Christopher J. Smolock

Efficacy of covered stent placement for central venous occlusive disease in hemodialysis patients

OBJECTIVES Covered stents have been proposed as an endovascular option for recalcitrant cases of hemodialysis-related central venous occlusive disease (CVOD). This study evaluated the efficacy and durability of covered stents in treating CVOD to preserve a functional dialysis access circuit. METHODS A retrospective review was performed of all patients with clinically significant CVOD who were treated by placement of covered stents from April 2007 to September 2010. Demographics, lesion locations and anatomic characteristics, stent graft, and access patency rates were determined. Complications, reinterventions, and factors influencing their outcomes were examined. RESULTS In 25 patients (56% men; mean age, 57 ± 29 years) with CVOD, covered stents were used in 20 to treat symptomatic venous hypertension or in 5 at the time of access creation to enable functionality. The target lesion was accessed via the dialysis access site or the common femoral vein. The Viabahn endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz) was used in 24 patients (average size and length, 11 mm × 5 cm) and a 13-mm × 5-cm Fluency covered stent (Bard Peripheral Vascular, Tempe, Ariz) was implanted in 1 patient. Technical success was 100%, and resolution of arm edema occurred after covered stent deployment in symptomatic patients. Two postprocedural cases (8%) of thrombosis occurred, one within 30 days and another at 3 months. Both required percutaneous thrombectomy and percutaneous transluminal angioplasty (PTA). Three additional patients (12%) required PTA due to restenosis in one of the ends of the device. Covered stent primary patency (PP), assisted primary patency (APP), and secondary patency (SP) were 56%, 86%, and 100% at 12 months, respectively. Access patency rates at 12 months were 29%, 85%, and 94% for PP, APP, and SP, respectively, in patients that received a covered stent for access salvage; patency rates were 74%, 85%, and 94% for PP, APP, and SP, respectively, in patients in whom the access was created after the venous outflow restoration. CONCLUSIONS Placement of covered stents for hemodialysis-related CVOD is safe, effective in relieving symptoms, and enabled functionality of new dialysis access circuits. Further prospective and randomized studies are necessary to determine whether covered stents provide superior long-term results to those achieved with PTA and bare metal stents.

Impact of metabolic syndrome on the outcomes of superficial femoral artery interventions

BACKGROUND Metabolic syndrome (MetSyn) is an epidemic in the United States and is associated with early onset of atherosclerosis, increased thrombotic events, and increased complications after cardiovascular intervention. MetSyn is found in ∼50% of patients with peripheral vascular disease. However, its impact on peripheral interventions is unknown. The aim of this study is to determine the outcomes of superficial femoral artery (SFA) interventions in patients with and without MetSyn. METHODS A database of patients undergoing endovascular treatment of SFA disease between 1999 and 2009 was retrospectively queried. MetSyn was defined as the presence of ≥3 of the following criteria: blood pressure ≥130 mm Hg/≥85 mm Hg; triglycerides ≥150 mg/dL; high-density lipoprotein ≤50 mg/dL for women and ≤40 mg/dL for men; fasting blood glucose ≥110 mg/dL; or body mass index ≥30 kg/m(2). Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. RESULTS A total of 1018 limbs in 738 patients (64% male, average age 67 years) underwent endovascular treatment for symptomatic SFA disease with 45% of patients meeting the criteria for MetSyn. MetSyn patients were more likely to be female (P = .001), to present with critical ischemia (rest pain/tissue loss: 55% MetSyn vs 45% non-MetSyn; P = .001), have poorer ambulatory status (P = .001), and have more advanced SFA lesions (TransAtlantic Inter-Society Consensus II C/D: 51% vs 11%; P = .001) and worse tibial runoff (P = .001). MetSyn patients required more complex interventions (P = .0001). There was no difference in mortality and major adverse cardiac events, but systemic complications (4% vs 1%; P = .001) and major adverse limb events (12% vs 7%; P = .0009) were significantly higher in the MetSyn group. Immediate postprocedural hemodynamic improvement, resolved or improved symptoms, and restoration of impaired ambulation were equivalent in both groups. Early failure (<6 months) was more common in those with MetSyn. At 5 years, primary, assisted primary, and secondary patencies were not affected by the presence of MetSyn. The presence of MetSyn was associated with a decrease in clinical efficacy, decreased freedom from recurrent symptoms, and decreased freedom from major amputation at 5 years. CONCLUSIONS MetSyn is present in nearly half of the patients presenting with SFA disease. These patients present with more advanced disease and have poorer symptomatic and functional outcomes compared with those patients without MetSyn.

Comparison of Outcomes of One-Stage Basilic Vein Transpositions and Two-Stage Basilic Vein Transpositions

BACKGROUND Basilic vein transpositions (BVTs) provide autologous hemodialysis access in the upper extremity. We report and compare our experience using the two techniques that are commonly performed to create BVTs: the one-stage and the two-stage technique. METHODS A retrospective review was performed on patients who underwent BVT from June 2006 to June 2010 from a database of all patients undergoing dialysis access procedures. One hundred six patients, mean age of 54 years (41% male), who received upper-arm basilic vein-only transposition were identified and were stratified based on one-stage and two-stage BVTs. Anatomic outcomes and functionality were determined and compared between stages. RESULTS Seventy-seven patients underwent two-stage BVT, and 29 underwent one-stage BVT. Fifty-one percent and 79% of the two-stage group and the one-stage group, respectively, had had a previous failed ipsilateral permanent access. Catheter dialysis at time of surgery was 14% in one-stage BVT and 43% in two-stage BVT. Immediate technical success was obtained in all cases. The rate of primary failure was 21% in the one-stage group and 18% in the two-stage group. Reintervention rates for the one-stage group and the two-stage group were 62% and 66%, respectively. Primary patency for the one-stage group and the two-stage group at 1 year was 82% and 67%, at 2 years was 81% and 27%, and at 3 years was 51% and 18%, respectively. Secondary patency for the one-stage group and the two-stage group at 1 year was 91% and 81%, at 2 years was 80% and 61%, and at 3 years was 58% and 45%, respectively. Thirty-day mortality was 0% in both groups, and all-cause morbidity was 12% in both groups (counting all stages). CONCLUSION One-stage BVTs have a similar number of initial failures and secondary interventions as two-stage BVTs. One-stage BVTs achieved better primary and cumulative patencies. There appears to be no advantage to a two-stage BVT in equally matched patients.

A longitudinal view of improved management strategies and outcomes after iatrogenic iliac artery rupture during endovascular aneurysm repair.

BACKGROUND Intraoperative rupture of the iliac artery is a serious complication of endovascular aneurysm repair (EVAR), the outcomes of which have changed with increasing experience and improved endovascular tools over the past 2 decades. Over the past 15 years, the incidence and management of iliac rupture has changed as devices have improved and experience has grown. This study reviews our longitudinal experience with this complication. METHODS All cases of iliac artery rupture during EVAR from 1997 through 2011 were reviewed for presentation, treatment strategies, and outcomes. RESULTS Iliac artery rupture complicated 20 (3%) of 707 EVARs performed. Sixteen (80%) common and four (20%) external iliac arteries were ruptured. Hypotension (systolic blood pressure: <90 mm Hg) was present in 11 (55%) cases. Five open bypasses were performed (25%), whereas 15 were repaired using an endovascular approach (75%). All open repairs (100%) were associated with postoperative morbidity (one wound infection, four multiorgan system failure), whereas three of the 15 patients (23%) repaired endovascularly experienced postoperative morbidity (cerebrovascular accident, myocardial infarction, line infection). There were no intraoperative deaths. There were four (20%) early deaths in the intensive care unit (<3 days postoperatively), all of which were associated with resection of bilateral hypogastric arteries and were due to complications of pelvic ischemia and/or multiorgan system failure. CONCLUSIONS Iliac artery rupture remains relatively uncommon but can carry a high morbidity and mortality. As device technology, imaging quality for preoperative planning, and experience level have improved, iliac rupture has become less common, and outcomes in the setting of iliac rupture have significantly improved. Endoluminal management has evolved as the primary treatment strategy. Resection of both hypogastric arteries is associated with mortality from pelvic ischemia, a likely indicator of systemic disease.

Hybrid approach for removal of an errant intra-vascular pedicle spinal fixation screw in the thoracic aorta

Late presentation of aortic injuries secondary to internal fixation hardware is uncommon and generally associated with pseudoaneurysm formation. We herein present a case of transmural migration of a pedicle screw into the descending thoracic aorta, which was revealed incidentally by computed tomography scan after almost 4 years of hardware implantation. Approximately 75% of the pedicle screw was exposed to the bloodstream, and was successfully removed using endovascular segmental exclusion to avoid aortic cross-clamping and an open approach via left thoracotomy. This case illustrates the successful repair of an iatrogenic aortic injury using a hybrid technique.

Increasing dialysis access options in lower extremity: Retroperitoneal approach for external iliac artery-vein arteriovenous graft

Background Exhaustion of upper extremity dialysis access options is becoming more prevalent due to the longer survival of this patient population. In addition, central venous occlusive disease (CVOD) increases the risk of losing access viability in the ipsilateral extremity. Purpose We describe a novel technique of lower extremity arteriovenous graft (AVG) placement in which the external iliac artery and vein are utilized, as illustrated in 2 selected cases. Methods Two dialysis patients presented with exhausted upper extremity access options and bilateral intrathoracic CVOD. In patient 1, a venogram demonstrated complete occlusion of the left common iliac vein and severe stenosis of the right common femoral vein, rendering these unsuitable for access creation. In patient 2, with a history of peripheral arterial disease, an arteriogram revealed that the common and superficial femoral arteries were inadequate for access creation bilaterally. A retroperitoneal approach was utilized for a right external iliac artery and vein arteriovenous graft tunneled under the inguinal ligament to the anterior thigh. Results Adequate thrill and uneventful postoperative course were observed in both cases. At 10 months, patient 1 has done well on hemodialysis without the need for further intervention. Patient 2 has only recently had the procedure and is not yet using her graft. Conclusions As the number of patients requiring lower extremity vascular access increases, new surgical techniques will become available to handle the clinical and anatomic challenges encountered in this population.

Outcomes of Femoropopliteal Interventions for Critical Ischemia in the Hemodialysis-Dependent Patient

BACKGROUND The number of patients maintained on hemodialysis is rising. There are limited data on the outcomes of femoropopliteal interventions, both open and endovascular, in this population. This report examines the anatomic and clinical outcomes in this population. METHODS A database of patients undergoing open (OPEN) and endoluminal (ENDO) intervention for femoropopliteal disease (2000 to 2010) was retrospectively queried. Patients on hemodialysis with critical ischemia at the time of surgery or intervention were selected. Patients who underwent tibial bypass or had concomitant tibial interventions were excluded. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed for time-dependent variables. RESULTS One hundred sixty-one hemodialysis-dependent patients underwent either OPEN or ENDO procedures for critical ischemia. Of these, 70 patients were treated with OPEN procedures and 91 with ENDO procedures. ENDO patients were more likely to present with a higher cardiac risk index (P = 0.0001), metabolic syndrome (P = 0.02), cerebrovascular disease (P = 0.01), and a dependent living status preoperatively (P = 0.04). ENDO patients presented with more rest pain and tissue loss (P = 0.03). OPEN patients presented with more advanced lesions (P = 0.04). Combined morbidity was higher in the OPEN group (P = 0.05). Cumulative patency (P = 0.04) and clinical efficacy (P = 0.05) were higher in the OPEN group compared to those in the ENDO group. CONCLUSIONS Hemodialysis patients undergoing femoral-popliteal endovascular interventions for symptomatic disease have a low cumulative patency and clinical efficacy. Although open surgical revascularization has higher perioperative morbidity and a trend toward higher perioperative mortality, it provides a superior 5-year cumulative patency and clinical efficacy and should be considered in this population subgroup.

Clinical efficacy of concomitant tibial interventions associated with superficial femoral artery interventions in critical limb ischemia

BACKGROUND Combined superficial femoral artery (SFA) and tibial angioplasty (TA) are a common treatment for critical limb ischemia. Poor tibial runoff significantly compromises durability and clinical effectiveness of SFA interventions. The aim of this study is to determine clinical and anatomic outcomes of SFA interventions in patients with equally compromised runoff, with and without concomitant TA. METHODS The database of patients undergoing endovascular treatment of SFA (1999-2009) was retrospectively queried. Patients with poor runoff, scored>10 by modified Society for Vascular Surgery criteria, were selected. Preoperative angiograms were reviewed to assess distal popliteal and tibial runoff. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed for time-dependent variables. RESULTS A total of 162 limbs with a runoff score>10 (56% men; average age, 69 years) underwent endovascular intervention for symptomatic SFA disease: 61 (54% men) underwent TA but the remaining 101 (57% men) did not. The groups were matched for age, sex, and SFA anatomy (Trans-Atlantic Inter-Society Consensus II C/D lesions: 56% no TA vs 62% TA; P=.5). Presenting symptoms were similar between no TA and TA groups (rest pain: 40% vs 32%; tissue loss: 60% vs 68%; P=.3). Three-year survival favored the TA group (79%±5%) vs no TA (68%±5%; P=.06). Three-year anatomic outcomes in no TA vs TA group, including primary patency (45%±6% vs 63%±8%; P=.04), assisted primary patency (55%±6% vs 75%±7%; P=.03), and secondary patency (57%±6% vs 77%±7%; P=.03) were all superior in the TA group. Target vessel revascularization in no TA vs TA (61%±6% vs 74%±8%; P=.002) and target extremity revascularization (42%±6% vs 59%±8%; P=.06) also favored the TA group. However the comparison of no TA vs TA for clinical success (39%±6% vs 47%±8%; P=.6), freedom from recurrent symptoms (59%±6% vs 60%±9%; P=.1), amputation-free survival (46%±5% vs 63%±7%; P=.06), and limb salvage at 3 years (63%±6% vs 74%±7%; P=.6) were similar. CONCLUSIONS TA in patients with poor runoff has a positive effect on SFA anatomic outcomes. However, clinical success was not affected. Concomitant TA appears not to add clinical benefit to SFA intervention in critical limb ischemia.

Successful endovascular repair of two ruptured thoracic aortic aneurysms in nonagenarians.

BACKGROUND Ruptured thoracic aortic aneurysm (rTAA) is a catastrophic and mortal event. Thoracic endoVascular aortic repair (TEVAR) has emerged as an alternative to open repair. We report the first two successful TEVAR performed for rTAA in nonagenarians. METHODS AND RESULTS Patient 1 was a 92-year-old man with multiple comorbidities with a 5.6 cm thoracic aortic aneurysm who was admitted for anticoagulation for pulmonary embolism. Twelve hours later, he was found to be hypotensive and the X-ray showed an opacified left hemithorax (Fig. 1). A 40 mm × 20 cm Gore TAG stent-graft (W. L. Gore & Associates, Inc., Flagstaff, AZ) was deployed to successfully exclude the rupture. The postoperative course was uncomplicated and on day 9, he was discharged to a skilled nursing facility. Patient 2 was a 94-year-old man with a history of multiple comorbidites and endovascular aneurysm repair for ruptured abdominal aortic aneurysm 3 years earlier, who presented to the emergency room in hemorrhagic shock. Computed tomography scan revealed hemomediastinum and left hemothorax suggesting thoracic aorta rupture (Fig. 2A). Emergently, a 34 mm × 30 cm Gore TAG stent-graft was deployed (Fig. 2B). A left chest tube was placed. Postoperative course was briefly complicated by acute renal failure and pneumonia and on day 14, he was discharged to a rehabilitation center. CONCLUSION TEVAR for rTAA is an effective option and advanced age alone should not deter definitive repair of the thoracic aorta.

Inferior vena cava bypass for the treatment of obliterative hepatocavopathy with five-year follow-up

Inferior vena cava (IVC) thrombosis at its hepatic portion (also known as obliterative hepatocavopathy [OH]), in the absence of systemic or local diseases such as vasculitis, coagulopathy, infection and malignancy, is a rare event. We report the case of a 25-year-old woman with progressive abdominal pain and leg edema after exercise. Imaging showed congestive liver and IVC occlusion at the intrahepatic portion. A liver biopsy demonstrated portal congestion without evidence of fibrosis; after unsuccessful percutaneous attempts for recanalization, consideration was given to liver transplantation with IVC reconstruction versus IVC bypass. Due to the presence of preserved liver function, an externally supported 16-mm ringed polytetrafluoroethylene graft was used to bypass from the suprarenal IVC to the suprahepatic IVC. At five years, she remains symptom-free, with normal liver function and a patent graft on systemic anticoagulation. This report highlights the successful surgical management of a patient with OH with a thick membrane. It supports other published proposals that this entity differs significantly from classic Budd–Chiari syndrome with thrombosis that affects only the hepatic veins and, thus, OH should be approached and managed differently.