Asymptomatic Females Are at Higher Risk for Perioperative TIA/Stroke and Males Are at Higher Risk for Long-Term Mortality after Carotid Artery Stenting: A Vascular Quality Initiative Analysis

The study aims to review the sex differences with respect to transient ischemic attack (TIA)/stroke and death in the perioperative period and on long-term follow-up among asymptomatic patients treated with carotid stenting (CAS) in the vascular quality initiative (VQI). All cases reported to VQI of asymptomatic CAS (ACAS) patients were reviewed. The primary end point was risk of TIA/stroke and death in the in-hospital perioperative period and in the long-term follow-up. The secondary end point was to evaluate predictors of in-hospital perioperative TIA/stroke and mortality on long-term follow-up after CAS. There were 22,079 CAS procedures captured from January 2005 to April 2019. There were 5,785 (62.7%) patients in the ACAS group. The rate of in-hospital TIA/stroke was higher in female patients (2.7 vs. 1.87%, p  = 0.005) and the rate of death was not significant (0.03 vs. 0.07%, p  = 0.66). On multivariable logistic regression analysis, prior/current smoking history (odds ratio = 0.58 [95% confidence interval or CI = 0.39-0.87]; p  = 0.008) is a predictor of in-hospital TIA/stroke in females. The long-term all-cause mortality is significantly higher in male patients (26.9 vs. 15.7%, p  < 0.001). On multivariable Cox-regression analysis, prior/current smoking history (hazard ratio or HR = 1.17 [95% CI = 1.01-1.34]; p  = 0.03), coronary artery disease or CAD (HR = 1.15 [95% CI = 1.03-1.28]; p  = 0.009), chronic obstructive pulmonary disease or COPD (HR = 1.73 [95% CI = 1.55-1.93]; p  < 0.001), threat to life American Society of Anesthesiologists (ASA) class (HR = 2.3 [95% CI = 1.43-3.70]; p  = 0.0006), moribund ASA class (HR = 5.66 [95% CI = 2.24-14.29]; p  = 0.0003), and low hemoglobin levels (HR = 0.84 [95% CI = 0.82-0.86]; p  < 0.001) are the predictors of long-term mortality. In asymptomatic carotid disease patients, women had higher rates of in-hospital perioperative TIA/stroke and a predictor of TIA/stroke is a prior/current history of smoking. Meanwhile, long-term all-cause mortality is higher for male patients compared with their female counterparts. Predictors of long-term mortality are prior/current smoking history, CAD, COPD, higher ASA classification of physical status, and low hemoglobin level. These data should be considered prior to offering CAS to asymptomatic female and male patients and careful risks versus benefits discussion should be offered to each individual patient.

Diabetic kidney disease induces transcriptome alterations associated with angiogenesis activity in human mesenchymal stromal cells

BACKGROUND

Therapeutic interventions that optimize angiogenic activities may reduce rates of end-stage kidney disease, critical limb ischemia, and lower extremity amputations in individuals with diabetic kidney disease (DKD). Infusion of autologous mesenchymal stromal cells (MSC) is a promising novel therapy to rejuvenate vascular integrity. However, DKD-related factors, including hyperglycemia and uremia, might alter MSC angiogenic repair capacity in an autologous treatment approach.

METHODS

To explore the angiogenic activity of MSC in DKD, the transcriptome of adipose tissue-derived MSC obtained from DKD subjects was compared to age-matched controls without diabetes or kidney impairment. Next-generation RNA sequencing (RNA-seq) was performed on MSC (DKD n = 29; Controls n = 9) to identify differentially expressed (DE; adjusted p < 0.05, |log₂fold change|> 1) messenger RNA (mRNA) and microRNA (miRNA) involved in angiogenesis (GeneCards). Paracrine-mediated angiogenic repair capacity of MSC conditioned medium (MSCcm) was assessed in vitro using human umbilical vein endothelial cells incubated in high glucose and indoxyl sulfate for a hyperglycemic, uremic state.

RESULTS

RNA-seq analyses revealed 133 DE mRNAs (77 upregulated and 56 down-regulated) and 208 DE miRNAs (119 up- and 89 down-regulated) in DKD-MSC versus Control-MSC. Interestingly, miRNA let-7a-5p, which regulates angiogenesis and participates in DKD pathogenesis, interacted with 5 angiogenesis-associated mRNAs (transgelin/TAGLN, thrombospondin 1/THBS1, lysyl oxidase-like 4/LOXL4, collagen 4A1/COL4A1 and collagen 8A1/COL8A1). DKD-MSCcm incubation with injured endothelial cells improved tube formation capacity, enhanced migration, reduced adhesion molecules E-selectin, vascular cell adhesion molecule 1 and intercellular adhesion molecule 1 mRNA expression in endothelial cells. Moreover, angiogenic repair effects did not differ between treatment groups (DKD-MSCcm vs. Control-MSCcm).

CONCLUSIONS

MSC from individuals with DKD show angiogenic transcriptome alterations compared to age-matched controls. However, angiogenic repair potential may be preserved, supporting autologous MSC interventions to treat conditions requiring enhanced angiogenic activities such as DKD, diabetic foot ulcers, and critical limb ischemia.

Superior mesenteric venous thrombosis: Endovascular management and outcomes

BACKGROUND

Superior mesenteric venous thrombosis (SMVT) is a rare but fatal condition that is typically treated initially with anticoagulation therapy, and if this fails, with endovascular interventions. However, due to its rarity, there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT.

AIM

To evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes.

METHODS

A retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed. Technical success was defined as angiographic improvement in SMV flow after intervention. Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention. Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up. The adverse events were reported through Clavien-Dindo classification.

RESULTS

Twenty-four patients were included for analysis. The median age at intervention was 60 years (35-74 years) and 16 (67%) were men. Nineteen patients presented with acute thrombosis (79.2%) and 5 with chronic thrombosis with acute manifestations (20.8%). The most commonly used endovascular modalities were thrombectomy in 12 patients (50.0%) and catheter-directed thrombolysis in 10 patients (41.7%). Technical success was achieved in 18 patients (75%). The 14-d and 30-d primary patency rates were 88.9% and 83.3%, respectively. Adverse events were reported in two patients (8.3%), one marked as grade IIIB, and 1 death marked as grade V. Five-year overall survival rate was 82% (58%-100%).

CONCLUSION

Endovascular intervention with anticoagulation appears to be effective for managing SMVT. This treatment combination may be considered as first-line therapy for SMVT management in select patients.

Proximal fixation of endovascular aortic device may not be associated with renal function decline after abdominal aortic aneurysm repair

OBJECTIVE

Significant debate exists among providers who perform endovascular abdominal aortic aneurysm repair (EVAR) regarding the renal function change between suprarenal (SuF) and infrarenal (InF) fixation devices. The purpose of this study is to review our institution's experience using these devices in terms of renal function.

METHODS

This is a retrospective review of all elective EVARs performed within a three-site health system (Florida, Minnesota, and Arizona) during the period of 2000 to 2018. The primary outcome was renal function decline on long-term follow-up depending on the anatomical fixation of the device (SuF vs InF). Secondary outcomes were length of hospitalization (LOH) and progression to hemodialysis. Multivariable regression analysis was performed to test for associations affecting LOH.

RESULTS

There were 1130 elective EVARs included in our review. Of those, 670 (59.3%) had SuF and 460 (40.7%) InF. Long-term follow-up was 4.8 ± 3.7 years, and the rate of change in creatinine and estimated glomerular filtration rate (eGFR) were not statistically significant among groups (SuF vs InF). LOH was higher in those individuals with a SuF device (3.4 ± 2.2 vs 2.3 ± 1.0 days; P < .001). Ten patients with chronic kidney disease progressed to hemodialysis at 6.7 ± 3.8 years from EVAR. On Kaplan-Meier analysis, patients with chronic kidney disease with SuF were more likely to progress to hemodialysis (P = .039). On multivariable regression, female sex (Coef, 2.4; 95% confidence interval [CI], 0.17-0.41; P = .02), SuF (Coef, 9.5; 95% CI, 0.11-1.11; P < .0001), and intraoperative blood loss of greater than 150 mL (Coef, 15.4; 95% CI, 0.11-1.76; P < .0001) were predictors of prolonged LOH.

CONCLUSION

Our three-site, single-institution data indicate that, although the starting eGFR was statistically lower in those individuals undergoing elective EVAR with InF, device fixation type did not affect the creatinine and eGFR on long-term follow-up. However, caution should be exercised at the time of abdominal aortic aneurysm repair in those individuals who already presented with renal dysfunction.

Deep vein thrombosis and pulmonary embolism among hospitalized coronavirus disease 2019-positive patients predicted for higher mortality and prolonged intensive care unit and hospital stays in a multisite healthcare system

Objective

We assessed the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hospitalized patients with coronavirus disease 2019 (COVID-19) compared with that in a matched cohort with similar cardiovascular risk factors and the effects of DVT and PE on the hospital course.

Methods

We performed a retrospective review of prospectively collected data from COVID-19 patients who had been hospitalized from March 11, 2020 to September 4, 2020. The patients were randomly matched in a 1:1 ratio by age, sex, hospital of admission, smoking history, diabetes mellitus, and coronary artery disease with a cohort of patients without COVID-19. The primary end point was the incidence of DVT/PE and the odds of developing DVT/PE using a conditional logistic regression model. The secondary end point was the hospitalization outcomes for COVID-19 patients with and without DVT/PE, including mortality, intensive care unit (ICU) admission, ICU stay, and length of hospitalization (LOH). Multivariable regression analysis was performed to identify the variables associated with mortality, ICU admission, discharge disposition, ICU duration, and LOH.

Results

A total of 13,310 patients had tested positive for COVID-19, 915 of whom (6.9%) had been hospitalized across our multisite health care system. The mean age of the hospitalized patients was 60.8 ± 17.0 years, and 396 (43.3%) were women. Of the 915 patients, 82 (9.0%) had had a diagnosis of DVT/PE confirmed by ultrasound examination of the extremities and/or computed tomography angiography of the chest. The odds of presenting with DVT/PE in the setting of COVID-19 infection was greater than that without COVID-19 infection (0.6% [5 of 915] vs 9.0% [82 of 915]; odds ratio [OR], 18; 95% confidence interval [CI], 8.0-51.2; P < .001). The vascular risk factors were not different between the COVID-19 patients with and without DVT/PE. Mortality (P = .02), the need for ICU stay (P < .001), duration of ICU stay (P < .001), and LOH (P < .001) were greater in the DVT/PE cohort than in the cohort without DVT/PE. On multivariable logistic regression analysis, the hemoglobin (OR, 0.71; 95% CI, 0.46-0.95; P = .04) and D-dimer (OR, 1.0; 95% CI, 0.33-1.56; P = .03) levels were associated with higher mortality. Higher activated partial thromboplastin times (OR, 1.1; 95% CI, 1.00-1.12; P = .03) and higher interleukin-6 (IL-6) levels (OR, 1.0; 95% CI, 1.01-1.07; P = .05) were associated with a greater risk of ICU admission. IL-6 (OR, 1.0; 95% CI, 1.00-1.02; P = .05) was associated with a greater risk of rehabilitation placement after discharge. On multivariable gamma regression analysis, hemoglobin (coefficient, −3.0; 95% CI, 0.03-0.08; P = .005) was associated with a prolonged ICU stay, and the activated partial thromboplastin time (coefficient, 2.0; 95% CI, 0.003-0.006; P = .05), international normalized ratio (coefficient, −3.2; 95% CI, 0.06-0.19; P = .002) and IL-6 (coefficient, 2.4; 95% CI, 0.0011-0.0027; P = .02) were associated with a prolonged LOH.

Conclusions

A significantly greater incidence of DVT/PE occurred in hospitalized COVID-19–positive patients compared with a non–COVID-19 cohort matched for cardiovascular risk factors. Patients affected by DVT/PE were more likely to experience greater mortality, to require ICU admission, and experience prolonged ICU stays and LOH compared with COVID-19–positive patients without DVT/PE. Advancements in DVT/PE prevention are needed for patients hospitalized for COVID-19 infection.

Renal artery revascularization using the inferior mesenteric artery as an inflow source with a long-term follow-up

This case describes a 72-year-old woman with a history of chronic kidney disease stage III presented with bilateral renal artery stenosis with a progressively atrophied right kidney. At the time of surgery, the atrophied kidney was nonfunctional. Therefore, the patient underwent unilateral renal artery revascularization via the inferior mesenteric artery as an inflow. A 7-year follow-up revealed improvement in the kidney function and stabilization of blood pressure, which was controlled with less number of antihypertensive medications. In brief, open surgical correction of the renal artery stenosis using the inferior mesenteric artery as an inflow source can retrieve renal function in selected hypertensive patients with ischemic nephropathy.

Women have similar mortality but higher morbidity than men after elective endovascular abdominal aortic aneurysm repair

OBJECTIVE

Sex disparities regarding outcomes for women after open and endovascular abdominal aortic aneurysm repair have been well-documented. The purpose of this study was to review whether these disparities were also present at our institution for elective endovascular aneurysm repair (EVAR) and whether specific factors predispose female patients to negative outcomes.

METHODS

All elective EVARs were identified from our three sites (Florida, Minnesota, and Arizona) from 2000 to 2018. The primary outcome was in-hospital mortality and three-year mortality. Secondary outcomes included complications requiring return to the operating room, length of hospitalization (LOH), intensive care unit (ICU) days, and location of discharge after hospitalization. Multivariable logistic regression models were used to assess for the risk of complications.

RESULTS

There were 1986 EVARs; 1754 (88.3%) were performed in male and 232 (11.7%) in female patients. Female patients were older (79 years [interquartile range (IQR), 72-83 years] vs 76 years [IQR, 70-81 years]; P < .001), had a lower body mass index (median, 26.1 kg/m² [IQR, 22.1-31.0 kg/m²] vs 28.3 kg/m² [IQR, 25.3-31.6 kg/m²]; P < .001 and hematocrit (median, 37.6% [IQR, 33.4%-40.6%] vs 39.4% [IQR, 35.6%-42.6%]; P < .001) and had higher glomerular filtration rate (median, 84.4 mL/min per 1.73m² [IQR, 62.3-103 mL/min/1.73 m²] vs 51.1 mL/min/1.73 m² [IQR, 41.8-60.8 mL/min/1.73 m²]; P < .001. Female patients were also more likely to be active smokers (15.3% vs 13.1%; P < .001) and have chronic obstructive pulmonary disease (24.7% vs 15.3%; P = .001). They were less likely to have coronary artery disease (31.6% vs 45.6%; P < .001). Aneurysms in women were slightly smaller in size (median, 54 mm [IQR, 50.0-58.0 mm] vs 55 mm [IQR, 51.0-60.0 mm]; P = .004). In-hospital mortality and mortality at the 3-year follow-up was not significant between female and male patients (0.86% vs 0.17%; P = .11 and 38.4% vs 36.2%; P = .57). However, female patients returned to the operating room with a greater frequency than male patients (3.9% vs 1.4%; P = .011). LOH (mean, 3.4 ± 3.8 days vs 2.5 ± 2.4 days; P < .001) and ICU days (mean, 0.3 ± 2.0 days vs 0.1 ± 0.5 days; P < .001) were longer for female patients. After hospitalization, female patients were discharged to rehabilitation facilities in greater proportion (12.7% vs 3.1%; P < .001) than their male counterparts. On multivariable analysis, female sex was associated with a return to the operating room (odds ratio, 6.4; 95% confidence interval [CI], 1.4-3.5; P = .02), longer LOH (Coef 4.0; 95% CI, 1.0-2.5; P = .00007), more ICU days (Coef 2.8; 95% CI, 1.1-3.0; P = .005), and a greater likelihood of posthospitalization rehabilitation facility placement (odds ratio, 5.8; 95% CI, 1.5-2.4; P = .0001).

CONCLUSIONS

Our three-site, single-institution data support sex disparities to the detriment of female patients regarding return to the operating room after EVAR, LOH, ICU days, and discharge to rehabilitation facility. However, we found no differences for in-hospital or 3-year mortality.

Higher Risk for Reintervention in Patients after Stenting for Radiation-Induced Internal Carotid Artery Stenosis: A Single-Center Analysis and Systematic Review

BACKGROUND

This study aimed to review short- and long-term outcomes of all carotid artery stenting (CAS) in patients with radiation-induced (RI) internal carotid artery (ICA) stenosis compared with patients with atherosclerotic stenosis (AS).

METHODS

We performed a single-center, multisite case-control study of transfemoral carotid artery intervention in patients stented for RI or AS. Cases of stented RI carotid arteries were identified using a CAS database covering January 2000 to December 2019. These patients were randomly matched 2:1 with stented patients because of AS by age, sex, and year of CAS. A conditional logistic regression model was performed to estimate the odds of reintervention in the RI group. Finally, a systematic review was performed to assess the outcomes of RI stenosis treated with CAS.

RESULTS

There were 120 CAS in 113 patients because of RI ICA stenosis. Eighty-nine patients (78.8%) were male, and 68 patients (60.2%) were symptomatic. The reasons for radiation included most commonly treatment for diverse malignancies of the head and neck in 109 patients (96.5%). The mean radiation dose was 58.9 ± 15.6 Gy, and the time from radiation to CAS was 175.3 ± 140.4 months. Symptoms included 31 transient ischemic attacks (TIAs), 21 strokes (7 acute and 14 subacute), and 17 amaurosis fugax. The mean National Institutes of Health Stroke Scale in acute strokes was 8.7 ± 11.2. In asymptomatic patients, the indication for CAS was high-grade stenosis determined by duplex ultrasound. All CAS were successfully completed. Reinterventions were more frequent in the RI ICA stenosis cohort compared with the AS cohort (10.1% vs. 1.4%). Reinterventions occurred in 14 vessels, and causes for reintervention were restenosis in 12 followed by TIA/stroke in two vessels. On conditional regression modeling, patients with RI ICA stenosis were at a higher risk for reintervention (odds ratio = 7.1, 95% confidence interval = 2.1-32.8; P = 0.004). The mean follow-up was 33.7 ± 36.9 months, and the mortality across groups was no different (P = 0.12).

CONCLUSIONS

In our single-center, multisite cohort study, patients who underwent CAS for RI ICA stenosis experienced a higher rate of restenosis and a higher number of reinterventions compared with CAS for AS. Although CAS is safe and effective for this RI ICA stenosis cohort, further data are needed to reduce the risk of restenosis, and close patient surveillance is warranted. In our systematic review, CAS was considered an excellent alternative option for the treatment of patients with RI ICA stenosis. However, careful patient selection is warranted because of the increased risk of restenosis on long-term follow-up.

Results of surgical resection of carotid body tumors: A twenty-year experience

This study examines whether surgical resection of carotid body tumors (CBTs) is acceptable in light of potential significant neurologic complications. This IRB-approved retrospective study analyzed data from 24 patients undergoing surgical treatment for CBTs between April 1998 and April 2017 at Mayo Clinic (Florida campus only). For patients who underwent multiple CBT resections, only data from the first surgery was used in this analysis. CBT resection occurred in 24 patients with the following demographics: fourteen patients (58.3%) were female, median age was 56.5 years, median BMI was 29. A prior history of neoplasm was found in ten patients (41.7%). A known family history of paraganglioma was present in five patients (20.8%). Two patients were positive for succinate dehydrogenase mutation (8.3%). Multiple paragangliomas were present in seven patients (29.2%). There was nerve sacrifice in three patients (12.5%) during resection. Carotid artery reconstruction and patch angioplasty occurred in one patient (4.2%). Complete resection occurred in 24 patients (100.0%). Postoperatively, one patient (4.2%) suffered stroke. No mortalities occurred within or beyond 30 days of surgery. Persistent cranial nerve injury occurred in two patients (8.3%) with vocal cord paralysis. There was no recurrence of CBT through last follow-up. Five patients (20.8%) were diagnosed with other neoplasms after resection, including basal cell carcinoma, contralateral carotid body tumor, glomus vagale, and glomus jugulare. There was 100% survival at 1 year in patients followed for that time (n = 17). Surgical treatment remains the first-line curative treatment to relieve symptoms and ensure non-recurrence. While acceptable, neurologic complications are significant and therefore detailed preoperative informed consent is mandatory.

Upper extremity reconstruction following open surgical repair of giant arteriovenous fistula aneurysm: clinical case and systematic review of the literature

Background:

Nearly 30% of arteriovenous fistulas (AVFs) located in the upper extremity for hemodialysis access result in short- and long-term adverse effects, such as rupture, necessitating emergent surgical management and extensive soft-tissue reconstruction. With this systematic review, we aimed to compile all reported open surgical techniques used for complicated AVF repair in the upper extremity, the respective soft-tissue reconstructive outcomes, and vascular patency rates at final follow-up.

Methods:

Using Ovid Medline/PubMed databases, we conducted a review of the English-language literature on AVF aneurysm surgical management in the upper extremity, filtered for relevance to open surgical technique and outcomes in vascular patency after aneurysmal repair at long-term follow-up (≥6 months postoperatively). We include a detailed case of surgical removal of a giant AVF aneurysm and subsequent flap elevation and reconstruction of the upper extremity.

Results:

Of 150 articles found in the initial search, 19 (from 2010-2017) met inclusion criteria. From the reviewed studies, 675 patients underwent open surgical repair of AVF aneurysm in the upper extremity. Surgical approaches included partial-to-full aneurysm excision, interposition graft, tubularized extracellular matrix, sutured and stapled aneurysmorrhaphy, and stent graft. Rates of vascular patency at repair site ranged from 47% to 100%, with a pooled average of 78% at 6 months or longer postoperatively.

Conclusions:

For plastic and hand surgeons, aneurysmal ligation and excision is feasible even in severe cases and is associated with overall good vascular and soft-tissue reconstructive outcomes in the upper extremity. (www.actabiomedica.it)

A multi-institutional review of endovenous thermal ablation of the saphenous vein finds male sex and use of anticoagulation are predictors of long-term failure

BACKGROUND

To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins.

METHODS

A review of our EVA database (1998-2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate.

RESULTS

542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46-018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69-0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate.

CONCLUSION

Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

Endarterectomy for Iliac Occlusive Disease during Kidney Transplantation: A Multicenter Experience

Little is known about the surgical challenges and outcomes of kidney transplantation (KT) in the face of severe iliac occlusive disease (IOD). We aim to examine our institution's experience and outcomes compared with all KT patients. Retrospective review of our multi-institutional transplant database identified patients with IOD requiring vascular surgery involvement for iliac artery endarterectomy at time of KT from 2000 to 2018. Clinical data, imaging studies, and surgical outcomes of 22 consecutive patients were reviewed. Our primary end-point was allograft survival. Secondary end-points included mortality and perioperative complications. A total of 6,757 KT were performed at our three sites (Florida, Arizona, and Minnesota); there were 22 (0.32%) patients receiving a KT with concomitant IOD requiring iliac artery endarterectomy. Mean patient age was 61.45 ± 7 years. There were 13 (59.1%) male patients. The most common etiology of renal failure was diabetic nephropathy in 10 patients (45.5%) followed by a combination of hypertensive/diabetic nephropathy in five patients (22.7%), and hypertensive nephrosclerosis in three patients (13.6%). The majority ( n  = 16, 72.7%) of patients received renal allografts from deceased donors and six (27.3%) were recipients from living donors. Mean time from dialysis to transplantation was 2.9 ± 2.9 years. Mean follow-up was 3.5 ± 2.5 years. Mean length of hospital stay was 6.3 ± 4.3 days (range: 3-18 days). Graft loss within 90 days occurred in two (9.1%) patients, one due to renal vein thrombosis and another due to acute tubular necrosis. Overall allograft survival was 90.1% at 1-year and 86.4% at 3-year follow-up. Overall mortality occurred in 6 (27.3%) patients. Perioperative complications (Clavien-Dindo Grade 2-4) occurred in 13 (59.1%) patients, including 10 (45.5%) with acute blood loss anemia requiring transfusion, 2 (9.1%) reoperations for hematoma evacuation, 1 (4.5%) ischemic colitis requiring total abdominal colectomy, and 1 (4.5%) renal vein thrombosis requiring nephrectomy. IOD patients selected for KT are not common and although challenging, they have similar outcomes to our standard KT patients. The 1- and 3-year allograft survivals were 90.1 and 86.4% versus 96.0 and 90.3% in the general KT patient population. With these excellent outcomes, we recommend expanding the criteria for KT to include patients with IOD with prior vascular surgery consultation to prevent progression of IOD or prevention of wait list removal in select patients who are otherwise good candidates for KT.

Prevalence of Intracranial Aneurysms in Patients with Infrarenal Abdominal Aortic Aneurysms: A Multicenter Experience

Prior studies suggest high prevalence of intracranial aneurysms (IA) in patients with infrarenal abdominal aortic aneurysms (AAA). We reviewed our multicenter experience in clinical detection/treatment of IAs in AAA patients and estimated the risk of IA in patients with AAA relative to patients without AAA. We reviewed cases of vascular surgery infrarenal AAA repairs at three Mayo Clinic sites from January 1998 to December 2018. Concurrent controls were randomly matched in a 1:1 ratio by age, sex, smoking history, and head imaging characteristics. Conditional logistic regression was used to calculate odds ratios. We reviewed 2,300 infrarenal AAA repairs. Mean size of AAA at repair was 56.9 ± 11.4 mm; mean age at repair, 75.8 ± 8.0 years. 87.5% of the cases ( n  = 2014) were men. Head imaging was available in 421 patients. Thirty-seven patients were found to have 45 IAs for a prevalence of 8.8%. Mean size of IA was 4.6 ± 3.5 mm; mean age at IA detection, 72.0 ± 10.8 years. Thirty (81%) out of 37 patients were men. Six patients underwent treatment for IA: four for ruptured IAs and two for unruptured IAs. All were diagnosed before AAA repair. Treatment included five clippings and one coil-assisted stenting. Time from IA diagnosis to AAA repair was 16.4 ± 11.0 years. Two of these patients presented with ruptured AAA, one with successful repair and a second one that resulted in death. Odds of IA were higher for patients with AAA versus those without AAA (8.8% [37/421] vs. 3.1% [13/421]; OR 3.18; 95% confidence interval, 1.62-6.27, p  < 0.001). Co-prevalence of IA among patients with AAA was 8.8% and is more than three times the rate seen in patients without AAA. All IAs were diagnosed prior to AAA repair. Surveillance for AAA after IA treatment could have prevented two AAA ruptures and one death.

Endovascular Aortic Aneurysm Repair with the Zenith AAA Endovascular Graft: Does Gender Affect Procedural Success, Postoperative Morbidity, or Early Survival?

The purpose of this study was to analyze the effect of gender on deployment, early morbidity, and survival after endovascular aortic aneurysm repair (EVAR) using the Zenith Endovascular Graft. Data were obtained from the U.S. Multicenter Zenith Endograft trial and complemented with results from the Zenith female registry, including 40 women (10.9%) and 326 men (89.1%). Data analysis included preoperative medical risk factors, aneurysm morphology, deployment, and postoperative morbidity data, and 30-day and 1-year results. Preoperatively, women more often had experienced thromboembolic events (13% vs 4.3%; P = 0.04), but less angina pectoris (24% vs 49%; P = 0.002) or myocardial infarction (18% vs 38%; P = 0.01) compared with men. Women had more angulated aneurysm necks and narrower iliac arteries compared with men. Procedural success, cardiovascular, pulmonary, renal, bowel-related, neurologic, or other adverse events were comparable, as were 30-day and 1-year survival. Females experienced more wound dehiscences (5.0% vs 0.0%; P = 0.01) and open surgical conversions in the first year (5%) compared with men (0.31%) ( P = 0.03). With more challenging aneurysm morphologies, women were found to be at a higher risk for conversion in the first year after EVAR using the Zenith endograft. This however does not translate into inferior survival or higher overall morbidity compared with men.

Acute Mesenteric Ischemia Remains a Highly Morbid Diagnosis after Initial Hospitalization Survival

Acute mesenteric ischemia (AMI) remains a vascular emergency. Our aim was to explore readmission for AMI. We identified all patients admitted for AMI from the state of California through the Healthcare and Utilization Project from 2005 to 2011. Our primary end point was the rate and etiology for readmission. Our secondary end points were the length of hospitalization and in-hospital mortality. Cox proportional hazard regression was utilized to assess risk of 30-day readmission. There were 534 (9.9%) readmissions at 30 days. The mean age was 67 ± 17 years and 209 (39.1%) were male. The five most common etiologies for readmission were AMI (7.6%), cardiac events (5.3%), severe sepsis (1.2%), dehydration (1.1%), and acute kidney failure (1.1%). Once readmitted, these patients were most likely to experience cardiac catheterizations (25.4%), red blood cell transfusions (23.6%), intubation and mechanical ventilation (17.6%), biopsy of the large intestine (13.9%), reoperation for small bowel resection (10.9%), administration of total parenteral nutrition (10.5%), and transfusion of other blood products (6.9%). This hospitalization was 8.8 ± 12.7 days long. In-hospital mortality was 36 patients (6.7%). On multivariable Cox-regression analysis, severe (hazard ratio [HR]: 2.1 [1.4-3.2], p  = 0.0005) and moderate (HR: 1.5 [1.03-2.13], p  = 0.04) Elixhauser Comorbidity Group, complications (HR: 1.5 [1.2-1.9], p  = 0.0007), and longer index hospitalization (HR: 1.02 [1.01-1.02], p  < 0.0001) were predictors of readmission. Conclusion  AMI remains a vascular emergency. Readmissions have a significant rate of morbid invasive procedures and can lead to an in-hospital mortality of 6.7%. The adoption of guidelines similar to the European Society for Trauma and Emergency Surgery should be considered.

Complex Repair of Juxtarenal Abdominal Aortic Aneurysm with an Anatomical Variant of the Renal Arteries

Hybrid repair involves both open and endovascular interventions. This technique has been increasingly used in treating complex aortic aneurysms as an alternative to conventional open repairs, mainly because of the avoidance of aortic cross-clamping and the associated increased ischemia time to the viscera. We report a hybrid repair of a juxtarenal abdominal aortic aneurysm complicated by a nonstandard right renal artery originating just proximal to the aortic bifurcation in the setting of a nonfunctional left kidney.

What to expect with major vascular reconstruction during Whipple procedures: a single institution experience and literature review

Background

Major vascular reconstruction during a pancreaticoduodenectomy (PD), also known as a Whipple procedure, leads to controversial postoperative outcomes compared to conventional Whipple. Discussion with the patient regarding postoperative expectations is a crucial component of holistic surgical healthcare. The aim of this study was to report our 8-year experience of Whipple procedures involving vascular reconstruction and to review relevant literature to further evaluate expectant outcomes, therefore leading to more accurate discussion.

Methods

A retrospective review of patients undergoing Whipple procedures from January 2010, through December 2017 was performed. Patch, graft, and primary anastomosis during Whipple procedures were considered major vascular reconstruction. Literature on the current understanding of the outcomes associated with vascular reconstruction during Whipple procedures was reviewed.

Results

Twenty-nine from a total of 405 patients that met inclusion criteria had a Whipple procedure that involved major vascular reconstruction. Twelve patients were male and 17 were female (mean age, 65.2 years). Median hospital and intensive care unit (ICU) stay [range] of patients with vascular reconstruction was 12 [5-92] days and 3 [0-59] days, respectively. Thirty-day survival and 1-year survival of patients with vascular reconstruction was 93.1% and 55.2%, respectively, compared to non-vascular reconstruction patients 96.0% and 83.5%, respectively (P=0.35, P<0.001). Ninety-day readmission for vascular reconstruction patients was 31.0% compared to 14.6% in non-vascular reconstruction patients (P=0.03). The 1-year survival of those who had patch reconstruction, graft reconstruction, and primary anastomosis was 50.0%, 62.5%, 53.8%, respectively.

Conclusions

Compared to conventional Whipple procedures, those requiring major vascular reconstruction are associated with decreased survival. When vascular reconstruction is a valid option patients should be well aware of the associated outcomes.

Durability of Carotid Endarterectomy with Bovine Pericardial Patch

BACKGROUND

Multiple studies have shown that patch angioplasty after carotid endarterectomy (CEA) reduces the risk of stroke and restenosis when compared with primary closure. Biological, synthetic, or vein patches have been traditionally used in CEA. This article reports the early and long-term outcomes of bovine pericardium (BP) for patch angioplasty in CEA.

METHODS

A retrospective, consecutive analysis of 874 patients who underwent CEA during the past 17 years at Mayo Clinic, Florida, was performed. BP patch (BPP) was used in 680 patients. Other CEA techniques were used in 194 patients (standard without patch, 78; standard with Dacron, 74; standard with vein patch, 16; and other techniques: bypasses, 26). We defined group 1 as those who underwent BPP angioplasty and group 2 as those who underwent all other techniques. Early and late clinical outcomes and patch-related complications (restenosis, infection, and hematoma) were recorded and analyzed.

RESULTS

Median follow-up for the entire series was 39.6 months. There were no statistically significant differences in 30-day mortality and morbidity between the 2 groups, except that BP group has less 30-day stroke (0.1%, 1 of 680) versus other techniques (1.5%, 3 of 194, P = 0.03). Thirty-day postoperative mortality rate was 0.1% (1 of 680) in BPP group and 1.0% (2 of 194) in other technique group (P = 0.13). No statistically significant difference was noted in 30-day postoperative major complications (transient ischemic attack [TIA], wound infection, hematoma requiring surgical evacuation, and nerve injury) between the 2 groups. Ten-year freedom from stroke/TIA were 97.8% in the BP group compared with 98.5% in the other group (P = 0.86). Ten-year freedom from restenosis was also similar between groups (89.0% BP vs. 90.4% others, P = 0.69). Ten-year survival rate was 38.4% in BP group and 45.0% in other technique group, and this was statistically significant on univariate analysis only.

CONCLUSIONS

CEA with BP angioplasty has excellent early and late outcomes with minor morbidity and mortality.

A Comparison of AneuRx Aortic Cuff and Zenith Distal Flare Exclusion of Common Iliac Artery Ectasia for Endovascular Aneurysm Repair

Stent-grafts are ideally terminated within the common iliac artery (CIA). However, CIA ectasia may require hypogastric artery occlusion, with stent-graft extension to the external iliac artery. Alternatively, the diameter of the distal stent-graft may be increased, or flared, to allow exclusion of the abdominal aortic aneurysm. This report details the authors’ experience with this technique. Forty-one patients received bifurcated stent-grafts (BSG): 20 received an AneuRx device, and 21 received a Zenith device. CIA ectasia (diameter 15–25 mm) was treated with a distal flare of 2–4 mm greater than the CIA diameter. Patients were followed up with computed tomography scan at 1, 6, and 12 months. Statistical analysis was performed using ANOVA within groups and unpaired two-tailed t test between groups. A p value of <0.05 was considered significant. Eight of 20 patients (40%) (11 CIA) received an AneuRx device and 13/21 (62%) (17 CIA) received a Zenith device, with a distal flare. Values are (n) mean (mm) ± SE. There were no deaths, endoleaks, migrations, or conversions to open repair. Follow-up mean was 24.7 and 20.6 (range 15–28) months for AneuRx and Zenith groups, respectively. In comparing initial and 12-month CIA diameters, AneuRx grafts 20 ±0.8 vs 21.5 ±1.0 were not significantly different, p= 0.2, nor was the same comparison for Zenith, 17 ±0.5 vs 19.1 ±0.4, significant, p= 0.57. At a mean follow-up of 12 months, distal flare of iliac limbs with either AneuRx or Zenith devices affords a seal for CIA ectasia and/or aneurysms complicating EVAR.

Management of a Large Intraoperative Type IIIb Endoleak in a Bifurcated Endograft

The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.

Prevalence of erectile dysfunction in vascular surgery patients

Erectile dysfunction (ED) is frequently associated with cardiovascular disease. Epidemiological data on the frequency of ED in vascular surgery patients is rarely reported. We evaluated the prevalence of this comorbidity in patients consulting the vascular surgery outpatient clinic. Over a 6-month period, a short version of the International Index of Erectile Function (IIEF) questionnaire consisting of six EDrelevant questions was handed out to 440 vascular surgery outpatients. Clinical data were collected from patients' records. Linear regression models with forward selection were used to investigate associations between erectile function score and possible risk factors. The return rate was 31% (137 patients). Eight patients (6%) were taking phosphodiesterase inhibitors. ED, as defined by an erectile function score of 25 or less and/or use of phosphodiesterase inhibitors, was found in 90% (95% CI: 84% to 95%) of cases. Moderate or severe ED, as defined by an erectile function score of 16 or less and/or use of phosphodiesterase inhibitors, was found in 70% (95% CI: 62% to 78%) of cases. Increased age, abdominal aortic aneurysm, peripheral arterial disease, urologic disease, insulin-dependent diabetes mellitus, and use of beta-blockers were significantly associated with a lower erectile function score. In conclusion, erectile dysfunction is a frequent and often missed comorbidity in vascular surgery patients. While ED may have a profound impact on the patient's quality of life, attention should also be paid to the patient's preoperative sexual function, considering the availability of oral pharmacotherapies and possible consequences concerning liability in postoperative patients in whom pre-existing ED was not identified properly.

Impact of Gender on the Outcome of Endovascular Aortic Aneurysm Repair Using the Zenith Stent-Graft: Midterm Results

Purpose:

To analyze the 2-year outcomes of female patients after endovascular aortic aneurysm repair (EVAR) with the Zenith AAA Endovascular Graft.

Methods:

A retrospective analysis was conducted of data from the US Zenith multicenter trial and the Zenith female registry on 40 women (10.9%, study group) and 326 men (89.1%, control group) enrolled. All patients had completed their 2-year follow-up. Primary study endpoints were survival, aneurysm rupture, and conversion rate. Significance was assumed if p<0.05.

Results:

Overall rates of mortality (12.5% for women versus 13.2% for men, p=0.94) and aneurysm rupture (2.5% for women versus 0% for men, p=0.11) were comparable between groups. Conversion to open repair within 2 years was significantly more frequent in women compared to men (7.5% versus 0.6%, p=0.01). The incidence of endoleaks of any type was equivalent between groups at 2 years (13.3% for women versus 6.9% for men, p=0.30). No difference was observed in the need for secondary interventions (15% for women versus 13.5% for men, p=0.81) or aneurysm dilatation >5 mm (10.5% for women versus 2.3% for men, p=0.10). None of the patients developed device migration .10 mm or required intervention for migration.

Conclusion:

While women underwent conversion to open repair more frequently compared to men at 2 years post EVAR, there was no difference in survival, freedom from aneurysm rupture, or need for secondary interventions between groups. As in men, the Zenith AAA Endovascular Graft provides reliable protection from aneurysm rupture and aneurysm-related death in women in a midterm follow-up.

Natural History of the Iliac Arteries after Endovascular Abdominal Aortic Aneurysm Repair and Suitability of Ectatic Iliac Arteries as a Distal Sealing Zone

Purpose:

To investigate the natural history of dilated common iliac arteries (CIA) exposed to pulsatile blood flow after endovascular abdominal aortic aneurysm repair (EVAR) and the suitability of ectatic iliac arteries as sealing zones using flared iliac limbs.

Methods:

Follow-up computed tomograms of 102 CIAs in 60 EVAR patients were investigated. Diameter changes in CIAs ≤16 mm (group 1) were compared with changes in vessels where a dilated segment >16 mm in diameter continued to be exposed to pulsatile blood flow (group 2). Within group 2, cases in which the stent terminated proximal to the dilated artery segment (2a) were compared with those that had been treated with a flared limb (2b).

Results:

The mean CIA diameter increased by 1.0±1.0 mm in group 1 (p<0.001 versus immediately after EVAR) and by 1.5±1.7 mm in group 2 (p<0.001 versus immediately after EVAR) within an average follow-up of 43.6±18.0 months. Diameter increase was more pronounced in dilated CIAs (p=0.048), and it was not significantly different between groups 2a and 2b (p=0.188). No late distal type I endoleak or stent-graft migration associated with CIA ectasia was observed.

Conclusion:

Dilatation of the CIA is significant after EVAR, and it is more pronounced in ectatic iliac arteries. Although ectatic iliac arteries appear to be suitable sealing zones in the short term, continued follow-up is mandatory.

Paravertebral Blockade with Propofol Sedation versus General Anesthesia for Elective Endovascular Abdominal Aortic Aneurysm Repair

The objective of this study was to evaluate the applicability of paravertebral blockade (PVB) for endovascular abdominal aortic aneurysm repair compared with general anesthesia (GA).

Data from patients who underwent elective infrarenal endovascular abdominal aortic aneurysm repair between August 2001 and July 2002 using PVB or GA were retrospectively reviewed and compared with respect to risk factors, intraoperative hemodynamic characteristics, operative outcome, and complications.

Ten patients underwent elective infrarenal endovascular abdominal aortic aneurysm repair under PVB, whereas 15 patients were operated on under GA. One conversion from PVB to GA was necessary for block failure. The perioperative (< 30 days) cardiovascular morbidity and overall mortality were zero in both groups. The PVB group benefited significantly with respect to the incidence of intraoperative hypotension ( p < .05) and blood pressure lability ( p < .01), as well as postoperative nausea ( p < .01). Our preliminary results indicate that PVB is feasible and can be performed safely in a patient population with significant comorbidities.

Use of Proximal Aortic Cuffs as an Adjunctive Procedure during Endovascular Aortic Aneurysm Repair

The purpose of this study was to evaluate the incidence and durability of additional proximal cuffs during endovascular abdominal aortic aneurysm repair (EVAR). A retrospective review of 90 EVAR patients was conducted. Postoperative survival, proximal sealing zone–related complications, and secondary procedures were analyzed.

Additional proximal cuffs were used in 11%. Their use did not affect postoperative survival ( p = .58), type I endoleak rate (4.4%; p = .19), or the need for sealing zone–related secondary procedures (6.3%; p = .38) compared with patients without cuff placement but was related to a higher cumulative graft migration rate (2.2% overall p = .02). Two patients (2.5%; p = .79) underwent conversion to open surgery, both for proximal sealing zone–related complications.

Application of proximal cuffs appears to be an effective intraoperative adjunctive procedure to achieve a proximal seal during EVAR, with favorable midterm results. However, the risk of late endograft migrations may be elevated in this group.

Management of cervical thoracic duct cyst with cyst-venous anastomosis

INTRODUCTION

Cervical thoracic duct cyst (CTDC) is a rare cause of lateral neck mass. Surgical excision with ligation of the cervical thoracic duct is the current standard for definitive management with symptomatic patients. We report the first case of an alternative method of management performing a cyst venous anastomosis for decompression.

PRESENTATION OF CASE

A 77 year old female presented with a six month history of left arm pain, swelling and a left-sided cystic neck mass. She was treated with cyst-venous anastomosis between the cyst wall and the left internal jugular vein. At two year follow-up, she has had resolution of pain and no recurrence of the mass.

DISCUSSION

Many potential etiologies have been proposed for CTDC, though surgical management of this rare problem has consistently required cyst excision and thoracic duct ligation. Few innovative modes of therapy have been developed to address this problem in a less invasive manor. Maintaining a more natural thoracic duct anatomy decreases the likely of complications associated with duct ligation.

CONCLUSION

Cyst-venous anastomosis for the management of CTDC provides an effective, novel form of treatment which maintains the integrity of the thoracic duct and avoids potential complications associated with duct ligation.

Abstract 3686: Stroke, TIA, Amaurosis Fugax, or No Symptoms as Predictors of Outcomes in the Carotid Revascularization Endarterectomy versus Stenting Trial

Background In previous carotid revascularization trials, stroke as a qualifying symptom has had the greatest importance as a predictor of subsequent outcomes. However, the importance of stroke, TIA, amaurosis fugax, and asymptomatic status has not been analyzed together and comparatively as predictors of outcome for carotid stenosis in a randomized clinical trial (RCT).

Methods Qualifying events were analyzed for the 1321 symptomatic patients in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) and were modeled as predictors of the primary outcome (stroke, myocardial infarction, and death during a 30-day peri-procedural period, or ipsilateral stroke over the follow-up period out to 4 years); the potential predictive value was also tested for the outcome of stroke and death. The model included other potential predictors such as age, sex, and treatment.

Results The distribution of pre-randomization qualifying events among symptomatic patients in CREST was 572 strokes, 550 TIA, and 199 amaurosis fugax. Relative to symptomatic patients qualifying for the study with stroke, the risk of subsequent primary endpoint was 15% lower for those qualifying with TIA (HR=0.85; 95% CI = 0.57 - 1.28), 36% lower for those qualifying with amaurosis fugax (HR=0.64; 95% CI = 0.3 - 1.23), and 48% lower for asymptomatic patients (HR=0.52; 95% CI = 0.35 - 0.76). The risk of stroke or death was 11% lower for TIA (HR=0.89; 95% CI = 0.57 - 1.40), 18% lower for amaurosis fugax (HR=0.82; 95% CI = 0.42 - 1.60), and 57% lower for asymptomatic patients (HR=0.43; 95% CI = 0.28 - 0.67) when compared to symptomatic patients qualifying with stroke. The risk for patients with stroke or TIA did not differ significantly, and the risk for asymptomatic patients and patients with amaurosis fugax did not differ significantly.

Conclusion Outcomes in patients with carotid disease were predicted in descending order by stroke, TIA, amaurosis fugax, and asymptomatic status in a large RCT. Asymptomatic status and amaurosis fugax have a comparatively benign prognosis. Better understanding of these predictors may help in determining who will benefit from carotid revascularization and how quickly they may benefit given the perioperative risks.

Surgical and interventional visceral revascularization for the treatment of chronic mesenteric ischemia--when to prefer which?

BACKGROUND

The purpose of the present study was to compare surgical and endovascular revascularization for chronic mesenteric ischemia (CMI).

METHODS

Forty-nine patients underwent surgical (SG) or endovascular (EG) treatment. Relief of symptoms was considered the primary endpoint; patency, morbidity, and mortality were secondary endpoints. For statistical analysis, significance was assumed if P values < or = 0.05.

RESULTS

Twenty-six patients (53%) underwent surgical revascularization; 23 patients (47%), endovascular repair. Mean follow-up was 25 +/- 21 months (SG) versus 10 +/- 10 (EG) months (P = 0.07). Except for body mass indices (SG 18.9 +/- 2.7 versus EG 23.6 +/- 4.8; P = 0.001), preoperative data were comparable. Freedom from symptoms was 100% (SG) versus 90% (EG) after intervention (P = 0.194), and 89% (SG) versus 75% (EG) at the end of follow-up. Reocclusion or re-stenosis occurred in 8% (SG) versus 25% (EG) (log-rank test: P = 0.003), and mesenteric ischemia developed in 0% (SG) versus 9% (EG) (P = 0.04). Reintervention for CMI was required in 0% (SG) versus 13% (EG) (P = 0.01). Surgical patients experienced more early complications (42% versus EG 4%; P = 0.02) and longer hospital stays (11.6 +/- 10.9 days versus EG 1.3 +/- 0.5 days; P < 0.001). Overall mortality at the end of follow-up was 31% (SG) versus 4% (EG) (log-rank test: P = 0.08), including all patients with combined open mesenteric and aortic reconstruction (P = 0.001).

CONCLUSIONS

Surgical treatment has superior long-term patency and requires fewer reinterventions, but it is also more invasive with greater morbidity and mortality compared to endovascular treatment. Endovascular techniques may be preferable in patients with significant co-morbidities, concomitant aortic disease, or indeterminate symptoms.

Unusual etiology of upper extremity ischemia in a scleroderma patient: thoracic outlet syndrome with arterial embolization

Although the causes of digital ischemia and necrosis are diverse in women, the most common etiology is connective tissue disease. We describe a patient with scleroderma who presented with arm ischemia secondary to arterial embolization from thoracic outlet syndrome. Her sublavian artery was compressed by the anterior scalene muscle and a cervical rib, leading to a stenosis with poststenotic dilation of the artery. Within the aneurysmal formation was a thrombus, which was probably the source of the distal embolization. The patient underwent surgical resection of the cervical and first rib. The abnormal portion of the subclavian artery was resected and replaced with an interposition graft.

Abdominal aortic aneurysm neck remodeling after open aneurysm repair

PURPOSE

Proximal endovascular aortic graft fixation and maintenance of hemostatic seal depends on the long-term stability of the aortic neck. Previous investigations of aortic neck dilation mostly focused on the infrarenal aortic diameter. Fenestrated and branched stent grafts facilitate suprarenal graft fixation and may thereby improve the long-term integrity of the aortic attachment site. For these devices, the natural history of the suprarenal aortic segment is also of interest. We investigated the natural history of the supra- and infrarenal aortic segment after open abdominal aortic aneurysm (AAA) repair.

METHODS

For this retrospective analysis, we reviewed the preoperative and the initial postoperative as well as the most recent CT series that were obtained from 52 patients undergoing conventional repair of an infrarenal abdominal aortic aneurysm between January 1998 and December 2002. Measurements were performed using electronic calipers on a "split screen", allowing direct comparison of subsequent CT series at corresponding levels along the vessel. Main outcome measures were changes in postoperative measures of the supra- and infrarenal aortic diameters.

RESULTS

The first postoperative exam was at a mean (+/-SD) of 7.0 +/- 3.5 months, and the final exams were at 44.4 +/- 21 months. Over this time period, the estimated rate of change in suprarenal diameter was 0.18 mm/ y with 95% confidence interval (CI) from 0.08 to 0.27. The estimated rate of change for the infrarenal diameter was 0.16 (95% CI: 0.05 to 0.27). A clinically relevant diameter increase of >or=3 mm was observed in seven patients (13%). There was evidence of larger diameter increases associated with larger AAA diameters (P = .003 and <.001 for suprarenal and infrarenal diameters), an inverted funnel shape (P = .002 and <.001), and marginal evidence of association with a history of inguinal hernia (P = .043 and .066).

CONCLUSIONS

Although there is statistically significant evidence of increases in the supra- and infrarenal aortic diameters after conventional AAA repair, mean annual increases tended to be small and clinically relevant increases of 3 mm or more were observed in only a small proportion of cases.

Percutaneous protective coil occlusion of the proximal inferior mesenteric artery before N-butyl cyanoacrylate embolization of type II endoleaks after endovascular repair of abdominal aortic aneurysms

Bowel ischemia can complicate treatment of type II endoleak with liquid or semiliquid agents such as n-butyl cyanoacrylate (NBCA) if nontarget embolization of the inferior mesenteric artery (IMA) occurs. The current report describes four cases of type II endoleak in which the IMA was the main outflow vessel and was prophylactically occluded with embolization coils before NBCA injection into the endoleak nidus. The purpose was to prevent unintentional embolization of the NBCA into IMA branches. If feasible, protective IMA coil occlusion should be considered in type II endoleaks with IMA outflow in cases of NBCA embolization.

Common Carotid Artery Imbrication as an Adjunct to Carotid Endarterectomy to Prevent Postoperative Carotid Kinking

Mobilization of a tortuous carotid artery during endarterectomy may produce redundancy of the carotid artery, and kinking. We reviewed our experience with common carotid artery (CCA) imbrication as a technique to shorten the common and internal carotid artery postendarterectomy and to avoid carotid kinking. A retrospective chart review of 163 patients who underwent carotid endarterectomy by the same surgeon between August 1998 and February 2006 was performed. All patients underwent conventional endarterectomy via a longitudinal arteriotomy with an indwelling shunt and patch angioplasty. Patients undergoing concomitant carotid artery imbrication were identified. Twelve patients who underwent carotid imbrication were identified. The mean age was 74.9 ± 8.8 years. Nine patients underwent imbrication of the CCA, and in three cases, the internal carotid artery was plicated. Follow-up duplex ultrasound examinations were available for 10 individuals and mean follow-up time was 10.7 months (range, 1–58 months). There were no cases of peri- or postoperative cerebral accidents and there was no case of restenosis. CCA imbrication as an adjunct to carotid endarterectomy is a feasible technique in preventing postoperative carotid kinking.

Common carotid artery imbrication as an adjunct to carotid endarterectomy to prevent postoperative carotid kinking

Mobilization of a tortuous carotid artery during endarterectomy may produce redundancy of the carotid artery, and kinking. We reviewed our experience with common carotid artery (CCA) imbrication as a technique to shorten the common and internal carotid artery postendarterectomy and to avoid carotid kinking. A retrospective chart review of 163 patients who underwent carotid endarterectomy by the same surgeon between August 1998 and February 2006 was performed. All patients underwent conventional endarterectomy via a longitudinal arteriotomy with an indwelling shunt and patch angioplasty. Patients undergoing concomitant carotid artery imbrication were identified. Twelve patients who underwent carotid imbrication were identified. The mean age was 74.9 +/- 8.8 years. Nine patients underwent imbrication of the CCA, and in three cases, the internal carotid artery was plicated. Follow-up duplex ultrasound examinations were available for 10 individuals and mean follow-up time was 10.7 months (range, 1-58 months). There were no cases of peri- or postoperative cerebral accidents and there was no case of restenosis. CCA imbrication as an adjunct to carotid endarterectomy is a feasible technique in preventing postoperative carotid kinking.

Endovascular repair of an infrarenal abdominal aortic aneurysm with a dominant middle mesenteric artery: A case report

The middle mesenteric artery is a rare anomalous mesenteric vessel that may supply variable segments of the colon. Occlusion of this artery during endovascular aortic aneurysm repair may bear a significant risk of bowel ischemia. We report the successful interventional treatment of a patient with a 5.3 cm infrarenal abdominal aortic aneurysm, sparing a dominant middle mesenteric artery.

Long-term results of endovascular aneurysm repair with aortouni-iliac custom-made stent grafts

The purpose of this study was to review the outcome of endovascular abdominal aortic aneurysm repair (EVAR) using custom-made aortouni-iliac (AUI) devices with femorofemoral bypass. Between June 1999 and March 2001, 23 consecutive patients (1 female, 22 male) at high risk of open aortic aneurysm repair underwent EVAR with custom devices in an AUI configuration. The mean follow-up was 37 months (range 2-72 months), and the mean age was 76.8 years (range 67.5-88.7 years). Increased surgical risk was evidenced by 92% and 69% of patients with significant pulmonary or cardiac disease, respectively. The preoperative mean aneurysm diameter (n = 23) 62 +/- 8.2 mm was significantly greater than the postoperative diameter, (n = 23) 54 +/- 16.4 mm. Ten endoleaks occurred. Migration of the stent graft occurred in 9% (n = 2). Secondary interventions were necessary in 23%, whereas tertiary interventions were required in 9%. Patients at high risk of open aneurysm repair received sufficient protection from aneurysm rupture with custom-made AUI devices.