 95% CI, $34,814-$46,242) vs GSVB ($21,618; 95% CI,
$15,932-$28,070), and more reinterventions are required after stenting (1.03 per patient) vs GSVB (0.52
per patient), making GSVB the preferred strategy for all outcomes considered. Stenting is preferred in
patients who are at high risk for open repair (>6% 30-day mortality) or if the 5-year primary patency rates of
stenting increase to 80%. For very old patients (>95 years) and patients with a very short life expectancy
(<1.5 years), OMT yields higher QALYs.Conclusions: GSVB is the preferred treatment in 65-year-old
patients with aPAAs for all outcomes considered. However, patients at high risk for open repair or without
suitable vein should be considered as candidates for endovascular repair. Very elderly patients and patients
with a short life expectancy are best treated with OMT. Further improvement of endovascular techniques
that increase patency rates of endovascular stents could make this the preferred therapy for more patients
in the future.
Depression Promotes Cognitive Decline in Patients With Diabetes
27 Nov 2013 12:00 am
Individuals with type 2 diabetes who also have depression had an accelerated cognitive decline during a
40-month cohort study of participants in the Action to Control Cardiovascular Risk in Diabetes–Memory in
Diabetes (ACCORD-MIND) trial (Sullivan MD et al. JAMA Psychiatry. 2013;70[10]:1041-1047).
Diabetic women are poor responders to exercise rehabilitation in the treatment of
claudication - Corrected Proof
18 Nov 2013 12:00 am
Background: It is not clear whether subgroups of patients with peripheral artery disease (PAD) and
claudication respond more favorably to exercise rehabilitation than others. We determined whether sex and
diabetes were factors associated with the response to exercise rehabilitation in patients with
claudication.Methods: Eighty patients were randomized to home-based and supervised exercise programs,
and 60 finished with complete exercise intervention data. Exercise consisted of intermittent walking to near
maximal claudication pain for 3 months. Primary outcome measures included claudication onset time (COT)
and peak walking time. Patients were partitioned into diabetic and nondiabetic groups and then further
partitioned by sex to form four groups.Results: Overall, exercise adherence was high (84%), and there was
no significant difference (P > .05) in the amount of exercise completed among the four groups. All groups
had significant improvements (P < .05) in COT and peak walking time after exercise rehabilitation, except
for diabetic women (P > .05). Only 37% of women with diabetes had an increase in COT compared with
100% of men with diabetes (P < .01), and their risk ratio for nonresponse was 9.2 (P < .0001).Conclusions:
Women with PAD and claudication, particularly those with diabetes, represent a vulnerable subgroup of
patients who respond poorly to a program of exercise rehabilitation. Diabetic women with PAD and
claudication may need a greater dose of exercise or another intervention separate from or in combination
with exercise to elicit improvements in claudication measures that are similar to nondiabetic women and to
diabetic and nondiabetic men.
Discussion - Corrected Proof
18 Nov 2013 12:00 am
Dr Eva Rzucidlo (Lebanon, NH). You have presented so nicely the historical data showing that women have
always been reported to have worse outcomes. So what is your hypothesis for this change to equal
outcome with men: is it better risk factor medical management?
Editorial Board
01 Dec 2013 12:00 am
Endovascular therapy for long-segment atherosclerotic aortoiliac occlusion - Corrected
Proof
18 Nov 2013 12:00 am
Objective: This retrospective nonrandomized study investigated the outcomes of endovascular therapy for
long-segment atherosclerotic aortoiliac occlusion.Methods: From May 2008 to January 2013, 20 patients
(one woman and 19 men; mean age, 66.1 years; range, 43-89 years) underwent stent implantation, with or
without catheter-directed thrombolysis (CDT), for long-segment aortoiliac occlusion (>10 mm).Results: The
technical success rate was 95% (19 of 20). No in-hospital mortality was recorded. Aortic thrombus was
successfully eliminated with CDT in four patients before percutaneous transluminal angioplasty (PTA) and
stenting. Retroperitoneal hemorrhage occurred in one patient, who refused further endovascular surgery.
Another 15 patients were treated with PTA and stenting. Postoperative ankle-brachial indexes increased
significantly from preoperative values (P < .05). Seventeen patients showed clinical improvement from
baseline by an average of 2.5 Rutherford categories. The mean follow-up interval was 17.6 months (range,
4-39 months). The primary patency rates were 93.3% ± 6.4% at 6 months, 83% ± 11.3% at 18 months, and
66.4% ± 17.4% at 24 months.Conclusions: Through brachial and femoral artery puncture, PTA, stenting,
and CDT, endovascular therapy is feasible for complete long-segment infrarenal aortic occlusion, with lower
complication rates and favorable midterm patency.
Endovascular-first approach is not associated with worse amputation-free survival in
appropriately selected patients with critical limb ischemia - Corrected Proof
04 Nov 2013 12:00 am
Objective: Endovascular interventions for critical limb ischemia are associated with inferior limb salvage
(LS) rates in most randomized trials and large series. This study examined the long-term outcomes of
selective use of endovascular-first (endo-first) and open-first strategies in 302 patients from March 2007 to
December 2010.Methods: Endo-first was selected if (1) the patient had short (5-cm to 7-cm occlusions or
stenoses in crural vessels); (2) the disease in the superficial femoral artery was limited to TransAtlantic
Inter-Society Consensus II A, B, or C; and (3) no impending limb loss. Endo-first was performed in 187
(62%), open-first in 105 (35%), and 10 (3%) had hybrid procedures.Results: The endo-first group was older,
with more diabetes and tissue loss. Bypass was used more to infrapopliteal targets (70% vs 50%, P = .031).
The 5-year mortality was similar (open, 48%; endo, 42%; P = .107). Secondary procedures (endo or open)
were more common after open-first (open, 71 of 105 [68%] vs endo, 102 of 187 [55%]; P = .029). Compared
with open-first, the 5-year LS rate for endo-first was 85% vs 83% (P = .586), and amputation-free survival
(AFS) was 45% vs 50% (P = .785). Predictors of death were age >75 years (hazard ratio [HR], 3.3; 95%
confidence interval [CI], 1.7-6.6; P = .0007), end-stage renal disease (ESRD) (HR, 3.4; 95% CI, 2.1-5.6; P <
.0001), and prior stroke (HR, 1.6; 95% CI, 1.03-2.3; P = .036). Predictors of limb loss were ESRD (HR, 2.5;
95% CI, 1.2-5.4; P = .015) and below-the-knee intervention (P = .041). Predictors of worse AFS were older
age (HR, 2.03; 95% CI, 1.13-3.7; P = .018), ESRD (HR, 3.2; 95% CI, 2.1-5.11; P < .0001), prior stroke (P =
.0054), and gangrene (P = .024).Conclusions: At 5 years, endo-first and open-first revascularization
strategies had equivalent LS rates and AFS in patients with critical limb ischemia when properly selected. A
patient-centered approach with close surveillance improves long-term outcomes for both open and endo
approaches.
Experience of the Zenith Dissection Endovascular System in the emergency setting of
malperfusion in acute type B dissections - Corrected Proof
18 Nov 2013 12:00 am
Objective: This study evaluated the safety and effectiveness of the Zenith Dissection Endovascular System
(Cook Medical, Bloomington, Ind) in the urgent treatment of acute type B aortic dissections complicated by
organ malperfusion.Methods: Between June 2011 and June 2013, we prospectively enrolled all patients
with acute type B dissection (<14 days) complicated by visceral malperfusion and treated by the Zenith
Dissection Endovascular System, including a proximal covered stent and a distal noncovered stent. Organ
malperfusion was diagnosed during the clinical, biological, and morphologic follow-up of patients admitted
to a dedicated intensive care unit (SOS Aorta). End points were 30-day mortality and morbidity, and
reoperation rate, survival, and remodelling of the dissected aorta during follow-up.Results: Fifteen patients
(11 men; mean age, 60 ± 12 years) were treated in emergency procedures with a median delay of 36 hours.
Malperfusions included renal ischemia in all patients, intestinal ischemia in nine, and lower limb ischemia in
six. The proximal entry tear in each patient was covered by a stent Zenith TX2 graft (mean diameter,
36 mm; mean length, 170 mm; Cook Medical), supplemented by a noncovered aortic stent (diameter, 36 or
46 mm; length, 164 mm) with a technical success rate of 100%. The left subclavian artery in 10 patients
was covered without revascularization. One chimney was necessary to revascularize the left common
carotid artery. Six patients required complementary arterial branch stenting for persistent static
malperfusion, using eight peripheral stents (five iliacs, three renals). No deaths were recorded during the
30-day postoperative period. Major adverse events were reported in three patients (20%): 1 paraparesis
with complete recovery, 1 colonic resection, 1 stroke, and 2 transient renal failures. The mean hospital stay
was 14 ± 6 days. During a mean follow-up of 8 ± 3 months, one sudden death, no aortic-related
complications, and no reoperations or conversions were recorded. Remodelling with healing of the thoracic
false lumen was obtained in 10 patients (67%), and five others had a partially thrombosed false lumen
without remodelling.Conclusions: Used as a treatment for organ malperfusion complicating acute type B
dissections, the Zenith Dissection Endovascular System achieved safely and effectively satisfactory clinical
results in the short term. The long-term effect of this composite treatment on aortic remodelling remains to
be determined.
First implantation of Gore Hybrid Vascular Graft in the right vertebral artery for cerebral
debranching in a patient with Loeys-Dietz syndrome - Corrected Proof
18 Nov 2013 12:00 am
A 53-year-old woman with Loeys-Dietz syndrome developed progressive subclavian artery aneurysm and
common carotid artery dissection. She was treated successfully by plugging and coiling of the subclavian
aneurysm and its side branches after combined cervical debranching using standard carotid-axillary bypass
and Gore Hybrid Vascular Graft for vertebral revascularization. Follow-up control (4 weeks) documented
patent debranching, and only minimal residual flow in the subclavian aneurysm. The described off-label use
for sutureless cerebral revascularisation of the vertebral artery might be a fast, simple, and reliable solution
for cervical debranching in selective challenging patients. Further studies are necessary to evaluate side
effects and durability.
Forthcoming Events
01 Dec 2013 12:00 am
Gaps in preoperative surveillance and rupture of abdominal aortic aneurysms among
Medicare beneficiaries - Corrected Proof
18 Nov 2013 12:00 am
Objective: Screening and surveillance are recommended in the management of small abdominal aortic
aneurysms (AAAs). Gaps in surveillance after early diagnosis may lead to unrecognized AAA growth,
rupture, and death. This study investigates the frequency and predictors of rupture of previously diagnosed
AAAs.Methods: Data were extracted from Medicare claims for patients who underwent AAA repair between
2006 and 2009. Relevant preoperative abdominal imaging exams were tabulated up to 5 years prior to AAA
repair. Repair for ruptured AAAs was compared with repair for intact AAAs for those with an early diagnosis
of an AAA, defined as having received imaging at least 6 months prior to surgery. Gaps in surveillance were
defined as no image within 1 year of surgery or no imaging for more than a 2-year time span after the initial
image. Logistic regression was used to examine independent predictors of rupture despite early
diagnosis.Results: A total of 9298 patients had repair after early diagnosis, with rupture occurring in 441
(4.7%). Those with ruptured AAAs were older (80.2 ± 6.9 vs 77.6 ± 6.2 years; P < .001), received fewer
images prior to repair (5.7 ± 4.1 vs 6.5 ± 3.5; P = .001), were less likely to be treated in a high-volume
hospital (45.4% vs 59.5%; P < .001), and were more likely to have had gaps in surveillance (47.4% vs
11.8%; P < .001) compared with those receiving repair for intact AAAs. After adjusting for medical
comorbidities, gaps in surveillance remained the largest predictor of rupture in a multivariate analysis (odds
ratio, 5.82; 95% confidence interval, 4.64-7.31; P < .001).Conclusions: Despite previous diagnosis of AAA,
many patients experience rupture prior to repair. Improved mechanisms for surveillance are needed to
prevent rupture and ensure timely repair for patients with AAAs.
Gender-specific 30-day outcomes after carotid endarterectomy and carotid artery stenting in
the Society for Vascular Surgery Vascular Registry - Corrected Proof
18 Nov 2013 12:00 am
Objective: Although the optimal treatment of carotid stenosis remains unclear, available data suggest that
women have higher risk of adverse events after carotid revascularization. We used data from the Society
for Vascular Surgery Vascular Registry to determine the effect of gender on outcomes after carotid
endarterectomy (CEA) and carotid artery stenting (CAS).Methods: There were 9865 patients (40.6%
women) who underwent CEA (n = 6492) and CAS (n = 3373). The primary end point was a composite of
death, stroke, and myocardial infarction at 30 days.Results: There was no difference in age and ethnicity
between genders, but men were more likely to be symptomatic (41.6% vs 38.6%; P < .003). There was a
higher prevalence of hypertension and chronic obstructive pulmonary disease in women, whereas men had
a higher prevalence of coronary artery disease, history of myocardial infarction, and smoking history. For
disease etiology in CAS, restenosis was more common in women (28.7% vs 19.7%; P < .0001), and
radiation was higher in men (6.2% vs 2.6%; P < .0001). Comparing by gender, there were no statistically
significant differences in the primary end point for CEA (women, 4.07%; men, 4.06%) or CAS (women,
6.69%; men, 6.80%). There remains no difference after stratification by symptomatology and multivariate
risk adjustment.Conclusions: In this large, real-world analysis, women and men demonstrated similar
results after CEA or CAS. These data suggest that, contrary to previous reports, women do not have a
higher risk of adverse events after carotid revascularization.
High frequency of brachiocephalic trunk stent fractures does not impair clinical outcome Corrected Proof
18 Nov 2013 12:00 am
Objective: Stenting is the preferred, minimally invasive treatment for innominate artery (IA) stenosis or
occlusion. Stent fractures in the IA have not been assessed in larger cohorts. In this retrospective study, we
examined the frequency and risk factors of IA stent fractures.Methods: The final analysis included 32
patients (15 women; mean age, 59.4 ± 12.0 years) with 32 balloon-expandable stents (2000 to 2009). In
2010, the patients were asked to come back for a fluoroscopic examination of the implanted stents. Stent
fractures and their relationship to atherosclerotic risk factors, lesion characteristics, postprocedural
symptoms, and in-stent restenosis were analyzed. Fisher exact test and univariate Cox regression analysis
were used in the statistical evaluation.Results: Lesions were >20 mm in 14 patients (44%) or heavily
calcified in 13 (41%). The mean follow-up time was 33.4 ± 21.0 months. Postprocedural symptoms were
noted in nine patients (28%). Significant restenosis was detected in 22% of the implanted stents, and 11
stent fractures (34%) were found. The prevalence of heavily calcified lesions, postprocedural symptoms,
and in-stent restenosis did not differ significantly between groups with and without fracture. Long lesions
were associated with an increased incidence of stent fracture (hazard ratio, 5.09; 95% confidence interval,
1.33-19.48; P = .017). No correlation was observed between stent fractures and old age (≥70 years), female
gender, smoking, hypertension, hyperlipidemia, or diabetes mellitus.Conclusion: IA stent fractures are
common but seem to have no effect on symptoms and in-stent restenosis rates.
Hypogastric and subclavian artery patency affects onset and recovery of spinal cord
ischemia associated with aortic endografting - Corrected Proof
04 Nov 2013 12:00 am
Objective: Spinal cord ischemia (SCI) is a devastating complication associated with aortic aneurysm repair.
The aim of the current study was to evaluate factors affecting outcomes from SCI associated with
endovascular aortic aneurysm repair.Methods: A total of 1251 patients underwent endovascular repair of
aortic aneurysm as part of a device trial between 1998 and 2010 utilizing endovascular abdominal aortic
aneurysm repair (n = 351), thoracic endovascular aortic aneurysm repair (n = 201), fenestrated
endovascular aortic aneurysm repair (n = 227), and visceral branched endografts (n = 472). Records and
imaging studies were reviewed to supplement prospective outcome data. Demographics, type of repair,
collateral bed (hypogastric/subclavian) patency, clinical presentation, and outcomes were evaluated on
patients with SCI. Survival was calculated using life-table analysis.Results: SCI occurred in 2.8% (n = 36) of
patients: abdominal aortic aneurysm, 0.3%, juxtarenal, 0.4%, thoracic aortic aneurysm, 4.6%, and
thoracoabdominal aortic aneurysm, 4.8%). Four (11%) required carotid-subclavian bypass prior to
endografting, and two underwent coverage of the left subclavian artery. Unilateral hypogastric artery
occlusion was present in 11 (31%) patients prior to endograft placement, and three had bilateral occlusions.
An additional seven patients had occlusion of at least one hypogastric artery during surgery. SCI was
apparent immediately in 15 (42%) patients. Immediate onset of symptoms was observed in 73% of patients
with at least one occluded collateral bed but in only 24% of those with patent collateral beds (P = .021). Of
those presenting in a delayed fashion, nine (43%) had a clear precipitating event prior to onset of SCI
(hypotension, n = 6, and segmental artery drain removal, n = 3). Recovery occurred in 24 (67%) patients,
most within 7 days. Immediate presentation was a negative predictor of recovery (P = .025), as was
occlusion of at least one collateral bed (P = .035). Mean follow-up was 22 ± 4 months with 30-day and 1year survival of 92 ± 4.6% and 56 ± 8.3%. Survival was only 36% at 3 months in those with permanent SCI
compared with 92% (P < .001) in those with temporary symptoms.Conclusions: SCI continues to complicate
aortic surgery despite the advent of endovascular therapy. Occlusion of a single collateral bed is associated
with an increased risk for immediate onset of SCI and lack of recovery. These factors are harbingers of poor
outcomes and increased short-term mortality. This may be prevented by preserving collateral bed patency
in patients undergoing extensive endovascular procedures.
Intraprocedural and postprocedural perigraft arterial sac embolization (PASE) for endoleak
treatment - Corrected Proof
07 Nov 2013 12:00 am
Intervention may be necessary in up to one-third of patients with endoleaks after endovascular aortic
aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) to induce aneurysm thrombosis was
performed by intrasac injection of thrombin and gelfoam slurry. Thirteen patients were treated with PASE
since 2006. Eight patients underwent immediate PASE, and five patients were treated during surveillance
following EVAR. The median follow-up is 23.9 months (range, 2.6-66.1 months) for the entire cohort; 24.4
and 23.1 months for the immediate and delayed group, respectively. No patients had further aneurysm
growth. One (8%) patient maintained stable aneurysm size with a persistent type II endoleak, and 11 (85%)
patients had aneurysm shrinkage. PASE to induce sac thrombosis after EVAR is an alternative for the
treatment of endoleaks. Further study is required to define optimal patient selection, safety, long-term
efficacy and potential cost-savings of this technique.
Living in a medically underserved county is an independent risk factor for major limb
amputation - Corrected Proof
18 Nov 2013 12:00 am
Objective: Despite an increase in the incidence of hospital admissions for comorbid conditions, such as
diabetes, the incidence of major limb amputation in North Carolina has decreased. The decline in
amputation rate has not been uniformly realized across the state. The objective of this study was to
determine the association between major vascular limb amputation and living in an underserved county in
North Carolina.Methods: We analyzed discharges aged 18 to 100 years old with a peripheral arterial
disease (PAD)-related admission from the North Carolina Inpatient Discharge Database from 2006 to 2009.
Medically underserved counties are defined by the United States Health Resources and Services
Administration as having too few primary care providers, high infant mortality, high poverty, or high elderly
population. The association between major amputation prevalence and medically underserved counties was
calculated using a binomial regression model adjusted for sex, age, diabetes, end-stage renal disease,
PAD, and critical limb ischemia. Each confounder was assessed using backward elimination
modeling.Results: Among the 222,920 discharges with a PAD-related hospital admission from 2006 to
2009, 8601 (3.9%) were from medically underserved counties. There were 7328 major amputations. The
adjusted prevalence odds ratio of the association between underserved counties and major vascular limb
amputation is 1.29 (95% confidence interval, 1.16-1.44). None of the confounders significantly affected the
association between underserved counties and number of amputations.Conclusions: Living in an
underserved county in North Carolina is associated with a 29% increase in the odds of undergoing major
limb amputation. Gender, age, and comorbidities, including diabetes, end-stage renal disease, and PAD, do
not significantly affect the relationship.
Lower atherosclerotic burden in familial abdominal aortic aneurysm - Corrected Proof
18 Nov 2013 12:00 am
Objective: Despite the apparent familial tendency toward abdominal aortic aneurysm (AAA) formation, the
genetic causes and underlying molecular mechanisms are still undefined. In this study, we investigated the
association between familial AAA (fAAA) and atherosclerosis.Methods: Data were collected from a
prospective database including AAA patients between 2004 and 2012 in the Erasmus University Medical
Center, Rotterdam, The Netherlands. Family history was obtained by written questionnaire (93.1%
response rate). Patients were classified as fAAA when at least one affected first-degree relative with an
aortic aneurysm was reported. Patients without an affected first-degree relative were classified as sporadic
AAA (spAAA). A standardized ultrasound measurement of the common carotid intima-media thickness
(CIMT), a marker for generalized atherosclerosis, was routinely performed and patients' clinical
characteristics (demographics, aneurysm characteristics, cardiovascular comorbidities and risk factors, and
medication use) were recorded. Multivariable linear regression analyses were used to assess the mean
adjusted difference in CIMT and multivariable logistic regression analysis was used to calculate
associations of increased CIMT and clinical characteristics between fAAA and spAAA.Results: A total of
461 AAA patients (85% men, mean age, 70 years) were included in the study; 103 patients (22.3%) were
classified as fAAA and 358 patients (77.7%) as spAAA. The mean (standard deviation) CIMT in patients
with fAAA was 0.89 (0.24) mm and 1.00 (0.29) mm in patients with spAAA (P = .001). Adjustment for clinical
characteristics showed a mean difference in CIMT of 0.09 mm (95% confidence interval, 0.02-0.15; P =
.011) between both groups. Increased CIMT, smoking, hypertension, and diabetes mellitus were all less
associated with fAAA compared with spAAA.Conclusions: The current study shows a lower atherosclerotic
burden, as reflected by a lower CIMT, in patients with fAAA compared with patients with spAAA,
independent of common atherosclerotic risk factors. These results support the hypothesis that although
atherosclerosis is a common underlying feature in patients with aneurysms, atherosclerosis is not the
primary driving factor in the development of fAAA
Lumbar artery pseudoaneurysm in a patient with inferior vena cava filter and history of
strenuous physical exercise - Corrected Proof
18 Nov 2013 12:00 am
Lumbar artery pseudoaneurysms (LAPs) are a rare complication of inferior vena cava (IVC) filters. The few
reports in the literature describe treatment of patients presenting with ruptured LAPs. This case report
describes the successful management of a symptomatic LAP because of an IVC filter, which initially
presented as a retroperitoneal hematoma resulting from lumbar artery laceration by a filter strut. We
hypothesize that the strenuous abdominal exercises performed by the patient may have facilitated IVC
penetration by the filter, leading to development of a retroperitoneal hematoma and subsequent LAP. This
case suggests that patients with IVC filters should avoid strenuous exercise and underscores the
importance of timely retrieval of nonpermanent IVC filters.
Microcirculatory perfusion shift in the gut wall layers induced by extracorporeal circulation Corrected Proof
25 Nov 2013 12:00 am
Objective: Extracorporeal circulation (ECC) is regularly applied to maintain organ perfusion during major
aortic and cardiovascular surgery. During thoracoabdominal aortic repair, ECC-driven selective visceral
arterial perfusion (SVP) results in changed microcirculatory perfusion (shift from the muscularis toward the
mucosal small intestinal layer) in conjunction with macrohemodynamic hypoperfusion. The underlying
mechanism, however, is unclear. Therefore, the aim of this study was to assess in a porcine model whether
ECC itself or the hypoperfusion induced by SVP is responsible for the mucosal/muscular shift in the small
intestinal wall.Methods: A thoracoabdominal aortic approach was performed in 15 healthy pigs divided
equally into three groups: group I, control; group II, thoracic aortic cross-clamping with distal aortic
perfusion; and group III, thoracic aortic cross-clamping with distal aortic perfusion and SVP.
Macrocirculatory and microcirculatory blood flow was assessed by transit time ultrasound volume flow
measurement and fluorescent microspheres. In addition, markers for metabolism and intestinal ischemiareperfusion injury were determined.Results: ECC with a roller pump induced a significant switch from the
muscularis and mucosal layer of the small intestine, even with adequate macrocirculation
(mucosal/muscular perfusion ratio: group I vs II, P = .005; group I vs III, P = .0018). Furthermore, the
oxygen extraction ratio increased significantly in groups II (>30%) and III (>40%) in the beginning of the
ECC compared with the control (group I vs II, P = .0037; group I vs III, P = .0062). Lactate concentrations
and pH values did not differ between groups I and II; but group III demonstrated a significant shifting toward
a lactate-associated acidosis (lactate: group I vs III, P = .0031; pH: group I vs III, P = .0001).Conclusions:
We demonstrated a significant shifting between the small intestinal gut wall layers induced by roller pumpdriven ECC. The shift occurs independently of macrohemodynamics, with a significant effect on aerobic
metabolism in the gut wall. Consequently, an optimal intestinal perfusion cannot be guaranteed by a roller
pump; therefore, perfusion techniques need to be optimized.Clinical Relevance: Extracorporeal circulation
regularly induces intestinal dysfunction that results in bacteremia. We identified that a nonpulsatile flow of a
roller pump induces a small intestinal perfusion shift from the muscularis layer toward the mucosal layer,
followed by an increase in the oxygen extraction ratio. Consequently, extracorporeal perfusion techniques
have to be optimized.
Office-based endovascular suite is safe for most procedures - Corrected Proof
08 Nov 2013 12:00 am
Objective: This study was conducted to identify the safety of endovascular procedures in the office
endovascular suite and to assess patient satisfaction in this setting.Methods: Between May 22, 2007, and
December 31, 2012, 2822 patients underwent 6458 percutaneous procedures in an office-based
endovascular suite. Demographics of the patients, complications, hospital transfers, and 30-day mortality
were documented in a prospective manner. Follow-up calls were made, and a satisfaction survey was
conducted. Almost all dialysis procedures were done under local anesthesia and peripheral arterial
procedures under conscious sedation. All patients, except those undergoing catheter removals, received
hydrocodone and acetaminophen (5/325 mg), diazepam (5-10 mg), and one dose of an oral antibiotic
preprocedure and three doses postprocedure. Patients who required conscious sedation received fentanyl
and midazolam. Conscious sedation was used almost exclusively in patients having an arterial procedure.
Measurements of blood urea nitrogen, creatinine, international normalized ratio, and partial thromboplastin
time were performed before peripheral arteriograms. All other patients had no preoperative laboratory tests.
Patients considered high risk (American Society of Anesthesiologists Physical Status Classification 4),
those who could not tolerate the procedure with mild to moderate conscious sedation, patients with a
previous bad experience, or patients who weighed >400 pounds were not candidates for office based
procedures.Results: There were 54 total complications (0.8%): venous, 2.2%; aortogram without
interventions, 1%; aortogram with interventions, 2.7%; fistulogram, 0.5%; catheters, 0.3%; and venous filterrelated, 2%. Twenty-six patients required hospital transfer from the office. Ten patients needed an operative
intervention because of a complication. No procedure-related deaths occurred. There were 18 deaths in a
30-day period. Of patients surveyed, 99% indicated that they would come back to the office for needed
procedures.Conclusions: When appropriately screened, almost all peripheral interventions can be
performed in the office with minimal complications. For dialysis patients, outpatient intervention has a very
low complication rate and is the mainstay of treatment to keep the dialysis access patent. Venous
insufficiency, when managed in the office setting, also has a low complication rate. Office-based procedural
settings should be seriously considered for percutaneous interventions for arterial, venous, and dialysisrelated procedures.
Operative technique for tracheo-innominate artery fistula repair - Corrected Proof
18 Nov 2013 12:00 am
Background: Tracheo-innominate artery fistula (TIF) is a rare but serious complication of tracheostomy,
inevitably fatal unless treated surgically. Even with proper treatment, the condition has a high morbidity and
mortality due to the difficulty of early diagnosis, appropriate perioperative management, and the procedure
itself. No postoperative long-term results have been reported.Methods: Emergency surgery was performed
in seven patients with TIF between May 2003 and September 2011. The average patient age was
15.7 years; all patients had prior severe neurological deficits. The mean duration between tracheostomy
and TIF was 48.6 months. The diagnosis was made when patients with severe, sudden tracheal bleeding
demonstrated compression of the innominate artery by the trachea on computed tomography. Three of
seven patients were in hemorrhagic shock; control of preoperative bleeding was achieved in all patients
using tracheostomy tube cuff over-inflation. The innominate artery and the trachea were exposed through a
collar incision and partial upper sternotomy. The innominate artery was divided at the aortic arch and at the
bifurcation, with one exception. Cerebral blood flow was monitored by the blood pressure difference in the
bilateral upper extremities and by near-infrared spectroscopy. The tracheal fistula was left adherent to the
innominate artery in all but one patient. The follow-up rate was 100%; the mean follow-up period was 37 ±
33 months (range, 3-103 months).Results: All patients were discharged without new neurologic deficits or
severe morbidity. One patient died of acute pancreatitis 16 months postoperatively. Overall survival was
84% at 37 months, without any vascular, tracheal, or neurological events.Conclusions: Preoperative
bleeding control is crucial in patients with TIF; division of the innominate artery under cerebral blood flow
monitoring is appropriate treatment. When adhesions between the innominate artery and the trachea are
severe, separation of the innominate artery from the trachea is not required.
Outcomes of endovascular treatment for aortic pseudoaneurysm in Behcet's disease Corrected Proof
18 Nov 2013 12:00 am
Objective: To evaluate the effectiveness of endovascular stent grafting for surgical management of aortic
pseudoaneurysm in patients with Behcet's disease (BD).Methods: We present a single-institution
retrospective cohort of patients with aortic pseudoaneurysm and BD treated with aortic stent grafting.
Computed tomography imaging was obtained preoperatively in all patients and once within 2 weeks
postoperatively, and then annually. Clinical follow-up and erythrocyte sedimentation rate were used to
follow BD activity. Immunosuppressant therapy was instituted prior to endovascular treatment unless a
contraindication existed.Results: From 1998 to 2012, 10 patients (eight male, two female; median age, 39)
with BD and aortic pseudoaneurysm were treated with endovascular stent grafting at this institution. Ninety
percent of these patients received immunosuppressive therapy before and after surgical treatment. The
median follow-up period was 57 months (interquartile range, 43-72). The locations of the 12
pseudoaneurysms treated in this cohort were infrarenal abdominal aorta (seven), descending thoracic aorta
(four), and aortic arch (one). Median pseudoaneurysm size was 4.5 cm (interquartile range, 3.4-5.9). At
long-term follow-up, complete resolution of the aortic pseudoaneurysm was noted in all patients. No
endoleaks occurred. Newly developed pseudoaneurysm at the distal margin of the stent graft was noted in
one patient 17 months after the stent graft procedure. One patient required a subsequent stent graft
placement for an expanding pseudoaneurysm of the subclavian artery. No patient deaths occurred during
the follow-up period.Conclusions: Endovascular treatment of aortic pseudoaneurysm with stent-grafting in
patients with BD is safe and effective with long-term durability.
Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic
deficits - Corrected Proof
18 Nov 2013 12:00 am
Objective: The aim of the study was to assess the outcomes of carotid endarterectomy (CEA) performed in
an urgent setting on acutely symptomatic patients selected through a very simple protocol.Methods: From
January 2002 to January 2012, 193 symptomatic patients underwent CEA. Of these, 90 presented with
acute symptoms, and after a congruous carotid stenosis was identified, underwent urgent operations (group
1): 27 patients had transient ischemic attack (group 1A), 52 patients had mild to moderate stroke (group
1B), and 11 patients had stroke in evolution (group 1C). The remaining 103 patients with a nonrecent
neurologic deficit were treated by elective surgery in the same period (group 2). End points were 30-day
neurologic morbidity and mortality.Results: The median delay of urgent CEA (U-CEA) from deficit onset was
48 hours (interquartile range, 13-117 hours). Groups 1 and 2 were comparable in demographics. Acute
patients showed a higher rate of stroke at presentation (70% vs 37%; P = .001) and of history of coronary
artery disease (30% vs 13.5%; P = .007). Acute patients sustained six postoperative strokes (6.6%).
Neurologic outcomes were correlated to clinical presentation: no strokes occurred in group 1A patients, and
5.8% group 1B patients and 27.3% group 1C patients had postoperative stroke (P < .01). Postoperative
mortality was 4.4% for U-CEA: one fatal myocardial infarction, one intracranial hemorrhage, and two
thromboembolic strokes. Elective patients sustained four postoperative strokes (3.9%), with one death
(0.9%) as a consequence of hyperperfusion cerebral edema. U-CEAs performed ≤48 hours from symptom
onset had a lower postoperative stroke rate than those performed >48 hours (4.4% vs 8.8%; P = .3). Among
patients presenting with a stroke (group 1B), the National Institutes of Health Stroke Scale (NIHSS)
assessment at discharge showed improvement in 79% (although only 25% had ≥4 points in reduction),
stability in 17%, and deterioration in 4%. Patients with moderate stroke were slightly better in NIHSS
improvement than those with mild stroke (median NIHSS variation at discharge, −3 vs −1; P =
.001).Conclusions: Our results with U-CEA confirm that this population has a higher risk profile compared
with elective surgery. The type of acute presentation is correlated with perioperative risk. U-CEA was safe
when performed on patients presenting with transient ischemic attack. An acceptable complication rate was
achieved for patients with minor to moderate strokes. The poorest outcomes occurred in patients presenting
with stroke in evolution: U-CEA in these patients should be offered with extreme caution, although we are
aware that a conservative treatment may not grant a better prognosis.
Pitfalls of Population-Based Preventive Medicine
27 Nov 2013 12:00 am
To the Editor In a Special Communication, Dr Fineberg explored pitfalls of population-based preventive
medicine. Although unintended, the article confirmed for me that cardiovascular prevention practiced by
clinicians today is far different from classic prevention. Fineberg distinguished 2 medical approaches,
curative and preventive. My practice, and that of many other clinicians, is actually a hybrid, and
interventional prevention solves several problems cited by Fineberg. A hypothetical case helps elucidate
this.
Platelet inhibition by adjunctive cilostazol suppresses the frequency of cerebral ischemic
lesions after carotid artery stenting in patients with carotid artery stenosis - Corrected Proof
18 Nov 2013 12:00 am
Objective: Optimal platelet inhibition is an important therapeutic adjunct in patients with carotid artery
stenosis undergoing carotid artery stenting (CAS). Clopidogrel resistance is associated with increased
periprocedural thromboembolic complications from neurovascular stent placement procedures. The addition
of cilostazol to dual antiplatelet therapy (DAT) has been reported to reduce platelet reactivity and to improve
clinical outcomes after percutaneous coronary intervention. This study was undertaken to evaluate the
impact of adjunctive cilostazol in patients with CAS.Methods: Platelet function was assessed by light
transmittance aggregometry using the VerifyNow assay. Sixty-four consecutive patients who underwent
CAS received standard DAT, clopidogrel (75 mg daily), and aspirin (100 mg daily) more than 4 weeks
before the procedure. From 2010 to 2011 (period I), 28 patients underwent CAS under standard DAT. From
2011 to 2013 (period II), 36 patients prospectively had preoperative assessment of platelet function, and 13
patients with clopidogrel resistance received adjunctive cilostazol (200 mg daily) in addition to standard
DAT. The incidence of new ipsilateral ischemic lesions on diffusion-weighted imaging a day after CAS and
ischemic or hemorrhagic events within 30 days was assessed.Results: Clopidogrel resistance was
indentified in 12 patients (43%) in period I and 13 patients (36%) in period II (P = .615). In period II, the
addition of cilostazol significantly decreased P2Y12 reaction units and % inhibition (P = .006 and P = .005,
respectively), and there was a significant difference in P2Y12 reaction units between the two periods. New
ipsilateral ischemic lesions were significantly decreased in period II (2/36 patients) compared with period I
(7/28 patients; P = .034); however, there was no significant difference in hemorrhagic and thromboembolic
events between the two periods.Conclusions: Adjunctive cilostazol (triple antiplatelet therapy) in clopidogrelresistant patients reduces the rate of clopidogrel resistance and suppresses new ischemic lesions without
hemorrhagic complications, as compared with standard DAT. Antiplatelet management based on the
evaluation of antiplatelet resistance would be required for prevention of perioperative thromboembolic
complications in CAS.
Preloaded guidewires to facilitate endovascular repair of thoracoabdominal aortic aneurysm
using a physician-modified branched stent graft - Corrected Proof
22 Nov 2013 12:00 am
Branched stent grafts have been widely applied to treat complex aortic aneurysms. The technique often
requires brachial or axillary approach to provide antegrade access to directional branches, which are
bridged to target visceral arteries by self-expandable stent grafts. Preloaded guidewire catheterization may
facilitate access into directional branches, decreasing or eliminating catheter manipulations required during
this step of the procedure. We describe the use of a physician-modified branched stent graft using
preloaded guidewire catheterization to treat a patient with recurrent, type III thoracoabdominal aortic
aneurysm. The procedure was performed with no complications, and total operative time was 300 minutes,
fluoroscopy time was 81 minutes, and iodinated contrast dose was 210 mL. Computed tomographic
angiography revealed no endoleak and widely patent branches at 2 months.
Reinfection after resection and revascularization of infected infrarenal abdominal aortic
grafts - Corrected Proof
18 Nov 2013 12:00 am
Objective: Despite advances in perioperative care, long-term and amputation-free survival rates are poor
after resection of infected abdominal aortic grafts. We reviewed our cases to determine the rate of
reinfection and risk factors for mortality and limb loss.Methods: We reviewed cases with infrarenal aortic
graft infection from 1999 to 2013. Cases requiring graft excision were included for analysis. Thoracic and
thoracoabdominal aortic grafts were excluded. Reconstruction types included both extra-anatomic and in
situ grafts. Patient comorbidities, surgical outcomes, and known reinfection rates were assessed. Univariate
and Kaplan-Meier analysis were performed.Results: Twenty-eight patients had resection of infected
infrarenal abdominal aortic grafts during the study period. Most patients (26/28; 93%) had infected aortoiliac
or aortofemoral prosthetic bypass grafts, but two of 28 patients had infected endovascular aortoiliac stent
grafts. The median age was 69 years (range, 46-86 years), with 68% men and 32% women. Aortoenteric
fistulae or graft-enteric erosions were noted in 12 of 28 (43%) patients at operation. There were 79% of
patients who had in situ reconstruction, including 4 (14%) with polyester, 1 (4%) with
polytetrafluoroethylene, 3 (11%) with cadaveric homograft, 3 (11%) with composite grafts, and 11 (39%)
with native femoropopliteal vein grafts. Five (18%) patients had extra-anatomic bypass and one had
excision without revascularization. In-hospital mortality after initial graft excision and revascularization
occurred in two (7%) patients. Seven (25%) patients had evidence of reinfection after a median of
20 months, of whom five underwent reintervention with two additional in-hospital deaths. All in-hospital
deaths occurred in patients with graft-enteric contamination. Overall limb salvage and survival at a mean
follow-up of 2.5 years were 82% and 46%, respectively, and did not differ among revascularization types
(P = .85 and .74). One-year amputation-free survival was 47% overall. Three patients with native
femoropopliteal vein graft repair required amputation in follow-up. Diabetes was the only observed risk
factor for amputation (P = .05). Risks for mortality included history of cerebrovascular disease (P = .05) and
shock on presentation (P = .04). No other comorbid condition, type of revascularization, or perioperative
complication was associated with limb loss or mortality on univariate analysis.Conclusions:
Revascularization after excision of infected abdominal aortic grafts can be done with acceptable in-hospital
morbidity and mortality. Reinfection is problematic, regardless of revascularization conduit, and is
associated with limb loss and death. New and aggressive local anti-infective strategies are warranted.
Risks Higher for Some Estrogen Drugs
27 Nov 2013 12:00 am
Use of conjugated equine estrogens (CEEs) to relieve the vasomotor symptoms of menopause is
associated with about twice the risk of venous thrombosis compared with oral estradiol, according to a
population-based case-control study of postmenopausal women (Smith NL et al. JAMA Intern
Med.doi:10.1001/jamainternmed.2013.11074 [published online September 23, 2013]).
Selected Abstracts from the December Issue of the Journal of Vascular Surgery
01 Dec 2013 12:00 am
Charles J. Keith Marc A. Passman, Michael J. Gaffud, Zdenek Novak, Benjamin J. Pearce, Thomas C.
Matthews, Mark A. Patterson, and William D. Jordan Introduction: Size threshold for operative repair of
abdominal aortic aneurysms (AAAs) has been determined based on risks and outcomes of open repair vs
surveillance. The influence of endovascular aneurysm repair (EVAR) on this threshold is less established.
The purpose of this study is to determine whether long-term outcomes following EVAR are affected by
maximum diameter at the time of treatment.
Statins: new American guidelines for prevention of cardiovascular disease
30 Nov 2013 12:02 pm
Publication date: 30 November–6 December 2013
Source:The Lancet, Volume 382, Issue 9907
Author(s): Paul M Ridker , Nancy R Cook
Surgical management of isolated superficial femoral artery degenerative aneurysms Corrected Proof
07 Nov 2013 12:00 am
Objective: To investigate the mode of presentation, diagnosis, association with other aneurysms, operative
management, and outcomes of superficial femoral artery (SFA) aneurysms.Methods: Records of all patients
who underwent surgery for isolated, true SFA aneurysms (not due to infection, vasculitis, or tissue
disorders) from 2002 to 2012 in two European centers were retrospectively analyzed. Demographic (sex,
age), clinical (cardiovascular risk factors, location of the aneurysm, symptoms, presentation, emergency
setting), surgical and radiological data (diameter, surgical technique, runoff vessels patency, presence of
aneurysms elsewhere) were obtained for analysis. Follow-up was undertaken with clinical and ultrasound
examinations at 1 month, 3 months, 6 months, 12 months, and yearly thereafter. The patency of the graft
and the status of the anastomoses and inflow and outflow vessels were assessed. Main end points were
represented by 30 days and long-term mortality and amputation-free survival.Results: A total of 27 cases of
SFA aneurysm were analyzed. Mean age at operation was 78 years ± 8.5. At presentation, SFA aneurysms
were often symptomatic (rupture was present in 7/27 cases and acute distal ischemia in 6/27 cases), large
(mean diameter, 54 mm ± 33.1 mm), bilateral (38% of the cases), and associated with aneurysms
elsewhere (84%). Sixteen patients underwent resection of the aneurysm and polytetrafluoroethylene
interposition graft, seven patients exclusion of the aneurysm with a femoropopliteal bypass (autogenous
bypass in five cases, prosthetic in two), three patients simple ligation, and one patient underwent primary
amputation. Mean follow-up was 41.47 months (range, 0.43-128.67 months). Early (<30 days) mortality and
amputation rate were 4% and 7%, respectively. Estimated 5-year survival, limb salvage, and graft patency
rates were 62%, 88%, and 85%, respectively.Conclusions: Degenerative aneurysms of the SFA display
peculiar characteristics (in terms of clinical onset, diagnostic timing, and clinical behavior) so that they differ
from other peripheral aneurysms. In fact, they often grow to reach a considerable diameter before medical
attention is sought, presenting with rupture or ischemia at diagnosis. SFA aneurysms preferentially affect
elderly men and are often associated with aneurysms elsewhere. However, despite their rarity, the
treatment is usually feasible, and long-term outcomes are good.
The use of cryopreserved aortoiliac allograft for aortic reconstruction in the United States Corrected Proof
18 Nov 2013 12:00 am
Background: Aortic infections, even with treatment, have a high mortality and risk of recurrent infection and
limb loss. Cryopreserved aortoiliac allograft (CAA) has been proposed for aortic reconstruction to improve
outcomes in this high-risk population.Methods: A multicenter study using a standardized database was
performed at 14 of the 20 highest volume institutions that used CAA for aortic reconstruction in the setting
of infection or those at high risk for prosthetic graft infection.Results: Two hundred twenty patients (mean
age, 65; male:female, 1.6/1) were treated since 2002 for culture positive aortic graft infection (60%), culture
negative aortic graft infection (16%), enteric fistula/erosion (15%), infected pseudoaneurysm adjacent to the
aortic graft (4%), and other (4%). Intraop cultures indicated infection in 66%. Distal anastomosis was to the
femoral artery and iliac. Mean hospital length of stay was 24 days, and 30-day mortality was 9%.
Complications occurred in 24% and included persistent sepsis (n = 17), CAA thrombosis (n = 9), CAA
rupture (n = 8), recurrent CAA/aortic infection (n = 8), CAA pseudoaneurysm (n = 6), recurrence of
aortoenteric fistula (n = 4), and compartment syndrome (n = 1). Patients with full graft excision had
significantly better outcomes. Ten (5%) patients required allograft explant. Mean follow-up was 30 ±
3 months. Freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%,
respectively, at 5 years. Primary graft patency was 93% at 5 years, and patient survival was 75% at 1 year
and 51% at 5 years.Conclusions: This largest study of CAA indicates that CAA allows aortic reconstruction
in the setting of infection or those at high risk for infection with lower early and long-term morbidity and
mortality than other previously reported treatment options. Repair with CAA is associated with low rates of
aneurysm formation, recurrent infection, aortic blowout, and limb loss. We believe that CAA should be
considered a first line treatment of aortic infections.
Thoracic endovascular aortic repair in management of aortoesophageal fistulas - Corrected
Proof
07 Nov 2013 12:00 am
Objective: To provide a systematic review of the outcomes of thoracic endovascular aortic repair (TEVAR)
for aortoesophageal fistula (AEF) and to identify prognostic factors associated with poor
outcomes.Methods: Literature searches of the Embase, Medline, and Cochrane databases identified
relevant articles reporting results of TEVAR for AEF. The main outcome measure was the composite of
aortic mortality, recurrence of the AEF, and stent graft explantation. The secondary outcome measure was
aortic-related mortality.Results: Fifty-five articles were integrated after a literature search identified 72
patients treated by TEVAR for AEFs. The technical success rate of TEVAR was 87.3%. The overall 30-day
mortality was 19.4%. Prolonged antibiotics (>4 weeks) were administered in 80% of patients. Concomitant
or staged resection or repair of the esophagus was performed in 44.4% of patients. Stent graft explantation
was performed within the first month after TEVAR as a planned treatment in 11.1%. After a mean follow-up
of 7.4 months (range, 1-33 months), the all-cause mortality was 40.2%, and the aortic-related mortality was
33.3. Prolonged antibiotic treatment (P = .001) and repair of AEFs due to a foreign body (P = .038) were
associated with a significant lower aortic mortality. On univariate analysis, TEVAR and concomitant or
staged adjunctive procedures (resection, repair of the esophagus, or a planned stent graft explantation)
were associated with a significantly lower incidence of aortic-related mortality (P = .0121). When entered
into a binary logistic regression analysis, prolonged antibiotic treatment was the only factor associated with
a significant lower incidence of the endpoint (P = .003).Conclusions: Late infection or recurrence of the AEF
and associated mortality rates are high when TEVAR is used as a sole therapeutic strategy. Prolonged
antibiotic treatment has a strong negative association with mortality. A strategy of a temporizing
endovascular procedure to stabilize the patient in extremis, and upon recovery, an open surgical
esophageal repair with or without stent graft explantation is advocated.
Treatment of Atherosclerotic Renovascular Disease
18 Nov 2013 09:00 pm
New England Journal of Medicine, Volume 0, Issue 0, Ahead of Print.
Unplanned readmissions after vascular surgery - Corrected Proof
18 Nov 2013 12:00 am
Objective: Existing literature on readmission after vascular surgery is limited. The upcoming reduction in
Medicare reimbursement for institutions with high readmission rates mandates an accurate understanding
of this issue. In this study, we characterize the frequency and causes of 30-day unplanned readmissions
after elective vascular surgery.Methods: Patients who underwent elective carotid endarterectomy (CEA),
endovascular aortic repair (EVAR), open abdominal aortic aneurysm (oAAA) repair, or infrainguinal bypass
grafting (BPG) were identified from the American College of Surgeons (ACS) National Surgical Quality
Improvement Program (NSQIP) 2011 database (n = 11,246). Multivariable logistic regression was used to
determine variables that contributed to 30-day unplanned readmissions for each surgery type.Results: The
unadjusted unplanned readmission rates after the four vascular procedures ranged from 6.5% for CEA to
15.7% for BPG. In multivariable analyses, patient comorbidities were associated with unplanned
readmission after BPG and CEA (P < .05), whereas postoperative complications were more consistently
associated with unplanned readmission after EVAR and oAAA repair (P < .05). For all procedures,
complications leading to readmission developed more frequently after discharge. Thirty-day mortality was
significantly higher in readmitted patients after BPG (1.9% vs 0.3%), EVAR (3.9% vs 0.1%), and CEA (2.2%
vs 0.2%; P < .001 for each), but not after oAAA repair.Conclusions: Select comorbidities and postoperative
complications contribute to unplanned readmissions after vascular surgery. The characteristics of
readmitted patients vary with the type of procedure. Interventions designed to mitigate these factors have
the potential to reduce unplanned readmissions but likely need to vary with the type of vascular treatment.
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