Constantino Pena

Direct percutaneous sac injection for postoperative endoleak treatment after endovascular aortic aneurysm repair

BACKGROUND This study presents the short-term and midterm results of direct percutaneous sac injection (DPSI) for postoperative endoleak treatment after endovascular aortic aneurysm repair (EVAR). METHODS Between March 1994 and November 2011, EVAR was performed in 986 patients. The median follow-up was 63 ± 45 months (range, 0-211 months). A retrospective analysis was performed. DPSI was used in 21 patients for 19 type II endoleaks and two endoleaks of undefined origin (EOUO), of which 12 (57%) were after failure of a previous endovascular treatment attempt. RESULTS DPSI using thrombin (n = 16), coils (n = 7), gelfoam (n = 6), or glue (n = 3), or a combination, was technically feasible in all patients. Saccography during DPSI revealed a previously undetected type I endoleak in three patients. Immediate DPSI success was achieved in 16 of 18 procedures (88.9%), with two complications. Glue incidentally intravasated in the inferior vena cava, causing a clinically nonsignificant subsegmental pulmonary artery embolism in one patient, and the temporary development of a type III endoleak, possibly from graft puncture, in another. During a median follow-up of 39 months (interquartile range, 13-88 months) after DPSI, recurrent endoleaks were observed in nine patients (50.0%), one type I endoleak due to graft migration, five type II endoleaks, and three EOUO. The occurrence of a re-endoleak during follow-up was significantly associated with dual-antiplatelet medication (0% in patients without re-endoleak vs 44.4% in patients with re-endoleak; P = .023) and with a nonsignificant trend for the use of aspirin alone (33.3% in patients without re-endoleak vs 80% in patients with re-endoleak; P = .094). Re-endoleak occurred in 33.3% of the patients without antiplatelet medication and in 100% of patients with dual-antiplatelet medication (P = .026). Thrombin was used as the sole embolic agent during the initial DPSI in all patients with dual-antiplatelet therapy. No other factor was significantly associated with re-endoleaks. Reintervention was deemed necessary in six patients within a median of 10 months (interquartile range, 4-16 months) after DPSI, including six additional DPSI treatments in four patients with type II re-endoleaks, cuff placements in one type I endoleak, and endograft relining in one EOUO. CONCLUSIONS This initial experience suggests that DPSI is feasible as a technique for endoleak treatment after EVAR. However, complications and endoleak recurrence remain a concern. The role of antiplatelet therapy and different embolic agents on long-term embolization success needs to be studied in more detail.

Current Clinical Practice in Postoperative Endovascular Aneurysm Repair Imaging Surveillance

PURPOSE To investigate the current clinical practice in postoperative endovascular aneurysm repair (EVAR) imaging surveillance. MATERIALS AND METHODS Corresponding authors of EVAR publications during the years 2006-2011 and subscribers to an endovascular journal were invited to complete a 27-question online survey related to institutional demographics, standard post-EVAR imaging surveillance, and imaging protocols in special circumstances (eg, renal insufficiency). RESULTS The survey was completed by 515 of 9,631 physicians performing EVAR from 52 countries. Of respondents, 65.3% were affiliated with experienced centers where EVAR has been performed for > 10 years or with > 50 EVAR procedures performed per year. Computed tomography (CT) angiography was the modality used most often for standard surveillance with a maximum time interval between studies of 12 months in 78.8% of centers out to 5 years. Experienced centers were more likely to delay follow-up imaging to 1 year after an unremarkable initial post-EVAR imaging study (P < .001), to extend surveillance intervals > 12 months (P = .043), and to use ultrasound (P < .01) for surveillance. After the detection of a type II endoleak, CT angiography was favored for follow-up by 59.4% of the respondents. Experienced centers were more likely to favor ultrasound (P = .006) and to schedule this follow-up examination later (after 6-12 months, P < .001). Of respondents, 62.8% used a glomerular filtration rate threshold of < 30 mL/min for not performing contrast-enhanced CT scan. In patients with renal insufficiency, most respondents performed ultrasound with or without a concomitant noncontrast CT scan. CONCLUSIONS CT is the most frequently used method of long-term surveillance after EVAR. Use of ultrasound for long-term surveillance, extension of follow-up time intervals, or both were most often reported in experienced centers.

Endovascular repair of infrarenal aortic aneurysms in octogenarians and nonagenarians

OBJECTIVE The purpose of this report was to present short and midterm results of endovascular aortic aneurysm repair (EVAR) of infrarenal aortic aneurysms in octogenarians and nonagenarians. METHODS Between March 1994 and March 2011, elective EVAR was performed in 967 patients in our institution. This includes 279 patients older than 80 years at the time of the procedure (octogenarians: n = 252, nonagenarians: n = 27). Mean follow-up was 48.4 ± 34.5 months. A retrospective analysis was performed. Survival was calculated using Kaplan-Meier analysis and a survival comparison to patients who underwent EVAR <80 years old (n = 688) was performed. Cox hazard regression analysis was used to assess parameters that influence survival. RESULTS Technical success was 96% in octogenarians and 85% in nonagenarians. Technical failure in 15 of 279 patients includes primary type I endoleak (n = 6), procedure abortion due to inability to pass the iliac vessels (n = 6), and emergency conversion (n = 3). Thirty-day mortality was significantly higher for patients >80 years old (2.8% vs 1.0%; P = .044). Morbidity rates were 11.5% for octogenarians and 7.4% for nonagenarians with predominately cardiopulmonary complications. High-risk patients >80 years old showed a comparable perioperative mortality rate to low-/medium-risk patients >80 years old (2.9% vs 2.5%;P = .717), but a significantly higher complication rate (22.5% vs 9.2%; P = .0275) and reduced midterm survival with 1-, 3-, and 5-year survival rates of 79% ± SE 7%, 55% ± SE 8%, and 38% ± SE 9% (log-rank test P = .03). In high-risk patients age >80 years old, their age did not influence 30-day mortality (2.5% vs 2.7%; P = .978) and midterm survival. Survival in octogenarians at 1, 3, and 5 years was 87.9 ± SE 2.1%, 70.9 ± SE 3.0%, and 55.6% ± SE 3.5%, respectively. Survival in nonagenarians at 1 and 3 years was 96.3% ± SE 4% and 60.6% ± SE 10.4%. Higher cardiac (hazard ratio [HR], 1.22; P = .038) and renal risk scores (HR, 1.59; P = .0016), chronic obstructive pulmonary disease (HR, 1.56; P = .032), and anemia (HR, 2.1; P < .001) influenced midterm survival. CONCLUSION EVAR in octogenarians and nonagenarians is associated with a significantly higher but still low perioperative mortality compared to younger patients. Midterm survival in octogenarians and nonagenarians, although significantly lower than in younger patients, is still acceptable, indicating that age >80 years should not be an exclusion criteria for EVAR. Even high-risk patients >80 years can be treated safely with a low perioperative mortality and comparable midterm outcome to younger high-risk patients.

Cardiac CT in the emergency department: convincing evidence, but cautious implementation.

In clinical practice, assessment of chest pain patients presenting to the emergency department is difficult and the work-up can be lengthy and costly. There is growing evidence supporting the use of coronary computed tomography angiography (CTA) in early assessment of patients presenting with acute chest pain to the emergency department. CTA appears to be a faster and more accurate way to diagnosis or rule out coronary stenosis, leading to reduced hospital admissions, decreased time in the ED and lower costs. The focus of this article is to review the current literature of the use of Coronary CTA and “triple rule out” protocols in the emergency department setting and to provide a chest pain algorithm, showing how Coronary CTA can be implemented effectively in clinical practice. Potential pitfalls and requirements for implementation will also be discussed.

Treating the Diseased Superficial Femoral Artery

Vascular disease involving the superficial femoral artery (SFA) is common. Once the decision to treat the SFA is made, the benefits and limitations of angioplasty and stents must be applied to each specific patient. Additionally, the potential role of covered stents as well as drug eluting stents must be considered.

Endovascular Treatment of Popliteal Artery Aneurysms: A Single-center Experience

PURPOSE To evaluate the use of covered stent-grafts in the endovascular treatment (ET) of popliteal artery aneurysms (PAAs). MATERIALS AND METHODS A retrospective analysis was conducted over a period of 52 months in 18 consecutive patients (17 men; mean age +/- SD, 70 years +/- 11) undergoing ET of PAAs with the Viabahn endograft in a single center. Patient symptoms, aneurysm characteristics, technical outcomes, complications, and follow-up were assessed. RESULTS Aneurysm diameters ranged from 12 to 51 mm with a mean of 30 mm (+/-11). Thirteen aneurysms (72.2%) were partially thrombosed and 12 patients (66.6%) had symptoms of lower limb ischemia at presentation (11 chronic and one acute). The technical success rate was 94%. Intraprocedural emboli and endoleak occurred in one and two patients, respectively. Fourteen patients were available for follow-up after successful treatment, with a mean follow-up time of 15 months (range, 7-37 months). All stent-grafts were patent after 1 month, with no mortality or limb loss. The primary patency rate with complete exclusion of the aneurysm at 6 months was 86%. Pre- and postprocedural noninvasive arterial studies were available in 10 patients, demonstrating improvement of the ankle-brachial index from 0.96 +/- 0.41 to 1.17 +/- 0.18, respectively (P = .06). CONCLUSIONS Endovascular stent-graft repair of PAAs is a feasible treatment option. However, further follow-up studies regarding the durability of results are required.

Acute chest pain imaging in the emergency department with cardiac computed tomography angiography

In practice, the determination of ischemic chest pain in the emergency department (ED) population is difficult and errors are common. Cardiac computed tomography angiography has recently emerged for accurate noninvasive evaluation of coronary artery disease, and it may offer a promising new approach to improve the triage of patients presenting to the ED with acute chest pain, in particular in terms of a faster and accurate way to determine the diagnosis, which could effectively reduce hospital admissions and costs. The focus of this article is to review the current literature on the use of cardiac computed tomography angiography in the ED setting by providing pooled sensitivity, specificity, and positive and negative predictive values of the published literature to date. Moreover, different protocols for detection of patients with cardiac and other, noncardiac causes of chest pain (triple rule-out protocol) are discussed.

Computed Tomography Angiography and Magnetic Resonance Angiography Imaging in Critical Limb Ischemia: An Overview

Critical limb ischemia (CLI) is exhibited in patients with symptoms of severe claudication (rest pain) and ischemic tissue loss and gangrene. Magnetic resonance angiography and computed tomography angiography have risen to the forefront of vascular imaging over the last 2 decades. Both modalities have been shown to compare favorably with digital subtraction angiography in guiding the clinical management of patients with CLI. Understanding the advantages and limitations of both modalities allows for the proper selection of the best examination for a particular patient with CLI. Ultimately, the enhanced understanding of the vascular anatomy by obtaining noninvasive imaging should make subsequent revascularization safer and more effective.

Matched-pair Analysis of Endovascular versus Open Surgical Repair of Abdominal Aortic Aneurysms in Young Patients at Low Risk

PURPOSE To compare clinical outcomes of endovascular and open aortic repair of abdominal aortic aneurysms (AAAs) in young patients at low risk. It was hypothesized that endovascular aneurysm repair (EVAR) compares favorably with open aneurysm repair (OAR) in these patients. MATERIALS AND METHODS Twenty-five patients aged 65 years or younger with a low perioperative surgical risk profile underwent EVAR at a single institution between April 1994 and May 2007 (23 men; mean age, 62 years+/-2.8). A sex- and risk-matched control group of 25 consecutive patients aged 65 years or younger who underwent OAR was used as a control group (23 men; mean age, 59 years+/-3.9). Patient outcomes and complications were classified according to Society of Vascular Surgery/International Society for Cardiovascular Surgery reporting standards. RESULTS Mean follow-up times were 7.1 years+/-3.2 after EVAR and 5.9 years+/-1.8 after OAR (P=.1020). Total complication rates were 20% after EVAR and 52% after OAR (P=.0378), and all complications were mild or moderate. Mean intensive care unit times were 0.2 days+/-0.4 after EVAR and 1.1 days+/-0.4 after OAR (P<.0001) and mean lengths of hospital stay were 2.3 days+/-1.0 after EVAR and 5.0 days+/-2.1 after OAR (P<.0001). Cumulative rates of long-term patient survival did not differ between EVAR and OAR (P=.144). No AAA-related deaths or aortoiliac ruptures occurred during follow-up for EVAR and OAR. In addition, no surgical conversions were necessary in EVAR recipients. Cumulative rates of freedom from secondary procedures were not significantly different between the EVAR and OAR groups (P=.418). Within a multivariable Cox proportional-hazards analysis adjusted for patient age, maximum AAA diameter, and cardiac risk score, all-cause mortality rates (odds ratio [OR], 0.125; 95% CI, 0.010-1.493; P=.100) and need for secondary procedures (OR, 5.014; 95% CI, 0.325-77.410; P=.537) were not different between EVAR and OAR. CONCLUSIONS Results from this observational study indicate that EVAR offers a favorable alternative to OAR in young patients at low risk.

Technical Results of Vacuum-Assisted Thrombectomy for Arterial Clot Removal in Patients with Acute Limb Ischemia

PURPOSE To assess the efficacy and safety of a vacuum-assisted thrombectomy (VAT) catheter system for treating patients with acute limb ischemia (ALI). MATERIALS AND METHODS A retrospective study evaluated VAT systems (Penumbra, Alameda, California) in a consecutive series of 30 patients with ALI. ALI was defined as clinical symptoms within 2 weeks of presentation. The primary endpoint was improvement in blood flow across a lesion by improvement in Thrombolysis in Myocardial Infarction (TIMI) score that was adapted to peripheral arteries. Concomitant balloon angioplasty or stent placement in addition to VAT was considered a complementary treatment. Additional thrombectomy treatments, such as thrombolysis and mechanical thrombectomy, were considered technical failures. Target lesions were grouped anatomically into above-the-knee (ATK) or below-the-knee (BTK) lesions. RESULTS In 30 patients, 33 lesions (ATK, n = 13; BTK, n = 20) were treated. No complications were attributed to the VAT systems. The primary endpoint was obtained in 24/33 (72.7%) lesions (BTK, 17/20 [85.0%]; ATK, 7/13 [53.9%]; P = .050 by χ(2) test). TIMI scores were similar at baseline but differed after VAT between the ATK and BTK groups (P < .025 by t test). ATK lesions required more concomitant angioplasty or stent placement, or both (P < .015 by χ(2) test). CONCLUSIONS VAT is a safe, technically successful short-term therapeutic option for thrombus removal in patients with ALI.