Mohsen Bannazadeh

A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia

OBJECTIVESnFew centers have adopted endovascular therapy for the treatment of acute mesenteric ischemia (AMI). We sought to evaluate the effect of endovascular therapy on outcomes for the treatment of AMI.nnnMETHODSnA single-center, retrospective cohort review was performed on all consecutive patients with thrombotic or embolic AMI presenting between 1999 and 2008. Patients with mesenteric venous thrombosis, nonocclusive mesenteric ischemia, and ischemia associated with aortic dissection were excluded. Demographic factors, preoperative metabolic status, and etiology were compared. Primary clinical outcomes included endovascular technical success, operative complications, and in-hospital mortality.nnnRESULTSnSeventy consecutive patients were identified with AMI (mean age, 64 ± 13 years). Etiology of mesenteric ischemia was 65% thrombotic and 35% embolic occlusions. Endovascular revascularization was the preferred treatment (81%) vs operative therapy (19%). Successful endovascular treatment was achieved in 87%. Endovascular therapy required laparotomy in 69% vs traditional therapy in 100% (P < .05), with a median 52-cm necrotic bowel resected (interquartile range [IQR], 11-140 cm) vs 160 cm (IQR, 90-250 cm; P < .05), respectively. Acute renal failure and pulmonary failure occurred less frequently with endovascular therapy (27% vs 50%; P < .05 and 27% vs 64%; P < .05). Successful endovascular treatment resulted in a mortality rate of 36% compared with 50% (P < .05) with traditional therapy, whereas the mortality rate for endovascular failures was 50%. Endovascular therapy was associated with improved mortality in thrombotic AMI (odds ratio, 0.10; 95% confidence interval, 0.10-0.76; P < .05).nnnCONCLUSIONSnEndovascular therapy has altered the management of AMI, and there are measurable advantages to this approach. Using endovascular therapy as the primary modality for AMI reduces complications and improves outcomes.

Endovascular therapy for acute limb ischemia

BACKGROUNDnAcute limb ischemia (ALI) of the lower extremities remains a challenging clinical dilemma. Treatment of ALI has shifted toward endovascular therapies. The purpose of this study was to assess outcomes in patients treated for ALI with intra-arterial thrombolysis and/or adjuvant endovascular techniques.nnnMETHODSnConsecutive patients with ALI of the lower extremities treated via endovascular intra-arterial methods between January 1, 2005 and September 30, 2007 were identified and reviewed. Comparisons of success, thrombolysis days, and all 30-day outcomes except mortality were performed using generalized estimating equations with logistic and proportional odds regression. Thirty-day mortality was assessed using logistic regression. Long-term patency, limb salvage, and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models.nnnRESULTSnThe analyzed dataset included 129 limbs treated in 119 patients presenting with ALI (class I 68%, class IIa 23%, class IIb 9%). The mean follow-up was 16.8 months (range: 0-43 months). Technical success was achieved in 82% cases. The 30-day mortality rate was 6.0% with all 30-day deaths occurring in females (P = .002). One (0.76%) central nervous system hemorrhage (CNS) was noted in this cohort. Primary patency for the entire cohort at 12 and 24 months was 50.1% (95% confidence interval [CI], 39.5-60.7) and 37.7% (95% CI, 26.2-49.1), respectively, while secondary patency was 74.0% (95% CI, 64.9-83.1) and 65.3% (95% CI, 54.5-76.2). Multivariable analyses identified patients presenting with femoropopliteal (hazard ratio [HR] 2.63) or tibial thrombosis (HR 2.80); graft thrombosis (vs native artery thrombosis, HR 2.57) and long-term dialysis (HR 3.66, 95% CI, 2.35-5.71, P < .001) were associated with poorer primary patency rates. Cumulative limb salvage at 24 months was 68.8% (95% CI: 59.5-78.1) with female gender (HR 3.34, P = .002) and thrombolysis ≥ 3 days (HR 2.35, P = .019) associated with an increased risk of limb loss. Overall 36-month survival was 84.5% (95% CI: 77.5-91.6). Women had decreased survival rates both in the short- and midterm (HR 6.29; 95% CI, 1.78-22.28; P = .004).nnnCONCLUSIONSnEndovascular therapy with thrombolysis remains an effective treatment option for patients presenting with lower extremity ALI. Thrombolysis should be limited to <3 days. Female gender negatively affects the rates of limb salvage and survival.

Patterns of procedure-specific radiation exposure in the endovascular era: Impetus for further innovation

OBJECTIVEnAlthough patient preference and outcome data support continued development and use of minimally invasive endovascular therapies, only a few studies have documented radiation exposure to the patient. This report summarizes patient radiation exposure by endovascular procedure at Cleveland Clinic.nnnMETHODSnA retrospective review was undertaken of all endovascular procedures during a 30-month period. Procedures were categorized as infrarenal aortic aneurysm (IAA), isolated thoracic aneurysm (TA), visceral occlusive intervention, renal artery intervention, cerebrovascular intervention, cerebrovascular and lower extremity diagnostic, atherectomy, and lower extremity intervention. Radiation exposure was categorized by procedure. The estimated skin dose (ESD, mGy) and effective dose (ED, mSv) were calculated. Total computed tomography (CT) scans were tabulated for patients undergoing aneurysm stent grafting, and the cumulative ED was estimated. Statistical analyses were done with Kruskal-Wallis tests to detect overall differences, Wilcoxon rank sum exact tests for paired comparisons, and the Bonferroni post hoc test for group comparison.nnnRESULTSnFluoroscopy times were recorded in 2103 endovascular procedures. The more complex the procedure, the longer the fluoroscopy time and ESD. Patients undergoing atherectomy had significantly higher ESD, at 1260 mGy (900, 1542; P < .001) than all groups. When converting to ED, however, cerebrovascular intervention and IAA received the highest ED, at 120 mSV (100, 150 mSV) and 109 mSV (85, 151 mSV; respectively, P < .001) among other groups. TAA patients underwent a greater number of CT scans than IAA patients (7.4 +/- 0.3 vs 5.8 +/- 0.2; P < .004). Tabulating the cumulative ED, including procedure and CT scans, showed IAA patients had significantly higher doses of radiation exposure than TAA patients (217 +/- 5 vs 191 +/- 6; P < .004).nnnCONCLUSIONSnThe increasing complexity of endovascular interventions has resulted in increased radiation exposure to all involved, with the highest doses occurring in aneurysm repairs. Future innovations should concentrate on reducing the risk of radiation exposure to all personnel and developing newer imaging techniques.

Does sedation type affect colonoscopy perforation rates

BACKGROUND: Sedation with propofol is gaining popularity. It is unclear whether sedation with propofol is associated with colonoscopic perforation. OBJECTIVE: The purpose of this study was to compare perforation rates during colonoscopy using sedation with or without propofol. DESIGN: This was a retrospective case series study. SETTINGS: Data from a tertiary center were analyzed. Demographics, method of sedation, and type of endoscopic procedure performed were collected. PATIENTS: Patients who underwent a colonoscopy from January 2003 to October 2012 were analyzed. MAIN OUTCOME MEASURES: Perforation rate expressed per 10,000 colonoscopies was measured. RESULTS: A total of 118,004 colonoscopies were performed during the study period, with 48 perforations (0.041% or 4.1 per 10,000). Overall, the use of propofol was associated with a 2.5 times increased rate of perforation (6.9 vs 2.7 per 10,000; p = 0.0015). Similarly, in patients undergoing therapeutic colonoscopies, there was a 3.4-times increased risk of perforation associated with the use of propofol (8.7 vs 2.6 per 10,000; p = 0.0016). However, in patients undergoing diagnostic colonoscopies, there was no significantly increased risk of perforation with the use of propofol (4.2 vs 2.9 per 10,000; p = 0.64). In univariate and multivariate analyses, there were no differential perforation risks on the basis of sex, but each decade increase in age was associated with an increased risk of perforation. In those patients having a therapeutic colonoscopy, age (per decade) and propofol use were independently and significantly associated with an increased perforation risk, with adjusted ORs of 1.32 (p = 0.04) and 3.38 (p = 0.001). LIMITATIONS: This was a retrospective study with the potential for selection bias. CONCLUSIONS: This study shows that propofol administration is associated with an increased risk of colonoscopic perforation among patients undergoing a therapeutic colonoscopy; however, this association was not evident in patients undergoing a diagnostic colonoscopy. Further studies, such as a prospective, randomized clinical trial, should be done to further evaluate this association.

Midterm outcome predictors for lower extremity atherectomy procedures

PURPOSEnThe performance of atherectomy devices has been variable. The purpose of this study was to evaluate our experience using the SilverHawk atherectomy (Fox Hollow Technologies, Redwood City, Calif) device for lower extremity procedures to determine predictors of midterm success.nnnMETHODSnRecords of all patients who underwent lower extremity atherectomy with the SilverHawk atherectomy catheter were reviewed. Patient demographics, vessel treated, number of vessels treated, lesion characteristics, and postoperative courses were analyzed. Cumulative patency rates, limb salvage, mortality, and factors associated with outcomes were determined using the Kaplan-Meier Method with Cox Proportional Hazards modeling.nnnRESULTSnBetween January 2004 and January 2006, 167 vessels were atherectomized with the SilverHawk in 73 patients. There were 42 men and 31 women treated, and the mean age was 68.8 +/- 13.8. Five patients had both legs treated for a total of 78 legs treated. Of the 78 legs intervened on, 25.6% (20/78) had 1 vessel treated, 51.3% (40/78) had 2 vessels treated, 11.5% (9/78) had 3 vessels treated, 9% (7/78) had 4 vessels treated, and 2.6% (2/78) had 5 vessels treated. A total of 78% (61/78) of patients had intermittent claudication, 71% (56/78) had rest pain, and 58% (45/78) had tissue loss. Adjunctive procedures were performed in 63 vessels in 33 patients (61 percutaneous transluminal angioplasty [PTA] and 2 PTA + stent). Eighty-four vessels treated were totally occluded and 83 stenotic. Cumulative 1-year primary, primary assisted, secondary patency, limb salvage, and survival rates with confidence intervals, respectively, are: 43% (30,57), 49% (36,63), 57% (43,71), 75% (57,92), and 90% (80,100). Multivariable analysis demonstrated tobacco use, renal disease, diabetes, and tissue loss are all predictors of patency loss, while only diabetes and tissue loss were associated with greater limb loss. There was no difference in patency rates irrespective of location of Trans Atlantic Inter-Societal Consensus (TASC) classification, vessel treated (femoral vs tibial), or degree of stenosis (occluded vs stenotic). Also, multiple vessels treated in the same patients had no affect on patency. The mean ankle brachial index (ABI) pre-op was 0.57 +/- 0.19, and this increased to 0.81 +/- 0.21 (P < .001) at 30 days post-op.nnnCONCLUSIONnLower extremity atherectomy procedures with the SilverHawk device are safe and effective means in improving symptoms. However, there is decreased durability and significant patency and limb loss over time. Diabetes, renal disease, tobacco use, and tissue loss are all associated with inferior outcomes.

Reoperative Lower Extremity Revascularization with Cadaver Vein for Limb Salvage

We evaluated our experience using cryopreserved cadaver vein allografts (CVGs) for infrageniculate revascularization in patients with a history of failed bypass or no suitable autogenous vein. Records of all patients who underwent lower extremity revascularization with CVG for critical limb ischemia were reviewed. Patient demographics, vessel treated, and postoperative course were analyzed. Patients who had a redo cadaver vein bypass were compared to those with a first-time cadaver vein bypass. Cumulative patency rates, limb salvage, mortality, and factors associated with outcomes were determined using the Kaplan-Meier method with Cox proportional hazards. Between January 2000 and December 2006, 66 CVGs were done in 56 patients out of 1,726 total bypasses. There were 36 men and 20 women, and the mean age was 71.67 +/- 10.50 years. Mean follow-up was 12.12 +/- 14.16 months. Seventy-eight percent of patients had previous bypasses, and 50% of all failed bypasses were failed expanded polytetrafluoroethylene bypasses. Operative indications were tissue loss (73%) and ischemic rest pain (27%). The mean preoperative ankle-brachial index was 0.43 +/- 0.16, and this increased to 0.89 +/- 0.18 at 30 days (p = 0.001). Procedure-related complications included graft infection (3, 4%), graft thrombosis (3, 4%), pseudoaneurysm (3, 4%), and bleeding (2, 3%). Cumulative 1-year primary, primary assisted, secondary patencies, limb salvage, and survival rates with confidence intervals were 0.19 (0.10-0.36), 0.29 (0.18-0.47), 0.42 (0.29-0.60), 0.73 (0.62-0.86), and 0.77 (0.65-0.90). Reoperative procedures fared the same as primary procedures. Multivariable analysis showed that predictors for increased risk of secondary patency loss were age >70 (hazard ratio [HR] = 3.13, p = 0.009) and patients with secondary revascularization (HR = 3.36, p = 0.015). Older patients (HR = 2.92, p = 0.042) and those with renal insufficiency (HR = 2.92, p = 0.019) were at increased risk of mortality. CVG remains an option for reoperative lower limb revascularization for limb salvage if there is no autogenous vein available. However, patency rates are poor, and patients older than 70 are more likely to have inferior outcomes.

Outcomes for concomitant common iliac artery aneurysms after endovascular abdominal aortic aneurysm repair

Objective This study evaluated the morbidity of endovascular abdominal aortic aneurysm repair (EVAR) in patients with concomitant common iliac artery aneurysm (CCIAA). Methods This was a retrospective review of all patients who underwent elective EVAR from June 2006 through June 2012 at a single institution. Demographics, comorbidities, preoperative presentation, intraoperative details, and postoperative complications were tabulated. Patients with CCIAA were categorized into three groups according to the distal extent of their iliac limb: iliac limb extension into the external iliac artery with internal iliac artery coil embolization (EE); flared iliac limb ≥20 mm in diameter to the iliac bifurcation (FL); and iliac limb ≤20 mm ending proximal to the CCIAA (no‐FL). Results During this period, 627 consecutive patients underwent elective EVAR and preoperative computed tomographic angiograms were available for 523 patients to evaluate the presence of CCIAA. Of these, 211 patients (40.2%) had a CCIAA in at least one common iliac artery, with a total of 307 aneurysmal arteries. Of these 307 aneurysmal arteries, 62 (20.2%) were treated with EE, 132 (43.0%) were treated with FL, and 113 (36.8%) had a sufficient landing zone in the proximal common iliac artery to use an iliac limb ≤20 mm in diameter (no‐FL). The overall reintervention rate was 12.4% of patients, with a higher reintervention rate between patients with CCIAA compared with those without (15.2% vs 10.9%; P = .039). There were no significant differences in reintervention rates between the EE, FL, and no‐FL techniques (4.5% vs 4.8% vs 6.2%; P = .802) over a mean 59.8 months follow‐up. The FL and EE techniques had a lower risk of distal endoleak than the no‐FL technique, but the difference was not statistically significant (3.2% vs 2.3% vs 5.3% compared with 4.23% in the entire cohort). Conclusions Patients with CCIAA had a higher reintervention rate after EVAR for abdominal aortic aneurysm compared with non‐CCIAA patients. Of the techniques studied (EE, FL, and no‐FL), there was no significant difference in reintervention rates between the three. All three techniques remain viable options for the endovascular repair of CCIAA.

Aneurysmal Degeneration in Patients with Type B Aortic Dissection.

BACKGROUNDnThe optimal management of type B aortic dissection (TBAD) remains controversial in the era of endovascular therapies. This study reports the outcomes and complication rates of different treatment paradigms for TBAD.nnnMETHODSnA retrospective review was undertaken of all patients with TBAD from June 2006 to June 2012. Demographics, hospital course, and follow-up visits were analyzed. Patients who underwent surgical interventions were compared to those with medical therapy. Survival rates and predictors of outcome were determined using the Kaplan-Meier method with Cox proportional hazards.nnnRESULTSnOf 261 consecutive patients who were hospitalized during this period with a confirmed thoracic dissection, 134 (51%) had TBAD. Sixty-two (46%) were women, and the mean age was 66.4xa0±xa014.9. Median follow-up was 22.4 (0, 184) months. Thirty-five patients underwent surgical intervention with 20 thoracic endovascular aortic repair (TEVAR) and open surgery in 15. The overall 30-day mortality was 7%, and cumulative survival rates at 1, 3, and 5xa0years were 85% (95% confidence interval [CI], 79-91), 68% (95% CI, 59-78), and 57% (95% CI, 47-69) with no difference between medical versus surgical groups (Pxa0=xa00.8) and TEVAR versus open surgery group (Pxa0=xa01.0). Sixty-six (50%) patients developed aneurysmal expansion, which required surgical intervention in 26 (hazard ratios [HR], 0.99; Pxa0=xa00.96). Malperfusion and rupture only occurred in 5 (HR, 1.57; Pxa0=xa00.54) and 5 (HR, 3.64; Pxa0=xa00.01) patients, respectively. Multivariate analysis for overall survival found renal insufficiency (HR, 2.6; Pxa0=xa00.004) and age (HR, 1.06; Pxa0<xa00.0001) and rupture (HR 3.3, Pxa0=xa00.04) were independent predictors of mortality. Intramural hematoma was not a significant predictor of survival (HR, 0.49; Pxa0=xa00.11).nnnCONCLUSIONSnMedical therapy remains the mainstay of treating TBAD with low morbidity. Surgical interventions are indicated in selected patients with malperfusion or aneurysmal expansion with comparable survival rates.

Comparative Predictors of Mortality for Endovascular and Open Repair of Ruptured Infrarenal Abdominal Aortic Aneurysms

Background: The continued success of elective endovascular aneurysm repair (EVAR) has led to an extension of this technology to ruptured aortas. The purpose of this study was to evaluate our results of ruptured infrarenal aortic aneurysm (rAAA). Methods: The treatment results of all patients who underwent repair of rAAAs between January 1990 and May 2008 were reviewed retrospectively. Comorbidities, intraoperative details, and postoperative complications were tabulated. EVAR and open repair were compared. Results: Between January 1990 and May 2008, 160 patients underwent repair of rAAA. Of these, 32 (20%) underwent EVAR for rAAA; of 160 patients, 112 were considered to have free rupture (70%) and 48 had contained rupture (30%). The average Acute Physiology and Chronic Health Evaluation II score was 13.3 ± 6.7. The KaplaneMeier survival rates at 30 days, 6 months, 1 year, and 5 years were 69% (62,77), 57% (50,65), 50% (43,59), and 25% (19,34), respectively, with no difference seen in EVAR group as compared with open surgery ( p 1⁄4 0.24). Intraoperative mortality was 5.6%, with no patient undergoing EVAR suffering an intraoperative death ( p 1⁄4 0.03). However, 30-day mortality was 31.9% with no difference between EVAR and open surgery (31.2% vs. 32%; p 1⁄4 0.93) results. Multivariate analysis for 30-day mortality found renal insufficiency (RI) odds ratio (OR): 2.4 (1.1, 5.3), p 1⁄4 0.04; hypotension OR: 2.4 (1.1, 5.3), p 1⁄4 0.02; and cardiac arrest OR: 3.8 (1.1, 11.6, p 1⁄4 0.03), were all associated with the greatest mortality. Of all predictors analyzed, multivariate analysis found preoperative RI OR: 2.32 (1.55, 3.47), p < 0.001, was the only independent predictor of decreased long-term survival. Conclusions: Mortality rates for rAAA remain high. The use of EVAR for these procedures equals that for open repair with regard to 30-day and long-term mortality. Preoperative cardiac arrest and RI were associated with inferior results for both EVAR and open repair. Clinical judgment on when to use EVAR as a primary repair modality must be exercised.