Richard G. McWilliams

Endotension after endovascular aneurysm repair: definition, classification, and strategies for surveillance and intervention.

In the ongoing evolution of a categorization system for endoleak, the authors propose the term endotension to define persistent or recurrent pressurization of the aortic aneurysm sac after endovascular repair. Endotension is evidence that the aneurysm remains at risk of rupture and should, therefore, be considered an indication for secondary intervention. Management strategies and a grading system for endotension are offered.

In situ stent-graft fenestration to preserve the left subclavian artery.

Purpose: To report our first clinical application of a new technique for in situ fenestration of a thoracic stent-graft. Case Report: After completing a series of in vitro and in vivo experiments, in situ stent-graft fenestration was employed during endograft repair of a saccular thoracic aortic aneurysm in a 77-year-old woman. Because the stent-graft would have covered the left subclavian artery ostium, a modified Zenith TX1 thoracic stent-graft was deployed then fenestrated transluminally using a guidewire followed by serial cutting balloons, which created a fenestration over the LSA sufficiently large to accommodate a Jomed covered stent on an 8-mm balloon. Completion angiography showed exclusion of the aneurysm and brisk flow into the LSA. Following the procedure, the arm pressures were nearly equal. The 6-month CT scan showed no endoleak and a patent subclavian artery stent. Conclusions: In situ graft fenestration to preserve the left subclavian artery after deliberate coverage during endovascular repair of a thoracic aortic aneurysm appears feasible in this initial clinical application. There are uncertainties regarding the long-term stability of the fabric tears that are an inherent part of this technique.

Fenestrated endovascular repair for juxtarenal aortic aneurysm.

The outcome of fenestrated endovascular aneurysm repair (F‐EVAR) was evaluated.

Detection of Endoleak with Enhanced Ultrasound Imaging: Comparison with Biphasic Computed Tomography

Purpose: To compare unenhanced and enhanced ultrasound imaging to biphasic computed tomography (CT) in the detection of endoleak after endovascular abdominal aortic aneurysm (AAA) repair. Methods: Fifty-three patients (44 men; mean age 70 years) were examined during 96 follow-up visits after endovascular AAA repair. All patients had color Doppler and power Doppler ultrasound studies performed before and after the administration of an ultrasound contrast agent. Biphasic (arterial and delayed) CT was performed on the same day, and the ultrasound and CT studies were independently scored to record the presence or absence of endoleak and the level of confidence in the observation. Results: The sensitivity of the ultrasound techniques to detect endoleak improved with the use of ultrasound contrast media, ranging from a low of 12% with unenhanced color Doppler to 50% with enhanced power Doppler. However, the enhanced power Doppler failed to detect 9 type II endoleaks identified by CT (86% negative predictive value for endoleak). There were only 2 graft-related endoleaks in the study; one was diagnosed from the ultrasound image, but the other had nondiagnostic ultrasound scans because of poor views. Conclusions: Ultrasound scanning with or without contrast enhancement was not as reliable as CT in diagnosing type II endoleak. CT imaging remains our surveillance modality of choice.

Early Results of Fenestrated Endovascular Repair of Juxtarenal Aortic Aneurysms in the United Kingdom

Background— Fenestrated endovascular repair of abdominal aortic aneurysms has been proposed as an alternative to open surgery for juxtarenal and pararenal abdominal aortic aneurysms. At present, the evidence base for this procedure is predominantly limited to single-center or single-operator series. The aim of this study was to present nationwide early results of fenestrated endovascular repair in the United Kingdom. Methods and Results— All patients who underwent fenestrated endovascular repair between January 2007 and December 2010 at experienced institutions in the United Kingdom(>10 procedures) were retrospectively studied by use of the GLOBALSTAR database. Site-reported data relating to patient demographics, aneurysm morphology, procedural details, and outcome were recorded. Data from 318 patients were obtained from 14 centers. Primary procedural success was achieved in 99% (316/318); perioperative mortality was 4.1%, and intraoperative target vessel loss was observed in 5 of 889 target vessels (0.6%). The early reintervention (<30 days) rate was 7% (22/318). There were 11 deaths during follow-up; none were aneurysm-related. Survival by Kaplan–Meier analysis was 94% (SE 0.01), 91% (0.02), and 89% (0.02) at 1, 2, and 3 years, respectively. Freedom from target vessel loss was 93% (0.02), 91% (0.02), and 85% (0.06), and freedom from late secondary intervention (>30 days) was 90% (0.02), 86% (0.03), and 70% (0.08) at 1, 2, and 3 years. Conclusions— In this national sample, fenestrated endovascular repair has been performed with a high degree of technical and clinical success. Late survival and target vessel patency are satisfactory. These results support continued use and evaluation of this technique for juxtarenal aneurysms, but illustrate the need for a more robust evidence base.

Use of contrast-enhanced ultrasound in follow-up after endovascular aortic aneurysm repair

PURPOSE To investigate the use of contrast-enhanced ultrasound in the detection of endoleak after endovascular repair of abdominal aortic aneurysm. MATERIALS AND METHODS Eighteen patients underwent follow-up on 20 occasions after endovascular aortic aneurysm repair by arterial-phase contrast-enhanced spiral computed tomography (CT). All patients had unenhanced color Doppler ultrasound and Levovist-enhanced ultrasound on the same day. The ultrasound examinations were reported in a manner that was blind to the CT results. CT was regarded as the gold standard for the purposes of the study. RESULTS There were three endoleaks shown by CT. Unenhanced ultrasound detected only one endoleak (sensitivity, 33%). Levovist-enhanced ultrasound detected all three endoleaks (sensitivity, 100%). Levovist-enhanced ultrasound indicated an additional six endoleaks that were not confirmed by CT (specificity, 67%; positive predictive value, 33%). In one of these six cases, the aneurysm increased in size, which indicates a likelihood of endoleak. Two of the remaining false-positive results occurred in patients known to have a distal implantation leak at completion angiography. CONCLUSION In this small group of patients, contrast-enhanced ultrasound appears to be a reliable screening test for endoleak. The false-positive results with enhanced ultrasound may be due to the failure of CT to detect slow flow collateral pathways. Although the number of patients in this study is small, enhanced ultrasound may be more reliable than CT in detecting endoleak.

Aortic Side Branch Embolization before Endovascular Aneurysm Repair: Incidence of Type II Endoleak

PURPOSE To assess the feasibility of embolization of aortic side branches and its impact on the incidence of type II endoleak after endovascular aneurysm repair. MATERIALS AND METHODS Endovascular aneurysm repair was performed in 74 patients. Aortic side branch vessels were evaluated on the preoperative angiogram and computed tomography (CT) and, where embolization of lumbar and inferior mesenteric vessels was considered technically possible, this was attempted prior to endovascular repair. Follow-up CT was used to assess the presence of type II endoleak. RESULTS Seventy-two patients were followed up for longer than 1 month. Embolization was attempted in 25 cases, successfully in 10, with partial success in 11, and failure in four. Twenty patients with successful or partly successful preoperative embolization were discharged and followed-up. Four (20%) had demonstrable type II endoleak during follow-up, with two of these persisting at latest follow-up. Of 43 patients without previous embolization, there were 10 (23.3%) type II endoleaks during the follow-up period, four of these persisting. In cases with type II endoleak, mean sac diameter change was -0.5 mm in the cases with previous embolization and +3.1 mm without. The mean period to onset of type II endoleak was 6.9 months without, and 15.3 months with, previous embolization. CONCLUSION Although the cohort size is below a level that would confer significance, the trend of these findings is such as to suggest a lack of influence of aortic side branch embolization on the incidence of type II endoleak during the follow-up period.

Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy

The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis.

Late complications after ligation and bypass for popliteal aneurysm

Ligation and bypass is standard treatment for popliteal aneurysm. This technique does not abolish collateral circulation to the aneurysm, which may continue to expand and/or rupture. This study assessed whether complete thrombosis of the aneurysm sac occurs after operation and examined the long‐term clinical outcome.

Percutaneous thrombin injection of carotid artery pseudoaneurysm.

Purpose: To report the successful treatment of a carotid artery pseudoaneurysm by percutaneous thrombin injection. Case Report: A 71-year-old man with end-stage renal failure presented with acute left ventricular failure. The right common carotid artery (CCA) was punctured during attempted jugular line insertion, and he developed a large pseudoaneurysm connected to the CCA by a long, narrow neck. Ultrasound-guided compression was unsuccessful, so another technique was attempted. An occlusion balloon was inflated in the CCA at the neck of the aneurysm to avoid distal embolization, and 250 units of human thrombin were injected into the sac percutaneously; thrombosis was instantaneous. There were no procedural complications, and repeat ultrasound at 3 months showed resolution of the hematoma and no residual pseudoaneurysm. There were no neurological complications. Conclusions: Percutaneous thrombin injection may be a new and successful method of treating carotid artery pseudoaneurysms.