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ObjectiveWe sought to determine the effects of renal insufficiency on thoracic endovascular aortic repair (TEVAR) outcome and to identify predictors for adverse events.MethodsEighty-four patients with renal insufficiency (creatinine ≥1.5 mg/dL) were analyzed from a prospective TEVAR database from April 1, 1999, to January 1, 2008. Patients were subdivided into groups by creatinine level (mg/dL): group 1 (1.5-2.0), group 2 (2.0-3.0), group 3 (>3.0), and group 4 (preoperative dialysis-dependent). Demographics, aneurysm/aortic lesion characteristics, perioperative morbidity, mortality, and follow-up data were compared with 246 control patients (2.0 (odds ratio, 5.9; 95% confidence interval, 2.1-16.8; P = .001). Age, gender, adjunctive access, type of aortic pathology, and number of device components did not adversely affect outcome.ConclusionPatients with preoperative renal insufficiency maintain renal function after TEVAR. However, this patient population may be susceptible to increased adverse events, with emergency repair and baseline creatinine >2.0 mg/dL serving as strong predictors.

Objective: To determine whether there is a difference in outcome between endovascular repair of abdominal aortic aneurysm (EVAR) of small versus large aneurysms. Methods: A total of 192 patients from the Power-link trial were subdivided into small abdominal aortic aneurysms (AAA; ≤5 cm) and large AAA (>5 cm) groups. Demographics, perioperative morbidity, mortality, overall survival, and freedom from major adverse events, endoleak, aneurysm-related death, migration, and secondary procedures were assessed. Aneurysmal involvement of the iliacs as well as neck length and angulation was compared between groups. Results: Perioperative morbidity (P = 1.000), mortality (P = .4603), and extent of iliac involvement did not differ between groups (P = .2260). The necks in small AAA were longer (P = .0028) and less angulated (P < .0001). There was no difference in overall survival (P = .6066), freedom from major adverse events (P = .7842), endoleak, (P = .1832), migration (P = .5765), aneurysm-related death (P = .4728), or need for secondary procedures (P = .2323). Conclusion: Under controlled conditions of patient and device selection, there is no significant difference in outcome for EVAR of small versus large AAA.

The inhibitor of apoptosis protein survivin has long been of interest in the cancer literature for its role in both the regulation of cell proliferation and the inhibition of apoptosis. A growing body of literature has implicated survivin in the maladaptive pathways following vascular injury and, in particular, in the growth of vascular smooth muscle cells that comprise the hyperplastic neointimal lesions that characterize midterm vein bypass graft failure and restenosis following angioplasty and stenting. This review focuses on the emerging role of survivin in the regulation of smooth muscle cell growth and its implications for the prevention of restenosis following revascularization procedures. The expression, regulation, and function of survivin are addressed, as well as the current state of understanding regarding the effects of survivin inhibition in vitro and in vivo.

The development of thoracic endovascular aortic repair (TEVAR) has allowed a minimally invasive approach for management of an array of thoracic aortic pathologies. Initially developed specifically for exclusion of thoracic aortic aneurysms, TEVAR is now used as an alternative to open surgery for a variety of disease pathologies due to the lower morbidity of this approach. Advances in endograft technology continue to broaden the applications of this technique.

Objective Venous thromboembolism (VTE) is a potentially preventable complication following surgery. There is variation with regard to the most effective mode of prophylaxis. We sought to determine if an aggressive approach to VTE prophylaxis would reduce VTE rates on the inpatient vascular surgical service. Methods Vascular inpatients from a single institution from July 2010 to March 2013 were included in the analysis. A protocol for VTE prophylaxis was implemented on the inpatient vascular surgical service in November 2011. This included subcutaneous (SQ) heparin initiation within 24 h of admission unless deemed inappropriate by the attending, as well as intermittent compression devices (ICD) and compression stockings (CS). The rate of VTE was compared prior to and following the intervention. Patients were compared using AHRQ comorbidity categories, APR-DRG severity of illness, insurance status, and principle procedure. T-tests were used to compare continuous variables and chi-square analysis used to compare categorical variables. Results There were 1483 vascular patients in the pre-intervention group and 1652 patients in the post-intervention group. The rate of pharmacologic prophylaxis was 52.57% pre-intervention compared to 69.33% post-intervention ( p Conclusions The overall rate of VTE was reduced by 75% after the initiation of a standard protocol for pharmacologic VTE prophylaxis. These findings justify an aggressive approach to VTE prophylaxis in vascular surgery patients.

Retrievable inferior vena cava filters (IVCFs) left in place for a prolonged period can lead to complications including filter migration, fracture, and caval thrombosis. "Fall-back" techniques for IVCF retrieval that can be used when standard snaring is unsuccessful have been recently described. The purpose of this study was to analyze how incorporation of these new techniques affected the outcomes of IVCF retrievals at our institution during the past 5 years.Data were collected of all patients undergoing IVCF removal by vascular surgeons at a tertiary academic medical center between 2009 and 2013, including demographics and procedural and filter characteristics. A standard technique of snaring the retrieval hook was attempted first in all cases; if this was unsuccessful, a number of fall-back techniques were employed, including the use of endoscopic graspers, 18F sheaths, and snaring a second wire below the collar of the filter to collapse it into the sheath.IVCF retrieval was attempted in 275 patients; 3 were excluded intraoperatively because of thrombus in the filter. Most filters (97%) were Günther Tulips (Cook Medical, Bloomington, Ind); 70% had been placed prophylactically before bariatric surgery. A total of 268 filters (98.5%) were retrieved successfully, 213 (79%) by standard snaring and 55 (21%) with fall-back techniques. In patients undergoing fall-back techniques, technical success was achieved 100% of the time. The median time since insertion was significantly longer in the fall-back group (173 days vs 83 days; P.0001). Four intraoperative complications occurred; fractured wires embolized to the right atrium or pulmonary artery and were successfully removed endovascularly. The majority of the procedures (80%) were performed under sedation in both groups.Incorporation of fall-back techniques may allow 100% technically successful and safe removal of retrievable IVCFs and is especially useful in removing filters with prolonged dwell time.

Length of stay (LOS) is used as a quality metric to reduce cost and improve value of delivery of care. We sought to analyze trends in endovascular aortic aneurysm repair (EVAR) LOS at a tertiary academic institution over the last decade.A retrospective review of prospectively collected data was performed. Infrarenal EVARs from 2001 to 2013 were divided into 3 groups: group I (2001-2004), EVARs were performed as part of clinical trials; group II (2005-2008), EVARs were referred to a tertiary referral center with the most experience with EVAR; group III (2009-2013), EVARs were referred to academic institutions in the presence of severe patient comorbidities. Trends in LOS and correlation with severity of illness (SOI) as based on All Patient Refined Diagnosis Related Groups and admission and/or disposition status were analyzed. LOS index (LOSI) at our institution was then compared with University HealthSystem Consortium (UHC) Hospitals over the past 3 years.A total of 1,265 EVARs were performed during this time period: 325 in group I, 547 in group II, and 393 in group III. The median LOS was 4 days (inter quartile range [IQR], 2-6) vs. 3 days (IQR, 2-5) ± 0.28 vs. 4 days (IQR, 3-7), respectively (P0.01). Although moderate SOI was fairly constant over time (P = 0.66), major and/or extreme SOI constituted a greater proportion of patients in group I, was reduced in group II, and was again increased in group III, P0.01. The complication rate paralleled this pattern (group I, 15.2%; group II, 8.6%; group III, 10.4%; P = 0.02). The percentage of patients discharged to nursing home and/or rehab was 5.7% in group I, 8.2% in group II, 11.5% in group III (P = 0.03). Cases that were performed urgently and/or emergently increased over time: 11.6% in group I, 14.9% in group II, 21.6% in group III (P = 0.01). The risk-adjusted LOSI at our institution was significantly greater (1.25) when compared with UHC hospitals (0.75).Our study suggests a relationship between time period of EVAR, SOI, complications, admission status, and LOS. Attention to these trends could be used to decrease LOS in an increasingly complex patient population.

Successful surgical treatment of primary hyperparathyroidism requires the localization and excision of the parathyroid tissue responsible for excessive parathyroid hormone secretion while ensuring that the patient will have sufficient endogenous parathyroid hormone production to maintain eucalcemia. In selecting patients with primary hyperparathyroidism for unilateral parathyroidectomy the surgeon should be able to diagnose multiglandular disease either preoperatively or intraoperatively. We performed a retrospective review of 123 patients who underwent surgical treatment for primary hyperparathyroidism to determine the potential feasibility of selecting patients for minimally invasive surgery based on preoperative imaging studies. All patients were studied preoperatively with 99mtechnetium-sestamibi scintigraphy. High-resolution ultrasonography was performed in 119 of these patients. All patients except one underwent bilateral cervical exploration. A patient with an intrathoracic adenoma was successfully diagnosed by scintigraphy thereby allowing treatment by a limited thoracotomy. One hundred eight patients had solitary adenomas and 15 had multiglandular disease. In none of the patients with bilateral multiglandular disease were all abnormal glands localized preoperatively. Patients in our study with primary hyperparathyroidism and multiglandular disease were underdiagnosed by preoperative imaging. A minimally invasive approach based solely on preoperative imaging studies may result in treatment failure in patients with multiglandular involvement.

Background Some contend that gender differences in outcomes after lower extremity bypass (LEB) for peripheral arterial disease (PAD) relate to socioeconomic factors (SEFs). Here, we evaluate these disparities with attention to clinically relevant yet understudied SEF. Methods A retrospective cohort study of patients aged >50 y with PAD undergoing LEB was performed using data from Pennsylvania Health care and Cost Containment Council (2003–2011). Multivariable logistic regression modeling was performed to evaluate the association between gender and outcomes with adjustment for potential confounders including SEF such as income, insurance provider, distance to hospital, and race. Generalized estimating equations were used to adjust for hospital clustering. Independent models were developed to examine death or serious morbidity (DSM) and failure-to-rescue (FTR). Results Of 4202 patients identified, 1510 (36%) were women. SEF differed by gender. DSM was more frequent in women (15.6% versus 12.2%; P = 0.002). There was no association between gender and FTR in univariate analysis ( P = 0.49). SEFs were associated with DSM and FTR. After adjustment for potential confounders including SEF, women remained more likely to experience DSM (odds ratio = 1.28; P = 0.01). There remained no significant association between gender and FTR on independent modeling (odds ratio = 0.49; P = 0.11). Conclusions Women undergoing LEB in the state of Pennsylvania are at increased risk of poor outcomes, which is not completely explained by SEF. Quality of postoperative care does not appear to be different between gender as there was no difference in FTR. To improve these outcomes, efforts should be made to increase awareness of PAD and promote screening among high-risk women to ensure timely diagnosis and referral.

Objective Growing evidence suggests that peak wall stress (PWS) derived from finite element analysis (FEA) of abdominal aortic aneurysms (AAAs) predicts clinical outcomes better than diameter alone. Prior models assume uniform wall thickness (UWT). We hypothesize that inclusion of locally variable wall thickness (VWT) into FEA of AAAs will improve the ability to predict clinical outcomes. Methods Patients with AAAs (n=26) undergoing radiologic surveillance were identified. Custom MATLAB algorithms generated UWT and VWT aortic geometries from CTA images, which were subsequently loaded with systolic blood pressure using FEA. PWS and aneurysm growth (as a proxy for rupture risk and the need for repair) were examined. Results The average radiologic follow-up time was 22.0±13.6 months and the average aneurysm growth rate was 2.8±1.7 mm/year. PWS in VWT models significantly differed from PWS in UWT models (238±68 vs 212±73 kPa, P=0.025). In our sample, initial aortic diameter was not found to be correlated with aneurysm growth (r=0.26, P=0.19). A stronger correlation was found between aneurysm growth and PWS derived from VWT models as compared to PWS from UWT models (r=0.86 vs r=0.58, P=0.032 by Fisher’s r to Z transformation). The three panels in the figure demonstrate the correlation between aneurysm growth rate and (1) initial diameter, (2) PWS using UWT model, and (3) PWS using VWT model, respectively. Conclusion The inclusion of locally variable wall thickness significantly improved the correlation between PWS and aneurysm growth. Aortic wall thickness should be incorporated into future FEA models to accurately predict clinical outcomes.

We aimed to determine the optimal positioning of the interventionalist with regard to radiation exposure during endovascular aneurysm repairs (EVAR). The radiation absorption of two vascular surgeons and one trainee was prospectively monitored during a series of 10 routine EVARs. Position of the two vascular surgeons varied: surgeon A stood adjacent to the trainee and one person down from the image intensifier (II), whereas surgeon B stood directly across from the trainee at the same level as the II. Surgeon A absorbed significantly less mean body (0.004 mSv versus 0.036 mSv; P = 0.001), eye (0.036 versus 0.222 mSv; P < 0.001) and extremity (0.034 versus 0.212 mSv; P < 0.001) radiation doses compared with surgeon B and also had significantly lower doses of absorbed body (0.004 versus 0.04 mSv; P = 0.047), eye (0.036 versus 0.25 mSv; P = 0.043) and extremity (0.034 versus 0.248 mSv; P = 0.05) radiation relative to the trainee. In conclusion, there is considerable variation in radiation absorption due to the position of the interventionalist relative to the II and other operators. Although positioning of the operator next to the trainee may make it more difficult to assist and teach technical maneuvers, it greatly minimizes radiation exposure to the interventionalist.

ObjectiveTo explore the incidence, predictors, and outcomes of hemodynamic instability (HI) following carotid angioplasty and stenting (CAS).MethodsWe retrospectively evaluated data on 257 CAS procedures performed in 245 patients from 2002 to 2011 at a single institution. The presence of periprocedural HI, as defined by hypertension (systolic blood pressure >160 mm Hg), hypotension (systolic blood pressure

Background Variations in the intima-media thickness (IMT) of the carotid artery during the cardiac cycle are well established. The change in femoral IMT during the cardiac cycle is largely unknown. This study focuses on the variation of femoral IMT, vessel diameter, and cross-sectional area (CSA) of the IMT during the cardiac cycle. Methods Video clips of the femoral artery were obtained using B-mode ultrasonography in 60 patients between the ages of 18 and 50. IMT and diameter measurements were made using automated software, and CSA was subsequently calculated. Triplicate measurements of each femoral artery were made at three points in the cardiac cycle: the R wave, the T wave, and at the point of maximal vessel diameter falling after the T wave and before the following P wave. Results Femoral IMT, diameter, and CSA did not show a statistically significant difference with measurement on the R versus the T wave (P > 0.36, P > 0.28, and P > 0.76, respectively). Interestingly, when comparing measurements on the R or T wave with measurements taken at the maximum vessel diameter, there was a statistically significant difference in vessel diameter (P 0.2). Conclusions Unlike studies of the carotid artery, there were no statistically significant differences between measurements made at the R versus the T wave. There were, however, statistically significant differences noted in diameter and CSA when measurements were taken at a point later in the cardiac cycle. This has ramifications for future studies on vascular remodeling.

Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.

Objective The objective of this study was to examine the results of thoracic endovascular aneurysm repair (TEVAR) for chronic descending thoracic aortic (DTA) dissections with aneurysmal degeneration. Methods Over 70 months at a single institution, 27 patients underwent TEVAR for aneurysms related to chronic (>6 weeks) DTA dissections. Results Mean patient age was 67.5 ± 9.6 years; 18 were men. Primary indications for repair were aneurysm size (n = 20), rapid aneurysmal growth (n = 5), saccular aneurysm (n = 1), and rupture (n = 1). Preoperative false lumen status was patent in 18 patients, partially thrombosed in 8 patients, and unknown in the patient whose aneurysm ruptured. The proximal entry tear was covered in all 27 patients. Fourteen patients required coverage of the left subclavian artery, of which 9 patients underwent prophylactic revascularization. On completion angiogram, no patient had antegrade perfusion of the aneurysmal false lumen. There were three procedural complications: 2 patients sustained paraparesis (one resolved and one improved), and 1 patient had an access injury requiring stent graft placement. Thirty-day mortality was 3.7% (1 of 27); the one death was in the patient whose aneurysm ruptured. Of the 26 surviving patients, 23 (88.5%) had thrombosis of the aneurysmal false lumen. Twenty-two patients (84.6%) had stability or decrease in maximal aneurysm diameter on last radiographic follow-up at 18 ± 20 months. Three-year Kaplan-Meier survival was 90.3% ± 6.5% in the 26 patients who survived to hospital discharge, with a mean follow-up of 27.3 ± 22.1 months. In patients with preoperatively partially thrombosed false lumens (n = 8), 3-year survival was 100%. Conclusions TEVAR for aneurysms due to chronic dissections of the DTA can be performed safely and effectively at midterm follow-up according to this single-institution study. Stent graft therapy may be of particular benefit in patients presenting with partially thrombosed false lumens.

Objectives: To report a series of patients following thoracic endovascular aortic repair (TEVAR) presenting with rupture, who were effectively treated with TEVAR relining. Methods: Five patients who underwent repeat TEVAR in an urgent fashion were identified. Chart review was performed to identify demographics, device type, aneurysm characteristics, and postoperative course. Results: Mean time to relining procedure was 5.8 (range 2-10) years. All patients had ≥3 device components originally placed. Mean size of the original aneurysm was 7.2 cm (range 6.6-8). All patients underwent relining with proximal and distal extension with immediate technical success. At a mean follow-up of 1.3 years, there was no evidence of endoleak and no patients required repeat intervention. Conclusions: Complete relining with proximal and distal extension was effective in treating patients presenting with rupture. These findings suggest that proximal and distal landing zones provided, relining should be considered the initial management strategy in patients s/p TEVAR re-presenting with rupture

Objective The purpose of this study was to assess the incidence, risk factors, and clinical manifestations of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods A retrospective review of a prospectively collected database was performed for all patients undergoing TEVAR at a single academic institution between July 2002 and June 2010. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. Logistic regression analysis was performed to identify risk factors for the development of SCI. Results Of the 424 patients who underwent TEVAR during the study period, 12 patients (2.8%) developed SCI. Mean age of this cohort with SCI was 69.6 years (range, 44-84 years), and 7 were women. One-half of these patients had prior open or endovascular aortic repair. Indication for surgery was either degenerative aneurysm (n = 8) or dissection (n = 4). Six TEVARs were performed electively, with the remaining done either urgently or emergently due to contained rupture (n = 2), dissection with malperfusion (n = 2), or severe back pain (n = 2). All 12 patients underwent extent C endovascular coverage. Multivariate regression analysis demonstrated chronic renal insufficiency to be independently associated with SCI (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.2-16.6; P = .029). Onset of SCI occurred at a median of 10.6 hours (range, 0-229 hours) postprocedure and was delayed in 83% (n = 10) of patients. Clinical manifestations of SCI included lower extremity paraparesis in 9 patients and paraplegia in 3 patients. At SCI onset, average mean arterial pressure (MAP) and lumbar cerebrospinal fluid (CSF) pressure was 77 mm Hg and 10 mm Hg, respectively. Therapeutic interventions increased blood pressure to a significantly higher average MAP of 99 mm Hg (P = .001) and decreased lumbar CSF pressure to a mean of 7 mm Hg (P = .30) at the time of neurologic recovery. Thirty-day mortality was 8% (1 of 12 patients). The single patient who expired, never recovered any lower extremity neurologic function. All patients surviving to discharge experienced either complete (n = 9) or incomplete (n = 2) neurologic recovery. At mean follow-up of 49 months, 7 of 9 patients currently alive continued to exhibit complete, sustained neurologic recovery. Conclusion Spinal cord ischemia after TEVAR is an uncommon, but important complication. Preoperative renal insufficiency was identified as a risk factor for the development of SCI. Early detection and treatment of SCI with blood pressure augmentation alone or in combination with CSF drainage was effective in most patients, with the majority achieving complete, long-term neurologic recovery.

Frailty Increases Risk of Mortality After Elective Abdominal Aortic Aneurysm (AAA) Repair Independent of Age and Comorbidity Status Sung I. Kim, Yazan Duwayri, Luke P. Brewster, Ravi Veeraswamy, Atef Salam, Thomas Dodson, Shipra Arya. Emory University Rollins School of Public Health, Atlanta, Ga; Emory University School of Medicine Division of Vascular Surgery, Atlanta, Ga; Atlanta VA Medical Center, Decatur, Ga

Objectives Reducing rehospitalization rates has been proposed to improve care, reduce costs, and as a pay-for-performance criterion. Recent review of Medicare claims data indicates that vascular surgery patients have among the highest rates of 30-day rehospitalization at 23.9%. Methods We retrospectively examined all live patient discharges (n = 799) from the vascular surgery service at a single university hospital over 12 months. Planned and unplanned 30-day rehospitalizations were distinguished, and predictors of unplanned 30-day rehospitalization were determined. To identify whether patients were readmitted to other hospitals, a prospective study of patient discharges (n = 66) over 1 month was also performed. Results Ninety-five (11.9%) of the 799 patient discharges from the vascular surgery service were rehospitalized within 30 days. Of these, 71 were unplanned; therefore, the unplanned rehospitalization rate was 8.9%. The most common causes of unplanned 30-day rehospitalization were related to wound complications. Diabetes (P = .039) predicted unplanned 30-day rehospitalization by multivariate analysis. Patients with the diagnosis of critical limb ischemia (14.9%) and patients undergoing open lower extremity revascularization (14.6%) had the highest rates of unplanned 30-day rehospitalization. In the prospective portion of this study, no patient was readmitted to any other hospital. Conclusions Relatively low 30-day rehospitalization was accomplished in vascular surgery patients at a single university hospital. Moreover, planned rehospitalizations accounted for approximately 25% of readmissions in vascular surgery patients. Strategies designed to reduce rehospitalization in diabetics may be warranted.

Objective To determine the results of simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR). Methods Records were retrospectively reviewed. Eight patients underwent simultaneous TEVAR and EVAR between 1999 and 2010 at a single center. All patients had concomitant thoracic and abdominal aortic disease (aneurysms, penetrating aortic ulcers). Ranges for the thoracic and abdominal aneurysm diameters were 6.0 to 9.1 cm and 5.0 to 7.6 cm, respectively. Four patients were treated emergently, and the remainder had indications for simultaneous repair. The mean age was 72 years (six males). All patients had significant comorbidities. Results Average procedural time was 173 minutes ± 25 minutes. Spinal drainage and neuromonitoring was used in all cases. Thoracic endovascular aortic repair (TEVAR) was performed prior to EVAR. Three patients required left subclavian coverage and four patients had full coverage of the thoracic aorta. Only one patient had internal iliac artery (unilateral) coverage. One patient was lost to follow-up 6 weeks following discharge. The remainder were followed between 4 and 77 months postoperatively. No patients developed acute myocardial infarction, acute renal failure, or neurologic complications, including permanent paralysis or stroke. One patient developed transient lower extremity weakness that resolved with blood pressure augmentation. Mean blood loss was 325 mL ± 137 mL. The average intensive care unit and hospital stay was 3 days and 8 days, respectively. In follow-up, one patient developed a type II endoleak that was successfully embolized. Conclusion Combined TEVAR and EVAR can be performed successfully with minimal morbidity and mortality. In particular, in this limited series of eight patients, there have been no occurrences of lower extremity paralysis or renal failure despite a high proportion of emergent cases. When anatomically feasible, simultaneous TEVAR and EVAR can be considered as a viable alternative to staged or hybrid repair.

Thoracic endovascular aortic repair (TEVAR) is an important surgical option for the emergency treatment of ruptured thoracic aortic aneurysms, but is associated with a risk of spinal cord ischemia (SCI). Although risk factors for the development of SCI have been well described, the effectiveness of treatment to increase spinal cord perfusion pressure remains incompletely understood. We report the successful treatment of delayed-onset paraparesis after revision TEVAR for acute descending thoracic aortic rupture with the combined use of blood pressure augmentation and cerebrospinal fluid drainage. The clinical manifestations, pathophysiology, and management of SCI after TEVAR are reviewed.

ObjectivesThe purpose of this study was to examine the fate of aneurysmal iliac arteries managed during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA).MethodsWe analyzed data from the Cook Zenith trial. Follow-up was at 1 month, 6 months, 12 months, and then annually for 5 years. Patients were evaluated according to the largest iliac artery diameter: group A (≥20 mm) and group B (

Behçet’s disease is a chronic, relapsing multisystemic inflammatory disorder characterized by recurrent orogenital aphthous ulcers, uveitis, and skin lesions. Vascular involvement occurs in up to 38% of these patients. Herein, we report a 19-year-old male who initially presented with an isolated celiac artery aneurysm that was treated with open surgical repair. The patient was subsequently diagnosed with Behçet’s disease after the development of oral aphthous ulcers and multiple recurrent postoperative deep venous thromboses and thoracoabdominal arterial aneurysms. Ultimately, a hybrid approach was undertaken. This is the fifth celiac artery aneurysm ever reported in this patient group and the first to present with an isolated celiac artery aneurysm as the initial manifestation of Behçet’s disease.

Thoracic endovascular aortic repair has become the preferred modality for the treatment of diverse aortic pathologies of the thoracic aorta. This report is the first to describe the use of 2 different devices for successful exclusion of a dissecting thoracic aneurysm.

The objective of this study is to describe a single-center experience of caval thrombectomy in patients with renal cell carcinoma (RCC) and tumor thrombus extension into the inferior vena cava (IVC). We retrospectively reviewed 23 patients undergoing radical nephrectomy with caval thrombectomy. Follow-up included an office visit and computed tomography scan. Statistical comparisons were made using 2-sample t tests. Patients' ages ranged from 32 to 83 years (mean, 62 years; 18 male, 5 female). Tumor size ranged from 3 to 21 cm (mean, 8.6 cm). Tumor thrombus staging was based on the Nevus classification: level I (2/23), II (6/23), III (13/26), IV (2/23). Tumor thrombi were removed by means of digital extraction (20), Fogarty embolectomy (2), or endarterectomy (1-caval wall invasion). Lateral venorrhaphy was used for IVC repair in all cases. Hepatic mobilization and suprahepatic clamping were necessary in 14 patients. Clamp times were significantly different between the suprahepatic (SH) and infrahepatic (IH) groups (15 vs 9.4 minutes, P < .012). Mean blood loss was also significantly different (3.2 L vs 2 L, P < .045). In the SH group, 2 patients developed postoperative atrial fibrillation and 2 patients died (respiratory failure; missed enterotomy). The IH group had no perioperative morbidity or mortality. Median followup was 15 months (range, 1—54 months). Follow-up imaging was available for 19/23 patients. Ninety-five percent of patients had a patent IVC (18). One SH patient developed an IVC stenosis/thrombosis 12 months postoperatively with successful thrombolysis and stenting. There was a 16% (3/19) recurrence rate in follow-up, with all patients demonstrating renal vascular invasion and high Fuhrman grade upon final pathologic evaluation. Caval thrombectomy can be performed safely during radical nephrectomy for RCC with tumor thrombus extension. The need for suprahepatic clamping is associated with longer clamp times, increased blood loss, and increased morbidity and mortality. Lateral venorrhaphy with primary repair avoids complicated caval reconstructions and results in high patency rates, despite a not insignificant recurrence rate.

Background Survivin (SVV) is a unique inhibitor of apoptosis protein (IAP) that regulates both apoptosis and mitosis. Recent work suggests that SVV plays a critical role in the vascular injury response, but the molecular pathways remain unclear. Methods We examined the expression of SVV and the transcription factor, KLF5, in human venous smooth muscle cells (VSMC) by semi-quantitative reverse transcriptase polymerase chain reaction (RT-PCR) and Western blot analysis after treatment with angiotensin II (Ang II) or tumor necrosis factor-α (TNF-α). An adenoviral construct expressing SVV or GFP was also employed to assess effects on KLF5 expression. A rabbit carotid interposition vein graft model was used to assess the relevance of KLF5 to bypass graft healing. Results Stimulation of VSMC with Ang II and TNF-α led to a rapid upregulation of KLF5 expression, and a later increase in SVV, which was cell-cycle independent. Overexpression of SVV in VSMC led to an early and persistent induction of KLF5. KLF5 was upregulated in rabbit vein grafts early (1 day) after grafting. Conclusions We speculate that SVV is a central point of convergence of multiple signaling pathways in vascular injury, and that it regulates the local amplification of these pathways in the vessel wall.

Objective— Survivin (SVV) is an inhibitor of apoptosis protein (IAP) that is upregulated in cancer and has recently been implicated in vascular injury. We sought to investigate the role of SVV in vein graft hyperplasia. Methods and Results— Adenoviral constructs expressing a dominant-negative (AdT34A) and wild-type (AdWT) SVV were used. Proliferation and apoptosis were assayed on endothelial cells (ECs) and smooth muscle cells (SMCs) from human saphenous vein. A rabbit carotid interposition vein graft model (N=31) was used, with adventitial gene transfer of SVV constructs. In vitro, overexpression of SVV was associated with protection from cytokine-induced apoptosis in ECs and SMCs; conversely, AdT34A directly induced apoptosis in these cells. SMC proliferation was increased by AdWT infection, whereas AdT34A reduced proliferation; both effects were serum-dependent. Expression of platelet-derived growth factor (PDGF) in SMCs was regulated by functional SVV expression in analogous fashion. In vivo, proliferation and apoptosis (7 days), as well as wall thickness (30 days), were modified by adenoviral-mediated SVV expression. Adventitial angiogenesis was regulated by the SVV-expressing constructs in a fashion parallel to wall thickness changes. Conclusions— SVV is a critical regulator of multiple processes, including proliferation, apoptosis, and angiogenesis, that determine the remodeling response of vein grafts following arterialization.

ObjectiveGrowing evidence suggests that peak wall stress (PWS) derived from finite element analysis (FEA) of abdominal aortic aneurysms (AAAs) predicts clinical outcomes better than diameter alone. Prior models assume uniform wall thickness (UWT). We hypothesize that the inclusion of locally variable wall thickness (VWT) into FEA of AAAs will improve its ability to predict clinical outcomes.MethodsPatients with AAAs (n = 26) undergoing radiologic surveillance were identified. Custom MATLAB algorithms generated UWT and VWT aortic geometries from computed tomography angiography images, which were subsequently loaded with systolic blood pressure using FEA. PWS and aneurysm expansion (as a proxy for rupture risk and the need for repair) were examined.ResultsThe average radiologic follow-up time was 22.0 ± 13.6 months and the average aneurysm expansion rate was 2.8 ± 1.7 mm/y. PWS in VWT models significantly differed from PWS in UWT models (238 ± 68 vs 212 ± 73 kPa; P = .025). In our sample, initial aortic diameter was not found to be correlated with aneurysm expansion (r = 0.26; P = .19). A stronger correlation was found between aneurysm expansion and PWS derived from VWT models compared with PWS from UWT models (r = 0.86 vs r = 0.58; P = .032 by Fisher r to Z transformation).ConclusionsThe inclusion of locally VWT significantly improved the correlation between PWS and aneurysm expansion. Aortic wall thickness should be incorporated into future FEA models to accurately predict clinical outcomes.Clinical RelevanceThere is growing evidence in the literature suggesting that peak wall stress derived from finite element analysis of abdominal aortic aneurysms is a superior predictor of clinical outcomes compared with traditional maximum diameter measurements. Almost all biomechanical analyses to date assume an aortic wall of uniform thickness. In this study, the inclusion of a variable wall thickness aortic wall into finite element studies not only significantly altered calculated peak wall stress, but it also improved its correlation to the clinically relevant outcome of aneurysm growth. These results suggest that stress analysis-derived rupture risk stratification may be further improved using variable wall thickness aortic reconstructions.

Objective The purpose of this study was to describe the results of an alternative technique for inferior vena cava filter (IVCF) retrieval that can be used when the retrieval hook cannot be snared. Methods Retrospective review of all patients undergoing attempted IVCF retrieval by a single surgeon between March 2009 and March 2011 was undertaken. After December 2009, in cases where the retrieval hook could not be snared, an 18F/85 cm sheath was inserted into the internal jugular vein and a Bentson wire (Cook Medical, Bloomington, Ind) and snare were advanced across separate interstices of the filter. The resulting "lasso" was pulled up below the collar at the top of the filter, and the filter collapsed into the sheath. Results Over 28 months, 34 patients underwent attempted retrieval of Gunther Tulip filters (Cook Medical). Patients were 44 ± 15 years old; 59% were women (n = 20). Filters were placed for venous thromboembolism with contraindication to anticoagulation in seven cases and prophylactically in 27 cases. Of the prophylactic cases, 18 (67%) were placed before planned bariatric surgery. Before December 2009, the success rate was 86% (6 of 7): the retrieval hook of one filter could not be snared and seemed to be embedded in the wall of the cava. After adoption of the described technique, the success rate was 96% (26 of 27): one patient refused further attempts at central venous catheterization after multiple unsuccessful attempts. Filters retrieved conventionally by snaring the hook (n = 18) were implanted on average for 4.8 ± 3.7 months and 12.1 ± 10.1 months for those retrieved using the new technique (n = 14; P = .02). All patients were discharged on the day of the procedure without complication. The one patient in whom the retrieval hook could not be snared before December 2009 has refused another attempt at retrieval. Conclusions The method of IVCF retrieval described here was successful in every instance in which it was attempted. It was associated with no morbidity despite the customary use of an 18F sheath in the internal jugular vein. The approach constitutes an appropriate "fall-back" technique when the retrieval hook of a removable IVCF cannot be snared.