Irwin V. Mohan

Current optimal assessment and management of carotid and vertebral spontaneous and traumatic dissection.

Dissection of the internal carotid or vertebral artery has been recognized as a cause of stroke in young patients. It is disproportionate in its representation as a cause of stroke in this age group. Intimal tears, intramural hematomas, and dissection aneurysms may be the result of trauma or may occur spontaneously. Spontaneous dissection may be the result of inherent arterial weakness or in association with other predisposing factors. Clinical diagnosis is often difficult, but increased awareness and a range of modern investigations such as computerized tomography or magnetic resonance imaging may aid in diagnosis. Management options include antiplatelet therapy, anticoagulation, thrombolysis, and surgical or endovascular procedures. Prognosis is variable, and dissection may be asymptomatic but may lead to profound neurological deficit and death.

Improved Outcomes with Endovascular Stent Grafts for Thoracic Aorta Transections

OBJECTIVE To retrospectively assess the outcome of endovascular stent-graft implantation for thoracic aortic transections (ETAT). DESIGN Retrospective review. METHODS 16 patients median age 30 years, treated between May 2000 and April 2007. Median injury severity score was 33 (range 29 to 66) in 14 acute patients; 2 patients had thoracic pseudoaneurysms. The Cook-Zenith endograft was used in eight patients, Medtronic-Talent (6) and Gore-Excluder (2). Average procedure time was 90 minutes, blood loss 100 (range 40 to 3000) mls, screening time 10.8 (range 5.9 to 22.6) minutes, and contrast dose was 195 (range 60 to 400) mls. RESULTS Graft deployment was successful in all cases. There was one death within 30 days. The left subclavian artery was completely covered in one case, and partially in three. Two patients had Type I endoleak, and one delayed Type II endoleak. One patient had iatrogenic right coronary artery dissection. Two patients developed difficult to treat hypertension, and one acute renal failure. CONCLUSION Endovascular intervention is a safe and effective treatment for aortic transection in multiple trauma patients. ETAT reduces the major morbidity and mortality associated with open repair in multiple trauma patients. The majority of these patients are young and long-term follow up is necessary to assess graft durability.

Peripheral Arterial Aneurysms: Open or Endovascular Surgery?

Peripheral arterial aneurysms are uncommon; for some aneurysm types, data are limited to case reports and small case series. There is no Level A evidence in most cases to determine the choice between open or endovascular intervention. The evolution of endovascular technology has vastly improved the armamentarium available to the vascular surgeon and interventionalists in the management of these rare and unusual aneurysms. The choice of operative approach will ultimately be determined on an individual basis, dependent on the patient risk factors, and aneurysm anatomy. After consideration, some aneurysms (femoral, subclavian, carotid and ECAA) fare better with an open first approach; renal, splenic and some visceral artery aneurysms do better with an endovascular first approach. In our practice PAAs are treated with an endovascular first approach. For these rare conditions, both open and endovascular therapy will continue to work in harmony to enhance and extend the capabilities of modern surgical management.

Juxta-anastomotic stenting with aggressive angioplasty will salvage the native radiocephalic fistula for dialysis

OBJECTIVE This study describes our technique of aggressive angioplasty with juxta-anastomotic stenting (JXAS) in the autogenous arteriovenous fistula and reviews our outcomes with this technique in its mature form. METHODS We developed a JXAS technique during the last 7 years. Since 2006, we have placed 135 JXASs. The study period reviews 68 consecutive JXASs placed from 2008 to 2012 using the mature technique. We retrospectively analyzed the prospectively collected data. Thirty-three fistulas received JXAS for failure to mature, and 35 were mature but inadequately dialyzing fistulas (problem fistulas). The JXAS technique involves (1) treating the JXA segment as a unit, (2) aggressive angioplasty with rupture of stenoses, and (3) placement of an uncovered nitinol stent. RESULTS Technical success was 97%. Of the fistulas that had failed to mature, 75% were brought to maturity by 6 months and 88% by 12 months. Adequate dialysis was achieved in all 35 problem fistulas immediately postoperatively. Assisted fistula patency was 90% at 2 years and 80% at 4 years. CONCLUSIONS JXAS is an effective technique for maturing and maintaining the wrist radiocephalic arteriovenous fistula.

The Role of Stenting the Superior Vena Cava Syndrome in Patients With Malignant Disease

Superior vena cava (SVC) obstruction occurs in patients with intrathoracic malignancies. Clinical symptoms can be distressing but presentation is insidious. We investigated the outcome of endovascular management for patients with SVC syndrome. We retrospectively reviewed the case histories of 17 patients (9 men) from January 2003 to June 2009. All patients had malignant disease. There were 24 interventions (2 patients with 2 interventions and 2 patients with 3 interventions). All had SVC stenosis over 90%. All patients were treated with intrathoracic angioplasty and stenting. All procedures were technically successful, and all patients had insertion of 10 to 18 mm diameter stents with symptom resolution in 16 patients. There were 2 occlusions at 1 and 6 weeks and 2 patients with restenosis (3 and 7 months). Endovascular intervention is technically feasible for SVC occlusion, relieves symptoms, and is a useful palliation measure.

Use of inferior vena cava filters in a tertiary referral centre in Australia.

Introduction:  To investigate the use of inferior vena cava (IVC) filters in a tertiary referral centre, looking at indication, types of filters and, with temporary/optional filters, removal rates.

Do patients with asymptomatic carotid stenoses still benefit from surgical intervention

Monash’s Gippsland Medical School, where students are paired with researchers at local hospitals and paid for their time while working on research projects. As a student, surgical specialties are becoming more competitive and it feels as if research experience is becoming increasingly important to be competitive for acceptance into postgraduate surgical training. Therefore, I believe that postgraduate medical schools offering research programmes will be the schools that will graduate students which are the most competitive students for postgraduate surgical training programmes.

Geoffrey Hamilton White, MD, FRACS August 13, 1951-January 26, 2012.

Geoffrey Hamilton White graduated from the University of Sydney in 1976, the third generation of doctors in his family. He gained the FRACS in 1982, undertaking his early surgical training at Royal Prince Alfred Hospital. He furthered his vascular training in Los Angeles, where he was Assistant Professor of Surgery at the UCLA School of Medicine and Chief of Vascular Surgery at the VA Wadsworth Medical Center from 1984 to 1989. He returned to the Royal Prince Alfred Hospital (RPAH) in Sydney in 1989 as a Visiting Medical Officer and held a conjoint academic title as Associate Professor of Vascular Surgery at the University of Sydney. He was later appointed head of department at RPAH. His final position was Foundation Professor of Vascular Surgery at Macquarie University Hospital. He established a strong background in clinical work and research activity, with numerous publications, especially in relation to the development of medical devices and less invasive treatments for vascular disorders. Geoff exuded a quiet confidence borne of his extensive and intimate knowledge of the world of vascular surgery. He worked on the early development of endovascular devices and had a richly deserved international reputation for his contributions to the development of endovascular techniques that have changed the paradigm of vascular surgery from open surgery to minimally invasive techniques. His work and his ideas have been fundamental to the development and utilization of endovascular devices, much of which we take for granted today. He conceptualized the use of modular endoluminal stent-grafts, and he coined the term ‘‘endoleak’’ that is now part of the vascular and endovascular nomenclature, and sought to define terms like ‘‘endotension.’’ He also devised a functional classification for proximal attachment sites for aneurysm necks. He was a committed clinical educator, particularly at the postgraduate level. In 1994, he initiated the International Endovascular Symposium in Sydney, driving refinement of endovascular techniques and raising the profile of Australian vascular surgery. These meetings were also among the first in the world in which images from theaters were projected live to an interactive audience. Many renowned vascular surgeons from around the world came to Australia to work with Geoff and the vascular team at the RPAH, imparting their knowledge, and perhaps gaining some too. His international reputation and focus led to a constant stream of Fellows from Europe and North America. Geoff not only mentored their endovascular development with a sense of accomplishment and achievement but also demonstrated how to live a well-rounded Renaissance lifestyle. His hospitality and that of his wife, Kathy, was legendary. Many of 464 J ENDOVASC THER 2012;19:464–465

Carotid artery stenting: where are we up to with evidence‐based practice?

Interventions for carotid artery stenosis are among the most analysed in the history of surgery. Since the advent of endovascular technology and its application to carotid artery angioplasty and stenting (CAS) there have been many randomized trials comparing CAS with carotid endarterectomy (CEA), and numerous interpretations of the data; with contemporary studies utilizing techniques of rapid exchange technology for angioplasty and stenting, with or without the use of cerebral protection devices (CPD). Some new facet of information was gleaned from each of these trials, which requires careful consideration and analysis in order to incorporate such knowledge into our overall strategy for stroke prevention. In this commentary, we seek to assess and evaluate the evidence for the role of CAS in contemporary practice. In the Endarterectomy versus Angioplasty in patients with Severe Symptomatic Carotid Stenosis (EVA-3S) trial at 4 years, the overall probability of peri-procedural stroke/death, or non-procedural ipsilateral stroke was 11.1% for the CAS patients versus 6.2% for CEA. There was also no requirement to use embolic CPD in this trial as this was left to the discretion of the proceduralist, but in the EVA-3S, there was also a significantly lower risk of stroke or death in the CAS group, for those treated using CPD (7.9 versus 25%). This study was mainly criticized for the loose credentialing of specialists as CAS proceduralists, compared with CEA surgeons, but was also unique in that the most experienced CAS interventionalists (>50 carotid stent procedure) had the highest rate of procedural stroke (12.2%). In the Stent-protected Angioplasty versus CEA in symptomatic patients study (SPACE), the authors concluded that the trial failed to prove non-inferiority of CAS compared with CEA for the periprocedural complication rate. SPACE also concluded that restenosis was more common with CAS, which may be symptomatic. In a post-hoc analysis, the 30-day rate of ipsilateral stroke and death in patients undergoing CAS was lower in patients <68 years of age, compared with those >68 years; conversely, for CEA the 30-day rate of ipsilateral stroke and death was lower in older patients. In the International Carotid Stenting Study (ICSS), the 30 days risk of stroke, death or myocardial infarction (MI) was 7.4% CAS versus 4.0% CEA (P < 0.003), at 3 months this was 8.5 versus 5.2% (P < 0.006). The ICSS also included a magnetic resonance imaging (MRI) sub-study on 231 patients (124 CAS, 107 CEA) before and after treatment, new diffusion-weighted imaging (DWI) white matter lesions were noted in CAS patients who had a fivefold increased risk (hazard ratio (HR) 5.2 (95% confidence interval (CI) 2.8–9.8; P < 0.0001) ). Little is known about the prognostic implications of new ischaemic lesions (silent brain infarcts) after CAS or CEA. It is unknown whether these subclinical MRI lesions will produce structural damage to the brain or cause neuropsychological deterioration. The most likely cause of such lesions is embolization of atherosclerotic plaque material to the cerebral circulation in the ipsilateral hemisphere, perhaps as a result of manipulation of, dissection or use of shunt in CEA; and use of guidewires, sheaths, filters and stents in the ipsilateral carotid artery, and also in the aortic arch for contralateral new lesions in CAS. In a systematic review of cognitive performance, De Rango and colleagues found that there are no data indicating a cognitive change after CAS or CEA in patients who do not experience stroke complications, even if new silent embolic lesions, especially after CAS, were detected on cerebral imaging. However, Vemeer and colleagues in a longitudinal study (mean 3.6 years follow-up) found that the presence of silent brain infarcts on MRI at baseline in the general population doubled the risk of dementia, and that people with silent infarcts had a steeper decline in cognitive function than those without silent infarcts, but this decline was confined to people who had additional silent brain infarcts after baseline. They also demonstrated that the relation between infarcts and cognitive decline was stronger for multiple infarcts than for single infarcts and may also be reflected in a stepwise deterioration. Silent infarcts in the thalamus are associated with a greater decline in memory performance, whereas infarcts located elsewhere resulted in a greater decline in psychomotor speed. White matter lesions also predicted fall-related fractures and hospitalization, with an HR of 6.8 (95% CI: 1.5–30, P = 0.013). In the Carotid Revascularization, Endarterectomy versus Stent Trial (CREST), overall, the combined periprocedural risk (including symptomatic, and asymptomatic patients) of any death, stroke, or MI (also including asymptomatic ‘biochemical MI’) was not significantly different between CAS versus CEA (5.2 versus 4.5%, HR:1.18, P < 0.38). However, in symptomatic patients this was 6.0% CAS versus 3.2% CEA, stroke/death, HR 1.9 (95% CI: 1.1–3.2), and 2.5% CAS versus 1.4% CEA, HR 1.9 (95% CI: 0.8–4.4) for asymptomatic patients; an almost doubling of the risk of stroke and death from CAS. When MI was included, stroke/death and MI occurred in CAS (6.7%) versus CEA (5.4%) (HR 1.3 (95% CI: 0.8–2.0) for symptomatic patients, and CAS (3.5%) versus CEA (3.6%) (HR 1.0 (95% CI: 0.6–1.9) for asymptomatic patients. But what does a biochemical MI mean, and does biochemical MI confer a significantly worse prognosis for patients? In vascular surgery patients, elevated levels of troponin I (Tn I) in the early post-operative period was found to be associated with a sixfold increase in mortality at 6 months. In a similar project involving 447 vascular surgery patients, an elevated creatine kinase-MB fraction in the postoperative period was associated with a fourfold increase in late mortality, while elevated Tn I was associated with a twofold increase in late mortality. And, higher-quartile levels of Tn I were associated with higher mortality rates during follow-up. After emergency orthopaedic surgery, a high incidence of Tn I increases were noted and found to correlate to significantly worse mortality and cardiac events at 1 year. Troponin increases were asymptomatic, and there was no evidence that intervention improved outcome. In the Carotid Stenting Trialist Collaboration (CSTC; using pooled individual patient data from EVA-3S, SPACE, ICSS), with 486 Perspectives