Eugene Palchik

Endovascular Treatment of Tracheoinnominate Artery Fistula: A Case Report

Tracheoinnominate fistula is a rare but lethal condition that requires emergent surgical intervention to prevent ensuing exsanguinating hemorrhage. In clinical situations where the risk of open surgery is prohibitively high, endovascular repair may provide a life-saving alternative to control hemorrhage and serve as a temporizing or definitive solution based on a given clinical scenario. The authors report successful endovascular repair of the bleeding tracheoinnominate fistula with a stent in a liver transplant patient with high comorbidities and review the current literature.Digital noise reduction schemes are being used in most hearing aids currently marketed. Unlike the earlier analog schemes, these manufacturer-specific algorithms are developed to acoustically analyze the incoming signal and alter the gain/output characteristics according to their predetermined rules. Although most are modulation-based schemes (ie, differentiating speech from noise based on temporal characteristics), spectral subtraction techniques are being applied as well. The purpose of this article is to overview these schemes in terms of their differences and similarities.

Long-Term Outcomes of Endoluminal Therapy for Chronic Atherosclerotic Occlusive Mesenteric Disease

Percutaneous interventions for symptomatic chronic mesenteric arterial atherosclerosis are rapidly gaining popularity. This study evaluates the long-term anatomic and functional outcomes of endovascular therapy for chronic atherosclerotic occlusive mesenteric arterial disease at a tertiary referral academic medical center. A retrospective analysis of records from patients who underwent endovascular mesenteric arterial interventions between 1984 and 2006 for chronic mesenteric ischemia was performed. Cases of acute ischemia or cases with associated bowel resection were excluded. Results were standardized to current Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using either a multivariate model for fixed variables or a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- SEM. Thirty-one patients (84% female, average age 70, range 43-90, years) with 41 visceral vessel interventions were identified. Indications for intervention included weight loss >10 kg (61%) and/or postprandial pain (94%). The median SVS comorbidity score was 15 (range 10-24). All had three-vessel athero-occlusive mesenteric disease with a median of two vessels occluded on angiography. The median number of vessels revascularized was two. In all cases stenosis, and not occlusion, was treated. The 90-day mortality was 20% and the major morbidity was 6%. While primary and assisted patency rates for the interventions at 7 years were 69 +/- 8% and 72 +/- 9%, respectively (mean +/- SE, n > or = 10), cumulative freedom from recurrent symptoms was only 56 +/- 10%. Twenty percent of the vessels developed restenosis at a median interval of 0.29 years (range 0.3-2.8), with a freedom from restenosis of 79 +/- 8% at 5 years. Fifty percent of these, all with recurrent symptoms, were reintervened successfully with balloon angioplasty and resolution of their symptoms. There was no significant difference between the celiac and superior mesenteric artery outcomes. The correlation of recurrent symptoms and restenosis was significant (p < 0.001). Endoluminal therapy for chronic mesenteric ischemia carries a low morbidity and mortality in a high-risk population. While anatomic patency remains high, long-term therapeutic benefit is not achieved. In its present iteration, endovascular therapy for mesenteric ischemia should be limited to those patients without an open surgical option.

Outcomes of Endoluminal Therapy for Ostial Disease of the Major Branches of the Aortic Arch

While aggressive endoluminal therapy for occlusive disease of the major branches of the arch of the aorta (brachiocephalic [BCA], left common carotid [LCCA], and left subclavian [LSCA] arteries) is commonplace, long-term outcomes in this population are unclear. We examined the long-term outcomes of endoluminal therapy for ostial aortic arch disease at a single tertiary referral academic medical center. A prospective database of patients undergoing endovascular treatment of aortic arch vessel atherosclerotic occlusive disease between 1990 and 2004 was maintained and retrospectively analyzed. Patients with stenotic ostial lesions of the major thoracic aorta branches were selected. Angiograms were reviewed in all cases to assess lesion characteristics. Patency was assessed by routine clinical and, in the LCCA and LSCA, duplex ultrasound follow-up at 1, 6, and 12 months postintervention and every 12 months thereafter. Results were standardized to current Trans-Atlantic Inter-Society Consensus and Society for Vascular Surgery criteria. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- SEM. Forty-four patients (average age 64 +/- 2 years, 59% male) underwent 26 LSCA, 11 LCCA, and eight BCA interventions for primary indications of arm ischemia (29%), prevention or treatment of coronary steal syndrome (29%), or cerebrovascular signs/symptoms (42%). The technical success rate was 98%, with a 90-day mortality rate of 0% and a major adverse event rate of 2%. There were no strokes and no upper extremity embolic events. Cumulative patency was 88 +/- 8% at 3 years, with a reintervention rate of 7%. The overall symptom recurrence rate was 4%. No local or systemic factors were associated with poor outcomes. Endoluminal stenting for ostial disease of the branches of the aortic arch provides excellent and long-term patency rates with low morbidity, mortality, and secondary intervention rates. With an overall technical success of 98%, our results parallel those for lesions located more distally in the arch branches and support the continued use of percutaneous therapy for atherosclerotic disease throughout the arch branches.