Sandra C. Carr

Absence of buttock claudication following stent-graft coverage of the hypogastric artery without coil embolization in endovascular aneurysm repair.

Purpose: To evaluate the safety and efficacy of stent-graft coverage of the hypogastric artery origin without coil embolization during endovascular treatment of aortoiliac or iliac aneurysms. Methods: A retrospective study was conducted of patients who underwent endovascular aneurysm repair with endograft coverage of the hypogastric artery between September 2001 and September 2005. Among the 88 patients who underwent EVAR during the study period, 21 patients (19 men; mean age 77±6 years, range 67–86) had unilateral hypogastric artery coverage without coil embolization. Aneurysmal arteries included 11 aortoiliac, 8 isolated common iliac arteries (CIA), and 2 isolated hypogastric arteries. Preoperative AAA size was a mean 57 mm (range 46–73), and mean CIA aneurysm diameter was 36 mm (range 17–50). All covered hypogastric arteries were patent prior to the procedure. The stent-grafts implanted were 10 Excluder, 10 AneuRx, and 1 Zenith. Clinical outcome focused on mortality and morbidity, including the occurrence and duration of new-onset buttock claudication, which was further correlated with superior gluteal and profunda femoris artery patency. Results: Immediate seal was achieved in all patients. Mean follow-up was 16 months (range 1–54). No type I endoleaks developed from the aortic or external iliac artery, and no type II endoleaks were found from the origin of the hypogastric artery. New-onset buttock claudication occurred in 2 (9.5%) patients, but resolved in both within 4 months. No additional secondary procedures, aneurysm rupture, or aneurysm-related death occurred. Conclusion: Stent-graft coverage of the orifice of the hypogastric artery without coil embolization is a safe and effective adjunct during the treatment of aortoiliac or iliac aneurysm, with a low incidence of buttock claudication.

Surgical Treatment of Ovarian Vein Thrombosis

Ovarian vein thrombosis is a rare but serious condition that may cause sepsis in the postpartum patient or may be associated with thrombosis of the inferior vena cava or renal vein. A 30-year-old woman presented 2 weeks postpartum with sudden onset of dyspnea and rightsided pleuritic chest pain. She was diagnosed with a large pulmonary embolus and thrombosis of the right ovarian vein. After failure of percutaneous embolization of the right ovarian vein, the patient underwent open surgical excision of the right ovarian vein. The management of ovarian vein thrombosis may involve systemic anticoagulation, antibiotics, thrombolysis, open surgical treatment, or a combination of these.

Comparison of minimal incision aortic surgery with endovascular aortic repair

BACKGROUNDnEnthusiasm for endovascular aortic repair (EVAR) has been tempered by midterm outcomes that raise valid concern about long-term durability.nnnMETHODSnThis article compares outcome data from a prospective nonrandomized comparison of a less-invasive open surgical repair technique-minimal incision aortic surgery (MIAS)-and EVAR.nnnRESULTSnMIAS and EVAR had comparable intensive care unit stays (1 day or less), quick return to general dietary feeding (2 days), and comparable hospital length of stay (4.8 days [3.4 days for uncomplicated cases MIAS] and 2.0 days for EVAR). Overall morbidity and mortality for MIAS and EVAR were comparable (18% versus 27%). MIAS was more cost effective than EVAR (net revenue MIAS = +8,445 US dollars, EVAR -7,263 US dollars).nnnCONCLUSIONSnMIAS is a safe, cost-effective alternative to endovascular aortic repair.

Role of Magnetic Resonance Angiography in Peripheral Vascular Disease

Imaging of the vascular system is an essential component in the preoperative and postoperative management of patients with peripheral vascular disease of the lower extremities. Traditionally, contrast angiography, especially digital subtraction angiography, has been the gold standard for imaging of the arterial system. Digital subtraction angiography (DSA) provides excellent visualization of the inflow and outflow vessels in most cases. The disadvantages of DSA are that it is invasive, costly, and not completely safe. Complications are rare but include contrast-related nephrotoxicity, allergic reactions, arterial injury with hemorrhage, thrombosis, or embolization. Because of this, less invasive imaging techniques, such as magnetic resonance arteriography (MRA), have been developed.

Endovascular aortic repair or minimal incisional aortic surgery: Which procedure to choose for treatment of high-risk aneurysms?

BACKGROUNDnThis study evaluates use of endovascular aortic repair (EVAR) and minimal incision aortic surgery (MIAS) for treatment of high-risk patients with infrarenal aneurysms.nnnMETHODSnA retrospective review of patients treated with EVAR or MIAS between 2000 and 2002 was performed. High-risk criteria included age older than 80 years, creatinine level greater than 3.0 mg/dL, recent myocardial infarction, congestive heart failure, severe chronic obstructive pulmonary disease, hostile abdomen, or morbid obesity (body mass index greater than 30). Patient demographics, duration of stay, morbidity, and mortality were compared. Exclusionary criteria for EVAR treatment included neck less than 1.5 cm or greater than 26 mm in diameter, densely calcified iliac arteries less than 6 mm, or creatinine level greater than 3.0 mg/dL. Exclusionary criteria for MIAS included pararenal abdominal aortic aneurysm, aneurysm greater than 10 cm, and morbid obesity.nnnRESULTSnEighty-four patients were treated (61 EVAR, 23 MIAS). Average age for EVAR was 74 years and 72 years for MIAS. Average aneurysm size was 6 cm for both. American Society of Anesthesiologists score was 3.1 for EVAR and 3.0 for MIAS patients. Thirty-two of 61 EVAR patients (52%) had 2 risk factors, and 12 of 61 (20%) had 3 risk factors. Seven of 23 MIAS patients (30%) had 2 risk factors, and 7 had more than 3 risk factors (30%). There were 2 EVAR deaths (3%) from multiorgan failure and 1 MIAS death (4%) from myocardial infarction. Average duration of stay was 5.1 days for both EVAR and MIAS. Thirty-day morbidity was 18% for EVAR and 17% for MIAS patients.nnnCONCLUSIONSnEVAR and MIAS are comparable for the treatment of high-risk aneurysm patients.