Joseph J. Ricotta

Endovascular Repair With Fenestrated-Branched Stent Grafts Improves 30-Day Outcomes for Complex Aortic Aneurysms Compared With Open Repair

BACKGROUNDnEndovascular repair is associated with better 30-day outcomes than open surgical repair for patients with infrarenal aortic aneurysms. In patients with complex aortic aneurysms (CAAs) requiring suprarenal or supravisceral aortic cross-clamping during open repair, few data exist directly comparing the real-world outcomes of open repair versus endovascular repair with fenestrated-branched stent grafts (FEVAR).nnnMETHODSnOutcomes for patients who underwent elective CAA repair using open repair and FEVAR between 2005 and 2010 were analyzed using the American College of Surgeons National Surgical Quality Improvement Program database. CAA was defined as aneurysm of the aorta involving the visceral and/or renal arteries.nnnRESULTSnThis study compared 1091 patients who underwent open repair (group A: male, 71.5%; age, 71 ± 9 years) with 264 patients treated with FEVAR (group B: male, 82.2%; age, 74 ± 9 years). The 2 groups did not significantly differ with respect to American Society of Anesthesiologists (ASA) classification (ASA III/IV: A, 93%; B, 95%, P = 0.6), severe chronic obstructive pulmonary disease (A: 21%; B: 22%; P = 0.7), prior cardiac surgery (A: 24%; B: 20%; P = 0.19), or preoperative renal function (glomerular filtration rate: A: 69 ± 2; B: 70 ± 27; P = 0.535). Group A had significantly higher risk of any complication (A: 42%; B: 19%; P < 0.001), nonsurgical complications (A: 30%; B: 8%; P < 0.001), pulmonary complications (A: 21%; B: 2%; P < 0.001), renal complications (A: 10%; B: 1.5%; P = 0.001), and any cardiovascular complication (A: 8%; B: 2%; P < 0.001). The composite end point of surgical site infections/graft failure/bleeding transfusions were also higher in group A (A: 22%; B: 15%; P = 0.014). Thirty-day mortality was significantly lower for FEVAR (A: 5.4%; B: 0.8%; P = 0.001), as was total length of hospital stay (A: 11 ± 10 days; B: 4 ± 5 days; P < 0.001).nnnCONCLUSIONSnThis nationwide real-world database suggests that in similar patient populations, repair of CAAs with FEVAR is associated with reduced 30-day morbidity and mortality compared with open repair. Although long-term comparative studies are needed, FEVAR may represent a preferred treatment alternative to open repair for patients with CAAs.

Surgeon-modified fenestrated-branched stent grafts to treat emergently ruptured and symptomatic complex aortic aneurysms in high-risk patients.

INTRODUCTIONnFenestrated-branched stent grafts have been developed as a minimally invasive, endovascular alternative for the treatment of complex aortic aneurysms in high-risk patients. However, the manufacture of these devices can take as long as 6 to 12 weeks, and therefore, they cannot be used to treat aortic emergencies. We reviewed our experience with surgeon-modified, fenestrated-branched stent grafts (sm-FBSGs) in high-risk patients who presented as emergencies with ruptured or symptomatic complex aortic aneurysms.nnnMETHODSnAll patients treated with sm-FBSGs at our institution were retrospectively reviewed. Patients presenting with acute symptoms or an emergency indication for repair were analyzed.nnnRESULTSnTwelve high-risk patients (nine men), of which seven were at American Society of Anesthesiologists class 4 and five were at class 3, presented with seven symptomatic and five ruptured aortic aneurysms. Mean age was 71 years (range, 52-86 years), and mean maximal aneurysm size was 8.1 cm (range, 5-12 cm). Six patients (50%) had prior aortic surgery or a hostile abdomen. Relevant comorbidities included coronary disease in all 12 patients, and seven (58%) had an ejection fraction≤35%. Nine patients (75%) had severe pulmonary dysfunction. Four aneurysms were pararenal, and eight were thoracoabdominal (two type II, three type III, and three type IV). An average of three visceral vessels (range, 2-4) were treated per patient, with 35 branches targeted. Endografts were successfully implanted in all patients. There was no paraplegia or intraoperative death. One patient (8.3%) died of subarachnoid hemorrhage≤30 days. Reintervention was necessary in two patients, for a type 3 endoleak and for evacuation of a retroperitoneal hematoma. Morbidity included one myocardial infarction, and two patients each with transient respiratory failure and transient renal insufficiency not requiring dialysis. Mean postoperative length of stay was 4 days in the intensive care unit and 8 days in the hospital. At a mean follow-up of 9 months (range, 3-18 months), two patients died of non-aneurysm-related causes. Branch vessel patency was 100%. No late reinterventions were necessary. No type I or III endoleaks occurred. One type II endoleak is under observation.nnnCONCLUSIONSnSm-FBSG may play an important role in the treatment of select patients with symptomatic or ruptured complex aortic aneurysms who are at prohibitive risk for open surgery and in whom endovascular repair cannot be delayed to allow implantation of a custom-made commercial device. Until an off-the-shelf fenestrated-branched device is created that does not require a prolonged waiting period, this may be the best option to treat patients with symptomatic or ruptured complex aneurysms that are at excessively high surgical risk.

Open Surgical Repair of Thoracoabdominal Aortic Aneurysms

Despite much advancement in preoperative evaluation and perioperative care of patients with thoracoabdominal aortic aneurysms (TAAA), open surgical repair of TAAAs remains a formidable challenge for the vascular surgeon. It requires extensive dissection and mobilization of the aorta and its branches, as well as cross-clamping of the aorta above intercostal and visceral arteries. Over the past decade, the mortality and morbidity associated with open TAAA repair have improved significantly. However, it remains one of the most complex, extensive surgical procedures performed in the field of vascular surgery. Recently, there has been much attention directed at less invasive methods such as the so-called hybrid or debranching procedure, or complete endovascular repair with fenestrated and branched endografts for repairing TAAAs. However, the gold standard for repair of TAAA remains open surgery, and this article summarizes the clinical outcomes of open surgical repair of TAAAs during the past decade (2000-2010) to provide a benchmark for comparison with results from previous decades and also with which to compare the results of modern-day hybrid and/or complete endovascular techniques.

Characterization of resident surgeon participation during carotid endarterectomy and impact on perioperative outcomes

INTRODUCTIONnThe impact of resident surgeon participation during vascular procedures on postoperative outcomes is incompletely understood. We characterized resident physician participation during carotid endarterectomy (CEA) procedures within the 2005-2009 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and evaluated associations with procedural characteristics and perioperative adverse events.nnnMETHODSnCEAs were identified using primary current procedural terminology codes; those performed simultaneously with other major procedures or unknown resident participation status were excluded. Group-wise comparisons based on resident participation status were performed using χ(2) or Fishers exact test for categorical variables and t tests or nonparametric methods for continuous variables. Associations with perioperative adverse events (major = stroke, death, myocardial infarction, or cardiac arrest; minor = peripheral nerve injury, bleeding requiring transfusion, surgical site infection, or wound disruption) were assessed using multivariable logistic regression models adjusting for other known risk factors.nnnRESULTSnA total of 25,280 CEA procedures were analyzed, of which residents participated in 13,705 (54.2%), while residents were absent in 11,575 (45.8%). Among CEAs with resident physician participation, resident level was categorized as junior (postgraduate year [PGY] 1-2) in 21.9%, senior (PGY 3-5) in 52.7%, and fellow (PGY ≥6) in 25.3%. Major adverse event rates with and without resident participation were 1.9% versus 2.1%, and minor adverse event rates with and without resident participation were 0.9% versus 1.0%, respectively. In multivariable models, resident physician participation was not associated with perioperative risk for major adverse events (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.75-1.08) or minor adverse events (OR, 0.93; 95% CI, 0.72-1.21).nnnCONCLUSIONSnResident surgeon participation during CEA is not associated with risk of adverse perioperative events.

Open and Endovascular Repair of Popliteal Artery Aneurysms: Tabular Review of the Literature

Popliteal artery aneurysms (PAAs) have been referred to as the silent killer because of the devastating thromboembolic events they can cause without warning symptoms. Open surgical repair of PAA remains the gold standard, although the endovascular approach has being increasingly reported during the past years. Open repair can be performed over the medial or posterior approach, depending on the extent of the aneurysm and surgeons preference. The goal of the present article is to summarize the clinical results of open and endovascular repair of PAA and to serve as a practical and prompt literature search tool for all surgeons and endovascular specialists who encounter this disease process in their practices.

Society for Vascular Surgery (SVS) Vascular Registry evaluation of comparative effectiveness of carotid revascularization procedures stratified by Medicare age

OBJECTIVEnRecent randomized controlled trials have shown that age significantly affects the outcome of carotid revascularization procedures. This study used data from the Society for Vascular Surgery Vascular Registry (VR) to report the influence of age on the comparative effectiveness of carotid endarterectomy (CEA) and carotid artery stenting (CAS).nnnMETHODSnVR collects provider-reported data on patients using a Web-based database. Patients were stratified by age and symptoms. The primary end point was the composite outcome of death, stroke, or myocardial infarction (MI) at 30 days.nnnRESULTSnAs of December 7, 2010, there were 1347 CEA and 861 CAS patients aged < 65 years and 4169 CEA and 2536 CAS patients aged ≥ 65 years. CAS patients in both age groups were more likely to have a disease etiology of radiation or restenosis, be symptomatic, and have more cardiac comorbidities. In patients aged <65 years, the primary end point (5.23% CAS vs 3.56% CEA; P = .065) did not reach statistical significance. Subgroup analyses showed that CAS had a higher combined death/stroke/MI rate (4.44% vs 2.10%; P < .031) in asymptomatic patients but there was no difference in the symptomatic (6.00% vs 5.47%; P = .79) group. In patients aged ≥ 65 years, CEA had lower rates of death (0.91% vs 1.97%; P < .01), stroke (2.52% vs 4.89%; P < .01), and composite death/stroke/MI (4.27% vs 7.14%; P < .01). CEA in patients aged ≥ 65 years was associated with lower rates of the primary end point in symptomatic (5.27% vs 9.52%; P < .01) and asymptomatic (3.31% vs 5.27%; P < .01) subgroups. After risk adjustment, CAS patients aged ≥ 65 years were more likely to reach the primary end point.nnnCONCLUSIONSnCompared with CEA, CAS resulted in inferior 30-day outcomes in symptomatic and asymptomatic patients aged ≥ 65 years. These findings do not support the widespread use of CAS in patients aged ≥ 65 years.

Age-Stratified Results from 20,095 Aortoiliac Aneurysm Repairs: Should We Approach Octogenarians and Nonagenarians Differently?

BACKGROUNDnIn the endovascular era, elderly patients are offered repair of their aortoiliac aneurysms (AAA) more frequently than in the past. Our objective is to compare age groups and draw inferences for AAA repair outcomes.nnnSTUDY DESIGNnWe identified 20,095 patients who underwent AAA repair between 2005 and 2010 using the American College of Surgeons NSQIP national database. Preoperative characteristics and outcomes were compared among age groups (group A: 0 to 64 years; B: 65 to 79 years; C: 80 to 89 years; and D: 90 years and older).nnnRESULTSnThe age distribution of the cohort was A: 17.1%, B: 57.2%, C: 24%, and D: 1.7%. Nonagenarians presented significantly more often as emergencies in comparison with groups A to C (A: 13.8%, B: 10.8%, C: 12.9%, D: 22.1%; p < 0.001). Endovascular aneurysm repair was performed more frequently in older patients (A: 55.2%, B: 63.7%, C: 74.6%, D: 77.9%; p < 0.001). Risk of any complication was significantly different among groups, becoming more prevalent with advanced age (A: 22.8%, B: 23.4%, C: 24.7%, D: 27.8%; p = 0.041). Nonsurgical complications (A: 14.7%, B: 16.4%, C: 18%, D: 19.8%; p < 0.001) and cardiovascular complications (A: 3.9%, B: 4.5%, C: 5.5%, D: 5.2%; p = 0.003) were also higher with advanced age. Overall mortality was 3.1%, 4.9%,7.2%, and 13.2% for groups A to D, respectively (p < 0.001). Mortality after elective AAA repair was significantly higher for open surgery compared with endovascular aneurysm repair in all age groups (open surgery vs endovascular aneurysm repair, A:1.9% vs 0.5%; p = 0.001; B: 3.9% vs 1.2%; p < 0.001; C: 7.4% vs 2%; p < 0.001; D: 18.8% vs 3.8%; p = 0.004). After adjusting for confounders in the entire cohort, advanced age persisted as an independent factor for postoperative mortality with a higher risk of death of 1.8 (95% CI, 1.3-2.5), 2.7 (95% CI, 1.9-3.8), and 3.3 (95% CI, 1.8-6.1) times for groups B, C, and D, respectively (group A reference).nnnCONCLUSIONSnAdvanced age is independently associated with higher risk of death after AAA repair and indication for surgery should be adjusted for different age groups accordingly. Endovascular aneurysm repair should be preferred for octogenarians and nonagenarians with indication to undergo repair of their AAA.

Common Femoral Artery Endarterectomy for Lower-Extremity Ischemia: Evaluating the Need for Additional Distal Limb Revascularization

BACKGROUNDnThe role of common femoral artery endarterectomy (CFE) and the need for distal revascularization is challenging in certain clinical scenarios. For some patients with claudication or rest pain CFE alone may suffice, however, some surgeons advocated that in-line flow must be re-established in patients with major tissue loss for wound healing purposes. The decision when to perform CFE with or without distal revascularization is sometimes difficult. The objective of this study was to evaluate the outcomes of common femoral artery endarterectomy (CFE) to define predictive factors for additional distal revascularization.nnnMETHODSnRetrospective review of 262 consecutive CFEs in 230 patients with lower-extremity ischemia between 1997 and 2008. Patients were divided into two groups: group A (n = 169; CFE alone) and group B (n = 93; CFE + distal revascularization). Concomitant iliac intervention was included only if performed by endovascular approach. Patients were analyzed by Rutherford category (RC) and TransAtlantic InterSociety Consensus (TASC) II classification. Primary end points were mortality, patency, reintervention, and limb salvage.nnnRESULTSnDemographics, preoperative Society for Vascular Surgery score assessment, and TASC II classification did not differ between groups. Mean follow-up was 75 months (range: 1-128 months). Technical success was obtained in all patients. RC (3 ± 1.2 vs. 5 ± 1.4; P = 0.001), diabetes (33% vs. 52%; P = 0.005), mean operative time (+154 minutes; P < 0.001), and length of hospital stay (+1.7 days; P = 0.03) were higher in group B. Reintervention rates were higher in group B than group A (12% vs. 3%; P = 0.015). For patients with RC 5/TASC D lesions and patients with RC 6 regardless of TASC, initial distal revascularization (group B) was associated with fewer reinterventions or major amputations (29%) than CFE alone (67%) (P = 0.002). The cumulative 5-year primary patencies for groups A and group B were 96% and 92%, respectively. Secondary patency was 100% at both time points. Limb salvage was also lower in patients with RC 5 and 6 (P = 0.01; P = 0.02). Overall survival was 93% at 1 year and 77% at 5 years. Independent predictors for distal revascularization were RC 5 or 6 (P < 0.001), TASC D lesions (P < 0.0001), diabetes (P = 0.04), and being on anticoagulation (P = 0.003). There was no difference in survival between the two groups for RC 1 to 5 (P = 0.2), but for patients with RC 6, survival was improved in group B (39% vs. 67%; P = 0.9).nnnCONCLUSIONnCFE alone is sufficient for patients with lower-extremity ischemia who present with life-limiting claudication regardless of TASC lesion and for those with RC 5 and TASC lesions A to C. Patients with RC 5 and TASC D lesions and those with major tissue loss (RC 6) regardless of TASC lesion are better served with additional distal revascularization to improve limb salvage, reintervention, and survival rates.

Preservation of Hypogastric Artery Blood Flow During Endovascular Aneurysm Repair of an Abdominal Aortic Aneurysm With Bilateral Common and Internal Iliac Artery Involvement: Utilization of Off-the-Shelf Stent-Graft Components

A 72-year-old male presented with a 7.4-cm abdominal aortic aneurysm with bilateral common and internal iliac involvement. To maintain pelvic perfusion, preservation of the patients left hypogastric artery (HA) was pursued. Two weeks after right HA embolization, endovascular repair of the patients aneurysms was performed using a branched endograft approach. A 22-mm main body bifurcated endograft was unsheathed and the proximal covered stent was removed. The contralateral gate was preloaded with a wire and catheter. The device was resheathed and placed in the left common iliac artery. The preloaded wire in the contralateral gate was snared from the right side, establishing through-and-through femoral access. A contralateral femoral sheath was advanced up and over the aortic bifurcation from the right side into the contralateral gate of the bifurcated endograft. The repair was bridged to the left HA using a balloon-expandable stent-graft, followed by standard endovascular abdominal aortic aneurysm repair. Completion angiography demonstrated exclusion of patients aneurysms, without evidence of endoleak, and maintenance of pelvic blood flow through the left HA. The patient recovered without complication and was discharged home on postoperative day 4. This technique illustrates the technical feasibility of using a preloaded commercially available endograft to preserve HA blood flow and maintain pelvic perfusion during endovascular aortic aneurysm repair.

ViPS technique as a novel concept for a sutureless vascular anastomosis

OBJECTIVEnTo describe a novel technique (Viabhan Padova Sutureless [ViPS]) that connects a vascular prosthetic graft to a target artery in a sutureless fashion.nnnMETHODSnThe patient was a 74-year-old male with complete superficial femoral artery (FA) occlusion and reconstitution of a circumferentially calcified above-knee popliteal artery (ANPA). The proximal end of a surgeon-modified 7-mm Viabahn endoprosthesis was sutured to a 7-mm polytetrafluoroethylene graft (PTFEg). After surgical exposure, the ANPA was transected, and the undeployed distal portion of the Viabahn was inserted, supported by a stiff guidewire. The distal portion of the Viabahn graft was then deployed and ballooned with optimal apposition. Finally, the proximal end of the PTFEg was sutured to the common FA.nnnRESULTSnOperative time was 60 minutes. Completion angiogram and the computed tomography angiogram at 6 months demonstrated a patent graft.nnnCONCLUSIONnThe ViPS technique provides an alternative for bypass creation when challenging arterial anastomoses are required.