C. Steven Powell

Duplex-directed thrombin injection as a method to treat femoral artery pseudoaneurysms

The common femoral artery has long been the preferred site for percutaneous access to the arterial system because of its low complication rate. However, the exponential growth of arteriography has set the stage for an expanding rate of iatrogenic arterial injury, and these injuries now exceed all vascular injuries from gunshot and knife wounds. Historically, arterial thrombosis was the most common complication of percutaneous arterial access. Recently, however, the use of larger catheters and the more liberal use of anticoagulants have created a rising incidence of expanding hematoma and pseudoaneurysm. Many injuries are from errors in technique resulting in vessels that are difficult to compress (suprainguinal puncture), certain patient characteristics (advanced age, obesity, aberrant anatomy), or therapeutic adjuncts (anticoagulants). The highest rate of pseudoaneurysm formation occurs after coronary stenting (5% to 8%) and atherectomy (2.2%), and it occurs infrequently after diagnostic angiography (0.2% to 0.5%). If a pseudoaneurysm is suspected, color flow Doppler ultrasound should be performed, and if confirmed, ultrasound-directed compression can effectively be applied to a certain percentage of patients. Since the introduction of this technique by Fellmeth in 1991, ultrasound-guided compression of pseudoaneurysms has become the initial treatment of choice. Drawbacks of the technique are that it can be time consuming to use, both in terms of personnel and equipment and frequently requires intravenous sedation and analgesia. The technique is usually accompanied by a 24-hour period of bedrest and bandage compression. Even with these measures, the recurrence rate is still 20%. Finally, continued anticoagulation greatly reduces the rate of success. Consequently, surgical repair has been required for 20% to 30% of all femoral pseudoaneurysms. Surgical complication after repair of femoral pseudoaneurysm in large series approximates 20%, including a 2% to 3% mortality (Table 1). The average hospital stay was . 3 days in this group. An alternative method of treatment was suggested by Liau and associates in July 1997: direct, ultrasound-directed thrombin injection into the pseudoaneurysm. Their series of five patients demonstrated 100% efficacy, no recurrences at 1 to 28 months, and no procedure-related complications. Moreover, the procedure required only minutes to perform and was well tolerated by all patients, none of whom required sedation or analgesia. These excellent results were corroborated by Baker and Kang, who recently reported similar results in 22 pseudoaneurysms (including patients on anticoagulants) without complication or recurrence.

Cost per day of patency: Understanding the impact of patency and reintervention in a sustainable model of healthcare

BACKGROUND Healthcare resource utilization is an understudied aspect of vascular surgery. Initial cost of a given procedure is not an accurate reflection of resource utilization because it does not account for procedural durability and efficacy. Herein we describe an amortized cost model that accounts for procedural costs, durability, and re-intervention costs. METHODS A cost model was developed using patency data endpoints and total hospital costs (direct and indirect) associated with an inital revascularization and subsequent re-interventions. This model was applied to a retrospective database of femoropopliteal reconstructions. One hundred and eighty-three open cases were compared with 198 endovascular cases; and the endpoints of initial cost, amortized cost at 12 months, and assisted patency were examined. RESULTS The open and endovascular cases were not statistically different with respect to indication, patient co-morbid profiles, or post-procedural pharmacotherapy. Primary assisted patency was better in the open revascularization group at 12 months (78% versus 66%, P < .01). There was a statistically significant higher initial cost for open reconstruction when compared with endovascular (

The Association of Periprocedural Hypertension and Adverse Outcomes in Patients Undergoing Catheter-Directed Thrombolysis

12,389 +/-

Telemedicine and endovascular aortic grafting

408 versus

Original ArticlesTelemedicine and endovascular aortic grafting1

6,739 +/-

Age does not predict need for reintervention in patients with critical limb ischemia.

206, P < .001). However, at 12 months post-procedure, the initial cost benefit was lost for endovascular patients (

Endovascular Repair of Iatrogenic Iliocaval Fistula Causing High-Output Cardiac Failure after Spine Fusion

229 +/-

Considerations in the Management of Aneurysms of the Superior Mesenteric Artery

106 versus

Autologous Superficial Femoral Vein for Aortic Reconstruction in Infected Fields

185 +/-

Bifurcated Endovascular Grafting for Abdominal Aortic Aneurysm

124, P = .71). There was, however, a trend for endovascular cost savings in claudicants, though this did not reach significance (