Journal of Vascular Surgery - Articles in Press

Compression assisted by removable coils as a new treatment for iatrogenic femoral pseudoaneurysms - Corrected Proof

Sergi Bellmunt, Jaume Dilmé, Antonio Barros, José Román Escudero — 2010-09-03

To avoid undesirable effects that sometimes result from current treatments for postpuncture femoral pseudoaneurysms, we developed a new technique involving compression assisted by removable coils. Using ultrasound-guided percutaneous puncture, an Inconel coil with synthetic microfibers is inserted in the pseudoaneurysm, leaving a part of the coil above the skin. Short-duration, ultrasound-guided compression is applied, taking advantage of the coil's thrombogenicity. Following occlusion, the coil is removed, leaving no residual foreign material. The technique was effective in the first patient treated and may minimize or obviate the adverse effects associated with current approaches.

Aorto-left renal vein fistula is a rare complication of abdominal aortic aneurysm with unique clinical presentation - Corrected Proof

2010-09-03

Spontaneous aorto-left renal vein fistulas (ALRVF) are extremely rare, with only 30 cases presented in the literature. In the majority of the reported cases, the fistula involved an anomalous retroaortic left renal vein. In some aspects, the clinical findings differ from those of aortocaval fistulas, often making the correct diagnosis difficult and contributing to the delay in treatment. In this article, we present 2 such cases, review previously reported data, and discuss clinical features and treatment options of this rare condition.

Prospective randomized trial comparing endovenous laser ablation and surgery for treatment of primary great saphenous varicose veins with a 2-year follow-up - Corrected Proof

Jan T. Christenson, Salah Gueddi, Gino Gemayel, Henri Bounameaux — 2010-09-01

Background:: Endovenous laser therapy (EVLT) for ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity compared with high ligation and stripping (HL/S). Only a few randomized trials have reported early results. This prospective randomized trial compared EVLT (980 nm) and HL/S results at 1 and 2 years after the intervention.Method:: Patients with symptomatic varicose veins due to GSV insufficiency were randomized to HL/S (100 limbs) or EVLT (104 limbs). Four EVLT procedures failed primarily and were excluded. Phlebectomy and ligature of incompetent perforators were performed whenever indicated in both groups. Patients were re-examined clinically and by duplex ultrasound imaging preoperatively and at 12 days and at 1 and 2 years after treatment. Closure rate, complication rate, time to return to normal activity, the Aberdeen Varicose Vein Symptom Severity Score (AVVSS), the Varicose Venous Clinical Severity Score (VVCSS), and the Medical Outcome Study Short Form-36 scores were also recorded.Results:: There were no differences in patient demographics, CEAP class, Widmer class, or severity scores between the groups. Simultaneous interventions did not differ between the groups. Similar times for the return to normal activity and scores for postoperative pain were reported. No major complications after treatment were recorded. HL/S limbs had significantly more postoperative hematomas than EVLT limbs, and EVLT patients reported more bruising. Follow-up at 1 year was 100% for HL/S and 99% for EVLT. Two GSVs in the EVLT group reopened and three partially reopened. No open GSVs occurred in HL/S limbs. Ninety-eight percent of the limbs in both groups were free of symptoms. VCSS, AVVSS, and Short Form-36 scores did not reveal any group differences. At 2 years, no differences compared with 1-year results were observed, except that two more GSVs in the EVLT group were partially reopened.Conclusions:: Abolition of GSV reflux and improvement in quality of life was similar after HL/S and EVLT. After EVLT, however, two GSVs were found completely reopened and five were partially reopened, which was significantly higher than after HL/S. A prolonged follow-up is ongoing.

Spinal cord protection during thoracic endovascular aneurysm repair: Incidence, prevention, and management - Corrected Proof

Adnan Z. Rizvi, Timothy M. Sullivan — 2010-09-01

Until recently, patients with aneurysms of the thoracic and thoracoabdominal aorta had only one treatment option: open surgical repair. For those patients who could not tolerate an operation because of medical comorbidities, continued aneurysm enlargement and eventual rupture was a constant, yet unpredictable threat to their lives. Several studies have documented improved survival rates in those patients treated surgically.

Clinical applications of robotic technology in vascular and endovascular surgery - Corrected Proof

2010-09-01

Background:: Emerging robotic technologies are increasingly being used by surgical disciplines to facilitate and improve performance of minimally invasive surgery. Robot-assisted intervention has recently been introduced into the field of vascular surgery to potentially enhance laparoscopic vascular and endovascular capabilities. The objective of this study was to review the current status of clinical robotic applications in vascular surgery.Methods:: A systematic literature search was performed in order to identify all published clinical studies related to robotic implementation in vascular intervention. Web-based search engines were searched using the keywords “surgical robotics,” “robotic surgery,” “robotics,” “computer assisted surgery,” and “vascular surgery” or “endovascular” for articles published between January 1990 and November 2009. An evaluation and critical overview of these studies is reported. In addition, an analysis and discussion of supporting evidence for robotic computer-enhanced telemanipulation systems in relation to their applications in laparoscopic vascular and endovascular surgery was undertaken.Results:: Seventeen articles reporting on clinical applications of robotics in laparoscopic vascular and endovascular surgery were detected. They were either case reports or retrospective patient series and prospective studies reporting laparoscopic vascular and endovascular treatments for patients using robotic technology. Minimal comparative clinical evidence to evaluate the advantages of robot-assisted vascular procedures was identified. Robot-assisted laparoscopic aortic procedures have been reported by several studies with satisfactory results. Furthermore, the use of robotic technology as a sole modality for abdominal aortic aneurysm repair and expansion of its applications to splenic and renal artery aneurysm reconstruction have been described. Robotically steerable endovascular catheter systems have potential advantages over conventional catheterization systems. Promising results from applications in cardiac interventions and preclinical studies have urged their use in vascular surgery. Although successful applications in endovascular repair of abdominal aortic aneurysm and lower extremity arterial disease have been reported, published clinical experience with the endovascular robot is limited.Conclusions:: Robotic technology may enhance vascular surgical techniques given preclinical evidence and early clinical reports. Further clinical studies are required to quantify its advantages over conventional treatments and define its role in vascular and endovascular surgery.

Outcomes before and after initiation of an acute aortic treatment center - Corrected Proof

2010-09-01

Background:: Acute aortic syndromes remain life-threatening. Time is of the essence, as mortality rises with increasing time after the acute episode. The aim of this report is to show changes in practice and outcomes after the establishment of an acute aortic treatment center (AATC) to expedite the care of acute aortic syndromes in a major metropolitan area with the belief that “door to intervention time under 90 minutes” reduces mortality and morbidity from acute aortic disease.Methods:: A database of patients admitted with acute aortic disease (Type A and B aortic dissections, acute thoraco-abdominal aortic aneurysms, acute and ruptured abdominal aortic aneurysms) for 1 year prior to initiation (2007) and 1 year after initiation of the pathway (AATC) in 2008 was developed. Comorbidities were scored according to Society of Vascular Surgery criteria. Anatomic and functional outcomes were determined and categorized by Society of Vascular Surgery reporting criteria. Multivariate analysis was performed for categorical outcomes and Cox proportional hazard analyses for time-dependent outcomes.Results:: Six hundred twenty-one patients reported with aortic disease to the cardiovascular services; 306 patients were considered to have acute disease. When compared with the year before the AATC was instituted, there was a 30% increase in the total number of admissions and a 25% increase in acute pathology after setting up the AATC (P = .02). There was a two-fold increase in thoracic aortic dissections admitted to the service. Initiation of the treatment pathway resulted in a highly significant 64% reduction in time to definitive therapy (526 ± 557 vs 187 ± 258 minutes, mean ± SD pre-AATC vs AATC; P = .0001). Comorbidity scores were equivalent between the two cohorts. Despite the increase in acuity, mortality (4% vs 6%) and morbidity (41% vs 45%) rates were unchanged, and there was a significant decrease in intensive care unit length of stay (5 vs 4 days, pre-AATC cohort vs the AATC cohort), but total hospital length of stay (11 vs 10 days) was unchanged. There was no correlation between deaths within 30 days and length of stay in the intensive care unit.Conclusion:: Establishment of a multidisciplinary AATC pathway was associated with a 30% increase in volume, 64% reduction in time to definitive treatment, improved throughput with reduced intensive care unit time, and maintained clinical efficacy despite an increase in acute admissions. These results suggest the concept be further evaluated.

One hundred vascular surgery citation “classics” from the surgical literature - Corrected Proof

2010-09-01

From the early twentieth century to the present day, the field of vascular surgery has evolved from a fledgling specialty to one of the most technologically advanced surgical specialties in the modern era. Pioneering discoveries in disease pathophysiology and innovative techniques have laid the foundation for the vascular surgeon's role in managing vascular disease.

Eight-year experience with carotid artery stenting for correction of symptomatic and asymptomatic post-endarterectomy defects - Corrected Proof

Enrico Maria Marone, Giovanni Coppi, Yamume Tshomba, Roberto Chiesa — 2010-09-01

Background:: Carotid endarterectomy (CEA) has been shown to be superior to medical therapy alone in the prevention of stroke only if it can be safely performed (ie, with a complication rate less than 3% in asymptomatic patients and less than 6% in symptomatic patients). Technical defects are the most common cause of neurological complications after CEA, and their correction has traditionally been performed through standard surgical techniques.Methods:: From 1999, we started to treat intimal flaps, dissection, or partial thrombosis after CEA with carotid artery stenting (CAS). A retrospective analysis of the operating room registry and of the registry of our Interventional Cardiology laboratory was conducted in order to identify all the patients that underwent stenting of the internal carotid artery after CEA between January 2001 and June 2009.Results:: During the time period considered, 5012 CEA were performed at our institution and a total of 34 patients (34/5012; 0.6%) were found to have received carotid stenting after CEA, both for symptomatic and asymptomatic defects. Immediate technical success was obtained in all patients. One major cerebrovascular adverse event (1/34; 3%) in the immediate perioperative period was recorded. At a mean follow-up of 18.6 months (range, 3-84 months; median, 12 months), we did not observe any neurological symptoms related to the treated carotid artery, nor hemodynamic in-stent restenosis. Long-term follow-up (ie, equal or greater than 4 years) was available for five patients: all patients remained event-free during the entire period.Conclusions:: Our study adds to the assumption that CAS in post-CEA symptomatic and asymptomatic patients is safe and technically feasible, and represents a valid and quick alternative to standard surgical revision. Even if in a small group of patients, long-term results seem promising.

Endothelial cells are susceptible to rapid siRNA transfection and gene silencing ex vivo - Corrected Proof

2010-09-01

Background:: Endothelial gene silencing via small interfering RNA (siRNA) transfection represents a promising strategy for the control of vascular disease. Here, we demonstrate endothelial gene silencing in human saphenous vein using three rapid siRNA transfection techniques amenable for use in the operating room.Methods:: Control siRNA, Cy5 siRNA, or siRNA targeting glyceraldehyde-3-phosphate dehydrogenase (GAPDH) or endothelial specific nitric oxide synthase (eNOS) were applied to surplus human saphenous vein for 10 minutes by (i) soaking, (ii) applying 300 mm Hg hyperbaric pressure, or (iii) 120 mm Hg luminal distending pressure. Transfected vein segments were maintained in organ culture. siRNA delivery and gene silencing were assessed by tissue layer using confocal microscopy and immunohistochemistry.Results:: Distending pressure transfection yielded the highest levels of endothelial siRNA delivery (22% pixels fluorescing) and gene silencing (60% GAPDH knockdown, 55% eNOS knockdown) as compared with hyperbaric (12% pixels fluorescing, 36% GAPDH knockdown, 30% eNOS knockdown) or non-pressurized transfections (10% pixels fluorescing, 30% GAPDH knockdown, 25% eNOS knockdown). Cumulative endothelial siRNA delivery (16% pixels fluorescing) and gene silencing (46% GAPDH knockdown) exceeded levels achieved in the media/adventitia (8% pixels fluorescing, 24% GAPDH knockdown) across all transfection methods.Conclusion:: Endothelial gene silencing is possible within the time frame and conditions of surgical application without the use of transfection reagents. The high sensitivity of endothelial cells to siRNA transfection marks the endothelium as a promising target of gene therapy in vascular disease.Clinical relevance:: Vein bypass graft failure due to intimal hyperplasia and re-stenosis continues to be an obstacle to long-term vein graft durability. Currently, there are no agents available that can be applied to vein grafts to reduce the rate of failure. This work demonstrates the feasibility of intraoperative siRNA therapeutics directed at the endothelium. If developed further, siRNA cocktails could be designed that provide a protective effect by silencing endothelial gene expression that leads to intimal hyperplasia. In addition, endothelial gene silencing could be used to induce favorable effects on the vasculature in other realms of vascular surgery.

The effects of ginsenoside Rb1 on endothelial damage and ghrelin expression induced by hyperhomocysteine - Corrected Proof

Zhiwei Xu, Taohua Lan, Weikang Wu, Yiling Wu — 2010-09-01

Objective:: Studies have indicated that ginsenoside Rb1 and ghrelin could both prevent homocysteine (Hcy)-induced endothelial dysfunction through the endothelial nitric oxide synthase (eNOS)/nitric oxide (NO) mechanism. This study investigated whether endogenous ghrelin mediates the endothelial protection of ginsenosidee Rb1 through in vitro and in vivo experiments.Methods:: Rats were randomized into a control group, a hyperhomocysteine (HHcy) model group with a high methionine diet, a ginsenosides (GS) group, and HHcy plus GS group. Plasma ghrelin was detected by enzyme-linked immunosorbent assay. Aortic rings for control and HHcy groups were treated with ghrelin or not. Endothelium-dependent vasodilatation function was evaluated by the aortic ring assay, and the structural changes were visualized by hematoxylin and eosin staining. Human umbilical vein endothelial cells (HUVECs) were cultured, and the experimental conditions were optimized according to NO production. After treatment, the NO, ghrelin, and von Willebrand factor (vWF) levels in the media were detected and analyzed with linear regression. Ghrelin and eNOS expression were observed by cell immunohistochemical staining. Ghrelin receptor antagonist was used to detect the mechanism of ginsenoside Rb1 on NO production, which was reflected by diacetylated 4,5-diaminofluorescein-2 diacetate fluorescence.Results:: In vivo experiments demonstrated that plasma ghrelin levels in the HHcy group were significantly elevated vs controls (P < .05) and were significantly increased in the HHcy plus GS group (P < .01). Compared with control, endothelium-dependent vasodilatation function was greatly reduced in the HHcy group (P < .01), which was significantly increased in HHcy plus ghrelin group compared with HHcy group (P < .01). The arterial walls of HHcy group exhibited characteristic pathologic changes, which were repaired in HHcy plus ghrelin group. In vivo, compared with Hcy (200 μM) group, HUVECs pretreated with ginsenoside Rb1 (10 μM) for 30 minutes showed significant increases in NO and ghrelin levels and evident reduction in vWF levels. Linear regression analysis demonstrated that ghrelin levels were significantly positively correlated with NO levels and significantly negatively correlated with vWF levels. The addition of Rb1 to Hcy also greatly reversed Hcy-induced downregulation of ghrelin and eNOS expression. Ghrelin inhibition significantly abolished the upregulation of NO levels induced by Rb1.Conclusion:: Ghrelin can prevent Hcy-induced vascular endothelial dysfunction and structural damage. The compensatory elevation of plasma ghrelin levels in an Hcy-induced endothelial injury model may be a protective response. Ginsenoside Rb1 can significantly stimulate the ghrelin endocrine to inhibit endothelial injury. Ginsenoside also upregulates the NO signaling pathway reduced by Hcy through the ghrelin molecular mechanism.Clinical Relevance:: Homocysteine is an independent risk factor for endothelial injury and dysfunction. Ginsenoside Rb1, a major constituent of ginseng (traditional Chinese herb), can effectively block homocysteine-induced dysfunction of endothelium-dependent vasorelaxation as well as endothelial nitric oxide synthase (eNOS) downregulation. Ghrelin, a novel brain-gut peptide, has multiple cardiovascular protective effects, including vasorelaxation. The objective of this study was to determine the effect and molecular changes of ginsenoside Rb1. Our results showed that ginseng compounds have effects of vasorelaxation and endogenous ghrelin upregulation. Exogenous ghrelin can block homocysteine-induced endothelial injury and dysfunction in the rat thoracic aortic. Ginsenoside Rb1 can improve NO production, ghrelin, and eNOS expression in human umbilical vascular endothelial cells. This study indicated that ginsenoside Rb1 has a prospective clinical future in controlling homocysteine-associated vascular diseases through the ghrelin molecule and NO-signaling mechanism.

Proof-of-principle study of steam ablation as novel thermal therapy for saphenous varicose veins - Corrected Proof

Renate R. van den Bos, Rene Milleret, Martino Neumann, Tamar Nijsten — 2010-09-01

Introduction:: During the last decade, thermal ablation techniques such as endovenous laser ablation have been challenging the position of traditional surgery for the treatment of saphenous varicose veins. The newest method of thermal ablation is pulsated steam, which works by heating the vein with steam at 120°C. This study assessed the effectiveness of steam ablation of varicose veins in sheep and in humans.Methods:: The safety of the procedure in sheep was assessed by cardiovascular monitoring during treatment. We used ultrasound imaging to examine occlusion of the veins. Changes in treated veins were examined microscopically. In a pilot study, 20 veins in 19 patients with insufficiency of the great or the small saphenous vein were treated with pulsated steam ablation. Anatomic success, patient satisfaction, and complications were investigated for 6 months after the procedure.Results:: All veins in the sheep were occluded. No cardiovascular changes occurred during treatment. Histologic examination of treated veins showed typical changes of the vein wall, such as disappearance of the endothelial layer, fibrotic thrombosis, and major alterations in collagen fibers in the media. Steam ablation was effective in the 19 patients: 13 of 20 veins were completely closed, and 7 showed a very small segment of recanalization after 6 months of follow-up that did not seem to be clinically relevant. Nine patients had some ecchymoses at the puncture site, and one patient had a transient superficial phlebitis. A median maximal pain score of 1 (range, 0-10) was reported. No serious side effects, such as deep vein thrombosis, nerve injury, skin burns, or infections, were reported. Patients were very satisfied with the treatment, with a median satisfaction score of 9.25 (range, 0-10).Conclusions:: In this proof-of-principle study, pulsated steam ablation was an effective treatment for saphenous varicose veins.Clinical Relevance:: This article describes a proof-of-principle study on the newest thermal endovascular treatment, steam ablation. It describes the first group of patients treated with hyperheated steam of 120°C for ablation of saphenous varicose veins. It also reports basic experimental data of this treatment on sheep to investigate the safety profile and the morphologic and histologic changes resulting from steam ablation. Steam ablation in the patients was effective, safe, and very well appreciated by the patients. This article describes the steam ablation procedure in humans, shows the first results, and provides basic background information received from animal experiments.

First United States experience of the TX2 Pro-Form thoracic delivery system - Corrected Proof

2010-09-01

Objectives:: Failure to conform to the arch (“bird-beaking”) can lead to endoleak and graft collapse after thoracic endovascular aortic repair (TEVAR). We report the first United States experience with the new TX2 Pro-Form (Cook Inc, Bloomington, Ind), a novel delivery system that became commercially available in October 2009, designed to enhance circumferential apposition of the TX2 thoracic endograft to the arch.Methods:: This was a single-institution retrospective study. Endograft-to-arch conformance was quantitatively analyzed using intraoperative angiograms of consecutive, reverse chronologic cohorts of TX2 Pro-Form, TX2 Z-Trak (prior delivery system; Cook), and Gore TAG (W.L. Gore and Assoc, Flagstaff, Ariz). Only native aortic arch deployments in zones 2 and 3 were included.Results:: During a 6-week period, 20 Pro-Form cases were performed, of which 17 patients met inclusion criteria. These were compared with 17 Z-Trak and 17 TAG patients. Endografts were successfully delivered to their intended proximal landing zones in all 51 patients. A higher proportion of dissections were treated in the Z-Trak (65%) and TAG (76%) patients (P = .03), but similar rates of zone 2/3 deployments (P = .30). Despite the mean arch angle being greatest for the Pro-Form patients (90° vs 74° vs 71°, P = .18), the mean separation between the leading endograft edge and the aortic wall along the inner curvature of the arch was significantly less (1.4 vs 4.1 vs 5.7 mm; P = .0002), with complete apposition achieved in 65% of Pro-Form patients (18% Z-Trak, 6% TAG, P < .0001). This resulted in the lowest reduction in aortic luminal diameter at the proximal landing zone (5.5% vs 13.4% vs 19.3%; P = .0006) compared with Z-Trak and TAG. Rates of type Ia endoleak were similar (P = .38).Conclusions:: The Pro-Form delivery system significantly improves endograft conformation to the arch, resulting in minimum bird-beaking even in severely angulated anatomies.

Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection - Corrected Proof

2010-08-27

Background:: Stent graft-induced new entry (SINE), defined as the new tear caused by the stent graft and excluding those arising from natural disease progression or iatrogenic injury from the endovascular manipulation, has been increasingly observed after thoracic endovascular aortic repair (TEVAR) for Stanford type B dissection in our center. SINE appears to be remarkably life threatening. We investigated the incidence, mortality, causes, and preventions of SINE after TEVAR for Stanford type B dissection.Methods:: Data for 22 patients with SINE were retrospectively collected and analyzed from 650 patients undergoing TEVAR for type B dissection from August 2000 to June 2008. An additional patient was referred to our center 14 months after TEVAR was performed in another hospital. The potential associations of SINE with Marfan syndrome, location of SINE and endograft placement, and the oversizing rate were analyzed by Fisher exact probability test or t test.Results:: We found 24 SINE tears in 23 patients, including SINE at the proximal end of the endograft in 15, at the distal end in 7, and at both ends in 1. Six patients died. SINE incidence and mortality reached 3.4% and 26.1%, respectively. Two SINE patients were diagnosed with Marfan syndrome, whereas there were only 6 Marfan patients among the 651 patients. The 16 proximal SINEs were evidenced at the greater curve of the arch and caused retrograde type A dissection. The eight distal SINEs occurred at the dissected flap, and five caused enlarging aneurysm whereas three remained stable. The endograft was placed across the distal aortic arch during the primary TEVAR in all 23 patients. The incidence of SINE was 33.33% among Marfan patients vs 3.26% among non-Marfan patients (P = .016). There was no significant difference in mortality between proximal and distal SINE (25% vs 28.6%, P > .99), incidence of SINE between endograft placement across the arch and at the straight portion of descending thoracic aorta (23 of 613 vs 0 of 38, P = .39), and the oversizing rate between SINE and non-SINE patients (13% ± 4.5% vs 16% ± 6.5%, P = .98).Conclusions:: SINE appears not to be rare after TEVAR for type B dissection and is associated with substantial mortality. The stress yielded by the endograft seems to play a predominant role in its occurrence. It is important to take this stress-induced injury into account during both design and placement of the endograft.

Thoracic aortic endovascular repair for mycotic aneurysms and fistulas - Corrected Proof

2010-08-27

Optimal medical therapy, in the setting of infections of the thoracic aorta (either native or prosthetic), is frequently associated with aortic-related mortality. Classic surgical teaching in this setting describes removal of all infected tissue with extra-anatomic bypass for aortic reconstruction. Several groups have described outcomes with aortic resection or graft explantation along with in situ grafting of the thoracic aorta. The patient population in whom this condition arises is often debilitated, elderly, immunocompromised, or has other comorbidity increasing the risk of open surgical intervention. In recognizing this clinical conundrum, several groups have suggested the use of endovascular technology as a potential less invasive solution. Long-term outcomes with this approach, however, remain ill defined. In 2008, we described outcomes for one of the largest series of infected thoracic aortic pathology (ITAP) treated with an endovascular approach. This report serves to update this series (now to include 27 patients treated since 1993) and review the experience as reported by others. Our results suggest that (1) the overall prognosis of the patient undergoing TEVAR is poor; (2) results with TEVAR for an infected prosthesis are worse than that for native aortic infection; and (3) the cause of mortality is often secondary to associated comorbid conditions rather than reinfection. TEVAR is therefore viewed as a palliative therapy in a high-risk cohort, but individual assessment is needed to determine whether it remains the definitive repair.

Fenestrated and branched devices in the pipeline - Corrected Proof

Roy K. Greenberg, Moqueet Qureshi — 2010-08-27

A great deal of attention has been given to the use of endografts in anatomy that involves critical aortic branches, such as the visceral segment and the aortic arch. Hybrid techniques and other methods to preserve flow into such vessels have been met with questionable success. The recent publication of the endovascular aneurysm repair (EVAR) trial data, particularly their screening registry, indicates that the number of patients with aneurysms involving critical vessels is considerable compared with aneurysms with adequate infrarenal neck. This has renewed corporate interest in developing devices that will address these complex problems. Branches designed to preserve iliac flow, fenestrated and branched devices for the visceral aortic segment, and arch branch devices have all been used clinically with a variety of platforms. This article reviews the devices and treatment strategies that are being proposed or studied by both large and small companies.

Traumatic thoracic aortic injury and ruptures - Corrected Proof

Girma Tefera — 2010-08-27

Descending thoracic aortic injury (DTAI) is the most frequent cause of death at the site of severe motor vehicle crash and is associated with deceleration injury. Although the incidence of DTAI is low (18% of motor vehicle accidents), it is the second most common cause of trauma-related death and represents 1% of trauma admissions to the hospital. It has been estimated that over 80% DTAI patients die at the scene. For those patients who arrive alive to the hospital, the estimated mortality rate is 32%, with one-third of those patients dying before operative intervention. In those who survive the injury, even after controlling for associated injuries, the presence of DTAI in multiple trauma patients impacts negatively on survival and results in poor long-term function following discharge.

Starting a TEVAR practice: Required skills and interdisciplinary teams - Corrected Proof

Jean Starr — 2010-08-27

Thoracic endovascular aortic repair (TEVAR) has become an accepted and often preferred approach to the management of patients with thoracic aortic disease. Advanced endovascular skills and specific credentialing criteria should be attained prior to establishing a TEVAR program. Individual practitioners may not possess all the required skills, making interdisciplinary collaboration crucial for a successful program. Learning curve analysis supports a strong endovascular background and knowledge of thoracic aortic diseases. Institutional support is critical when beginning a TEVAR program in the areas of training, imaging, supply management, and marketing. With all of the elements in place, a well-organized TEVAR program will succeed in providing vascular patients with exceptional care.

Advanced thoracic endovascular aortic repair: Late complications of thoracic endografts - Corrected Proof

Pegge Halandras, Ross Milner — 2010-08-27

The endovascular treatment of aortic aneurysm disease was first presented as an alternative to open repair by the placement of an abdominal aortic endograft by Juan Parodi in 1991. In the same year, Volodos et al published their experience with endograft placement in the thoracic aorta. Since this time, endovascular repair of descending thoracic aortic aneurysms has emerged as an attractive treatment modality. Several studies have confirmed the safety of thoracic endovascular aortic aneurysm repair (TEVAR) for treatment of descending thoracic aortic aneurysms and showed both lower rates of aneurysm-related deaths and major adverse events compared with open aneurysm repair.

The middle-arm fistula as a valuable surgical approach in patients with end-stage renal disease - Corrected Proof

2010-08-27

Background:: American and European guidelines recommend the distal radial-cephalic fistula (dRCF) as the first and best hemodialysis access in patients with end-stage renal disease (ESRD). However, this kind of arteriovenous fistula (AVF) shows a limited primary unassisted patency and frequently needs surgical revisions or angiographic procedures, or both. When dRCF is not feasible, guidelines suggest a proximal brachiocephalic AVF. The middle-arm fistula (MAF), or autogenous forearm radial-median direct access, has been suggested as a possible alternative approach. This study evaluated MAF primary unassisted patency, the most frequent causes of MAF failure, and the possible related factors.Methods:: Data on patients with a MAF placed from January 1991 until June 2008 were retrospectively collected. The probability of MAF failure overall and by the main subgroups was estimated according to Kaplan-Meier with Greenwood standard error (SE). Comparison of failure among different subgroups was performed using the log rank test in univariate analyses. The Cox regression model was used to investigate factors that independently affected the overall hazard of failure and cause-specific hazard of thrombosis.Results:: At the end of follow-up, 14.0% of MAF failed (11.6% thrombosis, 1.7% stenosis, 0.7% failed maturation), and 44.2% of MAF were still working. Cumulative probability of MAF unassisted primary patency after 4 years from the creation was 79%. Univariate analyses highlighted that women (P = .019), underweight patients (P = .010), and MAF implantation after starting hemodialysis (P < .001) had a higher risk of MAF failure for any cause than men, normal and overweight patients, and MAF implanted before starting hemodialysis. Results of the Cox multivariate analysis for overall MAF failure confirmed that only MAF implantation before starting hemodialysis is a protective factor against any failure (P = .003), whereas female gender (P = .016) was associated with an increase of the thrombosis hazard ratio to 2.04 (95% confidence interval, 1.14-3.63).Conclusion:: Our data demonstrate that MAF has a good unassisted primary patency and suggest that this kind of AVF could be a valuable alternative surgical approach when dRCF is not feasible in ESRD patients.

Lymphatic malformation is a common component of Klippel-Trenaunay syndrome - Corrected Proof

Ning-Fei Liu, Qing Lu, Zhi-Xin Yan — 2010-08-27

Objectives:: Few previous studies have focused on the involvement of the lymphatic system in Klippel-Trenaunay syndrome (KTS), although some evidence suggests that lymphatic abnormalities are associated with the disease. The aim of the present study was to investigate the involvement of the lymphatic system in KTS.Methods:: Magnetic resonance lymphangiography (MRL) with the use of gadobenate dimeglumine as the contrast was performed on 32 patients with KTS involving the extremities to evaluate lymphatic vessels, lymph nodes, and veins.Results:: Thirty-one of 32 patients exhibited lymphatic vessel and/or lymph node anomalies, including hyperplasia (11/31), hypoplasia or aplasia (20/31) of lymphatic vessels, and lymphedema (31/31) of the affected limbs. Twenty-two patients showed asymmetry of the inguinal nodes exhibiting either the absence, or an increase or a decrease in number and size of the inguinal nodes. Venous dysplasia was found in 31 patients in superficial and/or deep veins. The results showed a high concomitance of malformations of the lymphatic system and veins in the affected limbs of patients with KTS.Conclusions:: Lymphatic system abnormalities as examined with MRL are commonly associated with KTS and are likely to play a significant role in the disorder.

A contemporary experience of open aortic reconstruction in patients with chronic atherosclerotic occlusion of the abdominal aorta - Corrected Proof

2010-08-23

Objective: To examine and report surgical results from a contemporary experience of open abdominal aortic reconstruction in patients with chronic atherosclerotic abdominal aortic occlusion (CAAAO).Methods: Between January 1999 through May 2010, 54 patients with CAAAO were identified and retrospectively reviewed. CAAAOs were categorized into infrarenal aortic occlusions (IRAOs) and juxtarenal aortic occlusions (JRAOs) based on superior extension of thrombus and requirement for supra-renal aortic clamping to repair. Morbidity, mortality, hospital stay, and operative variables were assessed. The χ2 or Fisher test and the Wilcoxon rank sum test were used to compare demographic and operative variables between two aortic occlusion groups (IRAO and JRAO). Univariate and multivariate analyses were performed to assess factors associated with surgical outcomes and hospital stay. The Kaplan-Meier method was used to calculate survival and patency rates.Results: Fifty patients underwent aortic reconstructions with aorto-bifemoral or iliac bypass, and three underwent a remote axillo-femoral bypass procedure. There were 35 (64.8%) males, and 19 (35.2%) females. Median age was 51.9 years (range, 32-72 years). Of the two CAAAO groups, there were 20 IRAOs and 33 JRAOs. Aorto-renal thromboendartectomy was performed in 26 (49.1%) patients; 26 (75.8%) among JRAOs versus 1 (5%) of IRAOs (P < .01). Proximal aortic clamps were required in 28 (85%) of JRAOs and 3 (15%) of IRAOs (P < .01). Thirty-day and in-hospital mortality was zero. Median length of hospital stay was 7 days (range, 4 to 66 days), and median intensive care unit length of stay was 3 days (range, 1-22 days). Complications included cardiopulmonary dysfunction in four (8%), postoperative renal insufficiency in 10 (18.9%), and other postoperative complications in 15 (28.3%). All 10 with renal insufficiency recovered renal function to baseline creatinine or a creatinine value <1.1 mg/dL. Mean increases in right and left ankle-brachial indicess were 0.54 ± 0.25 and 0.59 ± 0.22, respectively. On univariate analysis, coronary artery disease and African American race were predictors of postoperative complications (P = .048). Age was significantly associated with total complications. Patients with postoperative complications and/or renal insufficiency were older than those without such complications (P = .02) Independent predictors of prolonged hospital stay were intraoperative blood replacement (P = .003), postoperative complications (P < .01), and postoperative renal insufficiency (P < .01). Prolonged intensive care unit stay was predicted by JRAO (P = .04), postoperative complications (P = .02), and postoperative renal insufficiency (P = .013). Survival at 3, 5, and 7 years were 86.6%, 76.5% and 50.9%, respectively. The reduced survival rates were predicted by previous myocardial infarction and existing coronary artery disease (P < .01).Conclusion: Abdominal aortic reconstruction is a safe method for treating CAAAO with low associated morbidity and mortality. Aorto-renal thromboendartectomy with supra-renal aortic clamping and aortic replacement remains an effective treatment for those with significant pararenal aortic disease, and can be performed without significant renal impairment.

Long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep vein thrombosis in the TROMBOTEK trial - Corrected Proof

2010-08-23

Objective: The present study was designed to evaluate the long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep venous thrombosis (DVT).Methods: A total of 246 patients, comprising 128 men (mean age, 54.28 ± 16.48 years) and 118 women (mean age, 50.11 ± 16.47 years) with symptomatic lower extremity DVT, were included in this open-label, single-arm, multicenter, phase IV clinical trial conducted at 14 centers in Turkey. All patients were administered subcutaneous enoxaparin (1.5 mg/kg, once-daily) until international normalized ratio (INR) levels reached to 2 to 3, followed by oral warfarin (5 mg/d) for at least 3 months and elastic compression stockings (30-40 mm Hg). Clinical signs (leg circumference), symptoms (edema, pain, tenderness), recanalization rates upon duplex ultrasound examination, laboratory findings (D-dimer and INR levels), and postthrombotic syndrome status with CEAP classification were the efficacy parameters evaluated every 3 months during 18 months of follow-up. Safety end points included minor and major bleeding as well as serious adverse events.Results: Ambulatory treatment with enoxaparin plus warfarin significantly reduced physical symptoms, including tenderness, edema, pain (P < .001), and the circumference of the affected leg (P < .001). The leg circumference difference in almost all patients was <1.5 cm at the end of 18 months (P < .001). Recanalization rates for occluded iliofemoral vein were 76.1% at 3 months and 86.5% at 18 months (P < .001). An early and significant decrease obtained in D-dimer levels on day 10 continued to decline significantly until month 6 and remained unchanged afterwards (P < .001). Of four patients diagnosed with major bleeding during oral anticoagulant use, three recovered with conservative treatment (reduction in hemoglobin levels in 2 developed at visit 2 [day 10] and intracranial bleeding in 1 developed at visit 3 [day 30]), and one patient required a hysterectomy after menorrhagia developed at visit 7 (month 18). Two of the 65 (9.9%) adverse events documented were serious adverse events, but none of the serious adverse events leading to death were related to the study medications.Conclusion: Ambulatory treatment with enoxaparin plus warfarin seems to be effective in symptomatic healing and in clinical improvement by reducing thrombus formation and organization at all levels of lower extremity venous system with DVT, without a significant major bleeding risk. Therefore, the results of our conventional conservative treatment are in line with 1A level evidence reported in the recent American College of Chest Physicians guideline.

Carotid artery pseudo-pseudoaneurysm after excision of carotid body tumor - Corrected Proof

Tim E. Hotze, Taylor A. Smith, G. Patrick Clagett — 2010-08-23

A 37-year-old woman was referred for evaluation of a carotid body tumor. The patient gave a history of right neck fullness for several months before the mass was identified on physical examination during an evaluation for benign biliary disease. The lesion was initially diagnosed by computed tomography angiogram (CTA) and confirmed with duplex ultrasound imaging, which revealed a 4-cm vascular mass intimately associated with the internal and external carotid arteries.

Description and comparison of Food and Drug Administration-approved thoracic endovascular aneurysm devices - Corrected Proof

Sean P. Lyden — 2010-08-23

In 1991, endovascular aortic treatment was born. Less than 15 years later, the first thoracic endovascular device was approved to treat thoracic aortic aneurysms. Three devices are currently approved to treat thoracic aneurysms in the United States. This chapter describes the current devices approved to treat thoracic aortic pathology and compares differences between devices.

Regulatory TEVAR clinical trials - Corrected Proof

Manuel Garcia-Toca, Mark K. Eskandari — 2010-08-23

It has been almost two decades since the first report of a thoracic endovascular aneurysm repair (TEVAR) by Dake et al. The early devices were custom-made by the operators themselves, using woven Dacron grafts hand-sewn to Gianturco Z-stents (Cook Group Europe, Bjaeverskov, Denmark). A few years after the first published reports using custom-made devices, a handful of companies started to produce factory-made endografts. These first generation commercial devices were superior, particularly in regards to deployment, and facilitated the increased use of endografts to treat thoracic aortic pathology.

Endovascular management of type B aortic dissections - Corrected Proof

2010-08-23

There are approximately 9,000 new cases of aortic dissection in the United States each year. Uncomplicated type B aortic dissections are traditionally managed with medical therapy, controlling blood pressure and heart rate, with 30-day mortality rates between 4% and 10%. However, there is no consensus regarding the management of complicated (ie, presenting with malperfusion or refractory pain) type B dissections. Open surgical management of these patients carries an excessive mortality rate. Therefore, endovascular aortic fenestration and branch vessel stenting to relieve malperfusion was developed as an alternative to open surgical repair. While endovascular fenestration and stenting relieves malperfusion, it does not prevent late aneurysm degeneration of the aorta, which can occur in up to 30% of patients. Recently, the use of endovascular stent grafts to cover the primary and proximal entry tear has been examined, with the belief that this approach treats most cases of malperfusion and, in theory, prevents late aneurysm formation. The objective of this article is to examine the literature surrounding the endovascular management of type B aortic dissections, including fenestration and stenting, as well as stent graft placement.

Intraprocedural imaging: Flat panel detectors, rotational angiography, FluoroCT, IVUS, or still the portable C-arm? - Corrected Proof

Matthew J. Eagleton — 2010-08-23

Fluoroscopy is the current standard by which intraoperative imaging is performed during endovascular aortic interventions. The goal of the imaging system is to provide adequate visualization of the aorta and its branches throughout the entire range of the treatment area. This may range from the femoral arteries through the ascending aorta. While the endovascular treatment of descending thoracic aortic aneurysm and abdominal aortic aneurysms (AAA) is becoming commonplace, the evolution of this specialty is toward providing less invasive approaches to increasingly complex disease processes. The imaging systems that allow us to perform these procedures through small incisions, or needle punctures, must evolve with the device technology to facilitate this growing complexity. In addition to providing adequate visualization of the aorta, its branches, and the tools that are used to place them, the technology needs to be safe, for both the patient and the operative team. The imaging system should allow the operator to perform complex procedures with limited use of radiation and contrast agents. Limiting radiation exposure is also important for the operative team, as radiation effects are cumulative and will become compounded over a career of fluoroscopy-directed procedures. While it is easy to stay up-to-date with the latest endovascular therapies that may be offered to our patients, as vascular surgeons it is often more difficult to keep apprised of the advancements in imaging technology that will allow us to provide therapies in a more efficient and safe fashion. This review will highlight some of the current advances in imaging that are available.

Current Procedural Terminology (CPT) coding for endovascular intervention in the descending thoracic aorta - Corrected Proof

Gary R. Seabrook — 2010-08-23

Current Procedural Terminology (CPT), developed by the American Medical Association (AMA), is the coding process used to describe procedural or diagnostic procedures and other medical services. Five-digit numeric codes are used for reporting those activities to insurance carriers for payment. Within the resource-based relative value scale system, each CPT code is assigned a relative value unit (RVU) for physician work, practice expense, and professional liability insurance. The Centers for Medicare and Medicaid Services (CMS) calculate reimbursement for the work by adding the RVUs (adjusted for geographic differences) and multiplying that sum by a conversion factor expressed in dollars that is determined each year through elaborate budgetary formulae.

Prosthetic lower extremity hemodialysis access grafts have satisfactory patency despite a high incidence of infection - Corrected Proof

2010-08-23

Introduction:: Prosthetic arteriovenous grafts (AVGs) in the lower extremity represent a useful alternative for hemodialysis vascular access when all upper limb access sites have been used or in some patients when freedom of both hands is necessary during dialysis. Reported complications include an increased risk of infection and limb ischemia. This study evaluated our experience with the patency outcomes and complication rates of polytetrafluoroethylene (PTFE) AVGs placed in the thigh.Methods:: A retrospective outcomes analysis was performed of all femoral AVGs inserted between January 1992 and July 2007. Data were obtained by review of medical records for patient demographics, comorbidities, and AVG-related outcomes. Patency, complication rates, and risk factors for infection were determined.Results:: A total of 153 prosthetic AVGs were placed in 127 patients (63 men). Mean patient age was 52.7 ± 16.3 years. Median follow-up was 25 months (range, 1-169 months). The most common underlying renal disease was glomerulonephritis in 27 (21%). Hypertension and coronary artery disease were common comorbidities, respectively, in 49 (39%) and 23 patients (18%). The primary and secondary AVG patency rates at 12 months were 53.9% and 75.3%, respectively, and 2- and 5-year patency rates were, respectively, 39.6% and 19.3% (primary) and 63.8% and 50.6% (secondary). The mean AVG survival for all cases was 31.6 months (range, 0-149 months). Surgical thrombectomy was required in 82 (54%), and 22 AVGs (14%) required surgical revision for stenosis. Infection occurred in 41 AVGs (27%), and limb ischemia occurred in 2 (1.3%). Statistical analysis did not reveal a significant risk factor for infection.Conclusions:: Femoral AVGs are a suitable alternative to upper limb vascular access, with acceptable primary and secondary patency rates. Infection occurred in approximately one-quarter of cases, whereas steal was uncommon.

Surgical treatment of giant extracranial internal carotid artery aneurysm - Corrected Proof

Zan Mitrev, Atanas Jankulovski, Biljana Bozinovska, Nikola Hristov — 2010-08-23

Extracranial internal carotid artery aneurysms are rare manifestations but have the potential for a fatal complication as result of embolization, rupture, and local compression.

The ethical hierarchy of do not resuscitate orders: Never say never - Corrected Proof

James W. Jones, Laurence B. McCullough — 2010-08-23

Mrs G. Oner, a 58-year-old woman, had a massive myocardial infarction after an aneurysmectomy being kept alive for several weeks by a left ventricular assist device. It appears that she may survive. However, Mrs Oner has become clinically depressed and is strongly considering discontinuing hemodynamic support. After a discussion about her condition during which she learned that survival could not be assured, she elected what the hospital calls “code two” do not resuscitate (DNR) status (no cardiopulmonary resuscitation, no intubation) but wants all other treatment to continue “as long as it will help her.” She did not discuss this decision with her husband, an internationally acclaimed professor of law, beforehand. When he visits later that day, she unexpectedly has a stroke accompanied by respiratory difficulty and Professor Oner insists that “everything” be done. The team informs him that the patient will not be intubated, per the code two status. He insists that he is her legal surrogate and demands the DNR status be withdrawn. Which options are unethical?

Reducing venous stasis ulcers by fifty percent in 10 years: The next steps - Corrected Proof

Peter Henke, Bob Kistner, Thomas W. Wakefield, Bo Eklof, Fedor Lurie — 2010-08-19

The focus on prevention to improve health in the United States will increase with the recently passed health care reform act. No one can argue that prevention of disease is more cost effective than treatment once disease is established. Venous disease is a perfect example of a disease to prevent, be it venous thrombosis or the sequelae of post-thrombotic syndrome and primary venous insufficiency. Venous disease is not glamorous, but very common. Optimistically, the knowledge and tools are available now to significantly decrease a major morbidity of chronic venous disease, namely venous stasis ulcers.

Evidence for markers of hypoxia and apoptosis in explanted human carotid atherosclerotic plaques - Corrected Proof

2010-08-19

Objective: Apoptosis and inflammation are important features of atherosclerotic plaques. We investigated whether a common signal molecule can trigger these two apparently separate pathways. Hypoxia inducible factor (HIF-1α) is known to participate in atherosclerosis and to stimulate apoptosis signal-regulating kinase 1 (ASK-1), one of the mitogen-activated protein kinases, which is activated by various extracellular stimuli and involved in a variety of cellular function.Methods: We tested carotid artery specimens from 50 subjects who underwent angioplasty and five age-matched controls for either Western blot or histologic analysis. The hypoxic status was investigated by means of HIF-1α expression in carotid specimens.Results: HIF-1α was significantly upregulated in carotid specimens with respect to controls (P < .05), ASK-1 was detected in plaques of any composition from lipidic to calcific, and this expression increased with the stage of the plaque and with the expression of inflammatory (p-ERK, RANK-L, OPG) and apoptotic molecules (caspase 9, p-p-38, and p-JNK).Conclusion: Our data suggest that hypoxia is the key regulating factor that triggers inflammation as well as apoptosis in the human atherosclerotic plaque.Clinical Relevance: This study adds evidence that HIF-1α is important in the oxidative stress response in the developing atherosclerotic plaque as it modulates both inflammatory and mitochondrion-related apoptotic pathways. Future therapy targeting HIF-1α may limit atherosclerosis development.

Heparin versus bivalirudin for carotid artery stenting using proximal endovascular clamping for neuroprotection: Results from a prospective randomized study - Corrected Proof

2010-08-19

Background:: General recommendations indicate that, during a carotid artery stenting (CAS), sufficient unfractionated heparin (UFH) has to be given to maintain the activated clotting time between 250 to 300 seconds. Bivalirudin use is able to reduce postprocedural bleedings in percutaneous interventions when compared with UFH. The study purpose was to evaluate, in a randomized study, the safety and efficacy of bivalirudin versus heparin during CAS, using proximal endovascular occlusion (PEO) as a distal protection device.Methods:: From January 2006 to December 2009, 220 patients undergoing CAS using PEO have been randomly assigned to one of the study arms (control arm: 100 UI/kg UFH or bivalirudin arm: 0.75 mg/kg intravenous bolus and intraprocedural infusion at 1.75 mg/kg/h).Results:: Procedural success was achieved in all the patients. No episodes of intraprocedural thrombosis occurred. One major stroke occurred in the bivalirudin arm, and two minor strokes occurred, one in each group. A significant difference in the incidence of postprocedural bleedings was observed between the study groups; bivalirudin use was associated with reduced number of bleedings according to Thrombolysis In Myocardial Infarction criteria.Conclusions:: The use of bivalirudin should be considered a safe and effective anticoagulation regimen during CAS, using PEO as a distal protection device. Bivalirudin use is associated with a reduced incidence of bleedings.

Endovascular aneurysm repair for ruptured abdominal aortic aneurysm: How I do it - Corrected Proof

Manish Mehta — 2010-08-19

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today, endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality compared with the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help vascular surgeons deal with not just the technical aspects of these procedures but also address some of the challenges, including the availability of preoperative computed tomography, the choice of anesthesia, the percutaneous vs femoral cutdown approach, use of aortic occlusion balloons, need for bifurcated vs aortouniiliac stent grafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.

Long-term outcomes of secondary procedures after endovascular aneurysm repair - Corrected Proof

2010-08-19

Purpose:: This study evaluated the outcomes of secondary procedures after endovascular aneurysm repair (EVAR).Methods:: From 2002 to 2009, 1768 patients underwent EVAR for treatment of 1662 elective (94%) and 106 emergent (6%) infrarenal AAA with a variety of Food and Drug Administration-approved and commercially available stent grafts. Postoperative follow-up included clinical examination, pulse volume recording, duplex ultrasound imaging, and computed tomography and magnetic resonance angiography at 1, 6, and 12 months, and yearly thereafter. Patients with type I and III endoleaks, unexplained endotension, limb occlusion, stent graft migration, with and without type I endoleak, and aneurysm rupture underwent secondary interventions. Type II endoleak at >6 months without a decrease in the aneurysm sac underwent translumbar embolization. Data were prospectively collected.Results:: EVAR was performed in 1768 patients. During a mean follow-up of 34 (SD, 30.03) months, 339 patients (19.2%) required additional secondary procedures for aneurysm-related complications, including type I (n = 51, 15.0%), type II (n = 136, 40.1%), and type III (n = 5, 1.5%) endoleaks; endotension (n = 8, 2.4%), stent graft migration proximal fixation site (n = 46, 13.6%), stent graft iliac limb thrombosis or stenosis (n = 25, 7.4%), subsequent iliac aneurysm formation (n = 39, 11.5%), or aneurysm rupture after EVAR (n = 29, 8.6%). The mean age was 74 (SD, 9.15) years. Mean AAA size was 5.7 (SD 3.24) cm. Compared with secondary procedures for AAA rupture, the nonrupture patients had a significantly lower mortality (1.6% vs 17.2%, P < .05) and a higher likelihood of being managed by endovascular means (98.8% vs 44.8%, P < .05). When nonruptured EVAR patients required urgent secondary procedures for type I endoleaks and stent graft migration or limb thrombosis, the mortality was 6.0% vs 0.5% for elective procedures (P < .05).Conclusions:: Our long-term EVAR experience indicates that 18% of patients require additional secondary procedures, and most of these patients can be managed by endovascular means with an acceptable overall mortality of 2.9%. Most type I and II endoleaks can be successfully treated by transluminal embolization, and most patients with delayed aneurysm rupture after EVAR can be successfully managed by endovascular or open surgical repair.

Discussion - Corrected Proof

2010-08-19

Dr Marc A. Passman (Birmingham, Ala). I would like to congratulate Dr Mehta and his colleagues from Albany, New York, on an excellent paper, and applaud the program committee for inviting some cross-regional work onto our Southern Association for Vascular Surgery (SAVS) program. Over an 8-year experience, the group from Albany performed 1768 endovascular abdominal aortic aneurysm (AAA) repairs, of which 19.2%, or almost 1 in 5, required some secondary or tertiary procedure. Interestingly, we just reviewed our endovascular experience at University of Alabama at Birmingham (UAB), which will be presented at another vascular meeting later this year. Over a similar time period representing about 1100 stent graft repairs, in our experience only 9.2%, or 1 in 10, required a secondary procedure, a rate less than half of what was presented here. I will try to avoid the tempting regional comparison that perhaps we know how to do endovascular AAA repairs more definitively in our Southern region compared with the great state of New York. Rather, there are likely some differences in our respective experiences that form the focus of my questions.

Endovascular techniques for arch vessel reconstruction - Corrected Proof

G. Matthew Longo, Iraklis I. Pipinos — 2010-08-19

Endovascular management of aortic arch pathology consists of two primary approaches: hybrid operations (See Chapter 12) involving the combination of open and endovascular techniques and endovascular repair without open revascularization of the arch vessels prior to stent graft deployment. The latter are grouped into three basic techniques: (1) In vivo fenestrated stent grafts, (2) retrograde branch stenting (double barrel/chimney graft/snorkeling technique), and (3) prefabricated fenestrated and branched stent grafts (See Chapter 3). These techniques provide the opportunity to extend the proximal landing zone of thoracic stent grafts in an effort to improve endograft fixation and seal within the aortic arch. Furthermore, mastery of these techniques allows for endovascular salvage of an arch vessel if it is inadvertently covered, without having to resort to open operations to provide vessel perfusion. Ideally, utilization of these skills will permit a greater number of individuals to undergo endovascular repair of aortic arch pathology in situations where the open repair carries a prohibitive risk. Each of the interventions described are unproven with respect to the long-term durability of the procedure and utilize equipment in a manner that has not been tested or approved for these specific maneuvers or techniques.

Open techniques for arch vessel reconstruction during thoracic endovascular aneurysm repair (TEVAR) - Corrected Proof

Raghuveer Vallabhaneni, Luis A. Sanchez — 2010-08-19

Over the past several years, the use and applications of thoracic endovascular grafts have increased significantly. There are now three FDA approved devices for thoracic endovascular aneurysm repair (TEVAR) available in the United States. These new devices have allowed us to expand the number of patients as well as the conditions we treat with this technology. However, many patients are not candidates for traditional endovascular repair because of unsuitable anatomy for use of these devices. Commonly, this is due to an inadequate proximal landing zone on the aortic arch. The recommended proximal landing zone for thoracic endograft devices is typically 2 to 3 cm of seal. To achieve this proximal landing zone, up to 40% of thoracic aneurysms may require coverage of critical supra-aortic arch vessels including or proximal to the left subclavian artery. In this article, we will discuss the open surgical alternatives and techniques available in managing the proximal arch vessels in patients who have complex thoracic aortic anatomy.

Endoleak management and postoperative surveillance following endovascular repair of thoracic aortic aneurysms - Corrected Proof

Joseph J. Ricotta — 2010-08-19

Thoracic endovascular aortic repair (TEVAR) has evolved rapidly and has become an accepted, less invasive alternative to open surgical repair for the treatment of thoracic aortic aneurysms. Patients undergoing TEVAR require lifelong postoperative surveillance to detect some of the unique complications associated with endovascular thoracic aortic aneurysm repair, such as endograft migration and endoleak formation. Failure to achieve a proximal seal in the aortic arch resulting in a proximal type I endoleak remains an Achilles' heel of the TEVAR procedure. This article addresses strategies for postoperative surveillance imaging and endoleak management in patients after endovascular repair of thoracic aortic aneurysms.

Staged total exclusion of the aorta for chronic type B aortic dissection: A case report - Corrected Proof

2010-08-16

Hybrid techniques using extra-anatomic bypass of critical aortic branches to enable endovascular treatment of complex aortic pathology have been previously described. A staged endograft repair of a complex, chronic Stanford type B aortic dissection with aneurysmal degeneration is reported in a 50-year-old man. The aneurysmal portion of the dissection extended from the distal arch to both common iliac arteries and was covered with an endograft from the ascending aorta to both external iliac arteries. Aortic arch branches, visceral, and renal arteries were bypassed using open technique. The patient had no neurologic complications. This case report illustrates the feasibility of the hybrid technique in selected high-risk patients when confronted with complex aortic pathology.

Finnvasc score and modified Prevent III score predict long-term outcome after infrainguinal surgical and endovascular revascularization for critical limb ischemia - Corrected Proof

2010-08-16

Background:: Estimation of the risk of adverse long-term outcome is of paramount importance in the treatment of critical limb ischemia (CLI).Methods:: We evaluated the accuracy of two specific risk score systems, the Finnvasc score and the modified Prevent III (mPIII) score, in 1425 CLI patients who underwent unilateral, infrainguinal surgical (47.6%) or endovascular (52.4%) revascularization. The receiver operating characteristic (ROC) curve analysis was used to estimate the predictive value of these risk scoring methods.Results:: The area under the ROC curve of Finnvasc score for prediction of 30-day amputation was 0.609 (95% confidence interval [CI] 0.549-0.677) and of mPIII score 0.533 (95% CI 0.457-0.609). The area under ROC curve of Finnvasc score for prediction of 30-day amputation-free survival was 0.622 (95% CI 0.573-0.671) and of mPIII score 0.588 (95% CI 0.533-0.642). The area under the ROC curve of Finnvasc score for prediction of 1-year amputation-free survival was 0.630 (95% CI 0.597-0.663, P < .0001) and of mPIII score 0.634 (95% CI 0.600-0.667, P < .0001). Finnvasc score predicted leg salvage (relative risk [RR] 1.431, 95% CI 1.319-1.551), survival (RR 1.233, 95% CI 1.116-1.363), and amputation-free survival (RR 1.422, 95% CI 1.319-1.534). mPIII score also predicted leg salvage (RR 1.190, 95% CI 1.108-1.277), survival (RR 1.245, 95% CI 1.193-1.300), and amputation-free survival (RR 1.223, 95% CI 1.176-1.272).Conclusions:: Finnvasc and modified PIII risk scoring methods predict long-term outcome of patients undergoing infrainguinal revascularization for CLI. Finnvasc score seems to perform well also in predicting immediate postoperative outcome.

Outcomes of planned celiac artery coverage during TEVAR - Corrected Proof

2010-08-16

Objective: Successful thoracic endovascular aneurysm repair (TEVAR) requires adequate proximal and distal fixation and seal. We report our experience of planned celiac artery coverage during endovascular repair of complex thoracic aortic aneurysms (TAA).Methods: Since 2004, 228 patients underwent TEVAR under elective (n = 162, 71%) and emergent circumstances (66, 29%). Patients with inadequate distal stent grafts landing zones during TEVAR underwent detailed evaluation of the gastroduodenal arcade with communicating collaterals between the celiac and superior mesenteric artery (SMA) by computed tomography angiography and intraoperative arteriogram. If needed, in presence of a patent SMA and demonstration of collaterals to the celiac artery, the stent grafts were extended to the SMA with celiac artery coverage. Furthermore, instances when further lengthening of distal thoracic stent graft landing zone was needed to obtain an adequate seal, the SMA was partially covered with the endograft, and a balloon expandable stent was routinely deployed in proximal SMA to maintain patency. Outcome data were prospectively collected and analyzed retrospectively.Results: Thirty-one of 228 (14%) patients with TEVAR required celiac artery interruption; 24 (77%) had demonstrable collaterals to the SMA. Twelve (39%) of 31 patients underwent additional partial SMA coverage by stent graft, and proximal SMA stent. The majority of patients were females (n = 20, 65%), the mean age was 74 years (range 55-87 years), and the mean TAA size was 6.5 cm. Postoperative complications included visceral ischemia in 2 (6%) patients, paraplegia in 2 (6%) patients, and death in 2 (6%) patients. All type 1b endoleaks (n = 2, 6%) and type 2 endoleaks vial retrograde flow from the celiac artery (n = 3, 10%) were successfully treated by transfemoral coil embolization. Over a mean follow-up of 15 months, there have been no other complications of mesenteric ischemia, spinal cord ischemia, SMA in-stent stenosis, or conversion to open surgical repair.Conclusions: Our findings suggest that celiac artery coverage to facilitate adequate distal sealing during TEVAR with complex TAA is relatively safe in the presence of SMA-celiac collaterals. Pre-existing SMA stenosis can be successfully treated by balloon expandable stents during TEVAR, and endoleaks arising from distal stent grafts attachment site or via retrograde flow from the celiac artery can be successfully managed by transfemoral coil embolization. Although early results are encouraging, long-term efficacy of these procedures remains to be determined and vigilant follow-up is needed.

Outcomes in open repair of the thoracic and thoracoabdominal aorta - Corrected Proof

Charles Acher, Martha Wynn — 2010-08-16

There has been a significant decrease in mortality and paraplegia risk during the last 25 years in the treatment of thoracic and thoracoabdominal aortic disease (). The primary factors in this improvement have been the use of cerebrospinal fluid drainage and moderate to profound hypothermia, combined with optimizing arterial perfusion pressure and cardiac function and the use of neurochemical protection. Effective application of these critical concepts has resulted in a 75% to 80% reduction in paraplegia and a 50% reduction in mortality in most single-center reports where surgery is supported by a dedicated anesthesia and surgical team using treatment protocols that optimize these critical factors. However, there is still considerable variation in mortality and paraplegia rates in clinical reports, with little understanding of the causes of this variation in outcomes ().

Advanced thoracic endovascular aortic repair data update and technical tips - Corrected Proof

Brian G. Peterson — 2010-08-16

Despite technologic improvements in endovascular devices used to treat thoracic aortic diseases and rapidly growing physician familiarity with the use of these devices, access-related complications remain one of the most common sources of morbidity and mortality during thoracic endovascular aortic repair (TEVAR). Standard, remote arterial access through a femoral artery approach is often not possible during TEVAR when these patients have small-caliber or diseased iliofemoral vessels. Various methods have been developed to combat these issues and include the use of open iliac conduits or direct aortic access through retroperitoneal exposures, or more recently, endoconduits that enable treatment of remote disease processes in the thoracic aorta through a femoral approach. One of the goals of this chapter is to discuss the options available for addressing these access-related limitations of TEVAR—conduits and endoconduits—and provide physicians with descriptions of techniques that can become part of their armamentarium in treating these difficult patients.

Bioengineered vascular graft grown in the mouse peritoneal cavity - Corrected Proof

Lei Song, Lai Wang, Prediman K. Shah, Aurelio Chaux, Behrooz G. Sharifi — 2010-08-09

Background:: We tested the hypothesis that the mouse peritoneum can function like a bioreactor to generate directed bio-engineered tissues such as those used for bypass grafting. Additionally, we reasoned that the mouse animal model would allow us to elucidate the underlying cellular and molecular mechanisms that are responsible for the generation of tissue in peritoneal cavity.Methods:: Plastic tubes (two tubes/mouse) were implanted into the peritoneal cavity of three strains of mice (C57BL/6, BALB/c, and MRL). The tubes were harvested, tissue capsule surrounding the tubes was removed, and analyzed by immunostaining (five capsules/five mice/strain) and microarray (three capsules/three mice/strain). In addition, the tissue capsules that were harvested from MRL mice (n = 21) were grafted into abdominal aorta of the same mice as autografts. The patency of all grafts was monitored by micro-ultrasound, and their functionality was assessed by laser Doppler imaging of blood flow in femoral arteries. Venous (n = 13) and arterial isografts (n = 11) were used as positive controls. In a negative control group (five mice/strain), the abdominal aorta was occluded by double ligation with 9-0 silk.Results:: The implanted plastic tubes required at least 8 weeks of incubation in the peritoneum of the three strains of mice in order to generate useful grafts. No vascular cells were found in the tissue capsules. Microarray analysis of tissue capsules revealed that the capsular cells express a gene expression program that is vastly shared among the three strains of mice, and the cells exhibit a high degree of plasticity. The micro-ultrasound analysis of the grafts showed that 62% of autografts remained patent compared with 77% of venous isografts and 91% of arterial isografts. The laser Doppler imaging analysis showed that blood flow dropped by 40% and 35% in the autografts and vein isografts, respectively, 1 day after surgery. The flow, however, rebounded to the level of arterial isografts 1 month post-surgery and remained unchanged among all grafts for the next 4 months. Immunostaining of the autografts showed a thick vessel wall with endothelial cells that lined the lumen and smooth muscle cells that constituted the graft wall.Conclusion:: The mouse peritoneal cavity of mice has the ability to function like a bioreactor to generate bio-engineered tissues. The tissue capsules harvested from peritoneal cavity of a mouse are composed of nonvascular cells that display phenotype of progenitor cells. After grafting, however, the capsule autografts become arterialized and remained patent for at least 4 months after surgery, similar to venous or arterial isografts.Clinical Relevance:: This animal model will facilitate the understanding of the genetic, molecular, and functional bases of vascular graft remodeling; specifically, the role of progenitor vascular cells in the arterialization of grafts without the interference from the residing vascular cells.

A comparaison of the standard bolia technique versus subintimal recanalization plus Viabahn stent graft in the management of femoro-popliteal occlusions - Corrected Proof

2010-08-09

Objective: To assess the potential benefit of the addition of a covered stent to a subintimal recanalized artery in patients with femoro-popliteal occlusions.Methods: From September 2003 to October 2005, we retrospectively analyzed all patients admitted for severe claudication or critical limb ischemia related to long femoro-popliteal occlusions and treated with subintimal recanalization. Patients were divided into two groups depending on whether they received a stent or not. All patients in the group treated with stent received a stent graft, and the entire length of the recanalized artery was covered in each case. Demographic data, indications, procedure, and outcomes were examined using survival analysis statistical techniques.Results: Fifty-three patients (54 limbs) were treated consecutively for severe claudication (n = 19) or critical limb ischemia (n = 34). Thirty-four (64%) had a stent placed, while 19 (35.8%) did not. The mean length of the lesions treated was 20.11 cm (range, 5-35 cm). Statistically, there was no significant difference in lesion length, Rutherford stage of peripheral-artery disease, Transatlantic Inter-Society Consensus classification, and distal run-off between the two groups. The technical success rate was 94.5%, and two out of the three failures were treated with surgical bypass in one case and major amputation in the other. The third patient received only medical treatment. Combined procedures were required in the treatment of 68.2% of limbs in the no-stent group and 55.8% in the stent group. Mean follow up was 16.9 months (range, 1-35 months). At 1 year, primary, primary-assisted, and secondary patency for the stent vs no-stent groups was, respectively, 61.8% vs 78.9% (P = .49), 70.6% vs 78.9% (P = .78), and 88.2% vs 78.9% (P = .22). The 1-year limb salvage rate for the stent vs no-stent group was 94.1% vs 100% (P = .7).Conclusion: Combining subintimal angioplasty with a stent graft in femoro-popliteal lesions does not improve patency. The limb salvage rate remains high after addition of a stent graft. Rigorous monitoring is recommended to diagnose and treat restenosis early in order to improve patency.

Gender differences in daily ambulatory activity patterns in patients with intermittent claudication - Corrected Proof

2010-08-09

Objectives: To compare the pattern of daily ambulatory activity in men and women with intermittent claudication, and to determine whether calf muscle hemoglobin oxygen saturation (StO2) is associated with daily ambulatory activity.Methods: Forty men and 41 women with peripheral arterial disease limited by intermittent claudication were assessed on their community-based ambulatory activity patterns for 1 week with an ankle-mounted step activity monitor and on calf muscle StO2 during a treadmill test.Results: Women had lower adjusted daily maximal cadence (mean ± SE) for 5 continuous minutes of ambulation (26.2 ± 1.2 strides/min vs 31.0 ± 1.2 strides/min; P = .009), for 1 minute of ambulation (43.1 ± 0.9 strides/min vs 47.2 ± 0.9 strides/min; P = .004), and for intermittent ambulation determined by the peak activity index (26.3 ± 1.2 strides/min vs 31.0 ± 1.2 strides/min; P = .009). Women also had lower adjusted time to minimum calf muscle StO2 during exercise (P = .048), which was positively associated with maximal cadence for 5 continuous minutes (r = 0.51; P < .01), maximal cadence for 1 minute (r = 0.42; P < .05), and peak activity index (r = 0.44; P < .05). These associations were not significant in men.Conclusion: Women with intermittent claudication ambulate slower in the community setting than men, particularly for short continuous durations of up to 5 minutes and during intermittent ambulation at peak cadences. Furthermore, the daily ambulatory cadences of women are correlated with their calf muscle StO2 during exercise, as women who walk slower in the community setting reach their minimum calf muscle StO2 sooner than those who walk at faster paces. Women with intermittent claudication should be encouraged to not only walk more on a daily basis, but to do so at a pace that is faster than their preferred speed.

Ellagic acid inhibits oxidized LDL-mediated LOX-1 expression, ROS generation, and inflammation in human endothelial cells - Corrected Proof

2010-08-09

Background: LOX-1, a lectin-like receptor on endothelial cells, facilitates the uptake of oxidized low-density lipoprotein (oxLDL). Expression of LOX-1 is involved in the pathobiological effects of oxLDL in endothelial cells, including reactive oxygen species (ROS) generation, suppression of endothelial nitric oxide synthase (eNOS) activity, and leukocytic adhesion. Moderate consumption of phenolic-enriched food may have a protective effect against the development of atherosclerosis via the antioxidant capacity of phenolic compounds at the endothelial level. In this study, we determined whether ellagic acid, a polyphenolic compound widely distributed in fruits and nuts, protects against oxLDL-induced endothelial dysfunction by modulating the LOX-1-mediated signaling pathway.Methods: Human umbilical vein endothelial cells (HUVECs) were pretreated with ellagic acid at doses of 5, 10, 15, and 20 μM for 2 hours and then incubated with oxLDL (150 μg/mL) for an additional 24 hours.Results: LOX-1 protein expression was markedly lower after exposure to oxLDL in HUVECs pretreated with ellagic acid or diphenyleneiodonium, a well-known inhibitor of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, than in HUVECs exposed to oxLDL alone, suggesting that ellagic acid deactivates NADPH oxidase. We also found that oxLDL activated the membrane assembly of p47phox, Rac1, gp91 and p22phox, and the subsequent induction of ROS generation; however, ROS generation was markedly suppressed in cells pretreated with ellagic acid or anti-LOX-1 monoclonal antibody. In addition, oxLDL down-regulated eNOS and up-regulated inducible NO synthase (iNOS), thereby augmenting the formation of NO and protein nitrosylation. Furthermore, oxLDL induced the phosphorylation of p38 mitogen-activated protein kinase, activated the NF-κB-mediated inflammatory signaling molecules interleukin-(IL) 6 and IL-8 and the adhesion molecules intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selectin, and stimulated the adherence of THP-1 (a human acute monocytic leukemia cell line) to HUVECs. Pretreatment with ellagic acid, however, exerted significant cytoprotective effects in all events.Conclusion: Findings from this study may provide insight into a possible molecular mechanism by which ellagic acid inhibits LOX-1-induced endothelial dysfunction. Our data indicate that ellagic acid exerts its protective effects by inhibiting NADPH oxidase-induced overproduction of superoxide, suppressing the release of NO by down-regulating iNOS, enhancing cellular antioxidant defenses, and attenuating oxLDL-induced LOX-1 up-regulation and eNOS down-regulation.Clinical Relevance: Increased oxidative stress is an important factor contributing to the development of atherosclerotic lesions. This study underscores the potential clinical benefits and application of ellagic acid in prevention of oxLDL-associated atherogenic diseases.

Sourcing of superficial reflux in venous leg ulcers using duplex ultrasound - Corrected Proof

Alfred Obermayer, Katharina Garzon — 2010-08-09

Objective:: Mapping of venous reflux routes associated with medially or laterally located venous leg ulcers and their source of origin.Methods:: This prospective report presents the results of duplex investigations performed in consecutive leg ulcer patients, all with venous reflux, in a time period over 2 years. A total of 169 patients (183 legs), with chronic venous leg ulcers (CEAP: C6) were examined in a private practice. The data collection integrated an examination that included medical history and clinical diagnoses and incorporated measurements such as body mass index, oscillometric index, and range of motion of the ankle joint. Venous function was assessed with duplex ultrasound, and the cases were described using the advanced CEAP classification. Additionally, a “sourcing” technique was performed with duplex ultrasound investigation of the ulcer bed and the venous system under manual compression and release of the ulcer. The principle of “sourcing” is to follow venous reflux from the ulcer area to its proximal origin. The detected reflux routes were classified either as “axial” or “crossover” type.Results:: A total of 20% of the ulcer patients showed no clinically visible varicose veins. One hundred three patients had medial ulcers, 54 lateral ulcers, 21 medial and lateral, and five had gaiter ulcers. Sixty-four (35%) of the medially located ulcers had reflux in the great saphenous vein (GSV), 28 (15%) showed reflux in the medial perforating veins (axial types), and 11 (6%) had reflux in the small saphenous vein (SSV; crossover type). From 54 patients presenting with lateral ulcers, 25 (14%) showed GSV incompetence (crossover type) and only 13 (7%) SSV incompetence (axial type). Sixteen patients showed refluxes penetrating from deep into lateral perforating veins.Conclusion:: Crossover reflux routes were detected in 25 of 54 (46%) legs with lateral and in 11 of 103 (11%) legs with medial ulceration (χ2 44.34; P < .001). In venous ulcer patients, an extended examination (CEAP classification) and a special duplex technique (“sourcing”) are recommended to identify the specific route responsible for the venous reflux. This seems essential for planning a rational treatment of venous reflux ulcers.