Margaret C. Tracci

Staged hybrid approach using proximal thoracic endovascular aneurysm repair and distal open repair for the treatment of extensive thoracoabdominal aortic aneurysms

OBJECTIVE Repair of patients with extent I and II thoracoabdominal aortic aneurysms (TAAAs) is associated with significant morbidity and mortality, whereas repair of more distal extent III and IV TAAAs has a lower risk of paraplegia and death. Therefore, we describe an approach using thoracic endovascular aneurysm repair (TEVAR) as the index operation to convert extent I and II TAAAs to extent III and IV TAAAs amenable to subsequent open aortic repair to minimize patient risk. METHODS Between July 2007 and March 2012, 10 staged hybrid operations were performed to treat one extent I and nine extent II TAAAs. Aortic aneurysm pathology included five chronic type B dissections, three acute type B dissections, and two penetrating aortic ulcers. Initially, the proximal descending thoracic aorta was repaired with TEVAR for coverage of the most proximal fenestration or penetrating ulcer, with seven elective and three emergent repairs. Interval open distal aortic replacement was performed in a short-term planned setting or for progressive dilation of the distal aortic segment. In the open repair, the proximal end of the graft was sewn directly to the distal end of the TEVAR and outer wall of the aorta. RESULTS Average patient age was 48 years, and 60% were men. Risk factors included hypertension (80%), current tobacco use (50%), and Marfan syndrome (30%). Complications after TEVAR included type IA (n=1) and type II (n=3) endoleaks, pleural effusions (n=3), and acute kidney injury (n=1). Three patients required endovascular reinterventions. In patients with dissection, persistent filling of the false lumen was common and associated with distal thoracic aortic dilation. Complications of open repair included acute kidney injury in two patients, but no cardiac, pulmonary, or neurologic morbidity. Median time between TEVAR and open repair was 14 weeks. Most importantly, no deaths or neurologic deficits occurred after either procedure during a median follow-up of 35 weeks. CONCLUSIONS A staged hybrid approach to extensive TAAAs combining proximal TEVAR, followed by interval open distal TAAA repair, is safe and appears to be an effective alternative to traditional open repair. This approach may decrease the significant morbidity associated with single-stage open extent I and II TAAA repairs and may be applicable to multiple TAAA etiologies.

Outcomes of Coverage of the Left Subclavian Artery during Endovascular Repair of the Thoracic Aorta

PURPOSE To report outcomes of coverage of the left subclavian artery (LSCA) during thoracic endovascular aortic repair (TEVAR). MATERIALS AND METHODS A retrospective review was performed of 285 patients (160 male) with a mean age of 62 years (range, 13-91 y) who underwent TEVAR at a single institution between March 2005 and May 2013. The LSCA was covered to obtain an adequate proximal landing zone, and a selective LSCA revascularization and embolization strategy was employed. All patient outcomes were recorded including neurologic complications, left arm claudication, endoleak rates, and repeat procedures. RESULTS The origin of the LSCA was covered in 98/285 (34%) patients. Median follow-up was 533 days (range, 2-2,895 d). Cerebrovascular accident (CVA) rates for covered LSCA and noncovered groups were 11/98 (11%) and 5/188 (3%), respectively (P = .005). LSCA was revascularized at time of initial TEVAR in 44/98 (45%) patients. Of the remaining 54 patients, 10 (19%) required subsequent revascularization for claudication. LSCA embolization was done to prevent or treat endoleak in 41/98 (42%) patients, with 33/98 (34%) patients undergoing LSCA embolization at the time of LSCA coverage and 8 of the remaining 65 (12%) patients requiring subsequent embolization for persistent endoleak. CONCLUSIONS Coverage of the LSCA during TEVAR is feasible with low complication rates, although it carries an increased risk of CVA. The selective LSCA revascularization and embolization strategy was well tolerated. A more liberal strategy may be required to decrease the rate of delayed revascularization and embolization procedures to treat arm claudication and endoleaks, respectively.

Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection

OBJECTIVE Many patients with aortic dissection develop Crawford extent I or II thoracoabdominal aortic aneurysms (TAAA). Because open repair is associated with a high morbidity and mortality, hybrid approaches to TAAA repair are emerging. In this study, we evaluated the midterm outcomes and aortic remodeling of a hybrid technique that combines proximal thoracic endovascular aneurysm repair (TEVAR), followed by staged distal open thoracoabdominal repair for patients with Crawford extent I or II TAAAs secondary to chronic aortic dissection. METHODS We identified 19 patients with Crawford extent I (n = 1) or extent II (n = 18) TAAAs secondary to chronic aortic dissection who underwent a staged hybrid repair from 2007 to 2014 at our institution. Nine patients had previous open ascending aortic surgery for type I aortic dissection. Stage 1 TEVAR was performed via percutaneous (n = 8), femoral cutdown (n = 8), or iliac exposure (n = 3). The left subclavian artery was covered in nine patients and revascularized in eight patients using carotid-subclavian bypass (n = 7) or laser fenestration (n = 1). Stage 2 open repair was performed a median of 18 weeks later with partial cardiopulmonary bypass via left femoral arterial and venous cannulation for visceral and lower body perfusion. The open thoracoabdominal graft was anastomosed proximally in an end to end fashion with the endograft. We then assessed surgical morbidity and mortality, midterm survival, and freedom from reintervention. Aortic remodeling was measured and change in maximum aortic and false lumen diameter at last follow-up (median, 3 years) from baseline was assessed. RESULTS There were no deaths, strokes, or chronic renal failure in this cohort. After stage 1 TEVAR, three patients required repeat intervention for endoleak (type Ia, n = 1; type Ib, n = 1; type II, n = 1) before open repair. After stage 2 open repair, there was a single delayed permanent paralysis 2 weeks after discharge. At a median 3-year follow-up (range, 6 months-6.2 years), there were no deaths, neurologic events, endoleaks, or TAAA reinterventions. Complete false lumen thrombosis occurred in 100% of the patients, with maximum false lumen diameter decreasing from 34.3 ± 15.3 mm to 13.2 ± 12.0 mm (P < .01) and total aortic diameter decreasing from 60.2 ± 9.0 mm to 49.4 ± 9.6 mm (P < .01). CONCLUSIONS Staged hybrid TAAA repair, using a combination of proximal TEVAR with open distal repair, can be performed using established endovascular skills and technology coupled with traditional open aortic surgical techniques, with low surgical morbidity and mortality. In the midterm, staged hybrid TAAA repair was associated favorable survival, aortic remodeling, and freedom from reintervention.

Complicated postpartum type B aortic dissection and endovascular repair.

BACKGROUND: Fifty percent of aortic dissections in women younger than 40 years occur in association with pregnancy. Of these, half of type B dissections occur in the postpartum period. CASE: A 30-year-old woman was status post spontaneous vaginal delivery at 30 weeks of gestation for fetal death, complicated by an eclamptic seizure. On postpartum day 4, she suffered an acute, complicated type B aortic dissection treated with endovascular stent graft placement. CONCLUSION: Endovascular repair may be an attractive option for the treatment of complicated type B aortic dissections in pregnancy and the peripartum period, with reduced maternal and fetal mortality. This may allow the fetus to remain in situ and avoid the risks of surgery and possible cardiopulmonary bypass, with little radiation risk to the fetus.

Renal malperfusion: spontaneous renal artery dissection and with aortic dissection

Renal malperfusion associated with renal artery dissection can present as either an isolated disease process or in the setting of branch vessel stenosis complicating aortic dissection. Isolated renal artery dissection is a rare disorder, the clinical presentation of which often presents both diagnostic and therapeutic challenges. The true incidence and natural history of this phenomenon also remain unclear. Multiple approaches to management have been described. Medical therapy typically consists of anticoagulation and blood pressure management and is reserved for cases with well-controlled symptoms and blood pressure and preserved, stable renal function. Historically, surgical reconstruction with in situ or more complex ex vivo reconstruction has been described for the treatment of uncontrolled hypertension with preservation of renal perfusion. Nephrectomy, either partial or total, for control of hypertension, is reserved for cases where parenchymal injury necessitates this radical intervention. Recently, endovascular stenting of the renal artery has shown excellent and durable results and is now considered to be the first-line intervention for renal artery dissection. Renal malperfusion associated with complicated aortic dissection is a different entity and one that is consistently an independent predictor of poor prognosis. The pathogenesis of malperfusion can be dynamic, static, or a combination. In addition, renal hypoperfusion may occur with or without extension of the intimal flap into the renal artery itself. Traditional open surgical interventions to treat aortic dissection with malperfusion have a very high perioperative mortality rate. Endovascular fenestration and stenting of both the thoracic aortic and its branch vessels have significantly improved clinical outcomes in complicated aortic dissections relative to open surgical fenestration. Although a significant body of long-term data has yet to be accumulated, endovascular stent grafting has the added advantage over fenestration that it may affect aortic remodeling and prevent the very morbid complication of aneurysmal degeneration.

Median Arcuate Ligament Compression of the Mesenteric Vasculature

Compression of the celiac artery by fibrous bands of the diaphragmatic crura has been associated with gastrointestinal symptoms such as postprandial pain and delayed gastric emptying, a phenomenon known as median arcuate ligament syndrome. The hemodynamic effects of this compression have also been implicated in the development of aneurysms of the celiac artery or its visceral collaterals. Both open surgical decompression and laparoscopic decompression of the celiac artery have proven effective in the treatment of the compressive syndrome. Endovascular stent placement has largely supplanted open surgical reconstruction for residual stenosis following surgical decompression but is not recommended as the sole treatment modality due to high failure rates. Endovascular techniques have also become the mainstay of management of aneurysmal disease associated with celiac artery compression.

Anatomic popliteal entrapment syndrome is often a difficult diagnosis.

Anatomic popliteal artery entrapment can be challenging to diagnose. Four cases are described in which initial diagnosis and treatment failed to identify and correct the anatomic defect responsible for patients’ symptoms. In 3 of these cases, initial assessment and diagnosis was exertional compartment syndrome, yet compartment release did not resolve the complaint. Following accurate diagnosis, surgical release of aberrant popliteal fossa anatomy provided all 4 patients with lasting symptom resolution, though 1 patient with bilateral operations has had relief of only 1 side. In the diagnostic algorithm for these patients, angiography with forced plantarflexion against resistance aids in eliciting the pathognomonic images of arterial occlusion in this disorder.

Results of external iliac artery reconstruction in avid cyclists

OBJECTIVE We report the midterm results of external iliac artery reconstruction in 25 high-performance cyclists. METHODS Cyclists undergoing arterial reconstruction for symptomatic external iliac arteriopathy at a single institution between October 2004 and August 2010 were identified. With Institutional Review Board approval, data were collected from medical record review and telephone interview. Results were analyzed with χ(2) or independent t-test. RESULTS Twenty-five patients (31 limbs) underwent operation, which included arterial reconstruction with or without inguinal ligament release. The average patient age at operation was 43.8 ± 5.0 for graft and 35.1 ± 1.9 for patch (P = .08). The average time from competitive cycling until operation was 18.2 ± 5.8 years for graft and 20.0 ± 2.5 for patch repairs (NS). Patients included 14 males and 11 females. There were 23 unilateral and four bilateral arterial reconstructions, including 26 patch angioplasties for localized disease and five interposition grafts for extensive disease; three patients underwent contralateral reconstruction as a separate procedure. Concomitant ipsilateral inguinal ligament release was performed in 25 patients (28 limbs), with contralateral release done in 12 patients (12 limbs). Three patients with isolated ligament release required subsequent arterial intervention. Follow-up averaged 32 months (range, 2-74). Primary patency for all reconstructions was 100%; the four reoperations (five limbs; one bilateral) were for symptom recurrence, two postgraft and two postangioplasty. Three reoperations were for recurrent intimal hyperplasia, one for disease distal to the anastomosis, and one for concomitant atherosclerotic disease. Based on available data, postexercise ankle-brachial indices were improved in 18 of 23 limbs. Seventeen patients completed questions regarding satisfaction: 10 were satisfied or very satisfied (zero graft, 10 patch; P = .25), while four were unsatisfied (three graft, two patch; P = .017, including one patient with both a patch and graft repair). All 20 patients for whom follow-up data were available are still cycling, 10 competitively. Two of the four reoperated patients were unsatisfied; all four are still cycling, one competitively. CONCLUSIONS External iliac arteriopathy is a disease of prolonged, sustained, and repetitive trauma. Patch angioplasty yields a low rate of reoperation, more satisfied patients, return to competitive activity, and improvement in postexercise ankle-brachial indices. Interposition grafting is associated with slightly older patients, more extensive disease, and less satisfying results. Intimal hyperplasia is the most frequent complication necessitating reoperation. Both the decision to pursue arterial reconstruction and patient expectations must be tempered by the pattern of disease and the potential for unsatisfactory results.

Surgeon, not institution, case volume is associated with limb outcomes after lower extremity bypass for critical limb ischemia in the Vascular Quality Initiative

Objective Studies from large administrative databases have demonstrated associations between institutional case volume and outcomes after lower extremity bypass (LEB). We hypothesized that increased institutional and surgeon volume would be associated with improved outcomes after LEB. Using a national, prospectively collected clinical database, the objective of this study was to determine the effects of both surgeon and institutional volume on outcomes after LEB. Methods The Vascular Quality Initiative (VQI) was queried to identify all LEBs for critical limb ischemia or claudication between 2004 and 2014. Average annual case volume was calculated by dividing an institutions or surgeons total LEB volume by the number of years they reported to the VQI. Institutional and surgeon volumes were analyzed as continuous variables to determine the impact of volume on major adverse cardiac events (MACEs), major adverse limb events (MALEs), graft patency, and amputation‐free survival. Hierarchical regression models were used with cases clustered by surgeon and center. Time‐dependent outcomes were evaluated with multivariable shared frailty Cox proportional hazards models. Results From 2004 to 2014, there were 14,678 LEB operations performed at 114 institutions by 587 surgeons. Average annual institutional volume ranged from 1.0 to 137.5 LEBs per year, with a median of 26.9 (interquartile range, 14‐45.3). Average annual surgeon volume ranged from 1 to 52 LEBs per year with a median of 5.7 (interquartile range, 2.5‐9.3). Institutional LEB volume was not associated with MACEs or MALEs or with loss of patency. However, average annual surgeon volume was independently associated with reduced MALEs and improved primary patency. Institutional and surgeon volume did not predict MACEs. Conclusions In contradistinction to previous studies, there was no relationship in this study between institutional LEB volume and outcomes after LEB. However, greater average annual surgeon volume was associated with improved primary patency and decreased risk of MALEs. Open LEB remains a safe and effective procedure for limb salvage. Limb‐related outcomes in critical limb ischemia and claudication will be optimized if surgeons maintain adequate volume of LEB.

Surgical Treatment of Great Vessel Occlusive Disease

Occlusive disease of the supra-aortic trunks remains a diagnostic and therapeutic challenge to the surgeon. Although most cases in Western series are attributable to atherosclerotic disease, other entities such as Takayasu arteritis and radiation arteritis account for a substantial subset of patients in whom choice of therapy and clinical response may be significantly affected by the peculiarities of the disease process involved. This article reviews the anatomy, causes, and diagnosis of occlusive disease of the supra-aortic trunks. The indications, techniques, and outcomes of reconstruction are also discussed.