Evan J. Ryer

Comparison of outcomes with coils versus vascular plug embolization of the internal iliac artery for endovascular aortoiliac aneurysm repair

OBJECTIVEnTo compare the safety and efficacy of coil embolization (COIL) to Amplatzer vascular plug embolization (PLUG) to achieve internal iliac artery (IIA) occlusion prior to endovascular aortiliac aneurysm repair (EVAR).nnnMETHODSnData from consecutive patients who underwent IIA embolization prior to EVAR over a 6-year period (2004-2010) were retrospectively reviewed. Patient demographics, treatment modalities, and outcomes were compared.nnnRESULTSnFrom January 1, 2004 to December 31, 2010, a total of 53 patients underwent percutaneous embolization of 57 IIAs prior to EVAR. Twenty-nine IIAs underwent COIL and 28 IIAs underwent PLUG embolization. Patient demographics and risk factors were similar between the two groups. Patients underwent repair for aneurysmal dilation of the infrarenal aorta in conjunction with the common or internal iliac arteries (n = 35, 62%) or isolated iliac artery aneurysms (n = 19, 38%). A significantly greater number of embolization devices were used in the COIL group (5.8 ± 3.8 vs 1.1 ± 0.4; P < .0001). Patients undergoing PLUG embolization demonstrated significantly shorter procedure times (118.4 ± 64.7 minutes vs 72.6 ± 22.4 minutes; P = .008) and fluoroscopy times (32.6 ± 14.6 vs 14.4 ± 8.6 minutes; P = .002). However, radiation dose between the groups did not differ (COIL: 470,192.7 ± 190,606.6 vs PLUG: 300,972.2 ± 191,815.7 mGycm(2); P = .10). Overall periprocedural morbidity did not differ between the groups (COIL: 11% vs PLUG: 6%; P = 1.0), and there were no perioperative mortalities or severe complications. Nontarget embolization occurred in two COIL and no PLUG cases (COIL: 6.9% vs PLUG: 0%; P = .49). Patient-reported buttock claudication at 1 month was 17.2% for COIL and 39.3% for PLUG patients (P = .08). At last follow-up, persistent buttock claudication was reported in 13.8% of COIL and in 14.3% of PLUG embolizations (P = 1.0). There was no significant difference in charges for the embolization material, operating room, or overall hospital charges (COIL: 44,720 ± 19,153 vs 37,367 ± 10,915; P = .22). Lastly, zero endoleaks in the COIL group and three in the PLUG group (P = .40) were detected on the most recent follow-up computed tomography imaging. No endoleak was related to the site of IIA embolization.nnnCONCLUSIONSnCOIL and PLUG embolization both provide effective IIA embolization with low complication rates when used for EVAR. Buttock claudication did occur in approximately one-third of patients but resolved in half of those affected. PLUG embolization took significantly less time to perform and required decreased fluoroscopy times. Based on outcomes and cost-analysis, COIL and PLUG embolization are equivalent methods to achieve IIA occlusion during EVAR.

Ultrasound-guided percutaneous thrombin injection of iatrogenic upper extremity pseudoaneurysms

OBJECTIVEnThe objective of this study was to evaluate the safety and efficacy of ultrasound-guided thrombin injection (TI) for the treatment of upper extremity iatrogenic pseudoaneurysms (PAs) after percutaneous upper extremity arterial access.nnnMETHODSnThis is a retrospective single-institution study from January 2009 to December 2012. All patients with clinical suspicion of an upper extremity PA after arterial puncture underwent duplex examination. Patients with and without PAs were compared to identify risk factors for development of PAs. Outcomes were analyzed in those patients with PAs that were treated with TI.nnnRESULTSnBetween January 1, 2009, and December 31, 2012, there were 61 upper extremity arterial duplex examinations performed for a clinical suspicion of an upper extremity PA. Eighteen ultrasound examinations (29.5%) demonstrated an iatrogenic upper extremity PA (13 brachial and five radial). Those patients with an upper extremity PA were more likely to have a history of hypertension, atrial fibrillation, and chronic kidney disease. Sheath size, preprocedural antiplatelet therapy, periprocedural anticoagulation regimen, service specialty performing the procedure, and procedure type did not influence the development of PA. Of 18 patients with PA, 14 were treated with TI with an overall success rate of 86%. There was one PA that failed to thrombose with TI, and there was one native brachial artery thrombosis requiring emergent surgical intervention. Outpatient clinical follow-up in the successfully treated patients demonstrated no recurrences at an average follow-up of 8 months.nnnCONCLUSIONSnUltrasound-guided percutaneous TI appears safe and effective for the treatment of iatrogenic brachial and radial artery PAs.

Patients with familial abdominal aortic aneurysms are at increased risk for endoleak and secondary intervention following elective endovascular aneurysm repair

OBJECTIVEnA recent investigation has documented an increased risk of aneurysm-related complications after endovascular aneurysm repair (EVAR) of familial abdominal aortic aneurysms (fAAAs). We hypothesized that fAAA patients are not at increased risk for complications following open AAA repair or EVAR when compared with sporadic abdominal aortic aneurysm (spAAA) patients. To this end, we performed a single institution retrospective review.nnnMETHODSnEpidemiologic data were collected through the electronic medical record. Family history data were obtained from a questionnaire administered at the initial vascular surgery consultation. Major adverse events were defined as myocardial infarction, respiratory failure, renal failure, bowel ischemia, limb ischemia, multisystem organ failure, intracranial hemorrhage, paraplegia, hemorrhage, or death. Endoleaks were classified in accordance with the standardized reporting practices of the Society for Vascular Surgery. AAA-related complications were defined as the need for a secondary intervention due to endoleak, limb ischemia, or postimplantation rupture.nnnRESULTSnA total of 392 patients with complete clinical data underwent elective AAA repair from 2004 to 2014. Of these 392 patients, 89 (23%) were classified as fAAA patients and 303 (77%) were classified as spAAA patients. With the exception of increased rates of chronic obstructive pulmonary disease (Pxa0= .0009) and pack-years smoked (Pxa0= .03) in spAAA patients, demographics did not differ. Sixty-two percent (nxa0= 55) of fAAA patients and 68% (nxa0= 205) of spAAA patients underwent EVAR (Pxa0= .30). fAAA patients did not incur any significant difference in major adverse events following open AAA repair (fAAA, 9% vs spAAA, 11%; Pxa0= .75). Additionally, fAAA patients did not incur any significant difference in major adverse events following EVAR (fAAA, 4% vs spAAA, 5%; Pxa0= .70). Patients with fAAA did have a significantly increased rate of endoleak (fAAA, 24% vs spAAA, 12%; Pxa0= .03) and secondary intervention following EVAR (fAAA, 21% vs spAAA, 12%; Pxa0= .04).nnnCONCLUSIONSnThe current study shows that patients with fAAA do not have increased perioperative morbidity following open or endovascular AAA repair. However, patients with fAAA do have an increased risk of endoleak and secondary intervention following EVAR. These findings suggest that EVAR and open AAA repair are both safe and effective for fAAA patients. The increased rate of endoleak and secondary intervention in patients with fAAA suggests that this subpopulation may benefit from closer post-EVAR surveillance or open surgical repair in good risk patients.

Value of delayed duplex ultrasound assessment after endothermal ablation of the great saphenous vein.

OBJECTIVEnEndothermal ablation (ETA) of the great saphenous vein (GSV) is associated with a small but definite risk of endothermal heat-induced thrombosis (EHIT) extending into the common femoral vein. Follow-up duplex ultrasound imaging to detect EHIT after ETA is considered standard of care, although the exact timing of duplex ultrasound imaging to detect EHIT after ETA remains unclear. We hypothesized that an additional duplex ultrasound assessment 1xa0week after ETA would not identify a significant number of patients with EHIT and would significantly increase health care costs.nnnMETHODSnThis was a retrospective review of consecutive ETA GSV procedures from 2007 to 2014. All patients were evaluated with duplex ultrasound imaging on postprocedure day 1, and 79% of patients underwent a second ultrasound assessment 1xa0week postprocedure. EHIT was considered present when proximal GSV closure progressed to level ≥4, based on a six-tier classification system.nnnRESULTSnFrom January 1, 2007, until December 31, 2014, 842 patients underwent GSV ETA. Patients with EHIT were more likely to have had a prior deep venous thrombosis (DVT; Pxa0= .002) and a larger GSV (Pxa0= .006). Forty-three procedures (5.1%) were classified as having EHIT requiring anticoagulation, based on a level ≥4 proximal closure level. Of the 43xa0patients with EHIT, 20 (47%) were found on the initial ultrasound assessment performed 24xa0hours postprocedure, but 19 patients (44%) with EHIT would not have been identified with a single postoperative ultrasound scan performed 24xa0hours after intervention. These 19 patients had a level ≤3 closure level at the duplex ultrasound scan performed 24xa0hours postprocedure and progressed to EHIT on the delayed duplex ultrasound scan. Lastly, thrombotic complications in four patients (9%), representing three late DVT and one DVT/pulmonary embolism presenting to another hospital, would not have been identified regardless of the postoperative surveillance strategy. Maximum GSV diameter was the only significant predictor of progression to EHIT on multivariate analysis (Pxa0= .007). Based on 2014 United States dollars, the two-ultrasound surveillance paradigm is associated with health care charges of

Long-term comparative effectiveness of carotid stenting versus carotid endarterectomy in a large tertiary care vascular surgery practice

31,109 per identified delayed venous thromboembolism event.nnnCONCLUSIONSnDelayed duplex ultrasound assessment after ETA of the GSV comes with associated health care costs but does yield a significant number of patients with progression to EHIT. Better understanding of the timing, risk factors, and significance of EHIT is needed to cost-effectively care for patients after ETA for varicose veins.

Endovascular repair of a ruptured thoracic aortic dissection with a right sided aortic arch: A case report

Objective: Carotid interventional trials have strict inclusion and exclusion criteria that make translation of their results to the real‐world population challenging. Furthermore, the specialty of the operating surgeon and the role of clinical decision‐making are not well studied. This study compares the effectiveness of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) in a real‐world setting when the procedure is performed by fellowship‐trained vascular surgeons. Methods: A retrospective study was conducted of all consecutive patients undergoing CEA and CAS performed by vascular surgeons in a large rural tertiary health care system from 2004 to 2014. Postoperative outcomes of stroke, acute myocardial infarction (AMI), and death were analyzed at 30 days and during the long term (median follow‐up of 5.5 years for CEA and 4.8 years for CAS). Standard statistical analysis was performed. Differences in long‐term outcomes were expressed as cumulative incidence functions for nondeath outcomes (stroke and AMI), which account for the high death rate in this population of vascular patients, and as Kaplan‐Meier curves for death itself. Results: From January 1, 2004, through December 31, 2014, there were 2331 carotid interventions performed (CEA, 1853; CAS, 478), all by fellowship‐trained vascular surgeons. The average age of the patients was 71 years, and 63% were male, with more men in the CAS group (61.5% vs 67.8%; P = .011). Preoperatively, 30% of patients were symptomatic, and 77% of patients had high‐grade stenosis in the 70% to 99% range. CEA patients were more likely to have preoperative hypertension (89.7% vs 86.2%; P = .029) and were less likely to have a history of cardiovascular disease (53.4% vs 59.4%; P = .018). There were no significant differences in 30‐day outcomes between CEA and CAS (stroke, 1.1% vs 1.3% [P = .743]; AMI, 2.2% vs 1.7% [P = .474]; death, 0.7% vs 0.6% [P = .859]) or long‐term outcomes (stroke, 6.8% vs 7.7% [P = .321]; AMI, 22.7% vs 21.0% [P = .886]; death, 28.4% vs 28.2% [P = .122]). Conclusions: The short‐ and long‐term outcomes after CEA vs CAS are similar when the procedure is performed in a real‐world setting by fellowship‐trained vascular surgeons. Graphical abstract: Figure. No caption available.

Endovascular retrieval of an irrigation cannula from the thoracic aorta following cardiac surgery: A case report.

Highlights • Aortic pathology is more challenging in the setting of a right-sided aortic arch.• Meticulous follow-up is of utmost importance in these complicated patients.• Even with aberrant anatomy, endovascular treatment of the thoracic aorta is safe.

Endoleak Visualized With Carbon Dioxide Angiography During Endovascular Aneurysm Repair Using the Endurant Stent-Graft

Highlights • Endovascular techniques to retrieve intra-vascular foreign bodies are a necessary component of the Vascular surgeon’s skill set.• Endovascular retrieval of intravascular foreign bodies is minimally invasive, relatively simple, and carries minimal morbidity compared to conventional open surgical techniques.• It is important to have a working knowledge of techniques and instruments required for retrieval of intravascular foreign bodies.

Outcomes of familial abdominal aortic aneurysm repair in the Vascular Quality Initiative

Purpose To make interventionists aware of the potential for type IV endoleak on completion carbon dioxide (CO2) angiography during endovascular aneurysm repair (EVAR) using the Endurant stent-graft. Case Report A 74-year-old man with chronic kidney disease underwent EVAR with an Endurant stent-graft using CO2 angiography to guide graft placement. Completion CO2 angiography demonstrated immediate accumulation of CO2 in the aneurysm sac suggestive of an endoleak, but confirmatory angiography with conventional iodinated contrast showed no evidence of an endoleak. We speculate that this is a type IV endoleak, and graft porosity may be responsible. Conclusion Interventionists should be alerted to the possibility of visualizing these endoleaks through Endurant stent-grafts under CO2 angiography. Further work should be done to elucidate the exact mechanism of the endoleak.

Patency and limb salvage after femoral endarterectomy and iliac stenting are not affected by severity of iliac disease

Objective Recent investigations have reported increased rates of aneurysm‐related complications after endovascular aneurysm repair (EVAR) in familial abdominal aortic aneurysm (fAAA) patients. The purpose of this study was to evaluate the outcomes of open aortic repair (OAR) and EVAR in sporadic AAA (spAAA) and fAAA patients in the Society for Vascular Surgery Vascular Quality Initiative. Methods This was a retrospective review of all AAA repairs in the Vascular Quality Initiative from 2003 to 2017. Patients’ data were summarized, and standard statistical analysis was performed. Patients with known genetic syndromes and centers with long‐term follow‐up of <50% of patients were excluded. Results From 2003 to 2017, there were 1997 fAAA patients compared with 18,185 spAAA patients undergoing OAR and EVAR during the same study period. Compared with their spAAA counterparts, fAAA patients were younger (P < .001), were more likely to be living at home before surgery (P = .008), and demonstrated a lower incidence of coronary artery disease (P = .001) and hypertension (P = .039). Rates of smoking and end‐stage renal disease did not differ between groups. However, fAAA patients were more likely to have aneurysmal degeneration of their iliac arteries (P < .001) and to undergo OAR (P < .001). When analyzing patients undergoing OAR, we found that fAAA patients were more likely to require concomitant renal bypass surgery (P = .012) but were extubated sooner (P = .005), received fewer blood transfusions (P < .001), and had a shorter length of stay (P = .018). Although individual complication rates did not differ between fAAA and spAAA groups after OAR, a composite end point of all early postoperative complications was decreased in fAAA patients (P = .020). When comparing fAAA and spAAA patients who underwent EVAR, we found a greater incidence of early lumbar branch endoleaks (type II) in fAAA patients; however, the rate of proximal type IA endoleaks (P = .279) and the rate of late reintervention for sac growth (P = .786), any endoleak (P = .439), or rupture (P = .649) did not differ between the groups. Whereas spAAA patients undergoing EVAR required longer postoperative intensive care unit stays (P < .001) and had a greater incidence of blood transfusions (P < .001), fAAA and spAAA patients had similar rates of postoperative complications (P = .510), 30‐day mortality (P = .177), and long‐term mortality (P = .259). Conclusions This study shows that patients with a familial form of AAA do not have increased morbidity or mortality after AAA repair. Our findings suggest that EVAR and OAR are both safe and effective for fAAA patients. Further studies with longer follow‐up are needed to best care for this unique cohort of patients.