Albeir Y. Mousa

Novel Risk Score Model for Prediction of Survival Following Elective Endovascular Abdominal Aortic Aneurysm Repair

Objective: The purpose of this study was to identify significant predictors of long-term mortality after elective endovascular abdominal aortic aneurysm repair (EVAR). Methods: We included all cases with elective EVAR based on a national data set from the Society for Vascular Surgery Patient Safety Organization. Clinical and anatomic variables were analyzed with a Kaplan-Meier and Cox-regression model to determine predictors of mortality and develop a score equation to categorize patients into low, medium, and high long-term mortality risk. Results: A total of 5678 patients with EVAR were included with an average age of 73.6 ± 8.2 years. The majority were male (81.6%) with a history of smoking (86.1%). There were 3 deaths within 30 days (0.1%). Several factors were associated with poor survival: unstable angina (hazard ratio [HR], 2.8; P = .008), dialysis (HR, 3.7; P < .001), estimated glomerular filtration rate (eGFR) <30 (HR, 1.7; P = .044), eGFR 30 to 59 (HR, 1.4; P = .002), age >80 (HR, 3.2; P < .001), age 75 to 79 (HR, 2.2; P < .001), chronic obstructive pulmonary disease on oxygen (HR, 3.3; P < .001), aortic diameter >5.8 cm (HR, 1.2; P = .043), and high risk for surgery (HR, 1.4; P = .043). Preoperative aspirin use and body mass index 25 to 35 were both found to be protective (HR, 0.78; P = .017 and HR, 0.8; P = .024, respectively). With our scoring model, 5- and 10-year survival rates for patients with low, medium, and high risk were 89.2%, 80.7%, and 64.1% and 77.2%, 60.1%, and 40.1%, respectively (P < .001). Conclusion: Ten-year survival following EVAR in patients with a high-risk score utilizing the model provided was 40.1%. Patients with multiple comorbidities at risk for decreased long-term survival can be identified with our model, which is more applicable for high-volume contemporary institutions.

Traumatic Nonanastomotic Pseudoaneurysm of Axillofemoral Bypass Graft A Case Report and Review of the Literature

Traumatic nonanastomtic disruption of an axillofemoral bypass graft (AFBG) is a relatively rare entity. However, we are reporting on an 82-year-old female who presented with a pulsating mass on her left side, which was noticed about 2 weeks after she fell on her side. The patient had undergone an ABFG about 15 years earlier for limb revascularization, and she had an occluded aortobifemoral bypass graft. A diagnosis of localized rupture with pseudoaneurysm (PSA) was confirmed with arterial duplex ultrasound and computed tomograph (CT) angiogram scans. A 7-cm PSA with partial disruption of the polytetrafluoroethylene (PTFE) graft at the level of the fifth thoracic vertebrae was noted. An initial work-up to eliminate the possibility of sepsis and localized mycotic seeding was negative. The patient was taken to the hybrid angiogram room, and a percutaneous cut down of the AFBG was performed with local dissection below the site of rupture. A limited angiogram showed a focal PSA of the AFBG. An intravascular ultrasound (IVUS) was performed to calibrate the diameter of the AFBG, and a covered stent was deployed across the area of the disrupted graft. A completion angiogram showed complete exclusion of the PSA with good runoff throughout the graft. The authors will review the management of the traumatic PSA with an endovascular approach.

Atypical presentation of priapism in a patient with acute iliocaval deep venous thrombosis secondary to May-Thurner syndrome.

We report on a 42-year-old male who presented with priapism, severe scrotal swelling, and left lower extremity pain and swelling. Initial management of priapism failed, and he was noted to have both cavernosal and glandular venous obstruction. Computed tomography (CT) was performed and identified extensive acute thrombosis involving the distal inferior vena cava and the left iliac veins. Pharmacomechanical thrombolysis (PMT) was started over the course of two days. At completion of thrombolysis, the culprit lesion in the left common iliac vein was treated with angioplasty and stenting. His postoperative course was uneventful, and his priapism as well as the scrotal and leg swelling improved. He was discharged home on full anticoagulation. To our knowledge, this is the first available description of this rare presentation along with a literature review of the underlying vascular etiology for priapism.

Validation of subclavian duplex velocity criteria to grade severity of subclavian artery stenosis

Background: Validation of subclavian duplex ultrasound velocity criteria (SDUS VC) to grade the severity of subclavian artery stenosis has not been established or systematically studied. Currently, there is a paucity of published literature and lack of practitioner consensus for how subclavian duplex velocity findings should be interpreted in patients with subclavian artery stenosis. Objective: The objective of the present study was to validate SDUS measurements using subclavian conventional or computed tomography angiogram (subclavian angiogram [SA])‐derived measurements. Secondary objectives included measuring the correlation between SDUS peak systolic velocities and SA measurements, and to determine the optimal cutoff value for predicting significant stenosis (>70%). Methods: This is a retrospective review of all patients with suspected subclavian artery stenosis and a convenience sample of carotid artery patients who underwent SDUS and SA from May 1999 to July 2013. SA reference vessel and intralesion minimal lumen diameters were measured and compared with SDUS velocities obtained within 3 months of the imaging study. Percent stenosis was calculated using the North American Symptomatic Carotid Endarterectomy Trial method for detecting stenosis in a sufficiently large cohort. Receiver operating characteristic curves was generated for SDUS VC to predict >70% stenosis. Velocity cutoff points were determined with equal weighting of sensitivity and specificity. Results: We examined 268 arteries for 177 patients. The majority of the arteries were for female patients (52.5%) with a mean age of 66.7 ± 11.1 years. Twenty‐three arteries had retrograde vertebral artery flow and excluded from further analysis. For the remaining 245 arteries, the average peak systolic velocity was 212.6 ± 110.7 cm/s, with a range of 45‐626 cm/s. Average stenosis was 25.8% ± 28.2%, with a range of 0% to 100%. Following receiver operating characteristic analysis, we found a cutoff value of >240 cm/s to be most predictive of >70%. Area under the curve was 0.94 with 95% confidence intervals of 0.91 to 0.97. The sensitivity and specificity for predicting >70% stenosis was 90.9 and 82.5%, respectively. Conclusions: In patients with known or suspected disease involving the great vessels, a subclavian artery flow velocity exceeding 240 cm/s seems to be predictive of significant subclavian stenosis. Thus, we propose new SDUS VC, for predicting subclavian artery stenosis. However, because of the use of a convenience sample, it is possible that the current proposed cutoff point might need to be adjusted for other populations.

Issues related to renal artery angioplasty and stenting

Renal artery stenosis may play a significant role in the pathogenesis of secondary hypertension, renal dysfunction, and flash pulmonary edema. Currently correction of renal arterial inflow stenosis is reserved for resistant hypertension patients who have failed maximal medical therapy, have worsening renal function and/or unexplained proximal congestive failure. With the recent advances in minimally invasive percutaneous stent placement techniques, open surgical revascularization has been largely replaced by renal artery stenting. The potential benefit of revascularization seemed intuitive; however, the initial enthusiasm and rise in the number of percutaneous interventions have been tempered by many subsequent negative randomized clinical trials that failed to prove the proposed benefits of the percutaneous intervention. The negative randomized trial results have fallen under scrutiny due to trial design concerns and inconsistent outcomes of these studies compared to pivotal trials undertaken under US Food and Drug Administration scrutiny. Treatment of atherosclerotic renal artery occlusive disease has become one of the most debatable topics in the field of vascular disease. The results from recent randomized clinical trials of renal artery stenting have basically limited the utilization of the procedure in many centers, but not every clinical scenario was covered in those trials. There are potential areas for improvement focusing mainly on procedural details and patient selection with respect to catheter based treatment of atherosclerotic renal artery stenosis. We believe, limiting patient selection, enrollment criteria and outcomes measured functioned to reduce the benefit of renal artery stenosis stenting by not enrolling patients likely to benefit. Future studies incorporating potential procedural improvements and that include patients more likely to benefit from renal stenting than were included in ASTRAL and CORAL are needed to more carefully examine specific patient subgroups so that “the baby is not thrown out with the bath water.” We also discuss several other concerns related to renal artery stenting which include diagnostic, procedure, indication, and reimbursement issues.

Catheter-directed thrombolysis versus full anticoagulation alone in treating proximal iliofemoral deep venous thrombosis

Dear Editor, Venous thromoemolism (VTE) continues to be a major morbid condition in spite of much advancement in diagnostic and therapeutic measures. The incidence of VTE has been reported to be over 100 per 100,000 for some areas in the United States. Understanding the pathophysiology of the condition and the impact on proximal iliocaval occlusive disease has contributed to the improvement in the utilization of therapeutic measures to prevent and/or minimize postthrombotic syndrome (PTS). Full anticoagulation should be the initial therapy for VTE, even though it is associated with higher rate of PTS; the most up-to-date document from the College of Chest Physicians Clinical Practice Guidelines is in favor of full anticoagulation instead of catheter-directed thrombolysis (CDT). On the other hand, recommendations from the Society of Vascular Surgeons (SVS) and the American Venous Forum are in favor of using CDT with or without pharmacomechanical therapy (PMT) for patients with proximal iliofemoral DVT. Multiple retrospective and prospective studies have highlighted that CDT is associated with significant improvement in PTS and was associated with a better quality of life. Although, many interventionists still use temporary inferior vena cava (IVC) filters before lysis, there is no level 1-evidence that a filter is needed, and it has been suggested that they should only be used in select cases. CDT can be performed with a standard infusion catheter or via Ultrasound Endowave catheter (ECHO); still, there is no recommendation for one modality over the other. In conclusion, CDT with or without PMT is superior to full anticoagulation alone for treating patients with proximal iliofemoral DVT. There is no current consensus to recommend ECHO versus standard Catheter for CDT. This treatment modality should be offered to our patients as long as they have no contraindication to thrombolysis. References

Telehealth electronic monitoring to reduce postdischarge complications and surgical site infections after arterial revascularization with groin incision

It is intuitive that postdischarge surgical complications are associated with increased patient dissatisfaction, and are directly associated with an increase in medical expenditures. It is also easy to make the connection that many post-hospital discharge surgical complications, including surgical site infections (SSIs), could be influenced or exacerbated by patient comorbidities. The authors of a recent study reported that female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, and neurologic disease were significant predictors of SSIs after vascular reconstruction was performed. The main concern for optimal patient care, especially in geographically isolated areas of West Virginia, is to have early, expeditious, and prompt diagnosis of complications and SSI. This adjunct to existing approaches could lead to improved outcomes and patient satisfaction, minimizing third-party interventions and decreasing the total cost of care. It seems reasonable to believe that monitoring using telehealth technology and managing the general health care of patients after a hospital vascular intervention will improve overall health and reduce 30-day readmissions and SSIs.

The Importance of a Multidisciplinary Approach to Leg Ulcers

Critical limb ischemia is a complex disease process. The disease state inherently crosses several medical and surgical disciplines. As such, through a deliberate multidisciplinary approach, the wound healing and patient care will be optimized.