Aaron C. Baker

Application of duplex ultrasound imaging in determining in-stent stenosis during surveillance after mesenteric artery revascularization

OBJECTIVE Currently, there are no well-established duplex ultrasound (DUS) criteria for the evaluation of the mesenteric arteries after stenting for occlusive disease. Previous studies suggested DUS velocity criteria in the native superior mesenteric artery (SMA) overestimate stenosis in stented arteries, but most studies have not evaluated DUS imaging after SMA stenting longitudinally. This study was undertaken to determine the accuracy of DUS after mesenteric artery revascularization and, in particular, to evaluate the utility of DUS imaging for the detection of in-stent stenosis (ISS) of the SMA. METHODS A retrospective record review was performed for all patients who underwent SMA stenting for chronic mesenteric ischemia at a single institution from January 2004 to May 2011. RESULTS Mesenteric artery occlusive disease resulted in 24 patients undergoing mesenteric stenting of the SMA alone (n = 20) or the SMA and celiac artery simultaneously (n = 3). The mean ± standard deviation peak systolic velocity (PSV) in 13 prestent DUS images of the SMA was 464 ± 130 cm/s. Prestenting angiography revealed an average SMA stenosis of 79% ± 14%. After stenting, completion angiography in each case revealed <20% residual stenosis. No significant correlation was identified between SMA PSV and angiographic stenosis before and after stenting (P > .05). Follow-up SMA DUS imaging showed an average PSV of 335 ± 138 cm/s at 0.9 ± 1.5 months, 360 ± 143 cm/s at 4.8 ±2.6 months, and 389 ± 95 cm/s at 14.4 ± 5.1 months. A significant difference existed between the prestent and the first poststent mean SMA PSV (P < .05), but no significant difference existed between each poststenting interval. Eight reinterventions for SMA ISS were performed, with a mean elevated in-stent SMA PSV of 505 ± 74 vs 341 ± 145 cm/s in patients who did not undergo reintervention. Angiography before the eight reinterventions demonstrated an average SMA ISS of 53% ± 25%. In-stent SMA PSV decreased from 505 ± 74 to 398 ± 108 cm/s after the reintervention (P < .05). CONCLUSIONS Consistent with other reports, our data demonstrate the PSV in successfully stented SMAs remains higher than the PSV threshold of 275 cm/s used for the diagnosis of high-grade native SMA stenosis. In addition, in-stent SMA PSVs did not significantly change over DUS surveillance for patients who did not undergo reintervention. Thus, obtaining a baseline DUS early after mesenteric stenting should be considered to compare future surveillance DUS. An increase above this baseline or an in-stent SMA PSV approaching 500 cm/s should be considered suspicious for ISS, but larger prospective studies will be required to validate these preliminary findings.

Do Women Have Worse Amputation-Free Survival Than Men Following Endovascular Procedures for Peripheral Arterial Disease? An Evaluation of the California State-Wide Database

Objectives: Female gender has been shown to negatively affect the outcomes of surgical bypass for peripheral arterial disease (PAD). We examined gender-related disparities in outcomes of endovascular PAD procedures in a large population-based study. Methods: We used discharge data from California hospitals to identify patients who had PAD interventions during 2005 to 2009. Logistic regression was used for 12-month reintervention, and Cox proportional hazard regression was used for amputation-free survival comparisons. Results: A total of 25 635 patients had endovascular procedures (11 389 [44.4%] women). Women were more likely than men (34.5% vs 30.1%, P < .0001) to have critical limb ischemia (CLI). Twelve-month reintervention rate in women was similar to men. Amputation-free survival was better among women than men (hazard ratio 0.84, 95% confidence interval [CI] 0.76-0.93, P = .0006). Conclusion: Despite presenting more frequently with CLI, women had better amputation-free survival than men following endovascular procedures. Future research should determine whether findings favor one type of PAD treatment modality over another for women.

Pretransplant Free Fatty Acids (FFA) and Allograft Survival in Renal Transplantation1

BACKGROUND Fatty acids and their eicosanoid metabolites have been shown to be important mediators of the immune response in transplantation. We hypothesize that elevated pretransplant free fatty acids (FFA) levels may be associated with prolonged survival of kidney transplants. METHODS Archived pretransplant sera of 130 patients who received a kidney transplant from 1991 to 1997 were analyzed by gas liquid chromatography for a comprehensive FFA profile. FFA levels were categorized by quartiles, and the association between quartiles of the levels for each free-fatty acid and graft survival was initially screened by serial univariate analyses (Kaplan-Meier). All significant variables (FFAs and transplant-specific risk factors) were entered into a multivariable (Cox regression) model. RESULTS With > 10 y of follow-up, 68 kidney allografts were lost. Factors associated with decreased graft survival by univariate analysis included delayed graft function (DGF), acute rejection (AR), and cold ischemic time (CIT) > 24 h. High levels of arachidonic and γ-linolenic FFA were associated with higher graft survival rates. By multivariate analysis, only DGF, AR, CIT, and arachidonic acid levels were significant. The odds ratios for graft failure for the highest, third, and second quartiles of the pretransplant level of arachidonic acid, compared with the lowest quartile, were 0.18, 0.32, and 0.64, respectively (P = 0.050, log-rank test). For arachidonic acid the survival benefit appeared to be graded with the highest quartile associated with a greater than 80% reduction of risk of kidney graft failure. CONCLUSION Pretransplant level of arachidonic acid was independently associated with higher kidney graft survival rates. Further studies are necessary to identify the underlying mechanisms and to determine whether interventions aimed at increasing pretransplant arachidonic acid levels might prove beneficial for renal transplant outcomes.

Technical and Early Outcomes Using Ultrasound-Guided Reentry for Chronic Total Occlusions

BACKGROUND Subintimal angioplasty is a common treatment for chronic total occlusions (CTOs) in the iliac and infrainguinal arteries. Although technical success has been described using intravascular ultrasound-guided reentry devices (IVUS-RED), outcomes are still not well defined. This report describes the technical aspects and longitudinal follow-up after intravascular ultrasound-guided reentry of iliac and infrainguinal CTOs. METHODS A retrospective review was performed of 20 patients with lower extremity CTO treated with IVUS-RED from 2011 to 2013. A matched cohort of patients who underwent lower extremity interventions without the use of IVUS-RED was also identified. Procedural success, patency estimates, ankle-brachial indices (ABIs), complications, and limb salvage were analyzed. RESULTS Twenty patients (mean age, 69 ± 13 years), including 11 men and 9 women, underwent attempted IVUS-RED-guided recanalization. Median follow-up was 4.3 months (range, 0.4-24). Eleven patients presented with critical limb ischemia (CLI), and 9 presented with claudication. Technical success was achieved in 18 (90%) patients. Ten common iliac arteries, 3 external iliac arteries, and 5 superficial femoral arteries (SFA) were treated. No intraoperative complications resulted from device use. After procedure, ABIs significantly increased (0.5-0.9; P < 0.01) in the 13 patients with follow-up. Primary patency for the entire cohort was 62% at 12 months. No patient treated for claudication required reintervention, whereas 3 (27%) of those treated for CLI required repeat interventions. During follow-up, 2 patients died unrelated to the procedure, 1 patient required an amputation, and 1 patient eventually required open revascularization. When the IVUS-RED group was compared with a cohort matched on Trans-Atlantic Inter-Society Consensus and age, no difference was found in runoff scores and patency between the 2 groups during follow-up (P > 0.05). CONCLUSIONS Recanalization of CTO using IVUS-RED is safe and effective. Use of IVUS-RED does not adversely impact outcomes in conjunction with other endovascular techniques. Early follow-up demonstrates acceptable patency, especially in patients with claudication, and freedom from reintervention.

Repair of Aberrant Right Subclavian Artery Entirely via a Supraclavicular Approach

An aberrant right subclavian artery is a known arch variant with surgical intervention reserved for those patients presenting symptomatically, those with aneurysmal degeneration particularly of a Kommerell diverticulum, or those with adjacent aortic pathology. Varied surgical approaches have been described, often involving a supraclavicular approach in conjunction with a thoracotomy, or more recently, hybrid endovascular techniques. In the absence of aneurysmal degeneration or associated aortic pathology, surgical repair can be performed safely through a single supraclavicular incision. We present a case of a patient repaired in this fashion.

Upper Extremity and Junctional Zone Injuries

Abstract Injuries to blood vessels in the thoracic inlet and shoulder or junctional zone and in the upper extremity continue to present significant challenges to trauma and vascular surgeons. As with other vascular injuries, there is a severity spectrum dependent on mechanism, anatomic location, temporal circumstances, and concomitant injuries. Vascular trauma in the upper limb may result not only in life-threatening hemorrhage but also in tissue ischemia, leading to ischemic neuropathy/plexopathy, compartment syndromes, and muscular contracture. Associated injuries to the nerves, bones, and soft tissues may also contribute to dysfunction. In some instances, amputation is the result, either in the acute setting or in the chronic phase. Injuries leading to loss of function or amputation can be devastating and life-altering events for the patient. The best chance of successful management lies in early clinical review, correct application of damage control principles, proper use of diagnostic technologies, and efficient judgment as to the optimal treatment strategy. Junctional trauma requires early proximal control to stop bleeding; this may mean control from within the chest. As in other areas of vascular trauma, the use of endovascular technologies is becoming ever-more feasible to stop hemorrhage and to restore vessel perfusion, even beyond the root of the limb. Military experience has shown that, with better prehospital and in-hospital protocols, death rates from isolated upper limb vascular injury can be effectively reduced, placing the emphasis on functional outcomes as better benchmarks of care.

Burn care in the 1800s.

The 1800s show a wide range of both understanding and misinterpretation of the pathophysiology and treatment of burns. The objective of this paper was to describe the key advancements in the study and treatment of burns in the 1800s. We reviewed primary and secondary sources of ancient to modern burn care manuscripts. Prior to the 1800s, burn care was different iterations of poultices and oils placed over acute burns in the hope the patient would survive. The 1800s showed the discoveries of the Curling and Marjolin’s ulcers as well as the first understanding of inhalation injury and advancements in skin grafting, leading to further understanding of the disease process.

Management of a Chronic Carotid Artery Pseudoaneurysm

An 82-year-old female with a history of right carotid endarterectomy with patch closure 12 years prior presents with a pulsatile right neck mass with skin erosion and bleeding. The patient had been previously evaluated but refused the surgical intervention because a median sternotomy was recommended to obtain adequate proximal control. Her aneurysm was successfully repaired using a combination of open and endovascular method. The repair was performed through a right-hand side anterior sternocleidomastoid neck incision, and proximal vascular control was obtained with an 8.5-mm balloon positioned under fluoroscopic guidance via a femoral puncture.