Douglas A. Troutman

Updated strategies to treat acute arterial complications associated with total knee and hip arthroplasty

OBJECTIVE Traditional treatment of acute arterial complications associated with total knee arthroplasty (TKA) and total hip arthroplasty (THA) has generally included arteriography followed by open surgery. The purpose of this study was to describe our evolution from open surgery to preferential endovascular treatment for acute arterial complications of TKA and THA. METHODS We analyzed our computerized database registry and patient charts for vascular interventions associated with TKA and THA at a hospital with a large volume of orthopedic surgery to determine changing trends in endovascular intervention for these complications. RESULTS Between 1989 and 2012, 39,196 TKA (26,374 total: 23,205 primary; 3169 revisions) and THA (12,822 total: 10,293 primary; 2529 revisions) were performed. Vascular surgery consultation was provided for the treatment of acute ischemia, hemorrhage, ischemia with hemorrhage, and pseudoaneurysm formation. All interventions were performed within 30 days of joint replacement. A total of 49 (0.13%) acute arterial complications occurred over the 23-year period: 37 (76%) associated with TKA and 12 (24%) with THA. Arterial injury was detected on the same day as the orthopedic procedure in 28 patients, between postoperative days 1 and 5 in 18 patients, and between postoperative days 5 and 30 in three patients. The arterial complications caused ischemia in 28 patients (58%), hemorrhage in six (12%), ischemia with hemorrhage in six (12%), and pseudoaneurysm in nine (18%). Treatment included solely endovascular intervention in 12 (25%), failed endovascular treatment converted to open surgery in one (2%), and open surgery alone in 36 (73%) patients. Before 2002, only 6% (2/32; 2 TKA) of patients were successfully treated with endovascular intervention compared with 59% (10/17; 9 TKA, 1 THA) after June 2002 (P = .0004). There was no mortality, and limb salvage was achieved in all patients. CONCLUSIONS Although the majority of acute arterial complications after TKA and THA are diagnosed on the day of surgery, a high clinical awareness for acute arterial injury should also be present in the postoperative period. Although not always feasible, endovascular management is now our preferred treatment for injuries associated with TKA or THA. This offers substantially shorter time to vascular restoration, with less morbidity than open repair, and equivalent satisfactory outcomes.

Endovascular aortic aneurysm repair surveillance may not be necessary for the first 3 years after an initially normal duplex postoperative study

OBJECTIVE We have previously shown that duplex ultrasonography (DU) may replace computed tomography angiography (CTA) as the primary surveillance tool for endovascular aortic aneurysm repair (EVAR). Current Society for Vascular Surgery practice guidelines suggest that if CTA does not document endoleak, aneurysm sac enlargement, or limb stenosis by 12 months after EVAR, surveillance studies may be performed annually. The purpose of this study was to determine whether the time to the second surveillance DU study can be safely postponed to 3 years after EVAR if the initial study finding is normal. METHODS Between 1998 and 2013, DU surveillance was performed in our accredited noninvasive vascular laboratory at 1 week, 6 months, and annually after 410 EVARs (follow-up: mean, 35 months; range, 0.5-151 months). DU was used to measure sac diameter, intrasac endoleak peak systolic velocities (PSVs), and PSVs within endograft limbs. If an endoleak, limb stenosis, or increase in sac size was documented, DU surveillance was performed more frequently or CTA was performed, followed by intervention if appropriate. RESULTS On the basis of DU surveillance, 113 patients (28%) were diagnosed with either endoleak or graft limb stenosis during the follow-up period. There were 95 patients (23%) with 118 endoleaks (15 [13%] type I, 90 [76%] type II, 11 [9%] type III, 2 [2%] type IV). There were 18 (4%) patients with limb stenosis defined as PSV >300 cm/s. Intervention was performed in 32 (28%) of the 113 patients with endoleak or limb stenosis, or in 8% of the total group (32 of 410), during the follow-up period of 0.5 to 151 months. Only 2.2% of the patients (7 of 325) with an initially normal finding on post-EVAR DU went on to develop endoleak or limb stenosis that required intervention during 3-year follow-up compared with 25% of patients (21 of 85) with an initially abnormal finding on post-EVAR DU (P = .0001). CONCLUSIONS These findings suggest that follow-up DU surveillance can be postponed until 3 years after EVAR if the initial result of surveillance DU is normal (no endoleak, sac enlargement, stenosis), with minimal risk of an adverse clinical event.

Duplex ultrasound imaging to detect limb stenosis or kinking of endovascular device.

OBJECTIVE We attempted to correlate duplex ultrasound (DU) findings with the clinical outcome of graft limb stenosis or kinking after endovascular aneurysm repair (EVAR). METHODS Between 1998 and 2010, 248 patients underwent EVAR and postoperative DU surveillance of 496 graft limbs in our accredited noninvasive vascular laboratory by one of three experienced technologists. Routine DU surveillance was performed 1 week, 6 months, and annually after EVAR. Peak systolic velocities (PSVs) were measured in the body and midportion and distal attachment site of both limbs of the graft, and adjacent PSV ratios were calculated. RESULTS None of 479 graft limbs with a PSV of <300 cm/s occluded during long-term follow-up (mean, 22.3 months; range, 1-123 months). Of 17 graft limbs with a PSV >300 cm/s, seven occluded (0 of 479 vs 7 of 17, P < .01; sensitivity, 100%; specificity, 98%), five underwent prophylactic intervention (mean adjacent PSV ratio, 7.3), and five (30%) remained patent without intervention (mean PSV ratio, 3.2). CONCLUSIONS This large series of DU surveillance for failing EVARs grafts suggests that graft limbs with PSVs <300 cm/s can be safely monitored. However, limbs with more elevated PSVs may benefit from prophylactic intervention or more frequent surveillance to prevent limb occlusion.

Open Repair and Endovascular Covered Stent Placement in the Management of Bilateral Axillary Artery Aneurysms

A 72-year-old male with chronic obstructive pulmonary disease and hyperlipidemia presented with acute right upper limb ischemia. Arterial occlusion was found to be secondary to a thrombosed axillary artery aneurysm. An open repair was performed with a polytetrafluoroethylene (PTFE) graft. On further workup, the patient was found to have an asymptomatic axillary artery aneurysm on the left-hand side. Endovascular repair with a covered stent was chosen to treat this aneurysm.

The fate of endovascular aortic aneurysm repair after 5 years monitored with duplex ultrasound imaging

Background: Interventions for aortic aneurysm sac growth have been reported across multiple time points after endovascular aortic aneurysm repair (EVAR). We report the long‐term outcomes of patients after EVAR monitored with duplex ultrasound (DUS) imaging with respect to the need for and type of intervention after 5 years. Methods: We report a series of patients who were monitored with DUS imaging for a minimum of 5 years after EVAR. DUS imaging was performed in an accredited noninvasive vascular laboratory, and computed tomography angiography was only performed for abnormal DUS findings. Results: There were 156 patients who underwent EVAR with follow‐up >5 years (mean, 7.5 years; range, 5.1‐14.5 years). Interventions for endoleak, graft limb stenosis, or thrombosis were performed in 44 patients (28%) at some time during follow‐up. Of the 156 patients, 34 (22%) underwent their first intervention during the first 5 years (25 endoleaks, 9 limb stenoses, or occlusions). Four ruptures occurred, all in patients with their first intervention before 5 years. The remaining 10 patients (6%) underwent a first intervention >5 years after implantation: 3 for type I endoleak, 2 for type II endoleak with sac expansion, 2 for combined type I and II endoleaks 2 for type III endoleak, and 1 unknown type. Conclusions: Long‐term follow‐up of EVAR (mean, 7.5 years) revealed that approximately one in four patients will require intervention at some point during follow‐up. First‐time interventions were necessary in 22% of all patients in the first 5 years and in 6% of patients after 5 years, highlighting the need for continued graft surveillance beyond 5 years. All patients who had a first‐time intervention after 5 years underwent an endoleak repair; none of these patients had a thrombosed limb or a rupture as a result of the endoleak.

Stent graft placement for a tracheoinnominate artery fistula.

A 68-year-old woman with ventilator-dependent respiratory failure and multiple comorbidities developed acute massive hemoptysis. Computed tomographic angiogram revealed a 3.9-cm pseudoaneurysm arising from the innominate artery abutting the trachea. The patient was successfully treated with stent graft insertion via the right common carotid artery, with exclusion of the aneurysm from the proximal innominate to the right common carotid artery, with ligation of the proximal right subclavian artery and right common carotid to subclavian artery bypass. The patient remained medically stable for 3 months after the procedure with no evidence of endoleak or infection. She then developed recurrent hemoptysis with fatal cardiac arrest. Open surgical repair has been the treatment of choice for tracheoinnominate artery fistula. However, direct repair confers a high mortality risk. Endovascular exclusion offers a less invasive treatment option for tracheoinnominate artery fistula and can serve as a bridge for patients with potential for becoming better surgical candidates.

Bovine carotid artery xenografts for hemodialysis access

Objective: Bovine carotid artery (BCA) grafts have been described as a possibly superior alternative to expanded polytetrafluoroethylene hemoaccess grafts. However, published experience remains limited, and patency rates for nonautogenous arteriovenous grafts remain unsatisfactory. We report herein the largest published experience with the current generation of BCA grafts for dialysis access and analyze subgroups to determine whether obesity, gender, or prior access surgery influences patency. Methods: We retrospectively reviewed 134 BCA grafts (Artegraft, North Brunswick, NJ) implanted for hemodialysis access in the upper extremities of 126 patients between January 2012 and May 2015. Patients had a mean of 1.8 prior access operations. Primary, primary assisted, and secondary patency rates were calculated using the Kaplan‐Meier method, and longitudinal infection risk was tabulated. Patency differences were calculated using the log‐rank method. Results: For the entire group, 1‐year primary patency was 32%, primary assisted patency was 49%, and secondary patency was 78%. Ten of 133 grafts (7%) developed infection requiring graft excision between 1 and 9 months after implantation. There was no statistical difference between men and women in primary or secondary patency (P = .88, P = .69). There was no difference in primary patency or secondary patency for patients with body mass index >30 or <30 (P = .85, P = .54). Patients who had a BCA graft as their first access attempt had a higher primary and primary assisted patency than that of patients who had the graft placed after prior access failure (P = .039, P = .024). Conclusions: This represents the largest published series of BCA grafts for arteriovenous grafts in the modern era. The primary patency of BCA grafts in this series was lower than that reported in a smaller randomized study. However, primary assisted and secondary patency were similar. Infection rates in this series appear to be somewhat lower than polytetrafluoroethylene infection rates reported in the literature. BCA grafts are a satisfactory alternative to expanded polytetrafluoroethylene for hemodialysis access, but larger controlled studies are needed to determine whether superior primary patency previously reported is a reproducible finding.

Use of a hybrid polytetrafluoroethylene stent graft for iliofemoral bypass in the setting of femoral blow-out

Revascularization in the setting of anastomotic “blow-out” in the groin is a technically demanding and morbid undertaking, often mandating transabdominal or retroperitoneal exposure of the iliac artery for proximal control or anastomosis, or both. The Gore Hybrid Vascular Graft (W. L. Gore and Associates Inc, Flagstaff, Ariz) is an expanded polytetrafluoroethylene graft with an external nitinol stent on one end designed for remote venous implantation for proximal axillary vein dialysis access outflow. We recently used this device to treat femoral anastomotic disruptions in two postoperative patients.

Duplex Ultrasonography and its Use in Surveillance Post-EVAR

After endovascular aortic aneurysm repair (EVAR), patients require annual surveillance with either CT scan or duplex ultrasonography (DU). These studies should be used to identify patients who require reintervention for EVAR complications. DU, a less expensive and radiation free option, has been shown to accurately predict aneurysm sac size and endoleak. In addition, using criteria of PSV<300 cm/s and PSV ratio <3.5, DU can rule out limb stenosis. After a normal post-procedure DU, only 2.2% of patients require reintervention within the first 3 years suggesting that less frequent follow-up may be utilized. DU is an important tool in the surveillance of EVAR patients.

Repair of aortoenteric fistula secondary to graft placement for middle aortic syndrome.

When an aortoenteric fistula (AEF) arises secondary to suprarenal or more proximal aortic repair, mortality and the complexity of the surgery increases. We present the first reported case to our knowledge of a secondary AEF arising 13 years after surgical repair of middle aortic syndrome. We performed the original surgery on a 22-year-old male who presented with hypertension and claudication by placing a Dacron prosthetic patch on the juxtarenal and infrarenal aorta, bilateral vein bypasses to the left and right renal artery, and a Dacron bypass to the proximal superior mesenteric artery. Thirteen years later, he presented with massive gastrointestinal bleeding and syncope. We performed a distal descending thoracic aortic rifampin-soaked bifurcated Dacron graft to the left renal artery and to a large meandering mesenteric artery followed by excision of all previous prosthetic graft and insertion of a rifampin-soaked tube graft from the distal descending thoracic aorta to the distal abdominal aorta with omental flap coverage. After a complicated postoperative course, he was discharged 2 months later and remains on dialysis at his 6-month postoperative follow-up without evidence of recurrent infection.