Joshua I. Greenberg

Long-term results after accessory renal artery coverage during endovascular aortic aneurysm repair

OBJECTIVE Current information regarding coverage of accessory renal arteries (ARAs) during endovascular aneurysm repair (EVAR) is based on small case series with limited follow-up. This study evaluates the outcomes of ARA coverage in a large contemporary cohort. METHODS Consecutive EVAR data from January 2004 to August 2010 were collected in a prospective database at a University Hospital. Patient and aneurysm-related characteristics, imaging studies, and ARA coverage versus preservation were analyzed. Volumetric analysis of three-dimensional reconstruction computed tomography scans was used to assess renal infarction volume extent. Long-term renal function and overall technical success of aneurysm exclusion were compared. RESULTS A cohort of 426 EVARs was identified. ARAs were present in 69 patients with a mean follow-up of 27 months (range, 1 to 60 months). Forty-five ARAs were covered in 40 patients; 29 patients had intentional ARA preservation. Patient and anatomic characteristics were similar between groups except that ARA coverage patients had shorter aneurysm necks (P = .03). Renal infarctions occurred in 84% of kidneys with covered ARAs. There was no significant deterioration in long-term glomerular filtration rate when compared with patients in the control group. No difference in the rate of endoleak, secondary procedures, or the requirement for antihypertensive medications was found. CONCLUSIONS This study is the largest to date with the longest follow-up relating to ARA coverage. Contrary to previous reports, renal infarction after ARA coverage is common. Nevertheless, coverage is well tolerated based upon preservation of renal function without additional morbidity. These results support the long-term safety of ARA coverage for EVAR when necessary.

Results of a double-barrel technique with commercially available devices for hypogastric preservation during aortoilac endovascular abdominal aortic aneurysm repair.

OBJECTIVE To assess technical feasibility and short-term outcome of a novel hypogastric preservation technique in patients with aortoiliac aneurysms using commercially available endografts without device modification. METHODS Multi-institution review of prospectively acquired database of patients undergoing double-barrel endograft repair of aortoiliac aneurysms. RESULTS Twenty-two patients underwent endovascular aneurysm repair for aortoiliac aneurysms from 2010 to 2011, with 23 double-barrel hypogastric preservation procedures successfully completed in 21 patients. The technique involved bifurcated main body placement followed by simultaneous deployment of parallel endograft limbs into the external iliac (ipsilateral approach) and hypogastric (contralateral femoral or brachial approach) arteries. Bilateral hypogastric branches were performed in two patients, and unilateral branches with and without contralateral coil embolization were performed in nine and ten patients, respectively. Procedural success rate was 96%, technical success rate (successful implantation with immediate aneurysm exclusion and no observed endoleak) was 88%, and access was fully-percutaneous in 86%. Two type III endoleaks between branch components were noted on completion angiograms, but both resolved spontaneously on follow-up imaging. One type Ib endoleak was noted on postoperative imaging (contralateral to hypogastric branch, repaired with limb extension), as were three type II endoleaks (14%) without sac expansion. Early (<2 weeks) limb occlusion (one external iliac, two hypogastric) occurred in two patients, though no subsequent occlusions have occurred (mean follow-up, 7.2 months; range, 1-20 months). Primary patency for external iliac and hypogastric limbs at 6 months was 95% and 88%, respectively. There were no deaths; complications included groin hematoma in 10% and acute renal insufficiency in 5%. Buttock claudication (n = 4) only occurred in patients who had ipsilateral coil embolization of hypogastric arteries (n = 9) for bilateral iliac aneurysms in which only unilateral hypogastric preservation was performed, resulting in rate of 44% in these patients. CONCLUSIONS The double-barrel technique for hypogastric preservation is technically feasible across multiple interventionalists using commercially available endografts without device modification. These procedures are associated with minimal morbidity, acceptable short-term limb-patency rates, and reduced buttock claudication compared with those involving contralateral hypogastric embolization.

Cost Impact of Extension Cuff Utilization During Endovascular Aneurysm Repair

BACKGROUND Modular stent-graft systems for endovascular aneurysm repair (EVAR) most often require two to three components, depending on the device. Differences in path lengths and availability of main body systems often require additional extensions for appropriate aneurysm exclusion. These additional devices usually result in added expenses and can affect the financial viability of an EVAR program within a hospital. The purpose of this study was to analyze the use of extensions during EVAR, focusing on incidence, clinical impact, and financial impact, as well as determining the associated cost differences between two- and three-component EVAR device systems. METHODS We reviewed available clinical data, images, and follow-up of 218 patients (203 males and 15 females, mean age: 74 ± 9 years) who underwent elective EVAR at a single academic center from 2004 to 2007. Patients were divided into two groups: patients undergoing EVAR using the standard number of pieces, that is, no extensions used (group A, n = 98), and those needing proximal or distal extensions during the index procedure (group B, n = 120). RESULTS Both groups were similar in terms of demographics; preoperative characteristics, including aneurysm morphology; as well as intraoperative, postoperative, and midterm outcomes. Overall, 30-day operative mortality was 1.4%, with a mean follow-up of 24 months. Group A patients underwent repair with two-piece modular devices 41% of the time and three-piece systems 59% of the time, whereas group B patients underwent repair with two-piece modular systems 82% of the time and three-piece modular systems 18% of the time. The number of additional extensions per patient ranged from one to four (median: one piece). There was a 30% cost increase in overall mean device-related cost when using extensions versus the standard number of pieces (group A:

Vascular Injury Is Associated with Increased Mortality in Winter Sports Trauma

13,220 vs. group B:

Idiopathic true brachial artery aneurysm in an 18-month-old girl

17,107, p < 0.01). CONCLUSIONS Clinical midterm aneurysm-related outcomes after EVAR in patients who required additional extensions was comparable with those treated with the standard number of pieces. An increased number of extensions led to increased costs and could have potentially been minimized with appropriate preoperative planning or device selection. Consideration should be made toward per-case pricing instead of per-piece pricing to further improve cost efficiency without compromising long-term patient outcomes.

Minimal Thoracotomy Thoracic Bifemoral Bypass in the Endovascular Era

BACKGROUND Trauma is the leading cause of injury and death for individuals aged 1-44 years. Up to 8% of the US population participates in winter sports, and although vascular injuries are uncommon in these activities, little is published in this area. We sought to identify the incidence, injury patterns, and outcomes of vascular injuries resulting from winter sports trauma. METHODS Patients with winter sports trauma and the subset with vascular injuries were identified by accessing the National Trauma Data Bank querying years 2007-2010. Patients with and without vascular injuries were then compared. Admission variables included transport time, emergency department hypotension (systolic blood pressure < 90), Glasgow Coma Scale ≤ 8, Injury Severity Score ≥ 25, fractures, solid organ injury, and vascular injury. Outcomes were analyzed and associations with vascular injuries were determined. RESULTS A total of 2,298 patients were identified with winter sports-related trauma and 28 (1.2%) had associated vascular injuries. Overall, the top 3 injuries were head trauma (16.7%), thoracic vertebral fractures (5.5%), and lumbar vertebral fractures (5.1%). The most common associated vascular injures were to the popliteal artery (17.7%), splenic artery (14.7%), and brachial blood vessels (14.7%). In the entire cohort, 1 patient (0.04%) suffered an amputation and 15 patients (0.7%) died. There were no amputations in the vascular injury group. Mortality was 0.6% in patients without a vascular injury compared with 7.1% of those with a vascular injury (P = 0.01). CONCLUSIONS Although vascular injury is an uncommon associated finding in winter sports trauma, it is associated with a significant increase in mortality. These findings highlight the need for rapid identification of traumatic vascular injuries, which predicts worse overall outcomes in this patient population.

Early experience with the snorkel technique for juxtarenal aneurysms

An 18-month-old girl was transferred to our university hospital for the management of a 12-mm brachial artery aneurysm found by her mother while the child was being bathed. The patient had had an uneventful vaginal delivery, had met all milestones, and there was no evidence or history of physical trauma. No dysmorphic physical attributes were identified on careful examination. There was also no family history of childhood illnesses, aneurysmal disease, or rheumatic or connective tissue diseases. A whole-body computed tomography angiography demonstrated the partially thrombosed left brachial artery aneurysm with a well-developed profunda brachial artery (A; Cover). There werenootherectatic, aneurysmalor tortuousarteries.Resultsof complete laboratoryassessments, including standard rheumatologic assays were all negative. The lack of long-term data supporting ligation of such an aneurysm vis-a-vis extremity growth and the minimal morbidity of vein bypass in this setting prompted the family to consider brachial artery reconstruction. Preoperativegreat saphenous veinmappingdemonstratedvenousdiametersof15mmin the thighs. The patient was taken to the operating room for brachial artery excision and reconstruction with vascular and microvascular surgical teams. A great saphenous vein segment was isolated from the left thigh while the aneurysm was exposed (B) and controlled with microvascular clips (C). Aneurysmectomy and reconstruction with reversed great saphenous vein sewn end-to-end with 9-0 interrupted nylon suture was performed (D), similar to the description of other reports. An excellent graft Doppler signal and palpable pulses at the wrist were present at the conclusion of the procedure. Final pathology, shown as a cross-sectional image of the brachial aneurysm with elastin stain (E), revealed a true aneurysm with extensive thrombus and florid fibrointimal proliferative ingrowth without evidence of infection or arteritis.

Improved efficiency and safety for EVAR with utilization of a hybrid room.

BACKGROUND Endoluminal revascularization has supplanted open techniques for most aortoiliac occlusive disease with open surgery reserved for endovascular failure or long-segment aortoiliac occlusions. A number of clinical and anatomic issues can preclude the use of the infrarenal aorta for inflow. Our approach in these select patients is minimal thoracotomy thoracic bifemoral (mini-TBF) bypass. METHODS Mini-TBF bypass used a 2-team approach. The cardiac surgery team focused on arterial inflow from the distal descending aorta via a ≤8-cm thoracotomy at ninth interspace. The vascular surgery team focused on groin reconstruction and graft tunneling. The body of the graft was tunneled through the posterior left hemidiaphragm. The left limb was tunneled retroperitoneal over the psoas and the right limb anterior to the abdominal fascia below the umbilicus to the groin. RESULTS Thirteen patients (mean age, 64; 82% male) underwent mini-TBF bypass between 2009 and 2012 for claudication in 9 (69%) and critical limb ischemia in 4 (31%). Five patients had prior failed iliac endovascular revascularizations and 2 patients had failed prior infrarenal aortobifemoral bypass. The indication for use of thoracic aortic inflow was prior abdominal operations in 4 (31%), pelvic anatomy with a critical inferior mesenteric artery (IMA) in 5 (38%), and the condition of the infrarenal/juxtarenal aorta in 4 (31%). Median operative time was 240 min (range 181-513 min). Median length of stay was 8 days. There was no perioperative mortality. Postoperative complications occurred in 5 patients, stroke 1, pulmonary 2 (both contralateral lung issues), and 2 limb occlusion secondary to outflow disease. At median follow-up of 18 months, 2 patients required amputations, both from preexisting tissue loss despite secondary patent grafts. CONCLUSIONS Mini-TBF bypass provides another alternative to successfully revascularize Trans-Atlantic Inter-Society Consensus II type D lesions in patients with prior abdominal revascularization, pelvic anatomy with a critical IMA, or calcification/thrombus of the infrarenal/juxtarenal aorta precludes control.