Daniel K. Han

Endovascular Stent-Graft Repair of a Tuberculous Mycotic Aortic Aneurysm

Mycobacterium tuberculosis is a rare cause of mycotic aortic aneurysms, which have been classically treated with a combination of antimycobacterial medical therapy and open surgery. Endovascular therapy has been gaining popularity as an alternative to open surgery for mycotic aneurysms. We report a case of a tuberculous mycotic aneurysm of the descending thoracic aorta that was successfully treated with endovascular stent-graft placement with complete resolution of the pseudoaneurysm at 1 year. We also review other cases in the previously published data to identify factors that may affect the outcome of endovascular treatment of tuberculous mycotic aneurysms.

The Success of Endovascular Therapy for All TransAtlantic Society Consensus Graded Femoropopliteal Lesions

BACKGROUND Advances in technology and practice have led to increased endovascular management of all TransAtlantic Society Consensus (TASC)-graded lesions. This study aims to evaluate the success of endovascular therapy in the management of TASC-graded femoropopliteal lesions. METHODS Patients undergoing endovascular treatment for femoropopliteal lesions between July 1999 and August 2008 were divided by TASC scores and evaluated for primary, assisted-primary, and secondary patency rates at 12 and 24 months. Secondary endpoints included limb loss and postoperative complications. RESULTS A total of 499 femoropopliteal lesions in 427 patients were treated with endovascular interventions. Score distribution for TASC type A, type B, type C, and type D lesions was 26 (5.2%), 140 (28.1%), 168 (33.7%), and 165 (33.1%), respectively. Primary, assisted-primary, and secondary patency rates at 24 months were 77.7 ± 3.2%, 78.9 ± 3.2%, and 86.7 ± 2.6%, respectively, for TASC type A + B lesions, 76.0 ± 3.3%, 77.2 ± 3.2%, and 85.0 ± 2.8%, respectively, for TASC type C lesions, and 61.2 ± 3.8%, 61.2 ± 3.8%, and 78.2 ± 3.2%, respectively, for TASC type D lesions. Compared with TASC type A + B and TASC type C lesions, TASC type D lesions were associated with worse primary and assisted-primary patency rates. However, there was no statistically significant difference in secondary patency between TASC type A + B and TASC type D lesions. The TASC score was not a significant predictor of postoperative complication rates. The 24-month limb salvage rate in patients with TASC type D lesions presenting with critical limb ischemia was 71.9 ± 8.0%. CONCLUSION It was observed that all femoropopliteal lesions can be safely and effectively managed with endovascular therapy. Although TASC type D lesions do have lower primary and assisted-primary patency rates, high secondary patency rates comparable with other TASC scores can be achieved with effective prevention of limb loss. These data provide evidence to support endovascular therapy as primary management for all femoropopliteal lesions regardless of the TASC score.

A rare case of familial carotid body tumor in a patient with bilateral fibromuscular dysplasia

Carotid body tumors (CBTs) are neuroendocrine tumors that arise due to mutations of respiratory cycle enzymes. Fibromuscular dysplasia (FMD) is a disease that causes narrowing of medium-sized arteries. There is no documented link between CBT and FMD. In this article, we report a case of a patient with bilateral carotid FMD and familial CBT, including one in an identical twin who underwent successful surgical excision of the CBT. We describe specific considerations in the management of CBT in patients with concomitant carotid FMD. Also, we review the literature about the genetics of familial CBT and its possible relationship to the etiology of FMD.

Treatment of Carotid Disease in North America

Strokes are the third leading cause of death in the United States, with over 795,000 strokes leading to 140,000 deaths every year. Ischemic strokes caused by carotid stenosis are a significant contributor to these figures, and stroke prevention must weigh the risks and benefits of medical versus surgical management. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS) trials from North America helped establish some of the earliest guidelines for when best medical therapy versus surgical revascularization was more appropriate. But these recommendations have since been challenged as best medical therapy, particularly with the increased usage of statins, improves. Duplex ultrasound alone can often diagnose carotid stenosis, with cross-sectional imaging such as Computed Tomography Angiography (CTA) and Magnetic Resonance Angiography (MRA) often being used to provide better diagnostic imaging for pre-operative planning. In general, asymptomatic carotid stenosis >70 % and symptomatic stenosis >50 % merit revascularization, with carotid endarterectomy (CEA) the preferred treatment. Carotid stenting (CAS) has been shown in trials such as Carotid Revascularization Endarterectomy versus Stenting (CREST) to be non-inferior to CEA with regards to outcomes of stroke and myocardial infarction (MI), but is currently reserved for patients with medical or anatomical consideration that are not conducive to CEA. The upcoming CREST-2 trial should help establish guidelines for optimal utilization of best medical therapy (BMT) versus CEA versus CAS for carotid stenosis.

IP055. Defining the Computed Tomographic Angiographic (CTA) Features of the Aorta Following a Type B Aortic Dissection (AD)

noted between OAR and EVAR (11.7% vs 12.3%; P 1⁄4 .59). After adjusting for potential confounders, FTR was not significantly different in OAR compared to EVAR (adjusted odds ratio [aOR], 1.34; 95% confidence interval [CI], 0.94-1.91; P 1⁄4 .10). Factors impacting in-hospital FTR included older age (aOR, 1.05; 95% CI, 1.03-1.07; P < .001), prior failed open repair (aOR, 8.17; 95% CI, 5.4-12.4; P < .001), and a history of chronic obstructive pulmonary disease (aOR, 1.53; 95% CI, 1.08-2.15; P 1⁄4 .02; Table II). A similar analysis of 2916 patients with postdischarge complications showed that FTR in those patients was significantly higher in OAR compared to EVAR (aOR, 4.75; 95% CI, 2.45-9.25; P < .001). Conclusions: Although EVAR has fewer complications and lower in-hospital mortality than OAR, FTR after in-hospital complications does not depend on the type of surgical approach but rather on the severity of the complication, the age of the patient, a prior failed open repair and a history of chronic obstructive pulmonary disease. When an in-hospital major complication occurs following EVAR, surgeons should be alert that FTR risk resulting in mortality is similar to OAR and therefore, there is no safety net with EVAR.

Endovascular Treatment of 2 Synchronous Extracranial Carotid Artery Aneurysms Using Stent-Assisted Coil Embolization and Double Bare-Metal Stenting.

Extracranial carotid artery aneurysms located in the cervical region in close proximity to the skull are difficult to access using open surgical methods. Endovascular treatment has emerged as an alternative option for anatomically challenging internal carotid artery aneurysms. However, data comparing various endovascular techniques including stent grafting, coil embolization, double stenting, and stent-assisted coil embolization are lacking, making it difficult to determine the optimal treatment. We present a case of a patient with 2 fusiform extracranial carotid artery aneurysms treated successfully with a combination of double stenting and stent-assisted coil embolization. We also discuss technical considerations for selecting the appropriate endovascular intervention.