Sasan Najibi

Endovascular repair of abdominal aortic aneurysms: risk stratified outcomes.

ObjectiveThe impact of co-morbid conditions on early and late clinical outcomes after endovascular treatment of abdominal aortic aneurysm (AAA) was assessed in concurrent cohorts of patients stratified with respect to risk for intervention. Summary Background DataAs a minimally invasive strategy for the treatment of AAA, endovascular repair has been embraced with enthusiasm for all prospective patients who are suitable anatomical candidates because of the promise of achieving a durable result with a reduced risk of perioperative morbidity and mortality. MethodsFrom April 1994 to March 2001, endovascular AAA repair was performed in 236 patients using commercially available systems. A subset of patients considered at increased risk for intervention (n = 123) were categorized, as such, based on a preexisting history of ischemic coronary artery disease, with documentation of myocardial infarction (60%) or congestive heart failure (35%), or due to the presence of chronic obstructive disease (21%), liver disease, or malignancy. ResultsPerioperative mortality (30-day) was 6.5% in the increased-risk patients as compared to 1.8% among those classified as low risk (P = NS). There was no difference between groups in age (74 ± 9 years vs. 72 ± 6 years; mean ± SD), surgical time (235 ± 95 minutes vs. 219 ± 84 minutes), blood loss (457 ± 432 mL vs. 351 ± 273 mL), postoperative hospital stay (4.8 ± 3.4 days vs. 4.0 ± 3.9 days), or days in the ICU (1.3 ± 1.8 days vs. 0.5 ± 1.6 days). Patients at increased risk of intervention had larger aneurysms than low-risk patients (59 ± 13 mm vs. 51 ± 14 mm;P < .05). Stent grafts were successfully implanted in 116 (95%) increased-risk versus 107 (95%) low-risk patients (P = NS). Conversion rates to open operative repair were similar in increased-risk and low-risk groups at 3% and 5%, respectively. The initial endoleak rate was 22% versus 20%, based on the first CT performed (either at discharge or 1 month;P = NS). To date, increased-risk patients have been followed for 17.4 ± 15 months and low-risk patients for 16.3 ± 14 months. Kaplan-Meier analysis for cumulative patient survival demonstrated a reduced probability of survival among those patients initially classified as at increased risk for intervention (P < .05, Mantel-Cox test). Both cohorts had similar two-year primary and secondary clinical success rates of approximately 75% and 80%, respectively. ConclusionsEarly and late clinical outcomes are comparable after endovascular repair of AAA, regardless of risk-stratification. Notably, 2 years after endovascular repair, at least one in five patients was classified as a clinical failure. Given the need for close life-long surveillance and the continued uncertainty associated with clinical outcome, caution is dictated in advocating endovascular treatment for the patient who is otherwise considered an ideal candidate for standard open surgical repair.

Secondary conversion due to failed endovascular abdominal aortic aneurysm repair

Since Parodi et al reported their initial experience with endograft placement in patients with abdominal aortic aneurysm (AAA) more than a decade ago, endovascular repair has become an increasingly accepted treatment option for aneurysmal disease. Currently three endovascular grafts have been approved by the US Food and Drug Administration (FDA), namely, AneuRx, Ancure, and Excluder, and a number of other devices are at various stages of FDA review. Endovascular repair of infrarenal AAA has been extensively investigated, with encouraging short-term results. There is little doubt that endovascular repair of AAA is equivalent to open repair in the short term. The enthusiasm for this minimally invasive treatment is driven in part by shorter hospital course, decreased anesthetic risk, and expedient convalescent period, compared with the conventional open operation. Along with numerous positive short-term and mid-term reports of AAA endovascular repair, a growing number of reports are beginning to reveal some of the limitations of this evolving technology. Problems with device integrity, component separation, migration, infection, iliac limb occlusion, and aneurysm sac expansion with and without the presence of endoleak have been described. Many of these problems have resulted in device explantation and repair of the aneurysm with an open surgical approach. Explantation of an endovascular graft is reported as primary conversion if it is removed at the original endovascular grafting procedure, and as secondary conversion if it is removed sometime after the original endovascular grafting procedure. Clearly the rate of primary conversion has been significantly reduced with improved device design, patient selection, and increasing operator experience. Recently several investigators reported their rate of secondary conversion. Lyden et al evaluated 110 patients who received endovascular AAA treatment, 5 (4.5%) of whom required secondary conversion. Dattilo et al reported a secondary conversion rate of 2.2% (8 patients) over 7 years in 362 AAA endovascular grafts. Finally, Ohki et al, in a 9-year experience with 239 endovascular grafts, reported a secondary conversion rate of 2.1% (5 patients). In this article we review our experience in patients with late endovascular graft clinical failure in whom secondary conversion was required. In addition, we examine the indications, operative strategies, and technical maneuvers that may facilitate endograft explantation.

Iliac Artery Kinking with Endovascular Therapies: Technical Considerations

Iliac artery tortuosity should be considered when planning endovascular interventions from a femoral approach. Stiff guide wires across tortuous iliac segments can introduce foreshortening and temporary kinking. Recognition of this phenomenon and its implications is important when making anatomic measurements before endovascular device placement, when assessing iliac runoff, and when considering adjunctive procedures after aortoiliac interventions. Two illustrative cases of external iliac artery kinking are presented, one during an abdominal aortic aneurysm endograft procedure and another encountered during stent placement in an external iliac artery dissection. In both cases, the temporary nature of the deformity was recognized, avoiding unnecessary additional intervention.

Carotld body tumors

C Also known as cervical paragangliomas, these neoplasms are of the neuroectodermal paraganglion cells. Originating from the afferent ganglion of the glossopharyngeal nerve, carotid body tumors are generally located at the carotid bifurcation. These tumors carry more blood flow per gram than any other tumor. The primary blood supply is from the external carotid artery and its branches. The most common presentation is the development of an asymptomatic anterior neck mass without a thrill or bruit. Cranial nerve deficits are uncommon, but may be seen in patients with masses greater than 5 cm in size. CT scanning with contrast is the imaging modality of choice to define the size of the tumor (A). In addition, it can identify contralateral tumors. Using the CT scan, the Shamblin type of the tumor is identified. (B, Type I: small tumor, easily resectable; Type II: large tumor, adherent to the vessels; Type III: tumor surrounding the internal carotid artery, may encase nerves.) Contrast angiography generally shows a highly vascular mass at the carotid bifurcation (C). Test occlusion of the common carotid artery during angiography may predict the need for carotid shunting should carotid clamping be necessary during the resection.

Coil embolization combined with carotid-subclavian bypass for treatment of subclavian artery aneurysm.

Purpose: To report 2 cases of proximal subclavian artery aneurysm treated with carotid-subclavian bypass and coil embolization. Case Reports: A subclavian artery aneurysm was discovered incidentally during presurgical coronary angiography in 2 men (72 and 63 years of age). Both patients underwent planned carotid endarterectomy, during which a carotid-subclavian bypass was created with a Dacron graft; the distal subclavian artery was also ligated. The aneurysm was completely excluded from the circulation by coil embolization in a separate procedure. The patients were discharged after 3 days with no adverse events. Magnetic resonance angiography at 6 months showed continued aneurysm exclusion in both cases. The patients continue to be well >1 year after treatment. Conclusions: Embolization with supraclavicular bypass represents a viable alternative to traditional thoracotomy and subclavian artery reconstruction for treatment of subclavian artery aneurysms.

Platelets: Is Aspirin Sufficient or Must We Know How to Pronounce Abciximab?

Although vascular disease may present with symptoms that are representative of a focal exacerbation of atherosclerosis, it is inherently a systemic disease. Consequently, vascular surgeons must be capable of recommending to their patients pharmacologic approaches that will decrease future risk of cardiovascular-related morbidity and death. Antiplatelet treatments, in particular, have been shown to reduce future cerebrovascular and coronary events. Moreover, these medications have utility in maintaining peripheral vessel and graft patency after surgical bypass, endarterectomy, or percutaneous translumenal angioplasty. The future of optimal antiplatelet therapy will consist of strategies that block multiple platelet activation pathways simultaneously. Moreover, the use of directed antiplatelet medications promises more effective control of platelet physiology with a concomitant increase in safety. The authors review herein current recommendations for the use of aspirin, thienopyridines, and GP IIb/IIIa inhibitors in patients with peripheral vascular disease.