Georges E. Al-Khoury

Isolated femoral endarterectomy: Impact of SFA TASC classification on recurrence of symptoms and need for additional intervention

OBJECTIVES Atherosclerotic occlusive disease of the femoral artery is associated with symptoms ranging from claudication to tissue loss. This study examined the clinical and hemodynamic outcomes of isolated femoral endarterectomy (FEA) as well as the predictors of symptom recurrence and need for further intervention. METHODS Patients who underwent an isolated FEA between January 2001 and June 2008 were reviewed. Concurrent superficial femoral artery (SFA) disease was classified into Trans Atlantic Inter-Societal Consensus (TASC) II categories based upon angiographic findings. Hemodynamic success (HS) was defined as a postoperative ankle-brachial index (ABI) increase of >or=0.15. Clinical improvement was classified by Rutherford criteria. Multivariate analysis was used to identify predictors of clinical failure and need for additional intervention (AI). Kaplan-Meier estimates were used to determine the likelihood of both over time. RESULTS Ninety-five patients (105 limbs) with a mean age of 68.3 +/- 10.2 years were reviewed. Indications were severe claudication in 68 (64.8%) limbs and critical limb ischemia (CLI) in 37 (35.2%). Mean preprocedural ABI was 0.57 +/- 0.25. The SFA-popliteal segment was classified as: normal in 34% of limbs, TASC A 23%, B 19%, C 9%, and D in 15%. One fatal myocardial infarction accounted for a procedural mortality of 0.95%. Morbidity was 6.7% (four hematomas and three wound infections) and mean hospital stay was 2.5 +/- 3.1 days. Patency was 100% with a mean follow-up of 11 months (1-72). Complete resolution of symptoms was noted in 73.4% with some clinical improvement noted in 91% of limbs. HS was achieved in 85.1% with a mean ABI increase of 0.27 +/- 0.20, and this correlated with >or=2 runoff vessels (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04-0.96; P = .045). Kaplan-Meier estimates revealed that 83.8% of patients with marked initial clinical improvement remained symptom free at 2 years, whereas only 28.6% in the group with mild and moderate initial response maintained their clinical status. Freedom from AI at 2 years was 61.8%. Multivariate analysis revealed that TASC C and D lesions (OR 9.3 [2.43-35.63] P = .001) and diabetes (OR 3.64 [1.01-13.15] P = .048) were predictive of recurrent symptoms while extensive endarterectomy and >or=2 vessel tibial runoff decreased the need for AI. CONCLUSION FEA can achieve excellent immediate clinical and hemodynamic outcome in patients with claudication and CLI; however, patients with diabetes and femoropopliteal TASC C and D lesions are likely to experience recurrent symptoms. Long-term symptomatic improvement is associated with the degree of immediate clinical success as well as the status of the run-off vessels. Limited FEA and poor tibial runoff are associated with the need for AI.

Meta-analysis of open and endovascular repair of popliteal artery aneurysms

Objective: Endovascular popliteal artery aneurysm repair (EPAR) is increasingly used over open surgical repair (OPAR). The purpose of this study was to analyze the available literature on their comparative outcomes. Methods: The PubMed and Embase databases were searched to identify studies comparing OPAR and EPAR. Studies with only one treatment and fewer than five patients were excluded. Demographics and outcomes were collected. Bias risk was assessed using a modified version of the Newcastle‐Ottawa Scale. Results were computed from random‐effects meta‐analyses using the DerSimonian‐Laird algorithm. Results: A total of 14 studies were identified encompassing 4880 popliteal artery aneurysm repairs (OPAR, 3915; EPAR, 1210) during the last decade. OPAR patients were younger (standard mean difference, −0.798 [−0.798 to −1.108]; P < .001) and more likely to have worse tibial runoff (odds ratio [OR], 1.949 (1.15‐3.31); P = .013) than EPAR patients. OPAR had higher odds of wound complications (OR, 5.182 [2.191‐12.256]; P < .001) and lower odds of thrombotic complications (OR, 0.362 [0.155‐0.848]; P < .001). OPAR had longer length of stay (standardized mean difference, 2.158 [1.225‐3.090]; P < .001) and fewer reinterventions (OR, 0.275 [0.166‐0.454]; P < .001). Primary patency was better for OPAR at 1 year and 3 years (relative risk, 0.607 [P = .01] and 0.580 [P = .006], respectively). There was no difference in secondary patency at 1 year and 3 years (0.770 [P = .458] and 0.642 [P = .073], respectively). Conclusions: EPAR has a lower wound complication rate and shorter length of hospital stay compared with OPAR. This comes at the cost of inferior primary patency but not secondary patency out to 3 years. Studies reporting long‐term outcomes are lacking and necessary.

Contemporary Applications of Ultrasound in Abdominal Aortic Aneurysm Management

Ultrasound (US) is a well-established screening tool for detection of abdominal aortic aneurysms (AAAs) and is currently recommended not only for those with a relevant family history but also for all men and high-risk women older than 65 years of age. The advent of minimally invasive endovascular techniques in the treatment of AAAs [endovascular aneurysm repair (EVAR)] has increased the need for repeat imaging, especially in the postoperative period. Nevertheless, preoperative planning, intraoperative execution, and postoperative surveillance all mandate accurate imaging. While computed tomographic angiography and angiography have dominated the field, repeatedly exposing patients to the deleterious effects of cumulative radiation and intravenous nephrotoxic contrast, US technology has significantly evolved over the past decade. In addition to standard color duplex US, 2D, 3D, or 4D contrast-enhanced US modalities are revolutionizing AAA management and postoperative surveillance. This technology can accurately measure AAA diameter and volume, and most importantly, it can detect endoleaks post-EVAR with high sensitivity and specificity. 4D contrast-enhanced US can even provide hemodynamic information about the branch vessels following fenestrated EVARs. The need for experienced US operators and accredited vascular labs is mandatory to guarantee the reliability of the results. This review article presents a comprehensive overview of the literature on the state-of-art US imaging in AAA management, including post-EVAR follow-up, techniques, and diagnostic accuracy.

Occult type I or III endoleaks are a common cause of failure of type II endoleak treatment after endovascular aortic repair

Objective Most type II endoleaks have a benign natural history, but 6% to 8% are associated with sac enlargement and respond poorly to treatment. Our aim was to evaluate whether these enlargements are associated with delayed or occult type I and III endoleaks. Methods Patients with interventions for endoleak after endovascular aortic repair from 2000 to 2016 were reviewed retrospectively. Patient demographics, comorbidities, endoleak type, secondary procedures, aortic sac growth (≥5 mm), and mortality were collected. Successful treatment was defined as endoleak resolution with no further aortic sac growth. Secondary procedures, ruptures, endograft explant, and death were captured. Results There were 130 patients diagnosed with a primary type II endoleak after endovascular aortic repair at a median of 1.3 months (interquartile range, 1.0‐13.3 months). One hundred eighteen had their initial treatment for a primary type II. Twelve of the 130 were initially stable and observed, but were treated for a delayed type I or III endoleak. The 130 patients underwent 279 procedures for endoleaks (mean of 2.2 ± 1.3) over 6.9 ± 3.8 years of follow‐up. Of the 118 patients treated for primary type II endoleaks, 26 (22.0%) later required interventions for delayed type I and III endoleaks. The mean time to intervention for a delayed type I or III endoleak was 5.4 ± 2.8 years. Overall, there were 16 type IA, 11 type IB, 2 type III, 7 combined type IA/IB, and 2 type IA/III delayed endoleaks. The odds of harboring a delayed type I or III endoleak was 22.0% before the first attempt at type II endoleak treatment, 35.1% before the second, 44.8% before the third, and 66.6% before the fourth attempts. Rapid aortic sac growth of ≥5 mm/y before initial endoleak treatment was associated with increased risk for delayed type I or III endoleak (47.8 vs 14.1%; P = .003). Patients with delayed type I or III endoleaks had a lower successful treatment rate (8.3% vs 52.3%; P = .001) than those with only type II endoleaks. Late rupture was increased with delayed type I or III endoleak (P = .002), whereas mortality (P = .96) and aortic‐related mortality (P = .46) were similar. Graft explant (P = .06) trended toward an increase with a delayed type I or III endoleak, but was not statistically significant. Conclusions Failed attempts treating type II endoleaks and/or a rapid aortic sac growth of 5 mm/y or greater should raise the suspicion of a delayed or occult type I or III endoleak. Occult endoleaks are associated with decreased chance of endoleak resolution.