Heron E. Rodriguez

Inferior vena cava endograft to control surgically inaccessible hemorrhage

Open surgical repair of retrohepatic inferior vena cava (IVC) injuries can be technically difficult, usually requiring extensive hepatic mobilization and associated with significant morbidity. We report a case of uncontrolled hemorrhage from the retrohepatic inferior vena cava (IVC), which occurred during attempted resection of a large retroperitoneal leiomyosarcoma, and was successfully managed using an endoluminal stent-graft. This case demonstrates that endoluminal grafts can be successfully applied to control life-threatening hemorrhage arising from lesions in the retrohepatic IVC that are otherwise extremely difficult or inaccessible to direct surgical repair.

Abdominal Wall Hernias After Open Abdominal Aortic Aneurysm Repair: Prospective Radiographic Detection and Clinical Implications

The purpose of this study was to evaluate the prevalence of radiographically detected abdominal wall defects (AWD) after open abdominal aortic aneurysm (AAA) repair and to correlate it with prospectively gathered clinical information. Fine collimation, high-resolution, serial follow-up computed tomography (CT) scans for 99 patients in the control group of the Guidant Ancure device trial were reviewed. CT scans were obtained at 12, 24, 36, 48, and 60 months. AWDs, defined as discontinuity of the fascial layer with protrusion of abdominal contents, were identified. Clinical information regarding AWDs was retrieved from the study registry. The prevalence of AWD exceeds 20% and plateaus at 24 months. Eight patients (8%) had clinical evidence of ventral incisional hernias. One patient underwent repair, but no other patient developed hernia incarceration or intestinal obstruction or required additional procedures related to the AWD. AWDs are radiographic findings occurring frequently after open AAA repair. Radiographic evaluation is more sensitive than clinical observation for detection of ventral hernias. Clinical events and reinterventions related to these radiographic abnormalities are rare.

Arteriovenous Access: Managing Common Problems

The creation and maintenance of hemoaccess occupies a significant portion of most vascular and general surgery practices. In this article, the methods used to detect hemoaccess at risk for failure and the endovascular and surgical techniques used to prolong or restore their patency are reviewed. Also, the management of hemoaccess infection, aneurysmal degeneration, false aneurysm formation, and symptomatic arterial steal syndrome are described.

Chronic Mesenteric Ischemia Resulting from Isolated Lesions of the Superior Mesenteric Artery A Case Report

Atherosclerosis is a common cause of chronic mesenteric ischemia, generally affecting 2 or more arterial branches supplying the gut. The authors present a case in which symptomatic mesenteric ischemia was the result of 2 tandem atherosclerotic lesions in the superior mesenteric artery. Both the celiac axis and inferior mesenteric arteries were fully patent. The patient experienced complete relief of symptoms after percutaneous deployment of an intravascular stent across the proximal arterial narrowing. The case also documents the existence of an atheroma in a distal mesenteric artery.

Aortic Endograft Migration

Despite the popularity of endovascular repair of abdominal aortic aneurysms, important issues regarding its long-term efficacy and durability remain. Many hemodynamic and biomechanical forces interact between the endograft, its attachment systems, and the aortic wall. Migration is the longitudinal movement of all or part of the stent-graft. When the magnitude of this displacement is such that endograft seal is lost, repressurization of the previously excluded aneurysmal sac can result. This can lead to catastrophic consequences. In this article, we review the definition, prevalence, diagnosis, clinical implications, and management of stent-graft migration.

Deep venous reflux and incompetent perforators: significance and implications for therapy

Objectives: To define the significance of perforator and deep vein pathology in patients with chronic venous disease (CVD). Methods: Consecutive patients with CVD were referred for venous evaluation (group A). Both saphenous veins and all the deep veins including those in the calf area were evaluated. A separate group of patients with deep venous reflux and/or obstruction was identified from our database and analysed separately (group B). The CEAP classification (clinical, aetiological, anatomical and pathological) was used to grade the clinical severity of CVD. Results: Age, duration of disease and history of thrombosis increased significantly with disease severity (P <0.02). Reflux in the superficial veins was the most common pathology in group A and it was present in 75% of limbs in group B. The overall contribution of deep venous disease was 26% in group A and it increased significantly with the severity of disease in both groups. Isolated deep vein disease in group A was significantly less compared with group B (8% vs 23%, P<0.0001). Reflux in deep veins of post-thrombotic limbs was significantly longer compared with those with primary disease. The prevalence of incompetent perforator veins was higher in patients with skin damage from both groups. No patient had isolated perforator vein reflux. Reflux was the most common pathology in both groups, while obstruction alone was rare. Other than superficial reflux, which is very common, ipsilateral recurrent deep venous thrombosis (DVT), combined reflux and obstruction, and popliteal vein reflux were the strongest predictors for development of skin damage. Conclusions: Perforator and deep vein involvement increases significantly with the severity of CVD. Isolated deep vein disease in post-thrombotic limbs is more common than in consecutive venous patients. Reflux is the most common pathology and obstruction alone is rare. In post-thrombotic limbs, the most important predictors for skin damage are ipsilateral recurrent DVT, popliteal vein reflux and a combination of reflux and obstruction.

Current Status of Carotid Angioplasty and Stenting

Carotid endarterectomy is the gold-standard treatment for stroke risk reduction in selected patient populations with significant carotid stenosis. Despite the lack of definitive evidence, carotid artery stenting is rapidly emerging as the minimally invasive alternative to carotid endarterectomy. Carotid artery stenting is growing at a yearly rate of 20%. Among the physicians performing this procedure, vascular surgeons are the minority. We describe the evolution of the technique of carotid artery stenting, including the development of cerebral protection devices. The results of retrospective series of carotid artery stenting with protection devices are presented. A review of the ongoing registries and trials evaluating carotid artery stenting is provided. Current indications for carotid artery stenting and a proposed algorithm for the management of carotid stenosis are suggested..