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Between 1986 and 2005, 22 patients (mean age, 14.7 years; range, 3-21) with renal hypertension underwent renal artery revascularization for 28 lesions, 23 with open repair (OR) and 5 with percutaneous transluminal renal angioplasty (PTRA). Thirty-day morbidity was 17% (4/23). Hypertension was cured in 13 (57%), improved in 8 (38%), and unchanged in 1 (5%). Renal function worsened in 1. At a mean follow-up of 4.9 years, 1-year patency rate was 94% and maintained for 5 years. Hypertension at 1 year was cured in 6 of 14 patients (43%; OR, 4; PTRA, 2) and improved in 8 (57%; OR, 7; PTRA, 1); hypertension at 5 years was cured in 50% and improved in 50%. Renal function remained unchanged in all patients who were followed. The authors conclude that both OR and PTRA benefit pediatric patients. PTRA for selected patients may be promising as a first line treatment or as a bridge to definitive OR in children with small arteries. [ABSTRACT FROM AUTHOR]

Anatomic compression of the left renal vein in the angle between the aorta and superior mesenteric artery may be asymptomatic or may result in symptoms, including flank pain, hematuria, or pelvic pain and/or congestion. Patients can be referred to a vascular surgeon due to symptoms and/or radiologic findings. Because symptoms of nutcracker syndrome can be vague and/or nondiagnostic, careful evaluation, assessment, and counseling with patients are required before undertaking intervention, which is often an open surgical procedure. The definitive diagnosis is ideally confirmed with diagnostic venography, including pressure measurements from the left renal vein and inferior vena cava. The optimal treatment includes open decompression of the left renal vein with renal vein transposition or gonadal vein transposition, with or without concomitant management of pelvic varicosities if symptomatic. Because most patients with nutcracker syndrome are young, long-term follow-up with scheduled ultrasound examinations should be maintained., Competing Interests: None., (© 2023 The Author.)

This article provides an overview of acute mesenteric ischemia, chronic mesenteric ischemia, and visceral aneurysms, with a focus on treatment. Acute mesenteric ischemia can be a challenging diagnosis. Early recognition and adequate revascularization are key to patient outcomes. Chronic mesenteric ischemia is a more insidious process, typically caused by atherosclerosis. Various options for revascularization exist, which must be tailored to each patient. Visceral aneurysms are rare and the natural history is not well defined. However, given the risk of rupture and high mortality, treatment may be complex., (Copyright © 2023 Elsevier Inc. All rights reserved.)

In this article, we compare and contrast methods of reviewing, summarizing, and synthesizing the literature, including systematic reviews, scoping reviews, and narrative reviews. Review articles are essential to help investigators wade through the plethora of exponentially growing medical literature. In the era of evidence-based medicine, a systematic approach is required. A systematic review is a formalized method to address a specific clinical question by analyzing the breadth of published literature while minimizing bias. Systematic reviews are designed to answer narrow clinical questions in the PICO (population, intervention, comparison, and outcome) format. Alternatively, scoping reviews use a similar systematic approach to a literature search in order to determine the breadth and depth of knowledge on a topic; to clarify definitions, concepts, and themes; or sometimes as a precursor to a systematic review or hypothesis generator to guide future research. However, scoping reviews are less constrained by a priori decisions about which interventions, controls, and outcomes may be of interest. Traditional narrative reviews still have a role in informing practice and guiding research, particularly when there is a paucity of high-quality evidence on a topic., (Copyright © 2022. Published by Elsevier Inc.)

Background: Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting., Methods: Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed., Results: A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%-21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality ( P <0.01), whereas mortality was 3% in a score ≤9. Early complications occurred in 140 (73%) patients and included respiratory complications in 45 patients (22%) and spinal cord ischemia in 22 (11%), of whom 10 (45%) fully recovered. At 5 years, survival was 61±5%, primary graft patency was 90±2%, and secondary patency was 93±2%. The most significant predictor of late mortality was renal insufficiency ( P <0.0001)., Conclusions: Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers' experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

Objectives: To assess the ability of the current classification system for popliteal entrapment syndrome to accurately capture all patients, and if not, to design an all-inclusive new classification., Methods: Retrospective review of all interventions performed for popliteal entrapment syndrome between 1994 and 2013 at our institution was performed. Preoperative imaging and intraoperative findings were used to establish the compressive morphology of popliteal entrapment syndrome. Patients were categorized, when possible, into six types of the current classification system (Rich classification, modified by Levien) and into seven types of a new classification., Results: Sixty-seven limbs of 49 patients were operated on for unilateral (31) or bilateral (18) popliteal entrapment syndrome. The current classification system captured the anatomy of only 43 (64%) of 67 limbs with popliteal entrapment syndrome. Compressive morphologies without a defined class included aberrant insertion of the lateral head of gastrocnemius muscle, muscle slip originating from the lateral head of gastrocnemius or hamstrings, hypertrophied hamstring muscle, abnormal fibrous bands, perivascular connective tissue, and prominent lateral femoral condyle. The new classification captured 100% of the limbs with popliteal entrapment syndrome., Conclusions: Current classification of popliteal entrapment syndrome is inadequate as more than one-third of the cases reviewed fell outside of the standard classification system. Consideration of a more inclusive new anatomic classification system is warranted.

Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for the treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were reported. Since the 2011 guidelines, several studies and a few systematic reviews comparing CEA and CAS have been reported, and the role of medical management has been reemphasized. In the present publication, we have updated and expanded on the 2011 guidelines with specific emphasis on five areas: (1) is CEA recommended over maximal medical therapy for low-risk patients; (2) is CEA recommended over transfemoral CAS for low surgical risk patients with symptomatic carotid artery stenosis of >50%; (3) the timing of carotid intervention for patients presenting with acute stroke; (4) screening for carotid artery stenosis in asymptomatic patients; and (5) the optimal sequence of intervention for patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (grades of recommendation assessment, development, and evaluation) approach, as was used for other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low-risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin scale score, 0-2), carotid revascularization is considered appropriate for symptomatic patients with >50% stenosis and should be performed as soon as the patient is neurologically stable after 48 hours but definitely <14 days after symptom onset. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients with an increased risk of carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. For patients with symptomatic carotid stenosis of 50% to 99%, who require both CEA and coronary artery bypass grafting, we suggest CEA before, or concomitant with, coronary artery bypass grafting to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on the clinical presentation and institutional experience., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The role of inferior mesenteric artery (IMA) reimplantation during open aortic reconstruction is debated. We assessed outcomes after inferior mesenteric artery reimplantation (IMAR) for aortic aneurysmal disease to help shed light on this question., Methods: A single-center retrospective review of all IMARs performed during open aortic surgery over a 10-year period between 2000 and 2009 was carried out. The primary outcome was patency, while secondary outcomes included colonic ischemia and overall survival. Analysis was performed using Cox models and Kaplan-Meier estimates., Results: Of 840 patients who underwent elective abdominal aortic aneurysm (AAA) reconstructions during this period, 70 underwent IMAR. Indications for IMAR included intraoperative colonic ischemia (n = 24), poor back bleeding (n = 52), large IMA (n = 5), internal iliac disease (n = 5), and prior colon surgery (n = 1). Follow-up imaging studies were available in 35 of 70 patients (computed tomography in 30 [86%] and duplex in 5 [14%]). Patency was confirmed in 32 of 35 patients (91%) over a median follow-up of 98 months. Both losses in patency were at 4 months and did not require an operation. One patient underwent left colon resection on postoperative day 9 because of ischemia. (Patency could not be confirmed.) No statistically significant predictor of patency was noted. Incidence of colonic ischemia was 1.4% in patients undergoing IMAR. The overall mortality was 51% in patients undergoing IMAR over the median follow-up period. The overall 10-year survival was 30% in patients undergoing IMAR for aortic aneurysmal disease. The nature of aneurysm (juxtarenal or higher juxta renal abdominal aortic aneurysm [JRAAA]) was associated with mortality, with a hazard ratio of 1.8 (P = 0.08) approaching significance. Ten-year survival was worse if IMAR was performed for intraoperative colonic ischemia (26% vs 34%) or in JRAAA (19.0% vs 38%; P = 0.03). Age per year at the time of repair was the only statistically significant predictor of survival (P < 0.001)., Conclusion: IMAR for AAA remains necessary for select patients. Reimplantation is associated with excellent long-term patency and low risk of colonic ischemia., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The training of vascular surgeons in Canada has evolved over the past decade. Direct entry into a vascular surgery training program after medical school has been offered since 2012. At some institutions, it is the only option for surgery training. The smaller population of Canada and a single-payer health care system has resulted in unique opportunities and challenges for the training of vascular surgeons and providing opportunities for trainees to transition into clinical practice., (Copyright © 2019. Published by Elsevier Inc.)

Background: Cervical rib can often be symptomatic causing neurogenic thoracic outlet syndrome (nTOS). Surgical treatment involves rib resection through a supraclavicular, transaxillary or combined approach. We review outcomes of different approaches and describe our technique of transaxillary resection through a video., Methods: A single-center retrospective review of perioperative and short-term outcomes in subjects undergoing cervical rib resection for nTOS between 1994 and 2013 was performed., Results: Of the 75 operations performed for nTOS, 40% (30 procedures in 29 patients) required resection of cervical ribs. The first and cervical ribs were removed in 24 operations, whereas only the cervical rib was resected in 6. Scalenectomy was performed in all patients. Thirteen (43%) procedures were performed with a supraclavicular-only (SC group) approach, 9 (30%) with a transaxillary-only (TA group) approach, and 8 (27%) with a combined approach (TA + SC group). Incidence of persistent nTOS symptoms occurred in 3 (23%) of SC patients, 1 (13%) TA patient, and 2 (25%) TA + SC patients (P > 0.05). Recurrence of symptoms was noted in one patient (8%) in the SC group at 1-year follow-up. No patient required operative reintervention., Conclusions: Resection of cervical ribs and/or first ribs in the treatment of nTOS can be safely performed through SC, TA, or a combined approach. In young patients, a TA incision should be considered to avoid a neck incision, with outcomes similar to alternate approaches., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to define outcomes after carotid endarterectomy (CEA) in patients with symptomatic carotid artery stenosis (CAS) when patients are operated on within 14 days after onset of symptoms., Methods: Clinical data of consecutive patients who underwent CEA between 2003 and 2012 for symptomatic CAS were reviewed. Patients were classified into group 1, CEA ≤14 days of minor stroke or transient ischemic attack, and group 2, CEA >14 days. Primary end point was stroke/death; secondary end points were stroke, death, and myocardial infarction., Results: There were 233 patients (32% female; mean age, 72 ± 9.1 years) who underwent 238 CEAs. Group 1 included 57 CEAs in 56 patients; 11 CEAs were performed at 0 to 2 days, 23 at 3 to 7 days, and 23 at 8 to 14 days. Group 2 included 181 CEAs in 177 patients. One death (group 2) and five strokes (group 1, four; group 2, one) occurred at 30 days (stroke/death, 2.6%), more in group 1 vs group 2 (7.1% vs 1.1%; P = .03). In group 1, three strokes occurred when the patients were operated on within 2 days (27% [3/11]), more than at 3 to 7 days (0% [0/22]) or 8 to 14 days (4.3% [1/23]; P = .008). Patients operated on between days 3 and 14 had similar stroke/death rate to those operated on after 14 days (2.2% vs 1.1%; P = .49). Myocardial infarction occurred in six patients (2.5%; group 1, 0% [0/57]; group 2, 3.3% [6/177]; P = .34). Median follow-up was 7.0 years (interquartile range, 4.6-9.9 years). Freedoms from stroke/death were similar between groups (hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.75-1.99; P = .42), 69% for group 1 and 76% for group 2 at 5 years. Age ≥80 years, high surgical risk, and no preoperative P2Y 12 antagonist use predicted stroke/death. Freedoms from any stroke were similar in groups (HR, 2.46; 95% CI, 0.95-6.41; P = .06); survivals were also similar (HR, 1.12; 95% CI, 0.67-1.87; P = .67) at 5 years., Conclusions: In this single-center study, CEA in symptomatic patients had a 30-day stroke/death rate of 2.6%. Age ≥80 years and high surgical risk predicted late stroke or death; taking P2Y 12 antagonists was associated with late stroke. High stroke rates when patients were operated on immediately support CEA after 2 days in symptomatic patients with CAS., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare outcomes after repair of type III and type IV thoracoabdominal aortic aneurysms (TAAAs) by three different open surgical techniques at a tertiary care institution., Methods: Consecutive patients who underwent elective repair of type III and type IV TAAAs at our institution between 1999 and 2011 were retrospectively reviewed. Patients were divided into three groups according to surgical technique: clamp and sew (CS), left-sided heart bypass (LHB), and visceral branching (VB) followed by aortic reconstruction. Primary end points were early mortality and complications; secondary end points were need for blood transfusion, duration of operation, and long-term survival., Results: Between 1999 and 2011, there were 121 consecutive patients (83 men, 38 women) with 52 type III and 69 type IV TAAAs who underwent elective repair (CS, 65 patients; LHB, 31 patients; VB, 25 patients). Perioperative spinal drainage was used in 84%. Procedure duration was longest in the VB group (mean, 9.1 hours vs 7.7 hours and 5.7 hours for CS and LHB; P < .001), but transfusion requirement was largest in the LHB group (mean, 3.5 L vs 1.7 L and 2.1 L for CS and VB; P = .015). Mean duration of mesenteric ischemia was significantly shorter in the VB group vs CS and LHB (18 minutes vs 35 minutes for CS and 30 minutes for LHB; P < .0001). Mean intensive care unit and hospital stays were the same (9, 10, and 8 days [P = .82]; 18, 20, and 18 days [P = .76]). Overall 30-day mortality was 6.6%, not different between groups (6%, 10%, and 4%; P = .68). Mean follow-up was 45 ± 42 months, and actuarial overall survival at 3 and 5 years was 70% and 64%, with no difference between groups (P = .36)., Conclusions: For repair of type III and type IV TAAAs, the sequential VB technique has the longest duration, but it has the advantage of the shortest mesenteric and visceral ischemia times without improvement in early outcomes. Irrespective of the techniques used, complications, early mortality, risk of spinal cord injury, and survival were the same., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to define outcome of treatments of refractory chylous ascites using peritoneovenous shunts (PVSs)., Methods: Clinical data of patients with refractory chylous ascites treated with PVSs between 1992 and 2015 were retrospectively reviewed. The primary end point was clinical benefit, defined as cured, improved, or poor results; secondary end points were complications and reinterventions., Results: Seventeen patients (eight female [47%]; median age, 47 years [range, 19-78 years]) with refractory chylous ascites were studied. This group represented 6% of 284 patients treated for chylous ascites during the study period. The etiology was primary lymphangiectasia in 10 patients (59%) and secondary chylous ascites due to previous surgery, lymphatic obstruction with associated portal hypertension, or malignant tumor in 7 (41%). Eleven patients were treated with LeVeen shunts and six with Denver shunts. Thirty-day mortality, morbidity, and reintervention rates were 5.9%, 18%, and 12%, respectively. Reintervention rate at 6 months was 9.1% with LeVeen shunt, significantly lower than 100% with Denver shunt (P = .001). During a mean follow-up of 5.1 years (range, 17 days-22.7 years), 7 of 11 patients with LeVeen shunt and all 6 patients with Denver shunt required shunt replacement. Median duration of patency was 215 days (range, 2 days-9.0 years) of a total of 25 LeVeen shunts placed in 11 patients and 44 days (range, 6-91 days) of 20 Denver shunts placed in 6 patients. At last follow-up, patency of the LeVeen shunt was 36% (4/11); symptoms improved in 64% of the patients (7/11). Patency rate of Denver shunts was 33% (2/6), and symptoms improved in 33% (2/6)., Conclusions: Treatment of refractory chylous ascites continues to be a major challenge. The only currently available PVS, the Denver shunt, had a median patency period of <2 months; it required frequent replacements and resulted in intermittent short-term clinical benefit in one-third of the patients. Improvements in technology to design new shunts, to develop new therapies, or to adopt new techniques to treat chylous ascites are urgently needed., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate whether maximal aortic diameter affects outcome after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA)., Methods: Clinical data of patients undergoing EVAR between 1997 and 2011 for nonruptured asymptomatic AAAs in a tertiary center were reviewed. Patients were classified according to diameter of AAA: group 1, <5.0 cm; group 2, 5.0 to 5.4 cm; group 3, 5.5 to 5.9 cm; and group 4, ≥6.0 cm. The primary end point was all-cause mortality; secondary end points were complications, reinterventions, and ruptures., Results: There were 874 patients studied (female, 108 [12%]; group 1, 119; group 2, 246; group 3, 243; group 4, 266); mean age was 76 ± 7.2 years. The 30-day mortality rate was 1.0%, not significantly different between groups (P = .22); complication and reintervention rates were 13% and 4.1%, respectively, similar between groups (P < .05). Five-year survival was 68%; freedom from complications and reinterventions was 65% and 74%, respectively; rupture rate was 0.5%. Multivariate analysis revealed that factors associated with all-cause mortality included maximal aortic diameter, age, gender, surgical risk, cancer history, and endograft type (P < .05). Group 4 had increased risks of mortality (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.38-2.85; P = .002) and complications (HR, 1.6; 95% CI, 1.2-2.7; P = .009) relative to group 1. Reinterventions were more frequent for aneurysms ≥6.0 cm (HR, 2.0; 95% CI, 1.2-3.3; P = .01). Late rupture rate after EVAR was not different between groups., Conclusions: Maximal aortic diameter is associated with long-term outcomes after elective EVAR. Patients with large AAAs (≥6.0 cm) have higher all-cause mortality, complication, and reintervention rates after EVAR than those with smaller aneurysms. We continue to recommend that AAAs be repaired when they reach 5.5 cm as recommended by the guidelines of the Society for Vascular Surgery. On the basis of our data, EVAR should be considered even in high-risk patients with a maximal aortic diameter between 5.5 and 6.0 cm because surgical risk with aneurysm size above 6.0 cm will increase significantly., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Popliteal artery aneurysms (PAAs) in women are rare and their outcomes compared with men with PAA are unknown. The purpose of this study was to compare the surgical outcomes of PAA of women with men., Methods: All patients who underwent PAA repair at a single institution from 1985 to 2013 were reviewed. All women with degenerative PAA treated during that time frame were matched on year of repair to men. Presentation, mode of repair, and outcomes were reviewed. Survival and amputation-free survival were evaluated by life table analysis., Results: During the study interval, 8 women with degenerative PAA underwent surgical treatment (1.6% of 485 total PAA repairs). The overall median follow-up was 5 years (range 1 month to 19 years), but the median follow-up was shorter for women than men (1.6 vs. 6 years, P = 0.04). At the time of repair, women were of similar age compared with men (73.5 vs. 71.7 years) and had similar aneurysm size (2.7 vs. 2.9 cm). Women had similar urgency (25 vs. 17.5% emergent) and symptomatic status (50% vs. 55% acute) even though 7 of the 8 women had a thrombosed PAA at the time of repair. Operative time, approach, graft type, and inflow and outflow sources were similar between genders. No women received endovascular repair (0% vs. 10%, P = 0.5). One patient of each gender underwent major amputation (one woman on post-operative day 158 and one man on post-operative day 3). Overall, women had lower survival and amputation-free survival at 2 years (51% vs. 100% and 20% vs. 94%, P < 0.01 for both, standard error 0.2)., Conclusions: PAA requiring intervention in women is a rare clinical occurrence. Although our series is limited, women requiring PAA repair had higher long-term mortality compared with men with a similar pathology and treatment strategy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to develop a surgical site infection (SSI) prediction score for risk assessment before elective vascular surgery., Methods: We conducted a nested case-control study among patients who underwent elective vascular (abdominal aortic and peripheral arterial) surgery from January 1, 2003, to December 31, 2007, at Mayo Clinic (Rochester, Minn) an academic tertiary surgical center. Cases were patients with SSI requiring hospitalization; controls (one or two per case) were matched on type of procedure and date of surgery. Clinical data were collected by chart review. A risk score based on preoperative variables was developed using multivariable logistic regression and bootstrap resampling. The C statistic, equivalent to the area under the receiver operating characteristic curve, was used to assess discrimination. Calibration was assessed by plotting percentile risk groups of model-predicted values against observed proportions of subjects with SSI., Results: Eighty-four cases were compared with 160 controls. Preoperative variables independently associated with SSI risk were critical limb ischemia, previous SSI, prior revascularization procedure, and chronic obstructive pulmonary disease. A prediction model containing these variables was developed (model and risk score C statistic of 0.737 and 0.727, respectively). The calibration curve did not appear to deviate appreciably from the 45-degree line of identity., Conclusions: We developed an SSI risk score based on noninvasive preoperative variables with acceptable discrimination and calibration. This tool needs prospective and external validation., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this report was to define the natural history of penetrating aortic ulcers (PAUs) in the descending thoracic and abdominal aorta., Methods: Data from consecutive patients with PAU from January 1, 1998 to December 31, 2012 were retrospectively reviewed. Computed tomography (CT) scans were analyzed for anatomic changes. End points analyzed were changes in size, development of symptoms or signs of rupture, morbidity, and mortality., Results: Ninety-three patients were identified; 57 were followed up with two or more CT studies 3 months apart (group 1), and 20 had immediate repair (group 2). Sixteen had one CT scan and no intervention or follow-up and were excluded from analysis. In group 1, mean age was 75 years (29 men, 28 women), with 28 descending thoracic aorta and 29 abdominal aorta PAUs. Fifty patients were asymptomatic, whereas five had pain and two had emboli. Mean follow-up was 38 months (range, 3-108 months). Ulcer growth rate was as follows: length, 2.0 mm/y; depth, 1.2 mm/y; and aortic diameter, 2.2 mm/y. Thirteen (23%) went on to repair at a mean of 37 months after diagnosis because of size (54%; 7/13), rapid growth (31%; 4/13), and high-risk morphology (15%; 2/13). During surveillance, 11 patients died, 10 of unrelated causes, and 1 of rupture after refusing repair. All repairs in group 1 were endovascular. The 30-day surgical mortality was 0%. One patient had an access site complication requiring bypass after descending thoracic aorta PAU repair. At a mean follow-up of 32 months, all ulcers were excluded on CT; one (8%) had a type II endoleak. Group 2 included 13 men and seven women with a mean age of 70 years, with 12 descending thoracic and eight abdominal aorta PAUs. Repair indications were rupture (n = 3), symptoms (n = 10), or size (n = 7) and included one open and 19 endovascular repairs with 0% 30-day mortality. Major complications (3/20; 15%) included myocardial infarction, access site disruption, and hematoma; four of 20 patients had type II endoleaks., Conclusions: PAU growth rate and risk of rupture are low. Endovascular repair of symptomatic, ruptured, and large PAUs is safe and effective with excellent long-term results. For asymptomatic PAUs, serial CT surveillance is associated with a low rate of rupture or complications., (Published by Elsevier Inc.)

Background: Klippel-Trenaunay syndrome (KTS) is a mixed mesenchymal malformation characterised by varicose veins, venous and capillary malformations, and hypertrophy of soft tissue and bone. The purpose of this study was to evaluate the surgical outcomes in KTS patients to provide standards for comparison with endovenous therapy., Methods: The clinical data of consecutive patient with KTS who underwent open venous surgical treatment between January 1987 and December 2008 were reviewed. Demographics, clinical presentation, operative data, and clinical outcomes were recorded. Follow-up information was obtained from the medical records, mailed questionnaires and phone calls. Descriptive statistics, the Kaplan-Meier method and Log-rank statistics were used where appropriate., Results: Twenty-seven females and 22 males, (mean age 26.5 years, range 7.7-55.8) were included in this study. All had varicose veins, 36 (73%) had limb hypertrophy, and 33 (67%) had capillary malformations, with two of three clinical features present in all. The most frequent symptom was pain (N = 43, 88%). Forty-nine patients underwent operations on 53 limbs. Stripping of the GSV, small and accessory saphenous and lateral embryonic veins was performed in 17 (32%), 10 (19%), 9 (17%), and 15 (28%) limbs, respectively. Two patients developed deep vein thrombosis, one had pulmonary embolism (PE), and one patient had peroneal nerve palsy. Freedom from disabling pain at 1, 3 and 5 years was 95%, 77% and 59%, respectively, and freedom from secondary procedures was 78% at 3 years, and 74% at 5 years. At the last follow-up visit, the venous clinical severity score had decreased from 9.48 ± 3.27 to 6.07 ± 3.20 (P < 0.001)., Conclusions: In selected symptomatic patients with KT syndrome, open surgical treatment is safe and durable. Three-fourths of the patients remain free of disabling pain at five years, but secondary procedures are required in one-fourth of the patients. These data can serve as standards for comparison of endovenous therapy for KT syndrome., (© The Author(s) 2015.)

Objective: This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR)., Methods: Patients diagnosed with infected aortic endografts after EVAR/TEVAR between January 1, 2004, and January 1, 2014, were reviewed using a standardized, multi-institutional database. Demographic, comorbidity, medical management, surgical, and outcomes data were included., Results: An aortic endograft infection was diagnosed in 206 patients (EVAR, n = 180; TEVAR, n = 26) at a mean 22 months after implant. Clinical findings at presentation included pain (66%), fever/chills (66%), and aortic fistula (27%). Ultimately, 197 patients underwent surgical management after a mean of 153 days. In situ aortic replacement was performed in 186 patients (90%) using cryopreserved allograft in 54, neoaortoiliac system in 21, prosthetic in 111 (83% soaked in antibiotic), and 11 patients underwent axillary-(bi)femoral bypass. Graft cultures were primarily polymicrobial (35%) and gram-positive (22%). Mean hospital length of stay was 23 days, with perioperative 30-day morbidity of 35% and mortality of 11%. Of the nine patients managed only medically, four of five TEVAR patients died after mean of 56 days and two of four EVAR patients died; both deaths were graft-related (mean follow-up, 4 months). Nineteen replacement grafts were explanted after a mean of 540 days and were most commonly associated with prosthetic graft material not soaked in antibiotic and extra-anatomic bypass. Mean follow-up was 21 months, with life-table survival of 70%, 65%, 61%, 56%, and 51% at 1, 2, 3, 4, and 5 years, respectively., Conclusions: Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

A 4 year old tracheostomy dependent girl with Pfeiffer syndrome was noted on bronchoscopy to have a pulsatile tracheostomal mass. CT chest angiography was consistent with the innominate artery crossing anterior to the trachea and superior to the sternal notch. The patient underwent reimplantation of the innominate artery via a median sternotomy approach. Tracheoinnominate fistula is a potentially devastating complication of tracheostomy. We report discovery of a near tracheoinnominate fistula in order to highlight the importance of regular interval surveillance endoscopy in tracheostomy dependent children and to discuss a preventative surgical intervention employed in prevention of this potentially devastating complication., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: Narrowing of the distal aortic bifurcation can result in stent graft compression or arterial disruption during endovascular aortic aneurysm repair (EVAR). The aim of our study was to evaluate results of EVAR in patients with narrow distal aortic bifurcations., Methods: We reviewed the clinical data of 1070 patients who underwent EVAR between 2000 and 2011. Digital computed tomography angiograms were analyzed using centerline of flow measurements to determine aortic diameters. Patients with a distal aortic bifurcation diameter <18 mm were included in the study. End points were technical success, aortic disruption with retroperitoneal hemorrhage, stent graft complications (endoleaks, migration, sac enlargement, stenosis), reintervention, and iliac limb patency., Results: EVAR was used to treat 112 patients (84 men and 28 women; mean age, 75 years) with aortic bifurcation <18 mm, including 34 (30%) who had diameter of <14 mm. Mean outer and inner aortic bifurcation diameter was 16 ± 3 and 14 ± 2 mm, respectively. Bifurcated stent grafts were used in 106 patients (95%). Six patients (5%) had planned aortouniiliac converters with femoral crossover graft. The aortic bifurcation was dilated after placement of bifurcated stent grafts using kissing balloon angioplasty in 80 patients (75%). All bifurcated stent grafts were successfully implanted, with no conversions to open repair or aortouniiliac converters. There were two early deaths (1.8%), and 12 patients (11%) developed early complications. No aortic disruptions or retroperitoneal hematomas occurred in the group treated with bifurcated grafts. After a median follow-up of 35 months, 11 patients (11%) treated by bifurcated stent grafts required reintervention to treat endoleak (n = 6) or iliac limb stenosis/occlusion (n = 5). One patient (17%) treated by aortouniiliac converter developed critical stenosis of an aortouniiliac graft limb, which was successfully treated with balloon angioplasty 29 months after the initial surgery. At 1 and 5 years, freedom from reintervention was 91% ± 3% and 84% ± 4%, respectively, for bifurcated stent grafts and 100% and 83% ± 10%, respectively, for aortouniiliac converters. Primary and secondary iliac limb patency was 98% ± 3% and 100%, respectively, for bifurcated stent grafts and 83% ± 10% and 100%, respectively, for aortouniiliac converters., Conclusions: EVAR with bifurcated stent grafts is safe and effective in patients with a narrow distal aortic diameter, even when the aortic bifurcation measures <14 mm. Adjunctive balloon dilatation did not result in any bleeding complications from aortic disruption, and limb patency was excellent. Aortouniiliac converters are rarely needed for this indication., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Nutcracker syndrome (NS) is a rare cause of hematuria, flank pain, and renal venous hypertension due to compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery. To evaluate outcomes of open surgery and endovascular interventions, we reviewed our experience., Methods: A retrospective review of clinical data of all patients treated at our institution with an intervention for NS between January 1, 1994, and February 28, 2014, was performed. Primary outcomes were morbidity and mortality. Secondary outcomes included late complications, patency, freedom from reintervention, and resolution of symptoms., Results: Thirty-seven patients (30 female, seven male) with a mean age of 27 years (range, 14-62 years) were treated. The most frequent symptom was flank pain (97%); the most frequent sign was hematuria (68%). NS was diagnosed with duplex ultrasound scanning with measurement of LRV diameters and flow velocities (87%), with computed tomography or magnetic resonance venography (94%), and with contrast venography with measurement of pressure gradients (93%). Initial treatment was open surgery in 36 patients, endovascular in 1. Distal transposition of the LRV into the inferior vena cava (IVC) was performed in 31 patients. Adjunctive procedures to optimize venous outflow included great saphenous vein cuff in six patients, great saphenous vein patch in four, and both cuff and patch in four. Three patients had patch alone; two had transposition of the left gonadal vein into the IVC. Two patients had anterior reimplantation of retroaortic LRV into the IVC. There were no major early complications, renal failure, or mortality. Three patients underwent early reinterventions within 30 days (stent, two; open revision, one). All LRVs and left gonadal veins were patent at discharge. Follow-up was 36.8 ± 52.6 months (range, 1-216 months). Reinterventions after 30 days were performed in eight patients because of LRV stenosis (n = 7) or LRV occlusion (n = 1). One stent migrated into the IVC and required endovascular removal with repeated stenting. Six patients required stenting. Primary, primary assisted, and secondary patencies at 24 months were 74%, 97%, and 100%, respectively. Freedom from reintervention at 12 and 24 months was 76% and 68%, respectively. Resolution of symptoms occurred in 33 patients (87%)., Conclusions: Open surgery, mostly LRV transposition, remains a safe and effective treatment of patients with NS. However, one of three patients after open repair required reintervention, most frequently LRV stenting. Open reconstruction should be tailored to the patient's anatomy, and placement of vein cuff or patch may reduce restenosis. Although renal vein stents improved patency, the safety and durability of currently available stents need to be established., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Single-center experiences with the treatment of infected endografts after endovascular aortic repair (I-EVAR) have been reported. We performed a multicenter review of the surgical care of these patients to elucidate short-term and long-term outcomes., Methods: A retrospective analysis of all EVAR explants from 1997 to 2014 at four institutions was performed. Patients with I-EVAR undergoing surgical treatment were reviewed. Data were obtained detailing preoperative demographics, and postoperative morbidity and mortality., Results: Thirty-six patients (30 male) were treated with endovascular graft excision and revascularization for I-EVAR with a median age of 69 years (range, 54-80 years). Average time from the initial EVAR to presentation was 589 days (range, 43-2466 days). Preoperative comorbidities included hypertension, 32 (89%); tobacco use, 31(86%); coronary artery disease, 26 (72%); hyperlipidemia, 25 (69%), peripheral artery disease, 13 (36%); cerebrovascular disease, 10 (28%); diabetes, 10 (28%); chronic obstructive pulmonary disease, 9 (25%); and chronic kidney disease, 9 (25%). The most common presenting patient characteristics were leukocytosis, 23 (63%); pain, 21 (58%); and fever, 20 (56%), which were present an average of 65 days (range, 0-514 days) before explantation. Nine different types of endograft were removed. Three patients (8%) underwent emergency explantation. Thirty-four patients (89%) underwent total graft excision, and two patients (6%) underwent partial excision. Methods of reconstruction were in situ in 27 (75%) and extra-anatomic in nine (28%). Conduits used were Dacron (DuPont, Wilmington, Del), with or without rifampin, polytetrafluoroethylene, cryopreserved allograft, and femoral vein. Forty-nine organisms grew from operative cultures. Gram-positive organisms were the most common, found in 24 (67%), including Staphylococcus in 13 (36%) and Streptococcus in six (17%). Anaerobes were cultured in 6 patients (17%), gram-negative organisms in 6 (17%), and fungus in 5 (14%). Thirty-one patients (86%) received long-term antibiotics. Early complications included acute renal failure requiring dialysis, 12 (33%); respiratory failure, 3 (8%); bleeding, 4 (11%); and sepsis, 2 (6%). Six patients required re-exploration due to hematoma, infected hematoma, lymphatic leak, bowel perforation, open abdomen at initial operation, and anastomotic bleeding. Perioperative mortality was 8% (3 of 36), and long-term mortality was 25% (9 of 36) at a mean follow-up of 569 days (range, 0-3079 days). Type of reconstruction (in situ vs extra-anatomic) or conduit type did not affect perioperative or overall mortality., Conclusions: I-EVAR is a rare but potentially devastating clinical problem. Although perioperative mortality is acceptable, long-term mortality is high. The most common postoperative complication was acute renal failure requiring dialysis. Although this is the largest series of I-EVAR, further studies are needed to understand the risk factors and preventive measures., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Degenerative hepatic artery aneurysms (HAAs) are an uncommon pathologic process. The aim of this study was to evaluate the approach to and outcomes of operative management of HAA with open techniques (OTs) and endovascular techniques (ETs)., Methods: Twenty-one patients who underwent intervention for HAA from January 1, 1992, to January 30, 2015, at a single institution were retrospectively reviewed. Patient presentation, risk factors, and operative approach were reviewed. The primary outcome was operative morbidity and mortality. Secondary outcomes included long-term survival, patency, and need for reintervention., Results: Of the 21 patients, 14 (67%) were men. The mean age of all patients was 66 years (range, 30-85 years), with a mean HAA size of 45 ± 28 mm (12 common hepatic, 5 common and proper hepatic, 3 right hepatic, and 1 accessory left hepatic). Nine patients (43%) had connective tissue disorders. More than half of the patients (63%) had synchronous aneurysms (29% in the aorta, 24% in the splenic and iliac arteries, and 10% in the celiac arteries). Ten patients (48%) were asymptomatic. Right upper quadrant pain was the most common symptom at presentation (43%), followed by transaminitis (5%) and obstructive jaundice (5%). Five patients (24%) presented with rupture (size, 15-40 mm). OT was performed in 17 patients; 4 patients had ET. Fourteen patients (67%) underwent open reconstruction of the common hepatic (n = 10), the common and proper hepatic (n = 2), and the right and left accessory hepatic arteries (n = 1 each). Seven bypasses were performed with saphenous vein, six with Dacron, and one with polytetrafluoroethylene. Endoaneurysmorrhaphy alone, patch, and ligation were performed in one instance each. Postoperative complications occurred in six patients (29%), including hemorrhage, graft thrombosis, common bile duct stricture that required reoperation, duodenal perforation, and enterocutaneous fistula. ET was attempted in five patients; coil embolization was performed in four patients (two of the common and two of the right hepatic arteries). Overall mortality was 14% (6% after elective OT, 40% for emergency OT, 0% for ET). Mean follow-up was 32 ± 46 months. Overall survival was 86% at 5 years. Primary and secondary graft patency was 86% at 5 years. One patient underwent reintervention because of occlusion of saphenous vein graft., Conclusions: Open repair remains the mainstay treatment for degenerative HAA repairs to preserve arterial flow to the liver, with notable morbidity and mortality, particularly in the setting of rupture. However, coil embolization may be applied safely in select patients with aneurysms not involving the proper hepatic artery if adequate collateral circulation ensures hepatic perfusion., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare outcomes after open repair (OR) vs endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs)., Methods: Clinical data of consecutive patients treated for asymptomatic AAA between 2000 and 2011 were reviewed. Patients were stratified into low/normal-risk (comorbidity score ≤ 10) and high-risk (score > 10) categories. The primary end point was all-cause mortality; secondary end points were complications, reinterventions, conversions, and ruptures. Propensity score-based matching was performed to compare outcomes., Results: There were 1534 patients, of whom 207 were women (13%); 641 (42%) were treated with OR and 893 (58%) with EVAR. After propensity score matching, we selected 558 pairs of OR and EVAR (mean age, 73 ± 7.6 years); 158 were women (14%). The 30-day mortality rate was 1.3% after OR and 0.9% after EVAR (P = .56). In multivariable analysis, only high risk was an independent predictor of early mortality (odds ratio, 4.65; 95% confidence interval [CI], 1.20-18; P = .03). The early complication rate was lower for EVAR (13%; odds ratio, 0.5; 95% CI, 0.4-0.8; P < .001) than for OR (24%). Median follow-up was 7.6 years (31 days-13.1 years). The cumulative 5-year survival rate was 72% after EVAR and 81% after OR (hazard ratio, 1.44; 95% CI, 1.19-1.73; P < .001). The 5-year survival was not significantly different in matched cohorts operated on after 2005 (77% vs 81%; P = .57). High risk, advanced age, cancer history, AAA size, and EVAR predicted all-cause mortality. Freedom from reintervention was 74% after EVAR and 88% after OR (hazard ratio, 2.60; 95% CI, 1.92-3.51; P < .001). Freedom from rupture was 99.2% after EVAR and 99.8% after OR (P = .04). In multivariable models, female gender was associated with complications; EVAR was associated with reinterventions (P < .05)., Conclusions: In this retrospective propensity score-matched study, early mortality was similarly low after both EVAR and OR, significantly different from all except one large randomized controlled trial. EVAR had fewer early complications, but it was associated with late all-cause mortality and reinterventions and had a small but definite risk of late rupture. Significantly increased mortality at 5 years was no longer observed when operations were performed after 2005. High risk, advanced age, cancer history, and AAA size predicted late all-cause mortality. This study failed to confirm early or late survival benefit for EVAR vs OR. Improved surveillance, longer follow-up, and analysis of factors affecting late death in prospective studies are warranted., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Popliteal venous aneurysms (PVAs) are rare; however, they can lead to pulmonary emboli (PEs) and death. The purpose of this study was to review our institutional management of PVA., Methods: All patients with PVA undergoing intervention in our institution were identified over a 15-year period (1998-2013). A retrospective review including clinical presentation, modality of diagnosis, surgical treatment, 30-day morbidity and mortality, and follow-up are reported., Results: Five male and 3 female patients with PVA were identified. Mean age was 38.6 years (range, 14-65). Five patients presented with PE; 1 developed PE while on anticoagulation. Two presented with lower extremity pain. Two patients had PVA found incidentally. Diagnosis of PVA was made by duplex ultrasound (US) in 6 patients, physical examination confirmed with duplex US in 1 patient, and magnetic resonance imaging in 1 patient. Mean aneurysm size was 26 mm (range, 20-37). Four were saccular and 4 fusiform. Three PVAs contained thrombus, including 2 patients presenting with PE and 1 with calf pain. Five patients underwent aneurysmectomy with lateral venorrhaphy, and 3 patients had resection of the aneurysm with interposition vein graft. There were no operative or 30-day mortalities. Two patients with vein grafts had early postoperative complications; one developed a hematoma that required operative evacuation and one had thrombosis of the vein graft requiring thrombolysis. Mean follow-up was 26 months with 87.5% primary patency, 100% secondary patency, and no recurrences., Conclusions: PVAs are rare, but can lead to significant morbidity and death. Based on this small group, aneurysmectomy with lateral venorrhaphy appears to have fewer complications compared with those treated with vein grafts. Overall, operative repair of PVA is safe and recommended in select patients with PVA., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To describe an endovascular technique for treating a pseudoaneurysm of the thoracic aorta using an off-label "hourglass" stent-graft configuration., Case Report: A 68-year-old patient with prior open thoracic aorta coarctation repair presented with recurrent coarctation and concurrent enlarging 6-cm bilobed pseudoaneurysm involving the previous anastomosis. There was significant discrepancy in the aortic diameter (measured from wall to wall) proximal to the coarctation (14 mm), at the narrowest segment (8 mm), and distally (23 mm). Endovascular repair included deployment of an inverted iliac limb proximally, followed by an inverted aortic converter distally, giving an "hourglass" configuration. There were no perioperative or stent-graft-related complications at 5-year follow-up. The aneurysm regressed from 61 to 25 mm., Conclusion: The use of inverted stent-grafts can allow tapering and flaring to adapt to discrepant aortic diameters. This technique may be useful in select patients with prior coarctation repair who do not need excessive dilation of the narrow aortic segment., (© The Author(s) 2015.)

Objective: The objective was to study associations between clinical variables, demographic factors, and outcome after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA)., Methods: Data of consecutive patients who underwent EVAR between 1997 and 2011 at a tertiary center were analyzed. Comorbidity scores stratified patients into low/normal-risk (score ≤ 10) or high-risk categories (score > 10). The primary end point was mortality; secondary end points were morbidities, reinterventions, conversions, and ruptures., Results: The study included 934 patients, 117 women (13%) and 817 men (87%) (mean age, 76 ± 7.3 years; range, 51-99 years). There were 870 (93%) asymptomatic, 36 (3.9%) symptomatic, and 28 (3.0%) ruptured AAAs. The 30-day mortality was 1.4% (13 of 934), 1.0% (9 of 870) for asymptomatic patients, 2.8% (1 of 36) for patients with symptomatic AAAs, and 11% (3 of 28) for patients with ruptured AAAs (P = .004). Clinical presentation with symptoms or rupture was associated with more complications (P = .02), reinterventions (P = .003), and a lower 5-year survival (P = .04). Association between surgical risk, female gender, age, and outcome was studied in 870 asymptomatic patients. Both 30-day mortality and complication rates were higher for high-risk vs low/normal-risk patients (2.3% vs 0.2%, P = .003; 15% vs 10%, P = .04); reintervention rates were equivalent (3.8% vs 4.4%; P = .67). The 30-day mortality and complication rates were similar in women and men (2.8% vs 0.8%, P = .09; 17% vs 11%, P = .11), but reintervention rate was higher in women (8.5% vs 3.5%; P = .02). Follow-up averaged 3.8 years (1 month-13.5 years). In asymptomatic patients, 5-year survival was 74% for low/normal-risk patients and 54% for high-risk patients (P < .001); both had similar rates of freedom from complications (65% vs 63%; P = .24), reinterventions (71% vs 75%; P = .36), or rupture (99.3% vs 99.7%; P = .42). Women had more complications (47% vs 34%; P = .04) and reinterventions than men did (39% vs 26%; P = .02); freedom from rupture was the same (100% vs 99.3%; P = .30). There were eight ruptures, all in asymptomatic patients. In multivariate analysis, high surgical risk and age were associated with all-cause mortality (P < .001); female gender was associated with complications and reinterventions (P < .05) but not mortality., Conclusions: Clinical presentation predicts early mortality and complications, age predicts both early and late mortalities after EVAR. Although women had an increased rate of complications and reinterventions, women did not have significantly higher mortality than men., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Repetitive, high-stress, or high-impact arm motions can cause upper extremity arterial injuries. The increased functional range of the upper extremity causes increased stresses on the vascular structures. Muscle hypertrophy and fatigue-induced joint translation may incite impingement on critical neurovasculature and can cause vascular damage. A thorough evaluation is essential to establish the diagnosis in a timely fashion as presentation mimics more common musculoskeletal injuries. Conservative treatment includes equipment modification, motion analysis and adjustment, as well as equipment enhancement to limit exposure to blunt trauma or impingement. Surgical options include ligation, primary end-to-end anastomosis for small defects, and grafting., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Intervention on the great saphenous vein (GSV) has traditionally been limited to the above-knee (AK-GSV) segment for fear of saphenous neuralgia in spite of incompetence demonstrated in the below-knee (BK-GSV) segment. Residual symptoms and need for reintervention are reported to result in nearly half the patients if the refluxing BK-GSV is ignored. Experience with endovenous ablation of the BK-GSV at the time of AK-GSV treatment is sparsely reported in the literature. The aim of this study was to evaluate the safety of endovenous ablation of the refluxing BK-GSV., Methods: Data from consecutive patients treated with superficial venous ablation during a 48-month period from January 2010 to December 2013 were retrospectively reviewed. Demographic and procedure-related outcome and complication data were analyzed specifically for patients undergoing BK-GSV interventions., Results: A total of 550 patients were treated with superficial venous ablation during the study period. Of those, 61 (79 limbs) underwent BK-GSV ablation for reflux at this site. There were 36 women and 25 men (mean age, 55 years). Median Clinical, Etiologic, Anatomic, and Pathologic (CEAP) score was 3.4; 43 limbs were treated for symptomatic varicose veins (C 1-3) and 36 for advanced venous insufficiency (C 4-6); 14 limbs (18%) were treated for recurrent symptomatic varicose veins or venous insufficiency after prior superficial venous intervention with AK-GSV ablation, sclerotherapy, or stripping. Comorbidities included obesity (54%) with mean body mass index of 30.7 (range, 19 to 52), obstructive sleep apnea (10%), pulmonary hypertension (3%), and congestive heart failure (3%). Ablation was performed in 77 limbs (99%) with the VenaCure EVLT laser vein treatment (AngioDynamics, Queensbury, NY) and in two limbs by radiofrequency ablation with ClosureFAST system (VNUS Medical Technologies, San Jose, Calif). The mean length of GSV ablated was 51.2 cm (range, 26-67 cm). Endovenous ablation was performed concomitantly on 22 accessory GSVs (28%) and 10 incompetent perforators (13%). Ambulatory stab phlebectomy of branch varicosities was performed simultaneously in 59 limbs (75%). All veins treated were evaluated with ultrasound on postprocedure day 1, and no evidence of endovenous heat-induced thrombosis was detected. Eight patients (10%) went on to have preplanned sclerotherapy treatment for small-branch varicosities. Postoperative paresthesia occurred in three patients (4%) and resolved within 4 weeks. Wound infection in three (4%) stab phlebectomy wounds resolved with oral antibiotic therapy. Follow-up surveillance ultrasound was available in 32 of 79 limbs that were >6 months from the procedure. Partial late recanalization was noted in four of 32 limbs, but no patient had recurrent symptoms requiring repeated endovenous ablation during this period., Conclusions: Endovenous ablation of the refluxing BK-GSV segment can be performed safely with minimal complications. Consideration should be given to concomitant ablation of the BK-GSV in treatment of patients with varicose veins with reflux extending to the BK segment of the GSV to improve long-term outcomes., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate the anatomic feasibility of two off-the-shelf fenestrated stent graft designs to treat juxtarenal and pararenal abdominal aortic aneurysms (AAAs)., Methods: Digital computed tomography angiograms were analyzed in 520 consecutive patients treated by open or fenestrated endovascular repair for complex AAAs (2000-2012). The anatomic feasibility of two off-the-shelf fenestrated designs, Endologix Ventana (Endologix Inc, Irvine, Calif) and Cook p-Branch (Cook Medical, Brisbane, Australia), was analyzed with the instructions for use (IFU) proposed by investigational protocols., Results: There were 390 patients (75%) with juxtarenal and pararenal AAAs considered potential candidates for one of the two devices. Proximal seal (>15 mm) was achieved in all patients with the p-Branch and in 61% of the patients with the Ventana stent graft (P < .0001). The ability to incorporate visceral arteries was greater with the Ventana (90% vs 61%) compared with the p-Branch design (P < .0001). Less than a third of patients met strict IFU criteria with Ventana (27%) or p-Branch (33%; P < .05). By liberal IFU criteria, 42% of patients were candidates for Ventana and 49% for p-Branch (P < .03). Overall, 63% of the patients with juxtarenal and pararenal AAAs were candidates for endovascular repair with one of the two devices., Conclusions: The p-Branch design has greater anatomic feasibility and achieves proximal seal in all patients with juxtarenal and pararenal AAAs but is not able to incorporate visceral arteries in 40% of patients. The Ventana design allows incorporation of the visceral arteries in 90% of patients but fails to provide sufficient seal in 40%. Nearly 40% of juxtarenal and pararenal AAAs do not meet anatomic criteria for endovascular repair with one of the two devices, justifying the need for additional designs., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to compare outcomes after endovascular repair (ER) and contemporary open repair (OR) of popliteal artery aneurysms (PAAs)., Methods: Clinical data of PAA patients treated between 2005 and 2012 were reviewed. Primary end points were major adverse events (MAEs) including mortality, major amputation, patency, complications, and reinterventions., Results: A total of 149 PAAs were treated in 120 patients (mean age, 74 ± 10 years). ER was performed in 42 limbs of 35 men (mean age, 81 ± 6.5 years), in 32 electively and in 10 emergently. Technical success was 98%. The 30-day MAEs were more frequent after emergent repair (50% vs 9%; odds ratio [OR], 9.67; 95% confidence interval [CI], 1.74-54; P = .01); mortality and amputation rate was 0% after elective repair, 20% after emergent repair. Mean follow-up was 2.6 years (1 month-6.5 years); 3-year freedom from MAEs was lower after emergent repair than after elective repair (40% vs 66%; hazard ratio [HR], 3.13; 95% CI, 1.10-8.85; P = .03). OR was performed in 107 limbs of 91 patients (90 men; mean age, 71 ± 9.6 years), in 93 electively and in 14 emergently. The 30-day MAEs were more frequent after emergent repair (43% vs 5%; OR, 13; 95% CI, 3.29-53; P < .001); mortality was 1% after elective repair, 0% after emergent cases. Amputation rate was 0% for both elective and emergent repairs. Mean follow-up was 3.8 years (1 month-8.4 years); 3-year freedom from MAEs was lower after emergent repair (50% vs 80%; HR, 3.78; 95% CI, 1.55-9.20; P = .003). The 30-day MAE rates were equivalent between ER and OR independent of urgency of repair (elective: OR, 1.82; 95% CI, 0.41-8.09; P = .43; emergent: OR, 1.33; 95% CI, 0.26-6.81; P = .73). In elective interventions, ER had a trend to decreased freedom from MAEs (66% vs 80% at 3 years; HR, 1.93; 95% CI, 0.92-4.07; P = .08); freedom from reintervention was lower after ER (72% vs 88%; HR, 2.41; 95% CI, 1.02-5.70; P = .046). In emergent interventions, 1-year freedom from MAEs was similar (40% vs 50%; HR, 1.36; 95% CI, 0.49-3.74; P = .55). Emergent ER and poor runoff predicted MAEs., Conclusions: Our study failed to prove the superiority of ER over OR. If anatomy is suitable, ER of PAA in the elderly and high-risk patients is justified. For emergent PAA repairs, MAEs are frequent after both ER and OR; ER has not changed the severe prognosis of acute limb ischemia from PAA. A multicenter randomized controlled trial of PAA patients with acute presentation is warranted., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Disseminated intravascular coagulation (DIC) due to endoleak is a rare complication following endovascular aneurysm repair. Two of the four previously reported cases occurred in patients with cirrhosis. We describe three patients with normal liver function who developed DIC due to delayed high-flow (type Ia or III) endoleaks. Two patients underwent successful surgical repair, and the third was managed medically. All three patients had chronic thrombocytopenia prior to developing an endoleak as did the four reported cases in the literature. We propose that thrombocytopenia, like cirrhosis, be considered a risk factor for DIC due to endoleaks in patients undergoing endovascular aneurysm repair., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To evaluate outcomes of open (OR) and endovascular repair (II-EVAR) of internal iliac artery aneurysms (IIAAs) with or without preservation of internal iliac artery (IIA) flow., Methods: We reviewed the clinical data of consecutive patients treated for IIAAs between 2001 and 2012. End-points were morbidity, mortality, graft patency, and freedom from pelvic ischemic symptoms (buttock claudication, ischemic colitis, and spinal cord injury)., Results: There were 97 patients, 87 male and 10 female, with mean age of 74 ± 8 years. A total of 125 IIAAs (71 unilateral and 27 bilateral) with mean diameter of 3.6 ± 2 cm were treated. Eighty-two patients (86%) had elective repair and 15 (14%) required emergent repair (mean size, 6.7 ± 2.4 cm; range, 3.6-10 cm). OR in 60 patients (62%; 49 elective, 11 emergent) included IIA bypass in 36 (60%) patients and endoaneurysmorrhaphy in 24 (40%). II-EVAR in 37 patients (38%; 30 elective, 4 emergent) required IIA embolization in 29, iliac branch device in five or open IIA bypass in three, combined with bifurcated aortic stent grafts in 17. Early mortality was 1% for elective (1/49 open, 0/33 endovascular) and 7% for emergent repair (1/11 open, 0/4 endovascular). Early morbidity (43% vs 8%; P < .001) and length of stay (9 vs 1 day; P < .001) were significantly higher for OR as compared with II-EVAR. Pelvic ischemic complications occurred in 25 patients (26%), including hip claudication in 23, ischemic colitis in two, and paraplegia in one. Freedom from buttock claudication at 2 years was 25% in patients with no IIA preserved, 68% with preservation of one, and 95% with preservation of both IIAs (P = .002). Freedom from buttock claudication was higher after OR than after II-EVAR (79% vs 59%; P = .05). Primary and secondary patency rates of IIAA bypasses were 95%, and 80% at 1 and 3 years, respectively., Conclusions: II-EVAR of IIAAs is associated with fewer complications and shorter hospital stay compared with OR. Open and endovascular IIA reconstructions have very good long-term patency, and preservation of IIA flow is associated with higher freedom from buttock claudication., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the incidence and clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices (EPDs)., Methods: We reviewed the clinical data of 566 patients treated by 836 endovascular femoropopliteal interventions for lower extremity claudication (46%) or critical limb ischemia (54%) from 2002 to 2012. Outcomes were analyzed in 74 patients/87 interventions performed with EPDs (Spider Rx; Covidien, Plymouth, Minn) and 513 patients/749 interventions performed without EPDs. TransAtlantic Inter-Society Consensus (TASC) II classification, runoff scores, and embolic events were analyzed. End points were morbidity, mortality, reintervention, patency, and major amputation rates., Results: Both groups had similar demographics, indications, cardiovascular risk factors, and runoff scores, but patients treated with EPDs had significantly (P < .05) longer lesions (109 ± 94 mm vs 85 ± 76 mm) and more often had occlusions (64% vs 30%) and TASC C/D lesions (56% vs 30%). Embolic events occurred in 35 of 836 interventions (4%), including two (2%) performed with EPD and 33 (4%) without EPD (P = .35). Macroscopic debris was noted in 59 (68%) filter baskets. Embolic events were not associated with lesion length, TASC classification, runoff scores, treatment type, or indication but were independently associated with occlusion. Patients who had embolization required more reinterventions (20% vs 3%; P < .001) and major amputations at 30 days (11% vs 3%; P = .02). There was no difference in hospital stay (2.4 ± 4 days vs 1.6 ± 2 days; P = .08), reintervention (2% vs 4%), and major amputation (1% vs 4%) among patients treated with or without EPD, respectively. The two patients who developed embolization with EPDs had no clinical sequela and required no reintervention. Most emboli were successfully treated by catheter aspiration or thrombolysis, but eight patients (24%) treated without EPD required prolonged hospital stay, seven (21%) had multiple reinterventions, one (3%) had unanticipated major amputation, and one (3%) died from hemorrhagic complications of thrombolysis. Median follow-up was 20 months. At 2 years, primary patency and freedom from reintervention was similar for TASC A/B and TASC C/D lesions treated with or without EPDs., Conclusions: Rates of embolization are low in patients undergoing endovascular femoropopliteal interventions with (4%) or without (2%) EPD. Embolization is more frequent in patients with occlusions. While emboli in patients with EPD had no clinical sequel, those treated without EPD required multiple reinterventions in 21% or resulted in major amputation or death in 3%. Late outcomes were similar in patients treated with or without EPDs., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate outcomes of patients treated by intentional coverage of accessory renal artery (ARA) during endovascular abdominal aneurysm repair (EVAR)., Methods: The clinical data of 119 patients (110 male and nine female; mean age, 75 years) from a cohort of 811 patients treated by EVAR from 1998 to 2009 was reviewed. Patients who had intentional coverage of at least one ARA (group A) were compared with two control groups, which included patients with no ARA (group B) and those who had ARA preserved during EVAR (group C). All three groups of patients were matched for age, gender, hypertension, and preoperative estimated glomerular filtration rate (eGFR). Paired pre- and postoperative computed tomography angiography was analyzed for the presence and volume of kidney infarction. End points were changes in eGFR, chronic kidney disease (CKD) stage, blood pressure measurements, presence and volume of kidney infarction, freedom from reintervention, and endoleak., Results: There were 42 patients in group A, 42 in group B, and 35 in group C. Demographics, cardiovascular risk factors, and CKD classification were similar in all three groups. Among patients in group A, 44 ARAs were intentionally covered with ARAs originating from the proximal neck in 22 patients, the aneurysm sac in 20, and the iliac arteries in two. There was one (1%) early death in the entire study. Early morbidity was similar in all three groups, including four patients (9%) in group A, four (9%) in group B, and four (11%) in group C (P = .9). Six (5%) patients had >25% decrease in eGFR, including two who had ARA coverage. None of the patients required dialysis. After a mean follow-up of 37 months, there were no differences in late renal function deterioration, changes in eGFR, CKD stage, or blood pressure measurements among the three groups. Three of the 18 patients (17%) with ARA >3 mm arising from the aneurysm sac developed a type II endoleak requiring coil embolization. Kidney infarction was noted in 28 patients (67%) in group A. Freedom from reintervention at 2 years was similar in groups A (64%), B (80%), and C (96%; P = .09)., Conclusions: Intentional ARA occlusion during EVAR was not associated with changes in renal function or blood pressure measurements, even when performed in patients with more advanced renal dysfunction. Type II endoleak may result from persistent outflow into large (>3 mm) ARAs that arise from the aneurysm sac., (Copyright © 2013. Published by Mosby, Inc.)

Objective: To compare outcomes of mesenteric angioplasty and stenting using iCAST covered stents (CS; Atrium, Hudson, NH) or bare metal stents (BMS) in patients with chronic mesenteric ischemia (CMI)., Methods: We reviewed the clinical data of 225 patients (65 male and 160 female; mean age, 72 ± 12 years) treated for CMI at two academic centers (2000-2010). Outcomes were analyzed in patients who had primary intervention or reintervention using BMS (n = 164 patients/197 vessels) or CS (n = 61 patients/67 vessels). End points were freedom from restenosis, symptom recurrence, reinterventions, and patency rates., Results: Patients in both groups had similar demographics, cardiovascular risk factors, and extent of disease. In the primary intervention group (mean follow-up, 29 ± 12 months), patients treated by CS had higher freedom from restenosis (92% ± 6% vs 53% ± 4%; P = .003), symptom recurrence (92 ± 4% vs 50 ± 5%; P = .003), reintervention (91% ± 6% vs 56% ± 5%; P = .005), and better primary patency at 3 years (92% ± 6% vs 52% ± 5%; P < .003) than for BMS. In the reintervention group (mean follow-up, 24 ± 9 months), patients treated by CS had higher freedom from restenosis (89% ± 10% vs 49% ± 14%; P < .04), symptom recurrence (100% vs 64%± 9%; P = .001), and reintervention (100% vs 72% ± 9%; P = .03) at 1 year, and a trend toward improved primary patency at 1 year (100% vs 63% ± 9%; P = .054). Secondary patency rates were similar in both groups., Conclusions: In this nonrandomized study, CS were associated with less restenosis, recurrences, and reinterventions than BMS in patients undergoing primary interventions or reinterventions for CMI., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: This study was conducted to determine the outcomes and predictive factors for success during percutaneous endovascular aneurysm repair (PEVAR) using vascular closure devices (VCDs)., Methods: The clinical data of patients who underwent PEVAR between 2005 and 2012 were retrospectively reviewed. Patient demographics, body mass index, sheath size, device types, diameter of femoral arteries, and extent and location of femoral artery calcification were recorded. Included were all consecutive patients treated by PEVAR with sheath sizes ranging from 12 F to 24 F. End points were technical success, conversion to open femoral artery repair, and complications., Results: During this period, 752 patients were treated by EVAR. Of these, 391 femoral arteries in 222 patients (29.5%; 197 men, 25 women), with a mean age of 74.8 years (range, 51-93.7 years), underwent PEVAR (169 bilateral and 53 unilateral percutaneous access). Patients with >50% anterior femoral artery calcifications or those with previous femoral artery reconstructions were not offered PEVAR. Technical success of PEVAR was 96.4% (377 of 391), with an average of two VCDs used per groin. Fourteen intraoperative failures were managed with open femoral conversion using primary repair (five) or patch angioplasty (nine). In nine patients, the procedure was converted from local to general anesthesia. Four patients required a perioperative blood transfusion. There were no significant differences in body mass index (P = .26), femoral artery size preprocedure (P = .33) or postprocedure (P = .37), sheath size (≥ 20 F vs ≤ 18 F), or type of VCD used between the success and failure groups. Pairwise comparisons revealed increased failure rate (P < .001) between patients with <50% anterior wall calcification vs none, <50% anterior wall calcification vs <50% posterior wall calcification, and none vs >50% posterior calcification. There was no significant difference (P = .53) between patients with <50% posterior wall calcification and those with no calcification. The 30-day mortality of the entire group was 0.9% (2 of 222 patients). No deaths occurred after conversion to open femoral closure. At a mean follow-up of 30 months (range, 1-85.2 months), there were no long-term groin complications or iliac limb occlusions., Conclusions: PEVAR using VCDs can be performed with high technical success in patients with <50% anterior wall calcification, regardless of the size of the access sheath or the patient's body mass index. Femoral artery calcification, however, is a major determinant of failure., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Endovascular abdominal (EVAR) and thoracic (TEVAR) endografts allow aneurysm repair in high-risk patients, but infectious complications may be devastating. We reviewed treatment and outcomes in patients with infected aortic endografts., Methods: Twenty-four patients were treated between January 1997 and July 2012. End points were mortality, morbidity, graft-related complications, or reinfection., Results: Twenty males and four females with median age of 70 years (range, 35-80 years) had 21 infected EVARs and 3 TEVARs. Index repairs performed at our institution included eight EVARs and two TEVARs (10/1300; 0.77%). There were 19 primary endograft infections, 4 graft-enteric fistulae, and 1 aortobronchial fistula. Median time from repair to presentation was 11 months (range, 1-102 months); symptoms were fever in 17, abdominal pain in 11, and psoas abscess in 3. An organism was identified in 19 patients (8 mono- and 11 polymicrobial); most commonly Staphylococcus in 12 and Streptococcus in 6. All but one patient had successful endograft explantation. Abdominal aortic reconstruction was in situ repair in 21 (15 rifampin-soaked, 2 femoral vein, and 4 cryopreserved) and axillobifemoral bypass in three critically ill patients. Infected TEVARs were treated with rifampin-soaked grafts using hypothermic circulatory arrest. Early mortality (30 days or in-hospital) was 4% (n = 1). Morbidity occurred in 16 (67%) patients (10 renal, 5 wound-related, 3 pulmonary, and 1 had a cardiac event). Median hospital stay was 14 days (range, 6-78 days). One patient treated with in situ rifampin-soaked graft had a reinfection with fatal anastomotic blowout on day 44. At 14 months median follow-up (range, 1-82 months), patient survival, graft-related complications, and reinfection rates were 79%, 13%, and 4%, respectively., Conclusions: Endograft explantation and in situ reconstruction to treat infections can be performed safely. Extra-anatomic bypass may be used in high-risk patients. Resection of all infected aortic wall is recommended to prevent anastomotic breakdown. Despite high early morbidity, the risk of long-term graft-related complications and reinfections is low., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To compare outcomes of abdominal aortic aneurysm repairs before and after the endovascular era., Methods: Group A (1997-1998) included 331 patients, 321 (97%) with open repair (OR) and 10 (3%) with endovascular aneurysm repair (EVAR). Group B (2007-2008) included 330 patients, 136 (41%) with OR and 194 (59%) with EVAR., Results: Patients in Group B were older (74 ± 8.5 vs 73 ± 7.0 years, P = .02), had higher comorbidity scores (8.3 ± 4.8 vs 7.5 ± 4.6, P = .04), shorter hospitalization (5.1 ± 6.4 vs 9.8 ± 6.3, P < .001), less intensive care unit days than in Group B (0.9 ± 2.1 vs 2.2 ± 2.7, P < .001). Early mortality was 0.6% in both groups. Two-year survival was similar (88% vs 89%), with less reinterventions in Group A (4% vs 17%, P = .004). OR patients had similar 30-day mortalities (0.9% vs 0.7%, P = .89)., Conclusion: EVAR and OR have low mortalities. However, in the post-EVAR era we treat older patients with more comorbidities, hospitalization is shorter, and intensive care unit days are less; interventions in EVAR are, however, high.

Objective: Endovascular repair has emerged as a treatment option for popliteal artery aneurysms. Our goal was to analyze outcomes of elective and emergency endovascular popliteal artery aneurysm repair (EVPAR)., Methods: This was a retrospective review of clinical data of patients treated with EVPAR at our institution between 2004 and 2010. Stent-related complications, patency, outcome limb salvage, and survival were evaluated and analyzed., Results: EVPAR was performed in 31 limbs of 25 patients (mean age, 81 years; range, 65-89 years). Repair was elective in 19 limbs (61%) and emergent in 12 (39%). One aneurysm ruptured and 11 presented with acute thrombosis. All 11 underwent thrombolysis before EVPAR. Patients were implanted with a mean of 2.1 Viabahn stent grafts (range, 1-4). Ten procedures (32%) were performed percutaneously and 21 by femoral cutdown. Technical success was 97%. Overall 30-day mortality was 6.4%, with 0% in the elective group, and 16.7% in the emergent group (P = .14). Early complications included graft thrombosis in two limbs (6.4%) and hematoma in four (13%), all after percutaneous repair. Myocardial infarction and thrombolysis-associated intracranial hemorrhage occurred in one patient each (3.2%). The 30-day primary and secondary patencies were 93.6% and 96.7%, respectively, and were 100% in the elective group and 83.3% and 91.6%, respectively, for the emergent group. Mean follow-up was 21.3 months (range, 1-75 months). Primary patency at 1 year was 86% (95% for elective, 69% for emergent; P = .56), secondary patency at the same time was 91% (elective, 100%; emergent, 91%). One-year limb salvage was 97%. Two-year survival was 91% for the elective group and 73% for the emergent group (P = .15). Five stent occlusions were encountered after 30 days, four in the elective group. Four underwent successful reintervention, two had bypass, and two had thrombolysis, followed by angioplasty. The fifth patient was asymptomatic and nonambulatory and remains under observation. Stent graft infolding occurred in one limb (3.2%), with no clinical sequelae. No stent migration or separation was observed. One stent fracture was noted in an asymptomatic patient. Three (10%) type II endoleaks were detected but none had aneurysm expansion. One (3.2%) type I endoleak was treated percutaneously with placement of an additional stent graft. Overall, major adverse events, including death, graft occlusion with or without reoperation, or reoperation for endoleak or stent infolding occurred after 11 procedures (35.5%). On univariate analysis, no factors predicted stent failure, including runoff, antiplatelet therapy, emergency repair, number of stents implanted, heparin bonding of the stent, or degree of stent oversizing., Conclusions: These results support elective EVPAR in anatomically suitable patients with increased risk for open repair; however, major adverse events after EVPAR, mainly after emergency repairs, are frequent. A prospective randomized multicenter study to justify EVPAR in the emergent setting is warranted., (Copyright © 2013. Published by Mosby, Inc.)

Objective: To evaluate long-term patient survival and causes of death after open (OR) or endovascular (ER) mesenteric revascularization for atherosclerotic chronic mesenteric ischemia using propensity score-matched comparison and clinical risk stratification., Methods: The clinical data of 343 patients treated with mesenteric revascularization for chronic mesenteric ischemia between 1991 and 2010 were retrospectively reviewed. Clinical, anatomical, and procedure-related variables were analyzed using a multivariate model to identify independent predictors of any-cause early and late (>30 days) mortality. Cause of death was retrieved from review of the National Death Index. Patient survival was analyzed using Society for Vascular Surgery (SVS) comorbidity scores and propensity score-matched comparison based on independent predictors of any-cause mortality., Results: There were 187 patients treated by OR and 156 patients treated by ER. Early procedure-related mortality was 2.6% (9/343), including five OR (2.7%) and four ER (2.6%) patients. Median follow-up was 96 ± 54 months (range, 1-168 months). There were 144 late deaths, most commonly from cardiac causes in 35% (51/144), followed by cancer in 15% (21/144), pulmonary complications in 13% (19/144), and mesenteric ischemia in 11% (16/144). A further 21 patients died from various identifiable causes, and 14 patients (10%) died of unknown causes. Overall, 25 patients (7.3%) died of mesenteric-related causes, including nine early and 16 late deaths (OR, 10/187; 8.0%, and ER, 6/156; 6.4%). Multivariate analysis identified age >80, diabetes, chronic kidney disease (CKD) stage IV or V, and home oxygen therapy as independent predictors (P < .05) of any cause of death. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death (P < .05). Late patient survival at 5 years in the OR and ER groups was 75% ± 4% and 60% ± 9% for low SVS risk (<9), 52% ± 8% and 43% ± 9% for intermediate SVS risk (9-16), and 67% ± 15% and 30% ± 8% for high SVS risk (>16). Using propensity matched scores, 5-year survival was nearly identical for patients treated by OR (60%) or ER (57%; P = .7)., Conclusions: Long-term patient survival after mesenteric revascularization was not influenced by type of arterial reconstruction. Age >80 years, diabetes, CKD stage IV or V, and home oxygen were independent predictors of any-cause mortality. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)