Sean D. O'Donnell

Arteriography in the Delayed Evaluation of Wartime Extremity Injuries

Recent combat casualties have stimulated a reassessment of the principles of management of high-risk extremity injuries with a normal vascular examination. Rapid evacuations have presented numerous U.S. soldiers to our service for evaluation in the early postinjury period. The objective of this single-institution report is to analyze the application of liberal arteriography in the delayed evaluation of modern wartime extremity injuries. Data from consecutive wartime evacuees evaluated for extremity injuries between March 2002 and November 2004 were prospectively entered into a database and retrospectively reviewed. Analysis was focused on arteriography and its role in our current diagnostic and therapeutic approach. Information including injury sites and mechanisms, associated trauma, battlefield repairs performed, arteriography technique, complications, findings, and need for further intervention were reviewed. Indications for imaging in this high-risk group included proximity to vascular structures, abnormal or equivocal physical examination, adjunctive operative planning, and evaluation of battlefield repair. Ninety-nine of 179 patients (55%) with extremity injuries underwent arteriography, with 142 total limbs studied. The majority of them were wounded by explosive devices (82%) or high-velocity rifle munitions (14%). Abnormalities were found in 75 of 142 (52.8%) imaged limbs in 46 of the 99 (46.5%) patients. Twenty-four of these patients (52.2%) required additional operative intervention. Occult vascular injury findings were associated with bony fracture in 68% and nerve injury in 16%. Median delay between injury and stateside evaluation was 6 days. Two thirds of these soldiers presented with a normal physical examination result. There were no access site complications or incidents of contrast-induced acute renal failure. The liberal application of arteriography is a low-risk method to provide high-yield data in the delayed vascular evaluation of extremities injured from modern military munitions. Physical examination findings remain the most useful indicator, but a normal examination can be misleading and should not guide the decision for invasive imaging. Lesions are found and require further intervention at a higher rate than expected from the typical civilian trauma experience.

Review of standards for competence in catheter-based endovascular procedures: a resource and strategy for the interventional vascular surgeon.

The field of peripheral vascular disease management is evolving. As such, vascular surgeons can no longer be complacent and expect to be included in the rapidly expanding practice of endovascular intervention. If not engaged, vascular surgeons risk losing not only the patients who have largely driven this evolution but also their role as leaders in the management of vascular disease. Therefore vascular surgeons and vascular surgical training programs find themselves in an awkward and sometimes confrontational circumstance attempting to gain experience and training in catheter-based procedures. Individual societies, both surgical and nonsurgical, have put forth competence standards for catheter-based procedures. However these standards are not always consistent and the definition of competence is often a heated debate. In addition, combining the acquisition of endovascular skills with the multitude of available endovascular training experiences, didactic and “hands-on,” is not well coordinated. The objectives of this review are to summarize the literature as it relates to catheter-based endovascular competence, including publications from nonsurgical catheter-based specialties, and to place the acquisition of basic endovascular skills in context with the available endovascular courses in a stepwise strategy. A final objective is to provide a literature-based resource that outlines specific phases in the development of interventional vascular surgeons and training programs as they advance into the arena of catheter-based endovascular therapies.

Repair of bilateral iliac artery aneurysms associated with a congenital pelvic kidney.

The association of iliac artery aneurysms with a congenital pelvic kidney is extremely rare. Although multiple techniques are well described for renal preservation with renal ectopia in the setting of aortic reconstruction, few reports exist describing techniques for renal preservation in the setting of bilateral iliac artery aneurysms. A case is presented of a middle-aged man with a 6-cm right common iliac artery aneurysm and a 3-cm left common iliac artery aneurysm and a right pelvic kidney. A double-proximal-clamp technique and temporary shunting to the pelvic kidney were used during the aneurysm repair. The technical aspects of this procedure are presented as well as a brief discussion of the various options for renal preservation with renal ectopia when repairing complex aneurysmal disease.

Surgical Bypass in a 17 Year-Old Female with Takayasu Arteritis

Methods: After IRB approval, patients treated with tibial angioplasty between 2013 and 2015 were identified by CPT code from administrative database. Patients with suprageniculate disease more than 4cm in length were excluded to evaluate patents with predominantly tibial disease. Primary outcomes measured were 30 days and 6month major adverse limb events (MALE). Secondary outcomes measured were need for repeat endovascular intervention, wound healing, and need for bailout stenting. Results: 142 limbs in 118 patients were identified with predominantly infragenicular disease. The main indication for intervention was critical limb ischemia, with tissue loss in 66% and rest pain in 30%. Orbital atherectomy and plaque modifying balloons were used to intervene in just over half of the cases. A number were lost to follow up, around 30%. Of the remainingpatients, therewasa low30dayand6month MALE of 1.37% and 4.79% respectively. There was a 20% reintervention rate, and wound healing was reported in over 50% of the cases. Bailout stenting was required in 6 cases. Conclusions: Tibial interventions were performed with a low amputation rate, acceptable reintervention rate, and a good healing rate in patients who would otherwise likely progress to limb loss. There was a higher than expected rate of lost to follow up.

Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms

Background: The operative management of inflammatory abdominal aortic aneurysms has evolved based on a concept of minimal dissection and the morbidity associated with open repair of inflammatory aneurysms has decreased. Despite such progress, the technical challenges associated with open repair of inflammatory aneurysms are formidable, and an endovascular approach is an appealing alternative that extends the concept of minimal dissection. Objective: The objective of this report is to provide a literature-based statement on the endovascular repair of inflammatory abdominal aortic aneurysms concentrating on four main areas: feasibility of placement, efficacy of treatment, associated morbidity and mortality, and the response of perianeurysmal fibrosis and inflammation. Results: The published experience with endovascular repair of inflammatory abdominal aortic aneurysms is limited to two series of patients and fewer than 10 case reports. From this it appears that the endovascular repair of inflammatory abdominal aortic aneurysms is feasible and proceeds in a manner similar to the endovascular repair of degenerative aneurysms. Two aspects of endovascular repair influenced by the unique presentation of inflammatory aneurysms are the measurement of attachment site diameters and the flexibility of iliac arteries. Endovascular repair of inflammatory aneurysms is effective in preventing rupture and reducing perioperative morbidity. The response of perianeurysmal fibrosis to endovascular repair is varied and does not appear to be related to endograft type or endoleak status. Conclusions: Preliminary experience with endovascular repair of inflammatory abdominal aortic aneurysms suggests that this technique is feasible, safe, and effective. The varied response of perianeurysmal inflammation to endovascular repair is not dissimilar to clinical experience with open inflammatory aneurysm repair and is influenced by yet undefined factors.