Gregg S. Landis

Society for Vascular Surgery Vascular Registry evaluation of stent cell design on carotid artery stenting outcomes.

OBJECTIVE The Society for Vascular Surgery (SVS) Vascular Registry (VR) collects data on outcomes of carotid endarterectomy and carotid artery stenting (CAS). The purpose of this study was to evaluate the impact of open vs closed cell stent design on the in-hospital and 30-day outcome of CAS. METHODS The VR collects provider-reported data on patients using a Web-based database. Data were analyzed both in-hospital and at 30 days postprocedure. The primary outcome is combined death/stroke/myocardial infarction (MI). RESULTS As of October 14, 2009, there were 4337 CAS with discharge data and 2397 with 30-day data. Open cell stents (OPEN) were used in 3451 patients (79.6%), and closed cell stents (CLOSED) were used in 866 patients (20.4%). Baseline demographics showed no differences in age, gender, race, and ethnicity. However, the OPEN group had more patients with atherosclerosis (74.5% vs 67.4%; P = .0003) as the etiology of carotid artery disease. The OPEN group also had a higher prevalence of preprocedural stroke (25.8% vs 21.4%; P = .0079), chronic obstructive pulmonary disease (COPD; 21.0% vs 17.6%; P = .0277), cardiac arrhythmia (14.7% vs 11.4%; P = .0108), valvular heart disease (7.4% vs 3.7%; P < .0001), peripheral vascular disease (PVD; 40.0% vs 35.3%; P = .0109), and smoking history (59.0% vs 54.1%; P = .0085). There are no statistically significant differences in the in-hospital or 30-day outcomes between the OPEN and CLOSED patients. Further subgroup analyses demonstrated symptomatic patients had a higher event rate than the asymptomatic cohort in both the OPEN and CLOSED groups. Among symptomatic patients, the OPEN patients had a lower (0.43% vs 1.41%; P = .0349) rate of in-hospital mortality with no difference in stroke or transient ischemic attack (TIA). There were no differences in 30-day event rates. In asymptomatic patients, there were also no statistically significant differences between the OPEN and CLOSED groups. After risk adjustment, there remained no statistically significant differences between groups of the primary endpoint (death/stroke/MI) during in-hospital or 30 days. CONCLUSION In-hospital and 30-day outcomes after CAS were not significantly influenced by stent cell design. Symptomatic patients had higher adverse event rates compared to the asymptomatic cohort. As there is no current evidence of differential outcome between the use of open and closed cell stents, physicians should continue to use approved stent platforms based on criteria other than stent cell design.

The influence of contralateral occlusion on results of carotid interventions from the Society for Vascular Surgery Vascular Registry

OBJECTIVE Data on the influence of contralateral carotid occlusion (CCO) on carotid endarterectomy (CEA) are conflicting and are absent for carotid artery stenting (CAS). This study evaluated the influence of CCO on CEA and CAS. METHODS We evaluated patients with and without CCO in the Society for Vascular Surgery Vascular Registry. Primary outcome was a composite of periprocedural death, stroke, or myocardial infarction (MI) (major adverse cardiovascular events [MACE]) and its individual components. Further analysis was done to identify the influence, if any, of symptom status on outcomes. RESULTS There were 1128 CAS and 666 CEA patients with CCO. CAS patients were more often symptomatic with a greater incidence of coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and New York Heart Association class >III. Absolute risk of periprocedural MACE (2.7% for CAS vs. 4.2% for CEA), death (1.1% for CAS vs. 0.7% for CEA), stroke (2.1% for CAS vs. 3.1% for CEA), and MI (0.3% for CAS vs. 0.6% for CEA) was statistically equivalent for both. This equivalence was maintained when patients with CCO were segregated according to symptom status and after adjusting for periprocedural risk. There were 16,646 patients without contralateral occlusion (5698 CAS; 10,948 CEA). Patients without contralateral occlusion with CEA have better outcomes in periprocedural MACE (1.8% for patients without contralateral occlusion vs 4.2% for patients with CCO), and stroke (1.1% for patients without contralateral occlusion vs. 3.1% for patients with CCO) (P < .0001 for both). In CAS patients, CCO did not significantly affect periprocedural MACE (3.2% for patients without contralateral occlusion vs. 2.7% for patients with CCO), death (0.8% for patients without contralateral occlusion vs. 1.0% for patients with CCO), stroke (2.3% for patients without contralateral occlusion vs. 2.1% for patients with CCO), or MI (0.6% for patients without contralateral occlusion vs. 0.3% for patients with CCO). In CEA patients, CCO increased MACE, primarily by increasing stroke rates in asymptomatic (0.7% vs. 2.0%; P = .0095) and symptomatic (1.7% vs. 4.9%; P = .0012) patients. CONCLUSIONS Although CEA is preferred in patients without contralateral occlusion, regardless of symptom status, based on lower rates of periprocedural MACE, death, and stroke, the benefit of CEA is lost in patients with CCO because of increased stroke rates in CCO patients after CEA but not after CAS regardless of symptom status. The results of CAS and CEA in patients with CCO are equivalent and within acceptable American Heart Association guidelines.

Suprarenal Fixation Barbs Can Induce Renal Artery Occlusion in Endovascular Aortic Aneurysm Repair

Renal artery occlusion following endovascular abdominal aortic aneurysm repair with suprarenal fixation is uncommon. We report one patient who was found to develop renal artery occlusion and parenchymal infarction 6 months after repair using an endovascular graft with suprarenal fixation. Our patient underwent emergent endovascular repair of a symptomatic 6 cm abdominal aortic aneurysm. The covered portion of the endograft was inadvertently deployed well below the renal artery orifices. At the completion of the procedure both renal arteries were confirmed to be patent. One month postoperatively, a computed tomographic (CT) scan showed exclusion of the aortic sac and normal enhancement of both kidneys. At 6 months, the patient was found to have elevated serum creatinine levels despite having no clinical symptoms. CT scanning revealed a nonenhancing left kidney, and angiography demonstrated an occlusion of the left renal artery. A barb welded to the bare metal stent appeared to be impinging on the renal artery. We believe that renal artery occlusion after endovascular repair can occur due to repetitive injury to the renal artery orifice from barbs welded to the bare metal stent. To our knowledge, this is the first reported case of renal artery occlusion caused by repetitive injury from transrenal fixation systems.

Spontaneous axillary artery aneurysm: a case report and review of the literature.

Degenerative arterial aneurysms can occur in any vascular territory. However, they are exceedingly rare in the axillary artery. Complications of axillary artery aneurysms may result in acute vascular insufficiency and neurological deficits. Prompt treatment should be employed in the management of this condition. We report a case of an atraumatic degenerative axillary artery aneurysm that was treated with transaxillary open surgical bypass.

New techniques and developments to treat long infrainguinal arterial occlusions: use of reentry devices, subintimal angioplasty, and endografts.

The endovascular recanalization of long infrainguinal arterial occlusions has made significant progress in the past decade. The technique of subintimal angioplasty has opened the door to the treatment of lesions uncross-able using standard transluminal approaches. With the advent of new wires and catheters designed to traverse long lesions, and reentry devices used to facilitate the subintimal approach, percutaneous treatment has made substantial inroads into territory previously dominated by surgical bypass. Advances in stent technology have improved deliverability and patency in these difficult applications. Percutaneously delivered covered endografts into the femoropopliteal segment may allow better patency by performing like endoluminal prosthetic bypasses. In this article, we review the latest technology available to treat occlusions of the femoropopliteal arterial segment.

Acute aortic occlusion from a Candida fungus ball.

Fungal arterial infections are well-described entities resulting in direct invasion of the arterial wall or embolic occlusion of small and medium-sized arteries. However, acute occlusion of large vessels such as the aorta by fungal material is exceedingly rare. A 53-year-old woman presented with acute bilateral lower extremity ischemia. She had a history of fungal endocarditis requiring two prosthetic mitral valve replacements; the last episode was 7 months before the current admission. Imaging studies revealed that she had an acute infrarenal aortic occlusion, with evidence of multiple end-organ emboli. After transfemoral thromboembolectomy, perfusion was restored to her lower extremities with minor neurologic sequelae. She ultimately responded to intravenous antifungal agents.

IP157. Modified Banding of Fistulas for Steal Syndrome With Quantitative Data

Objectives: Venous outflow stenosis secondary to intimal hyperplasia is a common cause of dialysis access failure. Currently, treatment with angioplasty and stenting has high rates of reintervention. We evaluated the efficacy of drug-eluting balloons (DEB) on the treatment of venous outflow stenosis of arteriovenous fistulas and grafts. Methods: We prospectively followed 13 patients on hemodialysis whose dialysis access had been treated with Bard Lutonix DEB (Paclitaxel) for venous outflow stenosis. Patients were not randomized, and treatments were at the discretion of the treating physician. Postinterventional follow-up consisted of clinic visits and routine duplex ultrasound imaging. Primary end points were time to reintervention and patency of target lesion. Results: All 13 patients had venous outflow stenosis diagnosed by duplex ultrasound imaging. Eight patients had brachiocephalic fistulas (AVFs), while the other five had grafts (AVGs). All patients underwent balloon angioplasty with DEB of the venous outflow stenosis. There was a mean follow-up of 10 months. Two patients died of unrelated events during the follow-up period. Of the 11 remaining patients, six (56%) were intervention free. Of those that require reintervention, two underwent angioplasty for central venous stenosis unrelated to the initial site of DEB angioplasty. Taking this into account eight (73%) of the AVFs/ AVGs whose venous outflow were treated with DEB were patent at 10 months. Only three patients required repeat angioplasty at the initial site of DEB angioplasty. Conclusions: Our study suggests favorable results for the treatment of venous outflow stenosis in arteriovenous fistulas and grafts with DEB however larger prospective studies are warranted prior to making a definitive recommendation.