Dennis Gable

Four-year randomized prospective comparison of percutaneous ePTFE/nitinol self-expanding stent graft versus prosthetic femoral-popliteal bypass in the treatment of superficial femoral artery occlusive disease

BACKGROUND This is a randomized prospective study comparing the treatment of superficial femoral artery occlusive disease percutaneously with an expanded polytetrafluoroethylene (ePTFE)/nitinol self-expanding stent graft (stent graft) versus surgical femoral to above-knee popliteal artery bypass with synthetic graft material. METHODS One hundred limbs in 86 patients with superficial femoral artery occlusive disease were evaluated from March 2004 to May 2005. Patient symptoms included both claudication and limb threatening ischemia with or without tissue loss. Trans-Atlantic InterSociety Consensus (TASC II) A (n = 18), B (n = 56), C (n = 11), and D (n = 15) lesions were included. Patients were randomized prospectively into one of two treatment groups; a percutaneous treatment group (group A; n = 50) with angioplasty and placement of one or more stent grafts, or a surgical treatment group (group B; n = 50) with a femoral to above-knee popliteal artery bypass using synthetic conduit (Dacron or ePTFE). Patients were followed for 48 months. Follow-up evaluation included clinical assessment, physical examination, ankle-brachial indices, and color flow duplex sonography at 3, 6, 9, 12, 18, 24, 36, and 48 months. RESULTS Mean total lesion length of the treated arterial segment in the stent graft group was 25.6 cm (SD = 15 cm). The stent graft group demonstrated a primary patency of 72%, 63%, 63%, and 59% with a secondary patency of 83%, 74%, 74%, and 74% at 12, 24, 36, and 48 months, respectively. The surgical femoral-popliteal group demonstrated a primary patency of 76%, 63%, 63%, and 58% with a secondary patency of 86%, 76%, 76%, and 71% at 12, 24, 36, and 48 months, respectively. No statistical difference was found between the two groups with respect to primary (P = .807) or secondary (P = .891) patency. CONCLUSION Management of superficial femoral artery occlusive disease with percutaneous stent grafts exhibits similar primary patency at 4-year (48 month) follow up when compared with conventional femoral-popliteal artery bypass grafting with synthetic conduit. This treatment method may offer an alternative to treatment of the superficial femoral artery segment for revascularization when prosthetic bypass is being considered or when autologous conduit is unavailable.

Heparin-bonded, Expanded Polytetrafluoroethylene-lined Stent Graft in the Treatment of Femoropopliteal Artery Disease: 1-Year Results of the VIPER (Viabahn Endoprosthesis with Heparin Bioactive Surface in the Treatment of Superficial Femoral Artery Obstructive Disease) Trial

PURPOSE To evaluate the performance of a heparin-bonded, expanded polytetrafluoroethylene (ePTFE)-lined nitinol endoprosthesis in the treatment of long-segment occlusive disease of the femoropopliteal artery (FPA) and to identify factors associated with loss of patency. MATERIALS AND METHODS In a single-arm, prospective, 11-center study (VIPER [Gore Viabahn Endoprosthesis with Heparin Bioactive Surface in the Treatment of Superficial Femoral Artery Obstructive Disease] trial), 119 limbs (113 patients; 69 men; mean age, 67 y), including 88 with Rutherford category 3-5 disease and 72 with Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) C or D lesions of the FPA, underwent stent graft implantation. The mean lesion length was 19 cm; 56% of lesions were occlusions. Follow-up evaluations included color duplex ultrasonography in all patients, with patency defined as a peak systolic velocity ratio< 2.5. RESULTS At 12 months, Rutherford category and ankle-brachial index (ABI) were significantly improved (mean category improvement, 2.4; ABI increased from 0.6±0.2 to 0.9±0.19; P<.0001). Primary and secondary patency rates were 73% and 92%. The primary patency for devices oversized<20% at the proximal landing zone was 88%, whereas the primary patency for devices oversized by>20% was 70% (P = .047). Primary patency was not significantly affected by device diameter (5 vs 6 vs 7 mm) or lesion length (≤20 cm vs>20 cm). The 30-day major adverse event rate was 0.8%. CONCLUSIONS The heparin-bonded, ePTFE/nitinol stent graft provided clinical improvement and a primary patency rate of 73% at 1 year in the treatment of long-segment FPA disease. Careful sizing of the device relative to vessel landing zones is essential for achieving optimal outcomes.

Randomized comparison of ePTFE/nitinol self-expanding stent graft vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral artery occlusive disease

BACKGROUND A randomized prospective study comparing the treatment of superficial femoral artery occlusive disease percutaneously with an expanded polytetrafluoroethylene (ePTFE)/nitinol self-expanding stent graft (stent-graft) vs surgical femoral to above knee popliteal artery bypass with synthetic graft material. METHODS One hundred limbs in 86 patients with superficial femoral artery occlusive disease were evaluated from March 2004 to May 2005. Patient symptoms included both claudication and limb threatening ischemia with or without tissue loss. The TransAtlantic InterSociety Consensus (TASC) II A (N = 18), B (N = 56), C (N = 11), and D (N = 15) lesions were included. Patients were randomized prospectively into one of two treatment groups; a percutaneous treatment group (group A; N = 50) with angioplasty and placement of one or more stent-grafts or a surgical treatment group (group B; N = 50) with a femoral to above knee popliteal artery bypass using synthetic conduit (Dacron graft or ePTFE). Patients were followed for a total of 24 months. Follow-up evaluation included clinical assessment and physical examination, ankle-brachial indices (ABI), and color flow duplex sonography at 3, 6, 9, 12, 18, and 24 months. RESULTS The mean total lesion length of the treated arterial segment in the stent-graft group was 25.6 cm (SD +/- 15 cm). The stent-graft group demonstrated a primary patency of 81%, 72%, and 63% with a secondary patency of 86%, 83%, and 74% at 6, 12, and 24 months, respectively. The surgical femoral-popliteal group demonstrated a primary patency of 84%, 77%, and 64% with a secondary patency of 89%, 86%, and 76% at 6, 12, and 24 months, respectively. No statistical difference was found between the two groups with respect to primary (P = .716) or secondary patency (P = .695). Grouping of less severe (TASC II A/B) vs more severe (TASC II C/D) lesions demonstrated patency at 24 months for the femoral-popliteal arm of 63% and 67%, respectively while that of the stent-graft arm was 64% and 47%, respectively. Secondary patency was 76% in both TASC classifications for the femoral-popliteal arm with 78% and 47% patency found respectively in the stent-graft group. These resulted in no significant difference for primary (P = .978) or secondary (P = .653) patency overall, although there is a trend for decreased patency with higher TASC II lesions. CONCLUSION Management of superficial femoral artery occlusive disease with percutaneous stent-grafts exhibits similar primary patency at 24-month follow-up when compared with conventional femoral-popliteal artery bypass grafting with synthetic conduit. This treatment method may offer an alternative to treatment of the superficial femoral artery segment for revascularization when prosthetic bypass is being considered or when autologous conduit is unavailable.

Comparison of quick parathyroid assay for uniglandular and multiglandular parathyroid disease

BACKGROUND The quick intraoperative parathyroid assay (qPTH) has been proposed as an effective tool in the surgical management of hyperparathyroidism. This assay may facilitate directed, unilateral exploration for uniglandular disease; however, its role in the management of multiglandular disease remains unclear. The purpose of this study is to evaluate the use of qPTH in parathyroid surgery, and to compare the results for uniglandular and multiglandular disease. METHODS A prospective analysis of 63 consecutive patients explored for hyperparathyroidism using the qPTH assay was performed. Preoperative localization studies including ultrasonography and sestamibi scan were routinely obtained. Blood samples for qPTH were routinely drawn prior to the surgical incision, prior to gland excision, as well as 5 and 10 minutes after gland excision. Patients with primary or secondary hyperplasia had blood samples drawn relative to a 3-1/2 gland resection. Additional samples were drawn as needed for patients with a double adenoma. A qPTH decline of greater than or equal to 50% of the highest preincision or gland preexcision level was considered successful. Unilateral neck exploration was routinely performed unless multiglandular disease was identified. Patients were followed up postoperatively with serum calcium levels and an 8-month median follow-up was recorded. RESULTS Forty-nine of 63 (78%) patients were found to have a solitary parathyroid adenoma. The qPTH assay was successful in 48 (97%) patients with uniglandular disease. Forty-four of these 48 patients showed an appropriate assay decline 5 minutes after adenoma excision. One patient with a single adenoma showed a delayed 50% decline in qPTH at 20 minutes. Fourteen (22%) patients were found to have multiglandular disease: 6 patients with primary hyperplasia, 4 patients with hyperplasia secondary to renal failure, and 4 patients with double adenomas. All patients with multiglandular disease demonstrated a successful decrease in qPTH levels. All patients with hyperplasia secondary to renal failure showed a successful assay decline 5 minutes after 3-1/2 gland resection. Eight of 14 (57%) patients with multiglandular disease (4 double adenomas, and 4 hyperplasia) were suspected to have solitary adenomas preoperatively. Overall, 62 of 63 (98%) patients showed an appropriate assay decline within 10 minutes after gland excision. Postoperatively, all patients were normocalcemic with a median follow-up of 8 months. CONCLUSIONS These data suggest that qPTH can accurately facilitate unilateral, directed neck exploration for uniglandular parathyroid disease, as well as guide the extent of gland resection for multiglandular disease. This assay reliably eliminates the most common cause of parathyroidectomy failure, which is unrecognized multiglandular disease. The qPTH assay can reliably be used with similar accuracy for patients with multiglandular disease as has been shown for uniglandular parathyroid disease.

Intermediate follow-up of carotid artery stent placement

BACKGROUND Carotid artery stent placement (CAS) is becoming more popular among various specialties for the treatment of primary and recurrent carotid artery disease. The morbidity associated with this procedure is improving but the intermediate- and long-term follow-up remains unknown. We report our restenosis rates and follow-up associated with CAS. METHODS Thirty-one interventions on 29 patients from May 1998 to January 2002 were reviewed. All patients have undergone serial follow-up using Doppler ultrasound at 3 and 6 months and every 6 months thereafter. Ten interventions (32%) were performed on patients with recurrent carotid artery disease and 21 (68%) on patients with primary disease. RESULTS Five periprocedural complications occurred (transient ischemic attack, n = 3; major stroke, n = 1; immediate intrastent restenosis requiring lysis, n = 1) for a total immediate complication rate of 16%. No deaths occurred. Follow-up was achieved in all 29 patients (mean 28 months; range 20 to 46). Twenty-seven patients (29 vessels; 94%) remain asymptomatic with less than 50% stenosis. Two vessels (6%) have been found to have a critical restenosis of greater than 90%. Both patients were symptomatic from their recurrence (transient ischemic attack, n = 1; acute stroke, n = 1). Cumulative major stroke and death rate including all follow-up was 6%. CONCLUSIONS CAS can be performed with an acceptable stroke/death rate (3%) in a properly selected patient population. In our small series of patients, the restenosis rate at a mean of 28 months after CAS is 6%.

Initial experience in the treatment of thoracic aortic aneurysmal disease with a thoracic aortic endograft at Baylor University Medical Center.

A retrospective review of 27 patients who underwent endovascular repair of thoracic aneurysms and of other thoracic aortic pathology with the thoracic aortic endograft (Gore Medical, Flagstaff, AZ) from June 2005 to July 2007 was performed. The mean follow-up period was 13.5 months (range, 2–25 months). Indications for thoracic endografting included descending thoracic aneurysms (n = 18), thoracoabdominal aneurysms (n = 3), traumatic aortic injuries (n = 3), penetrating aortic ulcers (n = 2), and contained rupture of a type B dissection (n = 1). One patient died during the procedure, for an overall mortality rate of 3.7%. The average length of stay was 8.1 days, with an average stay in the intensive care unit of 4.2 days. If patients with traumatic aortic injuries were excluded, the average overall and intensive care unit length of stay were 5.6 and 1.8 days, respectively. There was one incident of spinal cord ischemia (3.7%). There were five type I or type III endoleaks, three of which required revision (11.1%). In conclusion, thoracic endografting is a safe and viable option for the repair of descending thoracic aneurysms and other aortic pathologies. We have found it to be less invasive, even in conjunction with preoperative debranching procedures, with a shorter recovery time, decreased perioperative morbidity and blood loss, and decreased perioperative mortality compared with standard open repair.

Use of a Viabahn Stent for Repair of a Common Carotid Artery Pseudoaneurysm and Dissection

Carotid procedures in the previously operated neck are both technically demanding and subject to increased rates of complications. Adding radiation to the operated field only increases these risks. The incidence of cranial nerve injury in the reoperative neck has increased. Similarly, patients with a history of radiation are at increased risk for stroke, cranial nerve injury, and wound complications. Before the endovascular era, the only option for repair of an extracranial carotid aneurysm was open operation. Recently, more experience has been gained using endovascular techniques to repair these aneurysms. We present a patient with a history of radiation and radical neck dissection who developed a pseudoaneurysm of the common carotid artery. This pseudoaneurysm was repaired successfully using a Viabhan covered stent graft.

Work Effort, Productivity, and Compensation Trends in Members of the Society for Vascular Surgery

Objective: To survey the Society for Vascular Surgery (SVS) membership with regard to type of practice, employment status, work effort, and productivity criteria. Methods: A survey questionnaire was developed to gather information about member demographics, academic versus private practice, employment status, time in practice, measures of work, and productivity criteria. Results: Two-thirds of members were in private practice, 24% were employed by hospitals/health systems and 21% were in solo practice. Only 50.3% said they or their group kept record of relative value units/work relative value units (RVUs/WRVUs). Of those tracking RVUs, significantly greater number of private practice VS reported annual RVUs >10 000 compared to academic VS (P < .01). Net collections were the most common measure of productivity (51%) followed by WRVUs (36%). Conclusions: With a changing environment and employment status of VS, tracking measures of productivity and proper benchmarking become vitally important. The SVS should consider positioning itself to collect, store, manage, and provide such information to assist members in practice transition.

Changing practice paradigms: Negotiating your future

There are many recent and ongoing changes in the practice of medicine from a business standpoint as well as in overall practice management. Economic and lifestyle desires have pushed many physicians to a decision point of whether or not to join a large multispecialty group or to sell their practice and become an employee of a hospital system. There are advantages and disadvantages to both options; however, deciding on the most appropriate path for each individual can be a daunting task. At our recent breakfast session at the vascular annual meeting in Chicago, Illinois, in June 2011, we brought to light these topics to try and help enlighten physicians on which option may be right for them. There is no single answer/option that will fit every practice, but discussion for various practice management designs are outlined and critiqued. This article cannot fully discuss each view in the allotted space, but it is designed to encourage thought and discussion among the vascular surgical community as a whole.

Endovascular “Repair” of Abdominal Aortic Aneurysm and Iliac Artery Aneurysm

Endovascular aneurysm repair is currently being developed as an alternative to traditional surgical repair for patients with abdominal aneurysms. The divisions of vascular surgery and interventiona...