Kathleen J. Ozsvath

Long-term outcomes of secondary procedures after endovascular aneurysm repair

PURPOSE This study evaluated the outcomes of secondary procedures after endovascular aneurysm repair (EVAR). METHODS From 2002 to 2009, 1768 patients underwent EVAR for treatment of 1662 elective (94%) and 106 emergent (6%) infrarenal abdominal aortic aneurysm (AAA) with a variety of Food and Drug Administration-approved and commercially available stent grafts. Postoperative follow-up included clinical examination, pulse volume recording, duplex ultrasound imaging, and computed tomography and magnetic resonance angiography at 1, 6, and 12 months, and yearly thereafter. Patients with type I and III endoleaks, unexplained endotension, limb occlusion, stent graft migration, with and without type I endoleak, and aneurysm rupture underwent secondary interventions. Type II endoleak at >6 months without a decrease in the aneurysm sac underwent translumbar embolization. Data were prospectively collected. RESULTS EVAR was performed in 1768 patients. During a mean follow-up of 34 (SD, 30.03) months, 339 patients (19.2%) required additional secondary procedures for aneurysm-related complications, including type I (n = 51, 15.0%), type II (n = 136, 40.1%), and type III (n = 5, 1.5%) endoleaks; endotension (n = 8, 2.4%), stent graft migration proximal fixation site (n = 46, 13.6%), stent graft iliac limb thrombosis or stenosis (n = 25, 7.4%), subsequent iliac aneurysm formation (n = 39, 11.5%), or aneurysm rupture after EVAR (n = 29, 8.6%). The mean age was 74 (SD, 9.15) years. Mean AAA size was 5.7 (SD 3.24) cm. Compared with secondary procedures for AAA rupture, the nonrupture patients had a significantly lower mortality (1.6% vs 17.2%, P < .05) and a higher likelihood of being managed by endovascular means (98.8% vs 44.8%, P < .05). When nonruptured EVAR patients required urgent secondary procedures for type I endoleaks and stent graft migration or limb thrombosis, the mortality was 6.0% vs 0.5% for elective procedures (P < .05). CONCLUSIONS Our long-term EVAR experience indicates that 18% of patients require additional secondary procedures, and most of these patients can be managed by endovascular means with an acceptable overall mortality of 2.9%. Most type I and II endoleaks can be successfully treated by transluminal embolization, and most patients with delayed aneurysm rupture after EVAR can be successfully managed by endovascular or open surgical repair.

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.

The incidence, natural history, and outcome of secondary intervention for persistent collateral flow in the excluded abdominal aortic aneurysm

OBJECTIVE The goal of abdominal aortic aneurysm (AAA) repair is the prevention of rupture. Exclusion of the infrarenal AAA by means of operation or endovascular graft placement is an alternative therapy to achieve this goal. However, thrombosis of the excluded aneurysm sac does not always occur and further intervention may be needed. This study examines the efficacy of available screening methods to detect the persistence of aneurysm sac flow and the outcome of secondary procedures to treat this problem. METHODS During the past 14 years, 1218 patients have undergone operative retroperitoneal exclusion of AAA. To date, 48 patients have been found to have persistent flow in the excluded AAA sac with duplex scanning. Twenty-seven patients underwent surgical intervention, and seven of these procedures were performed for rupture. Six patients have undergone treatment with interventional techniques (four successfully). The patients were evaluated for preoperative angiographic, anatomic, and comorbid factors that may have predisposed them to failed exclusion. Also, perioperative morbidity and mortality, estimated blood loss, and survival were assessed in the patients who required surgical treatment. RESULTS There were no perioperative parameters that correlated with postoperative persistent flow in the excluded AAA sac. The mean time to secondary intervention was 51 months (range, 2 to 113 months). Two patients had false-negative computed tomographic angiogram results, eight patients had false-negative angiogram results, and six patients had duplex scan examinations that had initially negative results that were then positive for flow in sac. Reoperation had a 7.4% mortality rate (two deaths) and a median blood loss of 2600 mL, as compared with 500 mL for primary procedures. CONCLUSION Secondary operations for patent excluded aortic aneurysm sacs have higher mortality and intraoperative blood loss rates than do primary procedures for AAA repair. The localization of branch leaks with computerized tomographic angiography, angiography, and duplex scanning were imprecise, and better methods are needed to adequately diagnose patent sacs. Expansion of AAA sac may be the only reliable factor.

Radiation exposure and pregnancy

INTRODUCTION The effect of radiation on the fetus has been derived primarily from animal studies and human exposures to diagnostic and therapeutic radiation as well as atomic bomb exposure. Given the variety of sources, there is controversy over the dose of radiation in addition to the other environmental conditions that surrounded these events and their relationship to exposure today. METHODS The effects of ionizing radiation on the fetus, the prenatal period, parental exposure, the pregnant clinician, and the pregnant patient are discussed in the context of their exposure to radiation. RESULTS The fetus is most sensitive to radiation effects between 8 and 15 weeks of pregnancy. Stepping away from the table and using movable shields help reduce the exposure by a factor of four for every doubling of the distance between the operator and the radiation source. CONCLUSION Proposed guidelines for pregnancy during vascular residency training involving fluoroscopic procedures can help bring about awareness, clarify maximal exposure, and better delineate the role of the pregnant resident.

Outcomes of planned celiac artery coverage during TEVAR

OBJECTIVE Successful thoracic endovascular aneurysm repair (TEVAR) requires adequate proximal and distal fixation and seal. We report our experience of planned celiac artery coverage during endovascular repair of complex thoracic aortic aneurysms (TAA). METHODS Since 2004, 228 patients underwent TEVAR under elective (n=162, 71%) and emergent circumstances (66, 29%). Patients with inadequate distal stent grafts landing zones during TEVAR underwent detailed evaluation of the gastroduodenal arcade with communicating collaterals between the celiac and superior mesenteric artery (SMA) by computed tomography angiography and intraoperative arteriogram. If needed, in presence of a patent SMA and demonstration of collaterals to the celiac artery, the stent grafts were extended to the SMA with celiac artery coverage. Furthermore, instances when further lengthening of distal thoracic stent graft landing zone was needed to obtain an adequate seal, the SMA was partially covered with the endograft, and a balloon expandable stent was routinely deployed in proximal SMA to maintain patency. Outcome data were prospectively collected and analyzed retrospectively. RESULTS Thirty-one of 228 (14%) patients with TEVAR required celiac artery interruption; 24 (77%) had demonstrable collaterals to the SMA. Twelve (39%) of 31 patients underwent additional partial SMA coverage by stent graft, and proximal SMA stent. The majority of patients were females (n=20, 65%), the mean age was 74 years (range 55-87 years), and the mean TAA size was 6.5 cm. Postoperative complications included visceral ischemia in 2 (6%) patients, paraplegia in 2 (6%) patients, and death in 2 (6%) patients. All type 1b endoleaks (n=2, 6%) and type 2 endoleaks vial retrograde flow from the celiac artery (n=3, 10%) were successfully treated by transfemoral coil embolization. Over a mean follow-up of 15 months, there have been no other complications of mesenteric ischemia, spinal cord ischemia, SMA in-stent stenosis, or conversion to open surgical repair. CONCLUSIONS Our findings suggest that celiac artery coverage to facilitate adequate distal sealing during TEVAR with complex TAA is relatively safe in the presence of SMA-celiac collaterals. Pre-existing SMA stenosis can be successfully treated by balloon expandable stents during TEVAR, and endoleaks arising from distal stent grafts attachment site or via retrograde flow from the celiac artery can be successfully managed by transfemoral coil embolization. Although early results are encouraging, long-term efficacy of these procedures remains to be determined and vigilant follow-up is needed.

The impact of hemodynamic status on outcomes of endovascular abdominal aortic aneurysm repair for rupture

OBJECTIVE To date, there are no published reports comparing hemodynamically (Hd)-stable and Hd-unstable patients with ruptured abdominal aortic aneurysms (r-AAAs) undergoing endovascular aneurysm repair (EVAR). This study evaluates outcomes of EVAR for r-AAA based on patients Hd status METHODS From 2002 to 2011, 136 patients with r-AAAs underwent EVAR and were categorized into two groups based on systolic blood pressure (SBP) measurements before EVAR: 92 (68%) Hd-stable (SBP ≥ 80 mm Hg) and 44 (32%) Hd-unstable (SBP <80 mm Hg for >10 minutes). All data were prospectively entered in a database and retrospectively analyzed. Outcomes included 30-day mortality, postoperative complications, the need for secondary reinterventions, and midterm mortality. The effect of potential predictors on 30-day mortality was assessed by χ(2) and logistic regression. RESULTS Of the 136 r-AAA patients with EVAR, the Hd-stable and Hd-unstable groups had similar comorbidities (coronary artery disease, 63% vs 59%; hypertension, 72% vs 75%; chronic obstructive pulmonary disease, 21% vs 26%; and chronic renal insufficiency, 18% vs 18%), mean AAA maximum diameter (6.6 vs 6.4 cm), need for on-the-table conversion to open surgical repair (3% vs 7%), and incidences of nonfatal complications (43% vs 38%) and secondary interventions (23% vs 25%). Preoperative computed tomography scan was available in significantly fewer Hd-unstable patients (64% vs 100%; P < .05). Compared with Hd-stable patients, the Hd-unstable patients had a significantly higher intraoperative need for aortic occlusion balloon (40% vs 6%; P < .05), mean estimated blood loss (744 vs 363 mL; P < .05), incidence of developing abdominal compartment syndrome (ACS; 29% vs 4%; P < .01), and death (33% vs 18%; P < .05). ACS was a significant predictor of death; death in all r-EVAR with ACS was significantly higher compared with all r-EVAR without ACS (10 of 17 [59%] vs 22 of 119 [18%]; P < .01). CONCLUSIONS EVAR for r-AAA is feasible in Hd-stable and Hd-unstable patients, with a comparable incidence of conversion to open surgical repair, nonfatal complications, and secondary interventions. Hd-stable patients have reduced mortality at 30 days, whereas Hd-unstable patients require intraoperative aortic occlusion balloon more frequently, and have an increased risk for developing ACS and death.

Upper extremity bypass grafting for limb salvage in end-stage renal failure.

OBJECTIVE Patients with end-stage renal failure and upper-extremity arterial occlusive disease sometimes have painful digital ulceration. We evaluated the efficacy of distal bypass grafting from the brachial artery for limb salvage in this setting. METHODS All patients with end-stage renal disease with painful digital ulceration or gangrene of the hand seen from 1992 to 2002 were evaluated with clinical examination and noninvasive studies. Those with evidence of occlusive disease underwent conventional angiography. Individuals with forearm occlusive disease underwent bypass grafting, from the brachial artery to either the distal radial artery or ulnar artery at the level of the wrist or proximal hand. Follow-up was scheduled at regular intervals, and included duplex scanning. Limb salvage and bypass graft patency were determined with life table analysis. RESULTS Over 10 years, 18 forearm bypass procedures were performed in 15 patients. The outflow artery was the radial artery in 15 procedures and the ulnar artery in 3 procedures. Bypass conduit was autogenous in all patients. No patient had a functioning arteriovenous fistula at bypass grafting; six limbs had previously occluded fistulas. Two bypass grafts (11%) occluded in the early postoperative period, with resultant progression of gangrene. In the remaining 16 grafts patency was maintained (mean follow-up, 18 months), with pain control and tissue healing. CONCLUSION Treatment in patients with renal failure with upper extremity occlusive disease may be facilitated with brachiodistal bypass grafting. Pain control and reversal of progression of hand necrosis can be achieved.

Carotid endarterectomy in the elderly: does gender effect outcome?

OBJECTIVES Carotid endarterectomy (CEA) has a positive effect on stroke free survival in patients with either symptomatic or asymptomatic severe carotid bifurcation stenosis. However, most trials have excluded octogenarians. In addition, concerns have arisen regarding the benefits of CEA in the elderly population, especially in women. In this study, we performed an outcome analysis in patients undergoing CEA comparing those eighty and older to their younger counterparts. Additionally, we evaluated the elderly group based on gender. METHODS Over the past 10 years, all patients undergoing CEA for asymptomatic and symptomatic carotid disease have been entered into our vascular surgery registry. Demographics, indications for operative intervention, outcomes and survival of patients who had undergone CEA were reviewed. Procedures were preferentially performed under regional anesthesia with selective shunting. Chi square analysis was used to assess significance and assumed for P<0.05. RESULTS Over the last 10 years, 125 carotid endarterectomies were performed in 125 patients eighty years of age or older. Fifty-six were male and 69 were female. Mean age was 83 (range: 80-97). Asymptomatic disease was identified in 28 of the male patients (50%) and 44 of the female patients (64%). There were no deaths and a permanent neurological deficit occurred in one female patient. There was no difference in thirty-day morbidity or mortality in female patients compared to males. CONCLUSIONS These observations suggest that CEA can be safely performed in selected elderly patients with asymptomatic or symptomatic carotid artery stenosis. Furthermore, women over 80 may expect equally optimistic results as their male counterparts.

Ruptured Abdominal Aortic Aneurysm: Endovascular Program Development and Results

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality when compared to the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help ones ability to deal with not just the technical aspects of these procedures, but also address some of the challenges including: the availability of preoperative CT, the choice of anesthesia, percutaneous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs. aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.

Eversion carotid endarterectomy: a technical alternative that may obviate patch closure in women.

PURPOSE Recurrent carotid stenosis following standard longitudinal carotid endarterectomy (s- CEA), with and without patch angioplasty, effects the durability of the procedure and can lead to reintervention. The purpose of this study is to evaluate the incidence of restenosis following eversion carotid endarterectomy (e-CEA) in women. METHODS The records of all patients undergoing elective carotid endarterectomy (CEA) for symptomatic and asymptomatic high-grade carotid stenosis over a 5-year period from July 1994 to June 1999 were reviewed. Eversion endarterectomy was performed preferentially under regional anesthesia in awake patients. Postoperatively, patients were routinely evaluated by duplex scans at 3 months, 6 months, 12 months, and yearly thereafter. Hemodynamically significant restenosis (>70%) via duplex scans was confirmed by standard or magnetic resonance angiography. Students t-test and Chi square analysis were used to assess statistical significance and assumed for P<0.05. RESULTS Over this 5-year period, 3429 eversion carotid endarterectomies were done for symptomatic (female: 375, male: 573) and asymptomatic (female: 1091, male: 1390) high grade carotid stenosis. In the postoperative period 18 (0.9%) male and 12 (0.8%) female patients developed a permanent stroke (P = NS). Operative mortality was 0.6% (n = 12) in males and 0.5% (n = 8) in females (P = NS). Cranial nerve injuries, wound infections, and neck hematoma occurred in 7 (0.4%), 2 (0.1%), and 26 (1.3%) male and in 3 (0.2%), 3 (0.2%), and 15 (1.0%) female patients, respectively. Recurrent carotid stenosis greater than 70% via duplex scan (PSV >125 cm/s and EDV >100 cm/s) developed in 12 (1.0%) males and 15 (1.5%) females (P = NS). CONCLUSION The eversion technique for CEA requires both the transection and anastomosis of the internal carotid artery at the carotid bulb, and appears to result in a low incidence of restenosis in women. This is a straightforward technique and obviates the need for primary closure of distal smaller caliber internal carotid artery that can lead to narrowing, and the use of patch closure that has its attendant risks.