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Endovascular therapy is first-line treatment for aortoiliac occlusive disease. This shift has altered case volume, patient selection, and risk profile for aortobifemoral bypass (ABF). Given this, we sought to investigate factors influencing morbidity and mortality after ABF in the endovascular era.Data for patients undergoing primary ABF from 2000 to 2017 were queried. Primary endpoints included major complication (unplanned return to the operating room, life-or-limb-threatening complications, and 30-day readmission or death) and long-term survival. Logistic regression and Cox proportional hazard models determined predictors of primary endpoints. Kaplan-Meier analysis estimated patency, freedom from reintervention, and long-term survival.During these 17 years, 256 patients underwent primary ABF. Mean age was 67.9 ± 10.6 years and 51.2% were women. Most had claudication (69.5%); 28.9% had critical ischemia. Sixty-five (25.4%) patients had prior aortoiliac endovascular intervention, 106 (41.4%) required aortic cuff endarterectomy, 111 (43.3%) femoral outflow adjunct, 9 (3.5%) simultaneous lower extremity bypass, and 230 (89.8%) had Trans-Atlantic Inter-Society Consensus D lesions. Concomitant renovisceral revascularization was needed in 42 (16.4%) patients. Thirty-day mortality was 2.7%. Major complication occurred in 92 patients (35.9%). Predictors included prior endovascular intervention (odds ratio [OR], 2.2; 95% confidence interval [CI]: 1.2-4.1; P = 0.01), malignancy (OR, 2.6; 95% CI: 1.3-5.3; P = 0.01), intraoperative complication (OR, 3.3; 95% CI: 1.3-9.2; P = 0.03), operative blood loss, (OR, 1.0 per 100 ml; 95% CI: 1.0-1.0; P = 0.03), and cuff endarterectomy (OR, 1.8; 95% CI: 1.0-3.1; P = 0.04). Median follow-up was 5.3 years (interquartile range: 7.2 years). Survival at 1, 3, and 5 years was 94%, 90%, and 82% respectively. Primary patency and freedom from reintervention at 5 years were 76% and 79%, respectively. Predictors of late mortality included malignancy (hazard ratio [HR], 2.3; 95% CI: 1.3-3.9; P 0.01), chronic obstructive pulmonary disease (HR, 1.8; 95% CI: 1.1-3.1; P = 0.02), congestive heart failure (HR, 2.3; 95% CI: 1.2-4.3; P = 0.01), Rutherford's class (HR, 1.5; 95% CI: 1.1-2.1; P = 0.01), operative blood loss (HR 1.0 per 100 ml; 95% CI: 1.0-1.0; P = 0.04) and chronic kidney disease (HR, 2.3; 95% CI: 1.2-4.2; P = 0.01).Although late outcomes after ABF in the contemporary era remain acceptable, major complications are frequent. Operative complexity and prior endovascular revascularization predict complications. Long-term survival is driven by degree of limb ischemia and comorbidities. These should be considered in selection for ABF, potentially modifying approach to improve outcomes.

ObjectiveCancer screening should be equitably accessed by all populations. Uptake of colorectal cancer screening was examined using the Scottish Health and Ethnicity Linkage Study that links the Scottish Census 2001 to health data by individual-level self-reported ethnicity and religion.SettingData on 1.7 million individuals in two rounds of the Scottish Bowel Cancer Screening Programme (2007–2013) were linked to the 2001 Census using the Scottish Community Health Index number.Main outcome measureUptake of colorectal cancer screening, reported as age-adjusted risk ratios (RRs) by ethnic group and religion were calculated for men and women with 95% CI.ResultsIn the first, incidence screening round, compared with white Scottish men, Other White British (RR 109.6, 95% CI 108.8 to 110.3) and Chinese (107.2, 95% CI 102.8 to 111.8) men had higher uptake. In contrast, men of all South Asian groups had lower uptake (Indian RR 80.5, 95% CI 76.1 to 85.1; Pakistani RR 65.9, 95% CI 62.7 to 69.3; Bangladeshi RR 76.6, 95% CI 63.9 to 91.9; Other South Asian RR 88.6, 95% CI 81.8 to 96.1). Comparable patterns were seen among women in all ethnic groups, for example, Pakistani (RR 55.5, 95% CI 52.5 to 58.8). Variation in uptake was also observed by religion, with lower rates among Hindu (RR (95%CI): 78.4 (71.8 to 85.6)), Muslim (69.5 (66.7 to 72.3)) and Sikh (73.4 (67.1 to 80.3)) men compared with the reference population (Church of Scotland), with similar variation among women: lower rates were also seen among those who reported being Jewish, Roman Catholic or with no religion.ConclusionsThere are important variations in uptake of bowel cancer screening by ethnic group and religion in Scotland, for both sexes, that require further research and targeted interventions.

Despite advancements, aortofemoral bypass (AFB) remains the most durable option for aortoiliac occlusive disease. Although runoff has been shown to be associated with AFB patency, the association of the Society for Vascular Surgery (SVS) thigh runoff scoring system with patency has not been assessed. The aim of the present study was to evaluate the association between the SVS runoff scoring system and limb-based primary patency after AFB.Institutional data for patients undergoing AFB with preoperative runoff imaging available from 2000 to 2017 were queried. Runoff scores were assigned according to the presence of occlusive disease in the superficial femoral artery and profunda femoris artery (minimum, 1; maximum, 10) as described by the 1997 SVS reporting standards for lower extremity ischemia. Limb-based patency was the primary endpoint. Kaplan-Meier analysis was used to compare the long-term limb-based patency and freedom from reintervention between limbs with runoff scores ≥6 and those with runoff scores 6. Propensity score-weighted Cox proportional hazards modeling was used to evaluate the association between a runoff score of ≥6 and primary patency loss, controlling for other factors associated with primary patency.In 161 patients, 316 limbs had undergone revascularization. The mean patient age was 66.7 ± 11.3 years, and 51.6% were women. Most limbs had undergone revascularization for claudication (56.5%). Most (89.4%) had TransAtlantic InterSociety Consensus class D lesions, 27.3% had required suprarenal or higher clamping, and 11.2% had undergone concomitant mesenteric intervention. A femoral outflow adjunct and concurrent lower extremity bypass was required in 41.8% and 2.9% of limbs, respectively. Those with a runoff score of ≥6 had experienced greater rates of 30-day myocardial infarction (11% vs 1%; P = .005), respiratory failure (11% vs 1%; P = .005), and mortality (8% vs 0%; P ≤ .006). The median follow-up period was 4.0 years (interquartile range, 6.5 years). The 1-, 3-, and 5-year primary patency was 94.6% (95% confidence interval [CI], 91.9%-97.3%), 89.2% (95% CI, 85.4%-93.2%), and 81.4% (95% CI, 76.0%-87.1%), respectively. The 5-year primary-assisted patency, secondary patency, and freedom from reintervention were 84.9% (95% CI, 79.7%-90.5%), 91.7% (95% CI, 87.3%-96.3%), and 83.3% (95% CI, 78.3%-88.7%), respectively. Patients with a runoff score of ≥6 had lower primary (log-rank P .01), primary-assisted (P .01), and secondary patency (P = .01). The factors associated with the loss of primary patency included a high runoff score (runoff score of ≥6: hazard ratio [HR], 4.1; 95% CI, 2.1-8.0; P .01), simultaneous mesenteric endarterectomy (HR, 13.5; 95% CI, 1.9-97.8; P = .01), and chronic kidney disease (HR, 4.6; 95% CI, 1.5-14.6; P = .01). Increasing age (HR, 0.94 per year; 95% CI, 0.91-0.97; P .01) and hyperlipidemia (HR, 0.44; 95% CI, 0.23-0.85; P = .01) were protective.The SVS femoral runoff score is an important factor associated with long-term AFB limb patency. Scores of ≥6 portend for worse limb outcomes and a greater incidence of operative complications. The SVS score can be determined from preoperative axial imaging studies and serve as a guide in decision-making and operative planning.

Despite endovascular advancements, aortofemoral bypass (AFB; aortounifemoral and aortobifemoral bypass) remains the most durable option for aortoiliac occlusive disease. Whereas AFB reduces vascular aortoiliac reintervention, the impact of laparotomy-associated and groin wound complications on morbidity and reintervention is unclear. The aim of this study was to establish the incidence of nonvascular complications after AFB and to determine their effect on reintervention.Institutional data for AFB (2000-2017) were queried. Primary end points included laparotomy-associated and groin wound complications. Total reintervention was defined as the composite outcome of reinterventions for laparotomy and groin wound complications and graft patency. Kaplan-Meier analysis estimated freedom from reintervention. Fine-Gray method for competing long-term risk determined predictors of laparotomy complications. Logistic regression, adjusting variability for patient-level clustering, determined predictors of wound complications.There were 553 limbs in 281 patients (272 aortobifemoral and 9 aortounifemoral bypasses; age, 67.6 ± 11.0 years; 50.5% female). Ninety (32%) patients had prior abdominal surgery, 3.2% had prior ventral hernia (VH) repair, 2.9% had untreated VH, and 0.7% had history of small bowel obstruction. The majority of patients underwent AFB for claudication (66.2%); 87.2% had TransAtlantic Inter-Society Consensus (TASC) D lesions, 31.4% required a suprarenal clamp or higher, 16.4% had concomitant renovisceral revascularization, and 6.4% were receiving anticoagulation. Sixty-seven (12.1%) limbs had redo femoral artery exposures, 32.4% required femoral outflow adjunct, and 1.8% had simultaneous lower extremity bypass. The 30-day mortality was 2.9%. During median follow-up of 5.3 years (interquartile range, 7.3 years), 21% had laparotomy complications (VH, 15.3%; small bowel obstruction, 7.5%; other, 2.1%), including 10.0% requiring operative intervention. Sixty-seven (12%) groins had a wound complication; 4.9% required intervention. Unadjusted 1-, 3-, and 5-year freedom from graft reintervention was 93.3% (95% confidence interval [CI], 90.1%-96.5%), 85.3% (80.7%-90.2%), and 79.6% (74.1%-85.5%), respectively. Freedom from total reintervention at 1 year, 3 years, and 5 years was 82.1% (95% CI, 77.4%-87.1%), 73.6% (68.0%-79.6%), and 65.1% (58.7%-72.2%). Predictors of laparotomy complications were untreated VH (P = .01) and hypertension (P = .01). Protective factors were thoracoabdominal approach (P .01) and aortounifemoral bypass (P .01). Predictors of wound complications included body mass index (per kg, 1.07; CI, 1.01-1.15; P = .018), anticoagulation (2.59; CI, 1.01-8.37; P = .049), and previous iliac stents (2.60; CI, 1.36-4.94; P = .004).Whereas AFB is a durable reconstruction with infrequent need for graft reintervention, laparotomy- and groin wound-associated complications contribute significantly to morbidity and reintervention after AFB. Predictive factors for laparotomy and groin wound complications should be considered in preoperative planning and selection of patients for AFB and in the discussion of outcomes.

Objective Concomitant carotid bifurcation and proximal ipsilateral arch branch disease is uncommon. A combined approach using carotid endarterectomy (CEA) with ipsilateral proximal endovascular (IPE) intervention (CEA+IPE) has been proposed as safe and durable, with similar results to isolated CEA. This study was conducted to identify diagnostic modalities and outcomes of this uncommon procedure at our institution. Methods Operative records were used to identify patients who underwent CEA+IPE between May 2003 and July 2014. Patients were excluded if they underwent open retrograde access for endovascular intervention only, without CEA. The primary end points were freedom from neurologic event and need for reintervention. Results Twenty-three patients (15 women [65%]) underwent CEA+IPE. Mean clinical follow-up was 44 ± 35 months. Average age was 69 ± 9 years. Most patients (22 [96%]) were taking a statin and at least one antiplatelet agent. Bilateral internal carotid stenosis (>50%) was present in 12 patients (52%), and eight (35%) were symptomatic. Seven patients (30%) had prior ipsilateral CEA. All patients underwent preoperative carotid duplex and axial imaging. Computed tomography angiography was the initial imaging assessment in 10 patients (43%). The proximal lesion was identified in 19 (83%) by blunted waveforms on carotid duplex. Most bifurcation operations were CEA with patch (20 [87%]), and 21 (91%) underwent the bifurcation procedure first, followed by IPE. All IPE included balloon-expandable stenting (22 of 23 [96%] bare-metal, 7 [30%] innominate artery, 16 [70%] left common carotid artery). Electroencephalographic changes occurred in two patients (9%). Shunting was used in three (13%). Three vessel dissections (13%) occurred at the IPE site; two required further stenting and one was complicated by stroke and death. There were two perioperative strokes (9%) and one death (4%). Mean imaging follow-up was 30.6. ± 27.2 months, with restenosis identified in five patients (23%; four bifurcation, one IPE in-stent). One patient required open reintervention with subclavian-carotid bypass at 13 months for recurrent transient ischemic attack. The 4-year actuarial survival was 85%. Stroke-free survival and freedom from reintervention were 80% and 90% at 36 months, respectively. Conclusions The stroke and death rate for CEA+IPE is higher than that of isolated CEA at our institution. Duplex findings can suggest proximal stenosis; however, confirmation with physical examination in conjunction with axial imaging are integral. This combined treatment strategy should be reserved for those with evident hemodynamically significant proximal stenosis and approached with caution in asymptomatic patients.

We describe a novel Solid-phase Reversible Sample-Prep (SRS) platform, which enables rapid sample preparation for concurrent proteome and N-glycome characterization by mass spectrometry. SRS utilizes a uniquely functionalized, silica-based bead that has strong affinity toward proteins with minimal-to-no affinity for peptides and other small molecules. By leveraging the inherent size difference between, SRS permits high-capacity binding of proteins, rapid removal of small molecules (detergents, metabolites, salts, etc.), extensive manipulation including enzymatic and chemical treatments on beads-bound proteins, and easy recovery of N-glycans and peptides. The efficacy of SRS was evaluated in a wide range of biological samples including single glycoprotein, whole cell lysate, murine tissues, and human urine. To further demonstrate the SRS platform, we coupled a quantitative strategy to SRS to investigate the differences between DU145 prostate cancer cells and its DIAPH3-silenced counterpart. Our previous studies suggested that DIAPH3 silencing in DU145 prostate cancer cells induced transition to an amoeboid phenotype that correlated with tumor progression and metastasis. In this analysis we identified distinct proteomic and N-glycomic alterations between the two cells. Intriguingly, a metastasis-associated tyrosine kinase receptor ephrin-type-A receptor (EPHA2) was highly upregulated in DIAPH3-silenced cells, indicating underling connection between EPHA2 and DIAPH3. Moreover, distinct alterations in the N-glycome were identified, suggesting a cross-link between DIAPH3 and glycosyltransferase networks. Overall, SRS is an enabling universal sample preparation strategy that is not size limited and has the capability to efficiently prepare and clean peptides and N-glycans concurrently from nearly all sample types. Conceptually, SRS can be utilized for the analysis of other posttranslational modifications, and the unique surface chemistry can be further transformed for high-throughput automation. The technical simplicity, robustness, and modularity of SRS make it a highly promising technology with great potential in proteomic-based research.

Background: \ud Cancers of Unknown Primary (CUP) are the 3-4th most common causes of cancer death and recent clinical guidelines recommend that patients should be directed to a team dedicated to their care. Our aim was to inform the care of patients diagnosed with CUP during hospital admission.\ud \ud Methods: \ud Descriptive study using hospital admissions (Scottish Morbidity Record 01) linked to cancer registrations (ICD-10 C77-80) and death records from 1998 to 2011 in West of Scotland, UK (population 2.4 m). Cox proportional hazards models were used to assess effects of baseline variables on survival.\ud \ud Results: \ud Seven thousand five hundred ninety nine patients were diagnosed with CUP over the study period, 54.4% female, 67.4% aged ≥ 70 years, 36.7% from the most deprived socio-economic quintile. 71% of all diagnoses were made during a hospital admission, among which 88.6% were emergency presentations and the majority (56.3%) were admitted to general medicine. Median length of stay was 15 days and median survival after admission 33 days. Non-specific morphology, emergency admission, age over 60 years, male sex and admission to geriatric medicine were all associated with poorer survival in adjusted analysis.\ud \ud Conclusions: \ud Patients with a diagnosis of CUP are usually diagnosed during unplanned hospital admissions and have very poor survival. To ensure that patients with CUP are quickly identified and directed to optimal care, increased surveillance and rapid referral pathways will be required.

Objective As branched/fenestrated endografts expand endovascular options for juxtarenal abdominal aortic aneurysms (JAAAs), long-term durability will be compared to that of open JAAA repair, which has not been documented in large contemporary series. The goal of this study was to assess the late clinical and anatomic outcomes after open JAAA repair. Methods From July 2001 to December 2007, 199 patients underwent open elective JAAA repair, as defined by a need for suprarenal clamping. End points included perioperative and late survival, long-term follow-up of renal function, and freedom from graft-related complications. Factors predictive of survival were determined by multivariate analysis. Results The mean patient age was 74 years, 71% were men, and 20% had baseline renal insufficiency (Cr >1.5). Thirty-seven renal artery bypasses, for anatomic necessity or ostial stenosis, were performed in 36 patients. Overall 30-day mortality was 2.5%. Four patients (2.0%) required early dialysis; one patient recovered by discharge. Two additional patients progressed to dialysis over long-term follow-up. There was one graft infection involving one limb of a bifurcated graft. Surveillance imaging was obtained in 101 patients (72% of survivors) at a mean follow-up of 41 ± 28 months. Renal artery occlusion occurred in four patients (3% of imaged renal arteries; one native/three grafts). Two patients (2.0%) had aneurysmal degeneration of the aorta either proximal or distal to the repaired segment, but there were no anastomotic pseudoaneurysms. Remote aneurysms were found in 29 patients (29% of imaged patients), 14 of whom had descending thoracic aneurysm or TAAA. Four patients underwent subsequent thoracic endovascular aneurysm repair (TEVAR). Actuarial survival was 74 ± 3.3% at 5 years. Negative predictors of survival included increasing age at the time of operation (relative risk [RR], 1.05; P = .01), steroid use (RR, 2.20; P = .001), and elevated preoperative creatinine (RR, 1.73; P = .02). Conclusions Open JAAA repair yields excellent long-term anatomic durability and preserves renal function. Perioperative renal insufficiency occurs in 8.5% of patients, but few of them progress to dialysis. Graft-related complications are rare (2% at 40 months); however, axial imaging revealed descending thoracic aneurysms in 14% of imaged patients, making continued surveillance for remote aneurysms prudent. These data provide a benchmark against which fenestrated/branched endovascular aneurysm repair (EVAR) outcomes can be compared.

Objectives Type IV thoracoabdominal aortic aneurysm (TAAA) repair, despite low risk of spinal cord ischemia (SCI), is reported to have significant morbidity and mortality. This has led some to apply adjuncts (eg, extracorporeal circulation) used in more extensive TAAA repair or to consider alternative approaches, such as hybrid operations. We have used a consistent, simplified surgical approach to type IV TAAA, and the goal of the present study is to review experience over 2 decades with such treatment and to identify correlates of surgical morbidity. Methods All type IV repairs at Massachusetts General Hospital from January 1989 through September 2009 were evaluated for clinical features, technical operative details, and 30-day outcomes. Logistic regression identified predictors of morbidity. Survival was assessed using Kaplan-Meier analysis. Results A total of 179 patients underwent type IV repair, with elective repair in 156 (87%) and urgent in 23 (13%). The clamp-and-sew technique was used for all operations, with routine hypothermic renal perfusion. Clinical features were age 73 ± 8 years, coronary artery disease in 89 (50%), and creatinine level >1.8 mg/dL defining chronic renal insufficiency (CRI) in 32 (18%). Operative reconstruction in 166 (93%) consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins (mean visceral clamp time, 36 ± 12 minutes) and a side-arm graft to the left renal artery. Technical details included previous abdominal aortic aneurysm (AAA) repair in 52 (29%), operative time of 290 ± 90 min, estimated blood loss of 2.7 ± 1.4 L, and splenectomy in 57 (32%). The 30-day outcomes were death in 5 (2.8%), myocardial infarction in 6 (3.4%), hemodialysis in 5 (2.8%), and any degree of SCI in 4 (2.2%). Regression analysis identified a history of CRI as an independent predictor of postoperative complication or death (odds ratio, 3.4; 95% confidence interval, 1.4-8). Survival rates at 1, 5, and 10 years were 89% ± 2%, 62% ± 4%, and 36% ± 5%, respectively. Conclusions A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. These data refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. CRI should figure prominently in clinical decision making. Long-term survival equates that observed after routine AAA repair.

Objective Persistent type 2 endoleaks (PT2, present ≥6 months) after endovascular aneurysm repair (EVAR) are associated with adverse outcomes. This study evaluated the preoperative risk factors and natural history of PT2 in order to define a population at high risk. Methods From January 1999 to December 2007, 595 of 832 EVAR patients had long-term computed tomography follow-up and comprised the study cohort. Preoperative anatomic and clinical variables were correlated with PT2 using Cox regression. Composite hazard ratios (HRs) were constructed with clusters of high-risk preoperative variables. Primary end points, including spontaneous resolution, sac enlargement >5 mm, and freedom from reintervention, were evaluated using Kaplan-Meier analysis. Results There were 136 PT2 patients (23%) with a median follow-up of 34.8 months (range, 6.4-121.2 months). Positive predictive factors included patent inferior mesenteric artery (IMA; HR, 4.00; 95% confidence interval [CI], 1.62-9.90; P = .003), increasing number of patent lumbar arteries (HR, 1.24; 95% CI, 1.10-1.41; P = .0006), increasing age (HR, 1.04; 95% CI, 1.01-1.06; P = .005), and increasing luminal diameter on CT-contrast opacified lumen (HR, 1.03; 95% CI, 1.02-1.05; P = .0001). During follow-up, spontaneous PT2 resolution occurred in 34 patients (25%), sac diameter remained stable in 63 (46%), and rupture occurred in 2 (1.5%). Kaplan-Meier analysis estimated that 35.2% ± 5.6% (95% CI, 23.8%-46.2%) of PT2 resolve spontaneously at 5 years after the index procedure. Freedom from sac enlargement >5 mm was 54.6% ± 7.2% (95% CI, 40.6%-69.4%) at 5 years. Fifty-nine reinterventions were performed in 39 patients with PT2. Freedom from reintervention was 67.3% ± 5.0% (95% CI, 57.0%-77.0%) at 5 years. The combination of a patent IMA and one risk factor of more than six patent lumbar arteries, maximum luminal diameter >30 mm, or age >70 years increased the odds of PT2 approximately ninefold. The combination of a patent IMA and any two risk factors increased the odds of PT2 approximately 18-fold. Conclusions Several readily identifiable preoperative variables are associated with PT2 whose natural history was benign in but 35% of patients. On the basis of the composite high-risk HRs, there is accordingly a cohort of patients in whom perioperative interventions to preclude PT2 should be considered.

e12558Background: Real world evidence (RWE) has been proposed as a means to address the ‘efficacy-effectiveness gap’ in evidence-based oncology. A major barrier to use of RWE is the perceived lack ...

The Clinical Practice Council of the Society for Vascular Surgery charged a writing committee with the task of updating practice guidelines, initally published in 2003, for surgeons and physicians who are involved in the preoperative, operative, and postoperative care of patients with abdominal aortic aneurysms (AAA). This document provides recommendations for evaluating the patient, including risk of aneurysm rupture and associated medical co-morbidities, guidelines for selecting surgical or endovascular intervention, intraoperative strategies, perioperative care, long-term follow-up, and treatment of late complications. Decision making related to the care of patients with AAA is complex. Aneurysms present with varying risks of

Objective The role of thoracic endovascular aortic repair (TEVAR) in the management of acute type B aortic dissection remains undefined. Entry tear coverage during the acute phase is an appealing method to treat acute complications, and by inducing false lumen thrombosis, might also prevent late aneurysm formation. This study evaluated structural changes by serial computed tomography (CT) in the thoracic aorta after TEVAR performed for acute complicated aortic dissection. Methods Between August 2005 and October 2007, 33 patients with complicated acute type B aortic dissection were treated with TEVAR (19 from a prospective industry sponsored trial, 14 from our institution). CT images obtained preprocedurally (PP), at 1 month (1M), and 1 year (1Y) were evaluated for each patient. Four patients with no postprocedural imaging were excluded. The largest diameters of the thoracic aorta, dissection true lumen, and false lumen were recorded at each time point. Canges in total aortic and true and false lumen diameters were evaluated using a mixed effect analysis of variance model of repeated measures. Results The average age was 58 years (range, 38-87 years); 26 (81%) were male. Indications for TEVAR included malperfusion syndrome in 17 (53%), refractory hypertension in 14 (44%), impending rupture in 12 (28%), and refractory pain in 14 (44%); 19 (59%) had more than one indication. The average length of aorta covered was 19.5 cm (range, 10-29.3 cm). The maximum aortic diameter decreased over time ( P = .04) and averaged 39.9 (PP), 41.3 (1M), and 34.8 mm (1Y). The true lumen diameter increased over time ( P = .02) and averaged 23.7 (PP), 29.0 (1M), and 31.1 mm (1Y). The false lumen diameter decreased ( P = .046) and averaged 19.5 (PP), 12.1 (1M), and 9.6 mm (1Y). Partial or complete thrombosis of the false lumen along the stented segment of aorta was recorded in 87% (PP), 93% (1M), and 88% (1Y). Conclusions TEVAR of acute complicated aortic dissection appears to promote early aortic remodeling. Nearly 90% of patients maintained at least partial false lumen thrombosis at 1 year. Because continued false lumen patency correlates strongly with late aneurysm formation, such favorable remodeling is considered a surrogate for prevention of late aneurysm, but longer follow-up is required.

To explore possible causes of the poor survival of Scottish lung cancer patients, a retrospective registry-based audit was conducted comparing demography, treatment and survival of 3833 Scottish patients and 2073 from British Columbia (BC). Patients from Scotland were older, had a lower rate of pathological confirmation (74% vs 89%, p

In the management of pediatric trauma, certain principles that are practiced in children who have sustained injuries more commonly seen in adults are extrapolated from the adult trauma literature. The increased use of computer tomography angiograms in the diagnosis of penetrating vascular trauma and endovascular therapy in treating vascular trauma in the adult population is being extended to the pediatric population. We present a case of a 14-year-old male with an axillary artery injury that was diagnosed by computer tomography angiogram and treated with an endovascular Stent graft with 1-year follow-up.

ObjectiveIn multiple comparisons of open vs endovascular (EVAR) repair of abdominal aortic aneurysms, the prior assumption that open repair produced superior durability has been challenged by advocates of EVAR. Although focus on EVAR reintervention has been intense, few contemporary studies document late outcomes after open repair; this was the goal of this study.MethodsFrom January 1994 to December 1998 (chosen to ensure a minimum 5-year follow-up), 540 patients underwent elective open repair. Surveillance imaging (computed tomographic and magnetic resonance imaging scans) was obtained for 152 (57%) of the 269 patients who remained alive at a mean follow-up of 87 months. Study end points included freedom from graft-related interventions and aneurysm-related and overall survival (Kaplan-Meier test); factors predictive of these end points were determined by multivariate analysis.ResultsThe mean age at operation was 73 years. A total of 76% of patients were male; 11% had renal insufficiency (creatinine ≥1.5 mg/dL), and 13% had chronic obstructive pulmonary disease. The aortic cross-clamp position was suprarenal in 135 (25%) patients, and 284 (53%) of patients had bifurcated grafts placed. Operative mortality (30 days) was 3%, and the median length of hospital stay was 7 days. Postoperative complications occurred in 68 (13%) patients. Predictors of postoperative complications included a history of myocardial infarction (hazard ratio [HR], 2.0; P = .01) and renal insufficiency (HR, 2.5; P = .02). The mean follow-up for all patients was 87 months. Actuarial survival was 70.7% ± 2% and 44.3% ± 2.4% at 5 and 10 years, respectively. Negative predictors of long-term survival included advanced age (HR, 1.1; P < .001), history of myocardial infarction (HR, 1.37; P = .02), and renal insufficiency (HR, 1.5; P = .04). Freedom from graft-related reintervention was 98.2% ± 0.8% and 94.3% ± 3.4% at 5 and 10 years, respectively. There were 13 late graft-related complications in 11 (2%) patients (mean follow-up, 7.2 years). Findings included seven anastomotic pseudoaneurysms (five were repaired), four graft limb occlusions, and two graft infections. Aneurysms were identified in noncontiguous arterial segments in 68 (45%) of 152 patients, most of which involved the iliac arteries and required no treatment because of small size. Late aortic aneurysms proximal to the repair were identified in 24% of patients, and 29 (19%) patients had multiple late synchronous aneurysms.ConclusionsOpen repair remains a safe and durable option for the management of abdominal aortic aneurysms, with an excellent associated 10-year survival in patients who undergo operation at 75 years of age or younger. In addition, the freedom from graft-related reintervention is superior to that of EVAR. Finally, continued surveillance after open repair is appropriate and should be directed toward the detection of other aneurysms.

ObjectiveType 2 endoleak occurs in up to 20% of patients after endovascular aneurysm repair (EVAR), but its long-term significance is debated. We reviewed our experience to evaluate late outcomes associated with type 2 endoleak.MethodsDuring the interval January 1994 to December 2005, 873 patients underwent EVAR. Computed tomography (CT) scan assessment was performed ≤1 month of the operation and at least annually thereafter. Sequential 6-month CT scan follow-up was adopted for those patients with persistent type 2 endoleaks, and reintervention was limited to those with sac enlargement >5 mm. Study end points included overall survival, aneurysm sac growth, reintervention rate, conversion to open repair, and abdominal aortic aneurysm (AAA) rupture. Preoperative variables and anatomic factors potentially associated with these endpoints were assessed using multivariate analysis.ResultsWe identified 164 (18.9%) patients with early (at the first follow-up CT scan) type 2 endoleaks. Mean follow-up was 32.6 months. In 131 (79.9%) early type 2 endoleaks, complete and permanent leak resolution occurred ≤6 months. Endoleaks persisted in 33 patients (3.8% of total patients; 20.1% of early type 2 endoleaks) for >6 months. Transient type 2 endoleak (those that resolved ≤6 months of EVAR) was not associated with adverse late outcomes. In contrast, persistent endoleak was associated with several adverse outcomes. AAA-related death was not significantly different between patients with and without a type 2 endoleak (P = .78). When evaluating patients with no early endoleak vs persistent endoleak, freedom from sac expansion at 1, 3, and 5 years was 99.2%, 97.6%, and 94.9% (no leak) vs 88.1%, 48.0%, and 28.0% (persistent) (P < .001). Patients with persistent endoleak were at increased risk for aneurysm sac growth vs patients without endoleak (odds ratio [OR], 25.9; 95% confidence interval [CI] 11.8 to 57.4; P < .001). Patients with a persistent endoleak also had a significantly increased rate of reintervention (OR, 19.0; 95% CI, 8.0 to 44.7); P < .001). Finally, aneurysm rupture occurred in 4 patients with type 2 endoleaks. Freedom from rupture at 1, 3, and 5 years for patients with a persistent type 2 endoleak was 96.8%, 96.8%, and 91.1% vs 99.8%, 98.5%, and 97.4% for patients without a type 2 endoleak. Multivariate analysis demonstrated persistent type 2 endoleak to be a significant predictor of aneurysm rupture (P = .03).ConclusionsPersistent type 2 endoleak is associated with an increased incidence of adverse outcomes, including aneurysm sac growth, the need for conversion to open repair, reintervention rate, and rupture. These data suggest that patients with persistent type 2 endoleak (>6 months) should be considered for more frequent follow-up or a more aggressive approach to reintervention.

Objective Compare long-term results of endovascular treatment and standard open repair of abdominal aortic aneurysms in a multicenter, concurrent-controlled trial. Methods 334 subjects were treated with standard open repair (control, n=99) or the original EXCLUDER Bifurcated Endoprosthesis (test, n=235). Five-year clinical evaluations and corelab radiographic results are analyzed. Results Overall and aneurysm-related survival are similar. There have been ten open conversions, most frequently for enlarging sacs without endoleak. Two patients died after conversion. Including reinterventions and complications of reinterventions as adverse events, there is significant, persistent long-term reduction in major adverse events. At 5 years, corelab reported 0% limb narrowing, 0% trunk migration, 0% component (contralateral leg, aortic extender, and iliac extender) migration, 0% fracture, endoleak in 3% (2 type II/68), and aneurysm growth (>5 mm compared to baseline) in 38% (30/78) of the test group. There are no aneurysm ruptures in either test or control group. Conclusions After 5 years follow-up, endovascular repair is a safer and effective treatment compared with open surgical repair for abdominal aortic aneurysms. Major adverse events are less frequent with the endograft despite the need for late reinterventions. Aneurysm expansion is observed in nearly two-fifths of patients but is not associated with endoleak or aneurysm rupture. Multicenter clinical trials are evaluating a newer version of this device designed to avoid this high rate of sac expansion.

Introduction Although lower-extremity bypass grafting has been the gold standard for infrainguinal revascularization, endovascular therapies have been increasingly applied to avoid operative morbidities. This study addresses the initial results of an implementation of infrainguinal percutaneous transluminal angioplasty (PTA) performed by vascular surgeons to treat lower-extremity ischemia. Methods From January 2002 to July 2003, 95 consecutive patients presenting with the spectrum of lower-extremity ischemic manifestations, in whom infrainguinal PTA was the initial choice of treatment, were assessed for treatment efficacy by clinical and noninvasive evaluation. Study end points of angiographic, hemodynamic, and clinical successes (Society of Vascular Surgery reporting standards) were recorded, and variables associated with ischemic category improvement were analyzed by univariate and multivariate analysis. During the same study interval, 87 patients underwent bypass grafting (not further considered). Results PTA was used to treat 100 limbs in 95 consecutive patients: 63 limbs (63%) had femoropopliteal PTA, 17 limbs (17%) had tibioperoneal PTA, and 20 limbs (20%) had multilevel PTA. Tissue-threatening ischemia was present in 47% of patients, and 53% were treated for claudication. Complications (no mortality) included one myocardial infarction (1%) and two access site hematomas (2%). Angiographic and hemodynamic success (a .10 increase in ankle-brachial index) was obtained in 97% and 90% of the treated limbs, respectively. With a mean follow-up of 14 months, clinical success was obtained in 85% of the treated limbs, and limb salvage for critical ischemia was achieved in 75% (30/40 limbs). Of the PTA failures, five patients (5%) underwent bypass grafting, and five patients (5%) underwent major amputation because of no further reconstructive options or extensive necrosis. Insulin-dependent diabetes mellitus (risk ratio [RR], 3.1; 95% confidence interval [CI], 1.1 to 8.7, P = .02), poor runoff into the foot (RR, 3.7; 95% CI, 1.6 to 8.6, P = .001), and renal insufficiency (serum creatinine >1.5 mg/dL) (RR, 3.7; 95% CI, 1.8 to 7.6, P = .001) were predictive of PTA failure. Conclusion Infrainguinal percutaneous transluminal angioplasty for lower-extremity ischemia is feasible, safe and provides acceptable hemodynamic and clinical results. PTA will become the initial treatment for most patients requiring lower-extremity revascularization.

BackgroundReoperative carotid endarterectomy (CEA) is an accepted treatment for recurrent carotid stenosis. With reports of a higher operative morbidity than primary CEA and the advent of carotid stenting, catheter-based therapy has been advocated as the primary treatment for this reportedly “high-risk” subgroup. This study reviews a contemporary experience with reoperative CEA to validate the high-risk categorization of these patients.MethodsFrom 1989 to 2002, 153 consecutive, isolated (excluding CEA/coronary artery bypass graft and carotid bypass operations) reoperative CEA procedures were reviewed. Clinical and demographic variables potentially associated with the end points of perioperative morbidity, long-term durability, and late survival were assessed with multivariate analysis.ResultsThere were 153 reoperative CEA procedures in 145 patients (56% men, 36% symptomatic) with an average age of 69 ± 1.3 years. The average time from primary CEA (68% primary closure, 23% prosthetic, 9% vein patch) to reoperative CEA was 6.1 ± 0.4 years (range, 0.3 to 20.4 years). At reoperation, patch reconstruction was undertaken in 93% of cases. The perioperative stroke rate was 1.9%, with no deaths or cardiac complications. Other complications included cranial nerve injury (1.3%) and hematoma (3.2%). Average follow-up after reoperative CEA was 4.4 ± 0.3 years (range, 0.1 to 12.7 years), with an overall total stroke-free rate of 96% and a restenosis rate (>50%) by carotid duplex of 9.2%. Among variables assessed for association with restenosis after reoperative CEA, only younger age was found to be significant (66 ± 2.5 years vs 70 ± 0.7 years, P < .05). The all-cause long-term mortality rate was 29%. Multivariate analysis of long-term survival identified diabetes mellitus as having a negative impact (hazard ratio, 3.4 ± 0.3, P < .05) and lipid-lowering agents as having a protective effect (hazard ratio, 0.42 ± 0.4, P < .05) on survival.ConclusionReoperative CEA is a safe and durable procedure, comparable to reported standards for primary CEA, for long-term protection from stroke. These data do not support the contention that patients who require reoperative CEA constitute a “high-risk” subgroup in whom reoperative therapy should be avoided.

ObjectivesCarotid endarterectomy (CEA) remains the gold standard for treatment of carotid stenosis. With inevitable comparisons of catheter-based therapy to all aspects of CEA, this study of a large contemporary series was undertaken to evaluate the determinants of anatomic durability of CEA.MethodsDuring the interval (1989 through 1999), 2,127 primary, isolated CEAs with selective patching (50.2%) were performed in 1,853 patients (61.8% male, 36.1% symptomatic). End points included patient longevity and perioperative morbidity as well as evidence of CEA anatomic durability as defined by duplex evaluation: CEA restenosis (moderate, >50%, or greater recurrent stenosis), which included CEA anatomic failure (severe, >70%, restenosis/carotid occlusion). The incidence of CEA recurrent stenosis was temporally assessed early (2 years) after operation. Clinical and surgical variables potentially associated with the study endpoints were analyzed by univariate and multivariate methods.ResultsThe perioperative stroke and death rate was 1.4% and the 2-year and 10-year survival was 88.1% and 44.9%, respectively. Anatomic failure after CEA developed in 3.9% at 2 years and in 8.5% at 5 years; only 3.2% of CEA patients underwent reoperation during a mean follow-up of 73.4 months. Early (2 years) results identified 9.8% progression of carotid stenosis and a 5.8% rate of anatomic failure. Multivariate analysis determined elevated creatinine (odds ratio [OR], 1.719, P < .001) and female gender (OR, 1.564; P < .02) correlated with early restenosis. Surgical patch closure and lipid-lowering drugs were protective for both early restenosis, with ORs of 0.543 (P < .0.001) and 0.601 (P < .007) and early anatomic failure ORs of 0.469 (P < .02) and 0.517 (P < .03), respectively. Although only elevated serum cholesterol (OR, 1.009; P < .03) correlated with late anatomic failure, only lipid-lowering drugs were protective for both late freedom from progression of disease (OR, 0.202; P < .0002) or late CEA anatomic failure (OR, 0.128; P < .0003).ConclusionsThe association of female gender and elevated cholesterol with recurrent carotid stenosis is confirmed, elevated creatinine is introduced as a risk factor, and surgical patch repair is protective for early CEA recurrent carotid stenosis. The unique findings of the significant, beneficial effects of lipid-lowering drugs on both early and late CEA anatomic durability and patient survival indicate that such therapy should be instituted in most patients after CEA.

Background and aims: Family history is used extensively to estimate the risk of colorectal cancer but there is considerable potential for recall bias and inaccuracy. Hence we systematically assessed the accuracy of family history reported at interview compared with actual cancer experience in relatives. Methods: Using face to face interviews, we recorded family history from 199 colorectal cancer cases and 133 community controls, totalling 5637 first and second degree relatives (FDRs/SDRs). We linked computerised cancer registry data to interview information to determine the accuracy of family history reporting. Results: Cases substantially underreported colorectal cancer arising both in FDRs (sensitivity 0.566 (95% confidence interval (CI) 0.433, 0.690); specificity 0.990 (95% CI 0.983, 0.994)) and SDRs (sensitivity 0.271 (95% CI 0.166, 0.410); specificity 0.996 (95% CI 0.992, 0.998)). There was no observable difference in accuracy of reporting family history between case and control interviewees. Control subjects similarly underreported colorectal cancer in FDRs (sensitivity 0.529 (95% CI 0.310, 0.738); specificity 0.995 (95% CI 0.989, 0.998)) and SDRs (sensitivity 0.333 (95% CI 0.192, 0.512); specificity 0.995 (95% CI 0.991, 0.995)). To determine practical implications of inaccurate family history, we applied family history criteria before and after record linkage. Only two of five families reported at interview to meet surveillance criteria did so after validation, whereas only two of six families that actually merited surveillance were identified by interview. Conclusions: This study has quantified the inaccuracy of interview in identifying people at risk of colorectal cancer due to a family history. Colorectal cancer was substantially underreported and so family history information should be interpreted with caution. These findings have considerable relevance to identifying patients who merit surveillance colonoscopy and to epidemiological studies.

ObjectiveClinical and anatomic factors predictive of a favorable response to renal revascularization performed for renal function salvage remain poorly defined. To clarify decision making in such patients we reviewed a contemporary experience of surgical renal artery revascularization (RAR) performed primarily for preservation of renal function.MethodsBetween June 1990 and March 2001 (ensuring 1 year minimum follow-up), 96 patients with renal insufficiency (serum creatinine [Cr] concentration ≥1.5 mg/dL) and hypertension underwent RAR for preservation of renal function. Study end points included early and late renal function response, progression to dialysis dependence, and long-term survival. Variables potentially associated with these end points were assessed with univariate analysis, Cox regression analysis, and logistic regression analysis, and survival was assessed with the Kaplan-Meier method.ResultsPerioperative failure of RAR occurred in 3 patients (3%), with perioperative mortality in 4 patients (4.1%); thus 92 patients were available for long-term follow-up (mean, 39 months). Mean patient age was 70 ± 9 years with a mean baseline Cr of 2.6 mg/dL (range, 1.5-7.8 mg/dL). Operative management consisted of aortorenal bypass in 38% of patients, extraanatomic bypass in 38% of patients, and endarterectomy in 24% of patients; 32% of patients required combined aortic revascularization and RAR, and 27% underwent bilateral RAR. At hospital discharge renal function had improved (20% decrement in Cr) in 41 (43%) patients, including 7 patients who were removed from dialysis; remained unchanged in 40 (41%) patients; and declined (20% increase in Cr) in 15 (16%) patients. At last follow-up renal function was either improved or unchanged in 72% of patients. Predictors of a favorable response to RAR at last follow-up included stable Cr at hospital discharge (odds ratio [OR], 7.1; 95% confidence interval [CI], 2.5-21.8; P = .0004) and decreased Cr at hospital discharge (OR, 16; 95% CI, 1.6-307.8; P < .0001); bilateral renal artery repair (OR, 3.1; 95% CI, 0.9-10.6; P = .07) approached clinical significance. Predictors of worsened excretory function at last follow-up included decline of renal function at hospital discharge (OR, 28.9; 95% CI, 5.0-165.4; P = .0002), intervention to treat unilateral renal artery stenosis (OR, 3.8; 95% CI, 0.8-16.6; P = .05), and level of baseline Cr (OR, 3.0; 95% CI, 1.0-4.0; P = .04). Progression to dialysis occurred in 16 (17%) patients. Dialysis-free survival at 5 years was 50%, and overall actuarial survival at 5 years was 59%. Predictors of progression to dialysis during follow-up included treatment of complete renal artery occlusion (OR, 6.2; 95% CI, 1.3-29.5; P = .02), early failure of RAR (OR, 3.1; 95% CI, 0.7-14.2; P = .04) and baseline Cr (OR, 2.9; 95% CI, 1.3-6.1; P = .006).ConclusionLong-term clinical success in the preservation of renal function, noted in 70% of patients, can be predicted by the initial response to RAR and by anatomic factors, in particular, bilateral repair. While extreme (mean Cr ≥3.2 mg/dL) renal dysfunction generally is predictive of poor long-term outcome, a subset of patients will experience favorable results, even to the extent of rescue from dialysis. These results may facilitate clinical decision making in the application of RAR for renal function salvage.

PurposeThis study was undertaken to assess the results of endovascular aortic aneurysm repair with the Lifepath abdominal aortic aneurysm (AAA) graft system.MethodIn a prospective clinical trial, 23 centers used the Lifepath System balloon-expandable, modular bifurcated stent graft for elective endovascular aortic aneurysm repair. Stent grafts were sized according to computed tomographic angiography–based diameter measurements. All repairs were performed in the operating room through bilateral surgically exposed femoral arteries. Results were assessed with contrast agent–enhanced computed tomography scans and plain abdominal x-ray films at 1, 6, 12, 24, 36, and 48 months postoperatively.ResultsOver 52 months (mean follow-up, 11 months), 227 patients (206 men, 21 women) were enrolled. Technical implant success rate was 98.7%. There were five (2.2%) conversions to open surgery: two emergently because of aortic perforation; to treat refractory endoleak, immediate in one and at 12 months in one; and to replace a device with wireform fractures that had migrated at 12 months, resulting in a proximal endoleak. The perioperative mortality rate was 1.3%. There was one operative death during a secondary procedure to repair perforation of the aorta. There were two perioperative deaths, from postoperative myocardial infarction (n = 1) and pulmonary embolus (n = 1). There were 12 late deaths, from coronary artery disease (n = 4), cancer (n = 2), respiratory failure (n = 2), sepsis (n = 1), or unknown cause (n = 3). Median length of stay was 2 days (mean, 4 days). There have been no AAA ruptures after successful implantation of the device, no graft limb thromboses, and no limb dislocations. At the time of operation endoleak was noted in 43 (19%) patients, but by 6 months this was reduced to 8 (5.9%) patients (type I, n = 1; type II, n = 7). There were no type III or type IV endoleaks. Secondary interventions to treat endoleaks included open conversion (n = 2), placement of extension cuffs (n = 4), repeated balloon dilation (n = 3), and coil embolization (n = 6). The two remaining secondary interventions were emergent treatment of postoperative bleeding from a groin incision, and a colon resection because of postoperative colonic ischemia, for a 12-month secondary intervention rate of 7.5%. Wireform fractures were noted in the first generation Lifepath device in 37 of 79 (47%) patients. Graft migration (>10 mm) was observed in five patients (2.2%), each of whom also had two or more fractures of the proximal anchoring wireforms. Migration resulted in a proximal attachment endoleak in one patient. In response to wireform fractures, the device was modified after the initial 79 patients were enrolled. Wireform fracture has been observed in six patients since this modification (4%), and in only one patient did this involve fracture of a proximal anchoring wireform; none of these patients has had endoleak or graft migration. By 12 months, mean aneurysm diameter was noted to decrease by 9 mm (P < .0001), and mean aneurysm volume by 42 mL (P < .0001) from the preoperative visit.ConclusionThe Lifepath System demonstrates a low endoleak and secondary intervention rate and high sac regression rate, compared with other devices. The unique balloon-expandable design offers the advantages of precise placement and high radial force. The device appears to be highly resistant to limb thrombosis and modular component separation. Patients were protected from AAA rupture after successful device implantation, and demonstrated significant reduction in AAA diameter and volume. Fractures of the wireforms of the main body of the device have been observed. Careful long-term follow-up is necessary.

Popliteal artery embolism has been a focus of study at the Massachusetts General Hospital for over 60 years. It is a formidable vascular problem with significant limb loss and mortality. To assess the impact of advances in cardiac and vascular therapies, we reviewed our outcomes over 12 years. A retrospective review from our databases identified 66 patients with 72 popliteal artery emboli between January 1989 and October 2000. Patients undergoing nonsurgical therapy or with in situ atherosclerotic thrombosis were excluded. Demographics, comorbidities, presentation, duration, etiology, treatment, and outcomes were analyzed. Patients were classified into those with acute (AP; symptoms7 days; 59 of 72, 82%) or delayed (DP; symptoms7 days; 13 of 72, 18%) presentation. The presentation was typically acute ischemia (85%) in the AP group and claudication (69%), rest pain (15.5%), or gangrene (15.5%) in the DP group. The most common etiology was embolism secondary to atrial fibrillation (17 of 72, 24%). Femoral artery access (15 of 72, 21%) was more prevalent than in our prior experience. In the AP group, 9 of 59 (15%) were treated with a femoral artery approach, 44 of 59 (75%) with a popliteal artery approach, and 6 of 59 (10%) with bypass. In the DP group, 11 of 13 (85%) were treated with a popliteal approach and 2 of 13 (15%) with bypass. Completion angiography was done in 17 cases (24%). Limb salvage rate was 88% (88% AP, 85% DP); the rate was 94% with angiography and 85% without it (p0.1). There were seven deaths (10%). The mortality rate was 33% after amputation and 7% after limb salvage (p0.05). Except for a greater prevalence of femoral artery access as an etiology, the demographics of patients with popliteal embolism were similar to those of prior reports. Although a femoral approach may be appropriate in select AP cases, a popliteal approach is preferred in most patients and is necessary in DP cases. Completion angiography should be performed to ensure adequacy of the embolectomy. Outcomes are unchanged. Future therapies should aim to improve limb salvage and mortality rates.

ObjectivesWe evaluated mid-term results of the multicenter EVT/Guidant aortouniiliac endograft (AI) trial and ascertained the durability of this endovascular technique in patients unable to undergo standard bifurcated endografting.MethodsFrom November 1996 to December 1998, 121 patients were enrolled to receive the AI device on the basis of complex iliac artery anatomy contraindicating bifurcated endografting. Clinical data were centrally collected, and radiographic data were evaluated by core facility.ResultsAI placement was technically successful in 113 of 121 patients. At operation, patients who underwent AI had significantly more arrhythmias, congestive heart failure, and peripheral occlusive disease (P < .05) compared with patients who underwent open aneurysmorrhaphy in the EVT/Guidant trials, indicating comorbid features in this anatomic cohort. Distal AI attachment was performed to the external iliac artery in 40 (36%) patients. Median follow-up was 38 months. In the AI group, overall aneurysm diameter decreased over the duration of study from 54.4 ± 9.6 mm to 44.4 ± 16.4 mm (P = .004). At 24 and 36 months after repair, reduction in aneurysm size was associated with absence of endoleak (P = .003 and P = .008, respectively). Aneurysms shrunk or remained stable in 109 (96.5%) patients. Endoleak was identified in 52.3% of patients at discharge, and at follow-up in 30.9% at 1 year, 34.8% at 2 years, 28.6% at 3 years, and 30.4% at 4 years. Type II endoleak predominated. Leak from failure to completely occlude contralateral iliac flow accounted for 8 of 58 endoleaks (13.8%) at discharge. Sixteen patients (14.2%) underwent postoperative endoleak treatment; in one of these patients open conversion was necessary at 20 months. Post-procedure thigh or buttock claudication developed in 16 patients (14.2%). Thirteen patients (81.3%) had either distal attachment in the external iliac artery or contralateral type IIA occlusion. Fifteen patients (13.3%) required intervention because of reduced limb flow; one of these patients underwent open conversion at 27 months, and another underwent axillofemoral grafting at 28 months. Device migration was confirmed in 2 (1.8%) patients, without current clinical sequelae. Whereas no femorofemoral graft thromboses occurred, graft infection developed in 3 patients (2.6%). During follow-up, aneurysm in 2 patients ruptured. Late death occurred in 41 patients (36.3%). Twenty-four patients (58.5%) died of cardiopulmonary disease; one death was endograft-related after aneurysm rupture; and one death was related to femorofemoral bypass infection. Actuarial survival was 78.4% (95% confidence interval [CI], 71%-86%) at 2 years and 63.4% (95% CI, 54%-73%) at 4 years.ConclusionsIn patients with significant comorbid conditions and complex iliac anatomy unfavorable for bifurcated endografting, AI with femorofemoral bypass grafting is safe and effective. In most patients this endovascular option provides satisfactory mid-term results.

PURPOSE To determine the prevalence of new renal perfusion defects and the association of these events with aneurysm neck atheroma during endovascular stent-graft repair of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS A retrospective review was performed of 50 patients who underwent AAA repair with bifurcated endovascular stent-grafts without suprarenal components between June 1998 and May 1999. Preand postprocedural computed tomographic (CT) angiograms were reviewed to determine the prevalence of new renal perfusion defects. The percent volume of atheroma of the aneurysm neck was determined by three-dimensional volumetric reformation and correlated with prevalence of new postprocedural renal perfusion defects. Follow-up CT angiography was performed between 6 months and 2 years after the procedure and used to evaluate the presence of residual defects and interval changes. RESULTS Of 50 subjects, 18% ( n = 9) had new perfusion defects presumed to be embolic in origin. Follow-up was available for four patients: scarring and cortical thinning consistent with infarction developed in two, whereas the defects resolved in the other two. Analysis of aneurysm neck revealed an average percentage of atheroma of 32% and a range of 0%–73%. In subjects with >40% neck atheroma, the prevalence of new renal perfusion defects was 45.4% (five of 11), compared to 10.3% (four of 39) in subjects with P = .0170). CONCLUSION In this series, the frequency of renal embolic events associated with AAA endovascular repair was 18%. Prevalence of renal embolic perfusion defects was shown to correlate with volume of aneurysm neck atheroma.

Purpose: Unlike abdominal aortic aneurysm repair, little information exists regarding aortic-related morbidity (synchronous/metachronous aneurysm or graft-related complications) after thoracoabdominal aneurysm (TAA) repair. This study was performed to define such events and identify factors related to their development. Methods: Over a 15-year interval, 333 patients underwent TAA repair (type I, n = 90; 27%; type II, n = 59; 18%; type III, n = 118; 35%; and type IV, n = 66; 20%). Late aortic events were defined as aortic disease causing death or necessitating further intervention or graft-related complications (infection, pseudoaneurysm, branch occlusion) after hospital discharge. Variables were assessed for their association with aortic events with Cox proportional hazards regression. Results: In-hospital mortality occurred in 28 patients (8.4%), which left 305 available for follow-up (mean length of follow-up, 26 months; interquartile range, 2.7 to 38.4 months). After TAA repair, aneurysm remained in 60 patients (19.7%; ascending/arch, n = 41; 68.3%; discontinuous infrarenal, n = 12; 20%; contiguous descending, n = 7; 11.7%; contiguous abdominal, n = 4; 6.7%). Events occurred in 33 individuals (10.8%) at 30 ± 27 months after surgery. Twenty-four patients (73% of events; 7.9% of cohort) had aortic-related events, including another elective aneurysm repair (n = 16), urgent/emergent aneurysm operation (n = 5), acute dissection (n = 2), and atherothrombotic embolization (n = 1). Nine patients (27% of events; 2.9% of cohort) had graft-related incidents, including renovisceral occlusion (n = 5), visceral patch pseudoaneurysm (n = 2), graft infection (n = 2), and graft-esophageal fistula (n = 1). Variables independently predictive of events were female gender (odds ratio [OR], 2.3; P = .03), initial aneurysm rupture (OR, 4.8; P = .04), partial disease resection (OR, 4.2; P = .0008), and expansion of remaining aortic segments on imaging surveillance (OR, 2.5; P = .03). The event-free survival rates were 96% (95% CI, 93% to 98%) and 71% (95% CI, 60% to 83%) at 1 and 5 years. Conclusion: Late aortic events occur in at least 10% of patients after TAA repair and are usually the result of native aortic disease in remote (or noncontiguous) aortic segments. Graft-related complications, in particular, degeneration of inclusion anastamoses, are rare. Female gender, original presentation with rupture, and unresected disease identify those at highest risk. These findings verify the anatomic durability of TAA repair and suggest indefinite aortic surveillance is indicated for those at risk of events. (J Vasc Surg 2003;37:254-61.)

Objective: The purpose of this study was to evaluate the safety and efficacy of a novel endovascular graft for elective treatment of infrarenal abdominal aortic aneurysm. The device is a modular bifurcated system with nitinol/expanded polytetrafluoroethylene components and a smaller profile than currently approved devices. Methods: In a multicenter, concurrent controlled phase II trial, 334 patients underwent treatment with the Excluder bifurcated endoprosthesis (test, n = 235; W. L. Gore & Associates, Inc, Sunnyvale, Calif) or with standard open repair (control, n = 99). Preoperative characteristics, perioperative variables, follow-up clinical evaluations, and radiographic examination results through the first 2 years were analyzed with univariable and multivariable statistics. Results: Patients in the test group had less blood loss (310 ± 19 mL versus 1590 ± 124 mL; P < .0001), fewer homologous transfusions (6% versus 32%; P < .0001), and shorter lengths of stay (2.0 ± 0.1 days versus 9.8 ± 1.4 days; P < .0001). Early major adverse events were markedly reduced in the test group (14% versus 57%; P < .0001), and this difference persisted at 2 years. No difference was seen in survival rate (P = .13). In the first 2 years, no deployment failure, early conversion, or aneurysm rupture occurred. At the 2-year timepoint, core laboratory read trunk migration in 1%, limb migration in 1%, limb narrowing in 1%, endoleak in 20%, and aneurysm growth in 14%. One wire discontinuity (0.6%) was identified in a discharge film. A 7% annual reintervention rate was seen in the test group in the first 2 years. Summary: The test device is a safe and effective treatment compared with open surgical repair for infrarenal abdominal aortic aneurysm. The most striking benefits are reduced blood loss, fewer complications, and faster recovery. Two-year survival rate was similar. (J Vasc Surg 2003;37:262-71.)

Purpose: We reviewed our initial thoracic aorta (TA) stent graft experience in 28 patients from the perspective of treatment with homemade devices (Dacron over Gianturco Z stents; 14 cases) and a commercial device (Excluder; W.L. Gore Co, Flagstaff, Ariz; 14 cases). Methods: From November 1996 to August 2001, 28 patients with a spectrum of disease (degenerative aneurysm, n = 18; chronic dissection, n = 4; pseudoaneurysm, n = 3, with 1 trauma and 2 anastomotic; intramural hematoma, n = 2; and coarctation, n = 1) underwent TA stent grafting. Clinical parameters included a mean age of 71 years, 12 female (43%) and 16 male (57%) patients, 14 of 28 patients (50%) with major comorbidities that prohibited open repair, and nine of 28 patients (32%) with urgent or ruptured conditions. Seven patients (25%) needed open surgical access to the aorta or iliac artery for either concomitant abdominal aortic aneurysm repair (n = 3) or device deployment (n = 4), and six of 28 patients (21%) needed left subclavian-carotid transposition to provide for an adequate proximal fixation site. Focal (

To determine and compare the average in-hospital costs of elective open surgical and endovascular repairs of infrarenal abdominal aortic aneurysms.Total actual cost data for patients undergoing elective endovascular (n = 181) or open surgical (n = 273) repair of abdominal aortic aneurysms between 1997 and 1999 were retrieved. The mean total hospital cost (including stent-graft costs and excluding attending physician fees) and mean postoperative length of stay were calculated for each treatment group. Costs were expressed in 1999 U.S. dollars.Endovascular repair yielded a shorter postoperative length of stay than did open surgery (mean stay, 3.4 vs 8.0 days; P.001) and a lower proportion of patients who were admitted to the intensive care unit for 1 full day or longer (2.8% vs 36.3%; P.001). The mean total hospital cost was significantly higher for endovascular repair than for open surgery ($20,716 vs $18,484; P.001).Hospital costs were higher for endovascular repair than for open surgical repair. However, endovascular repair was associated with a decreased length of stay and fewer intensive care unit admissions. The increased mean hospital cost for endovascular repair was smaller than one would expect, considering the higher costs of endovascular grafts, as compared with those for surgical grafts (approximately $6,400 according to literature data).

Purpose: Analysis endpoints of patient survival and aortic rupture at a reporting interval of 12 months are regularly used to compare endograft aortic aneurysm (EAG) repair to conventional open surgical (COS) repair. This study reports a multicenter EAG repair versus COS repair parallel cohort trial at 12 months and additional observations of specific device failure types and their impact on an aortic endograft design beyond that follow-up period. Methods: From August 1997 to September 1998, 240 patients who were treated with bifurcation EAG repairs and 28 patients who were treated with straight EAG repairs were compared with 98 patients who were treated with COS repair for elective infrarenal aortic aneurysm repair. Allocation to treatment was based on aneurysm anatomy. All cohorts underwent infrarenal procedures. Data from concurrent, nonrandomized patient accrual from 17 United States institutions were prospectively gathered and independently adjudicated for safety and efficacy. An independent core laboratory evaluated all imaging data. Results: There were 308 men and 58 women (mean age, 72 years; range, 42-94 years) treated for infrarenal aortic aneurysm (mean diameter, 55 mm; range, 40-115 mm). Mean preoperative aneurysm diameters were clinically similar (EAG repair, 54 mm vs COS repair, 57 mm). The two cohorts were not significantly different in terms of gender ( P = .30) or age ( P = .32). EAG repair technical success (aneurysm exclusion, graft patency, patient survival) at 30 days was 89.2%. Five patients required immediate conversion to COS repair, four caused by access complications and one caused by operator-induced EAG repair malposition. The 30-day mortality rate was 1.5% for EAG repair and 3.1% for COS repair ( P = .59). The 12-month survival rate was 94.3% for EAG repair and 95.9% for COS repair. The intermediate-term cumulative survival rate at 24 months was 84.9% for EAG repair and 80.3% for COS repair ( P = .48). EAG repair device failure occurred from fabric erosion in six patients, with two deaths from ruptured aneurysm at 18 and 28 months after endografting and four device failures resolved by secondary procedures. Five endograft limb dislocations were all resolved by secondary endovascular procedures. Major or minor endograft migration required secondary procedures in five patients, including conversion in two patients. Conclusion: The clinical outcome at 12 months demonstrated effective aneurysm treatment and comparable safety between EAG repair and COS repair by conventional endpoints. Ongoing follow-up beyond 12 months revealed device-related adverse events that required endograft design changes. Diligent surveillance of outcomes beyond 12 months is necessary to adequately evaluate EAG repair devices. (J Vasc Surg 2001;33:S55-63.)

Objective: Our objective was to present the results of the multicenter EVT/Guidant aorto-uni-iliac trial and to compare them with the tube, bifurcated graft, and open control series in regard to patient demographics, medical comorbidity, 30-day morbidity/mortality, and outcome at 1 year. Methods: One hundred twenty-one patients not eligible for tube or bifurcated endografts were entered into the aorto-uni-iliac trial (A-I). These were compared with 153 patients in a tube (T) group, 268 patients in a bifurcated endograft (BI) group, and 111 patients in an open control (C) group. All data were audited and independently analyzed for presentation to the Food and Drug Administration. Results: Group demographics were similar with the following exceptions. Aneurysm diameter was significantly less in the T group (51.2 mm) but similar for the A-I (57 mm), BI (54.6 mm), and C (55.6 mm) groups (P < .001). There were more male patients in all endograft groups (A-I 92.6%, BI 89.5%, T 85.6% vs 76.6% for C, P = .002). Peripheral arterial occlusion was present more frequently in the A-I group (25.6% vs 13.8% BI, 10.5% T, and 10.8% C, P = .003). However, no differences were found in mean age, incidence of coronary artery disease, and American Society of Anesthesiologists III/IV classification. Implantation was achieved in 94.2% of the A-I group, 90.3% of the BI group, and 92% of the T group. No significant difference was seen in the operative mortality rate (4.2% A-I, 2.6% BI, O% T, 2.7% C). Postoperative cardiac complications were similar for the A-I (22%) and C (20.7%) groups but significantly less for the BI and T groups (13.4% and 10.5%, P = .019), whereas pulmonary problems were significantly reduced in all endograft groups (A-I 11.9%, BI 10.1%, and T 7.2% vs 22.5% for C, P = .002). Transient renal dysfunction occurred in 6.8% of the A-I group and 8.2% of the BI group but in only 3.3% of the T group and 1.8% of the C group (P = .028). Operating time was significantly longer for the A-I group than for the BI, T, or C groups (258 minutes vs 156, 179, and 174 minutes). Median blood loss, intensive care unit use, and hospital stays were markedly and significantly reduced in all endograft groups compared with the control group. The incidences of type I endoleak at 1 year were 2.4% A-I, 2.3% BI, and 3.8% T, and no ruptures occurred in any of the patients treated with endografts. No femoral-femoral graft thromboses occurred in the A-I group. Conclusion: Despite the fact that patients with combined aortic and iliac aneurysms have a more complex repair requirement and have an increased rate of comorbidity, the results are competitive with endovascular repair of aortic aneurysm by tube and bifurcated graft systems and are associated with a lower morbidity than open operation. (J Vasc Surg 2001;33:S11-20.)

Purpose: We developed and applied a method for providing regional spinal cord hypothermia with epidural cooling (EC) during thoracoabdominal aneurysm (TAA) repair. Preliminary results indicated significant reduction in spinal cord ischemic complications (SCI), compared with historical controls, and a 5-year experience with EC was reviewed. Methods: From July 1993 to September 1998, 170 patients with thoracic aneurysms (n = 14; 8.2%) or TAAs (types I and II, n = 83 [49%]; type III, n = 66 [39%]; type IV, n = 7 [4.1%]) were treated with EC. An earlier aneurysm resection was noted in 44% of patients, an emergent operation was noted in 20% of patients, and an aortic dissection was noted in 16% of patients. The EC was successful (mean cerebrospinal fluid [CSF] temperature at cross-clamp, 26.4 ± 3°C) in 97% of cases, with all 170 patients included in an intention-to-treat analysis. The operation was performed with a clamp/sew technique (98% patients) and selective (T9 to L1 region) reimplantation of intercostal vessels. Clinical and EC variables were examined for association with operative mortality and SCI by means of the Fischer exact test, and those variables with a P value less than.1 were included in multivariate logistic regression analysis. Results: The operative mortality rate was 9.5% and was weakly associated (P =.07) with SCI; postoperative cardiac complications (odds ratio [OR], 35.3; 95% CI, 5.3 to 233; P

Objective: The purpose of this study was to determine the early efficacy of endovascular aortouniiliac stent grafts with femorofemoral bypass graft in the treatment of aortoiliac aneurysmal disease. Methods: We analyzed 51 consecutive patients from January 1997 to March 1999 with a mean follow-up of 15.8 months. Patients ranged in age from 44 to 93 years (mean, 75 years) with a mean aortic aneurysm diameter of 6.2 cm. Technical success was achieved in 50 patients; one patient required conversion to open repair intraoperatively. We placed 28 custom-made and 22 commercial devices. The mean operative time was 223 minutes. The endograft was extended to the external iliac artery in 42% of cases. The contralateral common iliac artery was occluded using either a closed covered stent or intraluminal coils. Results : The median hospital stay was 4 days with an average intensive care unit stay of 0.25 days. There were no operative mortalities. Two patients died during follow-up from unrelated conditions. Endoleaks occurred in 11 patients (22%); seven patients (14%) required intervention (four catheter based, three operative). Other complications occurred in 38% of patients but were largely remote or wound related. One femorofemoral bypass graft occluded immediately postoperatively as a result of an intraprocedural external iliac dissection yielding a 98% primary patency and 100% secondary patency. Clinical success was achieved in 88% of patients. Conclusions: These data suggest that this strategy represents a reliable method of repair of aortoiliac aneurysmal disease and extends the capability of an endoluminal approach to patients with complex iliac anatomy. (J Vasc Surg 2000;31:1135-41.)

PURPOSE To determine the clinical outcome of hypogastric artery occlusion in patients who underwent endovascular treatment of aortoiliac aneurysmal disease. MATERIAL AND METHODS From January 1994 to March 1998, 94 patients underwent endovascular treatment of aneurysmal diseases involving the infra-abdominal aorta or iliac arteries. Preoperative and intraoperative radiologic data were reviewed. Discharge summaries, clinic visits, and phone calls formed the basis for clinical follow-up, with a mean follow-up period of 7.3 months (range, 1–24 months). RESULTS Because of the anatomy of the aneurysms, 28 patients required occlusion of one or more hypogastric arteries. One of the 28 patients died of unrelated causes before follow-up. Seven (26%) of the remaining 27 patients developed symptoms attributable to the hypogastric artery occlusions. Five patients developed new buttock or thigh claudication; of these five patients, three with initially mild symptoms noted complete or near complete resolution of symptoms upon follow-up. One patient with originally significant claudication at 2-year follow-up noted near resolution of symptoms. The other patient with severe pain did not improve significantly on final 1-year follow-up before his death (of unrelated causes). Other clinical complications were worsening sexual function in one patient and a nonhealing sacral decubitus ulcer that developed in a debilitated patient in the postoperative setting, which required surgery. No bowel ischemia was observed. CONCLUSION When treating aortoiliac aneurysmal disease through an endovascular approach, the occlusion of internal iliac artery is often necessary but carries with it a small but finite chance of morbidity.

The Vanguard prosthesis (Boston Scientific Vascular, Natick, MA) has been in clinical use since 1996 for endoluminal repair of abdominal aortic aneurysm, with more than 3,500 implants worldwide. The device is a second-generation modular stent-graft consisting of a nitinol metal framework covered with polyester graft material. Proximal aneurysm neck diameters of 20 to 25 mm and lengths of greater than or equal to 15 mm are required for both the tube and bifurcated stent-graft. An infra-aneurysmal neck with the same dimensions allows placement of tube stent-graft. Neck angulation of greater than 60° and/or iliac artery angulation greater than 90° are exclusion criteria. Iliac artery attachment sites must be less than or equal to 13 mm in diameter and greater than or equal to 15 mm in length. Distal limb extensions and a proximal cuff are available. Careful preprocedural imaging and planning ensures a smooth, successful procedure. Flushing the preloaded delivery systems with iced saline before insertion in the body is an important feature of the Vanguard stent-grafts. The delivery process is simple, requiring withdrawal of an outer sheath while maintaining stability of the entire system. Intraprocedural problems such as negotiating an angled neck, proximal and distal leaks, difficult cannulation of the contralateral stump, and long or short grafts are discussed.

Purpose: Contrast arteriography is the accepted gold standard for diagnosis and treatment planning in patients with atherosclerotic renovascular disease (RVD). In this study, the results of a selective policy of surgical renal artery reconstruction (RAR) with magnetic resonance angiography (MRA) as the sole preoperative imaging modality are reviewed. Methods: From May 1993 to May 1998, 25 patients underwent RAR after clinical evaluation, and aortic/renal MRA performed with a gadolinium-enhanced and 3-dimensional phase contrast technique. Clinical presentations suggested severe RVD in all patients and included poorly controlled hypertension (16 patients), hospitalization for hypertensive crises and/or acute pulmonary edema (13), and deterioration of renal function within one year of operation (15). Thirteen patients had associated aortic pathologic conditions (12 aneurysms, 1 aortoiliac occlusive disease), and eight of these patients also underwent noncontrast computed tomography scans. Significant renal dysfunction (serum creatinine level, ≥2.0 mg/dL) was present in all but 4 patients with 14 of 25 patients having extreme (creatinine level, ≥3.0 mg/dL) dysfunction. Results: Hemodynamically significant RVD in the main renal artery was verified at operation in 37 of 38 reconstructed main renal arteries (24/25 patients). A single accessory renal artery was missed by MRA. RAR was comprehensive (bilateral or unilateral to a single-functioning kidney) in 21 of 25 patients and consisted of hepatorenal bypass graft (3 patients), combined aortic and RAR (13 patients), isolated transaortic endarterectomy (8 patients), and aortorenal bypass graft (1 patient). Early improvement in both hypertension control and/or renal function was noted in 21 of 25 patients without operative deaths or postoperative renal failure. Sustained favorable functional results at follow-up, ranging from 5 months to 4 years, were noted in 19 of 25 patients. Conclusion: MRA is an adequate preoperative imaging modality in selected patients before RAR. This strategy is best applied in circumstances where the clinical presentation suggests hemodynamically significant bilateral RVD and/or in patients at substantial risk of complications from contrast angiography. (J Vasc Surg 1999;29:1012-21.)

Purpose: To determine the safety, effectiveness, and problems encountered with endovascular repair of abdominal aortic aneurysm (AAA). Initial experience with endoluminal stent grafts was examined and compared with outcome for a matched concurrent control group undergoing conventional operative repair of AAA. Methods: Over a 3-year period, 30 patients underwent attempts at endovascular repair of infrarenal AAA. Of the 28 (93%) successfully implanted endografts, 8 were tube endografts, 8 bifurcated grafts, and 12 aortouniiliac grafts combined with femorofemoral bypass. Most of the procedures were performed in the past year because the availability of bifurcated and aortoiliac endografts markedly expanded the percentage of patients with AAA who might be treated with endoluminal methods. The follow-up period ranged from 1 to 44 months, with a mean value of 11 months. Results: Endovascular procedures demonstrated significant advantages with respect to reduced blood loss (408 versus 1287 ml), use of an intensive care unit (0.1 versus 1.75 days), length of hospitalization (3.9 versus 10.3 days), and quicker recovery (11 versus 47 days). Although the total number of postoperative complications was identical for the two groups, the nature of the complications differed considerably. Local and vascular complications characteristic of endovascular repair could frequently be corrected at the time of the procedure and tended to be less severe than systemic or remote complications, which predominated among the open surgical repair group. On an intent-to-treat basis, 23 (77%) of the 30 AAAs were successfully managed with endoluminal repair. The seven (23%) failures were attributable to two immediate conversions caused by access problems, three persistent endoleaks, one late conversion caused by AAA expansion, and one late rupture. Conclusions: Although less definitive than those for conventional operations, these early results suggest that endovascular AAA repair offers considerable benefits for appropriate patients. The results justify continued application of this method of AAA repair, particularly in the treatment of older persons at high risk. (J Vasc Surg 1998;27:992-1005.)

Purpose: Telemedicine coupled with digital photography could potentially improve the quality of outpatient wound care and decrease medical cost by allowing home care nurses to electronically transmit images of patients' wounds to treating surgeons. To determine the feasibility of this technology, we compared bedside wound examination by onsite surgeons with viewing digital images of wounds by remote surgeons. Methods: Over 6 weeks, 38 wounds in 24 inpatients were photographed with a Kodak DC50 digital camera (resolution 756 × 504 pixels/in2). Agreements regarding wound description (edema, erythema, cellulitis, necrosis, gangrene, ischemia, and granulation) and wound management (presence of healing problems, need for emergent evaluation, need for antibiotics, and need for hospitalization) were calculated among onsite surgeons and between onsite and remote surgeons. Sensitivity and specificity of remote wound diagnosis compared with bedside examination were calculated. Potential correlates of agreement, level of surgical training, certainty of diagnosis, and wound type were evaluated by multivariate analysis. Results: Agreement between onsite and remote surgeons (66% to 95% for wound description and 64% to 95% for wound management) matched agreement among onsite surgeons (64% to 85% for wound description and 63% to 91% for wound management). Moreover, when onsite agreement was low (i.e., 64% for erythema) agreement between onsite and remote surgeons was similarly low (i.e., 66% for erythema). Sensitivity of remote diagnosis ranged from 78% (gangrene) to 98% (presence of wound healing problem), whereas specificity ranged from 27% (erythema) to 100% (ischemia). Agreement was influenced by wound type (p < 0.01) but not by certainty of diagnosis (p > 0.01) or level of surgical training (p > 0.01). Conclusions: Wound evaluation on the basis of viewing digital images is comparable with standard wound examination and renders similar diagnoses and treatment in the majority of cases. Digital imaging for remote wound management is feasible and holds significant promise for improving outpatient vascular wound care. (J Vasc Surg 1998;27:1089-1100.)

Recent randomized prospective trials have defined more clearly the role of carotid endarterectomy (CEA) in both symptomatic and asymptomatic patients.1-4 Simultaneously, technical refinements in the use of carotid noninvasive (CNIE) examination for diagnosing and categorizing carotid artery disease have changed the role of CNIE in the eyes of many vascular surgeons. Once seen primarily as a screening tool for selecting patients for more accurate invasive testing, CNIE now has the capability, in some situations, to serve as the sole diagnostic study, by supplying the information needed to make treatment decisions in patients with known or suspected carotid disease. For the last decade reports have appeared in the literature suggesting that under certain circumstances, relying on CNIE as the sole diagnostic study for selecting patients for CEA was not only feasible, but beneficial in terms of morbidity and cost.5 Simultaneously, evolution in the technical aspects of CNIE have both improved its accuracy and ...

Purpose: We conducted a prospective study to clarify the clinical utility of magnetic resonance angiography (MRA) in the treatment of patients with lower extremity arterial occlusive disease. Methods: During the interval of September 1993 through March 1995, 79 patients (43% claudicants, 57% limb-threatening ischemia) were studied with both MRA and contrast arteriography (ANGIO) and underwent intervention with either balloon angioplasty (9%), surgical inflow (28%), or outflow (63%) procedures. MRA and ANGIO were interpreted by separate blinded vascular radiologists, and arterial segments from the pelvis to the foot were graded as normal or with increasing degrees of mild (25% to 50%), moderate (51% to 75%), or severe (75% to 99%) stenosis or occlusion. Treatment plans were formulated by the attending surgeon and were based initially on hemodynamic, clinical, and MRA data and thereafter with ANGIO. Additional study surgeons formulated independent and specific treatment plans based on MRA or ANGIO alone. Indexes of agreement (beyond chance) for arterial segments depicted by MRA and ANGIO were assessed (kappa value), and treatment plans formulated were compared (χ-square). Results: Precise agreement (%) and the percent of major discrepancies (segment classified as normal/mild stenosis on one study and severe stenosis/occlusion on the other) between MRA and ANGIO for respective arterial segments was as follows: common and external iliacs (n = 256) 77/3.5; superficial femoral and above-knee popliteal (n = 255) 73/6.7; below-knee popliteal (n = 131) 84/3.8; infrapopliteal runoff vessels (n = 864) 74/12.4; pedal vessels (n = 111) 69/19.8 Kappa values indicated moderate agreement (between MRA and ANGIO) beyond chance for all arterial segments. Treatment plans formulated by the attending surgeon, the MRA surgeon, and the ANGIO surgeon agreed in more than 85% of cases. Inability of MRA to assess the significance of inflow disease and inadequate detail of tibial/pedal vessels were the principal deficiencies of MRA in those cases where it was considered an inadequate examination. Conclusion: These findings suggest MRA and ANGIO are nearly equivalent examinations in the demonstration of infrainguinal vascular anatomy. MRA is an adequate preoperative imaging study (and may replace ANGIO), particularly in those circumstances when the risk of ANGIO is increased or when clinical and hemodynamic evaluation predict the likelihood of straightforward aortofemoral or femoral-popliteal reconstruction. (J Vasc Surg 1997;25:380-9.)