Richard Hershberger

Endovascular Grafts for Treatment of Traumatic Injury to the Aortic Arch and Great Vessels

BACKGROUND Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times. METHODS A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma. RESULTS In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%. CONCLUSION The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

Outcomes of endovascular abdominal aortic aneurysm repair in high-risk patients

OBJECTIVE Although the endovascular aneurysm repair trial 2 (EVAR-2) demonstrated no benefit of EVAR in high-risk (HR) patients, EVAR is still performed widely in this patient cohort. This study compares the midterm outcomes after EVAR in HR patients with those in normal-risk (NR) patients. In turn, these data are compared with the EVAR-2 data. METHODS A retrospective review from January 2006 to December 2013 identified 247 patients (75 HR [30.4%], 172 NR [69.6%]) who underwent elective EVAR for infrarenal aortic aneurysm in an academic tertiary institution and its affiliated Veterans Administration hospital. The same HR criteria used in the EVAR-2 trial were employed. Overall survival, graft-related complications, and reintervention rates were estimated by the Kaplan-Meier method. HR group outcomes were compared with the EVAR-2 data. RESULTS HR patients had a larger abdominal aortic aneurysm size and had a higher prevalence of cardiac disease (P < .01), chronic obstructive pulmonary disease (P = .02), renal insufficiency (P < .01), and cancer (P < .01). Use of aspirin (63% HR vs 66% NR; P = .6), statin (83% HR vs 72% NR; P = .2), and beta-blockers (71% HR vs 60% NR; P = .2) was similar; in the EVAR-2 trial, the corresponding use of these medications was 58%, 42%, and not available, respectively. Perioperative mortality (0% HR vs 1.2% NR; P = 1.0) and early complication rates (4% HR vs 6% NR; P = .8) were similar. In contrast, perioperative mortality in the EVAR-2 trial was 9%. At a mean follow-up of 3 years, the incidence rates of delayed secondary interventions for aneurysm- or graft-related complications were 7% for HR patients and 10% for NR patients (P = .5). The 1-, 2-, and 4-year survival rates in HR patients (85%, 77%, 65%) were lower than those in NR patients (97%, 97%, 93%; P < .001), but this was more favorable compared with a 36% 4-year survival in the EVAR-2 trial. No difference was seen in long-term reintervention-free survival in HR and NR patients (P = .8). Backward stepwise logistic regression analysis identified five prognostic indicators for post-EVAR death: age, chronic kidney disease stages 4 and 5, congestive heart failure, home oxygen use, and current cancer therapy. CONCLUSIONS EVAR can be performed in patients unfit for open surgical repair with excellent early survival and long-term durability. These outcomes in the HR group compare more favorably to the EVAR-2 trial data. However, not all HR patients for open surgical repair derive the benefit from EVAR. The decision to proceed with EVAR in HR patients should be individualized, depending on the number and severity of risk factors.

Failed superficial femoral artery intervention for advanced infrainguinal occlusive disease has a significant negative impact on limb salvage.

OBJECTIVE Endovascular treatment of superficial femoral artery (SFA) lesions is a well-established practice. The repercussions of failed SFA interventions are unclear. Our goal was to review the efficacy of SFA stenting and define negative effects of its failure. METHODS A retrospective chart review was conducted from January 2007 to January 2010 that identified 42 limbs in 39 patients that underwent SFA stenting. Follow-up ankle-brachial index and a duplex ultrasound scan was performed at routine intervals. RESULTS Mean patient age was 68 years (range, 43-88 years); there were 22 men (56%) and 17 women (44%). Intervention indication was claudication in 15 patients (36%), rest pain in seven patients (17%), and tissue loss in 19 patients (45%). There were 15 patients (36%) with TransAtlantic Inter-Society Consensus (TASC) A, nine patients (21%) with TASC B, five patients (12%) with TASC C, and 13 patients (31%) with TASC D lesions. The majority of lesions intervened on were the first attempt at revascularization. Three stents (7.7%) occluded within 30 days. One-year primary, primary-assisted, and secondary patency rates were 24%, 44%, and 51%, respectively. Limb salvage was 93% during follow-up. Seventeen interventions failed (40%) at 1 year. Of these, seven patients (41%) developed claudication, seven patients (41%) developed ischemic rest pain, and three patients (18%) were asymptomatic. During follow-up, three patients (7.7%) required bypass and three patients (7.7%) major amputation, one after failed bypass. All limbs requiring bypass or amputation had TASC C/D lesions. Thirty-day and 1-year mortality was 2.6% and 10.3%, respectively. CONCLUSIONS Interventions performed for TASC C/D lesions are more likely to fail and more likely to lead to bypass or amputation. Interventions performed for TASC C/D lesions that fail have a negative impact on limb salvage. This should be considered when performing stenting of advanced SFA lesions.

Aspirin usage is associated with improved prosthetic infrainguinal bypass graft patency

The American Heart Association recommends that, unless contraindicated, all patients undergoing surgical revascularization for critical limb ischemia should be placed postoperatively on antiplatelet therapy and remain on it indefinitely. The goal of this study was to evaluate if preoperative use of aspirin was associated with improved bypass grafting patency rates and limb salvage. We performed a four-year, retrospective review of one centers experience with open infra-inguinal bypass. We examined the effect pre- and postoperative usage of antiatherosclerotic agents (i.e. aspirin, statin, etc.) have on graft outcomes such as two-year secondary patency, stenosis and limb salvage via univariate Kaplan–Meir survival curve analysis and multiple regression analysis. Our cohort included 165 bypasses in individuals with multiple co-morbidities. The most frequent indication was critical limb ischemia (79%) and most bypasses crossed the knee (63%). Pre- and postoperative aspirin usage was associated with increased two-year secondary prosthetic graft patency over control (preoperative: 78% versus 44%, P < 0.002 and postoperative: 72% versus 50%, P < 0.01). Preoperative aspirin usage was associated with an improvement in the rate of amputation (odds ratio [OR] = 0.44 [95% CI 0.198–0.997]) and stenosis (OR = 0.45 [95% CI 0.217–0.956]). Medications commonly prescribed for atherosclerosis such as aspirin are associated with a significant patency benefit when administered pre- and postoperatively. In a population undergoing infrainguinal bypass with prosthetic graft for predominantly critical limb ischemia, medical optimization should include both pre- and postoperative antiatherosclerotic drug regimens.

Acute Pancreatitis after Percutaneous Mechanical Thrombectomy: Case Report and Review of the Literature

PurposeWe describe a case of severe acute pancreatitis after percutaneous mechanical thrombectomy (PMT) and review the literature for the occurrence of this complication.Materials and MethodsA 53-year-old man with a history of bilateral external iliac artery stent placement sought care for acute onset of lifestyle-limiting left claudication. Angiography confirmed left external iliac stent occlusion, and PMT with the AngioJet Xpeedior catheter (Possis Medical, Minneapolis MN) was performed.ResultsAfter PMT of the occluded external iliac artery, a residual in-stent stenosis required the placement of a second iliac stent. The procedure was complicated by severe acute pancreatitis. Other causes of pancreatitis were eliminated during the patient’s hospital stay. A literature review revealed nine cases of acute pancreatitis after PMT.ConclusionAlthough rare, pancreatitis can be a devastating complication of PMT. The development of pancreatitis seems to be related to the products of extensive hemolysis triggering an inflammatory process. To prevent this complication, we recommend that close attention be paid to the duration and extent of PMT, thereby avoiding extensive hemolysis and subsequent complications.

Neurologic complications of aortic diseases and aortic surgery.

Aortic disease processes have a wide range of clinical manifestations. The inflammatory disease process of Takayasus arteritis differs dramatically from the visceral ischemia of aortic dissection. The catastrophic event of aortic rupture tends to overshadow life-altering events such as stroke and paraplegia. However, these neurologic manifestations of aortic diseases have dramatic effects that extend beyond the individual patient to include both social and financial ramifications. This chapter focuses on the major aortic disease processes and how they can initiate, both directly and indirectly, adverse neurologic events. The chapter concludes with a brief discussion of aortic surgery, how interventions on the aorta can cause neurologic complications, and techniques to avoid these feared adverse neurologic outcomes.

Abdominal Aortic Aneurysm Associated with Congenital Solitary Pelvic Kidney Treated with Novel Hybrid Technique

Renal ectopia in the rare condition of associated abdominal aortic aneurysm presents a difficult clinical challenge with respect to access to the aorto-iliac segment and preservation of renal function because of its anomalous renal arterial anatomy and inevitable renal ischemia at the time of open repair. Multiple operative techniques are described throughout the literature to cope with both problems. We report a case of a 57-year-old male with an aorto-iliac aneurysm and a congenital solitary pelvic kidney successfully treated by hybrid total renal revascularization using iliorenal bypass followed by unilateral internal iliac artery coil embolization and conventional endovascular aortic aneurysm repair without any clinical evidence of renal impairment.

Proper hepatic artery reconstruction with gastroduodenal artery transposition during pancreaticoduodenectomy.

INTRODUCTION Vascular injuries to hepatic arterial blood flow present a challenge in reconstruction. The location and extent of the injury dictate intraoperative decision making, with repair being performed expeditiously to preserve hepatic function. Formal arterial repair either primarily or with interposition or transposition grafts is indicated in the majority of patients. Special consideration should be made in patients with underlying liver disease and those undergoing biliary reconstructions. This latter group of patients is at high risk of complications following the injury secondary to bile duct ischemia. METHODS A case of proper hepatic artery (PHA) transection repaired with gastroduodenal artery (GDA) transposition is presented with a relevant review of limited literature available on the subject. RESULTS During an elective pancreaticoduodenectomy the PHA was inadvertently transected just distal to the origin of the GDA. As the GDA had not been transected at this stage of the operation, it was available for transposition. This was performed, restoring arterial blood flow to the liver and the bile duct. The patient did well postoperatively with no evidence of biliary or pancreatic leak or hepatic dysfunction at both discharge and follow-up clinic visit. CONCLUSION Injuries to hepatic artery injury are uncommon in experienced hands. This case report is only the second instance of such injury requiring reconstruction in 434 cases of single operator experience pancreaticoduodenectomies. We present arterial transposition of GDA as a feasible method to ensure adequate arterial supply to the hepatobiliary system.

Right Renal Vein Aneurysm Discovered Incidentally During Laparoscopic Nephrectomy

Renal vein aneurysms are exceedingly rare. There are only 8 reported cases in the literature. We present the first case of a renal vein aneurysm discovered incidentally during a laparoscopic radical nephrectomy and discuss its intraoperative management.

Should Age Limit the Use of Catheter-Directed Thrombolysis: Results of National Survey.

Objective: To determine whether advanced age should be a contraindication to catheter-directed thrombolysis (CDT) based on hemorrhagic complication rate. Methods: A survey was generated via Survey Monkey and sent out to vascular surgeons who were members of the society of vascular surgery (SVS). Results: Of the responders, 32.7% state they do not have an age limit for tissue plasminogen activator (TPA) infusion, and the remaining 29.2% of the responders use 80 years of age as their limitation. When asked why place limits on age for TPA infusion, 56.6% stated concern for intracranial hemorrhage. Major complications were access site hemorrhage (58.4%) and intracranial hemorrhage (41.6%). Chi-square analysis did not show age as a limiting factor to thrombolysis. Furthermore, when asked in which age-group complications occurred most commonly, 72.4% were less than 80. Conclusion: Among vascular specialist, there seems to be no consensus on age limitations for TPA infusion. Serious complications do not seem to be age related and thus age alone should not be a contraindication for catheter-directed thrombolysis.