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Thoracic endovascular aortic repair (TEVAR) involving the aortic arch is increasingly being performed and novel endografts have been developed for this procedure, but the association of stroke and relative risk of procedural techniques remains unclear. This study evaluates the procedural risk factors for stroke and mortality with zone 0–2 TEVAR.

Purpose: To analyze differences in baseline characteristics, overall mortality, device-related mortality, and re-intervention rates in patients who underwent thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) with atherosclerotic/degenerative cause or acute aortic syndrome (AAS), using the Global Registry For Endovascular Aortic Treatment (GREAT).Materials and Methods: Patients submitted to TEVAR for AAS or DTAA, included in GREAT, were eligible for this analysis. Primary outcome was 30-day all-cause mortality rate. Secondary outcomes were 30-day aorta-related mortality and re-intervention rate, 1-year and 3-year all-cause mortality, aorta-related mortality and re-intervention rate.Results: Five-hundred and seventy-five patients were analyzed (305 DTAA and 270 AAS). Thirty-day mortality rate was 1.3% and 1.8% for DTAA and AAS, respectively (p=0.741). One-year and 3-year mortality rates were 6.2% versus 9.3 and 17.3% versus 15.9% for DTAA and AAS, respectively (p=0.209 and p=0.655, respectively). Aorta-related mortality rates at 30 days, 1 year and 3 years were 1.3%, 1.3%, and 2.6% for DTAA, 1.8%, 4.2%, and 4.2% for AAS (p=ns). Re-intervention rates at 30 days, 1 year, and 3 years were 1.3%, 4.3%, and 7.5% for DTAA, 3.3%, 8.1%, and 10.7% for AAS (p=ns). Furthermore, a specific analysis with similar outcomes was performed dividing follow-up in 3 periods (1-30 days, 31-365 days, 366-1096 days) and describing mutual differences between 2 groups and temporal trends in each group.Conclusion Patients who underwent TEVAR for DTAA or AAS experienced different mortality and re-intervention rates among years during mid-term follow-up. Although all-cause related deaths within 30 days were TEVAR-related, aorta-related deaths were more common for AAS patients within 1 year. A greater re-intervention rate was described for AAS patients, although only 1 year after TEVAR.

The risk of rupture of renal artery aneurysms (RAAs) remains undefined. A recent paper from the Vascular Low-Frequency Disease Consortium (VLFDC) identified only 3 ruptures in 760 patients. However, over 80% of patients in the VLFDC study were treated at large academic centers, which may not reflect the pattern of care of RAAs nationwide. Thus, the purpose of this study was to evaluate the pattern of nonelective versus elective surgery requiring inpatient admission for RAAs, including nephrectomies, and their outcomes using a national database.

•Type of research: Single-center, retrospective study•15 patients underwent IBE combined with FEVAR with 100% technical success.•Major adverse events were seen in 33.3% of patients.•1 type 1C endoleak at the internal iliac branch was seen at 14 months follow-up.•Take home message: IBE can be safely combined with FEVAR.

•Single-center retrospective review of prospectively collected data for 287 patients•Transfusion occurred frequently in undergoing lower extremity bypass•Major adverse cardiac events occurred in 15.7% of lower extremity bypass operations•Transfusion was associated with major adverse cardiac events for Hgb nadir >8 g/dL

PURPOSE: The purpose of this study was to prospectively evaluate the treatment of patients with occluded lower extremity bypass grafts, comparing surgical revascularization with catheter-directed thrombolysis. MATERIALS AND METHODS: One hundred twenty-four patients (68% male and 32% female) with lower limb bypass graft occlusion (46 autogenous and 78 prosthetic) were prospectively randomized to surgery (n = 46) or intra-arterial catheter-directed thrombolysis (n = 78) with recombinant tissue plasminogen activator (rt-PA) 0.1 mg/kg/h modified to 0.05 mg/kg/h for up to 12 hours, or urokinase (UK) 250,000 U bolus followed by 4,000 U/min for 4 hours, then 2,000 U/min for up to n hours. A composite clinical outcome including death, amputation, ongoing/recurrent ischemia, and major morbidity was analyzed on an intent-to-treat basis at 30 days and 1 year. RESULTS: The average duration of graft occlusion was 34.0 days, with 58 (48%) presenting with acute ischemia (0 to 14 days) and 64 (52%) with chronic ischemia (>14 days). Thirty-nine percent randomized to lysis failed catheter placement and required surgical revascularization. Overall, there was a better composite clinical outcome at 30 days (P = 0.023) and 1 year (P = 0.04) in the surgical group compared with lysis, due predominately to a reduction in ongoing/recurrent ischemia, most notable in autogenous grafts. However, following successful catheter placement, patency was restored by lysis in 84%, and 42% had a major reduction in their planned operation. One-year results of successful lysis compared favorably with the best surgical procedure, which was new graft placement. Acutely ischemic patients (0 to 14 days) randomized to lysis demonstrated a trend toward a lower major amputation rate at 30 days (P = 0.074) and significantly at 1 year (P = 0.026) compared with surgical patients, while those with > 14 days ischemia showed no difference in limb salvage but higher ongoing/recurrent ischemia in lytic patients (P < 0.001). Patients with occluded prosthetic grafts had greater major morbidity than did those with occluded autogenous grafts (P < 0.02). CONCLUSIONS: Proper catheter positioning currently limits the potential of catheter-directed thrombolysis for lower extremity bypass graft occlusion. Patients with graft occlusion > 14 days have a significantly better outcome when treated surgically, with a new bypass being the best surgical option. However, in patients with acute limb ischemia (

Phlegmasia cerulea dolens (PCD) is an uncommon, severe form of lower extremity deep venous thrombosis characterized by extremity swelling, cyanosis, and pain. Progression of the thrombotic process may result in extremity gangrene, amputation, and death. The relative value of specific therapeutic regimens in the treatment of this disease remains uncertain. Twelve patients, 9 females and 3 males, with PCD were treated during a 10-year period. Eighteen lower extremities were involved. Pre-existing conditions included malignancy (eight), postoperative state (four), diabetes (three), previous deep venous thrombosis (three), and hypercoagulation (two). Venous gangrene was present in four patients. All patients were treated initially with bedrest, fluid resuscitation, extremity elevation, and systemic high-dose heparin therapy. Five patients had complete resolution with this regimen alone. One patient required cessation of heparin therapy due to heparin-induced thrombocytopenia and developed gangrenous toes. Two patients whose condition failed to respond to heparin therapy underwent catheter-based delivery of urokinase with marked clinical improvement. Four patients, two with venous gangrene, died, three of whom had disseminated malignant disease. A significant percentage of patients with PCD will respond to extremity elevation, fluid resuscitation, and aggresive systemic anticoagulation therapy. Thrombolytic therapy selectively administered is beneficial in patients whose disease fails to respond promptly. Venous thrombectomy should be reserved for patients with contraindications to thrombolysis.

•Type of research: Single-center, retrospective cohort study•Key findings: 17 patients underwent at least one inner branch modification, with overall 94% technical success, 2 (11.8%) patients with major adverse events, 1 (3.7%) inner branch target vessel instability (occlusion) and no inner branch related rupture, death, endoleaks, or reinterventions during the follow up period of 174 days (5.8 months).•Take Home Message: Inner branches provide a safe alternative technique of branch incorporation during complex endovascular aortic repair.

Intravenous drug abusers may accidentally inject themselves in the artery, rather than the vein. This can cause severe complications such as acute and severe ischemia (decreased blood supply to tissues), usually involving an arm or leg. This ischemia can cause tissue death and permanent nerve damage. A report is presented of the results of treating 48 patients for ischemia of the extremity which occurred after an intraarterial drug injection. The treatment used included heparin, dextran 40, dexamethasone, and elevation and early mobilization of the extremity. Assessment of the degree of injury was performed using a tissue ischemia test which evaluated the color, capillary refill, sensory function, and temperature of the extremity. Scores ranged from 0 to 4; a normal score was 0. Half the patients had extremity tissue scores of less than or equal to 2. Following treatment, 22 of the 24 patients had normal extremities; two patients required digital amputation. Of the 24 patients with extremity tissue ischemia, those with scores greater than 2, 10 had normal extremities after treatment, three had decreased function, and 11 required digital amputation. Significantly better outcome was associated with patients treated within 24 hours of injury. It is concluded that tissue ischemia scoring is useful in evaluating and predicting the outcome of complications of intraarterial drug injection. Treatment within 24 hours of injury is important, particularly when there is evidence of severe ischemia. (Consumer Summary produced by Reliance Medical Information, Inc.)

Takayasu's arteritis is a rare inflammatory disease involving the aorta and its major branches, and is characterized by renal vascular hypertension (RVH) and progressive occlusion of the arteries. This condition usually occurs in young girls and women and can cause stroke, eye ischemia (tissue damage due to lack of adequate blood supply), ischemia of the extremities, aortic insufficiency, and aneurysm formation. Although surgical reconstruction is helpful in treating the symptoms, the usefulness of surgery in treating the arteritis has not been established. Twenty female patients (average age was 24 years) with Takayasu's arteritis were treated between 1973 and 1989. High blood pressure (hypertension) was present in 11 patients (55 percent), and ischemia of the extremities was present in 12 patients (60 percent). Seven patients had cerebrovascular insufficiency, inadequate blood flow to the brain. Nine patients were treated medically with corticosteroids, but symptoms of vascular insufficiency did not improve. There were 11 patients who underwent arterial reconstructive surgery for kidney insufficiency, extremity ischemia, cerebrovascular insufficiency, aortic insufficiency and aortic aneurysm (localized thinning of the wall of the aorta). All of these patients showed improvement and there were no deaths. At an average follow-up time of 5.75 years, all patients were alive. It is concluded that symptomatic Takayasu's arteritis often requires reconstructive surgery of the arteries, which can provide symptomatic improvement and better patient outcome. (Consumer Summary produced by Reliance Medical Information, Inc.)

During an 18-month period, 53 patients with unilateral blunt lower-extremity trauma were entered into a prospective study designed to determine how often clinically occult arterial injuries are identified by routine arteriography, and how often these injuries are of sufficient magnitude to warrant therapeutic intervention. Patients underwent diagnostic arteriography if one or more of the following abnormal clinical findings were present: distal pulse deficit, nerve deficit, soft-tissue loss, decreased capillary refill, bruit, or a history of hemorrhage or hypotension. In the absence of these findings, arteriography was performed for significant orthopedic injuries, i.e., knee dislocations or complex longbone fractures. In 31 patients 58%), arteriography was performed because I or more abnormal clinical findings were present and 12 arterial injuries were identified, 4 requiring arterial repair. The presence of a knee dislocation or complex longbone fracture was the only indication for arteriography in 22 patients (42%) and 3 arterial injuries were identified, none requiring operative intervention. For all patients, two variables, pulse deficit and delayed capillary refill, strongly correlated (p, Blunt injury to the lower extremity, particularly fractures and dislocations of the knee, is often associated with vascular (blood vessel) injury. Delay in diagnosis and treatment of these vascular injuries can lead to unacceptably high leg amputation rates. It has been standard practice to perform arteriography (X-ray study of an artery using radiopaque dye) if there is evidence to suggest vascular injury (pulse deficit or murmur, neurological deficit). However, it has recently become common to perform arteriography as a screening procedure for all patients with major blunt injury to the lower extremity, with or without clinical indication of vascular injury. A prospective study was undertaken to determine how often arterial injuries without clinical signs are identified by arteriography. There were 53 patients with blunt lower extremity injury; all had arteriography performed. There were 31 patients (58 percent) who had one or more abnormal clinical findings suggestive of possible vascular injury; using arteriography, 12 arterial injuries were identified with four requiring vascular repair. Of the other 22 patients (42 percent) undergoing arteriography, who had knee dislocation or long-bone fracture without clinical findings of vascular injury, 3 artery injuries were identified, none of which required surgery. For all patients, two variables, pulse deficit and delayed capillary refilling, were strongly correlated with artery injury as shown on the arteriogram. It is concluded that arteriography should be performed selectively, only on patients who have clinical evidence suggesting vascular injury; routine use of arteriography only rarely may identify a vascular injury requiring repair in a patient without clinical signs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Thoracic endovascular aortic repair (TEVAR) for type B aortic dissections is used to promote false lumen (FL) thrombosis and favorable aortic remodeling, but its impact on occlusion of FL origin branch vessels has not been widely described. We compare FL versus true lumen (TL) branch vessel patency after TEVAR.

Left subclavian artery revascularization during endovascular repair of aortic dissection is often accomplished by left carotid-subclavian artery bypass or transposition. In situ fenestration of thoracic stent grafts provides an alternative method of revascularization without manipulation of the left carotid artery. We describe a case whereby in situ laser fenestration, combined with catheter-directed thrombectomy, was utilized to revascularize a thrombosed left subclavian artery following a frozen elephant trunk repair of type A aortic dissection. A 75-year-old male presented with pericardial tamponade and aortic insufficiency, secondary to type A aortic dissection. Patient underwent an emergent replacement of the aortic root, valve, arch, and ascending aorta in the frozen elephant trunk configuration. The innominate and left carotid arteries were revascularized with a bifurcated bypass graft from the ascending aortic graft. The left subclavian artery (LSCA) was covered with an antegrade deployment of a cTAG stent graft. During the immediate postoperative period, the patient was found to have a dissection of the left common carotid artery (LCCA) and pseudoaneurysm of the bypass graft anastomosis. The left carotid artery was replaced up to the proximal internal carotid. During rehabilitation, the patient developed left subclavian steal syndrome, with a CT angiography demonstrating thrombosis of the subclavian origin, and duplex ultrasound showing a reversal of the left vertebral flow. In order to revascularize the left subclavian artery without using the left carotid as the inflow, the in situ laser fenestration technique was planned. The vertebral artery origin was protected with a neuroclip through a supraclavicular incision. Through a brachial artery cutdown, a 9Fr flex sheath was positioned at the origin of the subclavian artery. A suction thrombectomy catheter was used to create a central channel in the thrombus. A 0.035″ 3.2 mm over-the-wire laser atherectomy catheter was used to create a fenestration through the cTAG stent graft. The subclavian branch stent was stented with an iCast balloon-expandable covered stent, excluding the mural thrombus. The patient recovered well with resolution of symptoms and was discharged home. Postoperative CT scan showed patent left subclavian branch stent and no endoleak across the fenestration of the aortic stent graft. Delayed laser in situ fenestration of a PTFE stent graft can be performed safely. The vertebral artery protection and catheter-directed thrombectomy are important adjuncts to reduce the risk of posterior stroke.

Chronic type B aortic dissections with continued aneurysmal expansion of the thoracoabdominal aorta after the initial thoracic endovascular aortic repair represent a subset of aortic pathology in which staged distal extension to seal additional septal tears can be advantageous. This approach may require incorporation of visceral or renal branches into the distal seal zone, while maintaining the possibility of further distal extension in the future. We describe a novel technique for incorporation of the celiac axis, with a branch stent graft delivered from a transfemoral approach, then lifted cranially to create an antegrade sandwich graft configuration in a 59-year-old male who presented with a complicated type B aortic dissection requiring coverage of the celiac artery. Utilizing the previous thoracic endograft as a platform for sandwich grafting, a self-expanding stent graft was deployed into the celiac artery from a femoral approach. A steerable sheath with an anchoring balloon was used to lift the stent into an up-facing snorkel position, which was subsequently sandwiched with another thoracic stent graft terminating proximal to the superior mesenteric artery. When single visceral or renal branch incorporation is desired, sandwich grafting via a “lift” technique limits the extent of aortic coverage and reduces the number of branch components, without increasing the complexity of additional visceral and renal branch incorporation during future endovascular aortic repair.

System-based practice with an emphasis on quality improvement (QI) is a recent initiative for the American College of Surgeons and a core-competency for surgical trainees. Few surgical training programs have a curriculum for hospital-based QI.

Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2 hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a “hot foot line” for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.

Treatment of iliac artery aneurysms (IAAs) with the iliac branch endoprosthesis (IBE) during endovascular repair of infrarenal abdominal aortic aneurysm (endovascular aortic repair (EVAR)) has been well-documented as effective. However, limited data exist evaluating the safety and efficacy of treating complex abdominal (cAAAs) and thoracoabdominal aortic aneurysms (TAAAs) with associated IAA with combined physician-modified fenestrated-branched EVAR (PM-FBEVAR) and IBE. Moreover, limited studies exist assessing the impact of adding IBE on the outcomes following PM-FBEVAR. Therefore, we compared the clinical outcomes of patients who underwent PM-FBEVAR with and without IBE for the treatment of cAAA and TAAA.

Endovascular aneurysm repair has become the first-line treatment modality for infrarenal aortic aneurysms. However, obtaining successful long-term results frequently requires reinterventions. Particularly, delayed type 1a endoleaks pose a challenging problem, as they are often associated with proximal extension of the aneurysmal process to juxtarenal or pararenal aortic segments. We describe 2 remedial techniques to repair delayed type 1a endoleak by extending the seal zone to the suprarenal aorta, while incorporating the renal arteries. In the first case, a commercially available fenestrated stent graft was used. Parallel grafting technique was used in the other case. Both cases were technically successful. Follow-up imaging revealed endoleak resolution with patent renal arteries for both patients. In addition, we describe the difference between the 2 techniques, as well as relevant anatomic and device-specific considerations.

Abdominal compartment syndrome (ACS) has a reported incidence of 9%–14% among trauma patients. However, in patients with similar hemodynamic changes, the incidence of ACS remains unclear. Our aim was to determine the incidence of ACS among patients undergoing endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms (rAAAs) and to identify associated risk factors.

Total endovascular repair of a thoracoabdominal aortic aneurysm (TAAA) in an urgent setting requires an advanced endovascular skill set and an innovative approach. We describe a novel technique of treating a symptomatic Crawford extent 4 TAAA with a combination of multilayered parallel endografting and double-barrel Gore Excluder bifurcated endografts to achieve complete aneurysm exclusion with visceral and bilateral renal artery incorporation. A 75-year-old male presented with a symptomatic 10 cm Crawford extent 4 TAAA. Severe medical comorbidities, including chronic obstructive lung disease and cardiac arrhythmia, as well as prior open infrarenal aortic aneurysm repair made him high risk for an urgent re-do open repair. His previous open infrarenal aortic replacement created a short distance between the lowest renal artery and the flow divider of the aortic graft, which posed a challenge in using a bifurcated aortic endograft as a distal component of the previously described multilayered parallel endografting. Therefore, celiac and superior mesenteric arteries were treated with a multilayered parallel grafting configuration, whereas bilateral renal arteries were incorporated using side-by-side bifurcated modular stent grafts in double-barrel fashion. Contralateral gates served as cuffs for renal artery branch stent grafts, and ipsilateral limbs were deployed within the common iliac arteries. The patient recovered well and was discharged 3 days after repair. Follow-up imaging at 1 month demonstrated patent celiac, superior mesenteric, and bilateral renal artery flow, with no endoleak and stable aneurysm sac. The patient is doing well clinically 1 year after the operation.

Total endovascular repair of TAAA using branched, fenestrated stent grafts have been performed with promising midterm results. However, severe angulation of the aorta as well as close proximity of the visceral and renal artery ostia pose a significant technical challenge in designing and implanting branched, fenestrated stent grafts. Parallel grafting offers an alternative technique, allowing an urgent, or emergent total endovascular repair of symptomatic, or ruptured TAAA. We describe a technique of 4-vessel incorporation in a total endovascular repair of TAAA, using multilayered parallel endografting via bilateral femoral and unilateral brachial access. A 76-year-old male with severe chronic obstructive pulmonary disease and coronary artery disease presented with a symptomatic 9 cm extent IV thoracoabdominal aortic aneurysm. The thoracic, and paravisceral segments of his aorta, as well as the iliac arteries were severely angulated, whereas the superior mesenteric and the celiac arteries had a common origin. An urgent total endovascular aortic repair was performed. The aorta and the iliac arteries were straightened by placing stiff wires from bilateral femoral arteries in a “buddy” fashion. In addition, a brachiofemoral “body-floss” wire was established. Over this body-floss wire, thoracic stent grafts were deployed in multiple layers, alternating with parallel branch stents into visceral and renal arteries. Distally, a bifurcated modular stent graft was deployed down to the common iliacs, achieving complete aneurysm exclusion. Patient recovered well without complications and was discharged home in 5 days. Postoperative computed tomography scan showed patent visceral and renal stents and complete exclusion of the aneurysm without evidence of endoleak.

The majority of inguinal hernias that are concomitant with abdominal aortic aneurysms (AAAs) are clinically insignificant. However, management of AAA associated with a complex hernia can be challenging. We report a case of a 72-year-old male with a 7-cm AAA and a massive inguinal hernia involving loss of abdominal domain. Using a multidisciplinary approach, a staged hybrid endovascular and open repair of the AAA was performed followed by hernia repair.

Management of complicated indwelling inferior vena cava (IVC) filters has increased due to low retrieval rates. Filter migration and perforation are infrequent complications and require explantation of the filter. We report our recent experience with endovascular retrieval and surgical explantation of IVC filters after caval perforation.

Although asymptomatic arterial injuries are routinely treated surgically if they are detected with arteriography (X-ray of an artery after it has been filled with dye), it is possible that many may heal spontaneously. Such injuries consist of intimal fractures (damage to the arterial lining), small pseudoaneurysms (irregular widening of the artery's interior diameter), mural stenoses (irregular longitudinal narrowing of the artery), and small arteriovenous fistulas (abnormal connections between the venous and arterial systems). To better understand the progression of healing for such injuries, 50 patients with 61 arterial injuries (due mainly to gunshot wounds and blunt trauma) determined by arteriography were followed for several weeks after injury. Ten patients underwent embolization (removal of the arterial obstruction), which was successful in eight. Thirty injuries were studied subsequently with arteriography, of which six were in minor arteries, 24 in major arteries. All patients remained asymptomatic at an average time of five to six weeks after injury. Two of the minor-artery injuries resolved, one improved, one stabilized, and two progressed. Resolution, improvement, or stabilization occurred in 21 (87 percent) of the major-artery injuries. Only one patient with injury to a major artery required surgical intervention. A discussion is provided regarding the appropriateness of routine arteriography when injury is suspected. Specific injuries are described in detail. At present, it cannot be stated that such injuries should remain untreated. However, therapeutic options other than surgery should be considered if the injury meets certain criteria. (Consumer Summary produced by Reliance Medical Information, Inc.)

When tumors of the liver, gastrointestinal system, or bile duct system expand and obstruct the delivery of bile to the intestines, a back-up of bile leads to a condition known as hyperbilirubinemia. This is the retention of bile salts and pigments in the body, which leads to jaundice (bile pigment deposition in the skin). Hyperbilirubinemia is thought to increase risk from surgery, and in the early 1970s a technique to drain the bile by placing a catheter into the liver's secretory duct system through the skin (percutaneous biliary decompression) was developed to relieve this condition. The current case report documents the spread of tumor along the course of the catheter tract (the drainage tube), which is called seeding. The tumor developed four months after surgery in this patient at the exit site of the catheter. This metastatic (secondary) tumor was similar in pathology to the primary tumor. The patient died approximately one month later and at autopsy the tumor was found along the entire catheter tract. A review of the literature documented 17 similar cases. As a result of this study, the authors believe that patients whose tumors have a good chance of being removed should not routinely undergo the placement of catheters to decrease the pressure of their liver bile tract.

Caudal angulation and stenosis of the renal arteries pose significant challenges in branch cannulation during the standard fenestrated endovascular aortic aneurysm repair (FEVAR). We describe an alternative technique of branch cannulation during FEVAR in a patient with a 6.5-cm juxtarenal abdominal aortic aneurysm, renal artery stenosis, and bilateral caudally oriented renal arteries. A brachiofemoral or “body-floss” access was established by traversing the top scallop. The brachial sheath was deflected toward the target fenestration using a steerable robotic femoral sheath, enabling transbrachial cannulation of the downgoing target renal artery. Postoperatively, the patient was discharged without complications. Steerable sheath-guided body-floss technique may facilitate cannulation of severely downgoing branch vessels during FEVAR.

The Global Registry for Endovascular Aortic Treatment (GREAT) is a prospective observational multicenter cohort registry that was initiated in November 2011. The aim of the GREAT is to collect contemporary real-world data on the performance of all Gore aortic endografts in the treatment of multiple aortic pathologies. The primary and secondary objectives, design, and future directions of the GREAT are described.

Sartorius myoplasty (SM) has been used as an adjunct for soft tissue coverage in vascular groin wound complications. However, the reliability of SM as a primary muscle flap has been questioned. The purpose of this study is to determine the reliability of SM performed by vascular surgeons in the management of vascular groin wound complications. A retrospective review was performed on all patients who underwent SM from 1997 to 2012. The three indications for SM were prophylactic, infection, and noninfectious wound complication. Failure of SM was defined as operative reintervention for bleeding, persistent wound drainage, or infection. A total of 99 patients underwent 103 SM procedures. The patients were 43 per cent male and 57 per cent female; the mean age was 69 years. The indication for SM was infectious in 62 cases (60%), prophylactic in 21 cases (20%), and noninfectious in the remaining 20 cases. Failure of SM occurred in 11 cases (11%). Of these, salvage bypass and/or salvage muscle flap was required in eight cases (73%). When salvage bypass was required, extra-anatomic obturator bypass was performed in 80 per cent of cases. Salvage wound coverage included rectus abdominus flap (60%), rotational flap (20%), and skin grafting (20%). Seventy-three per cent of failures came from the infectious wound group. The most common reason for SM failure was hemorrhage (45%). In 82 per cent of the cases, the sartorius muscle was still viable at reoperation and was used for continued muscle coverage. SM performed by the vascular surgeon provides reliable soft tissue coverage for vascular groin wound complications and should be used as the primary muscle flap in the majority of patients. In cases of SM failure, the vascular surgeon should consider other more extensive muscle flap options.

The Vascular Quality Initiative (VQI)® is a national collaborative of regional quality groups that collect and analyze data to improve vascular health care. The Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe) is the regional quality group for southern California. Initial quality initiatives chosen by the So Cal VOICe are preoperative and discharge antiplatelet and statin therapy and vascular access guidance during percutaneous endovascular procedures. The objective of this study is to examine the influence of the regional quality group structure on the effectiveness of the So Cal VOICe. Data are entered by each institution into a cloud-based data collection and reporting system. So Cal VOICe data from January 2011 to July 2014 was analyzed in 6-month intervals. Preoperative statin and antiplatelet use increased from 58.87 to 71.81 per cent (P= 0.0082) and 60.8 to 78.38 per cent (P< 0.0001), respectively. Discharge statin and antiplatelet use increased from 69.09 to 80.37 per cent (P= 0.0037) and 80.47 to 88.11 per cent (P= 0.0148), respectively. Vascular access guidance improved from 32.89 to 76.23 per cent (P< 0.0001). Our results demonstrate the unique regional quality group structure of the VQI® improves compliance with selected process measures in the So Cal VOICe. Continued data collection will determine the impact of these process improvements on long-term patient outcomes.

To examine the value of routine postoperative surveillance duplex in identifying late graft-related complications after open aortic operations for occlusive and aneurysmal disease.

The objective of this clinical trial was to assess the safety and efficacy of carotid BAT in advanced HF.

Stroke is an exceedingly rare presentation of arterial thoracic outlet syndrome (aTOS). This report describes a case of cerebellar stroke secondary to aTOS and reviews the literature. A 56-year-old woman with no previous history of stroke or arm ischemia presented with vertigo. Computed tomography (CT) and magnetic resonance imaging confirmed a left cerebellar ischemic stroke. She subsequently developed ischemia of her left arm, which was treated by a thromboembolectomy. CT angiography revealed bilateral cervical ribs along with bilateral subclavian artery aneurysms. Staged resection of the cervical ribs and reconstruction of the subclavian arteries were performed. Symptomatic arterial thoracic outlet syndrome most commonly presents as arm ischemia because of embolization of intramural clot from a subclavian artery aneurysm or because of thrombosis of the subclavian artery aneurysm itself. In rare cases, the clot can propagate retrograde, resulting in stroke. In young patients presenting with ischemic stroke, arterial thoracic outlet syndrome should be considered as part of the differential diagnosis.

Late type III endoleaks result from complete or partial separation of endograft device components. Component separation repressurizes the aortic sac and may result in aortic rupture. We report 4 cases of late type III endoleaks after initial successful endovascular aneurysm repair for abdominal aortic aneurysm. Our cases include 3 aortic cuff separations and 1 iliac limb separation. The average time before graft separation was 3.25 years with an average aneurysm size at re-presentation of 8.2 cm. Management of these complex cases will be discussed, the literature reviewed, and recommendations for treatment offered.

Uterine fibroids are usually benign soft tissue tumors, however, when they become large, they can cause external venous compression. We present a case of a 45-year-old woman who presented with phlegmasia cerulea dolens from a large uterine fibroid. She was successfully treated with hysterectomy, venous thrombectomy, and fasciotomy. We review the literature for previous reports of venous thromboembolism resulting from uterine fibroids. The patient characteristics, thrombotic complications, and treatment modalities are reviewed.

Resistant hypertension affects 20% to 30% of patients with high blood pressure (BP). It is defined as failure to achieve goal BP despite using at least 3 antihypertensive drugs of different classes, at maximal tolerated doses, one of which must be a diuretic. Persistent suboptimal BP is the most common attributable risk for death worldwide and its prevalence will most likely increase over the next decade. We review the epidemiologic aspects and diagnostic challenges of resistant hypertension, barriers to achieving proper BP control, and causes of secondary hypertension. Lifestyle modification and pharmacologic and device approaches to treatment are discussed.

Perfusion techniques utilizing hyperthermic chemotherapy have been established as a successful modality of therapy for isolated metastatic malignant melanoma. The combination of chemotherapeutic agents (Dactinomycin, thiotepa and Mechlorethamine HCl) given in high doses, not possible systemically, combined with hyperthermia ( 40-42°C) in an isolated extremity has shown greater tumor regression compared with systemic medication only.

The purpose of this study is to examine follow-up rates and maturation rates after dialysis access surgery using a fistula-first approach in a county hospital with an indigent population.

To report a rare case of nonatherosclerotic renal artery disease (NARAD) in a patient with Erdheim–Chester disease (ECD), a non-Langerhans cell histiocytosis. The patient is a 75-year-old male who presented with 2 years of hypertension secondary to right renal artery occlusion incidentally found on cardiac catheterization. Open bilateral renal revascularization was performed because of improved long-term graft patency demonstrated in other forms of NARAD. Nine months postoperatively, the patient's hypertension was significantly improved and surveillance duplex demonstrated patent bilateral renal artery bypasses. Revascularization in patients with NARAD, such as ECD, should be managed in an open approach because of the superior long-term graft patency and blood pressure control in a disease where progression to vessel fibrosis and atherosclerosis could interfere with endovascular stent patency.