Christian Bianchi

Management of Symptomatic Spontaneous Isolated Visceral Artery Dissection: Is Emergent Intervention Mandatory?

Spontaneous dissection of a visceral artery without associated aortic dissection is rare, although more cases have recently been reported because of the advancement of diagnostic techniques. The risk factors, causes, and natural history of spontaneous isolated visceral artery dissection are unclear. Treatment with open surgery, endovascular stenting, or anticoagulation therapy has been proposed; however, there is no consensus on the optimal management. We present three cases of spontaneous and isolated dissection of visceral arteries. Dissection involved the superior mesenteric artery in one and the celiac artery in two. All three patients presented with acute abdominal pain but lacked any peritoneal irritation. The patients were treated nonoperatively with anticoagulants or antiplatelets. No surgical or endovascular intervention was performed. Follow-up imaging studies demonstrated improvement of the dissection in two patients and no change in one patient. All patients were symptom-free over a mean follow-up of 17 months. Nonoperative treatment with close observation is an acceptable strategy in the management of spontaneous isolated dissection of visceral arteries. Emergent intervention is not mandatory in symptomatic patients without evidence of acute bowel ischemia or hemorrhage.

Staged endovascular stent grafts for concurrent mobile/ulcerated thrombi of thoracic and abdominal aorta causing recurrent spontaneous distal embolization

Mobile thrombus of the thoracic aorta is an uncommon pathology with potentially catastrophic complications. Recurrent spontaneous distal embolization may also occur from an ulcerated thrombus of the abdominal aorta. The simultaneous presence of a mobile thrombus in the thoracic aorta and ulcerated thrombus of the abdominal aorta is extremely rare and poses a significant treatment dilemma. Although various approaches have been reported, there is no standard treatment. Direct replacement of the thoracoabdominal aorta is extremely morbid, while continued embolization despite anticoagulation mandate intervention. We herein present the first case report of successful treatment of symptomatic mobile/ulcerated thrombi of the thoracic and abdominal aorta using staged endovascular stent graft repair. Successful treatment of the thoracic component with a thoracic aortic graft (TAG, Gore-Tex, W. L. Gore & Assoc., Flagstaff, Ariz.) was followed one week later by exclusion of the infrarenal aortic lesion with a bifurcated stent graft. Endovascular stent graft exclusion of mobile/ulcerated thoracic and abdominal aortic thrombi is a minimal invasive operation. It can be employed as an alternative procedure in treatment of aortic thrombus with embolization in high risk patients. Long-term follow-up will be necessary to assess the durability of this technique.

Treatment of Superior Mesenteric Artery Portal Vein Fistula with Balloon-Expandable Stent Graft

Visceral artery to portal vein arteriovenous fistulas are rare and difficult to treat. Covered stents have made treatment of pseudoaneurysms and arteriovenous fistulas feasible utilizing minimally invasive techniques. We present a case of a 46-year-old male with a remote history of an exploratory laparotomy after a motorcycle accident who presented with abdominal pain, malaise, and jaundice. A computed tomographic scan revealed a superior mesenteric artery to portal vein arteriovenous fistula. A large arteriovenous fistula was confirmed by arteriography. A balloon-expandable stent graft was placed across the arteriovenous fistula in the superior mesenteric artery. Postprocedure, the patients abdominal pain resolved and his bilirubin decreased from 2.9 to 0.4. Endovascular repair of a superior mesenteric to portal arteriovenous fistula utilizing a stent graft is feasible and minimally invasive.

Arteriovenous Hybrid Graft with Outflow in the Proximal Axillary Vein

BACKGROUNDnThe patency of long-term hemodialysis access in end-stage renal disease patients remains a significant challenge. Often these patients are affected with limited venous outflow options, requiring limb abandonment, and creation of new access in the contralateral arm. Vascular surgeons are familiar with the exposure of the proximal axillary artery via an infraclavicular incision. The axillary vein is easily exposed through this technique. The use of the hybrid Gore graft can make the venous anastomosis easier. A hybrid graft with its venous outflow placed in the proximal axillary vein can extend the options of upper extremity access procedures. We reviewed our early experience with this technique.nnnMETHODSnA review of dialysis procedures at the Loma Linda VA was performed. All patients undergoing placement of arteriovenous grafts utilizing the Gore hybrid placed into the proximal axillary vein for outflow were identified. Outcomes in terms of primary and secondary patency rates were determined.nnnRESULTSnEight patients had placement of an arteriovenous hybrid graft in the proximal axillary vein via an infraclavicular incision. All patients had exhausted other options for hemodialysis access in the ipsilateral upper extremity. All grafts were used successfully for dialysis. The mean primary and secondary patency rates at 6xa0months were 37.5% and 62.5%, respectively. One patient developed steal syndrome, requiring proximalization of the graft. Seven out of the 8 patients required secondary procedures including thrombectomy (nxa0=xa016) and angioplasty (nxa0=xa017).nnnCONCLUSIONSnPlacement of a hybrid graft in the proximal axillary vein is an effective and suitable option for patients who have exhausted arteriovenous access sites in the arm. This procedure can easily be performed in an outpatient setting with a low complication rate and allowing for preservation of the contralateral upper extremity for future use.

Delayed Revascularization After a Trial of Conservative Therapy Is Safe and Effective for Ischemic Wounds in a Multidisciplinary Setting

Objective: Our group has previously shown that a high percentage of ischemic wounds in patients with peripheral arterial disease heal with conservative therapy alone. However, some patients require delayed revascularization. Our goal was to evaluate wound healing and limb salvage among patients with ischemic wounds when revascularization was necessary after a failure of conservative therapy. Methods: Patients with peripheral arterial disease and tissue loss were prospectively enrolled into our Prevention of Amputation in Veterans Everywhere (PAVE) program. Limbs were stratified on the basis of perfusion evaluation and a validated pathway of care. Conservatively treated limbs that failed to demonstrate a positive wound trajectory underwent delayed revascularization. Rates of wound healing, recurrence, limb salvage, and survival were retrospectively compared of patients who underwent delayed vs immediate revascularization by univariate and multivariate analysis, controlling for Wound, Ischemia, and foot Infection (WIfI) classification. Results: Between January 2008 and December 2017, there were 855 patients who were prospectively enrolled in our PAVE program. Of 236 limbs stratified to a conservative approach, 185 (78%) healed and 33 (14%) underwent delayed (mean, 2.76 2.6 months) revascularization. During this same period, 203 limbs underwent immediate revascularization. Mean long-term follow-up was 41.4 6 29.0 months. Delayed compared with immediate revascularization demonstrated similar rates of wound healing (67% vs 58%; P 1⁄4 .33), wound recurrence (24% vs 19%; P 1⁄4 .50), limb salvage (82% vs 75%; P 1⁄4 .39), and survival (55% vs 51%; P 1⁄4 .69). After adjustment for WIfI classification, delayed revascularization remained noninferior to immediate revascularization for wound healing (odds ratio [OR], 1.4; 95% confidence interval [CI], 0.6-3.1), recurrence (OR, 0.8; 95% CI, 0.3-1.8), limb salvage (OR, 0.7; 95% CI, 0.3-1.9), and survival (OR, 0.2; 95% CI, 0.6-2.5). Conclusions: Patients who fail to respond to conservative therapy and undergo delayed revascularization achieve similar rates of wound healing and limb salvage as those undergoing immediate surgical intervention, independent of WIfI classification. A stratified approach to critical limb ischemia achieves acceptable clinical outcomes without introducing increased risk in patients in whom an initial attempt at conservative therapy fails.

Analysis of Patients Undergoing Major Lower Extremity Amputation in the Vascular Quality Initiative

BACKGROUNDnDespite an aggressive climate of limb salvage and revascularization, 7% of patients with peripheral artery disease undergo major lower extremity amputation (LEA). The purpose of this study was to describe the current demographics and early outcomes of patients undergoing major LEA in the Vascular Quality Initiative (VQI).nnnMETHODSnThe VQI amputation registry was reviewed to identify patients who underwent major LEAs. Patient factors, limb characteristics, procedure type, and intraoperative variables were analyzed by the level of amputation. Factors associated with amputation level, 30-day complications, and mortality were analyzed using chi-squared analysis for significance with associated P values. Propensity score adjustment was used to balance statistically significant differences observed in subject characteristics by amputation level for the associated relative risk of a given outcome.nnnRESULTSnBetween 2013 and 2015, 2,939 major LEAs were recorded in the VQI amputation registry. The ratio of below-knee to above-knee amputation (BKA:AKA) was 1.29:1. The mean age was 66xa0years, 64% were male, 84% lived at home before admission, and 68% were ambulatory. Comorbidities included diabetes (67%), coronary artery disease (32%), end-stage renal disease (22%), and chronic obstructive pulmonary disease (23%). The mean preoperative ankle-brachial index (ABI) was 0.78. Overall, 43% had a history of prior ipsilateral revascularization. Indications for amputation were ischemic rest pain or tissue loss (58%), uncontrolled infection (31%), acute ischemia (9%), and neuropathic tissue loss (2%). The overall perioperative complication rate was 15%, 25% were discharged home, and the 30-day mortality was 5%. Patients who received an AKA versus BKA were more likely to be female (40.61% vs. 31.70%), more than age 70 (48.79% vs. 32.55%), underweight (18.63% vs. 9.18%), nonambulatory (40.22% vs. 25.18%), have an ABI <0.6 (58.00% vs. 45.26%), and carry nonprivate insurance (77.40% vs. 69.08%) (all Pxa0<xa00.001). Patients undergoing AKA were less likely to have 30-day postoperative complications (12.24% vs. 17.87%) but had higher 30-day mortality (6.70% vs. 3.09%) than BKA patients (all Pxa0<xa00.001).nnnCONCLUSIONSnIn the VQI registry, major LEA was performed predominantly for ischemic rest pain and tissue loss with a BKA:AKA ratio of 1.29:1. Patients undergoing AKA versus BKA were older, had lower ABI, lower rates of 30-day postoperative complications but higher rates of 30-day mortality. This registry offers an important real-world resource for studies pertaining to vascular surgery patients undergoing major lower extremity amputation.

Placement of Upper Extremity Arteriovenous Access in Patients with Central Venous Occlusions: A Novel Technique

BACKGROUNDnCentral venous occlusion is a common occurrence in patients with end-stage renal disease. Placement of upper extremity arteriovenous access in patients with occlusion of the brachiocephalic veins is often not an option. Avoidance of lower extremity vascular access can decrease morbidity and infection.nnnMETHODSnThe central venous lesions were crossed centrally via femoral access. The wire was retrieved in the neck extravascularly. A Hemodialysis Reliable Outflow catheter was then placed in the right atrium and completed with an arterial anastomosis.nnnRESULTSnWe describe a novel technique for placing upper extremity arteriovenous access in patients with occlusion of the brachiocephalic veins. This technique was utilized in 3 patients. The technical success was 100%.nnnCONCLUSIONSnThe placement of upper extremity arteriovenous access in patients with central venous occlusions is technically feasible.

Clinical outcomes of patients with peripheral artery disease and lower extremity wounds based on a predetermined intention-to-treat strategy

Achieving healing in patients with peripheral artery disease and lower extremity wounds represent a significant clinical challenge. Important outcome measures that define a successful therapeutic approach include wound healing rate, time to heal, and recurrence with time. This article reviews our experience managing a peripheral artery disease patient cohort at a Veterans Affairs medical center based on the initial clinical evaluation stratification and prospective enrollment into a predetermined treatment strategy.