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Objective Given the superior patency of arteriovenous fistulas (AVFs) and the decreased risk of infection compared with arteriovenous grafts, the Kidney Disease Outcomes Quality Initiative guidelines have recommended the fistula-first approach. However, ∼20% to 60% of all fistulas will fail to mature. We have described our experience with a novel technique using bovine pericardial patch angioplasty to increase the rate of AVF maturation. Methods We used 2-cm × 9-cm-long or 2.5-cm × 15-cm-long segment pericardial patch angioplasty to assist in the maturation of AVFs. A single-center, retrospective cohort study was conducted of all patients who had undergone patch angioplasty maturation (PAM) for AVFs that had failed to mature. The outcomes of interest were maturation status and patency, censored by the death and last known follow-up dates. Results From March 2007 to October 2019, 139 patients had undergone PAM. Follow-up data were available for 137 of the 139 patients (98.6%), with 126 AVFs (92.0%) progressing to maturation. Of the 126 patients with AVFs that had progressed to maturity, the previous hemodialysis (HD) method was known for 88 patients (69.8%). Of these 88 patients, 70 (79.5%) had previously been receiving HD via an HD catheter. Using a Kaplan-Meier estimator censored for death and loss to follow-up, the assisted primary patency rates at 1, 2, and 3 years were 87.3%, 78.1%, and 68.0%, respectively. Of the 137 patients, 69 (54.8%) had required no additional interventions after patch angioplasty. The complications requiring intervention were stenosis (n = 45; 32.8%), thrombosis (n = 10; 7.3%), infection (n = 3; 2.2%), steal syndrome (n = 3; 2.2%), noninfected wound complications (n = 1; 0.8%), and pseudoaneurysm (n = 1; 0.8%). The average interval to intervention after patch angioplasty was 4.56 months. Conclusions Long-segment bovine pericardial PAM can be performed safely to treat nonmaturing AVFs, with a 92.0% successful maturation rate and patency rates comparable to those for AVFs. PAM should be a consideration for patients with nonmaturing AVFs.

Objective: To compare the outcomes of elective percutaneous endovascular aneurysm repair (PEVAR) versus surgical cutdown endovascular aneurysm repair (SEVAR) procedures performed at a tertiary medical center from 2012 to 2015. Methods: This is a unique study using procedure data from two vascular surgeons who performed SEVAR in almost every case versus three vascular surgeons who performed PEVAR in all cases except when considered prohibitive on account of circumferential calcification or severe occlusive disease of the common femoral artery or some other technical consideration. Medical records of patients aged 18 years or older undergoing elective PEVAR or SEVAR between January 2012 and December 2015 were reviewed. Differences in readmissions and complications between patients who received PEVAR and those who received SEVAR were assessed using Fisher’s exact test. The exact Cochran-Armitage test was used to assess trends in length of stay between the PEVAR and SEVAR group. Results: A total of 183 patients were analyzed. In total, 132 underwent PEVAR and 51 underwent SEVAR. A statistically significant difference was noted with regard to 30-day readmissions (2.3% vs 13.7%, P = .006) in favor of PEVAR and categorical length of stay tended to be longer in the SEVAR group ( P = .003). The 30-day complication rate was not statistically different (6.8% vs 15.7%, P = .09). Conclusions: Surgical cutdown endovascular aneurysm repair results in more readmissions, often related to groin wound complications, which lead to prolonged length of stay and expense. Patients undergoing PEVAR tend to have a shorter length of stay. Overall complication rate was similar in the two groups. We recommend PEVAR for patients with appropriate anatomy.

Medical care in the United States has evolved into a more cost-conscious value-based health care system that necessitates a comparison of costs when there are alternative interventions considered to be acceptable in the treatment of a disease. This study compares the cost differences between regional anesthesia (RA) and general anesthesia (GA) for carotid endarterectomy (CEA).Data from 346 consecutive patients who underwent CEA between January 2012 and September 2014 were retrospectively reviewed for the type of anesthesia used, outcomes data, and cost variables. Overall hospital day costs were compared between RA and GA. Medians and interquartile ranges were compared using Wilcoxon-Mann-Whitney test. A P 0.05 was considered statistically significant using 2-sided tests.Median overall costs for GA were significantly higher than median costs for RA (medians [with interquartile ranges], $10,140 [$7,158-$12,658] versus $7,122 [$5,072-$8,511], P 0.001). Median total operative time for GA was significantly longer than median time for RA (168 [144-188] versus 134 [115-147] min, P 0.001). Median in-hospital length of stay (LOS) for GA was significantly longer compared with RA (2.0 vs 1.2 days, P 0.001). Patients who received GA were also more likely to be admitted to the intensive care unit.Decreased cost, operating room expenses, postoperative resources, and overall LOS were observed for individuals who underwent RA for CEA as compared with GA. In summary, RA is more cost-effective and should be the optimal choice when clinically appropriate.

Objective Adverse outcomes observed late in the Nellix EndoVascular Aneurysm Sealing (EVAS) System (Endologix, Inc, Irvine, Calif) investigational device exemption trial prompted refinement of the anatomic instructions for use (IFU). This study aimed to investigate the association of procedural factors during Nellix endograft deployment and patient outcomes. Methods We retrospectively reviewed 1-month imaging of 333 patients enrolled in the prospective, multicenter EVAS investigational device exemption trial between January 2014 and September 2016. Initial observations of those patients who met revised anatomic IFU yet still experienced late adverse events suggested that inadequate seal and low graft placement were common among these patients. Key procedural variables identified from a univariate analysis were applied to construct four cohorts stratified by procedural technical performance (technically adequate [P+] or technically inadequate [P−]) and the revised anatomic indications for use (anatomically within IFU [A+] or anatomically outside of IFU [A−]) and to compare them for aneurysm-related outcomes. A logistic regression analysis was performed to identify significant predictors of sac expansion or migration. Results Proximal and distal seal zones and low graft placement were identified by logistic regression analysis as significant predictors of sac expansion or migration. Accordingly, acquisition of ≥10-mm proximal and distal seal zones and the position of the lowest stent within 10 mm of the lowest renal artery were clinically justified as thresholds for a technically adequate procedure. Patients who did not achieve these parameters were deemed to have a technically inadequate procedure. By use of the proposed procedural adequacy criteria and established anatomic criteria, patients were stratified into four cohorts: A+/P+ (n = 77), A+/P− (n = 54), A−/P+ (n = 71), and A−/P− (n = 131). Three-year estimates of freedom from migration of 10 mm were 98.6% in A+/P+, 95.9% in A+/P−, 85.8% in A−/P+, and 80.1% in A−/P−; freedom from type IA endoleak estimates were 98.6% in A+/P+, 100% in A+/P−, 96.4% in A−/ P+, and 90.3% in A−/P− cohorts. Freedom from sac expansion and secondary intervention were 96.9% and 90.6% in A+/P+, 86.0% and 93.6% in A+/P−, 87.1% and 83.1% in A−/P+, and 80.5% and 79.8% in A−/P− groups, respectively. Two early deaths (aneurysm-related mortality) on days 4 and 12 postoperatively were reported within the A+/P− group. Kaplan-Meier estimates of freedom from all-cause mortality and aneurysm-related mortality at 3 years were similar between cohorts. Conclusions This post hoc analysis suggests that achieving a 10-mm proximal and distal seal with adequate positioning of the endograft with respect to the renal arteries is associated with improved patient outcomes.

Background The Nellix System (Endologix, Inc, Irvine, Calif) for endovascular aneurysm sealing (EVAS) is a novel approach to abdominal aortic aneurysm treatment and conceptually different from endovascular aneurysm repair, whereby polymer is employed to fill and actively manage the abdominal aortic aneurysm sac. One-year safety and effectiveness results of the Nellix pivotal trial demonstrated encouraging outcomes with very low morbidity and mortality and high procedural and treatment success. Two-year imaging revealed a signal of migration, leading to a field safety notification issued by the manufacturer on October 21, 2016, and a dedicated root cause analysis, resulting in refinements to the instructions for use (IFU). We report the 2-year results of the investigational device exemption pivotal trial stratified according to the new and original criteria for selection of patients. Methods Comprehensive engineering evaluations, statistical analyses, and clinical assessments were conducted looking at patients enrolled in the pivotal trial (N = 150), roll-in cohort (N = 29), and continued access program (N = 154). All patients in all cohorts were treated on-IFU at the time of enrollment. Logistic regression models supported the mechanism that migration with Nellix is associated with a small aortic flow lumen relative to a large aneurysm thrombus burden and large aortic neck diameters. Based on these findings, refinements to the IFU criteria were applied, excluding patients with a thrombus index (maximum aneurysm sac/maximum flow lumen diameter) >1.4, aortic neck diameter >28 mm, and aortic neck conicity (>10% diameter change along the infrarenal neck) and requiring a 10-mm distal seal zone in the iliac artery. Results Freedom from all-cause mortality at 2 years was 94%. Patient outcomes were then stratified on the refined morphologic criteria and analyzed retrospectively. Two-year freedom from composite endoleak was high among both cohorts (95% on-IFU vs 92% off-IFU). Freedom from migration was 97.7% on-IFU vs 93.2% off-IFU (P = .0125). Freedom from aneurysm enlargement was 98.1% on-IFU vs 93.5% off-IFU (P value is not available because of failure of log-rank test assumptions). Composite freedom from migration, type IA endoleak, or aneurysm expansion was 95.9% among the on-IFU cohort vs 85.1% in the off-IFU cohort (P = .0017). Conclusions Consistent with the introduction of a novel therapy, the presentation of failure modes of EVAS over time was inevitable. Using detailed imaging as well as engineering and statistical analysis, we were able to understand risk factors for adverse events specific to EVAS and defined those patients best suited for Nellix. With this EVAS-specific approach to defining IFU, on-IFU patients were identified as those with large aneurysms with little thrombus that would be prone to type II endoleaks and sac expansion with traditional devices. When treated with Nellix, these patients were predicted to experience exceptional results, especially with regard to a low composite endoleak rate and low all-cause mortality.

Multiple studies have evaluated the effect of anesthesia type on carotid endarterectomy with inconsistent results. Our study compared 30-day postoperative myocardial infarction, stroke, and mortality between carotid endarterectomy under local or regional anesthesia and carotid endarterectomy under general anesthesia utilizing National Surgical Quality Improvement Program database. All patients listed in National Surgical Quality Improvement Program database that underwent carotid endarterectomy under general anesthesia and local or regional anesthesia from 2005 to 2011 were included with the exception of patients undergoing simultaneous carotid endarterectomy and coronary artery bypass grafting. The data revealed substantial differences between the two groups compared, and these were adjusted using multiple logistic regression. Postoperative myocardial infarction, stroke, and death at 30 days were compared between the two groups. A total of 42,265 carotid endarterectomy cases were included. A total of 37,502 (88.7%) were performed under general anesthesia and 4763 (11.3%) under local or regional anesthesia. Carotid endarterectomy under local or regional anesthesia had a significantly decreased risk of 30-day postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia (0.4% vs 0.86%, p = 0.012). No statistically significant differences were found in postoperative stroke or mortality. Carotid endarterectomy under local or regional anesthesia carries a decreased risk of postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia. Therefore, patients at risk of postoperative myocardial infarction undergoing carotid endarterectomy, consideration of local or regional anesthesia may reduce that risk.

Carotid artery stenting (CAS) was presented by carotid revascularization endarterectomy versus stenting trial as a minimally invasive approach with less risk of postoperative myocardial infarction (MI) when compared to carotid endarterectomy (CEA). Our study aimed to compare the postoperative MI rate for CAS with CEA under general anesthesia (GA) and local anesthesia (LA). A retrospective study was conducted at our institution comparing CAS with CEA under LA and CEA under GA. Thirty-day postoperative MI and strokes were evaluated for the different subgroups. A total of 1127 procedures were included in the analysis: 421 CEAs under GA, 611 CEAs under LA, and 95 CAS. No significant difference in postoperative MI was encountered between CAS and CEA under LA (0.2% vs 1.1%, P = .25). The CEA under GA was found to have a statistically significant higher risk of MI compared to LA (1.2% vs 0.2%, P = .044). Our evidence suggests that CEA under LA does not have an increased risk of MI compared to CAS.

Objective The purpose of this study was to evaluate the trends in procedure volume, clinical sites of care, and Medicare expenditure for peripheral vascular interventions (PVIs) for lower extremity occlusive disease since the Centers for Medicare and Medicaid Services instituted reimbursement policy changes that broadened payment for procedures performed in physician-owned office-based laboratories (OBLs). Methods We analyzed fee-for-service Medicare claims data from 2011 to 2014 to obtain the frequency of use of PVI by type, care setting, and physician specialty. We also assessed changes in the total Medicare cost for PVI by setting. Results There was a 60% increase in atherectomy cases among Medicare beneficiaries between 2011 and 2014. During the same period, OBLs experienced a 298% increase in atherectomy volume vs a 27% increase in hospital outpatient settings and an 11% decrease for inpatient hospital settings. In 2014, OBLs were the most common setting for atherectomy. Nonatherectomy PVIs grew more modestly at just 3% but also experienced site of care shifts. Vascular surgeons and cardiologists accounted for the majority of office-based PVIs in 2014. Total Medicare costs for PVIs increased 18% from 2011 to 2014. Hospital inpatient costs declined 1%, whereas costs for hospital outpatient PVIs increased by 41% and physician office costs increased by 258%. Conclusions The migration of revascularization procedures for lower extremity peripheral arterial occlusive disease continues from the inpatient to the outpatient setting and especially to OBLs. Increased use of atherectomy in all segments of the lower extremity arterial system has been observed, particularly in OBLs, without substantial evidence in the literature of increased efficacy compared with standard angioplasty with or without stenting. Generous Medicare reimbursement for in-office atherectomy procedures is likely contributing to the volume shifts observed.

The true benefits of endovascular therapy will be realized when treatment for common vascular conditions can be performed effectively and safely, with minimal morbidity and in a cost-effective manner. We describe three cases of common iliac artery aneurysm repair performed as an outpatient procedure without problems. This was done in a cost-effective manner and with a high degree of patient satisfaction.

Stroke is a leading cause of disability and the third leading cause of death. Landmark studies have demonstrated that carotid endarterectomy (CEA) reduced the risk of stroke among selected patients with carotid stenosis. Renal insufficiency is a known risk factor for stroke and appears to be an independent risk factor for poor outcome after CEA. Studies have reported high morbidity and mortality after CEA in patients on dialysis. However, our experience has been that patients undergoing dialysis have no greater risk for a poor outcome. This study was a retrospective review of our CEA patients to ascertain our morbidity and mortality results in dialysis patients versus patients not on dialysis. An institutional retrospective chart review of CEAs from January 1999 to December 2007 was conducted. Patients on dialysis at the time of CEA were identified. Their charts were reviewed for complications 30 days after surgery. This was compared with our total experience with CEAs from January 1999 to December 2007. Of the 28 patients undergoing CEA while dialysis dependent, none had complications in the 30-day postoperative period. This compares favorably with the cohort of all CEAs by the same surgeons. In that group, 13 complications were identified (13 of 1,141). Patients undergoing dialysis are at no greater risk for complications when undergoing carotid endarterectomy than the general population.

Objective The Nellix EndoVascular Aneurysm Sealing system (Endologix, Inc, Irvine, Calif) is a novel approach to abdominal aortic aneurysm (AAA) endovascular repair whereby biocompatible polymer is employed to exclude and to seal the AAA sac. We report 30-day results of the U.S. pivotal trial. Methods Consecutive, eligible, consenting patients were enrolled at 29 sites in the United States and Europe. Inclusion criteria required an asymptomatic infrarenal AAA, with aortic neck length ≥10 mm and angle to the sac ≤60 degrees, aortic neck diameter of 18 to 32 mm, aneurysm blood lumen diameter ≤6 cm, common iliac artery lumen diameter of 9 to 35 mm, access artery diameter ≥6 mm, and serum creatinine level ≤2 mg/dL. Follow-up at 30 days included clinical assessment and computed tomography angiography evaluation of endoleaks and device integrity as assessed by a core laboratory. The primary safety end point is the incidence of independently adjudicated 30-day major adverse events (MAEs), with success defined as superiority with reference to the Society for Vascular Surgery open repair control group (56%). Results Between January and November 2014, 150 trial patients having a mean AAA diameter of 5.8 cm were enrolled and treated with the Nellix system with 100% procedural success. One early death (0.7%) occurred secondary to multisystem organ failure. All 149 surviving patients completed 30-day follow-up. There were no aneurysm ruptures, conversions, limb thromboses, stent fractures, or stent kinking. Five early MAEs occurred in four patients (2.7%) and included one death, bowel ischemia (1), renal failure (2), and respiratory failure (1). One (0.7%) secondary intervention to treat inadvertent coverage of a renal artery was performed. The core laboratory identified nine (6%) endoleaks (one type I, eight type II) on 30-day computed tomography angiography. Freedom from MAE was 97.3% (95% confidence interval, 93.3%-99.0%). Conclusions In selected patients, perioperative outcomes with the Nellix system for endovascular aneurysm sealing are encouraging, with very low 30-day morbidity and mortality and high procedural success. The primary safety end point has been achieved. Longer term follow-up is in progress.

Recent improvement in the survival of patients presenting with a ruptured abdominal aortic aneurysm (rAAA) has been credited to endovascular aneurysm repair (EVAR). We present our clinical series in the management of rAAA from 2007 to 2011. A total of 55 consecutive patient charts were reviewed. Thirty-eight patients underwent EVAR, 17 of the 55 patients did not have favorable anatomy for EVAR. Nine of the 17 patients underwent standard open repair. Eight patients underwent a ‘hybrid repair’ defined as suprarenal aortic endovascular balloon control followed by open repair. Overall 30-day mortality for all 55 patients was 22%. Mortality for the patients managed by endovascular aortic aneurysm repair was 26% compared with 22% with open repair. There were no deaths in the eight patients undergoing the hybrid repair. Endovascular balloon control of the aorta followed by open rAAA repair in patients who are not candidates for rEVAR has produced good results in our experience. Improved results being reported in the management of rAAA may not be on the basis of endovascular repair alone.

Fistula construction in the United States has remained steady for many years at approximately 30% to 40% (1,2). Other countries have reported higher success rates with primary autogenous hemodialysis access (3). Primary autogenous hemodialysis access has significantly improved since the new initiatives and goals set forth by Fistula First (www.fistulafirst.org). However, further improvement is required to reach the desired current goal of 66%. Native access has the best five-year patency rate and requires fewer interventions compared with prosthetic grafts (4). Autogenous radiocephalic direct wrist access provides the best permanent access with the fewest complications (5). Unfortunately, only 30% of patients are candidates for this type of access. The usual approach is first to construct a radiocephalic access followed by a brachiocephalic access, and second, to place a forearm graft. However, the use of a forearm graft has resulted in loss of the basilic vein as an autologous conduit from subsequent graft revisions (6). To increase the rate of fistula placement, in addition to constructing radiocephalic and brachiocephalic fistulas, other techniques must be used, such as forearm and upper arm basilic and cephalic transpositions. The present retrospective study reviews our experience with patients who underwent selective two-stage basilic vein transposition (BVT) and cephalic vein transposition (CVT) using modified proximal radial artery arteriovenous fistula (MPRAVF) as the first stage.

Purpose: There were two purposes to our study. The first was to characterize the ocular hyperperfusion associated with carotid endarterectomy. The second was to relate ocular hyperperfusion to the clinical presentation of cerebral hyperperfusion syndrome. Methods: This was a retrospective chart review of 2331 patients who underwent carotid endarterectomy at our institution between June 1978 and May 1991. Results: Twelve of these carotid endarterectomies were associated with ocular hyperperfusion on the side of operation. Clinical evidence of cerebral hyperperfusion syndrome was observed in five of these 12 procedures. In these five patients there were two associated fatal intracerebral hemorrhages and one permanent coma. In the latter three patients the contralateral internal carotid arteries were totally occluded. Conclusion: Ocular hyperperfusion, as documented with ocular pneumoplethysmography, is useful in alerting the physician to the potential for development of the cerebral hyperperfusion syndrome. (J VASC SURG 1993;17:690-5.)

Open repair of abdominal aortic aneurysm is still considered the gold standard against which endovascular repair is measured. We describe two cases of open repair complicated by bleeding where endovascular treatment proved to be life-saving.

The goal of this prospective study of the piezoelectric pulse sensor device was to determine its technical applications and its ability to detect lower extremity occlusive arterial disease. Ten extremities (five volunteers) were evaluated to assess the ability to place the sensor in the correct anatomic position on a foot without a palpable pulse during cuff occlusion so that pulsatile flow would be detected following cuff deflation; its sensitivity as an end-point detector for pulsatile perfusion; and whether there is a linear qualitative pulse wave response with increasing perfusion pressures. Forty extremities (20 patients) with suspected occlusive arterial disease were studied to evaluate its capability of detecting perfusion as compared with the presence of a palpable pulse, an audible Doppler signal, and a foot volume waveform. The placement of the sensor on 10 normal limbs with temporary arterial occlusion resulted in a recordable waveform following cuff deflation in 100% of the dorsalis pedis arteries and in 10% of the posterior tibial arteries. The piezoelectric pulse sensor was as sensitive for detecting pulsatile perfusion as an audible Doppler signal and demonstrated a linear change in the waveform's amplitude and shape with incremental changes in perfusion pressure. In the 40-extremities with ankle/brachial indices ranging from 0.00 to 1.35, there was uniform agreement between pulse volume and Pulse Check waveforms. The piezoelectric pulse sensor is a sensitive method for monitoring lower extremity arterial perfusion when supplied by the dorsalis pedis artery; however, it is inadequate for the posterior tibial artery. This may be useful in monitoring revascularization procedures in the immediate postoperative period or monitoring the hemodynamic effectiveness of thrombolytic therapy.

Acute deep venous thrombosis (DVT) continues to be a common clinical problem requiring objective evaluation. Hemo-dynamic testing for acute DVT has been popular, but is inadequate for evaluating asymptomatic patients and symptomatic patients with isolated calf vein thrombi. Venous duplex imaging (VDI) has rapidly gained in popularity, and is generally accepted to be the noninvasive technique of choice for the evaluation of patients with acute DVT. Twenty-five reports evaluate gray-scale venous duplex imaging versus ascending phlebography in 2,781 symptomatic patients. The sensitivity for proximal DVT and calf DVT is 96 and 80%, respectively. Seven reports review the use of VDI for surveillance in 857 asymptomatic patients, with an overall sensitivity of 76% for proximal DVT and of 11 % for isolated calf vein thrombosis. The results of color-flow duplex appear to be somewhat better; however, the numbers are considerably smaller. The results for identification of calf vein thrombosis in asymptomatic surveillance patients continue to be poor. VDI appears to be the best noninvasive diagnostic test for acute DVT, and may challenge ascending phlebography as the best diagnostic test for proximal DVT in symptomatic patients, although it will miss 20% of isolated calf DVT. VDI appears to be the best noninvasive screening technique for high-risk asymptomatic patients under surveillance; however, additional correlative studies with ascending phlebography are required. The addition of color Doppler images appears to have improved results, although these higher sensitivities may be the consequence of improved experience as much as the addition of color to the image.

Objective The first multicenter randomized controlled trial was designed and conducted to assess the safety and effectiveness of totally percutaneous endovascular aortic aneurysm repair (PEVAR) with use of a 21F endovascular stent graft system and either an 8F or 10F suture-mediated closure system (the PEVAR trial, NCT01070069). A noninferiority trial design was chosen to compare percutaneous access with standard open femoral exposure. Methods Between 2010 and 2012, 20 U.S. institutions participated in a prospective, Food and Drug Administration–approved randomized trial to evaluate percutaneous femoral artery access and closure by a "preclose" technique in conjunction with endovascular abdominal aortic aneurysm repair. A total of 151 patients were allocated by a 2:1 design to percutaneous access/closure (n = 101) or open femoral exposure (n = 50 [FE]). PEVAR procedures were performed with either the 8F Perclose ProGlide (n = 50 [PG]) or the 10F Prostar XL (n = 51 [PS]) closure devices. All endovascular abdominal aortic aneurysm repair procedures were performed with the Endologix 21F profile (outer diameter) sheath-based system. Patients were screened by computed tomography with three-dimensional reconstruction and independent physician review for anatomic suitability and adequate femoral artery anatomy for percutaneous access. The primary trial end point (treatment success) was defined as procedural technical success and absence of major adverse events and vascular complications at 30 days. An independent access closure substudy evaluated major access-related complications. Clinical utility and procedural outcomes, ankle-brachial index, blood laboratory analyses, and quality of life were also evaluated with continuing follow-up to 6 months. Results Baseline characteristics were similar among groups. Procedural technical success was 94% (PG), 88% (PS), and 98% (FE). One-month primary treatment success was 88% (PG), 78% (PS), and 78% (FE), demonstrating noninferiority vs FE for PG ( P = .004) but not for PS ( P = .102). Failure rates in the access closure substudy analyses demonstrated noninferiority of PG (6%; P = .005), but not of PS (12%; P = .100), vs FE (10%). Compared with FE, PG and PS yielded significantly shorter times to hemostasis and procedure completion and favorable trends in blood loss, groin pain, and overall quality of life. Initial noninferiority test results persist to 6 months, and no aneurysm rupture, conversion to open repair, device migration, or stent graft occlusion occurred. Conclusions Among trained operators, PEVAR with an adjunctive preclose technique using the ProGlide closure device is safe and effective, with minimal access-related complications, and it is noninferior to standard open femoral exposure. Training, experience, and careful application of the preclose technique are of paramount importance in ensuring successful, sustainable outcomes.

A 66-year-old woman had development of a rapidly enlarging juxtaceliac mycotic aneurysm after therapy for lumbar osteomyelitis and a psoas abscess. The aneurysm was repaired through a thoracoabdominal approach with a Dacron aortic graft sewn end to end to the thoracic aorta and end to side to the infrarenal aorta. Perfusion was restored after oversewing the abdominal aorta above the superior mesenteric artery and oversewing the celiac trunk. After reperfusion the foregut remained critically ischemic despite a patent superior mesenteric artery. Foregut reperfusion was achieved by removing the spleen and anastomosing the distal splenic artery to the aortic graft. Recovery was complicated by infarction of the body of the pancreas because of cholesterol emboli, resulting in a large pleural effusion. After undergoing a subtotal pancreatectomy that preserved the splenic artery, the patient recovered without additional complications. During 8 years of follow-up, the patient has normoglycemia and has had no further infections complications. The distal splenic artery offers an excellent inflow for foregut revascularization; however, the pancreas is intolerant of atheromatous emboli. (J VASC SURG 1995;21:530-6.)