Nitin Garg

Factors affecting outcome of open and hybrid reconstructions for nonmalignant obstruction of iliofemoral veins and inferior vena cava.

OBJECTIVES To identify factors affecting long-term outcome after open surgical reconstructions (OSR) and hybrid reconstructions (HR) for chronic venous obstructions. METHODS Retrospective review of clinical data of 60 patients with 64 OSR or HR for chronic obstruction of iliofemoral (IF) veins or inferior vena cava (IVC) between January 1985 and September 2009. Primary end points were patency and clinical outcome. RESULTS Sixty patients (26 men, mean age 43 years, range 16-81) underwent 64 procedures. Ninety-four percent had leg swelling, 90% had venous claudication, and 31% had active or healed ulcers (CEAP classes: C3 = 30, C4 = 12, C5 = 8, C6 = 12). Fifty-two OSRs included 29 femorofemoral (Palma vein: 25, polytetrafluoroethylene [PTFE]: 4), 17 femoroiliac-inferior vena cava (IVC) (vein: 3, PTFE: 14) and six complex bypasses. Twelve patients had HR, which included endophlebectomy, patch angioplasty, and stenting. Early graft occlusion occurred after 17% of OSR and 33% HR. Discharge patency was 96% after OSR, 92% after HR. No mortality or pulmonary embolism occurred. Five-year primary and secondary patency was 42% (95% confidence interval [CI] 29%-55%) and 59% (CI 43%-72%), respectively. For Palma vein grafts it was 70% and 78%, for femoroiliac and ilio-infrahepatic IVC bypasses it was 63% and 86%, and for femoro-infrahepatic IVC bypasses it was 31% and 57%, respectively. Complex OSRs and hybrid procedures had 28% and 30% 2-year secondary patency, respectively. The only factor that significantly affected graft patency in multivariate analysis was May-Thurner syndrome with associated chronic venous thrombosis. For HR, stenting into the common femoral vein patch vs iliac stents only significantly increased patency. At last follow-up, 60% of the patients had no venous claudication and no or minimal swelling. All ulcers with patent grafts healed but 50% of these recurred. CONCLUSIONS Both OSR and HR are viable options if endovascular procedures fail or are not feasible. Palma vein bypass and femoroiliac or iliocaval PTFE bypasses have excellent outcomes with good symptomatic relief.

Contemporary management of aberrant right subclavian arteries

BACKGROUND Aberrant origin of right subclavian arteries represents the most common of the aortic arch anomalies. This variant has few published series to guide management. Our goal was to review treatment options and results for these potentially complex reconstructions. METHODS A retrospective review was performed on all patients with a diagnosis of aberrant right subclavian artery at our institution between January 2003 and July 2009. RESULTS A total of 24 patients, which comprises one of the largest series reported, including 10 males and 14 females (mean age: 46.6 years, range: 7-77), were diagnosed with an aberrant right subclavian artery. Sixteen (66%) were diagnosed incidentally, but eight (33%) had symptoms of either dysphagia, upper extremity ischemia, or both. Computed tomography was most commonly used to establish the diagnosis (19 patients, 79%). Magnetic resonance imaging established the diagnosis in three patients (12%), upper gastrointestinal barium study in one (4%), and standard angiography in one (4%). A Kommerells diverticulum (KD) was the most common associated anomaly (seven patients, 29%). All seven patients (100%) with a KD required intervention for either symptoms or aneurysmal degeneration. Intervention was performed in 10 patients (42%), including carotid subclavian bypass in five (50%), carotid subclavian transposition in three (30%), and ascending aorta to subclavian bypass in two (20%). Four patients (40%) had additional intervention for management of aneurysmal disease of the aorta or KD, with open aortic replacement in two (20%) and aortic endografting in two (20%). There was one perioperative death (10%) in a patient undergoing aortic arch debranching with placement of an aortic endograft. In all, 18 patients survived without symptoms after a mean follow-up of 38 months. CONCLUSIONS Aberrant right subclavian arteries are most commonly found incidentally with computed tomography. The presence of a KD seemed to correlate with the need for intervention. Patients with no symptoms with the absence of a KD can safely be followed.

Carotid endarterectomy is superior to carotid angioplasty and stenting for perioperative and long-term results

Objective: Carotid angioplasty and stenting (CAS) has challenged carotid endarterectomy (CEA) as the therapy of choice for carotid disease. This meta-analysis aims at summarizing the most current body of evidence. Methods: All prospective, controlled clinical trials comparing CEA versus CAS were included. The outcome measures of interest were relative risk (RR) of 30-day stroke, 30-day stroke/death, long-term risk of stroke, and risk of restenosis. Results: The RR of 30-day stroke for CAS was 1.6 times that of CEA (RR 1.6; 95%CI 1.2-2.0, P = .001). The 30-day RR of stroke/death was 1.5 times higher for CAS (RR 1.5; 95%CI 1.1-2.1, P = .008). There was a higher risk of long-term stroke (RR 1.2; 95%CI 1.0-1.5, P = .043). The risk of restenosis was twice for CAS (RR 1.8; 95%CI 1.1-3.1, P = .04). Conclusion: The 30-day RR of stroke, stroke/death, long-term risk of stroke, and risk of restenosis are consistently higher for carotid artery stenting (CAS).

Endovascular Repair of Ascending Aortic Pseudoaneurysm

We describe a complex case of ascending aortic pseudoaneurysm after open repair of ascending aortic aneurysm and aortic valve replacement. Although treatment was complicated due to intra-operative graft migration, the patient was successfully treated with endovascular technique.

Quantification of iron in the presence of calcium with dual-energy computed tomography (DECT) in an ex vivo porcine plaque model

Iron deposits secondary to microbleeds often co-exist with calcium in coronary plaques. The purpose of this study was to quantify iron in the presence of calcium in an ex vivo porcine arterial plaque model using a clinical dual-energy CT (DECT) scanner. A material decomposition method to quantify the mass fractions of iron and calcium within a mixture using DECT was developed. Mixture solutions of known iron and calcium concentrations were prepared to calibrate and validate the DECT-based algorithm. Simulated plaques with co-existing iron and calcium were created by injecting the mixture solutions into the vessel wall of porcine carotid arteries and aortas. These vessel regions were harvested and scanned using a clinical DECT system and iron mass fraction was calculated for each sample. Iron- and calcium-specific staining was conducted on 5 µm thick histological sections of vessel samples to confirm the co-existence of iron and calcium in the simulated plaques. The proposed algorithm accurately quantified iron and calcium amounts in mixture solutions. Maps of iron mass fraction of 60 artery segments were obtained from CT images at two energies. The sensitivity for detecting the presence of iron was 83% and the specificity was 92% using a threshold at an iron mass fraction of 0.25%. Histological analysis confirmed the co-localization of iron and calcium within the simulated plaques. Iron quantification in the presence of calcium was feasible in excised arteries at an iron mass fraction of around 1.5% or higher using current clinical DECT scanners.

Contemporary management of giant renal and visceral arteriovenous fistulae.

Purpose To evaluate our experience with treatment of giant arteriovenous fistulae (AVFs) involving the renal and visceral vasculature and assess outcomes. Methods Clinical data from 12 consecutive patients (10 women; median age 58 years, range 37–79) undergoing intervention for 14 giant renal/visceral AVFs over a 15-year period (1994–2008) were retrospectively reviewed. Only patients with extra-parenchymal, wide arteriovenous communications were included. Thirteen were located in the renal artery and one in the splenic artery. The etiology was most likely post-traumatic/iatrogenic in 6 patients, idiopathic in 4 (1 bilateral), congenital in 1 (bilateral), and one was associated with fibromuscular dysplasia. In 4 cases, the lesion was asymptomatic. Results Two large renal AVFs were treated with open surgery: one elective AV fistula repair early in our experience and the other an emergent nephrectomy for rupture. Twelve AV fistulae were closed successfully using endovascular techniques performed solely through the feeding vessel without cannulating the draining vein. All symptomatic patients, except one with continued dyspnea from cardiac causes, had complete symptomatic relief. There was no mortality. Morbidity included 2 access site hematomas that were managed conservatively. Loss of renal parenchyma ranged from 5% to 30%, but median serum creatinine levels remained stable. Conclusion Endovascular treatment of giant renal/visceral AVFs is challenging but feasible and safe, with good organ preservation. Endovascular techniques have replaced open surgical repair as a first-line treatment for these challenging lesions.

Intimal sarcoma in an inflammatory aneurysm after endovascular aneurysm repair

Long-term outcomes after endovascular aneurysm repair (EVAR) for inflammatory aneurysms are unknown. We present a young patient with new-onset back pain and failure to thrive 6 years after EVAR for an inflammatory abdominal aortic aneurysm (AAA). Endograft explanation was performed with a presumed diagnosis of infection. Pathology revealed intimal sarcoma in the excluded aneurysm sac with liver metastasis. This report presents a detailed review of literature regarding potential association of prosthetic implantation and carcinogenesis.

Embolic Strokes After Peripherally Inserted Central Catheter Placement

Peripherally inserted central catheters (PICCs) have become popular for a range of indications in both inpatient and outpatient settings. Though PICCs are generally safe, they can be associated with a variety of complications. We present here a case with embolic strokes due to inadvertent arterial placement of PICC, an uncommon but potentially life-threatening complication. A high clinical suspicion with critical evaluation of radiographs is indispensable for suspecting misplaced PICCs.

Retrograde supra-aortic stent placement combined with open carotid or subclavian artery revascularization.

Purpose: To review the outcomes of retrograde supra-aortic vessel stent (RSAS) placement combined with open carotid or subclavian artery revascularization. Methods: Retrospective review of all consecutive patients between 1995 and 2010, excluding transfemoral procedures or isolated retrograde stent placement. Results: There were 11 patients (9 females, mean age 65 years). Open revascularization included carotid endarterectomy in 6 patients, carotid-subclavian bypass in 3, and carotid-carotid bypass in 2 patients. There were no operative deaths or neurological events. All symptomatic patients improved. Over a mean follow-up of 24 months, One patient developed common carotid artery (CCA) in-stent dissection and symptomatic restenosis treated with subclavian-carotid bypass. Another 3 patients had asymptomatic restenosis of the carotid bifurcation but required no intervention. Conclusions: Retrograde stenting of the common carotid or innominate artery is a safe and effective method to provide inflow in selected patients with severe supra-aortic vessel disease who require concomitant open carotid or subclavian artery reconstructions.