Carlos F. Bechara

Lower Extremity Bypass Using Bovine Carotid Artery Graft (Artegraft): An Analysis of 124 Cases with Long-Term Results

IntroductionAlthough biological grafts have been utilized as a vascular conduit in leg bypass for many years, reports of a bovine carotid artery graft (BCAG) in lower extremity revascularization have been scarce. This study analyzed the outcome of lower leg bypass using BCAG.MethodsA retrospective review of a prospectively collected database of all patients undergoing lower extremity bypass using BCAG from 2002 to 2017 was performed. Clinical outcomes including graft patency and limb salvage were evaluated.ResultsA total of 124 BCAG (Artegraft, North Brunswick, NJ) were implanted in 120 patients for lower extremity revascularization. Surgical indications included disabling claudication in 12%, rest pain in 36%, tissue loss in 48%, and infected prosthetic graft replacement in 3%. Autologous saphenous vein was either inadequate or absent in 72% of patients. BCAG was used in 46 patients (37%) who had a prior failed ipsilateral leg bypass. Distal anastomosis was performed in the above-knee popliteal artery, below-knee popliteal artery, and tibial artery in 30 cases (25%), 32 cases (26%), and 48 cases (39%), respectively. Distal anastomotic patch was created in all tibial artery to allow BCAG-tibial reconstruction. The yearly primary patency rates in 5xa0years were 86.5, 76.4, 72.2, 68.3, and 67.5%, respectively. The corresponding yearly secondary patency rates were 88.5, 84.7, 82.4, 78.5, and 75.6%, respectively. The limb salvage rate at one year was 83.6% and at five years was 86.2% for patients with critical limb ischemia. Multivariate analysis showed poor runoff score (Pxa0=xa00.03, 95% CI, 1.3–5.3; OR, 1.6) was independently associated with graft occlusion.ConclusionBCAG is an excellent vascular conduit and provides good long-term results in lower extremity bypass.

Feasibility of three-dimensional magnetic resonance angiography-fluoroscopy image fusion technique in guiding complex endovascular aortic procedures in patients with renal insufficiency

Objective: Three‐dimensional image fusion of preoperative computed tomography (CT) angiography with fluoroscopy using intraoperative noncontrast cone‐beam CT (CBCT) has been shown to improve endovascular procedures by reducing procedure length, radiation dose, and contrast media volume. However, patients with a contraindication to CT angiography (renal insufficiency, iodinated contrast allergy) may not benefit from this image fusion technique. The primary objective of this study was to evaluate the feasibility of magnetic resonance angiography (MRA) and fluoroscopy image fusion using noncontrast CBCT as a guidance tool during complex endovascular aortic procedures, especially in patients with renal insufficiency. Methods: All endovascular aortic procedures done under MRA image fusion guidance at a single‐center were retrospectively reviewed. The patients had moderate to severe renal insufficiency and underwent diagnostic contrast‐enhanced magnetic resonance imaging after gadolinium or ferumoxytol injection. Relevant vascular landmarks electronically marked in MRA images were overlaid on real‐time two‐dimensional fluoroscopy for image guidance, after image fusion with noncontrast intraoperative CBCT. Technical success, time for image registration, procedure time, fluoroscopy time, number of digital subtraction angiography (DSA) acquisitions before stent deployment or vessel catheterization, and renal function before and after the procedure were recorded. The image fusion accuracy was qualitatively evaluated on a binary scale by three physicians after review of image data showing virtual landmarks from MRA on fluoroscopy. Results: Between November 2012 and March 2016, 10 patients underwent endovascular procedures for aortoiliac aneurysmal disease or aortic dissection using MRA image fusion guidance. All procedures were technically successful. A paired t‐test analysis showed no difference between preimaging and postoperative renal function (P = .6). The mean time required for MRA‐CBCT image fusion was 4:09 ± 01:31 min:sec. Total fluoroscopy time was 20.1 ± 6.9 minutes. Five of 10 patients (50%) underwent stent graft deployment without any predeployment DSA acquisition. Three of six vessels (50%) were cannulated under image fusion guidance without any precannulation DSA runs, and the remaining vessels were cannulated after one planning DSA acquisition. Qualitative evaluation showed 14 of 22 virtual landmarks (63.6%) from MRA overlaid on fluoroscopy were completely accurate, without the need for adjustment. Five of eight incorrect virtual landmarks (iliac and visceral arteries) resulted from vessel deformation caused by endovascular devices. Conclusions: Ferumoxytol or gadolinium‐enhanced MRA imaging and image fusion with fluoroscopy using noncontrast CBCT is feasible and allows patients with renal insufficiency to benefit from optimal guidance during complex endovascular aortic procedures, while preserving their residual renal function.

Outcomes following operative management of thoracic outlet syndrome in the pediatric patients

Objectives Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients. Methods Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed. Results Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (nu2009=u200960, 88%) or combined supraclavicular and infraclavicular incisions (nu2009=u20098, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4u2009±u200911.6 months. Long-term symptomatic relief was achieved in 94% of patients. Conclusions Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.

VESS06. Clinical Outcome of Ultrasound-Accelerated Catheter-Directed Thrombolytic Therapy for the Treatment of Submassive Pulmonary Embolism

differences across the specialties. A total of 43% (157 of 368) of total cases involved death of the patient. Among the four specialties, there was a significant (P 1⁄4 .0004) difference in the primary allegation (informed consent, preprocedure negligence, intraprocedural complications, or postprocedural complications) underlying the litigation (Fig). For CTS and VS, there was a predominance of informed consent and preprocedure negligence allegations (70% [7 of 10] and 52% [28 of 54] respectively). Intraprocedural negligence was the most common allegation for IR (59% [23 of 39]), while allegations were more evenly distributed among IC. Conclusions: Key issues were identified regardingmalpractice litigation involving the specialties that commonly perform endovascular procedures. Despite the increasing number of ICs doing peripheral interventions, a largemajority of IC cases were related to coronary treatments. A surprisingly large percentage of VS cases were related to seemingly minor cases. There were significant interspecialty differences in the primary underlying allegations. As the scope of endovascular procedures broadens and deepens, it is important for clinicians to be aware of the legal considerations relevant to their practice.

Echocardiographic assessment with right ventricular function improvement following ultrasound-accelerated catheter-directed thrombolytic therapy in submassive pulmonary embolism

Introduction The objective of this study was to evaluate the efficacy of ultrasound-accelerated catheter-directed thrombolytic therapy in patients with submassive pulmonary embolism. Methods Clinical records of 46 patients with submassive pulmonary embolism who underwent ultrasound-accelerated catheter-directed pulmonary thrombolysis using tissue plasminogen activator, from 2007 to 2017, were analyzed. All patients experienced clinical symptoms with computed tomography evidence of pulmonary thrombus burden. Right ventricular dysfunction was present in all patients by echocardiographic finding of right ventricle-to-left ventricle ratiou2009>u20090.9. Treatment outcome, procedural complications, right ventricular pressures, and thrombus clearance were evaluated. Follow-up evaluation included echocardiographic assessment of right ventricle-to-left ventricle ratio at one month, six months, and one year. Results Technical success was achieved in all patients (nu2009=u200946, 100%). Our patients received an average of 18.4u2009± 4.7 mg of tissue plasminogen activator using ultrasound-accelerated thrombolytic catheter with an average infusion time of 16.5± 5.4 h. Clinical success was achieved in all patients (100%). Significant reduction of mean pulmonary artery pressure occurred following the treatment, which decreased from 36u2009±u20098 to 21u2009±u20095u2009mmHg (pu2009<u20090.001). There were no major bleeding complications. All-cause mortality at 30 days was 0%. No patient developed recurrent pulmonary embolism during follow-up. During the follow-up period, 43 patients (93%) showed improvement of right ventricular dysfunction based on echocardiographic assessment. The right ventricle-to-left ventricle ratio decreased from 1.32u2009±u20090.18 to 0.91u2009±u20090.13 at the time of hospital discharge (pu2009<u20090.01). The right ventricular function remained improved at 6 months and 12 months of follow-up, as right ventricle-to-left ventricle ratio were 0.92u2009±u20090.14 (pu2009<u20090.01) and 0.91u2009±u20090.15 (pu2009<u20090.01), respectively. Conclusion Ultrasound-accelerated catheter-directed thrombolysis is a safe and efficacious treatment for submassive pulmonary embolism. It reduces pulmonary hypertension and improves right ventricular function in patients with submassive pulmonary embolism.

Comparison of propaten heparin-bonded vascular graft with distal anastomotic patch versus autogenous saphenous vein graft in tibial artery bypass

Introduction Heparin-bonded expanded polytetrafluoroethylene grafts (Propaten, WL Gore, Flagstaff, AZ, USA) have been shown to have superior patency compared to standard prosthetic grafts in leg bypass. This study analyzed the outcomes of Propaten grafts with distal anastomotic patch versus autogenous saphenous vein grafts in tibial artery bypass. Methods A retrospective analysis of prospective collected data was performed during a recent 15-year period. Sixty-two Propaten bypass grafts with distal anastomotic patch (Propaten group) were compared with 46 saphenous vein graft (vein group). Pertinent clinical variables including graft patency and limb salvage were analyzed. Results Both groups had similar clinical risk factors, bypass indications, and target vessel for tibial artery anastomoses. Decreased trends of operative time (196u2009±u200934 min vs. 287u2009±u200965 min, pu2009=u20090.07) and length of hospital stay (5.2u2009±u20092.3 days vs. 7.5u2009±u20093.6, pu2009=u20090.08) were noted in the Propaten group compared to the vein group. Similar primary patency rates were noted at four years between the Propaten and vein groups (85%, 71%, 64%, and 57%, vs. 87%, 78%, 67%, and 61% respectively; pu2009=u20090.97). Both groups had comparable secondary patency rates yearly in four years (the Propaten group: 84%, 76%, 74%, and 67%, respectively; the vein group: 88%, 79%, 76%, and 72%, respectively; pu2009=u20090.94). The limb salvage rates were equivalent between the Propaten and vein group at four years (84% vs. 92%, pu2009=u20090.89). Multivariate analysis showed active tobacco usage and poor run-off score as predictors for graft occlusion. Conclusions Propaten grafts with distal anastomotic patch have similar clinical outcomes compared to the saphenous vein graft in tibial artery bypass. Our data support the use of Propaten graft with distal anastomotic patch as a viable conduit of choice in patients undergoing tibial artery bypass.

Computed tomography angiography-fluoroscopy image fusion allows visceral vessel cannulation without angiography during fenestrated endovascular aneurysm repair

Background: Fenestrated endovascular aneurysm repair (FEVAR) is an evolving technique to treat juxtarenal abdominal aortic aneurysms (AAAs). Catheterization of visceral and renal vessels after the deployment of the fenestrated main body device is often challenging, usually requiring additional fluoroscopy and multiple digital subtraction angiograms. The aim of this study was to assess the clinical utility and accuracy of a computed tomography angiography (CTA)‐fluoroscopy image fusion technique in guiding visceral vessel cannulation during FEVAR. Methods: Between August 2014 and September 2016, all consecutive patients who underwent FEVAR at our institution using image fusion guidance were included. Preoperative CTA images were fused with intraoperative fluoroscopy after coregistering with non‐contrast‐enhanced cone beam computed tomography (syngo 3D3D image fusion; Siemens Healthcare, Forchheim, Germany). The ostia of the visceral vessels were electronically marked on CTA images (syngo iGuide Toolbox) and overlaid on live fluoroscopy to guide vessel cannulation after fenestrated device deployment. Clinical utility of image fusion was evaluated by assessing the number of dedicated angiograms required for each visceral or renal vessel cannulation and the use of optimized C‐arm angulation. Accuracy of image fusion was evaluated from video recordings by three raters using a binary qualitative assessment scale. Results: A total of 26 patients (17 men; mean age, 73.8 years) underwent FEVAR during the study period for juxtarenal AAA (17), pararenal AAA (6), and thoracoabdominal aortic aneurysm (3). Video recordings of fluoroscopy from 19 cases were available for review and assessment. A total of 46 vessels were cannulated; 38 of 46 (83%) of these vessels were cannulated without angiography but based only on image fusion guidance: 9 of 11 superior mesenteric artery cannulations and 29 of 35 renal artery cannulations. Binary qualitative assessment showed that 90% (36/40) of the virtual ostia overlaid on live fluoroscopy were accurate. Optimized C‐arm angulations were achieved in 35% of vessel cannulations (0/9 for superior mesenteric artery cannulation, 12/25 for renal arteries). Conclusions: Preoperative CTA‐fluoroscopy image fusion guidance during FEVAR is a valuable and accurate tool that allows visceral and renal vessel cannulation without the need of dedicated angiograms, thus avoiding additional injection of contrast material and radiation exposure. Further refinements, such as accounting for device‐induced aortic deformation and automating the image fusion workflow, will bolster this technology toward optimal routine clinical use.

Short- and midterm results for internal jugular vein extension for short right renal vein kidney transplant

Renal transplantation remains the definitive treatment for end‐stage renal disease (ESRD). The shorter renal vein in right donor nephrectomies is associated with higher incidence of technical failure. We present here our experience with autologous internal jugular vein (IJV) conduits to facilitate living‐donor transplants. Six patients underwent right, living‐donor kidney transplant with simultaneous IJV harvest over a 1‐year period. All had bilateral jugular duplex scans preoperatively and were placed on aspirin 81 mg postoperatively. Patient demographics, comorbidities, and laboratories were retrospectively queried. Postoperative follow‐up and examination were performed per institutional protocol. The mean age and BMI were 51 ± 4.6 years and 30 ± 1.4 kg/m2, respectively. An average 4.5 ± 0.5 cm of IJV was taken, and anastomosed exsitu, end to end to the renal vein. One patient developed a perinephric hematoma requiring reexploration and another expired during follow‐up from septic shock of unknown etiology; there were no harvest site complications or deep vein thrombosis. All had immediate and stable graft function at 3.8 ± 1.7 (range: 0.7‐11.3) months follow‐up. Mean serum creatinine and estimated glomerular filtration rate were 1.3 ± 0.1 mg/dL and 55 ± 2.4 mL/min/1.73 m2, respectively. Internal jugular vein extension of short right renal veins for kidney transplant is a viable technique for ESRD patients with promising results.

A case of gross hematuria with flank pain in a 16-year-old boy: Questions

A 16-year-old Caucasian boy presented with intermittent gross hematuria for 3 months and an episode of bilateral flank pain 2 weeks before the clinic visit. He had no history of trauma, dysuria, frequency, urinary tract infections or passage of kidney stones. Initial workup showed normal serum creatinine of 0.7 mg/dL, normal complete blood count, normal C3, negative antinuclear antibody (ANA), and negative urine culture. Urine analysis showed 1+ blood with 51–100 red blood cells (RBC)/hpf, no RBC casts, crystals or protein. Urine calcium/Cr ratio was 0.19 mg/mg and urine protein/Cr ratio 0.14 mg/mg. Doppler renal ultrasound (RUS) performed at a local hospital showed normal renal artery blood flow. The right and left kidneys measured 11.1 cm and 11.2 cm respectively and there was no evidence of mass, hydronephrosis or stones, and the bladder was normal. His medical history was significant for HLA-B27 ankylosing spondylitis for which he was followed by rheumatology on Humira 40 mg SQ every 7 days. His family history was significant as his mother had had ankylosing spondylitis and kidney stones. Physical examination showed a healthy appearing male with normal blood pressure 126/74 and a body mass index 22.92 kg/m (75 % tile) in no apparent distress and unremarkable examination without any flank tenderness, rash or lower extremity edema. Because there was a family history of stones, he was advised to hydrate a minimum of 3 L/day and to monitor for recurrence of symptoms. The patient returned for follow-up 4 months later and reported intermittent episodes of gross hematuria at baseball practice, with no episodes of flank pain or proteinuria (was doing urine dipsticks at home). Evaluation was unremarkable except for microscopic hematuria, hence continued observation was planned. Four months later, he was seen at another hospital’s emergency room with severe left-sided flank pain associated with vomiting, gross hematuria, and with the passage of blood clots. Spiral computed tomography (CT) did not show any stones and he was sent home after a few hours of observation as the symptoms resolved with hydration and analgesia. The next day a CT angiography of the abdomen The answers to these questions can be found at http://dx.doi.org/10.1007 /s00467-016-3521-3

Retrograde Pedal Access

Retrograde pedal access is performed for difficult to cross arterial lesions. In conjunction with traditional brachial/femoral antegrade access, it can be used for the “body floss” technique. This chapter describes indications, essential steps, and complications of these procedures. It provides a detailed template operative note for the procedure.