Mathew Wooster

Axillary Artery Access as an Adjunct for Complex Endovascular Aortic Repair.

BACKGROUND The aim of this study was to review and compare our experience with 3 upper extremity access techniques (percutaneous single-sheath brachial, multi-sheath brachial cutdown, and axillary cutdown with conduit construction) in the setting of complex endovascular repair of paravisceral aneurysms. METHODS We performed a retrospective review of a prospectively collected endovascular aneurysm repair database. All patients who underwent parallel stent grafting or fenestrated repair with upper extremity arterial access were included. End points included the following: (1) local access complications, (2) number of vessels successfully snorkeled, and (3) technical success. RESULTS Fifty patients underwent treatment for paravisceral aneurysms using a combination of snorkel and fenestration techniques. All cases used one of the 3 upper extremity arterial access techniques--percutaneous single-sheath brachial, multi-sheath brachial cutdown, and axillary cutdown with conduit construction. Eighteen patients underwent open brachial exposure (15 for single vessel snorkel, 2 for two vessel snorkel, 1 for 4 vessel snorkel) with zero access site complications. Five patients underwent percutaneous brachial access (all for single vessel snorkel) with 2 brachial artery injuries and 1 median nerve injury. Twenty-seven patients underwent open axillary exposure with the conduit/sheath technique (1 for single vessel, 15 for two vessel, 6 for three vessel, and 5 for four vessel snorkel) with 2 access site hematomas requiring surgical evacuation. Successful cannulation of 95 of the 97 vessels was achieved. CONCLUSIONS Upper extremity arterial access is required to snorkel one or more of the visceral vessels during complex endovascular pararenal aortic aneurysm repair. There are several techniques of arm access that can be used. Brachial access is appropriate when a single visceral vessel must be cannulated, and by utilizing the conduit/sheath combination presented here, it is possible to safely approach multiple visceral vessels from an axillary access. Further evolution of this technique will expand our ability to treat complex paravisceral aneurysms.

Late Longitudinal Comparison of Endovascular and Open Popliteal Aneurysm Repairs

BACKGROUND We sought to define suitable anatomy predicting durable exclusion of popliteal artery aneurysms (PAAs) and define optimal patient selection criteria for endovascular repair (ER). METHODS Seventy-five PAAs were repaired in 66 patients (64 male and 2 female) over the past 13 years. Fifty-two aneurysms (69%) were treated with open surgical exclusion and/or bypass using autologous vein (69%) or polytetrafluorethylene (31%) conduit. Extended bypass targets required inflow from the common femoral artery in 15% of limbs and outflow via a tibial artery in 31%. Since May 2001, ER was considered in patients with high medical risk, limited vessel tortuosity, absence of significant occlusive disease (ankle-brachial index > 0.9), and PAA not involving below knee segments. Interventions were performed via antegrade femoral access in 23 limbs (31%) using commercially available endografts. Device diameters ranged between 7 and 13 mm, with a median of 2 devices per PAA, and mean treatment length was 22 cm (range, 5-36 cm). All patients were followed with duplex ultrasound surveillance and were prescribed clopidogrel and/or aspirin. RESULTS Patients treated endovascularly were older (82 vs. 70 years old, P = 0.01), but had shorter length of stay (2 vs. 12 days, P = 0.01) and lower complication rates (8% vs. 17%, P = 0.02). Mean surveillance interval was 39 months with similar 4-year survival (67.9% open and 73.7% endovascular). Primary and secondary patencies were 67.2%, 67.2% after ER and 65.5%, 78.4% for open at 4 years, respectively. Four of 6 endovascular failures were thrombosis within 4 months of intervention and had conversions to open repair (OR). Secondary interventions were required after 48.1% of endovascular and 54.1% of ORs. Three limbs were lost in the series (2 open and 1 endovascular). CONCLUSIONS Similar outcomes can be expected after endovascular and open PAA repair with adherence to specific anatomic and technical selection requisites.

Long-Segment Plication Technique for Arteriovenous Fistulae Threatened by Diffuse Aneurysmal Degeneration: Short-term Results

BACKGROUND A substantial number of patients with autologous arteriovenous fistulas (AVFs) develop diffuse aneurysmal degeneration, which frequently interferes with successful access. These AVFs are often deemed unsalvageable. We hypothesize that long-segment plication in these patients can be performed safely with acceptable short-term AVF salvage rates. METHODS We reviewed a prospectively maintained database to identify all patients with extensive AVF aneurysmal disease operated on for this problem. RESULTS Thirty-five patients, 25 (71%) male and 10 (29%) female were operated on between July 2012 and January 2014. AVFs included 23 (66%) brachiocephalic, 5 (14%) radiocephalic, and 7 brachiobasilic (20%) fistulae (one first stage only but in use). The cohort had one or a combination of local pain, arm edema, cannulation issue, recurrent thrombosis, dysfunctional during dialysis, or extreme tortuousity. Time range for AVF creation to consultation ranged from 3 months to 11 years. All underwent long-segment plication over a 20-Fr Bougie with or without segmental vein resection; 3 underwent concomitant first rib resection for costoclavicular stenosis; 21 patients had tunneled catheter placement for use while healing, whereas 13 were allowed segmental use of their AVF during the perioperative period (1 patient was not yet on dialysis). Early in our experience, AVFs were left under the wound, whereas all but one repaired since early 2013 were left under a lateral flap. All patients were followed by clinical examination and duplex. In the 30-day postoperative period, 2 AVFs (5.7%) became infected requiring excision, 2 occluded (5.7%), 1 day 1 and the other at 24 days out, 1 patient developed steal and required DRIL 1 week postoperatively, and 1 patient died, unrelated to his surgery. Postoperative functional primary patency was 88% (30 of 34). Of the patients needing temporary access catheter, mean time to first fistula use was 44 days. No wound or bleeding complications have occurred in repaired AVF left under skin flaps. CONCLUSIONS In this group of patients whose access was threatened by diffuse aneurysmal degeneration, long-segment placation allowed salvage of 88% of fistulae with relatively low morbidity. Fewer complications are associated by covering the revised fistula with intact skin.

Early Post-Registry Experience With Drug-Eluting Stents in the Superficial Femoral Artery

Objective: Restenosis remains the primary failure mode after stent placement in the superficial femoral artery (SFA). Drug-eluting technology aims to reduce intimal hyperplasia and subsequent stent failure, improving durability for endovascular management of SFA occlusive disease. We present our early experience with the Cook Zilver PTX stent. Methods: We retrospectively reviewed a prospectively collected database of patients undergoing placement of the Cook Zilver PTX stent for SFA or popliteal disease since its availability to our institution in October 2013. Patients treated with additional non-PTX stents were excluded. Patient demographics, comorbidities, concomitant procedures, TASC classification, procedural details, and follow-up were reviewed. Results: Thirty-one limbs in 30 patients were treated with Zilver PTX stents, 5 limbs were excluded for concomitant use of non-PTX stents, leaving 26 limbs in 26 patients for analysis. Indications for intervention were claudication in 17 (65.4%), rest pain in 1 (3.8%), and tissue loss in 8 (30.8%). A median of 2 PTX stents per limb was used to treat a mean length of 14.2 ± 11 cm with technical success of 100%. Concomitant inflow (N = 4) or atherectomy (N = 2) interventions were performed in 23%. Sixty-nine percent of lesions were TASC C (N = 7) or D (N = 11) and 42% were total occlusions. Over a mean 20-week follow-up, 2 occlusions were noted (mean 27 weeks), one was treated with surgical bypass and the other with endovascular salvage. Limb salvage in the series was 92.3% with 2 patients requiring major amputations for infected, non-healing wounds, despite patent stents. Conclusion: On mean 20-week follow-up, we have seen 92.3% primary patency and 96.2% secondary patency. A larger number of patients and longer follow-up will be required to determine the true real-world efficacy of this drug-eluting device, but early experience is encouraging and warrants continued trial.

True extracranial carotid artery aneurysm in a child

Isolated true aneurysm of the extracranial carotid artery is a rare entity in the pediatric population, with nine reported cases found in the literature. Contrary to adult carotid aneurysms, which are often due to atherosclerotic disease, pediatric aneurysms are more likely to be the result of congenital malformations, connective tissue diseases, or systemic inflammatory conditions. We present the case of a 10-year-old boy with an isolated true aneurysm of the internal carotid artery and a review of the literature.

Integrated Vascular Surgery Resident Satisfaction.

BACKGROUND This is the first survey to assess and quantify the level of satisfaction among the integrated vascular surgery residents. METHODS An anonymous 13-question survey was electronically distributed to 225 members of the Society of Vascular Surgery Resident listserv. The questions were a combination of multiple choice, free response, and 5-point Leichhardt scale. Satisfaction was defined as a score of 3 or higher on a 5-point scale. RESULTS Sixty-nine of 225 responded to the survey with fairly equal distribution across the postgraduate years. Trainees reported high rates of satisfaction, >90%, with regards to faculty, educational curriculum, case selection, their peers and interactions with the general surgery residents and faculty. Among nonvascular rotations, critical care, acute care services and/or trauma and cardiothoracic were most frequently rated as satisfactory (100%, 95%, and 92%, respectively). Minimally invasive and bariatric were rated as least satisfactory at 47% and 44%. CONCLUSIONS Overall vascular residents are satisfied with various aspects of their respective programs. Critical care, acute care services and/or trauma, and cardiothoracic were most universally deemed beneficial to overall education, whereas other rotations have more diverse responses, suggesting very program-specific distinctions between the services.

Intraoperative Gutter Leaks That Merit Our Attention

Introduction: The natural history and potential morbidity of gutter endoleaks are unclear. We present our experience with intraoperative gutter endoleaks and strategies to determine which of these require intervention. Methods: This is a retrospective review of all patients treated with parallel stent grafts from January 2010 to September 2015. We reviewed all operative records and intraoperative angiograms as well as all postoperative imaging and secondary interventions. All gutter leaks were classified as low-flow/nonsac-enhancing gutter endoleaks or high-flow/sac-enhancing gutter endoleaks. Adjunctive interventions to manage the gutter leaks were noted, as were all subsequent interventions for gutter leak and endoleak management. Results: Seventy-eight patients had 144 parallel stents placed over a 5-year period with an average of 1.8 stents per patient. Twenty-eight patients (36%) had gutter endoleaks diagnosed intraoperatively. Seventeen patients had adjunctive procedures to reduce gutter leaks prior to leaving the operating room (OR). Patients selected for treatment had gutters filling early during completion angiography and/or contrast enhancement of the aneurysm sac. Twenty-two patients (28%) left the OR with low-flow/delayed/nonsac-enhancing gutter endoleaks. At 30 days, a total of 6 persistent gutter endoleaks were diagnosed on computed tomographic angiography. This gives a 73% rate of resolution for low-flow/nonaneurysm sac-enhancing endoleaks. There were 2 de novo endoleaks not detected at the index procedure diagnosed at 6-month follow-up. Of the 8 total postoperative endoleaks, 5 required additional intervention with a 100% success rate. Multivariate analysis revealed that the only significant predictor of having a postoperative endoleak is leaving the OR with an endoleak. Conclusions: Intraoperative treatment of gutter endoleaks has an acceptable rate of resolution. It does have a high rate of converting high-flow endoleaks to low-flow endoleaks. Low-flow/nonsac-enhancing gutter endoleaks have a high rate of spontaneous resolution. Intraoperative gutter endoleaks are not predictive of future aneurysm sac growth.

IP005. Who Should Fix the Bowel

administrative data set would demonstrate disparities based on race with respect to access to this latest technology and the associated outcomes following EVAR. Methods: Using deidentified data from the Florida State Agency for Health Care Administration, we identified patients based on International Classification of Diseases-Ninth Revision procedure codes who underwent EVAR between the years 2000 and 2014. We then assigned these procedures with the specialty of the operating physician and then analyzed outcomes based on the race of the patient defined within the following groups: non-Hispanic white, non-Hispanic black, Hispanic, Asian, and other. We also analyzed differences in insurance/payer data. We then stratified patients and patient outcomes based on the classification of the practitioner performing the surgery. Results: We identified 36,601 EVAR procedures during the study period. The average age of the total sample was 73.38 6 9.87 years, with 81.2% (n 1⁄4 29,034) of the cohort being male. Breakdown of patients within each race category was as follows: 17,056 non-Hispanic whites (47.7%), 1630 non-Hispanic African Americans (4.6%), 16,431 Hispanics(46.0%), and 632 patients (1.8%) identified as “other.” An analysis of the differences between racial groups in demographic/background data showed significant differences between age at presentation, sex of patient, and comorbidity score of patients at presentation. There were significant differences in outcomes based on race with respect to total hospital charges, length of stay, and disposition. The Table shows the breakdown of the above analysis with associated significance values. Significant differences were also found in the payer status based of each racial group. There were 1786 practitioners who completed 35,749 EVARs where both practitioner and race data were available. Stratifying by type of practitioner treating, we also found significant differences in the type of practitioner treating the various racial groups as well as the academic status of the practitioner. Conclusions: Racial disparities were discovered with respect to EVAR treatment. African Americans present at younger ages, have the highest percentage of females requiring intervention, have the longest hospital stays, have the highest Medicaid payer source, and have the highest in-hospital total charges of any racial group. Hispanics present with the highest comorbidity scores as compared to their counterparts.

IP043. Hypogastric Preservation Using Retrograde Endovascular Bypass

Objectives: Maintenance of pelvic circulation reduces risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluated the mid to late follow-up of patients treated using one preservation technique, the endovascular external-to internal iliac artery (EIA-IIA) bypass. Methods: All patientsundergoing retrogradeEIA-IIAendovascular bypass were retrospectively reviewed from 2006 to 2016. Anatomic inclusion criteria were common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliacbifurcationangle>45 . Procedureswereperformedusingaortouniiliac (AUI) endografts extended to one EIA, cross femoral artery bypass, and retrograde placement of covered stent grafts into the contralateral IIA. For patients with prior open repair, AUI placement was not required. Surveillance included duplex ultrasound imaging 1 month and 6 months postoperatively, andannually thereafterwithcomputed tomographyCT scan (with selective contrast usage) 1 month postoperatively and annually thereafter. Results: Seventeenpatients (meanage, 70 years; 93%male)were treated over the period. Most were treated for primary disease (n 1⁄4 11), while the remainder underwent secondary interventions following open repair (n 1⁄4 4) or endovascular repair (n 1⁄4 2). Nine patients had bilateral common iliac aneurysms, one had bilateral IIA aneurysms, and the remainder had unilateral iliac aneurysmal degeneration with occluded or severely diseased ipsilateral hypogastric arteries. There was no preference for laterality (right iliac, n1⁄4 8; left iliac, n1⁄4 9). Retrograde bypasses were performed using Fluency (n1⁄4 1), Viabahn (n1⁄4 13), or Gore Excluder (n1⁄4 3) grafts. Hypogastric embolization with AUI extension to the EIA was required in six patients. Proximal extension requiring snorkel/fenestration was present in five patients. Technical success was 100%, with a mean operative time of 168 minutes (range, 50-300 minutes), and 71 mL contrast usage (range, 30-115 mL). Mean preoperative iliac artery aneurysm size was 4.0 cm with iliac bifurcation angle 71 (range, 51 -102 ). Median length of stay was 3 days (range, 1-13 days). Over a mean follow-up of 25.7 months, there were no aortic related deaths, one EIA-IIA bypass occlusion (asymptomatic), and one reintervention (for type II endoleak). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, paralysis, and bowel/bladder dysfunction was zero in the series. Conclusions: Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation.

Comparison of the integrated vascular surgery resident operative experience and the traditional vascular surgery fellowship

Objective: After almost 10 years since its approval, residents in integrated vascular surgery training programs now outnumber traditional vascular fellows. We examined the Accreditation Council for Graduate Medical Education (ACGME) case log data to assess whether there is a difference in operative experience between the graduating integrated residents and vascular fellows. Methods: We analyzed the total clinical experience of vascular surgery trainees during the academic years between 2012 and 2014 for the 30 graduated integrated vascular surgery residents (VSRs) and the 243 graduated vascular surgery fellows (VSFs). Data were compared on the basis of reported categories defined by the ACGME operation reporting system. VSR case totals were calculated by combining “surgeon chief,” “surgeon junior,” and “secondary procedures” categories. VSF “surgeon fellow” and “secondary procedures” case totals were combined with all vascular cases done in general surgery residency (using averages of general surgery resident ACGME case log data from the same years) to reflect their total vascular experience. Results: The average total vascular experience reported by VSRs was 1446.0 compared with 1421.8 for VSFs (P = .2086). VSRs performed 694.7 major vascular procedures on average compared with 616.3 major cases for VSFs (P = .0106). Highlighted comparisons include the following: open aortic aneurysm cases, VSRs 20.6 and VSFs 22.2 (P = .320); endovascular aortic aneurysm cases, VSRs 80.0 and VSFs 80.6 (P = .945); cerebrovascular cases, VSRs 78.8 and VSFs 85.0 (P = .1132); and peripheral obstructive cases, VSRs 343.6 and VSFs 293.4 (P = .0032). Conclusions: Integrated VSRs and traditional VSFs graduate with comparable overall vascular surgery clinical experience. VSRs reported, on average, a significantly higher number of major vascular procedures during their tenure as trainees as well as a significantly increased number of cases in six of the other ACGME categories.