Claire L. Griffin

Fate of Aneurysmal Common Iliac Artery Landing Zones Used for Endovascular Aneurysm Repair

Purpose: To determine outcomes of aneurysmal common iliac arteries (aCIA) used for landing zones (LZs) during endovascular aneurysm repair (EVAR). Methods: This single-center study retrospectively compared 57 EVAR patients (mean age 72±8 years; 56 men) with 70 aCIAs (diameter ≥20 mm) to 25 control EVAR subjects (mean age 73±7 years; 20 men) with 50 normal (≤15-mm) CIA LZs treated consecutively during the same time interval. The CIA LZ measurements were analyzed using random effects linear mixed models to determine diameter change over time. Life tables were used to estimate freedom from endoleak, reintervention, and all-cause mortality. Results: The mean maximum preoperative CIA diameter in the aCIA LZ group was 24.8±4.5 mm (range 20.0–47.3, median 23.9) vs 13.6±1.5 mm (range 9.2–15.0, median 13.9; p<0.001) in the controls. Nineteen aCIA LZs were treated outside the instructions for use of the device. Median follow-up in the aCIAs LZ cohort was 39.2 months [interquartile range (IQR) 15, 61] vs 49.3 months (IQR 36, 61) in the controls (p=0.06). The rate of aCIA LZ change (0.09 mm/mo, 95% CI 0.07 to 0.1) was significantly greater than controls (0.03 mm/mo, 95% CI −0.009 to 0.07; p<0.0001). No type Ib endoleaks developed in either group; however, aCIA LZ patients had 6 (11%) iliac limb–related reinterventions. There were significantly more endograft-related reinterventions in the aCIA LZ patients (n=10, 14%) compared with controls (n=2, 4%; p=0.06). There was no difference in mortality or freedom from any post–hospital discharge endoleak. Conclusion: Aneurysmal CIA LZs used during EVAR experience greater dilatation compared with normal LZs, but no significant difference in outcome was noted in midterm follow-up. However, an increased incidence of graft limb complications or endograft-related reintervention may be encountered. Use of aCIA LZs appears to be safe; however, greater patient numbers and longer follow-up are needed to understand the clinical implications of morphologic changes in these vessels when used during EVAR.

Carotid endarterectomy should not be based on consensus statement duplex velocity criteria

Objective: Randomized trials support carotid endarterectomy (CEA) in asymptomatic patients with ≥60% internal carotid artery (ICA) stenosis. The widely referenced Society for Radiologists in Ultrasound Consensus Statement on carotid duplex ultrasound (CDUS) imaging indicates that an ICA peak systolic velocity (PSV) ≥230 cm/s corresponds to a ≥70% ICA stenosis, leading to the potential conclusion that asymptomatic patients with an ICA PSV ≥230 cm/s would benefit from CEA. Our goal was to determine the natural history stroke risk of asymptomatic patients who might have undergone CEA based on consensus statement PSV of ≥230 cm/s but instead were treated medically based on more conservative CDUS imaging criteria. Methods: All patients who underwent CDUS imaging at our institution during 2009 were retrospectively reviewed. The year 2009 was chosen to ensure extended follow‐up. Asymptomatic patients were included if their ICA PSV was ≥230 cm/s but less than what our laboratory considers a ≥80% stenosis by CDUS imaging (PSV ≥430 cm/s, end‐diastolic velocity ≥151 cm/s, or ICA/common carotid artery PSV ratio ≥7.5). Study end points included freedom from transient ischemic attack (TIA), freedom from any stroke, freedom from carotid‐etiology stroke, and freedom from revascularization. Results: Criteria for review were met by 327 patients. Mean follow‐up was 4.3 years, with 85% of patients having >3‐year follow‐up. Four unheralded strokes occurred during follow‐up at <1, 17, 25, and 30 months that were potentially attributable to the index carotid artery. Ipsilateral TIA occurred in 17 patients. An additional 12 strokes occurred that appeared unrelated to ipsilateral carotid disease, including hemorrhagic events, contralateral, and cerebellar strokes. Revascularization was undertaken in 59 patients, 1 for stroke, 12 for TIA, and 46 for asymptomatic disease. Actuarial freedom from carotid‐etiology stroke was 99.7%, 98.4%, and 98.4% at 1, 3, and 5 years, respectively. Freedom from TIA was 98%, 96%, and 95%, freedom from any stroke was 99%, 96%, and 93%, and freedom from revascularization was 95%, 86%, and 81% at 1, 3, and 5 years, respectively. Conclusions: Patients with intermediate asymptomatic carotid stenosis (ICA PSV 230–429 cm/s) do well with medical therapy when carefully monitored and intervened upon using conservative CDUS criteria. Furthermore, a substantial number of patients would undergo unnecessary CEA if consensus statement CDUS thresholds are used to recommend surgery. Current velocity threshold recommendations should be re‐evaluated, with potentially important implications for upcoming clinical trials.

PC092. Patient-Reported Outcomes in Patients With End-Stage Renal Disease: Is Quality of Life Affected When Catheters Are Used for Hemodialysis versus Arteriovenous Fistulas?

FA access was performed in three arteries because of prior common FA interposition grafts. There were 18 (6%) access site complications (8 bleeding, 9 thrombosis, 1 infection) leading to immediate (n 1⁄4 12) or delayed (n 1⁄4 5) conversion to cutdown. Factors independently associated with percutaneous access site complication were sheath outer diameter to FA diameter ratio (odds ratio [OR], 58.9; 95% confidence interval [CI], 3.5-985.8; P 1⁄4 .005), morbid obesity with a body mass index of >40 kg/ m (OR, 16.0; 95% CI, 3.0-84.5; P 1⁄4 .001), FA stenosis of >50% (OR, 52.1; 95% CI, 7.7-351.5; P # . 001), FA stenosis of >75% (OR, 271.5; 95% CI, 15.14888.6; P # .001), and postoperative anticoagulation (OR, 10.5; 95% CI, 2.0-54.0; P 1⁄4 .005). A risk prediction model based on these criteria produced a C statistic of .91, a Hosmer-Lemeshow goodness of fit of 0.99, and a Brier score of .03. A risk score of >6 of 15 corresponded with a >10% probability of groin access complication (Table). Conclusions: Percutaneous ultrasound-guided access can be safely performed in almost all patients undergoing endovascular aortic procedures; however, access site failures still occur. Application of this risk score can help identify patients at high risk for complications after initial FA ultrasound-guided percutaneous access.

PC094. Two-Stage Brachiobasilic Arteriovenous Fistula Creation Is Cost Effective

FA access was performed in three arteries because of prior common FA interposition grafts. There were 18 (6%) access site complications (8 bleeding, 9 thrombosis, 1 infection) leading to immediate (n 1⁄4 12) or delayed (n 1⁄4 5) conversion to cutdown. Factors independently associated with percutaneous access site complication were sheath outer diameter to FA diameter ratio (odds ratio [OR], 58.9; 95% confidence interval [CI], 3.5-985.8; P 1⁄4 .005), morbid obesity with a body mass index of >40 kg/ m (OR, 16.0; 95% CI, 3.0-84.5; P 1⁄4 .001), FA stenosis of >50% (OR, 52.1; 95% CI, 7.7-351.5; P # . 001), FA stenosis of >75% (OR, 271.5; 95% CI, 15.14888.6; P # .001), and postoperative anticoagulation (OR, 10.5; 95% CI, 2.0-54.0; P 1⁄4 .005). A risk prediction model based on these criteria produced a C statistic of .91, a Hosmer-Lemeshow goodness of fit of 0.99, and a Brier score of .03. A risk score of >6 of 15 corresponded with a >10% probability of groin access complication (Table). Conclusions: Percutaneous ultrasound-guided access can be safely performed in almost all patients undergoing endovascular aortic procedures; however, access site failures still occur. Application of this risk score can help identify patients at high risk for complications after initial FA ultrasound-guided percutaneous access.