Peter A. Naughton

A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation

INTRODUCTION A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability. METHODS Patients with CIAA who underwent EVAR were identified in two teaching hospitals. Bell-bottom technique (BBT; iliac limb ≥20 mm) or internal iliac artery embolization and limb extension to the external iliac artery (IIE + EE) were used. Outcome between these two approaches was compared. RESULTS We identified 185 patients. Indication for EVAR included asymptomatic abdominal aortic aneurysm (AAA) in 157, symptomatic or ruptured aneurysm in 19, and CIAA in nine. Mean AAA diameter was 59 mm. Among 260 large CIAAs that were treated, BBT was used to treat 166 CIAA limbs, and 94 limbs underwent IIE + EE. Total reintervention rates were 11% for BBT (n = 19) and 19.1% for IIE + EE (n = 18; P = .149). Rates of reintervention for type Ib or III endoleak were 4% for BBT (n = 7) and 4% for IIE + EE (n = 4; P > .99). The difference in limb patency rates was not significant. The 30-day mortality rate was 1%. Median follow-up was 22 months. Complications did not differ significantly between the two groups; however, the combined incidence of perioperative complications and reinterventions was higher in the IIE + EE group (49% vs 22%; P = .002). CONCLUSIONS The combined incidence of perioperative complications and reinterventions is significantly higher with IIE + EE than with BBT; therefore, when feasible, BBT is desirable.

Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries Seven-Year Single-Center Experience

HYPOTHESIS Thoracic endovascular aortic repair (TEVAR) for acute blunt thoracic aortic injury has good early and mid-term results. DESIGN Single-center retrospective 7-year review from January 2001 to December 2008. SETTING Urban tertiary care hospital. PATIENTS Twenty-four consecutive patients with acute blunt thoracic aortic injury treated with TEVAR. MAIN OUTCOME MEASURES Procedure-related mortality, stroke, or paraplegia; injury severity score; and complications. RESULTS Among the 24 treated patients (mean age, 41 years; range, 20-71 years), the mean injury severity score was 43 (range, 25-66). Thoracic endovascular aortic repair was successful in treating the aortic injury in all patients and there were no instances of procedure-related death, stroke, or paraplegia. Access to the aorta was obtained through an open femoral/iliac approach (n = 7) or an entirely percutaneous groin approach (n = 17). Systemic heparin was not used in 84% of cases. Two access complications (8%) occurred, requiring an iliofemoral bypass in one patient and a thrombectomy in another. One patient required secondary intervention for device collapse, which was treated successfully with repeat endografting. There have been no delayed device failures or complications among the entire cohort at mid-term follow-up. CONCLUSION Thoracic endovascular aortic repair, via a percutaneous groin approach and without systemic anticoagulation, for blunt thoracic aortic injury can be performed safely with low periprocedural mortality and morbidity.

Intimal angiosarcoma causing abdominal aortic rupture

Intimal angiosarcomas are rare and difficult to diagnose preoperatively. Complete surgical resection is essential, but long-term survival is unlikely. We report a patient who presented with a contained ruptured infrarenal aorta with clinical and radiologic findings suggestive of infectious aortitis. Surgical resection, regional debridement, and reconstruction were completed using a cadaveric arterial homograft. However, pathologic evaluation revealed a high-grade intimal sarcoma.

Carotid Artery Reconstruction for Infected Carotid Patches

OBJECTIVES Infected carotid prosthetic patches (ICPP) are a rare but catastrophic complication of carotid endarterectomy (CEA). Prevention and appropriate surgical management is essential. We report our experience of carotid artery reconstruction for ICPP. DESIGN Single-center retrospective study. METHODS 10-year review of the surgical treatment of ICPP. RESULTS Twelve patients presented with patch infection following CEA. Three patients presented acutely with an expanding hematoma, eight with chronic complications (abscess/discharging sinus n = 5, carotid pseudoaneurysm n = 3). Mean age was 75 years. Replacement conduits included superficial femoral artery (n = 6), cadaveric homograft (n = 3), long saphenous vein (n = 2) and one patient had primary closure. Five patients had muscle flaps fashioned for carotid artery protection. Operative complications included hypoglossal nerve injury (1 patient), superficial skin infection (2 patients) and one patient was returned to the operating room for a neck haematoma. Five surgical specimens were culture positive for: Staphylococcus aureus (n = 3), Corynebacterium propionibacterium (n = 1) and Streptococcus anginous (n = 1). There were no 30-day mortalities. Mean hospital stay was 6 days. Median follow-up was 16 months (range 3-108 months). CONCLUSION Carotid artery reconstruction in a contaminated wound represents a significant surgical challenge. Unlike previous reports that used venous conduits, this is the first series where cadaveric or autologous arterial conduits were preferred. Arterial conduits achieved durable short term follow-up.

Successful Endovascular Treatment of a Hemodialysis Graft Pseudoaneurysm by Covered Stent and Direct Percutaneous Thrombin Injection

Vascular access for hemodialysis remains a challenge for nephrologists, vascular surgeons, and interventional radiologists alike. Arteriovenous fistula and synthetic grafts remain the access of choice for long‐term hemodialysis; however, they are subject to complications from infection and repeated needle cannulation. Pseudoaneurysms are an increasingly recognized adverse event. At present, there are many minimally invasive methods to repair these wall defects. We present a graft pseudoaneurysm, which required a combination of endovascular stent graft placement and percutaneous thrombin injection for successful occlusion.

Complicated Acute Type B Thoracic Aortic Dissections: Endovascular Treatment For Visceral Malperfusion And Pseudoaneurysms

Purpose: Morbidity and mortality of acute type B thoracic aortic dissections remain alarmingly high. Endoluminal options are promising. Methods: A single-center 5-year review of 17 acute type B aortic dissections complicated by visceral malperfusion (11) or pseudoaneurysm formation (6) treated with endovascular intervention. Interventional techniques included endografting (15) and/or percutaneous fenestration (4). Median follow-up is 28 months (range 0-76 months). Results: Median age was 55 years; 30-day death, stroke, and paraplegia rates were 0%, 17.6%, and 5.9%. Success reversing visceral ischemia or sealing a pseudoaneurysm was 100%. Cross-sectional imaging demonstrated that the false lumen was thrombosed in 9 patients, partially thrombosed in 6 patients. Late events include 1 delayed proximal type I endoleak, 1 delayed rupture of the thoracic aorta requiring successful emergent open surgical repair, and 2 unrelated late deaths. Conclusion: Endovascular approaches to type B dissections presenting with visceral malperfusion and/or pseudoaneurysm can achieve acceptable early results.

Comparing Supervised Exercise Therapy to Invasive Measures in the Management of Symptomatic Peripheral Arterial Disease

Peripheral arterial disease (PAD) is associated with considerable morbidity and mortality. Consensus rightly demands the incorporation of supervised exercise training (SET) into PAD treatment protocols. However, the exact role of SET particularly its relationship with intervention requires further clarification. While supervised exercise is undoubtedly an excellent tool in the conservative management of mild PAD its use in more advanced disease as an adjunct to open or endovascular intervention is not clearly defined. Indeed its use in isolation in this cohort is incompletely reported. The aim of this review is to clarify the exact role of SET in the management of symptomatic PAD and in particular to assess its role in comparison with or as an adjunct to invasive intervention. A systematic literature search revealed a total 11 randomised studies inclusive of 969 patients. All studies compared SET and intervention with monotherapy. Study results suggest that exercise is a complication-free treatment. Furthermore, it appears to offer significant improvements in patients walk distances with a combination of both SET and intervention offering a superior walking outcome to monotherapy in those requiring invasive measures.

Supervised exercise therapy in the management of peripheral arterial disease – an assessment of compliance

BACKGROUND Supervised exercise therapy (SET) is an effective option in the management of peripheral arterial disease (PAD). Unfortunately, poor compliance remains prevalent. This study aimed to assess patient exercise compliance and to identify factors influencing symptomatic improvement and SET participation. PATIENTS AND METHODS Data regarding attendance at SET for this cohort study were extracted from a prospectively maintained database of patients with claudication attending SET at Dublin City University. All patients had ankle brachial index confirmed PAD with associated intermittent claudication. Exercise performance and symptomatic data were gathered retrospectively using patient charts and interviews. RESULTS Ninety-eight patients were referred for SET during the study period. The mean age was 69.2 (± 10.1) with 18 % being female. Median follow-up was 25.1 months (IQ range 17.0-31.6). Overall, the mean number of sessions attended per patient was 19.5. Exercise compliance was associated with a significant improvement in symptoms (p = 0.001). Other factors including anatomical level of claudication (P = 0.042) and educational level (p = 0.007) were found to affect the outcome of SET. Multivariate analysis revealed hypertension as a predictor of symptomatic outcome after SET (p = 0.045). Furthermore, ex-smokers (p = 0.021) and those previously diagnosed with hypercholesterolaemia (p = 0.020) or ischaemic heart disease (p = 0.029) had superior exercise compliance. Using linear regression, smoking history (p = 0.024) was identified as a predictor of compliance to SET. CONCLUSIONS Establishing exercise compliance remains challenging in the PAD cohort. Pre-exercise patient education and personalised exercise prescriptions may result in improvements in function and compliance.

Zone I Gunshot Neck Injury Treated with Common Carotid and Esophageal Stent Grafts

Management of zone I gunshot injuries to the neck is controversial. Endovascular and endoscopic therapies are appealing minimally invasive alternatives, but they are still evolving. This case report demonstrates effective stent grafting of an arterial and an esophageal zone I neck injury after a civilian gunshot.