Ramyar Gilani

Endovascular therapy for acute limb ischemia

BACKGROUND Acute limb ischemia (ALI) of the lower extremities remains a challenging clinical dilemma. Treatment of ALI has shifted toward endovascular therapies. The purpose of this study was to assess outcomes in patients treated for ALI with intra-arterial thrombolysis and/or adjuvant endovascular techniques. METHODS Consecutive patients with ALI of the lower extremities treated via endovascular intra-arterial methods between January 1, 2005 and September 30, 2007 were identified and reviewed. Comparisons of success, thrombolysis days, and all 30-day outcomes except mortality were performed using generalized estimating equations with logistic and proportional odds regression. Thirty-day mortality was assessed using logistic regression. Long-term patency, limb salvage, and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models. RESULTS The analyzed dataset included 129 limbs treated in 119 patients presenting with ALI (class I 68%, class IIa 23%, class IIb 9%). The mean follow-up was 16.8 months (range: 0-43 months). Technical success was achieved in 82% cases. The 30-day mortality rate was 6.0% with all 30-day deaths occurring in females (P = .002). One (0.76%) central nervous system hemorrhage (CNS) was noted in this cohort. Primary patency for the entire cohort at 12 and 24 months was 50.1% (95% confidence interval [CI], 39.5-60.7) and 37.7% (95% CI, 26.2-49.1), respectively, while secondary patency was 74.0% (95% CI, 64.9-83.1) and 65.3% (95% CI, 54.5-76.2). Multivariable analyses identified patients presenting with femoropopliteal (hazard ratio [HR] 2.63) or tibial thrombosis (HR 2.80); graft thrombosis (vs native artery thrombosis, HR 2.57) and long-term dialysis (HR 3.66, 95% CI, 2.35-5.71, P < .001) were associated with poorer primary patency rates. Cumulative limb salvage at 24 months was 68.8% (95% CI: 59.5-78.1) with female gender (HR 3.34, P = .002) and thrombolysis ≥ 3 days (HR 2.35, P = .019) associated with an increased risk of limb loss. Overall 36-month survival was 84.5% (95% CI: 77.5-91.6). Women had decreased survival rates both in the short- and midterm (HR 6.29; 95% CI, 1.78-22.28; P = .004). CONCLUSIONS Endovascular therapy with thrombolysis remains an effective treatment option for patients presenting with lower extremity ALI. Thrombolysis should be limited to <3 days. Female gender negatively affects the rates of limb salvage and survival.

Overcoming challenges of endovascular treatment of complex subclavian and axillary artery injuries in hypotensive patients.

A subclavian and axillary artery injuries are located within a transition zone at the junction between the thorax, neck, and upper extremity, contained within a surrounding skeletal cage. Open exposure of these vessels through supraclavicular and infraclavicular incisions, sternotomy, and thoracotomy can be challenging and morbid. The application of endovascular therapy aims to overcome the drawbacks of open surgical management and offers an attractive alternative for injuries to these vessels. Yet, even up until recently, barriers to endovascular management of these injuries included hemodynamic instability, complete vessel transection, and vessel thrombosis. With this report, we aimed to describe an endovascular technique our service developed to overcome the previously mentioned barriers and report our experience with endovascular repair of complex subclavian and axillary artery injuries in hypotensive patients.

Endovascular management of traumatic peripheral arterial injuries

BACKGROUND Traumatic injuries to peripheral arterial vessels are increasingly managed with endovascular techniques. Early small series have suggested that endovascular therapy is feasible and decreases operative blood loss, but these data are limited. The purpose of this study was to evaluate the feasibility and outcomes of endovascular management of nonaortic arterial trauma. MATERIALS AND METHODS We reviewed records of traumatic nonaortic arterial injuries presenting at an urban level 1 trauma center from December 2009-July 2013. Patients undergoing treatment in interventional radiology and patients whose injuries occurred >72 h before presentation were excluded. Demographics, indicators of injury severity, operative blood loss, transfusion requirements, and clinical outcome were compared between patients undergoing endovascular and open management using appropriate inferential statistics. RESULTS During the study period, 17 patients underwent endovascular interventions and 20 had open surgery. There were 19 upper extremity and/or thoracic outlet arterial injuries, 15 lower extremity injuries and 11 pelvic injuries. Endovascular cases were completed using a vascular imaging C-arm in a standard operating room. Estimated blood loss during the primary procedure was significantly lower with endovascular management (150 versus 825 cc, P < 0.001). No differences were observed between cohorts in age, injury severity score, intensive care unit length of stay, arterial pH, transfusion requirements, inpatient complication rate, or mortality. CONCLUSIONS Our experience with endovascular management demonstrates its feasibility with commonly available tools. Operative blood loss may be significantly decreased using endovascular techniques. Further study is needed to refine patient selection criteria and to define long-term outcomes.

Challenges in the Diagnosis and Management of Unusual Presentations of Blunt Injury to the Ascending Aorta and Aortic Sinuses

BACKGROUND Blunt injury to the thoracic aorta continues to carry significant mortality and the diagnostic algorithms are evolving as new technology is developed. With improved pre-hospital care, patients with unusual blunt injuries to the aorta may survive to evaluation. While current algorithms for screening focus on the more common blunt injuries to the descending thoracic aorta, our service has seen four injuries to the ascending aorta that have had unusual presentations and presented significant challenges in their management. METHODS Retrospective chart review based on a cardiovascular injury database. RESULTS Four patients were identified who survived to hospitalization with an injury to the ascending thoracic aorta. Two were to the ascending aorta and two to the aortic sinuses. Two presented with closed head injury complicating management. One patient presented with aortic valve insufficiency. Motion artifacts at the aortic sinus made screening by CT challenging. These injuries were managed with primary repair (1), tube graft replacement (2), and aortic root replacement with reimplantation of the coronaries (1), all with cardiopulmonary bypass. CONCLUSION Injuries to the ascending aorta and aortic sinus that survive to evaluation present unique challenges to the screening algorithms. All required cardiopulmonary bypass for repair and potentially complex reconstructions with management decisions affected by the presence of associated injuries. New methodologies such as CT scan gated to cardiac motion may offer higher resolution in this area.

Evaluation of a Device Combining an Inferior Vena Cava Filter and a Central Venous Catheter for Preventing Pulmonary Embolism Among Critically Ill Trauma Patients

PURPOSE To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients. MATERIALS AND METHODS In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval. RESULTS The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission. CONCLUSIONS This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.

Endovascular repair of traumatic aortic injury using a custom fenestrated endograft to preserve the left subclavian artery.

Purpose: To describe the use of custom fenestrated endografts to preserve left subclavian artery (SCA) flow when requiring coverage during endovascular repair of blunt aortic injury (BAI). Case Report: A 39-year-old male involved in a motor vehicle accident sustained injuries including intracranial hemorrhage, BAI, and extremity fractures. Immediate neurosurgical intervention was required. Once neurologically stabilized, endovascular repair was performed with a commercially available device modified with a custom fenestration to preserve flow into the left SCA. Serial follow-up CT angiography (CTA) demonstrates satisfactory repair with prograde left SCA flow and no evidence of endoleak. Conclusion: Left SCA coverage is often required for successful endovascular repair of BAI. A subgroup of patients who undergo left SCA coverage will require revascularization. The use of custom fenestrated endografts for preserving left SCA during thoracic endovascular aortic repair (TEVAR) for BAI is an innovative and feasible option in patients who require revascularization.

Intravascular ultrasound enhanced aortic sizing for endovascular treatment of blunt aortic injury.

BACKGROUND Blunt aortic injury (BAI) in young patients with a compliant aorta and evolving hyperdynamic physiology may result in significant variation in aortic diameter during the cardiac cycle. Intravascular ultrasound (IVUS) may be useful to detect real-time variations in aortic diameters for more reliable sizing in patients undergoing thoracic endovascular aortic repair (TEVAR) of BAI. METHODS This is a single-institution retrospective study of patients who underwent TEVAR for BAI in a Level 1 trauma center from January 2004 to January 2014. Patients underwent either trauma survey computed tomography (CT) alone (CT group) or IVUS and CT (IVUS group). We compared predeployment aortic measurements, implanted device size, landing zones, and repair outcomes between the groups. RESULTS Forty-one patients underwent TEVAR for BAI: 28 were in the CT group and 13 in the IVUS group. Left subclavian artery (LSCA) coverage was performed in 50% (CT group) and 38% (IVUS group) of patients. CT-based median aortic diameter was similar in both groups (20.5 mm in the CT group vs. 19.0 mm in the IVUS group, p = 0.374). The median proximal diameter of the proximal device implanted was 26 mm in the CT group and 24 mm in the IVUS group (p = 0.329), which resulted in oversizing of 25.7% and 13.7% (p < 0.001), respectively. The implanted device was changed in 6 of 13 patients and in 4 of 5 patients in which the LSCA was covered because of IVUS measured-diameters. Graft extension proximal to the LSCA resulted in greater differences between the CT and IVUS measurements of the proximal aorta than if the graft was isolated to the descending aorta (18.8% vs. 5.57%, p = 0.005). Technical success of repair for both groups was 100%; no secondary interventions were required in either group. CONCLUSION In combination with CT, IVUS provides important separate sizing information at the point of implantation for more accurate device selection, eliminating need for a repeat CT. LEVEL OF EVIDENCE Therapeutic study, level IV.

Isolated limb perfusion with tissue plasminogen activator for acute hand ischemia

A 62-year old woman presented with an ischemic hand postoperatively from an open abdominal aortic aneurysm repair. Traditional open embolectomy techniques were attempted but failed < or = 24 hours. She was then taken for isolated limb perfusion with tissue plasminogen activator for ongoing ischemia of the hand. A satisfactory technical result was achieved, and the patient remains with a functional extremity.

Multicenter retrospective study of noncompressible torso hemorrhage: Anatomic locations of bleeding and comparison of endovascular versus open approach

BACKGROUND Rational development of technology for rapid control of noncompressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) management versus open (OPEN) management. METHODS This is a retrospective study of adult trauma patients with NCTH admitted to four urban Level I trauma centers in the Houston and San Antonio metropolitan areas in 2008 to 2012. Inclusion criteria include named axial torso vessel disruption, Abbreviated Injury Scale chest or abdomen score of 3 or higher with shock (base excess, <-4) or truncal operation in 90 minutes or less, or pelvic fracture with ring disruption. Exclusion criteria include isolated hip fractures, falls from standing, or prehospital cardiopulmonary resuscitation. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, Injury Severity Score, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients. RESULTS Five hundred forty-three patients with NCTH underwent ENDO (n = 166, 31%), OPEN (n = 309, 57%), or RT (n = 68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, whereas OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs. 34% vs. 32%); severe injuries (median Injury Severity Score, 34 vs. 27 vs. 21), and increased time to intervention (median, 298 vs. 92 vs. 51 minutes) compared with OPEN and RT. Mortality was 15% versus 20% versus 79%. ENDO was associated with decreased mortality compared to OPEN (relative risk, 0.58; 95% confidence interval, 0.46-0.73). CONCLUSION Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding. LEVEL OF EVIDENCE Therapeutic, level V.BACKGROUND Rational development of technology for rapid control of noncompressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) management versus open (OPEN) management. METHODS This is a retrospective study of adult trauma patients with NCTH admitted to four urban Level I trauma centers in the Houston and San Antonio metropolitan areas in 2008 to 2012. Inclusion criteria include named axial torso vessel disruption, Abbreviated Injury Scale chest or abdomen score of 3 or higher with shock (base excess, <−4) or truncal operation in 90 minutes or less, or pelvic fracture with ring disruption. Exclusion criteria include isolated hip fractures, falls from standing, or prehospital cardiopulmonary resuscitation. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, Injury Severity Score, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients. RESULTS Five hundred forty-three patients with NCTH underwent ENDO (n = 166, 31%), OPEN (n = 309, 57%), or RT (n = 68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, whereas OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs. 34% vs. 32%); severe injuries (median Injury Severity Score, 34 vs. 27 vs. 21), and increased time to intervention (median, 298 vs. 92 vs. 51 minutes) compared with OPEN and RT. Mortality was 15% versus 20% versus 79%. ENDO was associated with decreased mortality compared to OPEN (relative risk, 0.58; 95% confidence interval, 0.46–0.73). CONCLUSION Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding. LEVEL OF EVIDENCE Therapeutic, level V.

Endovascular therapy for overcoming challenges presented with blunt abdominal aortic injury.

Blunt abdominal aortic injury (BAAI) is a rare and lethal injury requiring surgical management. Injury patterns can be complex and surgical strategy should accommodate specific case circumstances. Endovascular solutions appear appropriate and preferred in certain cases of BAAI, which, however, may not be applicable due to device limitations in regard to patient anatomy and limited operating room capability. However, endovascular therapy can be pursued with limited fluoroscopy capability and consumable availability providing a solution that is expeditious and effective for select cases of BAAI.