Chad Jacobs

Endoleaks After Endovascular Abdominal Aortic Aneurysm Repair: Management Strategies According to CT Findings

OBJECTIVE With increasing use of endovascular techniques for repair of abdominal aortic aneurysms, the prevalence of leakage into excluded aneurysm sacs (endoleaks) as a complication has risen. We will describe and illustrate the imaging findings for endoleaks involving abdominal aortic aneurysms. We will also discuss which types of endoleaks require urgent catheter-based evaluation. CONCLUSION Radiologists should be familiar with the classification scheme for endoleaks and understand which types of endoleaks require urgent catheter-based evaluation.

Arteriovenous loop grafts for free tissue transfer.

Arteriovenous (AV) loop grafts are a type of vascular conduit that can be used to support free tissue transfer. Wounds of various etiologies may require free tissue transfer, and the AV loop graft is a useful adjunct when adjacent blood supply is inadequate. Here we present 2 cases and review the technique and published literature.

Deep Venous Thrombosis after Saphenous Endovenous Radiofrequency Ablation: Is it Predictable?

BACKGROUND Endovenous radiofrequency ablation (RFA) is a safe and effective treatment for varicose veins caused by saphenous reflux. Deep venous thrombosis (DVT) is a known complication of this procedure. The purpose of this study is to describe the frequency of DVT after RFA and the associated predisposing factors. METHODS A retrospective analysis was performed using prospectively collected data from December 2008 to December 2011; a total of 277 consecutive office-based RFA procedures were performed at a single institution using the VNUS ClosureFast catheter (VNUS Medical Technologies, San Jose, CA). Duplex ultrasonography scans were completed 2 weeks postprocedure in all patients. Risk factors assessed for the development of DVT included: great versus small saphenous vein (SSV) treated, right versus left side treated, number of radiofrequency cycles used, hypercoagulable state, history of DVT, tobacco use, medications (i.e., oral contraceptives, aspirin, warfarin, and clopidogrel), and vein diameter at the junction of the superficial and deep systems. RESULTS Seventy-two percent of the patients were women, 56% were treated on the right side, and 86% were performed on the great saphenous vein (GSV). The mean age was 54 ± 14 years (range: 23-88 years). Three percent of patients had a preprocedure diagnosis of hypercoagulable state, and 8% had a history of previous DVT. On postprocedural ultrasound, thrombus protrusion into the deep system without occlusion (endovenous heat-induced thrombosis) was present in 11 patients (4%). DVT, as defined by thrombus protrusion with complete occlusion of the femoral or popliteal vein, was identified in 2 patients (0.7%). Previous DVT was the only factor associated with postprocedural DVT (P = 0.018). Although not statistically significant, there was a trend toward a higher risk of DVT in SSV-treated patients. Factors associated with endovascular heat-induced thrombosis alone were male sex (P = 0.02), SSV treatment (P = 0.05), aspirin use (P = 0.008), and factor V Leiden deficiency (P = 0.01). CONCLUSIONS The use of RFA to treat patients with symptoms caused by saphenous reflux involves a small but definite risk of DVT. This study shows that the risk of post-RFA DVT is greater in patients with previous DVT, with a trend toward an increased risk in patients having treatment of the SSV. Periprocedural anticoagulation may be considered in this subset to reduce the risk of DVT after RFA. Thrombus protrusion without DVT was found to be more likely in patients with hypercoagulability, male sex, SSV treatment, and aspirin use. Additional prospective studies are required to analyze these and other factors that may predict thrombotic events after endovenous RFA.

Vulnerable Blood in High Risk Vascular Patients: Study Design and Methods

BACKGROUND Basic research suggests that rapid increases in circulating inflammatory and hemostatic blood markers may trigger or indicate impending plaque rupture and coronary thrombosis, resulting in acute ischemic heart disease (IHD) events. However, these associations are not established in humans. METHODS AND RESULTS The Biomarker Risk Assessment in Vulnerable Outpatients (BRAVO) Study will determine whether levels of inflammatory and hemostatic biomarkers rapidly increase during the weeks prior to an acute IHD event in people with lower extremity peripheral artery disease (PAD). The BRAVO Study will determine whether biomarker levels measured immediately prior to an IHD event are higher than levels not preceding an IHD event; whether participants who experience an IHD event (cases) have higher biomarker levels immediately prior to the event and higher biomarker levels at each time point leading up to the IHD event than participants without an IHD event (controls); and whether case participants have greater increases in biomarkers during the months leading up to the event than controls. BRAVO enrolled 595 patients with PAD, a population at high risk for acute IHD events. After a baseline visit, participants returned every two months for blood collection, underwent an electrocardiogram to identify new silent myocardial infarctions, and were queried about new hospitalizations since their prior study visit. Mortality data were also collected. Participants were followed prospectively for up to three years. CONCLUSIONS BRAVO results will provide important information about the pathophysiology of IHD events and may lead to improved therapies for preventing IHD events in high-risk patients.

Repair of a complex thoracic aneurysm from relapsing polychondritis.

A 29-year-old female with a history of relapsing polychondritis (RP) and open repair of a proximal descending thoracic aneurysm presented with 2 areas of asymptomatic thoracic aortic aneurysmal dilatation. The patient returned 3 months later with symptomatic aneurysm expansion, and she underwent ascending aortic arch replacement. She subsequently underwent staged endovascular repair of the distal descending thoracic aorta. RP is a rare disorder with an incidence of 3.5 per million persons annually, 4% to 7% of whom develop aneurysmal disease. Because of the aneurysmal potential of this disease, it is important for vascular surgeons to be aware of its presentation and treatment. To our knowledge, this is the first reported case describing endovascular technique to treat such a patient.

Primary Aortoduodenal Fistula Supplied by Type II Endoleak

Aortoenteric fistulas are a rare but potentially lethal condition. Here we present an unusual case of a fistula between the excluded portion of an infrarenal aneurysm repaired by stent-grafting and the duodenum. The fistula was supplied by a type II endoleak. The patient was successfully treated by extra-anatomic bypass grafting and removal of the aneurysm sac and the stent-graft.

Severe Lower Extremity Arterial Disease

Innovations in surgery, radiology, and medical management during the past 30 years have allowed patients who once faced certain amputation as a result of leg ischemia to be offered a variety of alternatives. Patients with limb-threatening ischemia differ from those with intermittent claudication in regard to both natural history and treatment requirements. Management of patients with claudication involves risk factor modification, exercise regimens, and pharmacologic intervention. This group rarely requires amputation. Patients with critical limb ischemia are most often treated surgically in order to preserve limb functionality. Five year rates of limb salvage for this patient population have been shown to be 81 % for femoropopliteal bypass and 47% for infrapopliteal bypass (1). However, despite continued additions to our treatment armamentarium, it has been shown that amputation rates have remained the same over the past decade (2). The mortality from major amputations is generally reported to be 3 to 10% (3), but in selected populations, such as those over 80 years old, mortality may be as high as 82% (4). In addition, the rehabilitation outcome after amputation for nonrecon-structible arterial disease is usually overestimated. One recent study (5) reported that only 26% of patients were able to ambulate outdoors with a prosthesis 2 years after major amputation. Another study predicted that the number of amputations performed in the geriatric population will double by the year 2030 (6).

Crush Deformation of a Balloon-Expandable Stent Implanted in an Infrainguinal Bypass Graft

A 59-year-old man with critical claudication underwent left femoro-anterior bypass grafting, which was uneventful. The graft was tunneled medially across the knee, then anterior to the tibia. His symptoms recurred 1 year later and he was found to have critical stenosis of the vein graft just proximal to the anterior tibial arterial anastomosis. This was treated with scaffolded balloon angioplasty and implantation of a coronary, zotarolimus-eluting balloon-expandable stent, which was also uneventful. However, his claudication again recurred 1 year later. Diagnostic angiography revealed crush, deformation and restenosis of the balloon-expandable stent requiring surgical revision of the bypass graft.

Chronic Lower Extremity Ischemia

Atherosclerotic occlusive disease is the most common cause of arterial insufficiency. Patients most at risk for this disease are those who have a smoking history (past or current), as well as other atherosclerotic disease processes such as diabetes, hypertension, and hyperlipidemia. The strongest correlation is seen with tobacco use; severe disease is rarely seen in the non-tobacco-using patient. Careful history taking is necessary to assess for risk factors and delineate arterial insufficiency from other etiologies that may mimic symptoms and findings. These include peripheral neuropathy, spinal stenosis, radiculopathies, arthritis, and rheumatologic diseases, or a combination thereof. Important information can be elicited that will guide decision making and clinical investigation.

Book Review: Schillinger M, Minar E (eds). Complications in Peripheral Vascular Interventions. London: Informa UK Ltd; 2007. (229 pp,

Specific chapters in part II discuss complications that can arise during carotid stenting, subclavian and vertebral intervention, treatment of aortic aneurysms, renal and mesenteric intervention, aortoiliac intervention, femoropopliteal intervention, tibioperoneal intervention, management of failing hemodialysis grafts, and venous intervention. The strength of this text is that chapters are uniformly organized, well written, and easy to read. The organization of the complications into specific anatomic areas makes for straightforward reference and practical review. The methods discussed for handling the complications are easily understood and clinically useful. The sections within each chapter dedicated to identifying patients at high risk for complication and the avoidance of complications are particularly helpful. This book will be a welcome and positive addition to the library of any practitioner of percutaneous peripheral vascular intervention, from novice to expert.