Britt H. Tonnessen

Redefining postoperative surveillance after endovascular aneurysm repair: Recommendations based on 5-year follow-up in the US Zenith multicenter trial

INTRODUCTION Recommended postoperative surveillance after endovascular aneurysm repair (EVAR) includes serial contrast-enhanced CT scans. The cumulative deleterious effect on renal function, radiation exposure, and significant cost of this surveillance regimen are all problematic. However, there are scant data to support modulation of current post-EVAR surveillance regimens. METHODS The study comprised patients who underwent EVAR as part of the prospective multicenter pivotal (phase II) and continued-access (phase III) US Zenith Endovascular (Cook, Bloomington, Ind) graft trials. A core lab prospectively recorded patient data. A composite aneurysm-related morbidity (ARM) variable was calculated to include aneurysm rupture, open conversion, any secondary intervention, limb thrombosis, migration, renal morbidity, or aneurysm-related death. The long-term freedom from ARM as a function of the presence or cumulative absence of any endoleak at 1, 6, and 12 months was analyzed. The potential additive predictive utility of aneurysm sac shrinkage (>/=5 mm) was assessed at 12 months. The instructions for use for aortic neck anatomy (>/=15 mm length, 18 to 28 mm diameter, </=60 degrees angulation) were followed. RESULTS EVAR was done in 739 patients (mean follow-up, 29.9 +/- 17.1 months). Freedom from endoleak at 1 month was highly predictive (P < .001) of reduced ARM: freedom from ARM was 92.3%, 89.8%, 85.2%, 83.1% and 83.1 % at 1, 2, 3, 4, and 5 years, respectively, in patients without endoleak (83.1%) and 75%, 67.1%, 61.5%, 55.9%, and 55.9% in patients with endoleak (16.9%). Cumulative absence of endoleak at 1 year (77.6%) was associated with 94%, 91.5%, 88.1%, 85.8%, and 85.8% 1- to 5-year freedom from ARM vs 73.3%, 66.7%, 56.6%, 52.5%, and 52.5% in patients with endoleak </=1 year (22.4%), P < .001. In patients without endoleak at 12 months, the subsequent risk of any ARM was 8.2% (5-year risk, 14.2%; 1-year risk, 6.0%). In patients with significant sac shrinkage (>/=5 mm) and cumulative absence of endoleak at 12 months, the subsequent risk of an ARM was 5.3% (5-year risk, 11.1%; 1-year risk, 5.8%). CONCLUSIONS Absence of endoleak at 30 and 365 days predicted greatly improved long-term freedom from ARM compared with early endoleak. A new EVAR surveillance regimen is recommended that modulates the intensity and frequency of postoperative imaging based on these early outcomes. In patients without early endoleak, the 6-month surveillance is eliminated, and aortic ultrasound is suggested for long-term surveillance >1 year. In most patients, this reduced surveillance regimen would be appropriate and could improve patient safety by reducing the cumulative deleterious effects of intravenous contrast and radiation exposure while also reducing health care costs. These subjective recommendations would be ideally validated in a randomized, prospective trial.

Paradigm shifts in the treatment of abdominal aortic aneurysm: Trends in 721 patients between 1996 and 2008

OBJECTIVE This study evaluated longitudinal trends in abdominal aortic aneurysm (AAA) management after later-generation endografts became available. METHODS We retrospectively analyzed non-suprarenal AAA repairs between January 1, 1996, and December 31, 2008, performed at a single institution. Patients were stratified by endovascular AAA repair (EVAR) or open repair and the presence or absence of rupture. Thirty-day mortality rates were compared with the Fisher exact test. RESULTS During a 13-year period, 721 patients underwent AAA repair, comprising 410 (56.9%) with EVAR and 311 (43.1%) with open repair. A bimodal distribution of EVAR usage was observed, with initial escalation in the 1990s to 70%. A nadir of EVAR occurred in the early 2000s (40%), correlating with more conservative EVAR use after the limitations of first-generation endografts were understood. Between 2005 and 2008, average EVAR use increased to 84%. The overall 30-day mortality rate for the entire cohort, including ruptured AAA, was 3.8%: 2.0% (8 of 410) for EVAR and 6.1% (19 of 311) for open repair (P < .05). Ruptured AAA had a mortality rate of 0% (0 of 8) for EVAR vs 31% (9 of 29) for open (P = .16). Non-ruptured AAA mortality was 2.0% (8 of 402) for EVAR vs 3.6% (10 of 282) for open (P = .23). EVAR and open repair both had reductions in mortality in the latter half of the series, combining to provide a significant decrease in overall mortality to 1.8% for patients treated from 2003 to 2008 compared with 4.9% for 1996 to 2002 (P < .05). Open AAA repair became more complex during the study period. The average rate for juxtarenal open AAA repair was 17.7% (range, 6.5%-34.6%) between 1996 and 2002 compared with 55.6% (range, 29.6%-100%) between 2003 and 2008 (P < .05). CONCLUSIONS AAA treatment has undergone a profound and sustained paradigm shift, now averaging 84% of repairs performed with EVAR between 2005 and 2008. Overall mortality from AAA repair, including ruptures, was reduced 64% (from 4.9% to 1.8%) during the 13-year study period. Although EVAR and open repair both had improved mortality in the latter half of the series, the primary driver in reduced mortality for AAA repair has been the shift to EVAR.

Brachial versus basilic vein dialysis fistulas: a comparison of maturation and patency rates.

OBJECTIVES Although the performance of basilic vein transpositions for dialysis access is well established, the utility and patency rates of brachial vein transpositions are poorly characterized. The brachial vein is being used increasingly as an alternative vein for transposition in an effort to increase the percentage of autogenous fistula utilization. The purpose of this study was to review a single-center comparative experience with these fistulas. METHODS A retrospective chart review was performed on 59 patients who received basilic and brachial vein transpositions between January 2000 and December 2006. Patient demographics, comorbidities, mortality, and morbidity were evaluated. Patency rates were calculated using Kaplan-Meier life-table analysis. RESULTS Of 59 vein transpositions, there were 42 basilic (71%) and 17 brachial (29%). The 30-day mortality was 0%. Maturation rates were 74% for basilic vein transpositions and 47% for brachial (P = .049). The mean time to maturation was 11.9 +/- 8.8 weeks. Primary patency rates at 12 months were 50% for basilic vein transpositions vs 40% for brachial (P = .115). The mean vein size was 4.9 +/- 0.9 mm. The mean basilic vein transposition diameter of 4.9 +/- 1.0 mm and brachial vein transposition diameter of 5.0 +/- 0.8 mm were not significant (P = .39). CONCLUSIONS Despite a higher rate of initial maturation in basilic vein transpositions, brachial and basilic vein transpositions had comparable patency rates at 12 months. These preliminary results require further follow-up and a larger cohort of patients for confirmation. Broader use of the brachial vein transposition for dialysis appears justified and can increase the overall percentage of autogenous fistula placement.

Endovascular debranching of the aortic arch during thoracic endograft repair

BACKGROUND Treatment of complex thoracic aortic pathology increasingly requires coverage of one or more aortic arch vessels. Endovascular debranching with a chimney technique can reduce or eliminate the need for surgical bypass. In this study, we evaluate our initial experience with planned endovascular debranching of the aortic arch. METHODS During a 13-month period, nine patients were treated with endovascular debranching during thoracic endograft placement. Balloon expandable (n = 7) or self-expanding stents (n = 2) were deployed (innominate, n = 2; left common carotid, n = 2; left subclavian, n = 5) along with either TAG (W. L. Gore, Flagstaff, Ariz; n = 8) or Talent (Medtronic, Minneapolis, Minn; n = 1) endografts. Four patients required six surgical bypasses to additional arch vessels (right to left common carotid artery, n = 2; left common carotid to subclavian artery, n = 4). RESULTS Indications for thoracic endograft placement were aortic transection (n = 4), aortic aneurysm (n = 2), aortotracheal fistula (n = 1), contained aortic aneurysm rupture (n = 1), and acute aortic dissection (n = 1). Endografts were deployed into zones 0 (n = 2), 1 (n = 2), and 2 (n = 5). Technical success of endovascular debranching was attained in eight of nine patients, with maintenance of branch perfusion and absence of endoleak. Perioperative morbidity included one myocardial infarction and one stroke that resulted in the patients death. During subsequent follow-up (range, 2-25 months), there were no instances of endoleak secondary to chimney stents. All debranched vessels maintained primary patency. CONCLUSION Endovascular debranching permits planned extension of the thoracic endograft over arch vessels while further minimizing the need for open reconstruction. Short-term results indicate technical feasibility of this approach. Long-term outcomes remain undefined.

Iatrogenic Injury From Vascular Access and Endovascular Procedures

Endovascular procedures inevitably result in iatrogenic injury in a small percentage of patients. Appropriate choice of access site, careful technique, and selective use of closure devices may reduce the incidence of these complications. The vascular interventionalist should be able to recognize and manage various access site complications, such as pseudoaneurysm, arteriovenous fistula, and retroperitoneal hematoma. Procedural complications such as arterial dissection can often be repaired with endovascular techniques. Newer techniques such as totally percutaneous endovascular aneurysm repair have special considerations to minimize the risk of hemorrhage or limb ischemia. The purpose of this review is to define the more common endovascular complications, their diagnosis, and management.

Reimbursement of long-term postplacement costs after endovascular abdominal aortic aneurysm repair

OBJECTIVE Postplacement cost of surveillance and secondary procedures over 5 years increases the global cost of endovascular aortic aneurysm repair (EVAR) by nearly 50%. This study identified and assessed the reimbursement received for long-term postplacement costs after EVAR. METHODS Between December 1995 and June 2007, 360 patients underwent EVAR at a single institution. The reimbursement collected from charges of postplacement surveillance and secondary procedures related to the aneurysmal disease was evaluated and compared against the actual costs. All amounts were converted to year 2007 dollars. To minimize costs associated with the early learning curve, the initial 50 EVAR patients between December 1995 and 1998 were excluded. Patients with <1 year follow-up were also excluded. Data are expressed as mean +/- standard error. RESULTS The mean follow up after EVAR for 152 patients was 38.8 +/- 1.8 months. Medicare, capitated insurance, and commercial insurance provided coverage for 85 (56.0%), 49 (32.2%), and 18 (11.8%) patients, respectively. The cumulative 5-year postplacement reimbursement received per patient was

Endovascular Repair of a Ruptured Internal Iliac Arterial Aneurysm With a Novel Application of the Aorto-uni-iliac Converter Device

9792 meeting 81.4% of the cumulative cost of

The New Anticoagulants

12,027 for a net loss of

Low-Molecular-Weight Heparin Versus Coumarin for the Prevention of Recurrent Venous Thromboembolism in Patients With Cancer

2235 per patient. Although 123 (80.9%) patients without secondary procedures generated a 5-year cumulative gain of

Better survival for African and Hispanic/Latino Americans after infrainguinal revascularization in the Society for Vascular Surgery Vascular Quality Initiative

1830 per patient, 29 (19.1%) patients with secondary procedures averaged a 5-year cumulative loss of