Annals of Vascular Surgery - Articles in Press

Intraoperative Duplex and Functional Popliteal Entrapment Syndrome: Strategy for Effective Treatment - Corrected Proof

2010-02-08

Functional popliteal entrapment syndrome (FPES) was first described by Rignault and colleagues in 1985 (Int. Angiol. 1985;4:341–343). This syndrome results from compression of the popliteal artery by a hypertrophied medial head of the gastrocnemius muscle with no other identifiable anatomical abnormality. The incidence, significance, natural history, and appropriate treatment of this syndrome remain controversial. We present three cases of FPES where intraoperative positional duplex scans guided gastrocnemius muscle resection and confirmed appropriate resection. Additionally, B-mode duplex obtained during one of the cases demonstrated intimal changes consistent with repetitive vessel trauma. All patients had resolution of their claudication and normal physiological testing postoperatively.

Use of a Viabahn Stent for Repair of a Common Carotid Artery Pseudoaneurysm and Dissection - Corrected Proof

Scott R. Golarz, Dennis Gable — 2010-02-08

Carotid procedures in the previously operated neck are both technically demanding and subject to increased rates of complications. Adding radiation to the operated field only increases these risks. The incidence of cranial nerve injury in the reoperative neck has increased. Similarly, patients with a history of radiation are at increased risk for stroke, cranial nerve injury, and wound complications. Before the endovascular era, the only option for repair of an extracranial carotid aneurysm was open operation. Recently, more experience has been gained using endovascular techniques to repair these aneurysms. We present a patient with a history of radiation and radical neck dissection who developed a pseudoaneurysm of the common carotid artery. This pseudoaneurysm was repaired successfully using a Viabhan® covered stent graft.

Laparoscopic Resection of Retroperitoneal Schwannoma Near the Inferior Vena - Corrected Proof

Mehmet Gorgun, Taylan Ozgur Sezer, Ozgur Kirdok — 2010-02-08

Background: Schwannomas are usually benign tumors that arise from the schwann cells in the neural sheaths of peripheral nerves. Most schwannomas occur in the head, neck, or limbs and rarely in the retroperitoneal space. In the retroperitoneal space, schwannomas are most commonly located near the adrenal gland. We report a successfully resected retroperitoneal benign schwannoma near the inferior vena cava (IVC) using laparoscopic surgery.Methods/Results: A 33-year-old woman presented with dull abdominal pain for several months. Magnetic resonance imaging confirmed the existence of a round, sharply demarcated retroperitoneal solid tumor, 42 × 52 mm in size, located between the anterior of the right kidney and the IVC, which was compressed but still patent. The lesion was laparoscopically resected, and pathologic examination revealed a degenerative schwannoma.Conclusion: Laparoscopic surgery is very useful and feasible in the diagnosis and treatment of retroperitoneal schwannoma, with minimal invasiveness and early postoperative recovery.

An 18-cm-Large Renal Arteriovenous Fistula Treated by Nephrectomy - Corrected Proof

2010-02-08

Idiopathic renal arteriovenous fistulas are extremely rare. They are believed to occur as the result of congenital renal artery aneurysm that erodes into an adjacent vein. We report a case of a 48-year-old man in whom we discovered fortuitously a painless mass of the right flank. Computed tomography revealed a huge renal artery aneurysm with giant arteriovenous fistula in the absence of any clinical stigmata. Given the size of the fistula and the partial destruction of the renal parenchyma, nephrectomy was successfully performed.

Use of Wall® Stent to Exclude a Thrombosed Inferior Vena Cava Filter - Corrected Proof

Scott R. Golarz, Brad Grimsley — 2010-02-08

The use of inferior vena cava (IVC) filters has increased dramatically over the last two decades. Thrombosis of the IVC is a potentially catastrophic complication of caval filter placement, and its reported incidence ranges 3.6-11.2%, depending on filter type. We present a 69-year-old female with a history of deep vein thrombosis of the right leg. Prior to a planned spinal operation, a Gunther Tulip filter was placed (Cook Medical, Bloomington, IN). Postoperatively, the patient developed bilateral iliofemoral thrombosis that extended into the IVC filter. Several weeks passed, and after unsuccessful attempts at recanalization in the community setting, the patient was referred to our group for treatment. After an unsuccessful attempt at balloon angioplasty, two 10×60mm Protégé GPS stents (EV3, Plymouth, MN) were deployed in the common femoral, external, and internal iliac veins bilaterally. After an unsuccessful attempt at retrieval, the Tulip filter was excluded from the IVC using a 16×60mm Wall Stent (Boston Scientific, Natick, MA). Unobstructed flow was now noted from the femoral system all the way through the superior vena cava. The patient experienced immediate relief of her symptoms.

Bifurcated Endograft Repair of Ilio-iliac Arteriovenous Fistula Secondary to Lumbar Diskectomy - Corrected Proof

2010-02-08

Ilio-iliac arteriovenous (AV) fistula is a rare complication after lumbar diskectomy. Endovascular repair of such fistulas is a growing trend in vascular surgery. This is a case report of an endovascular exclusion of an ilio-iliac AV fistula in a 51-year-old male. This man presented with high-output congestive heart failure and ascites. The AV fistula was discovered 17 years after a lumbar diskectomy. Computed topography (CT) revealed a right common iliac artery pseudoaneurysm connecting to the left common iliac vein. The fistula was repaired using a bifurcated Gore Excluder endograft. There were follow-up CT scans at 6 and 10 months confirming exclusion of the AV fistula. Endovascular AV fistula repair offers a safe, effective method for managing ilio-iliac AV fistulas.

Endovascular Treatment of Late “Endoleak” Following Open Surgical Repair Using Bypass and Exclusion Aneurysm Repair - Corrected Proof

2010-02-08

Background: We sought to present endovascular management options of persistent or recurrent aneurysm sac flow (“endoleak”) after operative retroperitoneal exclusion of infrarenal abdominal aortic aneurysm (AAA).Methods: Recurrent or persistent aneurysm perfusion was diagnosed in three patients primarily treated with aneurysm exclusion and bypass. The medical history, course of disease, and surgical management of these patients were reviewed.Results: Three patients primarily treated for infrarenal AAA by division of the aorta with suture closure of the proximal aneurysm end, ligation of the outflow vessels, and bypass of the excluded aortoiliac segment presented with persistent or recurrent AAA sac perfusion and growth. The feeding vessels were the iliac arteries in all cases. Endovascular repair using coil embolization and/or deployment of an occluder or stent-graft was successful in all patients with a follow-up of 42, 36, and 30, months respectively.Conclusion: Open AAA repair using the exclusion and bypass technique is associated with the risk of persistent perfusion or reperfusion of the aneurysm sac, which is similar to an endoleak after endovascular aortic aneurysm exclusion. Endovascular therapy should be considered as first-choice treatment when feasible.

Bifurcated Abdominal Aortic Endograft Deployment via the Carotid Artery - Corrected Proof

S. Paravastu, F. Farquharson, F. Serracino-Inglott — 2010-02-08

Background: We report the use of the common carotid artery as an alternate access in endovascular therapy.Methods/Results: A 77-year-old man with an enlarging abdominal aortic aneurysm in whom previous attempts at standard endovascular repair had failed because of difficult iliac access underwent endovascular repair via the left common carotid artery. A custom-made Zenith infrarenal bifurcated stent graft was reverse-loaded on a thoracic distal delivery device and deployed in a caudal-to-cranial fashion. The patient made an uneventful recovery without any complications. Computed tomography confirmed exclusion of the aneurysm.Conclusion: This case report highlights the role of the common carotid artery as an access vessel for stent-graft deployment when standard access via the femoral and iliac routes is unachievable.

Isolated Atherosclerotic Aneurysm of the Profunda Femoris Artery - Corrected Proof

Franko Milotic, Irena Milotic, Vojko Flis — 2010-02-08

Abstract: True aneurysms of the profunda femoris artery are extremely rare in comparison to pseudoaneurysms of the same artery. In most cases they are accompanied by aneurysms of the abdominal aorta or peripheral vessels. The most common reason for aneurysmic dilatation of vessels is a generalized vascular degenerative process. An isolated true aneurysm of the profunda femoris artery due to atherosclerosis is markedly unusual. These aneurysms have a high incidence of complication; therefore surgical management is mandatory for all diagnosed cases regardless of whether they are symptomatic or not. We describe a case of a 73-year-old man with a large isolated atherosclerotic aneurysm of the profunda femoris artery. He presented with an enlarging, progressively debilitating mass in his upper thigh. Ultrasound and computed tomography-angiography demonstrated a 15 × 14 cm large aneurysm of the profunda femoris artery. The patient was successfully treated by aneurysm neck ligation and sac decompression.

Novel Endovascular Techniques for Repair of Traumatic Bilateral Axillary Artery Disruption with Long-Term Follow-Up - Corrected Proof

2010-02-04

We describe a case of innovative endovascular techniques to repair traumatic bilateral axillary artery disruption. A 36-year-old male construction worker fell eight stories from a scaffold and sustained bilateral axillary artery injuries. The injuries between the brachial and axillary arteries were bridged using long bare self-expanding stents (Zilver). To the best of our knowledge, this is a novel case report from a level-one trauma center where endovascular techniques were employed to repair bilateral axillary arteries with long-term follow-up.

Paraparesis after Thoracic Stent-Graft Relining for an Unrecognized Type III Endoleak - Corrected Proof

2010-02-02

Purpose: We examined the reasons for missing a type III endoleak on conventional imaging and the pathophysiology of paraparesis after relining this stent graft.Case Report: A 46-year-old man was treated with a thoracic stent graft for thoracic rupture of a chronic type B thoracoabdominal dissection with aneurysm formation. In a second intervention, retrograde revascularization of the visceral and renal arteries was performed in combination with insertion of an abdominal stent graft. After initial shrinkage of the aneurysmal sac, the thoracic aortic diameter started increasing again. Consecutive three-phase helical computed tomographic scans did not reveal any endoleak. Because of unbearable back pain, an open surgical exploration was performed. This showed a type III endoleak. Relining of the thoracic stent graft was performed, but paraparesis developed.Discussion: In patients with unexplained increase of the aneurysmal sac contrast-enhanced magnetic resonance imaging could help to illuminate the underlying endoleak. The collateral network concept can explain spinal cord injury by even minor hemodynamic changes.

Strategies to Distinguish Benign Paroxysmal Positional Vertigo from Rotational Vertebrobasilar Ischemia - Corrected Proof

2010-01-28

Vertigo provoked by head rotation is a classic symptom of rotational vertebrobasilar ischemia (RVBI). Inner ear disease can cause positional vertigo and mimic RVBI. We review the case of a patient with vertigo consistently triggered by leftward head rotation when supine. Computed tomography angiogram and dynamic arteriogram failed to show compression of the vertebral arteries with head rotation. Further evaluation revealed benign paroxysmal positional vertigo (BPPV) as the underlying etiology. Treatment of her BPPV led to complete resolution of her symptoms. A succinct overview of this common otologic disorder is provided, and strategies to help distinguish it from RVBI are discussed.

Abdominal Wall Infected Ischemic Necrosis Mimicking Necrotizing Fasciitis - Corrected Proof

Paul David Ainsworth, Linda de Cossart — 2010-01-25

Emergency surgery to revascularize an ischemic leg in the presence of an aortic aneurysm presents a series of difficult management decisions in both the operative and postoperative phases. We present a case of infected ischemic necrosis that developed in a discrete tissue plane from a transverse incision mimicking necrotizing fasciitis. A 57-year-old man presented with an ischemic leg associated with a 5-cm abdominal aortic aneurysm. The sudden appearance of gangrenous tissue in the inferior flap of the transverse abdominal incision prompted urgent surgical debridement. This case report describes the management of a potentially misleading clinical condition. The key points to remember are to maintain a high index of suspicion for potentially life-threatening soft tissue infections, to be vigilant about regular wound inspection, and to act decisively when urgent wound debridement is indicated.

Surgical Treatment of an Infected Popliteal Artery Aneurysm 12 Years after Aneurysm Exclusion and Bypass: A Case Report and Review of the Literature - Corrected Proof

Luke M. Funk, William P. Robinson, Matthew T. Menard — 2010-01-25

The presence of persistent blood flow in popliteal artery aneurysms that have been treated with exclusion and bypass is surprisingly common. Complications from incompletely excluded aneurysms include aneurysm enlargement, local compressive symptoms, and sac rupture. Infection of a previously excluded and bypassed popliteal artery aneurysm is a notably rare complication. In this case report, we describe a patient with an infection of a popliteal artery aneurysm 12 years following surgical repair. The patient was successfully treated with aneurysm resection and soft tissue debridement.

Delayed Presentation of Popliteal Pseudo-aneurysm Following Soccer Football Injury - Corrected Proof

Y.C. Chan, A.C. Ting, K.X. Qing, S.W. Cheng — 2010-01-25

Abstract: Development of pseudo-aneurysm of the popliteal artery usually results from trauma, infection, or iatrogenic causes after orthopedic operations. This is to our knowledge the first reported case in the world's literature of a delayed presentation of a large above-knee popliteal artery pseudo-aneurysm following a soccer football injury. The pseudo-aneurysm severely compressed the native artery, and open exploration with surgical vein-patch repair of the artery was chosen in preference to endovascular stent-graft in view of the compressive symptoms and large size of the chronic pseudo-aneurysm. This case highlights the importance of imaging such as duplex ultrasound, computed tomography, or magnetic resonance angiography if symptoms persist after sports injury.

The Management of Aortic Stent-Graft Infection: Endograft Removal Versus Conservative Treatment - Corrected Proof

2010-01-25

Background: Aortic stent-graft infections (ASGIs) are associated with significant mortality. We report our experience of two cases of ASGI treated differently and successfully.Methods: Two patients presented with constitutional symptoms some months after scheduled endovascular repair of aortic aneurysm (EVAR). Patient 1 had an abscess formation around the endograft in continuity with the right groin. Due to patient comorbidities, a conservative treatment was performed. Patient 2 had an abscess formation with air surrounding the stent graft. The patient was treated successfully by endograft removal.Results: Computed tomographic scan follow-up at 6 months from surgery showed no evidence of recurrent infection.Conclusion: Despite the recommended treatment of ASGI being surgery, conservative treatment can be performed successfully in patients with high surgical risk, avoiding aortic clamping. We present the first reported case of ASGI due to Streptococcus haemolyticus, the second case due to a fungus, and the second reported case of spondylodiscitis after EVAR.

Recurrent Upper Extremity Embolism Due to a Crutch-Induced Arterial Injury: A Different Cause of Upper Extremity Embolism - Corrected Proof

In Sung Moon, Jeong Kye Hwang, Ji Il Kim — 2010-01-25

Acute embolism of the upper extremity is a relatively infrequent event compared to the lower extremity, but it will affect the function of the limb involved and may occasionally lead to amputation. Most upper extremity emboli are of cardiac origin, with the remainder arising from subclavian aneurysm, occlusive disease, or iatrogenic causes. Rarely, crutch-induced repetitive trauma of an upper extremity can produce recurrent embolic events. Frequently, this process is initially diagnosed and treated as a brachial artery embolism; such a misdiagnosis is associated with recurrent embolism. We report herein two uncommon cases of axillobrachial arterial injuries secondary to crutch trauma as a source of recurrent emboli to an upper extremity.

Carotid Artery Stenting - Corrected Proof

David Paul Slovut — 2009-12-25

ALKK, Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärtze Carotid Artery Stent Registry; ARCHeR, ACCULINK for Revascularization of Carotids in High-Risk Patients; BEACH, Boston Scientific EPI: A Carotid Stenting Trial for High-Risk Surgical Patients; CABERNET, Carotid Artery Revascularization Using the Boston Scientific FilterWire EX®/EZ™ and the Endotex™ NexStent®; CARESS, Carotid Revascularization Using Endarterectomy or Stenting Systems; CAS, carotid artery stenting; CASES-PMS, CAS with Emboli Protection Surveillance—Post-Marketing Study; CAST I, Carotid Artery Stent Trial; CAVATAS, Carotid and Vertebral Transluminal Angioplasty Study; CEA, carotid endarterectomy; CREATE, Carotid Revascularization with ev3 Arterial Technology Evolution; CREST, Carotid Revascularization Endarterectomy vs. Stenting Trial; CVA, cerebrovascular accident; EPD, embolic protection device; EVA-3S, Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; ICSS, International Carotid Stenting Study (CAVATAS-2); MAVErIC, Evaluation of the Medtronic AVE Self-Expanding Carotid Stent System with Distal Protection in the Treatment of Carotid Stenosis; MI, myocardial infarction; MRI, magnetic resonance imaging; NR, not reported; PRIAMUS, Proximal Flow Blockage Cerebral Protection during Carotid Stenting; Pro-CAS, Prospective Registry of Carotid Artery Stenting; PTA, percutaneous transluminal angioplasty; RCT, randomized controlled trial; SAPPHIRE, Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy; SECuRITY, Study to Evaluate the Neuroshield Bare Wire Cerebral Protection System and X-Act Stent in Patients at High Risk for Carotid Endarterectomy; SPACE, Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy; TLR, target lesion revascularization.

Acute Thrombosis of an Abdominal Aortic Aneurysm followed by Delayed Rupture Associated with Bacterial Infection - Corrected Proof

Brandon M. Ishaque, Phillip S. Ge, David Rigberg, Christian de Virgilio — 2009-12-25

Sudden thrombosis of an abdominal aortic aneurysm (AAA) is distinctly rare and is associated with up to 50% mortality. Almost equally rare is infection of a preexisting AAA. We report an extremely unusual case of an AAA that thrombosed leading to acute limb ischemia. This was followed several months later by a delayed rupture of the thrombosed AAA associated with an Escherichia coli infection. We suspect the aortic thrombus was hematogenously seeded by a urinary tract infection. A review of the literature revealed that bacterial infection of a previously thrombosed AAA, leading to a delayed rupture, has not been previously reported.

Aneurysmectomy With Arterial Reconstruction of Renal Artery Aneurysms in the Endovascular Era: A Safe, Effective Treatment for Both Aneurysm and Associated Hypertension - Corrected Proof

2009-12-25

Background: Renal artery aneurysms (RAAs) represent a rare vascular pathology with an estimated incidence of <1%. Although an endovascular approach is being increasingly used to treat RAAs, we hypothesized that open surgical repair of RAA, specifically via aneurysmectomy with arterial reconstruction (AAR), is a safe, effective treatment, particularly for those with complex aneurysm anatomy.Methods: A review was performed of all patients with RAA, identified by ICD-9 codes, from January 2003 to December 2008 seen at a tertiary care medical center. Data were collected regarding patient demographics, aneurysm characteristics, surgical repair, and outcomes, as well as follow-up care.Results: A total of 14 patients (10 women and 4 men; mean age, 48±19 years) were included, representing 15 aneurysms. Ten aneurysms underwent open repair via AAR and five were followed nonoperatively. Mean RAA size was larger for those undergoing repair (2.12cm vs. 1.62cm, p=0.037). Seven RAAs were repaired in situ with either patch angioplasty or primary repair; three required ex vivo reconstruction; and none underwent bypass. Average operative time was similar for repair type, with a higher blood loss with ex vivo repair. Median length of stay was 5 days (range, 4 to 14 days). Operative repair had no effect on mean systolic blood pressure or GFR. This repair, however, resulted in lower medication requirement for those with concurrent hypertension (2.7 pre vs. 1.6 post, p=0.03). There was a trend toward shorter time until oral intake for retroperitoneal approach compared with transperitoneal. Mean follow-up time was 11.6 months (range, 3 to 30 months). No incidences of rupture, death, nephrectomy, or renal failure occurred in the operative group.Conclusion: In the era of endovascular repairs for RAAs, open repair, specifically via AAR, of RAAs remains a safe treatment with low associated morbidity. RAA repair resulted in a reduction in medications for those with associated hypertension. Open repair of RAAs should be the primary treatment modality for complex RAA, with specific consideration given to those with associated hypertension.

Trials of Endovascular Treatment for Superficial Femoral Artery Occlusive Lesions: A Call for Medically Managed Control Patients - Corrected Proof

Samuel E. Wilson — 2009-12-25

Background: The prevalence of occlusive peripheral vascular disease in the superficial femoral artery approaches 20% in patients over the age of 60. Symptomatic peripheral arterial disease (intermittent claudication) is present in 3% to 7% of patients over the age of 60. The attraction of minimally invasive, percutaneous endovascular angioplasty (PTA) for this large number of patients has resulted in multiple trials of new PTA ± stenting devices. The purpose of this report is to determine whether trials should include controlled patients who have optimal medical management including supervised exercise.Methods and Results: In 2007 through 2008, there were 12 active trials of PTA and stent with 9 of the trials randomized and 6 trials using PTA as the control arm. No trial used a medically managed group. Between 1990 and 2008, a search of PubMed disclosed six publications (five randomized trials) comparing PTA ± stent with medically (exercise) managed claudicants. None of the medically managed patient groups experienced a significant increase in ABI, whereas endovascular patients had an early increase in ABI, which was variably sustained to 1 and 2 years. However, after 6 months, the maximum walking distance was significantly increased in the exercised patients and remained longer than that of the interventional group in four of five trials at 1 to 2 years.Conclusion: Endovascular treatment was superior to medical treatment in functional outcome at 1 year in only one of the five randomized trials for claudication. In the other four trials, medical treatment produced a greater maximum walking distance at 1 to 2 years. Current trials lack optimal medical controls. New trials of PTA + stent should include a medically managed group of patients in a supervised exercise program as the comparator arm. The outcome measure should be maximum walking distance to demonstrate added functional benefit of the new device.

Recurrent Cystic Adventitial Disease of the Ileofemoral Artery: A Case Report - Corrected Proof

Syed Rehman, Louise Hancock, John Wolfe — 2009-12-25

We present the case of a 39-year-old man with recurrence of intermittent claudication 4 years after successful Dacron patch repair of the right common femoral artery for cystic adventitial disease. Magnetic resonance angiography results were inconclusive, while conventional angiography demonstrated 90% stenosis of the right common femoral artery. The patient underwent excision and replacement of the affected artery with PTFE and was asymptomatic at 6-month follow-up. In recurrent cystic adventitial disease, excision and replacement of the affected artery with a prosthetic interposition graft provides a successful outcome with minimal chance of recurrence.

Acceptable Risk but Small Benefit of Endovascular Aneurysm Repair in Nonagenarians - Corrected Proof

2009-12-25

Background: We report the outcomes of a single-center experience with endovascular aneurysm repair (EVAR) in nonagenarians.Methods: Via a retrospective medical records review, we identified all patients ≥90 years old who underwent EVAR at a single university teaching hospital during a 5-year period (January 2004 to December 2008). Patients were evaluated for surgical risk factor profile, preoperative imaging, technical success, postoperative complications, length of hospital stay, and need for secondary intervention. In addition, mortality rates were evaluated at 30 days, 365 days, and 2 years.Results: There were 18 nonagenarians (12 male, 67%) with a mean age of 91.2 years (range 90-95). Each patient averaged 3.5 risk factors, and the mean preoperative maximal aneurysm size was 68.3mm (range 50-105). Sixteen (89%) patients were treated on an elective basis, and two patients were emergently treated for aneurysm rupture, with one undergoing aortouni-iliac stenting with femoral–femoral bypass. All other patients in the study had bifurcated stent grafts. There was 100% technical success with no need for open conversion. The mean length of hospital stay was 4.3 days with a mean intensive care unit stay of 0.6 days. Systemic complications occurred in three patients (17%) including one death within 30 days. Secondary interventions were required in two patients (11%). One had endovascular treatment of a type I endoleak at 4 months, and a second patient underwent femoral–femoral bypass at 25 months for severe flow-limiting limb angulation. Mortality rates were 5.6% at 30 days, 41.2% at 365 days, and 58.3% at 2 years. Mean survival of the 11 patients who expired beyond the first 30 days was 17.5 months (range 4-50). Of these, mean survival of the nine patients treated electively was 20.2 months (range 7-50). Mean survival of the six patients still alive is 25.6 months (range 8-65).Conclusion: EVAR is safe in nonagenarians despite their advanced age and significant surgical risk factor profile. The procedure can be performed with excellent technical success and a low rate of perioperative complications. However, mortality rates after 30 days are significant. The substantial long-term mortality raises the question of possible treatment futility in this unique population. While age should not be a contraindication for EVAR, recommendations for the procedure should be based on individual patient selection.

The Efficacy of Aortic Stent Grafts in the Management of Mycotic Abdominal Aortic Aneurysm—Institute Case Management with Systemic Literature Comparison - Corrected Proof

Chung-Dann Kan, Hsin-Ling Lee, Chwan-Yau Luo, Yu-Jen Yang — 2009-11-24

Background: Conventional surgery (CS) for treatment of mycotic aortic aneurysm has rather high surgical morbidity and mortality rates. The use of endovascular aortic repair (EVAR) might simplify the procedure and provide a good alternative for this critical condition, but this remains to be proved. We analyzed all mycotic abdominal aortic aneurysm (AAA) cases treated by CS or EVAR in our institute and the reported cases treated by EVAR from the literature to determine the risk factors for aneurysm-related mortality and morbidity and to clarify the efficacy of the EVAR technique.Methods and Results: All relevant literature reports of EVAR management of mycotic AAA and all cases treated in our institute, 41 cases, were included and analyzed. Of the 20 cases treated by EVAR, one had early mortality (1/20, 5%); of the remaining 21 cases that received CS, the early mortality rate was 4.8% (1/21). Patients in the CS group had a higher late mortality rate than those in the EVAR group (45% vs. 10.5%, p<0.05). However, the 24-month actual survival rate and actuarial aneurysm-related event-free rate were 83.9±8.6% and 78.3±9.7%, respectively, for the EVAR group and did not significantly differ from the CS group (70.4±10.2% and 80.1±8.9%). The significant predictors for aneurysm-related mortality and morbidity were age, Salmonella species infection, and leukocytosis, and possibly aortoenteric fistula and shock, but not the EVAR or CS procedures themselves.Conclusion: Compared with CS, EVAR might be an alternative strategy for managing mycotic AAAs.

Long-Term Use of Different Doses of Low-Molecular-Weight Heparin Versus Vitamin K Antagonists in the Treatment of Venous Thromboembolism - Corrected Proof

2009-11-24

Background: We evaluated whether the incidence of recurrent venous thromboembolic events (VTEs) during and after therapy differs for patients treated with full or reduced doses of low-molecular-weight heparin (LMWH) used long term compared with vitamin K antagonists (VKAs).Methods: We identified randomized studies of long-term treatment with LMWH or VKA by searching MEDLINE, EMBASE, BIOSIS, and PASCAL. Seventeen studies were included, with 4,002 patients.Results: In the assessment at 12 months of 1,957 patients without cancer, the recurrence rates of VTE in the LMWH/VKA groups were 8.3%/7.6% in the studies using full doses and 12.3%/12.1% in those using prophylactic doses. However, combined analysis after treatment to 1 year showed a nonsignificant (NS) trend to lower recurrent symptomatic VTE in favor of VKA (RR = 1.46, 95% CI 0.96-2.23). In 1,292 patients with cancer the recurrence rates of VTE in the LMWH/VKA groups were 6.5%/17.9% (p = 0.005) in the studies using full doses, 7.1%/13.4% (p = 0.002) in the studies using intermediate doses, and 14.3%/19.1% (p = NS) in the studies using prophylactic doses. Furthermore, the recurrences of VTE after discontinuation of treatment in the LMWH/VKA groups were 1.6%/9.5% (RR = 0.25, 95% CI 0.06-1.1) in 252 patients with full doses and 12%/7.4% (RR = 1.49, 95% CI 0.3-7.48) in 52 patients with prophylactic doses. In this population with cancer, the full-treatment LMWH regimen did not produce more major bleeding events than intermediate or prophylactic doses (5.1% vs. 6.3% or 8.1%, respectively).Conclusion: Full-dose LMWH for 3-6 months is as safe as intermediate and prophylactic doses for the long-term treatment of deep vein thrombosis. In patients with cancer it appears that there is an excess of VTE recurrence after treatment with prophylactic doses that does not occur with full therapeutic doses.

Complications Related to Inferior Vena Cava Filters: A Single-Center Experience - Corrected Proof

2009-11-09

We reviewed our experience with the different types of inferior vena cava (IVC) filters used over 4 years for the incidence of complications and correlated this with the type of filter used. This is a retrospective study involving chart reviews of all the patients who received IVC filters placed between January 2002 and January 2006. Data related to indications for filter insertion and the incidence of early (30 days) and late complications related to the filter insertion were collected. Complications were correlated to the type of filter and the indication for insertion. Statistical analysis was done using Fisher's exact test, and p<0.05 was considered significant. During this period 400 filters were inserted. There were 199 males (49.7%) and 201 females (50.25%). The mean patient age was 61 years (range 17–86). Filters used included TrapEase in 224 (56%), Greenfield filter in 95 (23.8%), Gunther-Tulip in 42 (10.5%), Bard recovery nitinol (all first-generation) in 34 (8.5%), and Simon Nitinol filter in five (1.2%). The indications for IVC filter insertion included acute venous thromboembolism (VTE) event in 273 patients (68.25%) and pulmonary embolism (PE) prophylaxis in 127 (31.75%) patients. In the group with VTE, 59 (21.6%) had contraindication for anticoagulation and 34 (12.5%) had hypercoagulable/malignant conditions. In the 127 patients who received the filter for PE prophylaxis in the absence of VTE, 107 (84.3%) had fractures, 43 (33.9%) had head injury, 32 (25.2%) had multiple trauma, and 15 (11.8%) had paralysis. Sixteen (12.6%) of the prophylaxis patients had IVC filter insertion prior to an elective surgical procedure. Complications in the form of hematoma at the site of filter insertion occurred in four (1%) patients, ipsilateral limb deep vein thrombosis in 15 (3.8%) patients, migration/tilt of filter in six (1.5%) patients, PE in six (1.5%) patients, and IVC thrombosis in 19 (4.75%) patients. Migration/tilt was higher in Bard filters compared to other filters, individually (p<0.004) and as a group (11.8% vs. 0.55%, p<0.0005). All other complication had a comparable incidence in all filters. However, in the group of patients (n=34) who had hypercoagulable/malignant conditions, the incidence of IVC thrombosis was higher with TrapEase filters compared to all other filters as a group (25% vs. 0%, p<0.05). In conclusion, IVC filters are frequently used for prophylaxis in the absence of VTE conditions. Complications are relatively low. All types of filters used in this study had comparable complications with the exception of the Bard filter, which had a higher incidence of tilt, and the TrapEase filter, which had a higher incidence of IVC thrombosis, in patients with hypercoagulable/malignant conditions.

Blood Transfusion and its Effect on the Clinical Outcomes of Patients Undergoing Major Lower Extremity Amputation - Corrected Proof

2009-11-09

Background: Patients in need of lower extremity amputation are often debilitated and have coronary artery disease and underlying anemia. The transfusion of blood is a common practice in the perioperative management of these patients. However, blood transfusion has been reported to have a negative effect on the incidence of perioperative complications in other patient populations. We undertook this study to determine the effect of blood transfusion on the incidence of adverse postoperative events in patients undergoing major amputations.Methods: We conducted a retrospective review of 300 consecutive patients undergoing either above-knee or below-knee amputation over a 5-year period at our institution. The demographic variables, medical comorbidities, need for blood transfusion, and clinical outcomes were recorded. The impact of blood transfusion on clinical outcome was analyzed.Results: Of the 300 patients undergoing major amputation, 191 (64%) had one or more blood transfusions. The demographic variables and incidence of medical comorbidities were comparable between the two groups. Patients undergoing blood transfusion were 2.5 more likely to suffer from a postoperative cardiac arrhythmia, 12.8 times more likely to develop acute renal failure, 5.7 times more likely to have pneumonia, and 2.2 times more likely to have a urinary tract infection. Each of these adverse postoperative events was statistically more likely in the transfused group. The postoperative mortality was 13% for the transfused group and 6% for those not transfused, which was a nonsignificant difference. The intensive care unit stay and overall hospital stay were significantly longer in patients who had blood transfusions (difference of 2.1 and 5.4 days, respectively).Conclusion: Blood transfusion in patients undergoing major lower extremity amputation is associated with an increased incidence of adverse postoperative events and prolonged intensive care unit and hospital stays. We therefore suggest a restricted approach to blood transfusion in patients requiring major amputation.

Carotid Artery Stenting in Recently Symptomatic Patients: A Single Center Experience - Corrected Proof

Carlo Setacci, Gianmarco de Donato, Emiliano Chisci, Francesco Setacci — 2009-11-04

Background: The effective and early management of patients with acute symptoms due to carotid stenosis remains the subject of debate. The inability to predict who is at higher early risk of a recurrent stroke after a cerebrovascular event (transient ischemic attack [TIA] or stroke) may explain the variation in management of acute strokes from physician to physician and institution to institution. The aim of this study is to evaluate the clinical outcome of recently symptomatic patients with carotid stenosis treated with urgent or deferred carotid artery stenting (CAS) on the basis of a preidentified protocol in a single center.Methods: From January 2006 to October 2008, 43 patients with symptomatic carotid stenosis greater than 70% underwent urgent or deferred CAS (26 TIA, 17 minor stroke). The exclusion criteria were major stroke, cerebral ischemic lesion greater than 2.5 cm as documented by a computed tomography scan, loss of consciousness, and signs of intracranial hemorrhage. Patients who had a TIA underwent urgent CAS within 24 hours of the cerebral event, while patients who had had a minor stroke underwent deferred CAS, performed within a short space of time from the event (treatment within 1 to 30 days from the onset of symptoms, according to the stabilization of cerebral symptoms: mean time, 6.5 days; range, 2 to 28 days).Results: Successful stent implantation was achieved in all cases (100%), respecting the use of a cerebral protection device (filter device: 76%, proximal occlusion device: 24%). The new adverse events in the TIA patients at 1 month were 1 non-neurological death (3.8%) and 1 TIA (3.8%). In the minor stroke group, at 1 month, 10 of 17 patients (58.8%) experienced an improvement in their initial neurological deficit (decrease in National Institutes of Health Stroke Scale less than 2), while in 35.3% of patients (6 of 17), the deficit remained stable, and only one patient had a neurological impairment.Conclusion: Our study demonstrated that early treatment with protected carotid stenting is both feasible and safe in selected patients with first episode or recurrent TIA or minor stroke. This preliminary study in a limited series of patients revealed that an urgent endovascular approach is associated with a satisfactory outcome considering the very high-risk profile of the patient population.

Femoral-Popliteal Bypass with Endoscopically Harvested Saphenous Vein in Patients with TASC D Disease of the Superficial Femoral Artery - Corrected Proof

George L. Hines, Reese A. Wain, Joann Montecalvo, Martin Feuerman — 2009-11-04

Objective: This study evaluated patients undergoing femoropopliteal bypasses using endoscopically harvested vein to treat Trans-Atlantic Inter-Society Consensus (TASC) stage D lesions. Primary patency and primary assisted patency were evaluated, as were perioperative morbidity and mortality and hospital length of stay (LOS). Results for this minimally invasive alternative to femoropopliteal bypass with conventional open vein harvesting were analyzed.Methods: A retrospective analysis was performed on patients who underwent femoral-popliteal bypass with endoscopic saphenous vein harvest and angiographic TASC D anatomy. Postoperative duplex exams were evaluated, and the study end points of graft thrombosis or the development of a high-grade stenosis prompting reintervention were sought. Patient demographics, morbidity, mortality, and hospital LOS were analyzed.Results: Twenty-seven patients meeting our inclusion criteria underwent surgery between June 2002 and June 2007. Indications for surgery in these patients were claudication (n=10), gangrene or ulceration (n=9), and ischemic rest pain (n=8). Fifty-two percent of the patients were male, 50% had cardiac disease, 65% had hypertension, 54% were diabetic, and 65% had a significant smoking history. Median LOS was 2.5 days in claudicants, 3.0 days in patients with rest pain, and 7.0 days in patients with gangrene or ulceration (p<0.05). Kaplan-Meier primary patency and primary assisted patency rates were 73.2% and 80.8% at 1 year, respectively; and these rates were maintained for 70 months. The only perioperative complication was a superficial wound infection, and two patients died during follow-up from causes unrelated to the surgery.Conclusion: Femoropopliteal bypass using endoscopic vein harvest is a durable reconstructive vascular procedure which can be performed with minimal postoperative morbidity, short LOS, and satisfactory long-term patency.

The Role of Oxidative Stress and Antioxidant Defenses in Buerger Disease and Atherosclerotic Peripheral Arterial Occlusive Disease - Corrected Proof

2009-01-06

The aim of this study was to determine the status and the role of oxidative stress and antioxidant defenses in patients with Buerger disease and atherosclerotic peripheral arterial occlusive disease (PAOD). Seventy-three subjects resembling each other in general characteristics were involved in the study: 21 with lower extremity PAOD (mean age 53.05 ± 10.8 years, 17 men and four women), 22 with Buerger disease (mean age 38.59 ± 6.4 years, 19 men and three women), and 30 healthy volunteers (mean age 38.59 ± 6.4 years, 22 men and eight women). We measured the levels of plasma malondialdehyde (MDA), paraoxonase (PON1), protein carbonyls, arylesterase, nitric oxide (NO), serum oxidized low-density lipoprotein (ox-LDL) and MDA, glutathione (GSH), glutathione reductase (GSH-red), glutathione peroxidase (GSH-px), superoxide dismutase (SOD), and catalase (CAT) in erythrocytes. Plasma protein carbonyls, serum ox-LDL, and plasma and erythrocyte MDA were significantly high in the Buerger disease group compared to the PAOD and control groups (p < 0.001). Plasma PON1 levels and GSH and GSH-px levels in erythrocytes in the Buerger disease group were significantly low compared to the PAOD and control groups (p < 0.001). GSH-red, SOD, and CAT levels in erythrocytes in the Buerger disease group were significantly lowcompared to the PAOD group (p < 0.01, p < 0.001, and p < 0.001, respectively). NO levels were significantly lower in the PAOD group compared to the control group (p < 0.05). The balance between oxidative stress and antioxidant capacity is more seriously impaired in Buerger disease than PAOD.

WITHDRAWN: Immediate and mid-term results following hybrid procedures for the treatment of thoracoabdominal aneurysms (TAAA) and secondary expanding aortic dissections (SED) - Corrected Proof

2008-09-10

This article has been withdrawn at the request of the Editor-in-Chief. The publisher apologizes for any inconvenience this may cause.