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Objective/Introduction: Increased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following EVAR in AAA patients. Methods: Patients who underwent elective EVAR between 2004 and 2018 were reviewed. Thoracic tortuosity index (TTI) was measured using 3D reconstruction software. Patients were dichotomized across the median TTI into high tortuosity [HT] (TTI >1.27, Figure1(a)) and low tortuosity [LT] (TTI ≤1.27, Figure 1(b)) groups. Perioperative complications, postoperative outcomes, and CT-based features of thoracic aortic wall degeneration (Figure 1(c)-(e)) were collected and analyzed. Results: 136 patients underwent treatment: 70 HT patients, including 54 males and 16 females (mean age: 77 years), and 66 LT patients, including 62 males and 4 females (mean age: 70 years) (age; P <.001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P =.045, P =.01). Presence of degenerative aortic wall markers was greater in HT patients (P =.045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P =.002). Frequency of AAA rupture/dissection was 4.3% for HT and 1.5% for LT (P =.339). A trend was observed in all cause 30-day mortality in the HT group (P =.061). Other perioperative complications and postoperative outcomes were similar between groups. Conclusion: High TTI was associated with older age at time of EVAR, greater prevalence of degenerative markers in the descending thoracic aortic wall, and widespread aorto-iliac dilation. While not predictive of EVAR outcomes, TTI can provide valuable information regarding aneurysm pathophysiology. [ABSTRACT FROM AUTHOR]

Introduction: With the aging U.S. population, peripheral vascular procedures will become increasingly common. The objective of this study is to characterize the factors associated with increased total costs after peripheral bypass surgery. Methods: Data for 34,819 patients undergoing peripheral bypass surgery in NY State were extracted using the Statewide Planning and Research Cooperative System (SPARCS) database for years 2009-2017. Patient demographics, All Patient Refined Diagnostic Related Groups (APR) severity score, mortality risk, hospital volume, and length of stay data were collected. Primary outcomes were total costs and length of stay. Data were analyzed using univariate and multivariate analysis. Results: 28.1% of peripheral bypass surgeries were performed in New York City. 7.9% of patients had extreme APR severity of illness whereas 32.0% had major APR severity of illness. 6.3% of patients had extreme risk of mortality and 1 in every 5 patients (20%) had major risk of mortality. 24.9% of patients were discharged to a facility. The mean length of stay (LOS) was 9.9 days. Patient LOS of 6-11 days was associated with +$2,791.76 total costs. Mean LOS of ≥ 12 days was associated with + $27,194.88 total costs. Multivariate analysis revealed risk factors associated with an admission listed in the fourth quartile of total costs (≥$36,694.44) for peripheral bypass surgery included NYC location (2.82, CI 2.62-3.04), emergency surgery (1.12, CI 1.03-1.22), extreme APR 2.08, 1.78-2.43, extreme risk of mortality (2.73, 2.34-3.19), emergency room visit (1.68, 1.57-1.81), discharge to a facility (1.27, CI 1.15-1.41), and LOS in the third or fourth quartile (11.09, 9.87-12.46). Conclusion: The cost of peripheral bypass surgery in New York State is influenced by a variety of factors including LOS, patient comorbidity and disease severity, an ER admission, and discharge to a facility. [ABSTRACT FROM AUTHOR]

Introduction: Extracranial carotid artery aneurysms and pseudoaneurysms (ECCAs) are rare pathologies with various etiologies, presentations, and management strategies. Historically, open aneurysm resection and arterial repair have been the gold standard management of ECCAs. Our study examines the evolving experience with endovascular management of ECCAs. Methods: We performed a literature review of multiple studies on endovascular and open management of carotid artery aneurysms and pseudoaneurysms. Conclusions: Endovascular stenting is technically feasible and clinically effective for the treatment of carotid artery aneurysms and pseudoaneurysms. Further follow-up is required regarding long-term safety and efficacy. [ABSTRACT FROM AUTHOR]

Extracranial carotid artery aneurysms located in the cervical region in close proximity to the skull are difficult to access using open surgical methods. Endovascular treatment has emerged as an alternative option for anatomically challenging internal carotid artery aneurysms. However, data comparing various endovascular techniques including stent grafting, coil embolization, double stenting, and stent-assisted coil embolization are lacking, making it difficult to determine the optimal treatment. We present a case of a patient with 2 fusiform extracranial carotid artery aneurysms treated successfully with a combination of double stenting and stent-assisted coil embolization. We also discuss technical considerations for selecting the appropriate endovascular intervention. [ABSTRACT FROM AUTHOR]

Objective: We evaluated the results of thoracic endovascular aneurysm repair (TEVAR) to determine what anatomic factors influenced the clinical outcomes. Methods: Preoperative computed tomography (CT) angiograms of 65 patients who underwent TEVAR were analyzed using 3-dimensional imaging. The proximal and distal neck, thoracic aneurysm, and iliac arteries were measured for angulation, diameter, length, calcification, and tortuosity. Immediate technical success and clinical success were measured. Results: Immediate technical success was achieved in 91% (59 of 65) of the patients analyzed. One patient died in the operating room during treatment of rupture. Clinical success was achieved in 83%(54 of 65) of patients at follow-up. Four patients had small endoleaks with no sac enlargement at follow-up. One patient was converted to open repair. Severe iliac calcification was found to be significant for deployment failure. The mean follow-up is 8 months (1-36 months). Conclusion: Increased iliac calcification and increased iliac tortuosity correlate with an inability to successfully deploy the device. [ABSTRACT FROM AUTHOR]

Objective: We reviewed our institution's experience with carted artery pseudo-occlusion (CAPO), to investigate whether internal carted artery (ICA) end-diastolic velocity (EDV) as measured by duplex ultrasonography, was a predictor of need for further intervention. Methods: From February 2003 to January 2008, 7478 patients underwent duplex ultrasonographic evaluation of their carted arteries. Diagnosis of CAPO included the appearance of a narrow flow jet (string sign) on power doppler images, low velocities in the ICA and additional criteria listed below. Results: Ten patients (0.13%) were identified as having a CAPO. All patients were asymptomatic and had anEDV<78cm/s.Occlusion or functional occlusion was identified in nine patients on contrast imaging studies. Eight of these patients were treated medically without neurologic complication on follow-up. Two patients were treated with interventions and were asymptomatic at follow up. The mean follow up for the entire group was 12 months. Conclusions: Although this is a low volume study, there is evidence to suggest that asymptomatic patients with lowEDV in the setting of carted artery pseudo-occlusion found of duplex, may be safely managed medically. [ABSTRACT FROM AUTHOR]

Visceral artery aneurysms, although uncommon, can present with life-threatening hemorrhage. The increasing use of imaging studies has allowed for earlier identification and intervention of these aneurysms, thus avoiding the high morbidity and mortality associated with rupture. The treatment options for visceral artery aneurysms range from conventional open surgical repair to minimally invasive techniques using covered stents or embolization materials. Anatomic features and patient selection determine which treatment option would result in the most durable treatment and outcome. This article reviews our experience with the endovascular treatment of visceral artery aneurysms. [ABSTRACT FROM AUTHOR]

This study was performed to evaluate the efficacy of a balloon-expandable Palmaz stent common iliac artery occluder device for endovascular stent-graft repair of aortoiliac aneurysms. Eighty-four patients (79 men, 5 women; age range 60-95 yr; mean age, 76 yr) with aortoiliac aneurysms underwent endovascular stent-graft repair. The repair consisted of a stent-graft extending from the abdominal aorta to the iliac or common femoral artery, a cross-femoral bypass graft, and an endovascular arterial occluder device within the contralateral common iliac artery. The occluder device consisted of a 5-cm segment of 6-mm diameter polytetrafluoroethylene (PTFE) graft with a purse-string suture occluding the leading end and a Palmaz stent sutured to the trailing end. The occluder device was delivered through a 17F catheter via an arteriotomy. Eighty-three of the 84 patients received aortic endografts. In one case, infrarenal aortic rupture occurred during deployment of the aortic stent requiring conversion to an open surgical repair. Initial technical success for occluder device insertion was achieved in 78 of the remaining 83 patients. Failure to advance the occluder device delivery sheath through a diseased iliac artery occurred in one patient. Common iliac artery rupture occurred during balloon expansion and occluder device deployment in two patients. Two patients required additional coil embolization of the common iliac artery adjacent to the occluder device at the time of stent-graft insertion to correct incomplete iliac occlusion. Delayed occluder device-related complications included one patient with a postoperative iliac endoleak who required percutaneous coil embolization and one patient with a postoperative iliac endoleak in whom a contained aortic aneurysm rupture developed that was treated by surgical ligation of the common iliac artery. Use of the Palmaz stent-based iliac artery occluder device is an effective technique to induce common iliac artery thrombosis to facilitate endoluminal stentgraft aneurysm repair. [ABSTRACT FROM PUBLISHER]

The experience with the use of endovascular covered stents for aortic lesions has been growing. The early results of using endovascular covered stents for the exclusion of thoracic and infrarenal abdominal aortic aneurysms have been promising and are being investigated in multiple ongoing trials. Their usage for other aortic lesions has been reported sporadically, often as resourceful options in unusual and difficult clinical situations. The authors report a patient who had previously undergone resection of a thoracic aortic sarcoma and subsequently presented in extremis from an aortobronchial fistula. The evaluation and treatment of an aortic sarcoma and the successful urgent exclusion of an aortobronchial fistula through use of an endovascular covered stent are discussed. [ABSTRACT FROM PUBLISHER]

New endovascular procedures are increasing the options available to the vascular surgeon for the treatment of arterial disease. These techniques, alone or in combination with conventional surgical techniques, may allow the safer treatment of complex aortoiliac pathology, particularly in patients with comorbid medical illnesses who have high morbidity and mortality rates associated with open surgical repair. The authors describe the successful treatment of two noninfected aortoiliac false aneurysms eight years after the original arterial reconstruction with a bifurcated graft. The pseudoaneurysms were treated by use of a combination of endovascular and standard surgical techniques in a patient with significant comorbid medical conditions that limited standard surgical repair. [ABSTRACT FROM PUBLISHER]

Background: We endeavored to characterize the anesthesia experience with endovascular aneurysm repair (EVAR) at a large academic medical center in the United States. Methods: A retrospective review of electronic medical records was conducted for all patients undergoing elective EVAR from 2002 to 2007 in a large academic medical center. Results: A total of 522 cases met inclusion criteria, with 4% of cases using general anesthesia (GA), 92% regional anesthesia (RA), and 4% local anesthesia (LA). There was no statistically significant difference between the groups for duration of surgery or in-hospital mortality. In-hospital length of stay was longer for GA than LA or RA. Four cases were converted to open repair. Two mortalities occurred during the perioperative period (0.4% of cases). Conclusions: The vast majority of EVAR were successfully performed under RA, involved mild blood loss, involved infrequent need for conversion to GA, and resulted in brief in-hospital length of stay and low mortality rate. [ABSTRACT FROM AUTHOR]

A 63-year-old female presented to clinic following an incidental finding of an abdominal aortic aneurysm (AAA). Preoperative imaging was consistent with an infrarenal AAA over 5-cm in diameter with both renal arteries originating above the superior mesenteric artery (SMA). The patient subsequently underwent an endovascular aneurysm repair (EVAR) using the AFX stentgraft (Endologix, Inc, Irvine, Calif). Notably, the proximal stent-graft piece was unsheathed with the image intensifier in a lateral position to ensure deployment below the SMA. Postoperative course was unremarkable and the patient is currently recovering well. [ABSTRACT FROM AUTHOR]