Naveed U. Saqib

A multi-institutional experience in adventitial cystic disease.

Background: Adventitial cystic disease (ACD) is an unusual arteriopathy; case reports and small series constitute the available literature regarding treatment. We sought to examine the presentation, contemporary management, and long‐term outcomes using a multi‐institutional database. Methods: Using a standardized database, 14 institutions retrospectively collected demographics, comorbidities, presentation/symptoms, imaging, treatment, and follow‐up data on consecutive patients treated for ACD during a 10‐year period, using Society for Vascular Surgery reporting standards for limb ischemia. Univariate and multivariate analyses were performed comparing treatment methods and factors associated with recurrent intervention. Life‐table analysis was performed to estimate the freedom from reintervention in comparing the various treatment modalities. Results: Forty‐seven patients (32 men, 15 women; mean age, 43 years) were identified with ACD involving the popliteal artery (n = 41), radial artery (n = 3), superficial/common femoral artery (n = 2), and common femoral vein (n = 1). Lower extremity claudication was seen in 93% of ACD of the leg arteries, whereas patients with upper extremity ACD had hand or arm pain. Preoperative diagnosis was made in 88% of patients, primarily using cross‐sectional imaging of the lower extremity; mean lower extremity ankle‐brachial index was 0.71 in the affected limb. Forty‐one patients with lower extremity ACD underwent operative repair (resection with interposition graft, 21 patients; cyst resection, 13 patients; cyst resection with bypass graft, 5 patients; cyst resection with patch, 2 patients). Two patients with upper extremity ACD underwent cyst drainage without resection or arterial reconstruction. Complications, including graft infection, thrombosis, hematoma, and wound dehiscence, occurred in 12% of patients. Mean lower extremity ankle‐brachial index at 3 months postoperatively improved to 1.07 (P < .001), with an overall mean follow‐up of 20 months (range, 0.33‐9 years). Eight patients (18%) with lower extremity arterial ACD required reintervention (redo cyst resection, one; thrombectomy, three; redo bypass, one; balloon angioplasty, three) after a mean of 70 days with symptom relief in 88%. Lower extremity patients who underwent cyst resection and interposition or bypass graft were less likely to require reintervention (P = .04). One patient with lower extremity ACD required an above‐knee amputation for extensive tissue loss. Conclusions: This multi‐institutional, contemporary experience of ACD examines the treatment and outcomes of ACD. The majority of patients can be identified preoperatively; surgical repair, consisting of cyst excision with arterial reconstruction or bypass alone, provides the best long‐term symptomatic relief and reduced need for intervention to maintain patency.

Indications and Outcomes of Open Inferior Vena Cava Filter Removal

BACKGROUND Despite recommendations for retrieval of inferior vena cava (IVC) filters, most are not removed in a timely manner. Longer IVC filter dwell times are associated with caval wall perforation and tilting that make percutaneous retrieval more difficult. Open IVC filter removal is generally reserved for patients with symptoms referable to the filter, such as chronic back and abdominal pain. We present our management algorithm and review of cases of open IVC filter removal. METHODS Patients referred for management of implanted IVC filters from May 2010 to May 2016 were included. Demographic and imaging were reviewed for cases requiring open surgical removal. RESULTS There were 221 percutaneous retrieval attempts in 218 patients. Successful retrieval occurred in 196 (89%) attempts. There were 7 patients who had open surgical IVC filter removal after failure of percutaneous retrieval. One patient had 2 filters and another had 3 filters. Except for 1 case with complications during the percutaneous retrieval procedure, the remaining patients all suffered from back or abdominal pain. All had significant filter strut penetration through the caval wall into adjacent structures. Postoperatively, all patients had relief of pain. There were no deaths and 1 patient had a minor ileus that spontaneously resolved. CONCLUSIONS Patients who fail percutaneous IVC filter retrieval can expect low morbidity and prompt resolution of symptoms after open surgical removal via minilaparotomy.

Stenting of a Retropharyngeal Internal Carotid Artery

A retropharyngeal course of the carotid artery is an uncommon variant. Recognition of this anatomic anomaly is important in avoiding severe hemorrhage with endotracheal intubation and oropharyngeal procedures and for planning carotid interventions. We present a rare case of stenting for an asymptomatic, high-grade stenosis in a retropharyngeal internal carotid artery.