Raghuveer Vallabhaneni

Open techniques for arch vessel reconstruction during thoracic endovascular aneurysm repair (TEVAR)

Over the past several years, the use and applications of thoracic endovascular grafts have increased significantly. There are now three FDA approved devices for thoracic endovascular aneurysm repair (TEVAR) available in the United States. These new devices have allowed us to expand the number of patients as well as the conditions we treat with this technology. However, many patients are not candidates for traditional endovascular repair because of unsuitable anatomy for use of these devices. Commonly, this is due to an inadequate proximal landing zone on the aortic arch. The recommended proximal landing zone for thoracic endograft devices is typically 2 to 3 cm of seal. To achieve this proximal landing zone, up to 40% of thoracic aneurysmsmayrequirecoverageofcriticalsupra-aorticarch vessels including or proximal to the left subclavian artery. 1 In this article, we will discuss the open surgical alternatives and techniques available in managing the proximal arch vessels in patients who have complex thoracic aortic anatomy.

Early Protection and Compression of Residual Limbs May Improve and Accelerate Prosthetic Fit: A Preliminary Study

BACKGROUND The goal of rehabilitation following lower extremity amputation is to restore the highest level of independent function. As much as possible, this includes the functional use of a prosthetic device fitted to the residual limb. Early prosthetic fit depends, in turn, on rapid healing of the amputation site. METHODS We hypothesized that compliance with a novel custom-designed amputation protection and compression system (CAPCS) to the residual limb can accelerate and improve the likelihood of successful prosthesis use. We conducted a retrospective study of all patients who were offered CAPCS by certified prosthetists (Hanger Prosthetics and Orthotics, Bethesda, MD) during the period between April 2004 and November 2009. Variables included age, sex, indication for amputation, and compliance with CAPCS. Compliance was defined as consistent observed wearing of the CAPCS as directed. The primary end point was the fitting of a prosthetic device to the amputated limb, with time to prosthetic fit being the secondary outcome. RESULTS Out of 100 patients who were offered CAPCS (n = 100) during the study period, 76% were considered compliant (n = 76). Sixty five patients (65%) were ultimately fitted with prosthetic limbs. In multivariate analysis, we found that patients who had compliant use of CAPCS were significantly more likely to be successfully fit with prosthesis (72 vs. 42%, p = 0.005). At 100 days post amputation, the cumulative incidence of prosthesis fitting was significantly higher in CAPCS compliant patients (69.7 vs. 22.2%, p = 0.012). CONCLUSIONS Compliant use of a CAPCS following amputation is associated with earlier and more frequent use of a prosthetic. Based on this limited data set, a conclusion can be drawn that the potential exists to significantly improve functional outcomes after amputation, but well-designed prospective studies are needed to confirm this association.

Transient cortical blindness after thoracic endovascular aneurysm repair

We report a patient who presented with transient cortical blindness 12 hours after completion of a thoracic endovascular aneurysm repair. Computed tomography of the brain demonstrated no acute findings. The patients symptoms resolved spontaneously after 72 hours. To our knowledge, this is the first report of transient cortical blindness after endovascular aortic aneurysm repair. This is an uncommon diagnosis that is important to recognize in a modern vascular surgery practice.

The role of selective stenting for superior mesenteric artery scallops during fenestrated endovascular aneurysm repair

Objective: Stenting of small fenestrations of the Zenith fenestrated endograft (ZFEN; Cook Medical, Bloomington, Ind) is necessary during fenestrated endovascular aneurysm repair (FEVAR) of complex abdominal aortic aneurysms to avoid malalignment. However, stenting of superior mesenteric artery (SMA) scallops of ZFEN devices is optional according to the instructions for use. The objective of this study was to assess the early and midterm outcomes of selective use of stents in SMA scallops of ZFEN during FEVAR procedures. Methods: This study is a single‐institution retrospective review of prospectively enrolled patients treated at the University of North Carolina at Chapel Hill between July 2010 and August 2014. Only patients with SMA scallops were included for analysis. We compared results between patients grouped as stented or unstented SMA scallops. The scallops were stented when one or more of the following criteria were present: misalignment of scallop determined by balloon testing intraoperatively; configuration consisting of an SMA scallop and a single renal fenestration or stent; and pre‐existing stenosis in the vessel adjacent to the graft scallop. The study was approved by the local Institutional Review Board. Primary outcomes addressed were mortality, vessel patency, early and late complications, and reintervention rates. Baseline characteristics of the patients and procedure data were also described. Results: During the 48‐month study period, 61 patients were treated for complex abdominal aortic aneurysms at the University of North Carolina with a mean age of 73 years, and 74.3% of patients were male. Thirty‐nine of 61 patients (63.9%) had a device design with an SMA scallop and were included for analysis. Eleven of 39 patients (28%) had the SMA primarily stented and 28 (72%) were unstented. There was only one death (2.5%) during the 30‐day postoperative period, with 100% technical success and branch patency. In the unstented group, there were three SMA complications during follow‐up, two requiring reintervention; however, there were no associated deaths. Among the stented group, there was one branch‐related complication that occurred during the procedure but no stent stenosis or occlusion during the long‐term follow‐up. During the mean follow‐up period of 21.7 months, no SMA stent thrombosis occurred. There was no statistical difference in outcomes between groups. Conclusions: Single‐wide SMA scallops of ZFEN during FEVAR procedures may be selectively stented using specific criteria and rigorous follow‐up, without compromising the safety and efficacy of the SMA.

Comparison of commercially available versus customized branched-fenestrated devices in the treatment of complex aortic aneurysms

Objective To evaluate and compare the early outcomes of patients treated for complex aortic aneurysms using a commercially available Zenith fenestrated endograft (ZFEN) or an advanced customized fenestrated‐branched endovascular repair, which includes custom‐made device or off‐the‐shelf p‐branch devices available for use in a physician‐sponsored investigational device exemption (PSIDE). Methods Between July 2012 and July 2015, patients who underwent to complex aortic aneurysms repair at University of North Carolina‐Chapel Hill were retrospectively analyzed using data prospectively collected in electronically maintained aortic database. Patients were separated in two groups: ZFEN and PSIDE (custom‐made device and p‐branch). Demographics data, cardiac risk factors, comorbidities, computed tomography angiography anatomic measurements (aneurysm diameter, length of aortic coverage above the celiac artery), procedural data (operative time, estimated blood loss, intraoperative complications), and 30‐day outcomes (mortality, major adverse cardiac events, stroke/transient ischemic attack, paraplegia, gastrointestinal complications, visceral branch complications, and endoleak) were analyzed. Results Among the 131 repairs for complex aortic aneurysms (juxtarenal or thoracoabdominal), there were 60 ZFEN and 71 PSIDE devices. Demographics and risk factors had similar distribution between groups, except that PSIDE patients more commonly had a history of previous aortic surgery (33% vs 5% [ZFEN]; P = .0001). PSIDE patients had a greater number of stented vessels (3.4 vs 2.2; P < .001) and length of aortic coverage (72 mm vs −13.4 mm) than ZFEN; however, no differences were seen in operative time, estimated blood loss or fluoroscopic time. Early outcomes were similar between groups, except for duration of hospital stay, which was significantly longer in PSIDE cohort (4.4 days vs 3.3 days; P = .05). Conclusions More advanced fenestrated‐branched endovascular repair does not seem to increase the complications associated with repair compared with patients receiving a ZFEN device in an experienced treatment center. Although mortality and morbidity were comparable between the groups, further studies evaluating long‐term outcomes are needed.

Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair

OBJECTIVE The purpose of this study is to determine the incidence and clinical significance of renal infarcts after fenestrated endovascular aortic aneurysm repair (FEVAR). MATERIALS AND METHODS All patients who underwent FEVAR with unenhanced and contrast-enhanced CT angiography during a 4-year period were retrospectively reviewed. Two staff radiologists reviewed pre- and post-FEVAR CT examinations for the presence of renal infarcts. Pre- and postoperative serum creatinine levels were examined to determine statistical significance. The incidence of renal infarct and percentage of renal volume reduction were calculated. RESULTS Ninety patients were included for analysis. All patients had a mild progressive increase in serum creatinine level after FEVAR. Twenty-three patients (26%) had a renal infarct identified on post-FEVAR CT, nine (39%) of which were secondary to intentional exclusion of an accessory renal artery and 14 (61%) of which were presumed to be embolic. Two patients with presumed embolic infarcts and three with exclusion of an accessory renal artery had an increase in serum creatinine level of greater than 0.3 mg/dL at 1 month after FEVAR. CONCLUSION Although renal infarcts are common after FEVAR, the clinical relevance of these events appears to be limited, with less than one-quarter of patients with renal infarcts experiencing a decline in renal function.