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Purpose: To determine the clinical and anatomical risk factors for cerebrovascular accidents (CVA) in patients undergoing thoracic endovascular aortic repair (TEVAR).Methods: Between September 2000 and December 2006, 196 patients (135 men; mean age 68.6+/-13.5 years, range 17-92) underwent TEVAR for a variety of aortic pathologies. The majority (156, 79.6%) were treated with the TAG stent-graft. Demographics, pathologies, intraoperative procedure-related measures, device usage, and postoperative outcomes were assessed. CVA was defined as a new focal or global neurological (motor or sensory) deficit lasting >48 hours associated with acute intracranial abnormalities on computed tomography or magnetic resonance brain imaging. Spinal cord ischemia was excluded. In a subset of patients with planned left subclavian artery (LSA) coverage and an incomplete circle of Willis or a dominant left vertebral artery, prophylactic carotid-subclavian bypasses were performed.Results: Nine (4.6%) patients suffered a CVA. Factors not predictive of a CVA on univariate analysis included aortic pathology, urgency of repair, ASA classification, type of anesthesia, blood loss, procedure time, and device used. Proximal extent of repair (with or without extra-anatomical revascularization) was significantly associated with a higher incidence of strokes (zones 0-2 versus 3-4, p=0.025). Five (55.6%) patients with a CVA had documented intraoperative hypotension (systolic blood pressure<80 mmHg). Additionally, while 2 patients had hemispheric infarcts, 5 had acute posterior circulation infarcts involving the cerebellum and brainstem; a single patient had both anterior and posterior circulation infarcts. Seven of the CVA patients had proximal coverage of the thoracic aorta in zones 0-2; of these, 6 had posterior circulation infarcts. Selective LSA revascularization based on preoperative cerebrovascular imaging resulted in lower rates of CVA (6.4% to 2.3%, p=0.30) and posterior circulation infarcts (5.5% to 1.2%, p=0.13).Conclusion: Proximal extent of repair may serve as a surrogate marker for greater severity of degenerative disease of the aortic arch. Avoidance of intraoperative hypotension and preservation of antegrade vertebral perfusion may be important in prevention of posterior circulation strokes. [ABSTRACT FROM AUTHOR]

Objective: Although endovascular aneurysm repair (EVAR) reintervention is common, conversion to open repair (EVAR-c) occurs less frequently but can be associated with significant technical complexity and perioperative risk. There is a paucity of data highlighting the evolution of periprocedural results surrounding EVAR-c and change in practice patterns, especially for referral centers that increasingly manage EVAR failures. The purpose of this analysis was to perform a temporal analysis of our EVAR-c experience and describe changes in patient selection, operative details, and outcomes., Methods: A retrospective single-center review of all open abdominal aortic aneurysm repairs was performed (2002-2019), and EVAR-c procedures were subsequently analyzed. EVAR-c patients (n = 184) were categorized into two different eras (2002-2009, n = 21; 2010-2019, n = 163) for comparison. Logistic regression and Cox proportional hazards modeling were used for risk-adjusted comparisons., Results: A significant increase in EVAR-c as an indication for any type of open aneurysm repair was detected (9% to 27%; P < .001). Among EVAR-c patients, no change in age or individual comorbidities was evident (mean age, 71 ± 9 years); however, the proportion of female patients (P = .01) and American Society of Anesthesiologists classification >3 declined (P = .05). There was no difference in prevalence (50% vs 43%; P = .6) or number (median, 1.5 [interquartile range (IQR), 0-5]) of preadmission EVAR reinterventions; however, time to reintervention decreased (median, 23 [IQR, 6-34] months vs 0 [IQR, 0-22] months; P = .005). In contrast, time to EVAR-c significantly increased (median, 16 [IQR, 9-39] months vs 48 [IQR, 20-83] months; P = .008). No difference in frequency of nonelective presentation (mean, 52%; P = .9] or indication was identified, but a trend toward increasing mycotic EVAR-c was observed (5% vs 15%; P = .09). Use of retroperitoneal exposure (14% vs 77%; P < .0001), suprarenal cross-clamp application (6286%; P = .04), and visceral-ischemia time (median, 0 [IQR, 0-11] minutes vs 5 [IQR, 0-20] minutes; P = .05) all increased. In contrast, estimated blood loss (P trend = .03) and procedure time (P = .008) decreased. The unadjusted elective 30-day mortality rate improved but did not reach statistical significance (elective, 10% vs 5%; P = .5) with no change for non-elective operations (18% vs 16%; P = .9). However, a significantly decreased risk of complications was evident (odds ratio, 0.88; 95% confidence interval, .8-.9; P = .01). One- and 3-year survival was similar over time., Conclusions: EVAR-c is now a common indication for open abdominal aortic aneurysm repair. Patients frequently present nonelectively and at increasingly later intervals after their index EVAR. Despite increasing technical complexity, decreased complication risk and comparable survival can be anticipated when patients are managed at a high-volume aortic referral center., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Aberrant subclavian artery (ASA), a well-described aortic arch anomaly, is frequently associated with dysphagia and development of Kommerell diverticulum (KD) with aneurysmal degeneration. Historically, open repair has been performed, which can be associated with significant morbidity. More recently, hybrid approaches using different arch vessel revascularization techniques in combination with thoracic endovascular aortic repair (hybrid TEVAR) have been described, but there is a paucity of literature describing outcomes. The objective of this analysis was to describe our experience with management of complicated ASAs using hybrid TEVAR, further adding to the literature describing approaches to and outcomes of hybrid ASA repair., Methods: A retrospective, single-institution review was performed of all patients treated for ASA complications using hybrid TEVAR (2002-2018). The primary end point was technical success, defined as absence of type I or type III endoleak intraoperatively and within 30 days postoperatively. Secondary end points included complications, reintervention, and survival. Centerline measurement of KD diameters (maximum diameter = opposing aortic outer wall to diverticulum apex) was employed. Kaplan-Meier methodology was used to estimate secondary end points., Results: Eighteen patients (1.4% of 1240 total TEVAR procedures; male, 67%; age, 59 ± 13 years) were identified (left-sided arch and right ASA, 94% [n = 17]; right-sided arch and left ASA, n = 1 [6%]; retroesophageal location and associated KD, 100%); median preoperative KD diameter was 60 mm (interquartile range [IQR], 37-108 mm). Operative indications included diverticulum diameter (61%), dysphagia (17%), rupture (11%), rapid expansion (6%), and endoleak after TEVAR (6%). All procedures used some combination of supraclavicular revascularization and TEVAR (staged, 50% [n = 9]), whereas partial open arch reconstruction was used in 17% (n = 3). There were no perioperative deaths or spinal cord ischemic events. Major complications occurred in 22% (n = 4): nondisabling stroke, one; arm ischemia, one; upper extremity neuropathy, one; and iatrogenic descending thoracic aortic dissection, one. Technical success was 83%, but 44% (n = 8) had an endoleak (type I, n = 3; type II, n = 5 [intercostal, n = 2; aneurysmal subclavian artery origin, n = 3]) during follow-up (median, 4 months; IQR, 1-15 months). Two endoleaks resolved spontaneously, three were treated, and three were observed (1-year freedom from reintervention, 75% ± 10%). Median KD diameter decreased by 7 mm (IQR, 1-12 mm), and 78% (n = 14) experienced diameter reduction or stability in follow-up. The 1- and 3-year survival was 93% ± 6% and 84% ± 10%, respectively., Conclusions: Hybrid open brachiocephalic artery revascularization with TEVAR appears to be safe and reasonably effective in management of ASA complications as evidenced by a low perioperative complication risk and reasonable positive aortic remodeling. However, endoleak rates raise significant concerns about durability. Therefore, if this technique is employed, the mandatory need for surveillance and high rate of reintervention should be emphasized preoperatively. This analysis represents a relatively large series of a hybrid TEVAR technique to treat ASA complications, but greater patient numbers and longer follow-up are needed to further establish the role of this procedure., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Patch infection after carotid endarterectomy (CEA) is a rare but devastating complication. A variety of different treatment options are reported; however, there is currently no consensus on how to manage this highly morbid problem. The purpose of this study was to review our experience with management of infectious patch complications after CEA and to highlight utility of femoral vein interposition bypass grafting., Methods: All CEA patch infection operations at the University of Florida from 2002 to 2017 were reviewed retrospectively. Preoperative history, intraoperative details, and postoperative complications were recorded. Bypass patency was verified with duplex ultrasound imaging (1 month, 6 months, annually). The primary end point was 30-day stroke or death; secondary end points included cranial nerve injury, reintervention, reinfection, and survival. Life tables were used to estimate end points., Results: Twenty-nine patients (mean age, 70 ± 9 years; male, 76%) were identified. The index CEA occurred at a median of 15 months (interquartile range, 1-55 months) preoperatively (39% <2 months after the index procedure). A variety of patch materials were implicated (Dacron, n = 9; unknown/undocumented, n = 8; bovine pericardium, n = 5; expanded polytetrafluoroethylene, n = 3; unidentified nonbiologic prosthetic, n = 3; saphenous vein, n = 1). Carotid reintervention antecedent to the infected patch presentation occurred in 41% (incision and drainage, n = 10; carotid stent, n = 2; vein patch, n = 1). The most common infecting organisms were Staphylococcus and Streptococcus species (52%; n = 15). The most frequent presentation (46%; n = 13) was pericarotid abscess or phlegmon (pulsatile neck mass or pseudoaneurysm, 28% [n = 8]; carotid-cutaneous fistula, 28% [n = 8]). Reconstruction strategy included femoral vein interposition bypass in 24 patients (83%; nonreversed configuration, 16/24 [67%]), saphenous vein patch in 4 patients (14%), and femoral vein patch in 1 patient (3%). Median postoperative length of stay was 5 days (interquartile range, 4-8 days). Twelve patients (41%) experienced a complication, and the 30-day stroke/death rate was 7% (death, n = 1; stroke, n = 1). The single postoperative death occurred in a patient with history of congestive heart failure who developed a pulseless electrical activity arrest on postoperative day 11 that resulted in multiorgan system failure. Cranial nerve injury occurred in 28% (n = 8; cranial nerves X [3], VII [2], XII [2], and IX [1]), all of which resolved by last follow-up. In follow-up (mean clinical follow-up, 17 ± 14 months; mean survival time, 108 months [95% confidence interval, 81-135 months]), two (7%) complained of limb edema with femoral cutaneous nerve palsy that resolved by 3 months. One interposition bypass occluded at 3 months (asymptomatic); the remaining grafts remained patent with no restenosis, reinfection, or reintervention events. The 1- and 5-year survival was 87% ± 6% and 82% ± 8%, respectively., Conclusions: CEA patch infection can be successfully managed with femoral vein interposition bypass with acceptable postoperative outcomes. Excellent patency can be anticipated with good long-term survival. This strategy can be considered especially in cases with carotid size mismatch or if there is limited availability of alternative biologic conduits., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Acute mesenteric ischemia (AMI) is a challenging clinical problem associated with significant morbidity and mortality. Few contemporary reports focus specifically on patients undergoing open mesenteric bypass (OMB) or delineate outcome differences based on bypass configuration. This is notable, because there is a subset of patients who are poor candidates for endovascular intervention including those with flush mesenteric vessel occlusion, long segment occlusive disease, and a thrombosed mesenteric stent and/or bypass. This analysis reviewed our experience with OMB in the treatment of AMI and compared outcomes between patients undergoing either antegrade or retrograde bypass., Methods: A single-center, retrospective review was performed to identify all patients who underwent OMB for AMI from 2002 to 2016. A preoperative history of mesenteric revascularization, demographics, comorbidities, operative details, and outcomes were abstracted. The primary end point was in-hospital mortality. Secondary end points included complications, reintervention, and overall survival. Kaplan-Meier estimation and Cox proportional hazards regression were used to analyze all end points., Results: Eighty-two patients (female 54%; age 63 ± 12 years) underwent aortomesenteric bypass (aortoceliac/superior mesenteric, n = 44; aortomesenteric, n = 38) for AMI. A history of prior stent/bypass was present in 20% (n = 16). A majority (76%; n = 62) underwent antegrade bypass and the remainder received retrograde infrarenal aortoiliac inflow. Patients receiving antegrade OMB were more likely to be male (53% vs 25%; P = .02), have coronary artery disease (48% vs 25%; P = .06), chronic obstructive pulmonary disease (52% vs 25%; P = .03), and peripheral arterial disease (60% vs 35%; P = .05). Concurrent bowel resection was evenly distributed (antegrade, 45%; retrograde, 45%; P = .9) and 37% (n = 30) underwent subsequent resection during second look operations. The median duration of stay was 16 days (interquartile range, 9-35 days) and 78% (n = 64) experienced at least one major complication with no difference in rates between antegrade/retrograde configurations. In-hospital mortality was 37% (n = 30; multiple organ dysfunction, 22; bowel infarction, 4; hemorrhage/anemia, 2; arrhythmia, 1; stroke, 1; 30-day mortality, 26%). The median follow-up was 8 months (interquartile range, 1-26 months). The 1- and 3-year primary patency rates were both 82% ± 6% (95% confidence interval, 71%-95%), with 10 patients requiring reintervention. Estimated survival at 1 and 5 years was 57% ± 6% and 50% ± 6%, respectively. Bypass configuration was not associated with complication rates (P > .10), in-hospital mortality (log-rank, P = .3), or overall survival (log-rank, P = .9). However, a higher risk of reintervention was observed in patients undergoing retrograde bypass (hazard ratio, 3.0; 95% confidence interval, 0.9-11.0; P = .08)., Conclusions: OMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with comparable outcomes as retrograde OMB. The bypass configuration choice should be predicated on patient presentation, anatomy, physiology, and surgeon preference; however, an antegrade configuration may provide a lower risk of reintervention., (Copyright © 2018 Society for Vascular Surgery. All rights reserved.)

Purpose: To compare uncomplicated acute type B aortic dissection (UATBAD) patients with intractable pain/refractory hypertension treated with thoracic endovascular aortic repair (TEVAR) to UATBAD subjects without these features receiving best medical therapy (BMT)., Methods: Interrogation of the hospital database identified 101 consecutive UATBAD patients admitted between January 2011 and December 2014. Of these, 74 patients (mean age 62±13 years; 44 men) were treated with BMT; the other 27 UATBAD patients (mean age 63±13 years; 17 men) were subsequently treated with TEVAR for intractable pain (24, 89%) and/or refractory hypertension (3, 11%) at a mean 2.4±3.3 days (median 1, range 0-12) after admission. Mixed models were employed to determine differences in centerline measured aortic remodeling. Propensity analysis was employed to mitigate selection bias. Kaplan-Meier methodology was used to estimate reintervention and survival., Results: The groups were well matched; there was no difference in demographics, comorbidities, or proportion with visceral involvement (70% for TEVAR vs 86% for BMT, p=0.08). There was no significant difference in length of stay (9.6±6.3 for TEVAR vs 10.3±7.8 for BMT, p=0.3), complications (19% for TEVAR vs 24% for BMT, p=0.6), or 30-day mortality (0 for TEVAR vs 7% for BMT, p=0.1). One (4%) TEVAR patient experienced retrograde dissection. BMT resulted in greater mean increase in discharge antihypertensive medications (1.7±1.9 vs 0.7±1.7 for TEVAR, p=0.03), but there was no difference in narcotic utilization. Mean follow-up was greater in the TEVAR group (17.9±16.0 months) compared with BMT patients (11.5±10.8 months, p=0.05). TEVAR significantly improved rates of aortic diameter change (1.5% vs 12.9% for BMT, p=0.007), complete false lumen thrombosis (41% vs 11% for BMT, p=0.004), and true lumen expansion (85% vs 7% for BMT, p<0.01). However, there was no difference in reintervention (25.9% for TEVAR vs 23% for BMT, p=0.2) or survival (log-rank p=0.8)., Conclusion: TEVAR for UATBAD with intractable pain/refractory hypertension is safe but offers no short-term outcome advantage when compared to UATBAD patients without these features receiving BMT. A significant improvement in aortic remodeling was identified after TEVAR. The potential long-term reintervention and aorta-related mortality benefits of this favorable remodeling have yet to be defined and randomized trials are warranted.

Background: Aortic coarctation (AC) is most commonly identified in pediatric patients; however, adults can present with late sequelae of untreated coarctation or complications of prior open repair. To date, there are limited data about the role of thoracic endovascular aortic repair (TEVAR) in this group of patients. The purpose of this analysis was to describe our experience with management of adult coarctation patients using TEVAR., Methods: All TEVAR patients treated for primary coarctation or late sequelae of previous open repair (eg, pseudoaneurysm, recurrent coarctation or anastomotic stenosis related to index open coarctation repair) were reviewed. Demographics, comorbidities, procedure-related variables, postoperative outcomes, and reintervention were recorded. Computed tomography centerline assessments of endograft morphology were completed to delineate stent anatomy at the coarctation site. Survival and reintervention were estimated using life-table analysis., Results: A total of 21 patients were identified (median age, 46 years [range, 33-71 years]; 67% male [n = 14]). Nine patients (43%) were treated for symptomatic primary (n = 6) or recurrent (n = 3) coarctation. Other indications included degenerative thoracic aneurysm (n = 6), pseudoaneurysm (n = 4), and dissection (n = 2). Technical success was 100% (95% confidence interval [CI], 84%-100%). No 30-day mortality or paraplegia events occurred; however, two patients (10%) experienced postoperative nondisabling stroke. In primary or recurrent coarctation patients with available computed tomography imaging (n = 8 of 9), nominal stent graft diameters were achieved proximal and distal to the coarctation (range, -0.4 to -1.2 mm of desired final stent diameter). Specific to the coarctation site, there was a significant increase in aortic diameter after TEVAR (before stenting, 11.5 [95% CI, 6.8-12.3] mm; after stenting, 15 [95% CI, 13.7-15.7] mm; P = .004). Concurrently, systolic arterial blood pressure at time of discharge was significantly lower (before stenting: 147 mm Hg; 95% CI, 137-157 mm Hg; after stenting: 124 mm Hg; 95% CI, 118-134 mm Hg; P = .02). For all patients, median clinical follow-up time was 8 months (interquartile range, 3-13 months; range, 1-106 months). Three endoleaks were detected, all of which were type II related to left (n = 2) or aberrant (n = 1) subclavian arteries. Four patients (19%) underwent reintervention (median time, 7 months; range, 2-12 months), with three of four being subclavian artery embolization; one was an aortic root replacement for ascending aneurysm with bicuspid aortic valve. One-year freedom from reintervention was 78% ± 9% (95% CI, 42%-92%). The 1- and 3-year survival was 95% ± 5% (95% CI, 71%-99%). One late death was related to complications from pre-existing congenital heart disease., Conclusions: Adult AC patients can be treated safely with TEVAR, and the annular constriction of an AC can be successfully dilated by the stent graft. Given these findings, a greater number of patients with longer term follow-up is warranted to further define the role of TEVAR in the management of adult AC patients., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Spinal cord ischemia (SCI) is a devastating complication after branched or fenestrated endovascular aortic repair (B/FEVAR) for thoracoabdominal aortic disease. The purpose of this analysis was to describe the impact of a bundled clinical care protocol designed to reduce the risk of SCI in this population of patients., Methods: A bundled SCI prevention protocol including cerebrospinal fluid drainage, blood pressure parameters, transfusion goals, and pharmacologic adjuncts (steroids, naloxone) was initiated in May 2015. Before that date, portions of the protocol (cerebrospinal fluid drainage in particular) were used in an informal fashion in patients perceived to be at high risk. B/FEVAR cases completed from January 2012 to May 2016 were reviewed, and outcomes before (n = 223) and after (n = 70) SCI bundle application were compared. The primary end point was the incidence of SCI events. Secondary end points included length of stay, complications, and survival. High-risk patients for SCI were defined as those undergoing B/FEVAR resulting in aortic coverage equivalent to open Crawford extent I to III thoracoabdominal aortic aneurysm (TAAA) repair. Survival was estimated using Kaplan-Meier life-table analysis., Results: Postprotocol patients were more likely to be older (75 ± 7 vs 72 ± 8 years; P = .03), to have an American Society of Anesthesiologists class 4 designation (94% vs 81%; P = .04), and to be treated for TAAA (67% vs 56%; P = .004). Postprotocol pre-emptive spinal drain use was greater in high-risk patients (100% vs 87%; P = .04) but significantly decreased in lower risk patients (suprarenal aneurysm or extent IV TAAA: 5% after protocol implementation vs 21% before protocol implementation; P = .04). Rates of any SCI before and after implementation of the bundled protocol were 13% (n = 29 of 223) and 3% (n = 2 of 70; P = .007), respectively. In comparing high-risk patients, protocol use resulted in an even more significant reduction in SCI rate (19% [28 of 144] vs 4% [2 of 50]; P = .004). Postoperative morbidity (41% vs 33%; P = .2) and 30-day mortality (5% vs 1%; P = .3) were not different between groups. However, patients treated on protocol had significantly improved 1-year survival (99% ± 1% after protocol implementation vs 90% ± 2% before protocol implementation; log-rank, P = .05)., Conclusions: Implementation of a bundled multimodal protocol may significantly reduce risk of SCI after B/FEVAR, with the greatest risk reduction occurring in the most vulnerable patients. Interestingly, reduction in SCI risk was associated with improvement in 1-year survival., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Aortic arch disease is a challenging clinical problem, especially in high-risk patients, in whom open repair can have morbidity and mortality rates of 30% to 40% and 2% to 20%, respectively. Aortic arch chimney (AAC) stents used during thoracic endovascular aortic repair (TEVAR) are a less invasive treatment strategy than open repair, but the current literature is inconclusive about the role of this technology. The focus of this analysis is on our experience with TEVAR and AAC stents., Methods: All TEVAR procedures performed from 2002 to 2015 were reviewed to identify those with AAC stents. Primary end points were technical success and 30-day and 1-year mortality. Secondary end points included complications, reintervention, and endoleak. Technical success was defined as a patient's surviving the index operation with deployment of the AAC stent at the intended treatment zone with no evidence of type I or type III endoleak on initial postoperative imaging. The Kaplan-Meier method was used to estimate survival., Results: Twenty-seven patients (age, 69 ± 12 years; male, 70%) were identified, and all were described as being at prohibitive risk for open repair by the treating team. Relevant comorbidity rates were as follows: coronary artery disease/myocardial infarction, 59%; oxygen-dependent emphysema, 30%; preoperative creatinine concentration >1.8 mg/dL, 19%; and congestive heart failure, 15%. Presentations included elective (67%; n = 18), symptomatic (26%; n = 7), and ruptured (7%; n = 2). Eleven patients (41%) had prior endovascular or open arch/descending thoracic repair. Indications were degenerative aneurysm (49%), chronic residual type A dissection with aneurysm (15%), type Ia endoleak after TEVAR (11%), postsurgical pseudoaneurysm (11%), penetrating ulcer (7%), and acute type B dissection (7%). Thirty-two brachiocephalic vessels were treated: innominate (n = 7), left common carotid artery (LCCA; n = 24), and left subclavian artery (n = 1). Five patients (19%) had simultaneous innominate-LCCA chimneys. Brachiocephalic chimney stents were planned in 75% (n = 24), with the remainder placed for either LCCA or innominate artery encroachment (n = 8). Overall technical success was 89% (one intraoperative death, two persistent type Ia endoleaks in follow-up). The 30-day mortality was 4% (n = 1; intraoperative death of a patient with a ruptured arch aneurysm), and median length of stay was 6 (interquartile range, 4-9) days. Seven (26%) patients experienced a major complication (stroke, three [all with unplanned brachiocephalic chimney]; respiratory failure, three; and death, one). Nine (33%) patients underwent aorta-related reintervention, and no chimney occlusion events occurred during follow-up (median follow-up, 9 [interquartile range, 1-23] months). The 1-year and 3-year survival is estimated to be 88% ± 6% and 69% ± 9%, respectively., Conclusions: TEVAR with AAC can be performed with high technical success and acceptable morbidity and mortality in high-risk patients. Unplanned AAC placement during TEVAR results in an elevated stroke risk, which may be related to the branch vessel coverage necessitating AAC placement. Acceptable midterm survival can be anticipated, but aorta-related reintervention is not uncommon, and diligent follow-up is needed., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Open conversion after endovascular aortic aneurysm repair (EVAR-c) is performed nonelectively in up to 60% of cases. EVAR-c has been reported to have significantly greater risk of postoperative morbidity and mortality than primary aortic repair, but few data exist on outcomes for symptomatic or ruptured presentations. This study determined outcomes and identified predictors of postoperative major adverse cardiac events (MACEs) and mortality for patients undergoing nonelective EVAR-c compared with nonelective primary aortic repair (PAR) in the Vascular Quality Initiative (VQI)., Methods: All VQI patients undergoing urgent/emergency EVAR-c or urgent/emergency PAR from 2002 to 2014 were reviewed. Urgent presentation was defined by repair ≤24 hours of a nonelective admission, and emergency operations had clinical or radiographic evidence, or both, of rupture. End points included in-hospital MACE (myocardial infarction, dysrhythmia, congestive heart failure) and 30-day mortality. Possible covariates identified on univariate analysis (P < .2) were entered into a multivariable model, and stepwise elimination identified the best subset of predictors. Generalized estimating equations logistic regression analysis was used to determine the relative effect of EVAR-c compared with PAR on outcomes., Results: During the study interval, we identified 277 EVAR-c, and 118 (43%) underwent urgent/emergency repair. nonelective PAR was performed in 1388 of 6152 total (23%). EVAR-c patients were older (75 ± 9 vs 71 ± 10 years; P < .0001), more likely to be male (84% vs 74%; P = .02), and had a higher prevalence of hypertension (88% vs 79%; P = .02) and coronary artery disease (38% vs 27%; P = .01). No differences in MACE (EVAR-c, 31% [n = 34] vs PAR, 30% [n = 398]) or any major postoperative complication (EVAR-c, 57% [n = 63] vs PAR, 55% [n = 740]; P = .8) were found; however, 30-day mortality was significantly greater in EVAR-c (37% [n = 41]) than in (PAR, 24% [n = 291]; P = .003), with an odds ratio (OR) of 2.2 (95% confidence interval [CI], 1.04-4.77; P = .04) for EVAR-c. Predictors of any MACE included age (OR, × 1.03 for each additional year; 95% CI, 1.01-1.03; P = .0002), male gender (OR, 1.3; 95% CI, 1.03-1.67; P = .03), body mass index ≤20 kg/m 2 (OR, 1.8; 95% CI, 1.13-2.87; P = .01), chronic obstructive pulmonary disease (OR, 1.2; 95% CI, 0.86-1.80; P = .25), congestive heart failure (OR, 1.5; 95% CI, 0.98-2.34; P = .06), preoperative chronic β-blocker use (OR, 1.3; 95% CI, 0.97-1.63; P = .09), and emergency presentation (OR, 2.3; 95% CI, 1.8-3.01; area under the curve, 0.70; P < .0001). Significant predictors for 30-day mortality were age (OR × 1.07 for each additional year; 95% CI, 1.05-1.09; P < .0001), female gender (OR, 1.6; 95% CI, 1.01-2.46; P = .04), preoperative creatinine >1.8 mg/dL (OR, 1.6; 95% CI, 1.04-2.35; P = .03), an emergency presentation (OR, 4.8; 95% CI, 2.93-7.93; P < .0001), and renal/visceral ischemia (OR, × 1.1 for each unit increase log (time-minutes); 95% CI, 1.02-1.22; area under the curve, 0.84; P = .01)., Conclusions: Nonelective EVAR-c patients are older and have higher prevalence of cardiovascular risk factors than PAR patients. Similar rates of postoperative complications occur; however, urgent/emergency EVAR-c has a significantly higher risk of 30-day mortality than nonelective PAR. Several variables are identified that predict outcomes after these repairs and may help risk stratify patients to further inform clinical decision making when patients present nonelectively with EVAR failure., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To study the short and mid-term outcomes of thoracic aortic operations in patients ≥80 years old., Methods: This is a retrospective chart review of patients ≥80 years old who underwent thoracic aortic operation in our institution between 2006 and 2013., Results: Ninety-eight patients were studied. Fifty-four patients underwent open repair; 41 underwent endovascular repair; and three underwent hybrid repair with aortic arch debranching and subsequent endovascular stent graft. Hospital mortality rate among the entire cohort was 11/98 (11%): 7/54 (13%) for open repair; 2/41 (5%) for endovascular repair; and 2/3 (66%) for hybrid repair. Major adverse events occurred in 23/98 (23%) in the entire cohort: 15/54 (28%) in open repair; 5/41 (12%) in endovascular repair; and 3/3 (100%) in hybrid repair. Mean follow-up was 31 ± 28 months (median 26 months). Two- and five-year survival rates were 57%, and 34% for the open approach and 71%, and 43% for the endovascular approach respectively., Conclusions: Both open and endovascular thoracic aortic repairs can be performed with favorable mortality and perioperative morbidity in appropriately selected octogenarian patients. doi: 10.1111/jocs.12722 (J Card Surg 2016;31:334-340)., (© 2016 Wiley Periodicals, Inc.)

Objective: Risk of open conversion after endovascular aortic aneurysm repair (EVAR-c) is poorly defined. The purpose of this analysis was to determine outcomes of elective EVAR-c compared with elective primary open abdominal aortic aneurysm repair (PAR) in the Vascular Quality Initiative., Methods: Vascular Quality Initiative patients who underwent elective EVAR-c and PAR (2002-2014) were reviewed. Candidate predictors of major adverse cardiac event (MACE) and/or 30-day mortality were entered into a multivariable model, and stepwise elimination was used to reduce the number of covariates to a best subset of predictors. To estimate the additive risk of EVAR-c for MACE or 30-day mortality over PAR, this variable was added along with the best subset of predictors into generalized estimating equations logistic regression models., Results: We identified 159 EVAR-c and 3741 PAR patients. EVAR-c patients were older (73.5 ± 8.1 vs 69.5 ± 8.4 years; P < .0001), more likely to have diabetes (21% vs 15%; P = .03), and history of lower extremity bypass (9% vs 4%; P = .0006). EVAR-c was associated with a higher incidence of retroperitoneal aortic exposure (41%; n = 64 vs PAR, 26%, n = 976; P < .0001), use of a bifurcated graft (65%; n = 101 vs PAR, 52%; n = 1923; P = .001), greater blood loss (median [interquartile range], 2000 mL [1010-3500] vs PAR, 1200 mL [750-2000]; P < .0001) and longer procedure times (EVAR-c, 275 ± 122 minutes vs PAR, 232 ± 9 minutes; P < .0001). However, PAR more frequently was completed with a suprarenal and/or mesenteric cross-clamp (74%, n = 2749 vs EVAR-c, 53%, n = 83; P < .0001) and had a higher incidence of concomitant procedures (26%; n = 972 vs EVAR-c, 18%; n = 28; P = .03). Nonadjusted 30-day mortality was greater after EVAR-c: EVAR-c, 8% (n = 10) vs PAR, 3% (n = 105); P = .009. There was no difference in complication rates: EVAR-c, 33% (n = 52) vs PAR, 28% (n = 1056); P =.3. Preoperative 30-day mortality predictors included age (odds ratio [OR], 1.06/y, 95% confidence interval [CI], 1.04-1.1; P < .0001), chronic obstructive pulmonary disease (OR, 2.4; 95% CI, 1.6-3.5; P < .0001), history of leg bypass (OR, 2.3, 1.2-4.4;P =.01), suprarenal cross-clamp (OR 2.2, 1.2-4.1;P =.01), prior carotid revascularization (OR 2.2; 95% CI, 1.3-3.8; P = .0004), congestive heart failure (OR, 1.8; 95% CI, 0.9-3.5; P = .08), and female sex (OR, 1.6; 95% CI, 1.1-2.3; P = .02; area under the curve, 0.75). When controlling for covariates, EVAR-c was not significantly associated with MACE (OR, 1.2; 95% CI, 0.7-2.0; P = .4) or 30-day mortality (OR, 2.0; 0.9-4.2; P = .08)., Conclusions: EVAR-c patients are typically older, have more comorbidities, and experience greater blood loss and longer procedure times compared with PAR patients. However, postoperative morbidity and mortality are primarily driven by patient covariates and intraoperative factors, rather than the need for endograft explantation. Several preoperative variables were identified as predictors of 30-day mortality after elective EVAR-c and should be considered during the decision-making process for remedial treatment of failed endovascular PAR., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine outcomes of aneurysmal common iliac arteries (aCIA) used for landing zones (LZs) during endovascular aneurysm repair (EVAR)., Methods: This single-center study retrospectively compared 57 EVAR patients (mean age 72±8 years; 56 men) with 70 aCIAs (diameter ≥20 mm) to 25 control EVAR subjects (mean age 73±7 years; 20 men) with 50 normal (≤15-mm) CIA LZs treated consecutively during the same time interval. The CIA LZ measurements were analyzed using random effects linear mixed models to determine diameter change over time. Life tables were used to estimate freedom from endoleak, reintervention, and all-cause mortality., Results: The mean maximum preoperative CIA diameter in the aCIA LZ group was 24.8±4.5 mm (range 20.0-47.3, median 23.9) vs 13.6±1.5 mm (range 9.2-15.0, median 13.9; p<0.001) in the controls. Nineteen aCIA LZs were treated outside the instructions for use of the device. Median follow-up in the aCIAs LZ cohort was 39.2 months [interquartile range (IQR) 15, 61] vs 49.3 months (IQR 36, 61) in the controls (p=0.06). The rate of aCIA LZ change (0.09 mm/mo, 95% CI 0.07 to 0.1) was significantly greater than controls (0.03 mm/mo, 95% CI -0.009 to 0.07; p<0.0001). No type Ib endoleaks developed in either group; however, aCIA LZ patients had 6 (11%) iliac limb-related reinterventions. There were significantly more endograft-related reinterventions in the aCIA LZ patients (n=10, 14%) compared with controls (n=2, 4%; p=0.06). There was no difference in mortality or freedom from any post-hospital discharge endoleak., Conclusion: Aneurysmal CIA LZs used during EVAR experience greater dilatation compared with normal LZs, but no significant difference in outcome was noted in midterm follow-up. However, an increased incidence of graft limb complications or endograft-related reintervention may be encountered. Use of aCIA LZs appears to be safe; however, greater patient numbers and longer follow-up are needed to understand the clinical implications of morphologic changes in these vessels when used during EVAR., (© The Author(s) 2015.)

The use of "chimney" stents to augment the proximal landing zone for endovascular aneurysm repair has been increasingly reported. Despite mounting enthusiasm for this technique, the durability of this type of repair and capability to preserve perfusion to target branches remains a paramount concern. Here, we report management of a patient presenting with acute bilateral renal chimney stent thrombosis and a type Ia endoleak., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

The role of transcatheter aortic valve replacement (TAVR) continues to evolve and expand at a rapid pace. The advanced age and frailty of many TAVR candidates often presents complex vascular access challenges when contemplating the exact route of valve delivery. As the indications and approved routes of delivery have evolved, so have the direct open vascular and percutaneous techniques paramount to success. We review the spectrum of access options that may be available for consideration during TAVR procedures and highlight the "pearls and pitfalls" of each technique. We additionally highlight reasons a technique may be preferred for a specific patient subset, as well as the concerns addressed by the anesthesiologist in approaching TAVR., (© The Author(s) 2014.)

Objective: Endovascular surgery has revolutionized the treatment of aortic aneurysms; however, these improvements have come at the cost of increased radiation and contrast exposure, particularly for more complex procedures. Three-dimensional (3D) fusion computed tomography (CT) imaging is a new technology that may facilitate these repairs. The purpose of this analysis was to determine the effect of using intraoperative 3D fusion CT on the performance of fenestrated endovascular aortic repair (FEVAR)., Methods: Our institutional database was reviewed to identify patients undergoing branched or FEVAR. Patients treated using 3D fusion CT were compared with patients treated in the immediate 12-month period before implementation of this technology when procedures were performed in a standard hybrid operating room without CT fusion capabilities. Primary end points included patient radiation exposure (cumulated air kerma: mGy), fluoroscopy time (minutes), contrast usage (mL), and procedure time (minutes). Patients were grouped by the number of aortic graft fenestrations revascularized with a stent graft, and operative outcomes were compared., Results: A total of 72 patients (41 before vs 31 after 3D fusion CT implementation) underwent FEVAR from September 2012 through March 2014. For two-vessel fenestrated endografts, there was a significant decrease in radiation exposure (3400 ± 1900 vs 1380 ± 520 mGy; P = .001), fluoroscopy time (63 ± 29 vs 41 ± 11 minutes; P = .02), and contrast usage (69 ± 16 vs 26 ± 8 mL; P = .0002) with intraoperative 3D fusion CT. Similarly, for combined three-vessel and four-vessel FEVAR, significantly decreased radiation exposure (5400 ± 2225 vs 2700 ± 1400 mGy; P < .0001), fluoroscopy time (89 ± 36 vs 64 ± 21 minutes; P = .02), contrast usage (90 ± 25 vs 39 ± 17 mL; P < .0001), and procedure time (330 ± 100 vs 230 ± 50 minutes; P = .002) was noted. Estimated blood loss was significantly less (P < .0001), and length of stay had a trend (P = .07) toward being lower for all patients in the 3D fusion CT group., Conclusions: These results demonstrate that use of intraoperative 3D fusion CT imaging during FEVAR can significantly decrease radiation exposure, procedure time, and contrast usage, which may also decrease the overall physiologic impact of the repair., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Spinal cord ischemia (SCI) is a devastating but potentially preventable complication of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to determine what factors predict SCI after TEVAR., Methods: All TEVAR procedures at a single institution were reviewed for patient characteristics, prior aortic repair history, aortic centerline of flow analysis, and procedural characteristics. SCI was defined as any lower extremity neurologic deficit that was not attributable to an intracranial process or peripheral neuropathy. Forty-three patient and procedural variables were evaluated individually for association with SCI. Those with the strongest relationships to SCI (P < .1) were included in a multivariable logistic regression model, and a stepwise variable elimination algorithm was bootstrapped to derive a best subset of predictors from this model., Results: From 2002 to 2013, 741 patients underwent TEVAR for various indications, and 68 (9.2%) developed SCI (permanent: n = 38; 5.1%). Because of the lack of adequate imaging for centerline analysis, 586 patients (any SCI, n = 43; 7.4%) were subsequently analyzed. Patients experiencing SCI after TEVAR were older (SCI, 72 ± 11 years; no SCI, 65 ± 15 years; P < .0001) and had significantly higher rates of multiple cardiovascular risk factors. The stepwise selection procedure identified five variables as the most important predictors of SCI: age (odds ratio [OR] multiplies by 1.3 per 10 years; 95% confidence interval [CI], 0.9-1.8, P = .06), aortic coverage length (OR multiplies by 1.3 per 5 cm; CI, 1.1-1.6; P = .002), chronic obstructive pulmonary disease (OR, 1.9; CI, 0.9-4.1; P = .1), chronic renal insufficiency (creatinine concentration ≥ 1.6 mg/dL; OR, 1.9; CI, 0.8-4.2; P = .1), and hypertension (defined as chart history or medication; OR, 6.4; CI, 2.6-18; P < .0001). A logistic regression model with just these five covariates had excellent discrimination (area under the receiver operating characteristic curve = .83) and calibration (χ(2) = 9.8; P = .28)., Conclusions: This analysis generated a simple model that reliably predicts SCI after TEVAR. This clinical tool can assist decision-making about when to proceed with TEVAR, guide discussions about intervention risk, and help determine when maneuvers to mitigate SCI risk should be implemented., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Despite poor long-term patency, acceptable limb salvage has been reported with cryopreserved saphenous vein bypass (CVB) for various indications. However, utility of CVB in patients with critical limb ischemia (CLI) remains undefined. The purpose of this analysis was to determine the role of CVB in CLI patients and to identify predictors of successful outcomes., Methods: A retrospective review of all lower extremity bypass (LEB) procedures at a single institution was completed, and CVB in CLI patients were further analyzed. The primary end point was amputation-free survival. Secondary end points included primary patency and limb salvage. Life tables were used to estimate occurrence of end points. Cox regression analysis was used to determine predictors of limb salvage., Results: From 2000 to 2012, 1059 patients underwent LEB for various indications, of whom 81 received CVB for either ischemic rest pain or tissue loss. Mean age (± standard deviation) was 66 ± 10 years (male, 51%; diabetes, 51%; hemodialysis dependence, 12%), and 73% (n = 59) had history of failed ipsilateral LEB or endovascular intervention. None had sufficient autogenous conduit for even composite vein bypass. Infrainguinal CVB (infrapopliteal target, 96%; n = 78) was completed for multiple indications including Rutherford class 4 (42%; n = 34), class 5 (40%; n = 32), and class 6 (18%; n = 15). Eleven (14%) had CLI and concomitant graft infection (n = 8) or acute on chronic ischemia (n = 3). Intraoperative adjuncts (eg, profundaplasty, suprainguinal stent or bypass) were completed in 49% (n = 40) of cases. Complications occurred in 36% (n = 29), with 30-day mortality of 4% (n = 3). Median follow-up for CLI patients was 11.8 (interquartile range, 0.4-28.4) months with corresponding 1- and 3-year actuarial estimated survival (± standard error mean) of 84% ± 4% and 62% ± 6%. Primary patency of CVB for CLI was 27% ± 6% and 17% ± 6% at 1 and 3 years, respectively. Amputation-free survival was 43% ± 6% and 23% ± 6% at 1 and 3 years, respectively, and significantly higher for rest pain (59% ± 9%, 36% ± 10%) compared with tissue loss (31% ± 7%, 14% ± 7%; log-rank, P = .04). Freedom from major amputation after CVB for CLI was 57% ± 6% and 43% ± 7% at 1 and 3 years. Multivariable predictors of limb salvage for the CVB CLI cohort included postoperative warfarin (hazard ratio [HR], 0.4; 95% confidence interval [CI], 0.2-0.8), dyslipidemia (HR, 0.4; 95% CI, 0.2-0.9), and rest pain (HR, 0.4; 95% CI, 0.2-0.9). Predictors of major amputation included graft infection (HR, 3.1; 95% CI, 1.1-9.0)., Conclusions: In CLI patients with no autologous conduit and prior failed infrainguinal bypass, CVB outcomes are disappointing. CVB performs best in patients with rest pain, particularly those who can be anticoagulated with warfarin. However, it may be an acceptable option in patients with minor tissue loss or concurrent graft infection, but consideration should be weighed against the known natural history of nonrevascularized CLI and nonbiologic conduit alternatives, given potential cost implications., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: There are limited data describing the preclose technique with the Perclose ProGlide device (Abbott Vascular, Redwood City, Calif) in percutaneous thoracic endovascular aortic repair (P-TEVAR), particularly in obese patients, in whom use of this technique is thought to be relatively contraindicated. The purpose of this analysis was to describe our experience with P-TEVAR and to compare outcomes in patients with or without obesity., Methods: All TEVAR procedures at a single institution from 2005 to 2011 were reviewed, and P-TEVAR patients were stratified by body mass index (obesity ≥ 30 kg/m2). Preoperative computed tomography scans were analyzed for access vessel depth, calcification, and morphology. Technical success was defined as the ability to achieve hemostasis and to maintain limb perfusion without the need for common femoral artery exposure or obligate surgical repair of the vessel within a 30-day postoperative period. Generalized estimating equations and stepwise logistic regression were used to develop prediction models of preclose failure., Results: The review identified 536 patients, in whom 355 (66%) P-TEVAR procedures were completed (366 arteries; n = 40 [11%] bilateral). Compared with nonobese patients (n = 264), obese patients (n = 91) were typically younger (59 ± 16 years vs. 66 ± 16 years; P = .0004) and more likely to have renal insufficiency (28% vs. 17%; P = .05) or diabetes mellitus (19% vs. 9%; P = .02). The number of Perclose deployments was similar between groups (P = NS). Mean sheath size (25.4F vs 25.0F; P = .04), access vessel inner diameters (8.5 ± 1.9 mm vs. 7.9 ± 2.0 mm; P = .02), and vessel depth (50 ± 20 mm vs. 30 ± 13 mm; P < .0001) were greater in obese patients. Adjunctive iliac stents were used in 7% of cases (10 [11%] in obese patients vs 16 [6%] in nonobese patients; P = .2). Overall technical success was 92% (92% for nonobese patients vs 93% for obese patients; P = .7). Three patients required subsequent operations for access complications, two obese patients (2%) and one nonobese patient (0.4%) (P = .3). Independent predictors of failure were adjunctive iliac stent (odds ratio [OR], 9.5; 95% confidence interval [CI], 3.3-27.8; P < .0001), more than two Perclose devices (OR, 7.0; 95% CI, 2.3-21; P = .0005), and smaller access vessel diameter to sheath size ratio (OR multiplies by 1.1 for each .01 decrease in ratio; 95% CI, 1.02-1.2; P = .007) (area under the receiver operating characteristic curve = .75)., Conclusions: Obesity is not a contraindication to P-TEVAR. P-TEVAR can be performed safely, despite the need for larger diameter sheaths. However, patients predicted to need adjunctive stenting or possessing smaller access vessel diameter to sheath size ratios are at highest risk of preclose failure with the Perclose ProGlide device, and selective use of this technique is recommended., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: "Chimney" techniques used to extend landing zones for endovascular aortic repair (chEVAR) have been increasingly reported; however, concerns about durability and patency remain. The purpose of this analysis was to examine midterm outcomes of chEVAR., Methods: All patients at the University of Florida treated with chEVAR were reviewed. Major adverse events (MAEs) were recorded and defined as any chimney stent thrombosis, type Ia endoleak in follow-up, reintervention, 30-day/in-hospital death, or ≥25% decrease in estimated glomerular filtration rate after discharge. Primary end points included chimney stent patency and freedom from MAE. Secondary end points included complications and long-term survival., Results: From 2008 to 2012, 41 patients (age ± standard deviation, 73 ± 8 years; male, 66% [n = 27]) were treated with a total of 76 chimney stents (renal, n = 51; superior mesenteric artery, n = 16; celiac artery, n = 9) for a variety of indications: juxtarenal, 42% (n = 17, one rupture), suprarenal, 17% (n = 7), and thoracoabdominal aneurysm, 17% (n = 7); aortic anastomotic pseudoaneurysm, 15% (n = 6; three ruptures); type Ia endoleak after EVAR, 7% (n = 3); and atheromatous disease, 2% (n = 1). Two patients had a single target vessel abandoned because of cannulation failure, and one had a type Ia endoleak at case completion (technical success, 93%). Intraoperative complications occurred in seven patients (17%), including graft maldeployment with unplanned mesenteric chimney (n = 2) and access vessel injury requiring repair (n = 5). Major postoperative complications developed in 20% (n = 8). The 30-day mortality and in-hospital mortality were 5% (n = 2) and 7% (n = 3), respectively. At median follow-up of 18.2 months (range, 1.4-41.5 months), 28 of 33 patients (85%) with available postoperative imaging experienced stabilization or reduction of abdominal aortic aneurysm sac diameters. Nine patients (32%) developed endoleak at some point during follow-up (type Ia, 7% [n = 3]; type II, 10% [n = 4]; indeterminate, 7% [n = 3]), and one patient underwent open, surgical conversion. The estimated probability of freedom from reintervention (±standard error mean) was 96% ± 4% at both 1 year and 3 years. Primary patency of all chimney stents was 88% ± 5% and 85% ± 5% at 1 year and 3 years, respectively. Corresponding freedom from MAEs was 83% ± 7% and 57% ± 10% at 1 year and 3 years. The actuarial estimated survival for all patients at 1 year and 5 years was 85% ± 6% and 65% ± 8%, respectively., Conclusions: These results demonstrate that chEVAR can be completed with a high degree of success; however, perioperative complications and MAEs during follow-up, including loss of chimney patency and endoleak, may occur at a higher rate than previously reported. Elective use of chEVAR should be performed with caution, and comparison to open and fenestrated EVAR is needed to determine long-term efficacy of this technique., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

We report a case of a woman who presented with a symptomatic penetrating aortic ulcer of the descending aorta and prohibitive aortoiliac occlusive disease. The thoracic stent graft was delivered using surgical exposure of the ascending aorta., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Patients presenting with occluded aortobifemoral (ABF) bypass grafts are managed with a variety of techniques. Redo ABF (rABF) bypass procedures are infrequently performed because of concerns about procedural complexity and morbidity. The purpose of this analysis was to compare midterm results of rABF bypass with those of primary ABF (pABF) bypass for aortoiliac occlusive disease to determine if there are significant differences in outcomes., Methods: A retrospective review was performed of all patients undergoing ABF bypass for occlusive disease between January 2002 and March 2012. A total of 19 patients underwent rABF bypass and 194 received pABF bypass during that period. Data for an indication- and comorbidity-matched case-control cohort of 19 elective pABF bypass patients were collected for comparison to the rABF bypass group. Primary end points included rate of major complications as well as 30-day and all-cause mortality. Secondary end points were amputation-free survival and freedom from major adverse limb events., Results: The rABF bypass patients more frequently underwent prior extra-anatomic or lower extremity bypass operations compared with pABF bypass patients (P = .02); however, no difference was found in the incidence of prior failed endovascular iliac intervention (P = .4). By design, indications for the rABF and pABF bypass groups were the same (claudication, n = 6/6 [31.6%]; P = 1; critical limb ischemia, n = 13/13 [78.4%]; P = 1). Aortic access was more frequently by retroperitoneal exposure in the rABF bypass group (n = 13 vs n = 1; P < .0001), and a significantly higher proportion of the rABF bypass patients required concomitant infrainguinal bypass or intraprocedural adjuncts such as profundaplasty (n = 14 vs n = 5; P = .01). The rABF bypass patients experienced greater blood loss (1097 ± 983 mL vs 580 ± 457 mL; P = .02), received more intraoperative fluids (3400 ± 1422 mL vs 2279 ± 993 mL; P = .01), and had longer overall procedure times (408 ± 102 minutes vs 270 ± 48 minutes; P < .0001). Length of stay (days ± standard deviation) was similar (pABF bypass, 11.2 ± 10.4; rABF bypass, 9.1 ± 4.5; P = .7), and no 30-day or in-hospital deaths occurred in either group. Similar rates of major complications occurred in the two groups (pABF bypass, n = 6 [31.6%]; rABF bypass, n = 4 [21.1%]; observed difference, 9.5%; 95% confidence interval, -17.6% to 36.7%; P = .7). Two-year freedom from major adverse limb events (±standard error mean) was 82% ± 9% vs 78% ± 10% for pABF and rABF bypass patients (log-rank, P = .6). Two-year amputation-free survival was 90 ± 9% vs 89 ± 8% between pABF and rABF bypass patients (P = .5). Two-year survival was 91% ± 9% and 90% ± 9% for pABF and rABF bypass patients (P = .8)., Conclusions: Patients undergoing rABF bypass have higher procedural complexity compared with pABF bypass as evidenced by greater operative time, blood loss, and need for adjunctive procedures. However, similar perioperative morbidity, mortality, and midterm survival occurred in comparison to pABF bypass patients. These results support a role for rABF bypass in selected patients., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Type Ia endoleak after endovascular aortic repair (EVAR) can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion (OSC), reports of complex endoluminal salvage techniques are increasing. Despite development of these endovascular remedial strategies, many patients ultimately require OSC. The purpose of this analysis was to outcomes of elective OSC for type Ia endoleak and compare them with elective primary open juxtarenal aneurysm repair (OJAR) to determine if these concerns are warranted., Methods: From 2000 to 2012, 54 patients underwent EVAR OSC at median time of 27 months (interquartile range, 9-55 months). Indications included endograft thrombosis in 2 (4%), intraoperative EVAR failure in 3 (6%), rupture in 5 (9%), graft infection in 6 (11%), and type Ia endoleak in 25 (all: 38 [70%]). Because many OSCs are performed for emergency indications without endovascular options, we chose elective type Ia endoleak patients as our study group. These 25 patients were compared with an elective OJAR cohort matched by anatomy and comorbidities. Primary end points were 30-day and 1-year mortality. Secondary end points included early complications, cross-clamp time, procedure time, blood loss, and length of stay., Results: Demographic and comorbidity data in the OSC and OJAR groups did not differ, with the exception that OJAR patients presented with smaller aneurysm diameter and a higher rate of chronic obstructive pulmonary disease (P = .03). OSC patients more frequently underwent a nontube graft repair (OSC, n = 20 [80%] vs OJAR, n = 6 [24%]; P = .0002), required longer procedure times (P = .03), and received more plasma transfusions (P = .03). The 30-day mortality was 4% in both groups (observed difference in rates, 0%; 95% confidence interval for difference in mortality rates, -14.0% to 14.0%; P = 1). A similar rate of major complications occurred (OSC, n = 9 [36%] vs OJAR, n = 8 [32%]; P = 1). One-year survival was 83% in OSC and 91% in OJAR (observed difference, 7%; 95% confidence interval, -15% to 29%; P = .65)., Conclusions: Despite many advances in EVAR technology, the need for OSC persists and will likely become more common as older-generation devices fail or providers attempt EVAR in more anatomically complex patients. Elective OSC for type Ia endoleak can be technically challenging but is not associated with increased morbidity or mortality compared with OJAR in appropriately selected patients. These results should be considered before pursuing complex endovascular remediation of EVAR failures., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Despite improved short-term outcomes, concerns remain regarding durability of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to evaluate the pathology-specific incidence of secondary aortic interventions (SAI) after TEVAR and their impact on survival., Methods: Retrospective review was performed of all TEVAR procedures and SAI at one institution from 2004-2011. Kaplan-Meier analysis was used to estimate survival., Results: Of 585 patients, 72 (12%) required SAI at a median of 5.6 months (interquartile range, 1.4-14.2) with 22 (3.7%) requiring multiple SAI. SAI incidence differed significantly by pathology (P = .002) [acute dissection (21.3%), postsurgical (20.0%), chronic dissection (16.7%), degenerative aneurysm (10.8%), traumatic transection (8.1%), penetrating ulcer (1.5%), and other etiologies (14.8%)]. Most common indications after dissection were persistent false lumen flow and proximal/distal extension of disease. For degenerative aneurysms, SAI was performed primarily to treat type I/III endoleaks. SAI patients had a greater mean number of comorbidities (P < .0005), stents placed (P = .0002), and postoperative complications after the index TEVAR (P < .0005) compared with those without SAI. Freedom from SAI at 1 and 5 years (95% confidence interval) was estimated to be 86% (82%-90%) and 68% (57%-76%), respectively. There were no differences in survival (95% confidence interval) between patients requiring SAI and those who did not [SAI 1-year, 88% (77%-93%); 5-year, 51% (37%-63%); and no SAI 1-year, 82% (79%-85%); 5-year, 67% (62%-71%) (log-rank, P = .2)]., Conclusions: SAI after TEVAR is not uncommon, particularly in patients with dissection, but does not affect long-term survival. Aortic pathology is the most important variable impacting survival and dictated need, timing, and mode of SAI. The varying incidence of SAI by indication underscores the need for diligent surveillance protocols that should be pathology-specific., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Aortic infections, even with treatment, have a high mortality and risk of recurrent infection and limb loss. Cryopreserved aortoiliac allograft (CAA) has been proposed for aortic reconstruction to improve outcomes in this high-risk population., Methods: A multicenter study using a standardized database was performed at 14 of the 20 highest volume institutions that used CAA for aortic reconstruction in the setting of infection or those at high risk for prosthetic graft infection., Results: Two hundred twenty patients (mean age, 65; male:female, 1.6/1) were treated since 2002 for culture positive aortic graft infection (60%), culture negative aortic graft infection (16%), enteric fistula/erosion (15%), infected pseudoaneurysm adjacent to the aortic graft (4%), and other (4%). Intraop cultures indicated infection in 66%. Distal anastomosis was to the femoral artery and iliac. Mean hospital length of stay was 24 days, and 30-day mortality was 9%. Complications occurred in 24% and included persistent sepsis (n = 17), CAA thrombosis (n = 9), CAA rupture (n = 8), recurrent CAA/aortic infection (n = 8), CAA pseudoaneurysm (n = 6), recurrence of aortoenteric fistula (n = 4), and compartment syndrome (n = 1). Patients with full graft excision had significantly better outcomes. Ten (5%) patients required allograft explant. Mean follow-up was 30 ± 3 months. Freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. Primary graft patency was 97% at 5 years, and patient survival was 75% at 1 year and 51% at 5 years., Conclusions: This largest study of CAA indicates that CAA allows aortic reconstruction in the setting of infection or those at high risk for infection with lower early and long-term morbidity and mortality than other previously reported treatment options. Repair with CAA is associated with low rates of aneurysm formation, recurrent infection, aortic blowout, and limb loss. We believe that CAA should be considered a first line treatment of aortic infections., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Open surgical revascularization for subclavian artery occlusive disease (OD) has largely been supplanted by endovascular treatment despite the excellent long-term patency of bypass. The indications for carotid-subclavian bypass (C-SBP) and subclavian transposition (ST) have been recently expanded with the widespread application of thoracic endovascular aortic repair (TEVAR), primarily to augment proximal landing zones or treat endovascular failures. This study was performed to determine the outcomes of patients undergoing C-SBP/ST in the context of contemporary endovascular therapies and evolving indications., Methods: A prospective database including all procedures performed at a single institution from 2002 to 2012 was retrospectively queried for patients who underwent subclavian revascularization for TEVAR or OD indications. Patient demographics and perioperative outcomes were recorded. Patency was determined by computed tomography angiography in the TEVAR group. Noninvasive studies were used for the OD patients. Life-table methods were used to estimate patency, reintervention, and survival., Results: Of 139 procedures identified, 101 were performed for TEVAR and 38 for OD. All TEVAR patients underwent C-SBP/ST to augment landing zones (49% preoperative; 41% intraoperative), treat arm ischemia (8% postoperative), or for internal mammary artery salvage (2%). OD patients had a variety of indications, including failed stent/arm fatigue, 49%; asymptomatic >80% internal carotid stenosis with concurrent subclavian occlusion, 18%; symptomatic cerebrovascular OD, 13%; redo bypass, 8%; and coronary-subclavian steal, 5%. Differences in postoperative stroke and death, primary patency, or freedom from reintervention were not significant. The 30-day postoperative stroke, death, and combined stroke/death rates were, respectively, 10.8%, 5.8%, and 13.7% for the entire cohort; 8.9%, 7.1%, and 12.9% in TEVAR patients; and 15.8%, 2.6%, and 15.8% in OD patients. The 1- and 3-year primary patencies were, respectively, 94% and 94% for TEVAR and 93% and 73% for OD patients. Survival was similar between the groups, with an estimated survival rate of 88% at 1 year and 76% at 5 years., Conclusions: Stroke risk in this contemporary series of C-SBP/ST performed for TEVAR and OD indications may be higher than previously reported in historical series. In TEVAR patients, this may be attributed to procedural complexity of the TEVAR in patients requiring subclavian revascularization. In OD patients, this is likely due to the changing patient population that requires more frequent concomitant carotid interventions. Despite the short-term morbidity, excellent bypass durability and equivalent long-term patient survival can be anticipated., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Spinal cord ischemia (SCI) is a potentially devastating complication of thoracic endovascular aortic repair (TEVAR) that can result in varying degrees of short-term and permanent disability. This study was undertaken to describe the clinical outcomes, long-term functional impact, and influence on survival of SCI after TEVAR., Methods: A retrospective review of all TEVAR patients at the University of Florida from 2000 to 2011 was performed to identify individuals experiencing SCI, defined by any new lower extremity neurologic deficit not attributable to another cause. SCI was dichotomized into immediate or delayed onset, with immediate onset defined as SCI noted upon awakening from anesthesia, and delayed characterized as a period of normal function, followed by development of neurologic injury. Ambulatory status was determined using database query, record review, and phone interviews with patients and/or family. Mortality was estimated using life-table analysis., Results: A total of 607 TEVARs were performed for various indications, with 57 patients (9.4%) noted to have postoperative SCI (4.3% permanent). SCI patients were more likely to be older (63.9 ± 15.6 vs 70.5 ± 11.2 years; P = .002) and have a number of comorbidities, including chronic obstructive pulmonary disease, hypertension, dyslipidemia, and cerebrovascular disease (P < .0001). At some point in their care, a cerebrospinal fluid drain was placed in 54 patients (95%), with 54% placed postoperatively. In-hospital mortality was 8.8% for the entire cohort (SCI vs no SCI; P = .45). SCI developed immediately in 12 patients, delayed onset in 40, and indeterminate in five patients due to indiscriminate timing from postoperative sedation. Three patients (25%) with immediate SCI had measurable functional improvement (FI), whereas 28 (70%) of the delayed-onset patients experienced some degree of neurologic recovery (P = .04). Of the 34 patients with complete data available, 26 (76%) reported quantifiable FI, but only 13 (38%) experienced return to their preoperative baseline. Estimated mean (± standard error) survival for patients with and without SCI was 37.2 ± 4.5 and 71.6 ± 3.9 months (P < .0006), respectively. Patients with FI had a mean survival of 53.9 ± 5.9 months compared with 9.6 ± 3.6 months for those without improvement (P < .0001). Survival and return of neurologic function were not significantly different when patients with preoperative and postoperative cerebrospinal fluid drains were compared., Conclusions: The minority of patients experience complete return to baseline function after SCI with TEVAR, and outcomes in patients without early functional recovery are particularly dismal. Patients experiencing delayed SCI are more likely to have FI and may anticipate similar life-expectancy with neurologic recovery compared with patients without SCI. Timing of drain placement does not appear to have an impact on postdischarge FI or long-term mortality., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The safety and feasibility of fenestrated/branched endovascular repair of acute visceral aortic disease in high-risk patients is unknown. The purpose of this report is to describe our experience with surgeon-modified endovascular aneurysm repair (sm-EVAR) for the urgent or emergent treatment of pathology involving the branched segment of the aorta in patients deemed to have prohibitively high medical and/or anatomic risk for open repair., Methods: A retrospective review was performed on all patients treated with sm-EVAR for acute indications. Planning was based on three-dimensional computed tomographic angiogram reconstructions and graft configurations included various combinations of branch, fenestration, or scallop modifications., Results: Sixteen patients (mean age [± standard deviation], 68 ± 10 years; 88% male) deemed high risk for open repair underwent urgent or emergent repair using sm-EVAR. Indications included degenerative suprarenal or thoracoabdominal aneurysm (six), presumed or known mycotic aneurysm (four), anastomotic pseudoaneurysm (three), false lumen rupture of type B dissection (two), and penetrating aortic ulceration (one). Nine (56%) had previous aortic surgery and all patients were either American Society of Anesthesiologists class IV (n = 9) or IV-E (n = 7). A total of 40 visceral vessels (celiac, 10; superior mesenteric artery, 10; right renal artery, 10; left renal artery, 10) were revascularized with a combination of fenestrations (33), directional graft branches (six), and graft scallops (one). Technical success was 94% (n = 15/16), with one open conversion. Median contrast use was 126 mL (range, 41-245) and fluoroscopy time was 70 minutes (range, 18-200). Endoleaks were identified intraoperatively in four patients (type II, n = 3; type IV, n = 1), but none have required remediation. Mean length of stay was 12 ± 15 days (median, 5.5; range, 3-59). Single complications occurred in five (31%) patients as follows: brachial sheath hematoma (one), stroke (one), ileus (one), respiratory failure (one), and renal failure (one). An additional patient experienced multiple complications including spinal cord ischemia (one) and multiorgan failure resulting in death (n = 1; in-hospital mortality, 6.3%). The majority of patients were discharged to home (63%; n = 10) or short-term rehabilitation units (25%; n = 4), while one patient required admission to a long-term acute care setting. There were no reinterventions at a median follow-up of 6.2 (range, 1-16.1) months. Postoperative computed tomographic angiogram was available for all patients and demonstrated 100% branch vessel patency, with one type III endoleak pending intervention. There were two late deaths at 1.4 and 13.4 months due to nonaortic-related pathology., Conclusions: Urgent or emergent treatment of acute pathology involving the visceral aortic segment with fenestrated/branched endograft repair is feasible and safe in selected high-risk patients; however, the durability of these repairs is yet to be determined., (Copyright © 2013 Society for Vascular Surgery. All rights reserved.)

Background: The Food and Drug Administration has approved devices for endovascular management of thoracic endovascular aortic aneurysm repair (TEVAR); however, limited data exist describing the outcomes of TEVAR for aneurysms attributable to chronic type B aortic dissection (cTBAD). This study was undertaken to determine the results of endovascular treatment of cTBAD with aneurysmal degeneration., Methods: A retrospective analysis of all patients treated for cTBAD with aneurysmal degeneration at the University of Florida from 2004 to 2011 was performed. Computed tomograms with centerline reconstruction were analyzed to determine change in aortic diameter, relative proportions of aortic treatment lengths, and false lumen perfusion status. Reintervention and mortality were estimated using life-tables. Cox regression analysis was completed to predict mortality., Results: Eighty patients underwent TEVAR for aneurysm due to cTBAD (mean age [± standard deviation], 60 ± 13 years [male, 87.5%; n = 70]; median follow-up, 26 [range, 1-74] months). Median time from diagnosis of TBAD to TEVAR was 16 (range, 1-72) months. Prior aortic root/arch replacement had been performed in 29% (n = 23) at a median interval of 28.5 (range, 0.5-312) months. Mean preoperative aneurysm diameter was 62.0 ± 9.9 mm. In 75% (n = 60) of cases, coverage was proximal to zone 3, and 24% (n = 19) underwent carotid-subclavian bypass or other arch debranching procedure. Spinal drains were used in 78% (pre-op 71%, n = 57; post-op 6%, n = 5). Length of stay was 6.5 ± 4.7 days with a composite morbidity of 26% and in-hospital mortality of 2.5% (n = 2). Overall neurologic event rate was 17% (spinal cord ischemia 10% [n = 8], with a permanent deficit observed in 6.2% [n = 5]; stroke 7.5%). Aneurysm diameter reduced or stabilized in 65%. The false lumen thrombosed completely within the thoracic aorta in 52%, and reintervention within the treated aortic segment was required in 16% (n = 13).One- and 3-year freedom from reintervention (with 95% confidence interval [CI]) was 80% (range, 68%-88%) and 70% (range, 57%-80%), respectively. Survival at 1 and 5 years was 89% (range, 80%-94%) and 70% (range, 55%-81%) and was not significantly different among patients requiring reintervention or experiencing favorable aortic remodeling. Multivariable analysis identified coronary artery disease (hazard ratio [HR], 6.4; 95% CI, 2.3-17.7; P < .005), prior infrarenal aortic surgery (HR, 8.6; 95% CI, 2.3-31.7; P = .001), and congestive heart failure (HR, 11.9; 95% CI, 1.9-73.8; P = .008) as independent risk factors for mortality. Hyperlipidemia was found to be protective (HR, 0.2; 95% CI, 0.05-0.6; P = .004). No significant difference in predictors of mortality were found between patients who underwent reintervention vs those who did not (P = .2)., Conclusions: TEVAR for cTBAD with aneurysmal degeneration can be performed safely but spinal cord ischemia rates may be higher than previously reported. Liberal use of procedural adjuncts to reduce this complication, such as spinal drainage, is recommended. Reintervention is common, but long-term survival does not appear to be impacted by remediation., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The treatment goals of access-related hand ischemia (ARHI) are to reverse symptoms and salvage the access. Many procedures have been described, but the optimal treatment strategy remains unresolved. In an effort to guide clinical decision making, this study was undertaken to document our outcomes for distal revascularization and interval ligation (DRIL) and to identify predictors of bypass patency and patient mortality., Methods: A retrospective review was performed of all patients who underwent DRIL at the University of Florida from 2002 to 2011. Diagnosis of ARHI was based primarily upon clinical symptoms with noninvasive studies used to corroborate in equivocal cases. Patient demographics, procedure-outcome variables, and reinterventions were recorded. Bypass patency and mortality were estimated using cumulative incidence and Kaplan-Meier methodology, respectively. Cumulative incidence and Cox regression analysis were performed to determine predictors of bypass patency and mortality, respectively., Results: A total of 134 DRILs were performed in 126 patients (mean [standard deviation] age, 57 [12] years) following brachial artery-based access. The postoperative complication rate was 27% (19% wound), and 30-day mortality was 2%. The wrist-brachial index and digital brachial index increased 0.31 (0.25) and 0.25 (0.29), respectively. Symptoms resolved in 82% of patients, and 85% continued to use their access. Cumulative incidences (± standard error of the mean) of loss of primary and primary-assisted patency rates were 5% ± 2% and 4% ± 2% at 1 year and 22% ± 5% and 18% ± 5% at 5 years, respectively, with mean follow-up of 14.8 months. Univariate predictors of primary patency failure were DRIL complications (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.2-8.9; P = .02), configuration other than brachiobasilic/brachiocephalic autogenous access (OR, 3.4; 95% CI, 1.4-8.3; P = .009), and two or more prior access attempts (OR, 4.1; 95% CI, 1.6-10.4; P = .004). Brachiocephalic access configuration (OR, 0.2; 95% CI, 0.04-0.8; P = .02) and autogenous vein conduit (OR, 0.2; 95% CI, 0.06-0.58; P = .004) were predictors of improved bypass patency. All-cause mortality was 28% and 79% at 1 and 5 years, respectively. Multivariable predictors of mortality were age >40 (hazard ratio [HR], 8.3; 95% CI, 2.5-33.3; P = .0004), grade 3 ischemia (HR, 2.6; 95% CI, 1.5-4.6; P = .0008), complication from DRIL (HR, 2.4; 95% CI, 1.3-4.5; P = .004), and smoking history (HR, 2.2; 95% CI, 1.3-4; P = .007). Patients with no prior access attempts had lower predicted mortality (HR, 0.5; 95% CI, 0.3-0.9; P = .02)., Conclusions: The DRIL procedure effectively improves distal perfusion and reverses the symptoms of ARHI while salvaging the access, but the long-term survival of these patients is poor. Given the poor survival, preoperative risk stratification is critical. Patients at high risk for DRIL failure and mortality may be best served with alternate remedial procedures., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Thoracic endovascular aortic repair (TEVAR) is known to have a survival benefit over open repair in patients with descending thoracic aneurysms and has become a mainstay of therapy. Because death before 1 year after TEVAR likely indicates an ineffective therapy, we have created a predictive model for death within 1 year using factors available in the preoperative setting., Methods: A registry of 526 TEVARs performed at the University of Florida between September 2000 and November 2010 was queried for patients with degenerative descending thoracic aneurysm as their primary pathology. Procedures with emergent or urgent indications were excluded. Preoperatively available variables, such as baseline comorbidities, anatomic-, and procedure-specific planning details, were recorded. Univariate predictors of death were analyzed with multivariable Cox proportional hazards to identify independent predictors of 30-day (death within 30 days) and 1-year mortality (death within 1 year) after TEVAR., Results: A total of 224 patients were identified and evaluated. The 30-day mortality rate was 3% (n = 7) and the 1-year mortality rate was 15% (n = 33). Multivariable predictors of 1-year mortality (hazard ratios [95% confidence interval]) included: age >70 years (5.8 [2.1-16.0]; P = .001), adjunctive intraoperative procedures (eg, brachiocephalic or visceral stents, or both, concomitant arch debranching procedures; 4.5 [1.9-10.8]; P = .001), peripheral arterial disease (3.0 [1.4-6.7]; P = .006), coronary artery disease (2.4 [1.1-4.9]; P = .02), and chronic obstructive pulmonary disease (1.9 [1.0-3.9]; P = .06). A diagnosis of hyperlipidemia was protective (0.4 [0.2-0.7]; P = .006). When patients were grouped into those with one, two, three, or four or more of these risk factors, the predicted 1-year mortality was 1%, 3%, 10%, 27%, and 54%, respectively., Conclusions: Factors are available in the preoperative setting that are predictive of death within 1 year after TEVAR and can guide clinical decision making regarding the timing of repair. Patients with multiple risk factors, such as age ≥ 70 years, coronary artery disease, chronic obstructive pulmonary disease, and a need for an extensive procedure involving adjunctive therapies, have a high predicted mortality within 1 year and may be best served by waiting for a larger aneurysm size to justify the risk of intervention., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Simultaneous treatment of multilevel aortic disease is controversial due to the theoretic increase in morbidity. This study was conducted to define the outcomes in patients treated electively with simultaneous thoracic endovascular aortic aneurysm repair (TEVAR) and abdominal aortic endovascular endografting for synchronous aortic pathology., Methods: Patients treated with simultaneous TEVAR and endovascular aneurysm repair (T&E) at the University of Florida were identified from a prospectively maintained endovascular aortic registry and compared with those treated with TEVAR alone (TA). The study excluded patients with urgent or emergency indications, thoracoabdominal or mycotic aneurysm, and those requiring chimney stents, fenestrations, or visceral debranching procedures. Demographics, anatomic characteristics, operative details, and periprocedural morbidity were recorded. Mortality and reintervention were estimated using life-table analysis., Results: From 2001 to 2011, 595 patients underwent TEVAR, of whom 457 had elective repair. Twenty-two (18 men, 82%) were identified who were treated electively with simultaneous T&E. Mean ± standard deviation age was 66 ± 9 years, and median follow-up was 8.8 months (range, 1-34 months). Operative indications for the procedure included dissection-related pathology in 10 (45%) and various combinations of degenerative etiologies in 12 (55%). Compared with TA, T&E patients had significantly higher blood loss (P < .0001), contrast exposure (P < .0001), fluoroscopy time (P < .0001), and operative time (P < .0001). The temporary spinal cord ischemia rate was 13.6% (n = 3) for the T&E group and 6.0% for TA (P = .15); however, the permanent spinal cord ischemia rate was 4% for both groups (P = .96). The 30-day mortality for T&E was 4.5% (n = 1) compared with 2.1% (n = 10) for TA. Temporary renal injury (defined by a 25% increase over baseline creatinine) occurred in two T&E patients (9.1%), with none requiring permanent hemodialysis; no significant difference was noted between the two groups (P = .14). One-year mortality and freedom from reintervention in the T&E patients were 81% and 91%, respectively., Conclusions: Acceptable short-term morbidity and mortality can be achieved with T&E compared with TA, despite longer operative times, greater blood loss, and higher contrast exposure. There was a trend toward higher rates of renal and spinal cord injury, so implementation of strategies to reduce the potential of these complications or consideration of staged repair is recommended. Short-term reintervention rates are low, but longer follow-up and greater patient numbers are needed to determine procedural durability and applicability., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: In patients with Marfan syndrome, the complications of aortic degeneration, including dissection, aneurysm, and rupture represent the main cause of mortality. Although contemporary management of ascending aortic disease requires open surgical reconstruction, endovascular repair is now available for management of descending thoracic and abdominal aortic pathology (ie, thoracic endovascular aortic repair [TEVAR], endovascular aneurysm repair [EVAR]). The short- and long-term benefit of endovascular repair in Marfan patients remains largely unproven. We examine our outcomes after EVAR in this patient population., Methods: All patients with a diagnosis of Marfan syndrome who were treated with TEVAR/EVAR were evaluated in a retrospective review. Perioperative, procedure-specific and patient covariate data were aggregated. Primary endpoints were overall mortality and procedural success as divided into three categories: (1) successful therapy, (2) primary failure, or (3) secondary failure., Results: Between 2000 and June 2010, 16 patients were identified as having undergone 19 TEVAR/EVAR procedures. These included three emergent operations (two for acute dissection/malperfusion and one for anastomotic disruption early after open repair). All 16 patients had previously undergone at least one (range, 1-5) open operation of the ascending aorta or arch at a time interval from 33 years to 1 week prior to the index endovascular repair. During a median follow-up of 9.3 months (range, 0-46 months), there were four deaths (25%). Six patients (38%) had successful endovascular interventions. Despite early success, there was one death in this group at 1 month postintervention. Seven patients (44%) experienced primary treatment failure with five undergoing open conversion and one undergoing left subclavian coil embolization (the seventh was lost to follow-up and presented 4 months later in cardiac arrest and expired without repair). There were three deaths in the primary treatment failure group. Two patients experienced secondary treatment failure. One underwent the index TEVAR for acute dissection with malperfusion and required a subsequent TEVAR for more distal aortic pathology. He is stable without disease progression. The other patient underwent open conversion after a second EVAR with four-vessel "chimney" stent grafts and is stable with his entire native aorta having been replaced., Conclusions: Aortic disease associated with Marfan syndrome is a complex clinical problem and many patients require remedial procedures. Endovascular therapy can provide a useful adjunct or bridge to open surgical treatment in selected patients. However, failure of endovascular therapy is common, and its use should be judicious with close follow-up to avoid delay if open surgical repair is required., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Thoracic endovascular aneurysm repair (TEVAR) has been rapidly introduced as a primary treatment modality for thoracic aortic diseases with limited data available on midterm to late-term outcomes., Methods: A retrospective single institution study comparing hospital and midterm outcomes and costs for TEVAR versus open elective repair of descending thoracic aneurysms was conducted. Fifty-seven patients were included between 2005 and 2007 (TEVAR=28; open=29) and were followed until May 2010., Results: Patients in the TEVAR group were older (73.2 versus 62.3 years; p<0.001). Hospital mortality was higher in the open repair group (10.3% versus 3.6%; p=0.611). There was no statistical difference in stroke, paraparesis or paralysis, sepsis, or renal failure; however, a composite major adverse event variable showed a higher complication with open repair versus TEVAR (37.9% versus 14.3%; p=0.043). Mean follow-up was 42.6 months for open repair versus 26.9 for TEVAR (p=0.002). Kaplan-Meier survival analysis showed the initial survival benefit for TEVAR was lost in less than 6 months; however, the difference did not reach statistical significance during follow-up (log-rank test p=0.232). Mean surveillance imaging costs for a TEVAR patient were $1,800.38 higher than for an open patient at 2 years. Compliance of TEVAR patients with follow-up imaging was 78%, 64%, 50%, and 42% at 1, 6, 12, and 24 months, respectively, and was even lower in those not registered in device trials., Conclusions: Patients in the TEVAR group had favorable early outcomes; however, midterm survival was reduced secondary to comorbidities. This study raises concern for the ongoing costs of surveillance imaging in TEVAR as well as patient compliance with follow-up., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Obesity has reached an epidemic in the United States and, not surprisingly, there has been a dramatic increase in obesity-associated comorbidities, complete with a host of new, related surgical challenges. The creation and maintenance of permanent hemodialysis access, particularly autogenous access, is generally considered more difficult in the obese patient because of the increased risk of perioperative complications, as well as a decreased maturation rate. Most of the data documenting these adverse outcomes come from retrospective studies and, therefore, the reliability of the data is somewhat limited, given the inherent selection bias. In the United States, most obese patients dialyze through prosthetic access, despite the national initiatives targeted at maximizing autogenous access. However, it is possible to construct an autogenous access in most patients, including obese patients, presenting for permanent access using proper, diligent preoperative imaging and an aggressive postoperative surveillance protocol until access maturation. This is facilitated by careful preoperative planning and liberal use of multiple diagnostic and therapeutic maneuvers to improve overall access function. In this review, the outcomes associated with permanent hemodialysis access in the obese are discussed and helpful suggestions to facilitate a functional access provided., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To compare early outcomes of endovascular repair of juxtarenal and suprarenal aneurysms using the chimney technique with open repair in anatomically-matched patients., Methods: Between January 2008 and December 2009, 21 patients underwent endovascular repair of juxtarenal and suprarenal aortic aneurysms with chimney stenting (Ch-EVAR) of 1 or 2 renal and/or superior mesenteric artery (SMA) vessels. These were compared with 21 anatomically-matched patients that underwent open repair (OR) during the same time period. Primary end points were 30-day mortality, chimney stent patency, and type Ia endoleak. Secondary end points included early complications, renal function, blood loss, and length of stay (LOS)., Results: Despite a higher proportion of women, oxygen-dependent pulmonary disease and lower baseline renal function, 30-day mortality was identical with one death (4.8%) in each group. Blood loss and total LOS were significantly less for Ch-EVAR. Six patients (29%) in the chimney group had acute kidney injury (AKI) compared with the open group, in which there were one (4.8%) AKI and four (19%) acute renal failures, of which two (9.5%) required chronic hemodialysis. Renal function at 12 months demonstrated similar declines in the overall estimated glomerular filtration rate (eGFR) in the Ch-EVAR and OR groups (11.1 ± 19.6 vs 10.4 ± 25.2, P = NS, respectively). There was one asymptomatic SMA stent occlusion at 6 months and partial compression of a second SMA stent which underwent repeat balloon angioplasty. Primary patency at 6 and 12 months was 94% and 84%, respectively. There was one type Ia endoleak noted at 30 days which resolved by 6 months., Conclusions: Ch-EVAR may extend the anatomical eligibility of endovascular aneurysm repair using conventional devices. It appears to have similar mortality to open repair with less morbidity. Long-term durability and stent patency remain to be determined., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: We compared outcomes of arch debranching (AD) and elephant trunk (ET) techniques when used with thoracic endovascular aortic repair., Methods: A review was performed of consecutive patients with proximal thoracic aortic pathologies repaired with a hybrid approach., Results: Between 2005 and 2009, 58 patients underwent first-stage ET (n = 21) or AD (n = 37). Cardiopulmonary bypass was utilized in 100% of ET procedures and 68% of AD procedures (p < 0.01). Circulatory arrest was used in 86% of ET and 27% of AD cases (p < 0.01). The second stage was completed in 76% of ET and 76% of AD patients. Rates of spinal cord ischemia (ET 0 of 21, AD 0 of 37, p = 1.0), stroke (ET 2 of 21, AD 4 of 37, p = 1.0), and 30-day mortality (ET 4 of 21, AD 6 of 37, p = 1.0) were similar. Each group had one major aortic complication between the two stages. Type Ia endovascular leak at 1 and 12 months occurred in 13% ET patients and 4% AD patients at 1 month (p = 0.54) and in 0% ET patients and 4% AD patients at 12 months (p = 1.0). Kaplan-Meier estimates of survival at 1 and 12 months were 90.5% ± 6.4% and 73.1% ± 10% in the ET group, and 86.5% ± 5.6 and 71.6% ± 8.5 in the AD group, respectively (p = 0.68). The risk of a secondary procedure at 1 and 12 months was 76.2% ± 9.3% and 58.7% ± 12% in the ET group, and 71.0% ± 7.8% and 52.8% ± 10% in the AD group, respectively (p = 0.86)., Conclusions: Arch debranching achieves equivalent results to standard elephant trunk repair but with a decreased need for cardiopulmonary bypass and circulatory arrest., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Surgical repair of proximal right subclavian artery aneurysms can be difficult. They typically require a combined mediastinal exposure to control the innominate and right common carotid arteries and a supra- or infraclavicular exposure for distal control, with either a segmental resection and bypass or a bifurcated reconstruction. In this report, we present four cases utilizing a single-stage, hybrid technique combining an endovascular stent graft and an extra-anatomical bypass to repair proximal right subclavian artery aneurysms without the need for mediastinal exposure or extensive surgical reconstruction. There were no deaths and two minor neurologic events., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Aortic injury is the second leading cause of death in trauma. Thoracic endovascular aortic repair (TEVAR) has recently been applied to traumatic thoracic aortic injuries (TTAIs) as a minimally invasive alternative to open surgery. We sought to determine the impact of TEVAR on national trends in the management of TTAI., Methods: We queried the Nationwide Inpatient Sample from the years 2001 to 2007 to select patients diagnosed with TTAI (International Classification of Disease-9 code 901.0). Patients were evaluated based on open surgical repair, TEVAR, or nonoperative management, before and after widespread adoption of TEVAR (2001-2005 and 2006-2007). Outcomes of interest were inpatient mortality, length of stay (LOS), and major complications., Results: An estimated 1180 annual admissions occurred for TTAI in the United States. Comparing the two time periods, there was an increase in TEVAR (P < .001) with a simultaneous decrease in open repair (P < .001) in 2006 to 2007. The overall number of interventions also increased (P < .001). Overall mortality decreased (25.0% vs 19.0%;P < .001), corresponding to improved survival in the nonoperative group (28.0% vs 23.2%; P < .001). There was no improvement in open repair mortality rates between the two time periods. Comparing intervention types, the TEVAR group had a higher percentage of patients with brain injury (26.1% vs 20.6%; P = .008), lung injury (25.0% vs 17.7%; P < .001), and hemothorax (32.5% vs 21.7%; P < .001) than the open surgery group. There were no differences in the number of intra-abdominal injuries or major orthopedic fractures. The open surgery group had more respiratory complications (43.9% vs 54.2%; P < .001), whereas TEVAR had a higher stroke rate (1.9% vs 0.7%; P = .021). There were no differences in paraplegia or renal failure. Overall in-hospital mortality was 23.2% (nonoperative group 26.7%, open repair 12.4%, and TEVAR 10.6%). Mortality between open repair and TEVAR groups were not significantly different. LOS was shorter among the TEVAR group vs open (15.7 vs 22.9 days; P < .001)., Conclusion: TEVAR has replaced open repair as the primary operative treatment for TTAI and has extended operative treatment to those patients not previously considered candidates for repair. Increased utilization of TEVAR is associated with improved overall mortality. There is no difference in mortality between TEVAR and open repair groups in our study, which likely reflects the multisystem nature of injury and greater preoperative risk in the TEVAR group., (Published by Mosby, Inc.)

Background: The US Food and Drug Administration approved the first thoracic aneurysm endograft in 2005. However, because the United States lacks a thoracic aneurysm endovascular repair registry, implications of Food and Drug Administration endograft approval on surgical management of thoracic aneurysms in clinical practice are unknown., Methods: Retrospective review of thoracic aneurysm repair rates for 2000 to 2007 and analysis of patient characteristics and complications for 2006 and 2007 cohorts uses the National Inpatient Sample. International Classification of Diseases, 9th Revision codes were used to identify unruptured descending thoracic aneurysm cases undergoing either thoracic endovascular aortic repair (39.73) or open repair (38.45)., Results: Thoracic aneurysm open repair averaged 3.3 per million from 2000 to 2002 and increased to 5.6 per million in 2003 with introduction of 16 slice computed tomographic scanners. In 2005 endovascular repair was 1.2 repairs per million, which increased dramatically to 6.1 repairs per million in 2006. In 2007, endovascular repair decreased to 4.8 repairs per million while the open repair rate was 3.1 repairs per million. The 2006 and 2007 open repair cohorts had more favorable baseline characteristics compared with the endovascular cohort. Open repair mortality was significantly greater than endovascular mortality in 2006 (estimated relative risk, 8.48; 95% confidence interval 3.03 to 23.75), but not in 2007 (estimated relative risk, 0.71; 95% confidence interval 0.12 to 4.24). Length of stay was greater for open repair in 2006 and 2007., Conclusions: Thoracic endovascular aortic repair has been rapidly adopted in the United States resulting in increased treatment of thoracic aortic aneurysms. Despite older age and comorbidities, endovascular repair had better outcomes and shorter hospital stays., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The proximity of thoracic aortic pathologies to the left subclavian artery has occasionally required intentional coverage of this vessel. With increased collective experience with thoracic endovascular techniques, indications for revascularization in this setting have evolved. Coverage of the left subclavian artery without revascularization has been associated with left arm claudication, spinal cord ischemia, posterior circulation strokes, and, in certain instances, myocardial ischemia. The occurrence of these events has not been uniform and, in some patients, the left subclavian artery can be covered without significant clinical sequelae. In this review, we discuss the incidence of these complications, their risk factors, and indications for elective revascularization of the left subclavian artery during thoracic endovascular aortic repair.

Spinal cord ischemia (SCI) is one of the most feared complications after treatment of thoracic aortic diseases. Based on limited evidence from clinical trials of investigational devices the incidence appears to be lower in endovascular compared to open thoracic aortic repairs. To date, several clinical and procedural factors have been associated with an increased risk of SCI, including the type of aortic pathology, length of endograft coverage, and perioperative hypotension. The treatment options mostly consist of spinal fluid drainage and systemic blood pressure elevation in an effort to maximize spinal cord perfusion. In this article, we review the risk factors for development of SCI, some diagnostic tests that may allow for its earlier detection, and potential strategies for its prevention.

Background: Although a large proportion of patients with traumatic thoracic aortic injury die before undergoing definitive repair, those who survive still face ongoing risk of death and morbidity. Endovascular therapy may offer a minimally invasive alternative in the repair of the aortic injury., Study Design: We reviewed our experience with endovascular repair of traumatic aortic injuries using medical records, imaging studies, and a prospectively maintained endovascular and institutional trauma database., Results: Twenty-two patients underwent thoracic endovascular repair (TEVAR) of traumatic aortic injuries over 44 months. The mean (SD) age was 34+/-12 years and 68% were men. Among the 16 patients registered with our trauma database, the mean Injury Severity Score was 33+/-16 (range, 13 to 45). All injuries were sustained from blunt trauma; 95% of patients had nonaortic thoracic injuries, and 64% and 55% had extremity and abdominal injuries, respectively. Intraoperatively, 91% were repaired under general anesthesia, the mean procedure time was 80+/-52 minutes, and mean blood loss was 219+/-72 mL. The mean fluoroscopy time was 13+/-5 minutes and contrast volume 98+/-23 mL. Twenty-one patients (95%) required coverage of the left subclavian artery to achieve an adequate proximal landing zone. There were no in-hospital or 30-day deaths. The median length of stay was 8 days (range, 1 to 62 days), and 11 (50%) patients were able to be discharged home (versus to another extended care facility). At a mean followup of 7.7 months (range, 0 to 40 months) there were 2 patients (9%) who required endograft-related reintervention at 1 and 6 months. One was an access-related complication, and the second was complete device collapse with acute aortic occlusion, resulting in the patient's death., Conclusions: Although patients who undergo endovascular repair of traumatic thoracic aortic transections typically have significant concomitant injuries, the procedure itself is well tolerated and can be performed rapidly with minimal blood loss and contrast administration. But close followup is necessary given the risk of late complications.

Objectives: Surgical management of acute, complicated type B aortic dissection is associated with significant morbidity and mortality. This study examined the feasibility and safety of endovascular treatment of this pathology., Methods: We reviewed a prospectively maintained thoracic endovascular database and medical records at a single institution from 2005 to 2007. The study group comprised of acute, complicated type B dissections, defined as duration of symptoms

Objectives: Extensive aneurysms of the ascending, arch, and descending thoracic aorta traditionally have been managed with a 2-stage "elephant trunk" procedure. Single-stage transmediastinal repairs have also been used, because in some patients the entire repair is not completed owing to either complications during first-stage repair or magnitude of the second-stage operation. Since 2006, second-stage elephant trunks have been preferentially completed with endovascular stent grafts in anatomically appropriate patients. This study compares outcomes of 2-stage elephant trunk, single-stage, and hybrid endovascular repairs of extensive thoracic aortic aneurysms., Methods: This is a single-institution retrospective cohort study of 103 patients (1992-2007) with extensive thoracic aortic aneurysms undergoing 2-stage elephant trunk repair with either surgical (OPEN) or endovascular (TEVAR) completion versus single-stage transmediastinal replacement (SS). Outcomes were analyzed with Statistica 8.0 software (Tulsa, Okla)., Results: Of 103 patients, 74 had elephant trunk procedures, 24 TEVAR-eligible and 50 OPEN, and 29 had SS. Completion rates were higher with TEVAR than OPEN (78% vs 47%; P = .01). Seven of 18 TEVARs were performed during the index hospitalization. TEVAR patients had shorter second-stage hospital stay (5.5 vs 16.5 days [P < .01]), required fewer transfusions (P < .01), and had less acute kidney injury (P = .04). There were no differences in mortality, paraplegia, or stroke. Six-month Kaplan-Meier survival estimates for OPEN, TEVAR, and SS were 64%, 78%, and 64% (P = .08)., Conclusion: More patients complete the second stage when TEVAR is used after elephant trunk repair, with fewer hospital days and transfusions. TEVAR is feasible and safe in the hybrid management of extensive thoracic aortic aneurysms.

Objective: To examine the incidence of and the anatomic factors that may contribute to spinal cord ischemia (SCI) in patients with a history of abdominal aortic aneurysms (AAA) after thoracic endovascular aortic repair (TEVAR)., Methods: The medical records, computed tomography (CT) angiograms, and a prospectively maintained clinical database of all TEVAR patients at a single institution between 2000 and 2007 were reviewed. Select preoperative demographics, thoracoabdominal aortoiliac anatomy, intraoperative procedural variables, and postoperative outcomes were examined. Univariate and multivariate analyses were performed and odds ratio estimates were reported with 95% confidence intervals., Results: Of the 261 patients who underwent TEVAR, 27 developed SCI (10%). Thirteen (48%) of these 27 patients were completely reversed with spinal drainage, and 14 (52%) were permanent. Patients with SCI tended to be older (P = .006), male (P = .049), and required more emergent procedures (P = .051) performed under general anesthesia (P = .004). Interestingly, while prior AAA repair (50/261, 19%) alone was not associated with SCI (P = .44), a history of either repaired or unrepaired AAA (101/261, 39%) was a predictor of SCI on multivariate analysis (odds ratio [OR] = 4.35 [1.43, 14.3], P = .10), independent of thoracic aortic coverage (P = .001) and lumbar artery patency (P = .008), both of which were also associated with SCI., Conclusion: Although the causes of SCI after TEVAR are multifactorial, abdominal aortic anatomy appears to be associated with development of this complication. Patients with either prior AAA repair or those with unrepaired AAA appear to be at increased risk for SCI.