Robert F. Cuff

Complication rates for percutaneous lower extremity arterial antegrade access

HYPOTHESISnThe antegrade access (AA) for percutaneous arterial interventions is associated with a higher complication rate than is the retrograde access (RA).nnnDESIGNnRetrospective case review.nnnSETTINGnA statewide consortium for peripheral vascular interventions consisting of 13 Michigan hospitals collecting data on their endovascular procedures.nnnPATIENTSnDemographic and procedure data on all patients receiving a percutaneous peripheral arterial intervention were entered prospectively by a full-time clinical nurse specialist in each hospital site.nnnMAIN OUTCOME MEASURESnWe evaluated vascular complications as a composite of retroperitoneal hematoma, pseudoaneurysm, hematoma requiring blood transfusion, arteriovenous fistula, acute thrombosis, or the need for surgical repair of the access site.nnnRESULTSnIn a 2-year period, we collected 6343 cases, of which 5918 had complete data regarding arterial access; of these, 745 (12.6%) were performed via an AA. There were fewer women and smokers (P < .001) in the AA group but more diabetic patients (P < .001). The indications for intervention were more frequently rest pain (P < .001) and limb salvage (P < .001) in the AA group. Multivariate regression analysis showed that the odds of complications were significantly higher with a larger sheath (95% confidence interval, 1.53-4.06; P < .001). Also, the incidence of blood transfusion and subsequent amputation was significantly higher in the AA group (P < .001).nnnCONCLUSIONnEndovascular procedures performed via an AA are more likely to result in perioperative complications and therefore should be used cautiously.

Preliminary results of Zenith Fenestrated abdominal aortic aneurysm endovascular grafts

BACKGROUNDnPatients with juxtarenal aortic aneurysms who are unfit for open repair may be considered for fenestrated endovascular repair (fenEVAR). We report our initial experience with fenEVAR.nnnMETHODSnWe reviewed the data on all our patients receiving fenEVAR for juxtarenal aortic aneurysms.nnnRESULTSnEight patients, average age 75 years, underwent fenEVAR. Endografts were designed from details obtained from preoperative computed tomography angiography. There were 6 grafts with superior mesenteric scallops and bilateral renal fenestrations, 1 with bilateral renal scallops, and 1 with a single renal fenestration. All patients survived 30 days. There was no renal failure requiring dialysis. At 10 weeks, 1 patient died from acute intestinal ischemia and multisystem organ failure, and another died from respiratory failure.nnnCONCLUSIONSnIt is feasible to offer fenEVAR to patients who are poor candidates for open repair. However, these procedures are technically challenging. Early outcomes are less favorable than other aortic endovascular procedures.

Vascular procedures in nonagenarians and centenarians are safe

BACKGROUNDnAn increasing number of elderly patients present for elective and emergent vascular procedures. The purpose of this study was to analyze the 30-day and long-term outcome of patients in their 10th decade of life undergoing vascular procedures.nnnMETHODSnWe reviewed the outcomes of all patients in the 10th decade of life included in our registry.nnnRESULTSnIn a 15-year period, there were 176 patients, 102 women and 74 men, with a mean age of 92 (range 90-102) undergoing 196 vascular operations for acute and chronic limb ischemia, aortic and popliteal aneurysms, and carotid stenosis. Overall morbidity and mortality rates were comparable as well as the return to preoperative functional status.nnnCONCLUSIONSnPatients in their 90s can safely undergo vascular procedures with reasonable early outcomes. Most patients return to their preoperative status. Age alone should not be a determinant in refusing surgery in this age group.

Initial results of a thoracic aortic endovascular program: safer in high-risk patients.

Results are presented from our single-institutional experience with thoracic endovascular aortic repair to confirm that it is safe in patients with significant comorbidities. A retrospective review of all patients undergoing endovascular or open thoracic aortic repair at our institution since 2002 was performed. Main outcome measures included clinical presentation, demographics, preoperative risk factors, operative details, and clinical outcomes. The endovascular group included 37 patients (22 males), whereas the open group included 19 patients (eight males). Eight patients per group were treated emergently for trauma or rupture (22% and 42%, respectively; p=0.11). Endovascular patients were significantly older with more comorbid conditions (p<0.05). However, the overall perioperative complication rate was similar in the two groups (32.4% and 31.6%, respectively). Postoperative renal failure occurred only in four open patients (21.1% vs. 0%, p < 0.05). Operative time, ventilator days, and total length of stay were also greater for open patients (p<0.05). There was one death in the endovascular group and three in the open group (2.7% and 15.8%, respectively; p=0.07). Endovascular patients had shorter operative time and length of stay, fewer ventilator days and intensive care unit days, and fewer transfusions. Although the endovascular patients were significantly older with more comorbidities, the complication rate was similar to the open group. Also, there was a trend toward lower mortality in the endovascular group (p=0.07). Endovascular repair is the procedure of choice for treating the descending thoracic aorta in high-risk patients even in the emergent setting.