Jeffrey Hnath

Strategies to improve spinal cord ischemia in endovascular thoracic aortic repair: Outcomes of a prospective cerebrospinal fluid drainage protocol

PURPOSE Although endovascular repair of thoracic aortic aneurysm has been shown to reduce the morbidity and mortality rates, spinal cord ischemia remains a persistent problem. We evaluated our experience with spinal cord protective measures using a standardized cerebrospinal fluid (CSF) drainage protocol in patients undergoing endovascular thoracic aortic repair. METHODS From 2004 to 2006, 121 patients underwent elective (n = 52, 43%) and emergent (n = 69, 57%) endovascular thoracic aortic stent graft placement for thoracic aortic aneurysm (TAA) (n = 94, 78%), symptomatic penetrating ulceration (n = 11, 9%), pseudoaneurysms (n = 5, 4%) and traumatic aortic transactions (n = 11, 9%). In 2005, routine use of a CSF drainage protocol was established to minimize the risks of spinal cord ischemia. The CSF was actively drained to maintain pressures <15 mm Hg and the mean arterial blood pressures were maintained at >/=90 mm Hg. Data was prospectively collected in our vascular registry for elective and emergent endovascular thoracic aortic repair and the patients were divided into 2 groups (+CSF drainage protocol, -CSF drainage protocol). A chi(2) statistical analysis was performed and significance was assumed for P < .05. RESULTS Of the 121 patients with thoracic stent graft placement, the mean age was 72 years, 62 (51%) were male, and 56 (46%) underwent preoperative placement of a CSF drain, while 65 (54%) did not. Both groups had similar comorbidities of coronary artery disease (24 [43%] vs 27 [41%]), hypertension (44 [79%] vs 50 [77%]), chronic obstructive pulmonary disease (18 [32%] vs 22 [34%]), and chronic renal insufficiency (10 [17%] vs 12 [18%]). None of the patients with CSF drainage developed spinal cord ischemia (SCI), and 5 (8%) of the patients without CSF drainage developed SCI within 24 hours of endovascular repair (P< .05). All patients with clinical symptoms of SCI had CSF drain placement and augmentation of systemic blood pressures to >/=90 mm Hg, and 60% (3 of 5 patients) demonstrated marked clinical improvement. CONCLUSION Perioperative CSF drainage with augmentation of systemic blood pressures may have a beneficial role in reducing the risk of paraplegia in patients undergoing endovascular thoracic aortic stent graft placement. However, selective CSF drainage may offer the same benefit as mandatory drainage.

Comparative results of open lower extremity revascularization in nonagenarians

INTRODUCTION The average lifespan in the United States continues to lengthen. We have observed a similar trend in our patients, with an increased number of nonagenarians presenting for evaluation of vascular disease. This study evaluated outcomes of lower extremity revascularization in patients aged >or=90 years. METHODS The vascular registry at Albany Medical College was retrospectively reviewed for all lower extremity bypasses performed between 1996 and 2006. We evaluated patient demographics, indications, procedure, patency rates, and complications. Patients were divided into groups based on age >or=90 years (>or=90 group) and <90 years (<90 group). Variables were evaluated by chi(2) analysis. Outcomes were prepared using life-table methods and compared with log-rank analysis. RESULTS During the last 10 years, 5443 lower extremity bypasses were performed on patients aged <90 years and 150 on patients aged >or=90 years. The <90 group had significantly more men (61.4% vs 29.3%) and was obviously younger, at 68 years (range 7-89 years) vs 92 years (range, 90-101 years). The <90 group had more comorbidities in terms of diabetes, active tobacco use, and hypercholesterolemia. No significant difference was noted in coronary artery disease or chronic renal insufficiency between the groups. Critical limb ischemia as an indication was significantly higher in the >or=90 group (149 [99%] vs 4472 [82%]; P < .0.5). Strikingly, the primary patency was significantly higher in the >or=90 group at 4 years (77% vs 62%; P < .05). Complication and amputation rates did not differ between the groups. Perioperative (15% vs 3%; P < .05) and 1-year (45% vs 11%; P < .05) mortality rates were significantly higher in the >or=90 group. CONCLUSION Lower extremity bypass for nonagenarians offers acceptable patency and limb salvage but at a significantly higher mortality rate.

Percutaneous axillary artery access for endovascular interventions

Background: As endovascular therapy becomes increasingly complex, adjunct techniques such as upper extremity arterial access facilitate visceral branch interventions. The purpose of this study was to assess the viability of axillary artery percutaneous access in endovascular repair. Methods: Records of all patients undergoing axillary artery percutaneous access as part of an endovascular intervention from December 2015 to December 2016 were examined. Demographics of the patients (age, sex, medical comorbidities, smoking status, and anticoagulation) were documented. Each case was examined for technical success and perioperative complications, including hematoma, brachial plexus injury, and return to the operating room. Early functional outcomes were assessed using clinic follow‐up documentation. Results: During the study interval, 25 axillary artery punctures in a total of 19 patients were performed for endovascular intervention. The mean age was 72 years; most patients were male (68%), and the cohort had a typical vascular comorbidity profile (hypertension in 84%, hyperlipidemia in 90%, diabetes in 21%, coronary artery disease in 58%, and chronic obstructive pulmonary disease in 47%; 90% were active or former smokers). Axillary access was obtained as part of complex endovascular aneurysm repair in 13 patients, mesenteric vessel intervention in 3 patients, and iliac intervention in 3 patients. Sheath size was most frequently 6F (6 punctures) or 7F (15 punctures). Closure devices included Perclose (Abbott Vascular, Santa Clara, Calif) in 36% and Angio‐Seal (Terumo Interventional Systems, Somerset, NJ) in 64%. There were two perioperative deaths and one instance of return to the operating room for hematoma. There was no perioperative stroke, axillary occlusion, or severe brachial plexus injury. One patient had transient ipsilateral postoperative thumb numbness, and one patient had residual bleeding after closure requiring manual pressure. Conclusions: Percutaneous axillary artery access is a viable strategy to facilitate complex endovascular interventions. This technique avoids the need for brachial or axillary artery exposure and allows larger sheath sizes because of the caliber of the axillary artery. There were no major neurologic or ischemic complications. This technique is a relatively safe and practical alternative to approaches involving exclusively femoral and brachial access.

RS05. Pedal Exploration of Angiographically Nonvisualized Arteries for Extreme Limb Salvage

cluster 2, 14.8% (66 of 447); cluster 3, 28.1% (36 of 128); and cluster 4, 51.2% (21 of 41; Fig 2). The between sum of squares/total sum of squares was 93%. Revascularization benefit was greatest in limbs with small or moderate wounds, moderate to severe ischemia, and moderate to severe foot infection (W2 I2 fI3; W1 I3 fI2). Initially WIfI clinical stage 4, these presentations behaved as lower risk cluster 2 after revascularization. Multiple linear regression revealed wound grade most strongly predicted LEA (F-value 17.25; P < .001). Ischemia (F-value 6.51; P 1⁄4 .001) and infection (F-value 5.7; P 1⁄4 .003) were similarly associated with LEA risk. Interaction terms between each component of WIfI score were not significant. Conclusions: WIfI is a promising tool to identify chronic limb-threatening ischemia presentations most likely to benefit from revascularization, and could be used to better inform patients, guide decision making, and risk-adjust quality and outcomes assessments. Wound severity is most strongly associated with LEA risk. Ischemic and infectious grades confer additive, but not synergistic, risk. Future cluster analyses comparing specific WIfI presentations treated with and without revascularization may quantify the benefit of revascularization for a given WIfI presentation and further refine the risk stratification provided by WIfI.

Duplex Ultrasound Imaging of the Radial Artery

Radial artery duplex ultrasound diagnostics is used in a variety of patient-specific clinical scenarios. Clinical applications include the use to document anatomic changes of the radial artery in patients with hypertension, end-stage renal disease, and coronary artery disease. Radial artery duplex testing is used for preoperative mapping of the radial artery to determine suitability prior to harvesting for coronary artery bypass grafting and in conjunction with forearm muscle flaps. Testing is performed to verify adequate conduit diameter, free from disease, and to minimize the risk of hand ischemia after excision and ligation. Radial artery duplex imaging is also performed to assess suitability for transradial coronary interventions and to evaluate patency after cannulation. Upper extremity arterial duplex mapping is useful for dialysis access planning and used prior to construction of a radiocephalic arteriovenous fistula to exclude the use of the calcified or small caliber radial artery, parameters associated with maturation failure. This chapter details our protocol for radial artery duplex ultrasound testing.

SS23 Long-Term Patency of Venous and Synthetic Conduits for Ipsilateral Internal Carotid Artery Bypass

Objectives: The video demonstrates the anatomical relations and the important steps in the surgical treatment of type 3 popliteal entrapment. This is the second leg treated in this young adult. It concludes with this anomaly shown on magnetic resonance imaging in four of the patient’s male relatives. http://www.conferenceabstracts.com/uploads/cfp2/attachments/ZRFDQ HCR/ZRFDQHCR–285491-1-ANY (1).mp4