Audra A. Duncan

Common iliac artery aneurysm: expansion rate and results of open surgical and endovascular repair.

OBJECTIVES To assess expansion rate of common iliac artery aneurysms (CIAAs) and define outcomes after open repair (OR) and endovascular repair (EVAR). METHODS Clinical data of 438 patients with 715 CIAAs treated between 1986 and 2005 were retrospectively reviewed. Size, presentations, treatments, and outcomes were recorded. Kaplan-Meier method with log-rank tests and chi2 test were used for analysis. RESULTS Interventions for 715 CIAAs (median, 4 cm; range, 2-13 cm) were done in 512 men (94%) and 26 women (6%); 152 (35%) had unilateral and 286 (65%) had bilateral CIAAs. Group 1 comprised 377 patients (633 CIAAs) with current or previously repaired abdominal aortic aneurysm (AAA). Group 2 comprised 15 patients (24 CIAAs) with associated internal iliac artery aneurysm (IIAA). Group 3 comprised 46 patients (58 isolated CIAAs). Median expansion rate of 104 CIAAs with at least two imaging studies was 0.29 cm/y; hypertension predicted faster expansion (0.32 vs 0.14 cm/y, P = .01). A total of 175 patients (29%) were symptomatic. The CIAA ruptured in 22 patients (5%, median, 6 cm; range, 3.8-8.5 cm), and the associated AAA ruptured in 20 (4%). Six (27%) ilioiliac or iliocaval fistulas developed. Repairs were elective in 396 patients (90%) and emergencies in 42 (10%). OR was performed in 394 patients (90%) and EVAR in 44 (10%). The groups had similar 30-day mortality: 1% for elective, 27% for emergency repairs (P < .001); 4% after OR (elective, 1%; emergency, 26%), and 0% after EVAR. No deaths occurred after OR of arteriovenous fistula. Complications were more frequent and hospitalization was longer after OR than EVAR (P < .05). Mean follow-up was 3.7 years (range, 1 month-17.5 years). The groups had similar 5-year primary (95%) and secondary patency rates (99.6%). At 3 years, secondary patency was 99.6% for OR and 100% for EVAR (P = .66); freedom from reintervention was similar after OR and EVAR (83% vs 69%, P = .17), as were survival rates (76% vs 77%, P = .70). CONCLUSIONS The expansion rate of CIAAs is 0.29 cm/y, and hypertension predicts faster expansion. Because no rupture of a CIAA <3.8 cm was observed, elective repair of asymptomatic patients with CIAA >or=3.5 cm seems justified. Although buttock claudication after EVAR remains a concern, results at 3 years support EVAR as a first-line treatment for most anatomically suitable patients who require CIAA repair. Patients with compressive symptoms or those with AVF should preferentially be treated with OR.

Open repair of juxtarenal aortic aneurysms (JAA) remains a safe option in the era of fenestrated endografts

OBJECTIVES Widespread application of infrarenal endovascular aneurysm repair (EVAR) has resulted in a proportionate increase in open juxtarenal aortic aneurysm (JAA) repairs. Fenestrated endograft technology for JAA is developing rapidly, but only limited outcomes are known. The aim of this study was to review our open JAA experience in an era of fenestrated endograft technology, identify factors associated with increased surgical risk, determine early and midterm outcome, and provide a basis for comparison for future endovascular procedures. METHODS Data from 126 consecutive patients who underwent elective JAA repair requiring suprarenal aortic clamping from 2001 to 2006 were analyzed retrospectively. Electronic medical chart reviews were used to record 30-day complication rates. Multivariate analyses were performed to identify risk factors associated with surgical morbidity. Mail-out questionnaires and telephone surveys were conducted to determine long-term follow-up. RESULTS Ninety-eight males and 28 females (median age 74 years; range 55 to 93) were included in the study. Preoperative risk factors included: coronary artery disease (CAD) 58%, pulmonary disease 41%, renal insufficiency (serum creatinine [Cr] > 1.5mg/dL) 17%, and diabetes 9%. Fifteen patients underwent concomitant renal artery revascularization. Mean operative time was 319 minutes (range 91 to 648). Thirty-day mortality was 1/126 (0.8%). Median hospital length of stay was 7 days (range 3 to 85); median intensive care unit length of stay was 2 days (1 to 64). Complications included renal insufficiency (Cr increase > 0.5 mg/dL) in 22 (18%), cardiac in 17 (13%), and pulmonary in 14 (11%). Five patients required temporary hemodialysis; only one after hospital dismissal. Mean follow-up was 48 months (range 9-80). On multivariate analysis, age > or = 78 years (P = .001), male gender (P = .04), hypertension (P =.01), previous myocardial infarction (P = .047), and diabetes (P =.009) were predictive of cardiac complications. Renal artery revascularization (P = .01) and prior MI (P = .04) were multivariate predictors of pulmonary complications. Both prolonged operative (> or =351 minutes, P = .02) and renal ischemia (> or =23 minutes, P =.004) times predicted postoperative renal insufficiency. One, 3, and 5-year cumulative survival rates were 93.9%, 78.3%, and 63.8%, respectively and were not significantly different than an age- and gender-matched sample of the US population (P = .16). Mortality was not predicted by any specific risk factors. CONCLUSIONS Open surgical repair of JAA is associated with low mortality and remains the gold standard. Although 18% had renal complications, only one patient had permanent renal failure. Patients with a combination of physiologic and anatomic risk factors identified on multivariate analysis may benefit from fenestrated endograft repair.

Revascularization for acute mesenteric ischemia

OBJECTIVE Acute mesenteric ischemia (AMI) remains difficult to diagnose, carries a high rate of complications, and is associated with significant mortality. We evaluated our experience with AMI over the last 2 decades to evaluate changes in management and assess current outcomes. METHODS Data from consecutive patients who underwent arterial revascularization for AMI over a 20-year period (January 1990-January 2010) were retrospectively reviewed. Patient demographics, treatment modalities, and outcomes over the last decade (2000-2010) were compared with those of the preceding decade (1990-1999) previously reported. RESULTS Over the last 2 decades, 93 patients with AMI underwent emergency arterial revascularization. Forty-five patients were treated during the 1990s and 48 during the 2000s. The majority of these patients were transferred from outside facilities. Patient demographics and risk factors were similar between the 2 decades with the exception that the more contemporary patients were significantly older (65.1 ± 14 vs 71.3 ± 14; P = .04). Etiology remained constant between the groups with in situ thrombosis being the most common followed by arterial embolus. The majority of patients were treated with open revascularization. Endovascular therapy alone or as a hybrid procedure was used in 11 total patients, eight of which were treated in the last 10 years. The use of second-look laparotomy was much more liberal in the last decade (80% vs 48%; P = .003) Thirty-day mortality was 27% in the 1990s and 17% during the 2000s (P = 0.28). Major adverse events occurred in 47% of patients with no difference between decades. There was no significant difference in outcomes between open and endovascular revascularization. On univariate analysis, elevated SVS comorbidity score, congestive heart failure, and chronic kidney disease predicted early death, while a history of chronic mesenteric ischemia appeared protective. On multivariate analysis, no factor independently predicted perioperative mortality. Bowel resection and cerebrovascular disease predicted postoperative morbidity, while advanced age and connective tissue disease predicted long-term mortality. CONCLUSIONS Morbidity and mortality from AMI continues to be high. Revascularization by endovascular means, although more frequent in the last decade, was still utilized in a minority of patients with severe AMI. Advanced ischemia with bowel infarction at presentation, and markers of generalized atherosclerosis are predictors of poor outcome, while history of chronic mesenteric ischemia is associated with better outcome.

Factors affecting outcome of open and hybrid reconstructions for nonmalignant obstruction of iliofemoral veins and inferior vena cava.

OBJECTIVES To identify factors affecting long-term outcome after open surgical reconstructions (OSR) and hybrid reconstructions (HR) for chronic venous obstructions. METHODS Retrospective review of clinical data of 60 patients with 64 OSR or HR for chronic obstruction of iliofemoral (IF) veins or inferior vena cava (IVC) between January 1985 and September 2009. Primary end points were patency and clinical outcome. RESULTS Sixty patients (26 men, mean age 43 years, range 16-81) underwent 64 procedures. Ninety-four percent had leg swelling, 90% had venous claudication, and 31% had active or healed ulcers (CEAP classes: C3 = 30, C4 = 12, C5 = 8, C6 = 12). Fifty-two OSRs included 29 femorofemoral (Palma vein: 25, polytetrafluoroethylene [PTFE]: 4), 17 femoroiliac-inferior vena cava (IVC) (vein: 3, PTFE: 14) and six complex bypasses. Twelve patients had HR, which included endophlebectomy, patch angioplasty, and stenting. Early graft occlusion occurred after 17% of OSR and 33% HR. Discharge patency was 96% after OSR, 92% after HR. No mortality or pulmonary embolism occurred. Five-year primary and secondary patency was 42% (95% confidence interval [CI] 29%-55%) and 59% (CI 43%-72%), respectively. For Palma vein grafts it was 70% and 78%, for femoroiliac and ilio-infrahepatic IVC bypasses it was 63% and 86%, and for femoro-infrahepatic IVC bypasses it was 31% and 57%, respectively. Complex OSRs and hybrid procedures had 28% and 30% 2-year secondary patency, respectively. The only factor that significantly affected graft patency in multivariate analysis was May-Thurner syndrome with associated chronic venous thrombosis. For HR, stenting into the common femoral vein patch vs iliac stents only significantly increased patency. At last follow-up, 60% of the patients had no venous claudication and no or minimal swelling. All ulcers with patent grafts healed but 50% of these recurred. CONCLUSIONS Both OSR and HR are viable options if endovascular procedures fail or are not feasible. Palma vein bypass and femoroiliac or iliocaval PTFE bypasses have excellent outcomes with good symptomatic relief.

In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric erosion or fistula

OBJECTIVE We previously reported that in situ rifampin-soaked grafts (ISRGs) were safe in select patients with aortic graft infections, with the best results in those with aortic graft enteric erosion or fistula (AGEF). This study evaluates the late results of ISRG for AGEF. METHODS From 1990 to 2008, 183 patients were treated for aortic graft infections (121 primary and 62 AGEF). We reviewed 54 patients treated for AGEF with a standard protocol, which included excision of the infected part of the graft, intestinal repair, ISRG with omental wrap, and long-term antibiotics. We excluded 8 patients with AGEF (13%) treated with axillofemoral grafts (AXFG, n = 5) or in situ femoral vein (n = 3) due to excessive perigraft purulence. Endpoints were early morbidity and mortality, late survival, reinfection, and graft-related complications. RESULTS There were 45 male patients and 9 female patients with a mean age of 69 ± 9 years. Presentation was gastrointestinal bleeding in 33 patients, fever in 25 patients, and hemorrhagic shock in 10 patients. Other features were perigraft fluid in 29 patients and purulence in 9 patients. Forty-two patients (80%) had infections isolated to a portion of the graft body or limb, with the remainder of the graft well incorporated. Total graft excision was performed in 31 patients and partial excision in 23 patients. Total operating time was 6.2 ± 1.9 hours. Postoperative complications occurred in 28 patients (52%), and there were 5 deaths (9%). Operative mortality was 2.3% in stable patients (1 of 44) and 40% in those with hemorrhagic shock (4 of 10; P < .001). The hospital stay was 20 ± 18 days. Mean follow-up was 51 months (range, 3-197 months). Five-year patient survival, primary graft patency, and limb salvage rates were 59 ± 8%, 92 ± 5%, and 100%, respectively. There were no late graft-related deaths. There were two (4%) graft reinfections, one that was treated with axillofemoral bypass, and the other with perigraft fluid aspiration and oral antibiotic suppression. CONCLUSION ISRGs with omental wrap and long-term antibiotics are associated with low reinfection rates in patients with AGEF who do not have excessive perigraft purulence. Graft patency and limb salvage rates are excellent.

Autogenous versus prosthetic vascular access for hemodialysis: a systematic review and meta-analysis.

OBJECTIVES The autogenous arteriovenous access for chronic hemodialysis is recommended over the prosthetic access because of its longer lifespan. However, more than half of the United States dialysis patients receive a prosthetic access. We conducted a systematic review to summarize the best available evidence comparing the two accesses types in terms of patient-important outcomes. METHODS We searched electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science and SCOPUS) and included randomized controlled trials and controlled cohort studies. We pooled data for each outcome using a random effects model to estimate the relative risk (RR) and its associated 95% confidence interval (CI). We estimated inconsistency caused by true differences between studies using the I(2) statistic. RESULTS Eighty-three studies, of which 80 were nonrandomized, met eligibility criteria. Compared with the prosthetic access, the autogenous access was associated with a significant reduction in the risk of death (RR, 0.76; 95% CI, 0.67-0.86; I(2) = 48%, 27 studies) and access infection (RR, 0.18; 95% CI, 0.11-0.31; I(2) = 93%, 43 studies), and a nonsignificant reduction in the risk of postoperative complications (hematoma, bleeding, pseudoaneurysm and steal syndrome, RR 0.73; 95% CI, 0.48-1.16; I(2) = 65%, 31 studies) and length of hospitalization (pooled weighted mean difference -3.8 days; 95% CI, -7.8 to 0.2; P = .06). The autogenous access also had better primary and secondary patency at 12 and 36 months. CONCLUSION Low-quality evidence from inconsistent studies with limited protection against bias shows that autogenous access for chronic hemodialysis is superior to prosthetic access.

Treatment strategies and outcomes in patients with infected aortic endografts.

OBJECTIVE Endovascular abdominal (EVAR) and thoracic (TEVAR) endografts allow aneurysm repair in high-risk patients, but infectious complications may be devastating. We reviewed treatment and outcomes in patients with infected aortic endografts. METHODS Twenty-four patients were treated between January 1997 and July 2012. End points were mortality, morbidity, graft-related complications, or reinfection. RESULTS Twenty males and four females with median age of 70 years (range, 35-80 years) had 21 infected EVARs and 3 TEVARs. Index repairs performed at our institution included eight EVARs and two TEVARs (10/1300; 0.77%). There were 19 primary endograft infections, 4 graft-enteric fistulae, and 1 aortobronchial fistula. Median time from repair to presentation was 11 months (range, 1-102 months); symptoms were fever in 17, abdominal pain in 11, and psoas abscess in 3. An organism was identified in 19 patients (8 mono- and 11 polymicrobial); most commonly Staphylococcus in 12 and Streptococcus in 6. All but one patient had successful endograft explantation. Abdominal aortic reconstruction was in situ repair in 21 (15 rifampin-soaked, 2 femoral vein, and 4 cryopreserved) and axillobifemoral bypass in three critically ill patients. Infected TEVARs were treated with rifampin-soaked grafts using hypothermic circulatory arrest. Early mortality (30 days or in-hospital) was 4% (n = 1). Morbidity occurred in 16 (67%) patients (10 renal, 5 wound-related, 3 pulmonary, and 1 had a cardiac event). Median hospital stay was 14 days (range, 6-78 days). One patient treated with in situ rifampin-soaked graft had a reinfection with fatal anastomotic blowout on day 44. At 14 months median follow-up (range, 1-82 months), patient survival, graft-related complications, and reinfection rates were 79%, 13%, and 4%, respectively. CONCLUSIONS Endograft explantation and in situ reconstruction to treat infections can be performed safely. Extra-anatomic bypass may be used in high-risk patients. Resection of all infected aortic wall is recommended to prevent anastomotic breakdown. Despite high early morbidity, the risk of long-term graft-related complications and reinfections is low.

Treatment of celiac artery compression syndrome: does it really exist?

Celiac artery syndrome exists, although it remains controversial, and in some patients a firm diagnosis cannot be established. Duplex scanning or computed tomographic, magnetic resonance, or contrast aortography will confirm intermittent or permanent compression of the celiac artery by the crus of the diaphragm, the median arcuate ligament, or fibrous ganglionic tissue. Preoperative ganglion block and exercise gastric tonometry are useful diagnostic tools to predict better outcome after treatment. In patients with well-defined syndrome of chronic mesenteric and gastric ischemia or with exercise-induced pain, good results can be expected with division of the median arcuate ligament with open celiac artery reconstruction. Patients with atypical pain or history of psychiatric disorders only occasionally benefit from surgical repair. The role of primary stenting of celiac artery compression is still not well defined, and current data do not support the use of balloon-expandable stents. Laparoscopic division of the median arcuate ligament followed by celiac artery stenting is an effective, minimally invasive technique to manage selected patients with celiac artery compression syndrome.

Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease

OBJECTIVE To compare outcomes of mesenteric angioplasty and stenting using iCAST covered stents (CS; Atrium, Hudson, NH) or bare metal stents (BMS) in patients with chronic mesenteric ischemia (CMI). METHODS We reviewed the clinical data of 225 patients (65 male and 160 female; mean age, 72 ± 12 years) treated for CMI at two academic centers (2000-2010). Outcomes were analyzed in patients who had primary intervention or reintervention using BMS (n = 164 patients/197 vessels) or CS (n = 61 patients/67 vessels). End points were freedom from restenosis, symptom recurrence, reinterventions, and patency rates. RESULTS Patients in both groups had similar demographics, cardiovascular risk factors, and extent of disease. In the primary intervention group (mean follow-up, 29 ± 12 months), patients treated by CS had higher freedom from restenosis (92% ± 6% vs 53% ± 4%; P = .003), symptom recurrence (92 ± 4% vs 50 ± 5%; P = .003), reintervention (91% ± 6% vs 56% ± 5%; P = .005), and better primary patency at 3 years (92% ± 6% vs 52% ± 5%; P < .003) than for BMS. In the reintervention group (mean follow-up, 24 ± 9 months), patients treated by CS had higher freedom from restenosis (89% ± 10% vs 49% ± 14%; P < .04), symptom recurrence (100% vs 64%± 9%; P = .001), and reintervention (100% vs 72% ± 9%; P = .03) at 1 year, and a trend toward improved primary patency at 1 year (100% vs 63% ± 9%; P = .054). Secondary patency rates were similar in both groups. CONCLUSIONS In this nonrandomized study, CS were associated with less restenosis, recurrences, and reinterventions than BMS in patients undergoing primary interventions or reinterventions for CMI.

Iliac artery stenting combined with open femoral endarterectomy is as effective as open surgical reconstruction for severe iliac and common femoral occlusive disease.

PURPOSE To compare outcomes of hybrid repair (HR) combining iliac artery stenting and open common femoral endarterectomy (CFE) with open aortoiliac and femoral reconstruction (OR) in patients with extensive iliac and common femoral occlusive disease (IFOD). METHODS Between 1998 and 2008, 92 patients (164 limbs) underwent OR and 70 (84 limbs) underwent HR. All patients underwent concomitant CFE. Thirty-day mortality and morbidity, long-term patency, procedurally related limb salvage, and overall survival were analyzed after stratification by iliac TransAtlantic InterSociety Consensus (TASC) classification into TASC A/B and TASC C/D. RESULTS HR patients were older for both TASC groups (A/B, P = .02; C/D, P = .01) and had higher Society for Vascular Surgery (SVS) cardiac comorbidity scores (A/B, P = .01; C/D, P < .001) compared with OR. Technical success was ≥99% in both groups. An increase in the ankle-brachial index after the procedure was significantly higher in OR patients (0.49 ± 0.28) with TASC A/B lesions than HR (0.22 ± 0.18, P = .031). Hospital and intensive care unit (ICU) lengths of stay were 3.9 days for HR patients in TASC C/D vs 9.4 days for OR patients (P = .005). Comparing HR and OR, 30-day morbidity (3% vs 5%, P = .55) and mortality (1.1% vs 1.4%, P = .85) were equivalent. Primary patency of HR vs OR at 3 years was similar (91% vs 97%, P = .29) and was maintained after stratification by TASC A/B (89% vs 100%, P = .38) and TASC C/D (95% vs 97%, P = .54). Multivariate analysis for patency indicated that major tissue loss (Rutherford class 6) at presentation in the HR group was predictive of decreased long-term patency (P = .02). Limb salvage at 3 years was 100% in both groups. Overall survival was 74% for OR vs 40% for HR (P = .007). CONCLUSION IFOD can be treated using HR with similar early and long-term efficacy vs OR. HR patients with TASC C/D lesions experienced a shorter ICU and hospital stay than OR patients. HR should be considered for all patients with IFOD regardless the severity of TASC classification, particularly in those with high surgical risk. When deciding between HR and OR, one must consider that major tissue loss at presentation is a negative predictor of long-term patency in patients undergoing HR.