Jesse Manunga

Femoral artery calcification as a determinant of success for percutaneous access for endovascular abdominal aortic aneurysm repair

OBJECTIVE This study was conducted to determine the outcomes and predictive factors for success during percutaneous endovascular aneurysm repair (PEVAR) using vascular closure devices (VCDs). METHODS The clinical data of patients who underwent PEVAR between 2005 and 2012 were retrospectively reviewed. Patient demographics, body mass index, sheath size, device types, diameter of femoral arteries, and extent and location of femoral artery calcification were recorded. Included were all consecutive patients treated by PEVAR with sheath sizes ranging from 12 F to 24 F. End points were technical success, conversion to open femoral artery repair, and complications. RESULTS During this period, 752 patients were treated by EVAR. Of these, 391 femoral arteries in 222 patients (29.5%; 197 men, 25 women), with a mean age of 74.8 years (range, 51-93.7 years), underwent PEVAR (169 bilateral and 53 unilateral percutaneous access). Patients with >50% anterior femoral artery calcifications or those with previous femoral artery reconstructions were not offered PEVAR. Technical success of PEVAR was 96.4% (377 of 391), with an average of two VCDs used per groin. Fourteen intraoperative failures were managed with open femoral conversion using primary repair (five) or patch angioplasty (nine). In nine patients, the procedure was converted from local to general anesthesia. Four patients required a perioperative blood transfusion. There were no significant differences in body mass index (P = .26), femoral artery size preprocedure (P = .33) or postprocedure (P = .37), sheath size (≥ 20 F vs ≤ 18 F), or type of VCD used between the success and failure groups. Pairwise comparisons revealed increased failure rate (P < .001) between patients with <50% anterior wall calcification vs none, <50% anterior wall calcification vs <50% posterior wall calcification, and none vs >50% posterior calcification. There was no significant difference (P = .53) between patients with <50% posterior wall calcification and those with no calcification. The 30-day mortality of the entire group was 0.9% (2 of 222 patients). No deaths occurred after conversion to open femoral closure. At a mean follow-up of 30 months (range, 1-85.2 months), there were no long-term groin complications or iliac limb occlusions. CONCLUSIONS PEVAR using VCDs can be performed with high technical success in patients with <50% anterior wall calcification, regardless of the size of the access sheath or the patients body mass index. Femoral artery calcification, however, is a major determinant of failure.

Hyperbaric Oxygen Treatment Outcome for Different Indications from a Single Center

BACKGROUND Hyperbaric oxygen (HBO) is used as an adjunctive therapy for a variety of indications. However, there is a lack of high-quality research evaluating HBO treatment outcomes for different indications available in the current literature. METHODS We retrospectively reviewed all patients who underwent HBO therapy at a single hyperbaric center from January 2010 to December 2013 using predetermined criteria to analyze successful, improved, or failed treatment outcomes for the following indications: chronic refractory osteomyelitis, diabetic foot ulcer, failed flap or skin graft, osteoradionecrosis, soft tissue radiation necrosis, and multiple coexisting indications. RESULTS Among the included 181 patients treated with adjunctive HBO at our center, 81.8% had either successful or improved treatment outcomes. A successful or improved outcome was observed in 82.6% of patients treated for chronic refractory osteomyelitis (n = 23), 74.1% for diabetic foot ulcer (n = 27), 75.7% for failed flap or skin graft (n = 33), 95.7% for osteoradionecrosis (n = 23), 88.1% for soft tissue radiation necrosis (n = 42), and 72.4% for multiple coexisting indications (n = 29). Among 4 patients treated for other indications, 100% of the cases were either successful or improved. CONCLUSIONS This study has provided a comprehensive outcome survey of using HBO for the previously mentioned indications at our center. It supplements the literature with more evidence to support the consideration of HBO in different indications.

Orbital Atherectomy as an Adjunct to Debulk Difficult Calcified Lesions Prior to Mesenteric Artery Stenting

Purpose To describe a technique in which percutaneous orbital atherectomy is used to debulk heavily calcified superior mesenteric artery (SMA) occlusions as an adjunct in patients undergoing angioplasty and stenting. Technique The technique is demonstrated in a 62-year-old woman with a replaced right hepatic artery originating from an SMA occluded by densely calcified lesions. Via a left transbrachial approach, a 7-F MPA guide catheter was used to engage the ostium of the SMA, which was crossed using a catheter and guidewire. The calcified lesion was debulked using the 2-mm Diamondback 360° orbital atherectomy system. The wire was exchanged for a 0.014-inch filter wire and 0.018-inch guidewire. Using a 2-guidewire technique, the SMA was stented with a self-expanding stent for the distal lesion that crossed side branches and a balloon-expandable stent at the ostium. A 0.014-inch guidewire was placed into the replaced hepatic artery through a cell of the self-expanding stent, followed by deployment of a small balloon-expandable stent to address the residual lesion. Conclusion The use of orbital atherectomy to debulk occluded and heavily calcified SMA lesions may optimize the technical results with angioplasty and stenting.

Arterial Embolisms and Thrombosis in Upper Extremity Ischemia

Objective: Upper extremity ischemia (UEI) is an uncommon condition that can lead to permanent disability. There is a limited understanding of the etiology, management, and outcomes of the disease. Methods: We retrospectively reviewed the charts of all patients who were diagnosed with “embolism and/or thrombosis of arteries of upper extremity” at our institution from January 2005 to December 2013. Results: Patients diagnosed with embolisms were older (P < .001), more likely to undergo thromboembolectomy (P < .001), had higher rates of hypertension (P = .001), and had longer lengths of hospital stay (P = .002). There were no significant differences in complications or mortality at 30 days and up to 1 year. Conclusion: At our center, embolism was found to be the most common etiology for UEI followed by thrombosis and stenosis. Patients presented with embolism were older, were more likely to undergo thromboembolectomy, and had higher rates of hypertension and longer hospital stays.

Regional anesthesia as the anesthetic of choice for high-risk surgical patients undergoing repair of juxtarenal aortic aneurysms with fenestrated stent grafts

&NA; Juxtarenal aortic aneurysms (JAAs) have been conventionally treated using open repair with excellent results. Recent approval of fenestrated stent grafts by the United States Food and Drug Administration has given patients with JAAs an alternative for repair. However, most of these procedures are still performed under general anesthesia, making some surgeons reluctant to offer repair to a subset of patients deemed too high risk for general anesthesia. We present three patients with JAAs at high surgical risk, including one patient with a ruptured aneurysm, who were successfully treated using a fenestrated stent graft under regional anesthesia.

Feasibility of endovascular repair of splenic artery aneurysms using stent grafts

OBJECTIVE Percutaneous transcatheter embolization of splenic artery aneurysms (SAAs) has been widely accepted as the first line of treatment in patients with symptoms, rupture, or large aneurysm size. Although embolization can usually be performed safely, ischemic complications, such as splenic infarct or abscess, occur in some patients. This study evaluated the feasibility and outcomes of endovascular SAA repair (ESAAR) using stent grafts, which may allow treatment while preserving flow to the spleen. METHODS We reviewed the clinical data of all consecutive patients who underwent ESAAR using stent grafts. Brachial access was used except for patients with favorable angle of origin from the aorta. To overcome tortuosity and provide support, a coaxial system with a hydrophilic sheath was used. Low-profile 0.018-inch stent grafts were used for distal SAAs with a 10-mm to 15-mm length of proximal and distal segment of splenic artery measuring 4 to 11 mm in diameter. Follow-up included clinical examination and computed tomography imaging within 4 to 6 months after the procedure and yearly thereafter. End points were morbidity, stent graft patency, and freedom from endoleaks and reinterventions. RESULTS ESAAR was attempted in 10 patients, four males and six females, with median age of 64 years (range, 48-77 years). Median SAA size was 2.8 cm (range, 2-5.7 cm). Nine patients were asymptomatic, and one had pancreatitis and gastrointestinal bleeding. The arterial access site was the brachial artery in six patients and the femoral artery in four. Two patients had brachial and femoral access to facilitate splenic artery stenting. Technical success of ESAAR using stent grafts was 80% (8 of 10). In two patients with distal SAAs, stent graft placement was not possible due to excessive vessel tortuosity, and treatment was by coil embolization. One patient developed brachial artery thrombosis, which was treated surgically. There were no ischemic complications in patients treated by ESAAR with stent grafts. Median length of stay was 1 day. One patient treated by coil embolization developed splenic infarct, which required readmission for pain control. Median follow-up was 9 months. Follow-up imaging in all successfully stented patients revealed patent stent grafts, no endoleak, and no aneurysm sac enlargement. No reinterventions were required. CONCLUSIONS ESAAR using self-expandable stent grafts offers a viable alternative to coil embolization in selected patients with SAAs. Distal SAAs with excessive vessel tortuosity may result in technical failure requiring embolization. Among patients who underwent successful ESAAR, there were no ischemic complications, stent graft occlusions, endoleaks, or sac enlargement.

Bifurcated Stent Technique: A Viable Option for Treatment of Patients With Unusual Anatomy Presenting With Combined Chronic Mesenteric Ischemia and Diffuse Ischemic Gastric Ulcers

Treatment of chronic mesenteric ischemia has evolved over the last two decades. Endovascular therapy is now the treatment of choice for patients with lesions amenable to such an approach. Open revascularization remains the standard of care but is frequently being reserved for lesions containing intraluminal thrombus or severe calcification. In most cases, celiac axis (CA) stenting is not needed since revascularization of the superior mesenteric artery (SMA) alone results in symptomatic resolution. This report describes a case of a patient with chronic mesenteric ischemia and diffuse gastric ulcers found to have a common origin of the SMA and CA that was treated endovascularly using a bifurcated stent technique.

Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts

Objective: The objective of this study was to evaluate outcomes of patients with complex abdominal aortic aneurysms (cAAAs) treated with open repair (OR) or fenestrated/branched endovascular aneurysm repair (F/B‐EVAR) from a single center. Methods: A retrospective analysis of consecutive patients with cAAAs treated electively by OR or F/B‐EVAR between January 2010 and February 2017 was conducted. Demographics of the patients, cardiovascular risk factors, procedure time, number of vessels incorporated, radiation dose, estimated blood loss, intensive care unit (ICU) length of stay (LOS), and hospital LOS were recorded. End points included target vessel patency, aneurysm rupture, freedom from reintervention, and major adverse events (MAEs). Results: During this period, 153 patients (OR, 69; F/B‐EVAR, 84) underwent repair of cAAA. The majority were male (OR, 55; F/B‐EVAR, 64), with a mean age of 75.8 ± 7.6 years (F/B‐EVAR) and 71.2 ± 7.9 years (OR). Patients in the F/B‐EVAR group were more likely to be American Society of Anesthesiologists class 3 and 4 (60% vs 0%; P < .001) and had a higher median Society for Vascular Surgery/American Association for Vascular Surgery comorbidity severity score (15 vs 7; P < .001). A total of 235 vessels were targeted in the F/B‐EVAR group, with a technical success of 97.6%. Thirty‐one patients in the OR group required concomitant renal artery revascularization. Transfusion requirements (100% vs 1.2%), MAEs (40.6% vs 13.1%), procedure length (304 minutes vs 140 minutes), estimated blood loss (2246 mL vs 165 mL), ICU LOS (3 days vs 1 day), and hospital LOS (7 days vs 2 days) were higher (P < .001) in the OR group compared with the F/B‐EVAR group. The 30‐day mortality was 2.9% and 2.4% (P = .84) in the OR group and F/B‐EVAR group, respectively. Supraceliac clamp site was associated with increased incidence of postoperative renal insufficiency. A decrease in procedure time, contrast volume, fluoroscopy time, and fluoroscopy dose was noted in the F/B‐EVAR group with increasing experience even as case complexity increased. More patients were discharged home after F/B‐EVAR (97.6% vs 59.4%; P < .001). With a mean follow‐up of 31 months (F/B‐EVAR, 17 months; OR, 48 months), the rate of secondary intervention was 3.7% and 5.8% (P = NS) for F/B‐EVAR and OR, respectively. Freedom from branch instability and reintervention was 99% (95% confidence interval, 96.2%‐99.8%) and 96% (95% confidence interval, 87.1%‐98.6%), respectively. Conclusions: Results of this “real‐world” experience suggest that the use of F/B‐EVAR for the treatment of cAAAs in high‐risk surgical patients is safe and effective and has comparable short‐term results to those of low‐risk patients undergoing OR. Patients treated by F/B‐EVAR had shorter ICU and hospital LOS, lower MAEs, and faster convalescence. A decrease in procedure time and radiation dose was noted as experience was gained, even as complexity increased.

Diagnosis, Management, and Outcome of Aortitis at a Single Center

Background: Aortitis is a rare condition with inflammatory or infectious etiology that can be difficult to diagnose due to the highly variable clinical presentation and nonspecific symptoms. However, current literature on the diagnosis, management, and prognosis of aortitis is extremely scarce. Methods: We retrospectively reviewed all patients’ charts who were diagnosed with giant cell arteritis, Takayasu arteritis, or noninfectious aortitis presenting at a single center between January 1, 2009, and April 17, 2015. Data collected included demographics, medical history, comorbidities, laboratory and imaging data, management, and outcome. Results: Among the included 15 patients presenting with aortitis at our center, 53% were diagnosed with Takayasu arteritis, 33% with idiopathic inflammatory aortitis, and 13% with giant cell arteritis. All patients received steroid treatment, 67% received adjunctive immunosuppressants or immunomodulators, and 33% underwent interventional procedures. Based on clinical presentation and laboratory and imaging findings at the last follow-up visit for each patient, 67% showed improvement, 27% had no change in disease activity, and 7% had a progression of the disease. Conclusions: Takayasu arteritis was found to be more common than idiopathic inflammatory aortitis and giant cell arteritis among our 15 cases diagnosed with aortitis. All patients received medical therapy and 33% received interventional procedures, leading to 67% improvement of disease activity or related complications. This article also offers a comprehensive review of the diagnosis, management, and outcome of aortitis, supplementing the very limited literature on this disease.

A prospective randomized comparison of contralateral snare versus retrograde gate cannulation in endovascular aneurysm repair

Objective: The objective of this study was to compare snare vs the standard retrograde gate cannulation method during endovascular aneurysm repair to determine the most efficient technique and to evaluate whether time was affected by graft design or the surgeons experience. Methods: This was a prospective randomized study involving single‐center elective endovascular aneurysm repairs. Patients were randomized to the snare or retrograde group in a 1:1 ratio. The initial method was attempted for 15 minutes; if it was unsuccessful, the team switched to the alternative technique for an additional 15 minutes. The protocol continued until success was achieved. Data collected on demographic, anatomic, and procedural factors were analyzed for statistically significant differences. Results: A total of 101 patients were included. Average age was 75.3 years, and 82% were male; 49 patients were randomized to snare and 52 to retrograde cannulation. The groups were overall similar. Median cannulation times were 3.9 minutes for the snare and 2.7 minutes for the retrograde technique (P = .13). The snare group attempts were successful within the initial 15‐minute period in all but one patient (98% success). In the retrograde group, 5 of the 52 (10%) crossed over to snare. This difference did not reach statistical significance (P = .11). A difference was seen in the extremes of cannulation times. The surgeons experience and graft design were not found to have significant effects on cannulation times. Further analysis of the retrograde group patients with long cannulation time found a relative breakpoint at the 5‐minute mark. In those exceeding this time mark, the chance of eventual cannulation within 15 minutes dropped to 67%. In this group, median time to cannulation was 12.2 minutes for retrograde compared with 7.1 minutes for snare after crossover. Conclusions: Gate cannulation was successful using both methods with no statistical difference between the two in median time. Retrograde cannulation was found to be more likely to have short times. If cannulation by retrograde technique had not been achieved in the first 5 minutes, the chances of eventual success dropped significantly, and crossover to snare was more efficient. This finding suggests that one should consider an alternative method of gate cannulation if it has not been accomplished within this time.