William E. Beckerman

PC010. Use of a Novel Flexible Covered Stent (GORE VIABAHN VBX) in Fenestrated and Parallel Grafts During Endovascular Treatment of Complex Perivisceral Aortic Aneurysms: Acute Results

bleeding (28% vs 19%; P 1⁄4 .04), and thromboembolic events (3.9% vs 1.1%; P 1⁄4 .03); however, mortality was similar (4.6% vs 6.3%; P 1⁄4 .46). These differences persisted following multivariable analysis (Table). Conclusions: Carotid-subclavian bypass done at the time of TEVAR does not prevent and may increase stroke rate. This practice should be abandoned. When indicated carotid-subclavian bypass should be performed before TEVAR.

Treatment of Carotid Disease in North America

Strokes are the third leading cause of death in the United States, with over 795,000 strokes leading to 140,000 deaths every year. Ischemic strokes caused by carotid stenosis are a significant contributor to these figures, and stroke prevention must weigh the risks and benefits of medical versus surgical management. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS) trials from North America helped establish some of the earliest guidelines for when best medical therapy versus surgical revascularization was more appropriate. But these recommendations have since been challenged as best medical therapy, particularly with the increased usage of statins, improves. Duplex ultrasound alone can often diagnose carotid stenosis, with cross-sectional imaging such as Computed Tomography Angiography (CTA) and Magnetic Resonance Angiography (MRA) often being used to provide better diagnostic imaging for pre-operative planning. In general, asymptomatic carotid stenosis >70 % and symptomatic stenosis >50 % merit revascularization, with carotid endarterectomy (CEA) the preferred treatment. Carotid stenting (CAS) has been shown in trials such as Carotid Revascularization Endarterectomy versus Stenting (CREST) to be non-inferior to CEA with regards to outcomes of stroke and myocardial infarction (MI), but is currently reserved for patients with medical or anatomical consideration that are not conducive to CEA. The upcoming CREST-2 trial should help establish guidelines for optimal utilization of best medical therapy (BMT) versus CEA versus CAS for carotid stenosis.

Symptomatic giant carotid artery aneurysm

A 49-year-old woman from Albania, who was a Jehovah’s Witness, presented to our hospital for management of a 3.6-cm right internal carotid artery (ICA) aneurysm. This otherwise healthy patient, without familial history of aneurysms, noticed worsening pain and pressure in her right neck for several months. Physical examination revealed a pulsatile mass, and imaging confirmed the aneurysm diagnosis. Computed tomography angiography detailed a 3.6-cm 2.9-cm 3-cm aneurysm of the right cervical ICA at the C1-C2 level with tortuous outflow of the distal ICA from the aneurysm sac (A). In the operating room, initial digital subtraction angiography displayed the morphology (B). Endovascular balloon occlusion testing combined with continuous electroencephalography monitoring showed that the patient could tolerate carotid clamping. Open repair was undertaken. Traditional exposure with incision anterior to the sternocleidomastoid was performed although extended more superiorly than usual because of the distal aneurysm location. This was facilitated with a special retractor designed for this purpose. Division of the posterior digastric belly allowed careful dissection of the aneurysm from behind the jaw, at which point the tortuosity of the ICA aneurysm inflow and outflow was truly appreciated (C). This tortuosity proved advantageous, because once the patient demonstrated tolerance of carotid clamping, the aneurysm was resected with ample healthy common ICA remaining to perform an end-to-end anastomosis. After closure, the patient was extubated demonstrating baseline neurologic function. The patient was discharged on postoperative day 1. Surgical pathology of the specimen demonstrated arterial wall with medial degeneration consistent with a true aneurysm. Consent for publication was obtained. Extracranial carotid artery aneurysms are rare, accounting for w0.9% of arterial aneurysms, with true aneurysms a rarer subset compared with pseudoaneurysms. Untreated, these aneurysms carry a high risk of rupture, thromboembolism, or cerebrovascular insufficiency. Although endovascular repair with covered stent grafts is an attractive option, open repair with resection and vein bypass or primary repair is still the gold standard with its necessity evident in this case based on aneurysm size, symptoms, distal location, and marked tortuosity.

IP053. Differences in Endovascular Aortic Aneurysm Repair (EVAR) Presentation and Outcomes Based on Method of Aneurysm Discovery

noted between OAR and EVAR (11.7% vs 12.3%; P 1⁄4 .59). After adjusting for potential confounders, FTR was not significantly different in OAR compared to EVAR (adjusted odds ratio [aOR], 1.34; 95% confidence interval [CI], 0.94-1.91; P 1⁄4 .10). Factors impacting in-hospital FTR included older age (aOR, 1.05; 95% CI, 1.03-1.07; P < .001), prior failed open repair (aOR, 8.17; 95% CI, 5.4-12.4; P < .001), and a history of chronic obstructive pulmonary disease (aOR, 1.53; 95% CI, 1.08-2.15; P 1⁄4 .02; Table II). A similar analysis of 2916 patients with postdischarge complications showed that FTR in those patients was significantly higher in OAR compared to EVAR (aOR, 4.75; 95% CI, 2.45-9.25; P < .001). Conclusions: Although EVAR has fewer complications and lower in-hospital mortality than OAR, FTR after in-hospital complications does not depend on the type of surgical approach but rather on the severity of the complication, the age of the patient, a prior failed open repair and a history of chronic obstructive pulmonary disease. When an in-hospital major complication occurs following EVAR, surgeons should be alert that FTR risk resulting in mortality is similar to OAR and therefore, there is no safety net with EVAR.

Endovascular Treatment of Dialysis Access–Induced Hand Ischemia Using a Flared Stent-Graft

Purpose: To report an investigation of a purely endovascular procedure to address access-induced hand ischemia in dialysis patients. Case Report: Two dialysis patients presented with stage III steal syndrome consisting of severe pain and numbness in their fingers. Preoperative fistulograms distal to the anastomosis showed alternating antegrade and retrograde flow. Under ultrasound guidance, the fistula was accessed and a 4-F micropuncture sheath placed. An angled guidewire was then advanced proximally into the brachial artery. A 6-F short sheath with marker was placed followed by a 4-F straight guide catheter inserted into the proximal brachial artery. A 9-F Flair endovascular stent-graft was advanced over a 0.035-inch stiff angled Glidewire into the fistula just distal to the arterial anastomosis and deployed. Postoperatively, pain and numbness resolved in both patients immediately. Postoperative fistulograms documented antegrade flow. Access flow velocity readings decreased significantly and pulse oximetry readings increased significantly in both patients, who were followed for >6 months with no reported complications. Conclusion: These 2 cases suggest that this endovascular approach to access-induced hand ischemia may be a viable alternative to open/hybrid surgery.