Benjamin J. Pearce

Anatomic Suitability of Aortoiliac Aneurysms for Next Generation Branched Systems

BACKGROUND Preservation of internal iliac flow is an important consideration to prevent ischemic complications during endovascular aneurysm repair. We sought to determine the suitability of aortoiliac aneurysms for off-the-shelf iliac branched systems currently in clinical trial. METHODS Patients undergoing abdominal aortic aneurysm repair from 2004 to 2013 at 2 institutions were reviewed. Centerline diameters and lengths of aortoiliac morphology were measured using three-dimensional workstations and compared with inclusion/exclusion criteria for both Cook and Gore iliac branch devices. RESULTS Of the nearly 2,400 aneurysm repairs performed during the study period, 99 patients had common iliac aneurysms suitable for imaging review. Eighteen of the 99 (18.2%) patients and 25/99 (25.3%) patients fit the inclusion criteria and would have been able to be treated using the Cook and Gore iliac branch devices, respectively. The most common reason for exclusion from Cook was internal iliac diameter of <6 or >9 mm (68/99, 68.7%). The most common reason for exclusion from Gore was proximal common iliac diameter of <17 mm (39/99, 39.4%) and inadequate internal iliac artery diameter of <6.5 or >13.5 mm (37/99, 37.3%). Comparing the included patients across both devices, a total of 35/99 (35.4%) of patients would be eligible for the treatment of aortoiliac aneurysms based on anatomic criteria. CONCLUSIONS Only 35% of the aneurysm repairs involving common iliac arteries would have been candidates for the 2 iliac branch devices currently in trial based on anatomic criteria. The major common reason for exclusion is the internal iliac landing zone for both devices. Design modifications for future generation iliac branch technology should focus on diameter accommodations for the hypogastric branch stent and proximal and distal sizes of the iliac branch components. Familiarity with alternate branch preserving techniques is still needed in the majority of cases.

Using IVUS during EVAR and TEVAR: Improving Patient Outcomes

Intravascular ultrasonography (IVUS) provides immediate and dynamic imaging of aortic pathology that can be helpful in treating aortic pathology. IVUS has been shown to reduce the need for contrast imaging during endovascular reconstruction for both infrarenal and thoracic aortic endografting. We provide a technique and rationale for routine use of IVUS during endovascular abdominal aneurysm repair to reduce contrast load, fluoroscopy time, and complications that ultimately can improve patient outcomes.

Outcomes after celiac artery coverage during thoracic endovascular aortic aneurysm repair

OBJECTIVE Coverage of celiac artery (CA) during thoracic endovascular aortic aneurysm repair (TEVAR) has been performed to extend the distal seal zone for which preliminary results and short-term follow-up have been reported. We aim to show the outcomes up to 81 months after CA coverage during TEVAR. METHODS Patients undergoing TEVAR with coverage of the CA origin from 2005 to 2013 were retrospectively analyzed. Points of analysis include indications for covering the CA, demonstration of collateral circulation between the CA and superior mesenteric artery (SMA), anatomic features of the distal landing zone, rate of reintervention, technical success, presence of clinical ischemic symptoms after the procedure, and mortality. RESULTS During the 9-year period, 366 patients underwent TEVAR, 18 (5%) of whom had CA coverage. Eleven (61%) had TEVAR with CA coverage due to a thoracic aneurysm, three (17%) had thoracic aortic dissection related to aneurysm, and four (22%) had previous TEVAR with a type Ib endoleak (EL) requiring distal coverage. Mesenteric angiography in preparation for TEVAR with CA coverage diagnosed a critical SMA stenosis in one patient that was treated with stenting before the index procedure. At the conclusion of the indicated procedure, two patients (11%) had a type Ia EL and two patients (11%) had a type Ib EL. Three of the type I ELs required reintervention. Two patients (11%) had a type II EL, both of which were managed with observation and resolved. Reintervention was required in 27% of patients. Postoperative complications included visceral ischemia in 2 (11%), weight loss in 1 (5%), spinal cord ischemia in 2 (11%), a cerebrovascular event in 1 (6%), and death in 1 (6%). The mean follow-up period was 38 months (range, 0.5-81 months). CONCLUSIONS This analysis of outcomes up to 81 months supports the suitability of covering the CA in selected patients for extending the distal landing zone to the visceral aortic level above the SMA or when alternative branch vessel treatment is unavailable. Preoperative angiographic evaluation of the mesenteric collaterals and early postoperative surveillance may limit postoperative complications. Once the CA is covered, new symptoms do not develop unless the SMA is compromised.

The current role of endovascular intervention in the management of diabetic peripheral arterial disease

Poor arterial inflow continues to be a major contributing factor in the failure to heal diabetic foot wounds. Options for revascularization have significantly increased with the development of sophisticated endovascular techniques. However, the application of this technology is variable due to relatively little prospective, randomized data on newer techniques. Further, multiple specialties are capable of performing endovascular interventions and proper referral can be difficult. This article will review the basics of application of endovascular intervention in the diabetic patient with arterial disease and provide a broad understanding of the literature behind the decision-making on appropriate therapy.

Analysis of emergency vascular surgery consults within a tertiary health care system

OBJECTIVE Patients with vascular disease often have multisystem atherosclerosis and multiple comorbidities requiring comprehensive interdisciplinary specialty care. Consultation is a critical component of a tertiary vascular surgery practice, but analysis of this service is under-reported in the literature. After-hours inpatient consultations and interhospital transfers are associated with urgent patient care. METHODS A retrospective analysis of vascular surgery consultations was carried out from January 1, 2013, to December 31, 2013. Consultations included inpatient services, the emergency department, surgical and medical intensive care unit, and interhospital transfers. Data analysis included number of consults, time of consultation (during hours, 0700-1859; after hours, 1900-0659), referring service, nature, and outcome of consultation. Consultations were then classified as urgent if vascular surgical intervention was required as an intraoperative consultation, within 24 hours, or during the same hospitalization. Patients without a same-hospital vascular surgical intervention were classified as nonurgent. RESULTS During a 1-year period, 823 independent consult requests of 749 patients were analyzed. It was found that 57.8% of after-hours consults resulted in urgent patient care (P = .003); 29.7% of medicine, 33.3% of medical intensive care unit, 41.9% of trauma surgery, and 60% of emergency department after-hours consultations were urgent; 73% of surgery and 79.2% of interhospital after-hours consults required urgent vascular surgical intervention. Extremity ischemia, aortic disease, and iatrogenic consults accounted for 44.8%, 20.4%, and 11.1% of after-hours consults, with 57.9%, 56.4%, and 70% requiring urgent vascular surgical intervention, respectively. CONCLUSIONS After-hours consultations are not always associated with an urgent vascular surgical intervention. Nonurgent after-hours consultations are requested more frequently from some services and may present an opportunity for education that could improve workflow of the vascular workforce.

Impact of Glucose Control and Regimen on Limb Salvage in Patients Undergoing Vascular Intervention

to 39 of 60 (65%) in the usual group (P < .001). The mean hospital length of stay in patients with BTAI at the unusual locations was 8.5 days compared with 20.3 days in the usual location group (P < .004). Mortality occurred in 5 of 14 (36%) in the unusual location group compared with 5 of 60 (8%) in the usual location group. No deaths were related to the BTAI itself in the unusual location group. Conclusions: BTAIs at unusual locations are associated with several characteristics. They are more frequently associated with thoracic spine injuries, are more common in women, tend to be lower grade, are less likely to require intervention, and appear to have a higher mortality due to other traumatic injuries.

PC046. Timing of Thoracic Endovascular Aortic Repair for Uncomplicated Acute Type B Aortic Dissection and Association With Complications

Objectives: Time from dissection to treatment with thoracic endovascular aortic repair (TEVAR) in acute type B aortic dissections has previously been linked to procedural complications, but more rigorous data are needed to inform decision making. We sought to evaluate the association of complications after TEVAR for uncomplicated acute type B aortic dissections to timing of treatment using national Vascular Quality Initiative data. Methods: The Vascular Quality Initiative TEVAR dataset was queried and limited to patients with TEVAR within 42 days of onset. Those with incomplete data or complicated dissection (malperfusion or rupture) were excluded. General demographic information, comorbidities, time from onset to TEVAR, procedural details, and complications were evaluated. Cohorts were defined as acute-early (0-2 days), acute-delayed (3-14 days), and subacute (15-42 days). The focus was on complications felt potentially related to dissection flap maturity, including return to the operating room for TEVAR-related issues, extremity/bowel/renal

Does Endovascular Repair Reduce the Risk of Rupture Compared to Open Repair in Splanchnic Artery Aneurysms

Aneurysms of the splanchnic circulation (VAA-visceral artery aneurysm) carry an especially high mortality with rupture. Repair of VAA requires a precise understanding of the collateral circulation and determination of whether maintenance of patency is required to prevent end organ ischemia. In elective cases of VAA repair, both open and endovascular techniques confer excellent results with limited mortality; the latter being mostly employed for ablative therapies. The main determinants of modality will be the need to maintain perfusion of the end organ and the complicating factors to surgical exposure. In cases where ablative aneurysm treatment is planned regardless of modality, endovascular repair is an appropriate first step. In cases requiring maintenance of in-line flow to the parent artery or when persistent aneurysm flow would result in ongoing bleeding, open surgery remains the most appropriate option.