Michael J. Hallisey

STENT PLACEMENT FOR TREATMENT OF MESENTERIC ARTERY STENOSES OR OCCLUSIONS

PURPOSE To evaluate stent placement in the treatment of mesenteric ischemia. PATIENTS AND METHODS Twelve patients (eight women, four men; mean age, 63 years) with chronic mesenteric ischemia underwent stent placement for stenoses or occlusions during a 5.5-year period. Nine patients with 10 stenoses (three celiac arteries, seven superior mesenteric arteries) and three patients with three chronic occlusions (two superior mesenteric arteries, one aortosuperior mesenteric artery bypass graft) were treated. RESULTS Initial technical success was achieved in 11 of the 12 patients (92%), including all three patients with chronic occlusions. There were no technical complications. There was one postprocedural death (<30 days) due to bowel ischemia and infarction, despite a technically successful procedure. Clinical follow-up was available in all 12 patients, with a mean follow-up of 15.7 months (range, 0-38.5 months). Primary and primary-assisted patency up to 18 months was 74% (standard error [SE], 13%) and 83% (SE, 11%), respectively. Secondary patency was 83% (SE, 11%) at 3 years. All three patients (100%) with chronic occlusions had relief of clinical signs and symptoms at a mean follow-up of 22 months (range, 13-38.5 months). CONCLUSIONS Stent placement is safe and clinically effective as an adjunctive therapy to angioplasty or as a primary method of treatment for chronic mesenteric ischemia in patients with focal visceral artery stenoses or occlusions.

Angioplasty for the Treatment of Visceral Ischemia

PURPOSE To evaluate percutaneous transluminal angioplasty (PTA) in the treatment of visceral ischemia. PATIENTS AND METHODS Over a 14-year period, 25 focal visceral artery stenoses were treated with PTA in 16 patients with acute or chronic visceral ischemia. Thirteen patients were women and three were men, with a mean age of 64.7 years (range, 54-79 years). PTA was performed in seven celiac arteries, 17 superior mesenteric arteries, and one inferior mesenteric artery. RESULTS PTA was technically successful in 14 of 16 patients (88%). Two patients were lost to follow-up. Nine of 12 patients (75%) demonstrated primary patency with relief of clinical symptoms at a mean follow-up of 2.3 years (range, 0.3-5 years). The remaining three patients underwent successful repeat PTA for recurrent symptoms. There was one postprocedural death, and one patient subsequently underwent successful surgical bypass for recurrent visceral ischemia. CONCLUSIONS Angioplasty of the visceral arteries may provide relief for select patients with intestinal ischemia, but redilation may be required in some patients.

Vascular Diseases: Surgical and Interventional Therapy

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Percutaneous transluminal stent placement in the abdominal aorta.

PURPOSE To retrospectively review and to report the results of stent placement for focal mid-abdominal aortic stenoses. MATERIALS AND METHODS During a 4-year period, 10 focal mid-abdominal aortic stenoses were treated with stent placement in nine patients (six women and three men; mean age, 61 years; range, 49-73 years). All of the stenoses were atherosclerotic in nature except for one at the proximal anastomosis of an aortobi-femoral graft, which may have been from fibrointimal hyperplasia. Seven of the 10 stenoses were treated with primary stent placement, whereas three were treated with stent placement after suboptimal angioplasty. RESULTS The technical success rate was 100%. Clinical success, defined as complete elimination or improvement of symptoms present before stent placement, was achieved in eight of the nine patients with a mean duration of follow-up of 1.6 years (range, 0.2-3.0 years). CONCLUSION In view of the excellent technical and clinical success, the authors believe that stent placement should be considered as an adjective therapy to angioplasty or as a primary method of treatment in properly selected patients with focal mid-abdominal aortic stenoses.

Percutaneous Transluminal Angioplasty of the Abdominal Aorta

PURPOSE To determine the long-term results of percutaneous transluminal angioplasty (PTA) of focal infrarenal abdominal aortic stenoses. PATIENTS AND METHODS Over a 10-year period, 15 focal infrarenal abdominal aortic stenoses were treated with PTA in 14 patients (13 women and one man; mean age, 53.2 years; range, 43-78 years). RESULTS The initial technical success rate was 100%. Clinical patency, as defined by continued absence or improvement in symptoms after PTA, was achieved in 14 of the 15 angioplasty procedures (93%) with a mean duration of clinical follow-up of 4.3 years (range, 0.6-9.8 years) in the 14 patients. Long-term noninvasive follow-up demonstrated continued patency of the angioplasty site in 11 of 11 patients available for study. The mean ankle-arm index in these 11 patients was 0.95 (range, 0.9-1.0) at a mean follow-up of 4.8 years (range, 0.6-9.8 years). There was no significant morbidity or mortality associated with the angioplasty procedures. CONCLUSION In view of the high degree of technical success and the excellent long-term patency, we believe that PTA should be considered a primary method of treatment in properly selected patients with focal abdominal aortic stenoses.

A Transluminally Created Abdominal Aortic Aneurysm Model

Purpose To develop a stable, transluminally created abdominal aortic aneurysm (AAA) within a live animal model. Materials and Methods Eight mongrel dogs were utilized to evaluate a new, catheter-based technique for the creation of an AAA. With use of a standard angioplasty balloon and a balloon-expandable intravascular metallic stent, the infrarenal abdominal aorta was overdilated to twice its measured diameter into a fusiform shape AAA in eight dogs. At 30 days, aortography was performed, the dogs were killed, and the aorta was resected and evaluated for histopathology. Results Seven of the eight dogs that underwent transluminal AAA creation survived the initial procedure. A stable, fusiform AAA was successfully created in these seven dogs. At 30 days, repeat angiography and histologic examination confirmed that the seven AAAs were still twice the diameter of the normal aorta (a four-fold increase in luminal area), that the branch arteries remained patent, and that the lumen was endothelialized. One of the eight dogs was killed 9 hours after the procedure because of inability to awaken from anesthesia. Gross and histopathologic results in this one dog also demonstrated an intact aorta containing an AAA. Conclusions A stable, infrarenal AAA model can be successfully created in the canine species with use of standard catheter-based techniques and equipment. This model can be used to test emerging endovascular treatments of AAA.

Direct Percutaneous Jejunostomy

PURPOSE Enteral feeding via gastrostomy or gastrojejunostomy tubes has an established role in patients unable to maintain adequate oral intake. However, creation and maintenance of a site for long-term nutritional support can be significant problems in patients who have undergone previous surgery or in patients with chronic aspiration, abnormal stomach position, or recurrent inadvertent tube dislodgment. Direct percutaneous jejunostomy (DPJ) tube placement performed with fluoroscopic guidance was evaluated in these patients. PATIENTS AND METHODS Fourteen DPJ tube placements for enteral feeding were attempted in 13 patients with use of local anesthesia, fluoroscopic guidance, the Seldinger technique, and jejunopexy. There were nine male and four female patients with a mean age of 75.2 years (range, 45-95 years). RESULTS DPJ was successful in 11 of 13 patients. A mean follow-up of 58.9 days (range, 3-291 days) was obtained in all 11 patients. CONCLUSIONS DPJ is a safe and viable alternative for the creation and maintenance of long-term enteral tube feeding, particularly in patients with underlying esophagogastric malignancy, recurrent inadvertent tube dislodgement, or previous gastric surgery.

Use of angioplasty in the prevention and treatment of coronary--subclavian steal syndrome.

PURPOSE The coronary-subclavian artery steal (CSS) syndrome is caused by critical stenosis in the subclavian artery proximal to a bypass graft from the internal mammary artery (IMA) to the coronary artery. The stenosis results in retrograde flow in the IMA and steal from the coronary artery. PATIENTS AND METHODS Percutaneous transluminal angioplasty (PTA) was performed in eight patients (five men, three women). In four patients (group 1), coronary ischemia had developed 0.5-70 months (mean, 31 months) after IMA-to-coronary artery bypass surgery. These four patients (mean age, 58 years; range, 44-68 years) underwent PTA of a single area of focal subclavian stenosis to treat CSS. In four other patients (group 2), atherosclerotic subclavian stenosis had developed proximal to a donor IMA before planned bypass surgery. These patients (mean age, 53 years; range, 50-57 years) underwent PTA of a single focal subclavian stenosis to prevent CSS. RESULTS Group 1 patients were free of myocardial ischemia at follow-up (mean follow-up, 39.0 months; range, 14-101 months). Three of four patients in group 2 underwent coronary artery bypass grafting with the ipsilateral IMA following PTA of the subclavian stenosis; they were free of angina at follow-up (mean follow-up, 14 months; range, 10-18 months). CONCLUSION PTA is a safe and efficacious short-term method for prevention and treatment of CSS syndrome.

Morbidity and Mortality Associated with Renal Insufficiency and Endovascular Repair of Abdominal Aortic Aneurysms: A 5-Year Experience

To evaluate the outcome of patients with renal insufficiency undergoing endovascular repair of abdominal aortic aneurysm (AAA), data were prospectively collected between 1998 and 2003 on patients undergoing elective repair of their AAA with a stent graft. The patients were divided into 2 groups: those with serum creatinine (Crs) concentrations <1.2 (Group A) and those with Crs = 1.2 mg/dL not requiring hemodialysis (Group B). The outcomes of the procedure for these 2 groups were compared. Different variables that existed between the 2 groups and contributed to mortality included estimated blood loss (EBL), volume of contrast used in the operating room, incidence of diabetes (DM), tobacco use, and history of myocardial infarction (MI). In total, 213 patients underwent elective repair of their AAA with use of a stent graft: 61% who had a Crs <1.2 mg/dL (Group A) and 39% who had a Crs =1.2 mg/dL not requiring dialysis (Group B). Among 129 patients with normal renal function there was an 18.6% complication rate and 1.6% mortality rate. Of 83 patients with renal insufficiency not on hemodialysis 30.1% (Fishers Exact Test = 0.076) had 1 or more complications and there was a 6% (Fishers Exact Test = 0.166) mortality rate. One patient in Group A (0.8%) progressed to hemodialysis and 5 (6%) patients in Group B progressed to end-stage renal disease requiring hemodialysis (p=0.068). A statistically significant higher proportion of the patients in Group B had a history of MI (p<0.001). There was no difference in the amount of EBL between the 2 groups, but a significantly lower amount of contrast (p<0.05) was used in patients with renal insufficiency.

Upper extremity thrombolysis

Recognition and appropriate treatment of upper extremity deep venous thrombosis is critical because it may be associated with significant acute and chronic morbidity. Thrombolysis has been shown to be a safe and effective method of reestablishing venous patency in both primary and secondary axillosubclavian vein thrombosis. Thrombolysis is currently an important component of a multidisciplinary approach to treating upper extremity deep venous thrombosis. The technique of upper extremity thrombolysis and its role in the management of upper extremity deep venous thrombosis is discussed in this article. In addition, a simplified algorithmic approach to treating both primary and secondary axillosubclavian vein thrombosis is presented.