Nayan Sivamurthy

Endovascular Management of Central Venous Stenoses in the Hemodialysis Patient: Results of Percutaneous Therapy

The purpose of this study was to determine the functional results of transvenous angioplasty for the treatment of central venous stenoses in patients with failing upper extremity arteriovenous access. Two hundred consecutive patients presented with threatened arteriovenous access from January 1999 through July 2002. Angiographic evidence of central venous stenosis was present in 35 patients (18%) (superior vena cava 5, brachiocephalic veins 14, and subclavian veins 18). Follow-up averaged 873 days from the date of initial intervention. The initial technical success rate was 89%. Primary patency for each intervention was 85% at 30 days, 55% at 6 months, 43% at 1 year, and 0% at 2 years. Assisted primary patency rates were 88% at 30 days, 80% at 1 year, and 64% at 2 years. Freedom from central venous dialysis catheter placement was 82% at 30 days, 63% at 3 months, 51% at 1 year, 37% at 2 years, and 25% at 3 years. Freedom from a dialysis catheter was superior in those patients with autogenous arteriovenous fistulas. Transvenous angioplasty appears to be beneficial for hemodialysis patients with central venous stenoses, and it helps preserve functional access in the affected extremity, particularly in patients with autogenous fistulas.

Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry

OBJECTIVE To assess outcomes after endovascular abdominal aortic aneurysm repair (EVAR) in an integrated health care system. METHODS Between 2000 and 2010, 1736 patients underwent EVAR at 17 centers. Demographic data, comorbidities, and outcomes of interest were collected. EVAR in patients presenting with ruptured or symptomatic aneurysms was categorized as urgent; otherwise, it was considered elective. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, endoleak status, major adverse events, and reintervention. RESULTS Overall, the median age was 76 years (interquartile range, 70-81 years), 86% were male, and 82% were Caucasian. Most cases (93.8%) were elective, but urgent use of EVAR increased from 4% in the first 5 years to 7.3% in the last 5 years of the study period. Mean aneurysm size was 5.8 cm. Patients were followed for an average of 3 years (range, 1-11 years); 8% were lost to follow-up. Intraoperatively, 4.5% of patients required adjunctive maneuvers for endoleak, fixation, or flow-limiting issues. The 30-day mortality rate was 1.2%, and the perioperative morbidity rate was 6.6%. Intraoperative type I and II endoleaks were uncommon (2.3% and 9.3%, respectively). Life-table analysis at 5 years demonstrated excellent overall survival (66%) and freedom from ARM (97%). Postoperative endoleak was seen in 30% of patients and was associated with an increase in sac size over time. Finally, the total reintervention rate was 15%, including 91 instances (5%) of revisional EVAR. The overall major adverse event rate was 7.9% and decreased significantly from 12.3% in the first 5 years to 5.6% in the second 5 years of the study period (P < .001). Overall ARM was worse in patients with postoperative endoleak (4.1% vs 1.8%; P < .01) or in those who underwent reintervention (7.6% vs 1.6%; P < .001). CONCLUSIONS Results from a contemporary EVAR registry in an integrated health care system demonstrate favorable perioperative outcomes and excellent clinical efficacy. However, postoperative endoleak and the need for reintervention continue to be challenging problems for patients after EVAR.

Endovascular Exclusion Of Subclavian Artery Pseudoaneurysm

Subclavian artery pseudoaneurysms are typically a rare occurrence commonly caused by iatrogenic injury and trauma. We describe an endovascular approach employing a brachiofemoral through-wire technique for the treatment of a left subclavian artery pseudoaneurysm in the presence of a hostile aortic arch and great vessel anatomy.