Dawn Olsen

Virtual histology intravascular ultrasound assessment of carotid artery disease: the Carotid Artery Plaque Virtual Histology Evaluation (CAPITAL) study.

Purpose: To determine the diagnostic accuracy of virtual histology intravascular ultrasound imaging (VH IVUS) of carotid plaque and to assess the feasibility of VH IVUS to identify plaque with embolic potential in patients undergoing carotid artery stenting (CAS). Methods: Thirty patients (17 men; mean age 74±7 years) were entered nonrandomly into a single-center, prospective, 2-arm study following FDA and Institutional Review Board approval. In one arm, 15 patients underwent VH IVUS examination of carotid plaque with a cerebral protection device immediately followed by carotid endarterectomy (CEA). A comparison of “virtual” with true histology was then performed, classifying plaque type by VH IVUS and histopathology in a blinded study. In the second arm, 15 patients undergoing CAS had a preliminary VH IVUS scan performed with cerebral protection. Debris collected from the filter following stenting was examined histologically and compared with the VH IVUS data. Results: The diagnostic accuracy of VH IVUS to agree with true histology in different carotid plaque types was 99.4% in thin-cap fibroatheroma, 96.1% for calcified thin-cap fibroatheroma, 85.9% in fibroatheroma, 85.5% for fibrocalcific, 83.4% in pathological intimal thickening, and 72.4% for calcified fibroatheroma. Filter debris was captured in 2 patients prior to CEA and in 4 patients undergoing CAS for restenosis; VH IVUS classification of plaque composition was consistent with the histological evaluation of filter fragments. Calcified nodules projecting into the carotid artery lumen were associated with a higher incidence of previous neurological symptoms (66.7% versus 33.3%, p<0.05), while patients on aspirin has significantly less necrotic lipid core plaque detected by VH IVUS than patients not taking aspirin (6.4%±4.7% versus 9.7%±2.8%, p<0.05). Conclusion: This study showed a strong correlation between VH IVUS plaque characterization and the true histological examination of the plaque following endarterectomy, particularly in “vulnerable” plaque types. The feasibility study to examine VH IVUS data and the filter debris histology in CAS patients supports a larger prospective study.

Acute traumatic rupture of the thoracic aorta treated with endoluminal stent grafts.

BACKGROUND Endovascular technologies provide a new therapeutic option in the treatment for acute traumatic rupture of the thoracic aorta. We report our experience with endoluminal stent graft repair of thoracic aortic ruptures. METHODS Five patients underwent repair of the thoracic aorta with an endoluminal stent graft for acute traumatic rupture. Data from patient history, the procedure, hospital course, and follow-up were analyzed. RESULTS All patient were involved in motor vehicle crashes. The mean Injury Severity Score was 51.8 +/- 6.38. All procedures were technically successful. Mean operating room time was 111 minutes and mean estimated blood loss was 200 mL. There were no cases of postprocedural endoleaks or conversions. There were no procedural complications, paraplegia, or deaths. Average follow-up was 20.2 months. CONCLUSION Five cases of successful endograft repair of thoracic aortic rupture have been demonstrated. This should encourage future studies to determine whether endovascular repair of thoracic aortic ruptures is a safe and feasible alternative to conventional open repair.

Aortic remodeling after endografting of thoracoabdominal aortic dissection

PURPOSE This study assessed the clinical outcome, morphologic changes, and behavior of acute and chronic type B aortic dissections after endovascular repair and evaluated the extent of dissection and diameter changes in the true (TL), false (FL), and whole lumen (WL) during follow-up. METHODS From May 2000 to September 2006, preprocedural and follow-up computed tomography scans were evaluated in 106 patients. Indices of the TL (TLi) and FL (FLi) were calculated at the proximal (p), middle (m), and distal (d) third of the descending thoracic aorta by dividing the TL or FL diameter by the WL. Analyses were by paired t test and chi2. RESULTS Stent grafts were used to treat 106 patients (mean age, 55 years, 70% men) with acute 59 (55.7%) and chronic 47 (44.3%) lesions. The entry site was successfully covered in 100 patients. The incidences of paraplegia and paresis were 2.8% and 1.0%. Mortality was 7.5% (8 patients), including two intraoperative deaths of contained ruptures. Seven (6.6%) early endoleaks occurred. At a mean follow-up of 15.6 months, TLi improved from 0.45 to 0.88 in the proximal third (p/3), from 0.42 to 0.81 in the middle third (m/3), and from 0.44 to 0.74 in the distal third (d/3), demonstrating expansion of the TL. Two patients had decrease in TL due to endoleak needing reintervention. The FLi decreased from 0.41 to 0.06 in p/3, from 0.44 to 0.10 in the m/3, and from 0.42 to 0.21 in the d/3, indicating FL shrinkage. Changes in the TLi and FLi were statistically significant. The decrease in the WL after repair was statistically significant in the proximal and middle aorta. Fourteen patients (13.2%) had increase in WL; seven required a second intervention. FL thrombosis occurred in 69 (65.1%). During follow-up, 36 (36.9%) patients had no retrograde flow, with complete shrinkage of the FL. The FL completely shrank in 28 patients (26.4%) despite retrograde flow. The FL increased in eight patients (7.5%); five needed reintervention. Thrombosis of FL was statistically significant with acute dissections and when dissection remained above the diaphragm (type IIIA; P = .001 and P = .0133). CONCLUSION Remodeling changes were seen when the entry tear was covered. The fate of the FL was determined by persistent antegrade flow and the level of the retrograde flow. Endografting for thoracic type B dissection was successful and promoted positive aortic remodeling changes.

Endovenous Laser Ablation of the Saphenous Vein for Treatment of Venous Insufficiency and Varicose Veins: Early Results from a Large Single-Center Experience

Purpose: To report early results of a single-center experience with endovenous laser ablation of the saphenous vein (ELAS). Methods: From February 2002 to January 2003, 165 eligible patients (116 women; mean age 59.1 years, range 27–90) were treated with ELAS for venous insufficiency in 203 lower limbs. All patients were symptomatic, and the majority (62%) had class 4 or higher clinical disease (CEAP classification). Eighteen (8.9%) patients had ulcers. A 940-nm diode laser was used in an office setting under local tumescent anesthesia to deliver 100 to 140 laser applications along the course of the vein. Two weeks of compression bandages and a 1-week course of ibuprofen were prescribed postoperatively. All patients underwent a duplex scan of the target vein at 2 weeks. Results: The great (154, 76%), short 37 (18%), and accessory 12 (6%) saphenous veins were ablated, achieving a 97% clinical success rate. Postoperative complications were few (mild induration and ecchymosis) and well tolerated (no DVT or nerve injury). Of the 6 (3.0%) recanalized target veins, 4 were only partially open and successfully treated with sclerosis. Of the 18 patients with active ulceration, 15 (83%) demonstrated healing after ELAS. In a satisfaction survey of patients more than 1 year after ELAS treatment, 84% of the 31 responders claimed their symptoms had diminished to none or minimal; 97% were mostly or very satisfied with their treatment results. Conclusions: ELAS for symptomatic saphenous vein incompetence and varicose veins has excellent short-term subjective and objective outcomes. This technique appears to be very successful in reducing symptoms, resolving varicose veins, and healing ulcers.

Endoluminal stent-graft stabilization for thoracic aortic dissection.

Purpose: To review our experience with thoracic endografting for type B aortic dissection using the TAG Endoprosthesis. Methods: A retrospective analysis was performed of data collected prospectively from March 2000 to July 2004 under an investigational device exemption protocol for the TAG thoracic endograft. In this time period, 40 patients (29 women; mean age 67 years, range 39–91) were treated with this endograft for type B aortic dissection. Results: Technical success was 95%. There was 1 (2.5%) perioperative death, and 1 (3%) endoleak was treated with an additional graft on postoperative day 2. Fifteen (38%) patients experienced postoperative complications, mainly renal or pulmonary, and 1 (3%) patient developed postoperative paraplegia that did not resolve. The 1-year survival was 85%. Follow-up computed tomography was available for 31 patients with an average 15-month follow-up. There was no significant change in size of the thoracic aorta in 22 patients; 8 aneurysmal segments were significantly reduced in size and 1 thoracic aortic aneurysm expanded. No thoracic aortic ruptures were seen in this series. Conclusions: These early results indicate type B thoracic aortic dissections can be treated with acceptable morbidity and mortality using endografts. Stent-graft repair of the thoracic aorta may decrease the incidence of thoracic aortic expansion and rupture.

Management of endoleaks associated with endovascular treatment of descending thoracic aortic diseases

OBJECTIVE Endoluminal grafting is emerging as a less invasive alternative to the treatment of descending thoracic aorta diseases. Endoleaks (continued pressurization of the treated aorta external to the endoluminal graft) are a potential complication. We reviewed our cumulative endovascular experience for descending thoracic aorta pathologies with respect to the management of endoleaks and associated patient outcomes. METHODS As part of a single-site investigational device-exemption protocol, 249 patients (146 men, 103 women) with thoracic aortic diseases underwent attempted delivery of a TAG endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) between February 2000 and August 2005. Indications for study enrollment included 111 atherosclerotic aneurysms (44.6%), 67 aortic dissections (26.9%), 27 penetrating aortic ulcers (10.8%), 14 contained ruptures (5.6%), 11 pseudoaneurysms (4.4%), 9 acute aortic transections (3.6%), 7 aortobronchial fistulas (2.8%), 2 endoleaks (0.8%) after prior thoracic endoluminal grafting, and 1 (0.4%) adult coarctation. Endoleak surveillance was performed using serial computed tomography scans. RESULTS Mean patient age was 68 years (range, 23-91 years). Endoleak developed in 38 patients (15.3%): 15 distal type I (39.5%), 13 proximal type I (34.2%), 8 type II (21.1%) and 2 type III (5.3%). No surgical intervention was performed in 26 patients (68.4%), in which the endoleak spontaneously resolved in 14 (53.8%), 8 (30.8%) are being monitored and are asymptomatic, 3 (11.5%) died of unrelated causes, 2 (7.7%) withdrew from the study, and 1 (3.8%) was lost to follow-up. Twelve patients (31.6%) required reintervention using an additional endoluminal graft: 8 (66.7%) with a proximal type I endoleak, 2 (16.7%) with a distal type I endoleak, 1 (8.3%) with both distal type I and type III endoleaks, and 1 (8.3%) with a type III endoleak. Open conversions were necessary secondary to device deployment difficulties in two patients (0.8%), and due to expansion of a thoracoabdominal aneurysm and rupture of an aneurysm secondary to a type II endoleak in one patient (0.5%) each. CONCLUSION Endoleaks are an infrequent, yet important, complication after thoracic endografting. Many endoleaks will resolve spontaneously, but some patients may require another endovascular intervention. Close surveillance is recommended for these patients; however, open conversion is rarely indicated. Because more diseases of the thoracic aorta are being treated using an endovascular approach, a standardized treatment algorithm is essential to safely and effectively manage associated endoleaks.

Endovascular repair in the thoracic and abdominal aorta: no increased risk of spinal cord ischemia when both territories are treated.

Purpose: To evaluate the morbidity associated with thoracic and abdominal aortic repair using endovascular exclusion alone or combined endovascular and open repair. Methods: Between January 1998 and February 2007, 49 patients (36 men; mean age 70 years) underwent treatment for thoracic and abdominal aorta disease with descending thoracic aortic (DTA) stent-graft and abdominal aortic repair. Thirty-nine patients with coexisting thoracic and abdominal pathologies were classified with multilevel aortic disease (MLAD), whereas 10 patients presented with thoracoabdominal aneurysm. Patients were separated into 3 groups: 1: thoracic stent-grafts and open abdominal repair (n=18), group 2: thoracic and abdominal stent-grafts (n=21), and group 3: thoracic stent-grafts with visceral artery debranching (n=10). Prior carotid-subclavian bypass was performed in 3 (6%) patients with a dominant left vertebral artery. Results: Stent-graft deployment was technically successful in all cases. Eight (16%) patients underwent emergent thoracic stent-graft placement. In 9 (18%) patients, the left subclavian artery was covered. No incidence of spinal cord ischemia was observed. The 30-day mortality was 4%, and overall mortality was 6% over a mean 33-month follow-up. The endoleak rate was 6% (1 type I, 1 type II, and 1 type III). Conclusion: Conventional or endovascular abdominal open repair in combination with DTA stent-grafting is feasible and a safe alternative to traditional open repair. Management of MLAD did not show increased incidence of spinal cord ischemia and was associated with fewer complications and deaths than simultaneous or staged open thoracic and abdominal repairs.

The AneuRx stent-graft since FDA approval: single-center experience of 230 cases.

PURPOSE To compare a single-center experience with the AneuRx stent-graft system before and after FDA approval to results from the multicenter phase II clinical trial. METHODS The medical records of 230 consecutive patients (218 men; mean age 74 years) undergoing AneuRx stent-graft implantation for abdominal aortic aneurysm (AAA) exclusion since September 1999 were reviewed to collect patient characteristics, aneurysm morphology, procedure variables, perioperative morbidity, mortality, and short-term outcome. These data were compared to the 30 patients treated at our institution during the AneuRx phase II clinical trial and to the overall multicenter trial data. Stent-graft difficulty was categorized from 1 (straight neck and access of appropriate size) to 4 (proximal neck <10 mm long or angulated >60 degrees and/or difficult access) based on aneurysm morphology. RESULTS Data from the 30 patients enrolled in the phase II trial at our institution were comparable in terms of patient characteristics and procedure variables to patients treated after FDA approval and to the multicenter data. However, the proportion of cases involving aneurysms with a more complex morphology (levels 3 and 4) rose 22% after FDA approval, reflecting a change in referral patterns. Our postoperative endoleak and morbidity rates increased nonsignificantly with respect to our own phase II experience (17% versus 6%, 18% versus 11%, respectively); however, they were not significantly different from the multicenter data. Reintervention was performed in 15 of 38 endoleak cases, mostly type I. Only 5 (2.1%) cases had a persistent endoleak at the time of discharge. CONCLUSIONS Since FDA approval of the AneuRx device, our endovascular practice has changed toward the management of increasingly more complex AAAs. Although we are attempting more challenging cases, we are able to maintain similarly high short-term success rates while offering stent-grafting to an increasing number of patients. These results suggest that more patients may be candidates for endoluminal graft placement than determined by the clinical trial selection criteria, provided that strict surveillance and long-term follow-up is maintained.

Endovascular Repair of AAA Rupture 20 Months after Endoluminal Stent-Grafting

PURPOSE To demonstrate the feasibility of endovascular repair of a ruptured abdominal aortic aneurysm (AAA) previously treated with an endoluminal stent-graft. CASE REPORT An 84-year-old man with a 9.5-cm AAA underwent endoluminal repair with an Endologix stent-graft, but a type I endoleak was detected postprocedurally. The patient was discharged and lost to follow-up. Twenty months later, he suffered an aneurysm rupture, which was repaired using endovascular techniques. Although he had a postoperative course complicated by aspiration pneumonia and renal failure, he recovered fully and was discharged from the hospital with no evidence of endoleak on the postprocedural imaging studies. CONCLUSIONS Late ruptures after endoluminal AAA stent-grafting can be successfully treated with endovascular techniques.

Thoracic aortic dissections: unpredictable lesions that may be treated using endovascular techniques.

Abstract  Advances in endoluminal technology have enabled interventionists to treat a variety of pathologies that traditionally would require open surgery. Although excluding descending thoracic aortic aneurysms seems feasible, thoracic aortic dissection and its complications are an area in which the appropriateness of endovascular therapy has yet to be defined. Five case reports are presented, each with varying pathologies associated with type III dissections. The follow‐up of the cases ranged from 6 to 18 months with a mean of 12.2 months. The endovascular approach and the technical aspect of the intervention have been emphasized in each case. (J Card Surg 2003; 18:334‐350)