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Background: Arteriovenous fistula (AVF) formation remains the procedure of choice in patients requring hemodialysis. The feasibility of AVF creation in the setting of prior radial artery harvesting after aortocoronary bypass remains unknown. This investigation elucidates which patients might be candidates for AVF creation despite prior radial artery harvesting. Methods: A retrospective review was performed on 2,100 patients undergoing hemodialysis access procedures from 2003 to 2010. Of these patients, 11 (0.5%) were identified as having prior radial artery harvesting for aortocoronary bypass. Pre/Post-operative vein mapping, arterial duplex, digital plethysmography, selective angiography, and sestamibi scanning was performed to evaluate the ulnary artery and palmar arch. Patients with evidence suggesting an intact ulnar artery circulation then underwent AVF creation. Results: All 11 patients had an adequate preoperative work up. Seven (64%) of the 11 patients had digital plethysmography suggesting an intact ulnar artery/palmar arch and underwent successful AVF creation. Three (27%) of the patients had a variety of findings precluding successful AVF creation. One (9%) patient with normal preoperative plethysmography developed a steal syndrome requiring revision of the arteriovenous fistula. Conclusions: Successful AVF creation is feasible in patients with prior radial artery harvesting for aortocoronary bypass. The use of preoperative digital plethysmography, selective ulnar artery/palmar arch arteriography and sestamibi scanning to evaluate forearm muscle perfusion may be used as adjuncts to guide a successful intervention.

Objectives: Large medicare databases and meta-analyses recommend routine patching following carotid endarterectomy (CEA). Routine patching reduces perioperative stroke, carotid thrombosis, and restenosis. This 30 year experience evaluates the long term outcome of CEA with selective patching and without routine postoperative duplex examination. Methods: An IRB-approved retrospective review of all CEAs peformed by two surgeons over a 30 year period (1984-2014). Pre-operative imaging studies, operative reports, physical findings, co-morbid conditions, and pre- and postoperative medications were evaluated. Results: Over a 30-year period, 439 CEAs were performed for symptomatic carotid disease using a selective patch technique depending on gender, internal carotid artery diameter, cardiovascular risk factors, and preoperative arteriogram. In this group of 439 patients, 17 (3.9%) had patch closure of the carotid artery and the other 422 (96.1%) had primary closure. There were 2 (0.47%) perioperative strokes in the primary closure group and 4 (0.95%) patients in this group developed symptomatic carotid restenosis at a mean follow-up of 49.5 months (range 1 to 237 months). There was 1 (5.8%) carotid thrombosis in the patch closure group who also had a perioperative stroke and was serologically positive for a hypercoagulable disorder. The 4 patients who developed symptomatic restenosis had arteriographically proven > 90% stenosis and required repeat CEA. The remaining 418 (99.0%) patients having primary closure remained neurologically asymptomatic (mean follow-up 10.3 years, range 2.5 to 17 years). There was 1 (0.23%) operative death that occurred following the induction of general anesthesia. Conclusions: In this experience, there is no statistically significant difference in restenosis in the primary closure group and selective patch group following CEA. Although this data set is a small, single center, two surgeon, retrospective review, it does not support the generally well accepted view of routine patching following CEA

Background Diabetes mellitus is a known risk factor in the development of peripheral vascular disease. Hemoglobin A1c (HbA1c) has been used by clinicians as a means to measure short to intermediate term glucose control in diabetics. Trials evaluating tight glucose control using HbA1c measurements have recently been conducted for several medical conditions. The goal of this study is to determine if the level of hemoglobin A1c has any effect on disease severity in diabetic patients with limb threatening ischemia. Methods A retrospective review of all patients presenting with limb threatening ischemia between January 1 and December 31, 2007 was conducted. All patients underwent conventional arteriography prior to intervention. Of 148 patients, 73 were diabetics with a hemoglobin A1c level performed within 3 mo of presentation. Patients were placed into high (>7) and low (

Background To evaluate the incidence and characteristics of venous thromboembolic events (VTE) associated with pregnancy in a contemporary patient series. Methods We performed a retrospective review of 33,311 deliveries between June 2003 and June 2008. Patients with objective documentation of a VTE during pregnancy or the 3-month postnatal period were identified from hospital discharge International Classification of Disease Codes edition 9 codes. Diagnosis of deep venous thrombosis (DVT) was largely made by a Duplex ultrasound, whereas pulmonary embolism (PE) was diagnosed by a computerized tomographic angiography (CTA). Results Of 33,311 deliveries during the study period, 74 patients (0.22%) had a VTE. There were 40 incidents of DVT (0.12%) and 37 of PE (0.11%). DVT involved the iliac veins (6), the femoral or popliteal veins (16), the infrapopliteal veins (17), and the axillary vein (1). Most (57.5%) of the DVTs involved the left lower extremity. Thirty-eight (51.6%) of the VTEs occurred in the postnatal period, and of those 33 (87%) occurred within 1 week of delivery. Most of the postnatal VTEs (68%) were seen in patients who underwent a cesarean section. Among patients with VTE during pregnancy, there were 28% in the first trimester, 25% in the second, and 47% in the third. Events were distributed among maternal age groups as follows: 26% aged 13-24, 50% aged 25-34, and 24% aged 35-54. Of the 35 patients tested for a hypercoagulable disorder, 12 were found to have a positive test result. Five (6.8%) of these 74 patients had a prior history of VTE, with two having a hypercoagulable disorder. In addition, 45 of the 74 patients were on oral contraceptive therapy or received hormonal stimulation therapy before pregnancy. Patients with a VTE during pregnancy were treated with low molecular weight or unfractionated heparin. Most postnatal patients were treated with subcutaneous low molecular weight heparin and coumadin. Six inferior vena cava filters were placed in patients with bleeding complications as a result of anticoagulation. There were no deaths during the study period. Conclusions Comparing our results with historic controls (DVT: 0.04-0.14% and PE: 0.003-0.04%), the incidence of DVT in pregnancy has not changed significantly. We note, however, that the incidence of pulmonary embolus in our series is higher than previously reported. CTA has been used for the diagnosis of PE since the past decade. The increase in the rate of PE in the current series may be because of the higher sensitivity of CTA when compared with previous diagnostic modalities.

Objectifs Evaluer l’incidence et les caracteristiques des evenements thrombo-emboliques veineux (ETV) associes a la grossesse dans une serie contemporaine. Methodes Nous avons effectue une revue retrospective de 33 311 accouchements survenus entre juin 2003 et juin 2008. Les patientes ayant presente un ETV au cours de la grossesse ou des trois mois suivant la periode post-natale ont ete identifiees a l’aide de l’International Classification of Disease Codes a la sortie de l’hopital. Le diagnostic de thrombose veineuse profonde (TVP) a ete majoritairement effectue par echographie Doppler alors que celui d’embolie pulmonaire (EP) a ete effectue par angio-tomodensitometrie (ACT). Resultats 74 patientes (0,22%) ont presente un EVP a l’issue des 33 311 accouchements effectues durant la periode d’etude. Il y a eu 40 TVP (0,12%) et 37 EP (0,11%). Les TVP ont interesse les veines iliaques (6), femorales ou poplitees (16), sous-poplitees (17) et axillaires (1). La plupart (57,5%) des TVP a interesse le membre inferieur gauche. Trente-six (51,6%) des ETV sont survenus au cours de la periode post-natale et parmi eux 33 (87%) sont survenus dans la premiere semaine suivant l’accouchement. La majorite des ETV post-nataux (68%) a ete identifiee chez des patientes ayant eu une cesarienne. Les patientes presentant un ETV au cours de la grossesse etaient dans 28% des cas dans leur premier trimestre, 25% dans le second et 47% dans le troisieme. Les evenements etaient distribues selon l’âge maternel de la maniere suivante : 26% des patientes âgees de 13 a 24 ans, 50% des patientes âgees de 25 a 34 et 24% des patientes âgees de 35 a 54 ans. Douze parmi 35 patientes ayant eu la recherche d’un desordre de la coagulation ont eu un test positif. Cinq (6,8%) de ces 74 patientes avaient un antecedent d’ETV, deux d’entre elles ayant une hypercoagulabilite. De plus, 45 des 74 patientes recevaient une contraception orale ou avaient recu une stimulation hormonale avant la grossesse. Les patientes presentant un ETV au cours de la grossesse ont ete traitees par heparine de bas poids moleculaire ou heparine non fractionnee. La plupart des patientes ayant un evenement post-natal ont ete traitees par heparine de bas poids moleculaire sous-cutanee et par Coumadine. Six filtres de la veine cave inferieure ont ete places chez des patientes ayant des complications hemorragiques du traitement anticoagulant. Il n’y a eu aucun deces durant la periode d’etude. Conclusions Comparee aux donnees historiques (TVP : 0,04-0,14% et EP : 0,003-0,04%), l’incidence des TVP au cours de la grossesse ne s’est pas modifiee significativement. Nous observons cependant que l’incidence d’embolie pulmonaire dans notre serie est superieure a celle precedemment rapportee. L’ACT a ete utilisee pour les diagnostics d’EP au cours de la derniere decennie. L’augmentation du taux d’EP dans la serie presente pourrait etre liee a une plus forte sensibilite de l’ACT comparee aux plus anciennes modalites d’imagerie diagnostique.

Objectif Le pontage composite sequentiel femoro-popliteo-distal est une option valable pour le traitement de l’ischemie critique des membres inferieurs lorsque la disponibilite de la veine autologue est limitee et lorsqu’un segment arteriel isole popliteo-distal existe. Nous rapportons une technique modifiee de pontage sequentiel composite et le resultat de son utilisation sur une periode de 14 ans. Methodes Vingt-cinq procedures de pontages sequentiels composites modifies ont ete effectuees chez 24 patients pour traiter une gangrene, des ulceres ischemiques et des douleurs severes de repos. Des greffons veineux ont ete anastomoses entre un segment d’artere poplitee ou d’artere distale suspendu au-dessus du genou (7) ou sous le genou (18) et une artere distale de jambe incluant l’artere poplitee sous-articulaire (1), l’artere tibiale posterieure (5), l’artere tibiale anterieure (7) ou l’artere peroniere (12). Des pontages en Polytetrafluoroethylene ont ensuite ete intercales entre une artere donneuse satisfaisante et le segment proximal du greffon veineux. Resultats Les taux de permeabilite primaire cumules ont ete de 80% a trois ans et de 65% a 5 ans. Le taux de sauvetage de membre a ete de 85% a quatre ans. L’occlusion du segment prothetique avec un segment distal veineux restant permeable a ete authentifiee chez deux patients presentant une recidive moins severe d’ischemie. Le sauvetage de membre chez ces patients a ete obtenu en effectuant un nouveau pontage prothetique revascularisant le greffon veineux permeable. Conclusion Notre configuration modifiee d’anastomose entre la prothese et la veine pour la realisation d’un pontage sequentiel composite represente une alternative a la procedure conventionnelle et pourrait aider a preserver la permeabilite du greffon veineux en cas de thrombose de la prothese de polytetrafluoroethylene.

Background Composite sequential femoro-popliteal-distal bypass is a valuable option for treatment of critical limb ischemia when autogenous vein is limited and an isolated popliteal or distal arterial segment exists. We report a modified technique for composite sequential bypass and the results with its use over a 14-year period. Methods Twenty-five modified composite sequential bypass procedures were performed on 24 patients to treat gangrene, ischemic ulceration, and severe rest pain. Vein grafts were anastomosed from blind popliteal or blind distal arterial segments above-knee (7) or below-knee (18) to a distal outflow vessel including the below-knee popliteal (1), posterior tibial (5), anterior tibial (7), or peroneal (12) artery. Polytetrafluoroethylene bypass grafts were then placed from a suitable inflow artery to the proximal hood of the vein graft. Results Cumulative primary patency rates were 80% at 3 years, and 65% at 5 years. The limb-salvage rate was 85% at 4 years. Occlusion of the prosthetic segment with a patent distal vein segment was recognized in two patients who presented with less severe recurrent ischemia. Limb-salvage in these patients was achieved by a secondary prosthetic graft to the patent vein graft. Conclusion Our modified configuration of the prosthetic-vein anastomosis for composite sequential bypass is an alternative to the conventional procedure and may help preserve vein graft patency should the polytetrafluoroethylene graft thrombose.

Rationnelle Il a ete bien etabli que la mise en place d’un filtre de veine cave inferieure (VCI) au moment de la chirurgie ouverte de bypass gastrique (BGO) chez les patients ayant un indice de masse corporelle superieur a 55 kg/m2 reduit le taux d’embolie pulmonaire et la mortalite perioperatoire. Cependant, peu de choses sont connues au sujet des effets a long terme des filtres gastrique dans ce groupe particulier de patients. Methodes Sur une periode de huit ans, un total de 571 patients obeses morbides ont subi des procedures de BGO, et 58 (10%) d’entre eux ont necessite la mise en place d’un filtre VCI en preoperatoire. Chaque filtre VCI etait place par voie percutanee par une approche de veine femorale en utilisant un arceau mobile OEC. Les types de filtres VCI utilises dans notre etude etaient TrapEase (n = 35), Simon-Nitinol (n = 9), Greenfield (n = 2), et Bard Recovery (n = 12). Resultats Des 58 patients qui ont eu besoin d’un filtre VCI, 56 sont restes exempts de tout phenomene thromboembolique au cours de la periode de huit ans (extremes, 1-8 ans). Les deux autres patients ont developpe une thrombose veineuse profonde. Une patiente a ete traitee avec succes avec de l’heparine intraveineuse et six mois de Coumadine. Elle a eu la resolution complete de sa thrombose veineuse profonde et il a ete fortuitement trouve une mutation genique de la prothrombine 20210. L’autre patiente, qui a eu des complications multiples de la deviation gastrique, ne pouvait pas etre traitee efficacement avec de l’heparine intraveineuse et progressa jusqu’a la thrombose de la VCI. Elle a developpe une phlegmasia cerulea dolens et fut amputee des deux cotes au-dessus du genou. Elle est morte 3 mois apres ses procedures. Conclusion Il s’avere que la mise en place d’un filtre VCI lors d’un BGO est une intervention relativement benigne avec un avantage maximal. Il faudrait porter attention aux patients obeses qui ont une hypercoagulabilite et a ceux qui ont des complications liees a la deviation gastrique. Une attitude agressive, qui peut se composer d’une anticoagulation immediate apres les procedures (seulement si elle est consideree sure), devrait etre preconisee dans ce petit sous-groupe de patients obeses morbides.

L'obesite augmente de maniere independante le risque d'embolie pulmonaire (EP). Nous comparons une population de grands obeses (index de masse corporelle [BMI] > 55 kg/m2) subissant des courts-circuits gastriques a ciel ouvertes (OGB) a un groupe apparie de courts-circuits gastriques laparoscopiques (LGB) pour voir si l'incidence de l'EP est differente. Nous avons inclus tous les patients subissant un OGB ( n = 193, BMI moyen = 51 kg/m2) dans notre etablissement par un seul chirurgien entre juillet 1999 et avril 2001. Trente et un patients etaient de grands obeses (BMI > 55 kg/m2). Les LGB ont ete introduits dans notre etablissement en avril 2001. Depuis lors 213 patients (BMI moyen = 52 kg/m2) ont subi cette intervention. Cent neuf de ces patients etaient de grands obeses. La prophylaxie pre- et postoperatoire incluait des bas de compression graduee et de l'heparine sous-cutanee. En postoperatoire, les patients qui ont developpe des signes d'hypoxie, une tachypnee, ou une tachycardie ont eu une radiographie thoracique et un scanner helicoidal. En outre, tous les patients decedes au cours des 30 jours postoperatoires ont ete autopsies. Les donnees ont ete analysees a l'aide du test du Chi 2 . Dans le groupe OGB, quatre patients (2,1%) ont developpe une EP. Toutes les EP se sont produites chez les grands obeses avec BMI > 55 kg/m2. Trois furent fatales et une non fatale. Aucun de ces patients n'avait des antecedents de thrombose veineuse profonde (DVT), d'EP, d'insuffisance veineuse, ou d'hypertension pulmonaire. Dans le groupe LGB, un patient (0,9%) a eu une EP non fatale. Ce patient avait un antecedent de thrombose veineuse profonde. L'incidence de l'EP etait statistiquement plus elevee dans le groupe des grands obeses traites par OGB ( p 55 kg/m2 pourraient avoir un risque accru d'EP independamment de la voie d'abord.

Objective Patients undergoing open gastric bypass (OGB) for morbid obesity are at significant risk for pulmonary embolism (PE) despite the use of subcutaneous heparin injections and sequential compression devices. Prophylactic preoperative inferior vena cava (IVC) filter placement may reduce this risk. We report our experience with simultaneous IVC filter placement and OGB in an operating room setting. Methods From July 1999 to April 2001, 193 patients (group 1) underwent OGB. Eight patients had prophylactic intraoperative IVC filters placed for deep vein thrombosis, PE, or pulmonary hypertension. From May 2001 to January 2003, 181 patients (group 2) underwent OGB. There were 33 IVC filters placed for body mass index (BMI) greater than 55 kg/m 2 in addition to the above-mentioned criteria. To confirm observations made in group 1 and 2 patients, from July 2003 to May 2005, 197 patients (group 3) underwent OGB, and patients with a BMI greater than 55 kg/m 2 (n = 35) were offered IVC filter placement. Group 3A (n = 17) consented to IVC filter placement, and group 3B (n = 18) did not. Results Fifty-eight IVC filters were placed (100% technical success rate) with an increase in operating room time of 20 ± 5 minutes. In group 1, the eight patients with IVC filters had a BMI greater than 55 kg/m 2 . There were four PEs (3 fatal and 1 nonfatal) in the other 185 patients, all which occurred in patients with BMIs greater than 55 kg/m 2 . In group 2, there were no PEs. The perioperative PE rate in these patients was reduced from 13% (4/31; 95% confidence interval [CI], 1.1%-25.7%) to 0% (0/33; 95% CI, 0%-8.7%). Perioperative mortality was reduced from 10% (3/31; 95% CI, 0%-20.0%) to 0% (0/33; 95% CI, 0%-8.7%). There were no pulmonary emboli or deaths related to PE in group 3A patients. Group 3B patients had a 28% PE rate (two fatal and three nonfatal) and an 11% PE-related death rate. None of the remaining patients in group 3 had a PE. Conclusions Intraoperative IVC filter placement for the prevention of PE in morbidly obese patients undergoing OGB is feasible. We observed a significant reduction in the perioperative PE rate when a BMI greater than 55 kg/m 2 was used as an indication for IVC filter placement despite the use of subcutaneous heparin injections and sequential compression devices.

Objective Proximal neck dilatation (PND) and/or endograft migration with the subsequent development of type I endoleak is a significant cause of late endograft failure after endovascular abdominal aortic aneurysm repair (EVAR). Although there are numerous reports examining PND in patients receiving endografts that use self-expanding stents (SES) for proximal fixation, there are no such reports for patients treated with endografts that use balloon-expanding stents (BES). The purpose of this study was to investigate PND and endograft migration after EVAR with BES endografts. Methods We retrospectively reviewed all charts and all serial computed tomographic scans available for patients who underwent EVAR with a BES endograft (surgeon-made, aortounifemoral polytetrafluoroethylene graft with a proximal Palmaz stent) between August 1997 and October 2002. Only patients with longer than a 12-month follow-up were analyzed. Neck diameter was measured at the level of the lowest renal artery and at 5 mm below it. PND was defined as neck enlargement of 2.5 mm or more. To assess endograft migration, the distance between the superior mesenteric artery and the cranial end of the BES was measured. Stent migration was defined as a change of 5 mm or more. Results A total of 77 patients received this device during the study period. The technical success rate was 99%. The 1-, 3-, and 5-year survival was 66%, 48%, and 29.5%, respectively. Complete serial computed tomographic scans were available in 41 of the 48 patients who survived 12 months or longer after the operation. The mean follow-up period for these patients was 31 months (range, 12-66 months). The maximum aneurysm diameter was either unchanged or decreased in 35 patients (85%). The immediate postoperative proximal neck diameter was 19 to 29 mm (median, 24 mm). This was unchanged at the latest follow-up. None of the patients had significant PND. The cranial end of the BES was located in the area between 14 mm proximal and 36 mm distal to the superior mesenteric artery (median, 6 mm). None of the patients developed significant endograft migration. Conclusions Neither PND nor endograft migration was observed with the BES endograft. The nature of the SES may be responsible for the observed neck dilatation and device migration after EVAR with SES endografts. This study suggests that BES may be a better fixation method for EVAR.

Objective(s)We have previously shown that type II endoleak size is a predictor of aneurysm growth after aortic endografting. To better understand this observation, we investigated the influence of endoleak size on pressure transmitted to the aneurysm wall and its distribution within the aneurysm sac.MethodsIn an ex vivo model, an artificial aneurysm sac was incorporated within a mock circulation comprised of rubber tubing and a pulsatile pump. Three strain-gauge pressure transducers were placed in the aneurysm wall at different locations, including the site of maximum aneurysm diameter. The aneurysm was filled with either human aneurysm thrombus or dough that mimicked thrombus and simulated type II endoleaks of varying volumes (1 to 10 mL) were created. Aneurysm wall pressure (AWP) measurements were recorded at mean arterial pressures (MAPs) of 60, 80, and 100 mm Hg. Correlation coefficients (r) and analysis of variance were used to assess the relationship between endoleak volume and AWP.ResultsIncreasing endoleak volume ’3 cm3 resulted in proportionally increased AWP at all levels of MAP and at all sites, with highest pressures recorded at the site of the maximum aneurysm diameter (r = 0.83 when MAP = 100 mm Hg; r = 0.85 when MAP = 80 mm Hg; r = 0.88 when MAP = 60 mm Hg; P < .001). AWP plateaued when the endoleak volume was >3 cm3. Pressure distribution within the sac was not uniform. Although the difference was within ±10%, statistically significant higher AWPs were observed at the site of maximum aneurysm diameter (P

Background To evaluate whether abdominal aortic aneurysm (AAA) growth in individual patients can be characterized as continuous or discontinuous (staccato). Study design From 1996 to 2002, 609 patients presented with unruptured AAAs. Of these, 278 underwent prompt repair and 331 were observed. In this study, we included 52 patients (16% of the latter group) who had at least four CT scans and were observed for 18 months or longer without any intervention. AAA growth was defined as any increase in diameter of ≥ 3 mm over any observation period(s). AAA nongrowth was defined as absence of growth for at least 6 months. Staccato growth was defined as at least one period of nongrowth combined with at least one period of growth. Results The 52 patients had a mean age of 75 ± 8 (SD) years. The mean observation period was 42 ± 20 months and the mean AAA diameter growth rate was 3.6 ± 2.4 mm/y. Only 12 of these 52 patients (23%) demonstrated continuous growth. Staccato growth occurred in 34 patients (65%). Six patients (12%) showed no growth at all over 18 to 57 months (mean 30 months). No correlation was observed between initial diameter of AAAs and a patient's individual growth rate during the whole observation period ( R = 0.04, p = 0.46). Conclusions Individual AAA behavior is usually characterized by periods of nongrowth alternating with periods of growth, ie, staccato growth. Some aneurysms may have long periods of nongrowth. Accordingly, management decisions cannot be based on the presumption that observed growth rates of AAAs can be extrapolated to predict future growth rates.

The clinical significance of type II endoleaks is not well understood. Some evidence, however, indicates that some type II endoleaks might result in aneurysm enlargement and rupture. To identify factors that might contribute to aneurysm expansion, we analyzed the influence of several variables on aneurysm growth in patients with persistent type II endoleaks after endovascular aortic aneurysm repair (EVAR).In a series of 348 EVARs performed during a 10-year period, 32 patients (9.2%) developed type II endoleaks that persisted for more than 6 months. Variables analyzed included those defined by the reporting standards for EVAR (SVS/AAVS) as well as other endoleak characteristics. Univariate, receiver operating characteristic curve, and Cox regression analyses were used to determine the association between variables and aneurysm enlargement.The median follow-up period was 26.5 months (range, 6-88 months). Thirteen patients (41%) had aneurysm enlargement by 5 mm or more (median increase in diameter, 10 mm), whereas 19 (59%) had stable or shrinking aneurysm diameter. Univariate and Cox regression analyses identified the maximum diameter of the endoleak cavity, ie, the size of the nidus as defined on contrast computed tomography scan, as a significant predictor for aneurysm enlargement (relative risk, 1.12; 95% confidence interval, 1.04-1.19; P =.001). The median size of the nidus was 23 mm (range, 13-40 mm) in patients with aneurysm enlargement and 8 mm (range, 5-25 mm) in those without expansion (Mann-Whitney U test, P.001). Moreover, receiver operating characteristic curve and Cox regression analyses showed that a maximum nidus diameter greater than 15 mm was particularly associated with an increased risk of aneurysm enlargement (relative risk, 11.1; 95% confidence interval, 1.4-85.8; P =.02). Other risk factors including gender, smoking history, hypertension, need of anticoagulation, aneurysm diameter, type of endograft used, and number or type of collateral vessels were not significant predictors of aneurysm enlargement.In patients with persistent type II endoleaks after EVAR, the maximum diameter of the endoleak cavity or nidus is an important predictor of aneurysm growth and might indicate the need for more aggressive surveillance as well as earlier treatment.

The recent explosion of interest in morbid obesity surgery and its associated complications (deep venous thrombosis and pulmonary embolism) has inadvertently captured the attention of many vascular specialists. This article will focus on the indications and techniques used at Jack D. Weiler Hospital of the Albert Einstein College of Medicine for inferior vena cava filter placement prior to open and laparoscopic bariatric surgical procedures.

ObjectivesReduction of length of stay (LOS) is critical for optimal use of hospital resources. We developed and evaluated a system to aggressively reduce LOS for vascular surgery.MethodKey to this system, which we introduced on January 1, 2001, was appointment of a LOS officer, who communicated daily during hospitalization with patients and families about discharge planning, organized outpatient services for wound care and rehabilitation to transition patients quickly to nonhospital care, and had biweekly meetings with relevant paramedical services. LOS for 509 patients operated on in 2000 (standard group) was compared with LOS for 474 operated on in 2001 and 595 patients operated on in 2002 (LOS reduction groups). Data for all patients with aortic aneurysm, carotid artery stenosis, lower extremity critical ischemia or amputation, and foot debridement were included.ResultsLOS in 2000 averaged 8.5 days, compared with 5.9 days in 2001 and 5.6 days in 2002. All decreases in LOS for each diagnostic category in 2001 and 2002 were statistically significant (P = < .001-.03). There was no significant increase in readmission rate (2.2% vs 1.9% and 2.0%, respectively), mortality rate (0.8% vs 0.6% and 0.7%, respectively), or percent of patients who received endovascular treatment (18% vs 16% and 14%, respectively). These decreases in LOS saved the hospital more than $616,200 in 2001, and $847,550 in 2002 ($500/patient-day).ConclusionsA committed LOS officer with major specific daily responsibilities for decreasing LOS and discharging patients resulted in a 31% to 33% decrease in LOS, with important cost savings to the hospital and no negative effect on patient care.

Purpose: To evaluate the patency rates of femorofemoral grafts performed in conjunction with aortomonoiliac or aortomonofemoral (AMI/F) endografts. Methods: Over the past 8 years, 110 patients (98 men; mean age 77 ± 7 years, range 57–90) underwent aortoiliac aneurysm repair with an AMI/F endograft. Follow-up data in these patients were prospectively collected for a mean 2.3 years (range 1–68 months). Results: There were 2 early (Conclusions: Femorofemoral bypasses with AMI/F endografts for aneurysmal disease are durable procedures and have better patency than femorofemoral grafts used to treat occlusive disease. Femorofemoral bypass patency rates alone are not a disadvantage of aortomonoiliac endografts.

Background Total graft excision with in situ or extra-anatomic revascularization is considered mandatory to treat infection involving the body of aortic grafts. We present a series of nine patients with this complication and such severe comorbid medical illnesses or markedly hostile abdomens that traditional treatments were precluded. In these patients selective complete or partial graft preservation was used. Methods Over the past 20 years we have treated nine infected infrarenal aortic prosthetic grafts with complete or partial graft preservation, because excision of the graft body was not feasible. In all nine patients infection of the main body of the aortic graft was documented at computed tomography or surgery. Essential adjuncts included percutaneous or operative drain placement into retroperitoneal abscess cavities and along the graft, with instillation of antibiotics three times daily, repeated debridement of infected groin wounds, and intravenous antibiotic therapy for at least 6 weeks. Results One patient with purulent groin drainage treated with complete graft preservation died of sepsis. One patient with groin infection treated with complete graft preservation initially did well, but ultimately required total graft excision 5 months later, after clinical improvement. In four patients complete graft preservation was successful; two patients required excision of an occluded infected limb of the graft; and one patient underwent subtotal graft excision, leaving a graft remnant on the aorta, and axillopopliteal bypass. In summary, seven of nine patients survived hospitalization after complete or partial graft preservation; amputation was avoided in all but one patient; and no recurrent infection developed over mean follow-up of 7.6 years (range, 2-15 years). Conclusions Although contrary to conventional concepts, partial or complete graft preservation combined with aggressive drainage and groin wound debridement is an acceptable option for treatment of infection involving an entire aortic graft in selected patients with prohibitive risks for total graft excision. This treatment may be compatible with long-term survival and protracted absence of signs or symptoms of infection.

ObjectivesTransrenal fixation (TFX) of aortic endografts is thought to increase the risk for renal infarction and impaired renal function. We studied the late effects of TFX on renal function and perfusion.MethodsOf 189 patients with commercial aortic endografts, which we inserted between 1995 and 2002, we reviewed data for 130 patients (112 men, 18 women) with available creatinine (Cr) concentration and contrast enhanced computed tomography (CT) scans preoperatively and 1 to 97 months after the procedure. Of the 130 patients, 69 patients had TFX and 61 patients had infrarenal fixation (IFX). Both groups were physiologically comparable. Average age was 76 ± 8 years for patients with TFX and 75 ± 8 years for patients with IFX. Presence of renal infarct or renal artery occlusion was determined by nephrograms on serial contrast-enhanced CT scans.ResultsMean follow-up was 17 ± 16 months (range, 1-54 months) for TFX and 21 ± 21 months (range, 1-97 months) for IFX. Mean serum Cr concentration increased significantly during long-term follow-up in both groups (TFX, 1.3 ± 0.5 mg/dL to 1.5 ± 0.8 mg/dL, P < .01; IFX, 1.3 ± 0.7 mg/dL to 1.4 ± 0.8 mg/dL, P < .03). Creatinine clearance (CrCl) similarly decreased over long-term follow-up in both groups (TFX, 53.3 ± 17.7 mL/min/1.73 m2 to 47.9 ± 16.2 mL/min/1.73 m2, P < .01; IFX, 58.1 ± 22.7 mL/min/1.73 m2 to 53.1 ± 23.4 mL/min/1.73 m2, P < .02). There were no significant differences in the increase in Cr concentration (P = .19) or decrease in CrCl (P = .68) between TFX and IFX groups. Small renal infarcts were noted in four patients (5.8%) in the TFX group and one patient (1.6%) in the IFX group. No increase in Cr concentration or decrease in CrCl was noted in any patient with a renal infarct. Postoperative renal dysfunction developed in 7 of 69 patients (10.1%) in the TFX group and 7 of 61 patients (11.5%) in the IFX group. There were no statistically significant differences between groups with respect to number of patients with new renal infarcts (P = .37) or postoperative renal dysfunction (P = .81).ConclusionThere is a slight increase in serum Cr concentration and decrease in CrCl after aortic endografting. However, there was no significant difference in these changes between patients with TFX and IFX. Although TFX may produce a higher incidence of small renal infarcts, these do not impair renal function. Thus our midterm results suggest that TFX can be performed safely, with no greater change in renal function than observed after IFX.

Objective Inadequate infrainguinal runoff is considered an important risk factor for iliac stent failure. However, the influence of concomitant infrainguinal arterial reconstruction (CIAR) on iliac stent patency is unknown. This study evaluated the influence of CIAR on outcome of iliac angioplasty and stenting (IAS) in patients with poor distal runoff. Methods Over 5 years (1996 to 2001), 68 IAS procedures (78 stents) were performed in 62 patients with poor distal runoff (angiographic runoff score ≥5). The SVS/AAVS reporting standards were followed to define outcome variables and risk factors. Data were analyzed with both univariate analysis (Kaplan-Meier method [K-M]) and regression analysis (Cox proportional hazards model). Results Indications for iliac artery stenting were disabling claudication (59%) and limb salvage (41%). Of the 68 procedures, IAS with CIAR was performed in 31 patients (46%), and IAS alone was performed in 37 patients (54%). Patients undergoing IAS with CIAR were older ( P = .03) and had more extensive and multifocal iliac artery occlusive disease, with more TASC (TransAtlantic Inter-Society Consensus) type C lesions ( P = .03), compared with patients undergoing IAS alone. No other significant differences in risk factors were noted. Runoff scores between patients undergoing IAS with CIAR and those undergoing IAS alone were not significantly different (median runoff scores, 6 [range, 5-8] and 7 [range, 5-9], respectively; P = .77). Primary stent patency rate at 1, 3, and 5 years was 87%, 54%, and 42%, respectively, for patients undergoing IAS with CIAR, and was 76%, 66%, and 55%, respectively, for patients undergoing IAS. Univariate analysis revealed that primary stent patency rate was not significantly different between the 2 groups (K-M, log-rank test, P = .81). Primary graft patency rate for CIAR was 81%, 52%, and 46% at 1, 3, and 5 years, respectively. Performing CIAR did not affect primary iliac stent patency (relative risk, 1.1; 95% confidence interval, 0.49-2.47; P = .81). Overall, there was a trend toward improved limb salvage in patients undergoing IAS with CIAR, compared with those undergoing IAS alone (K-M, log rank test, P = .07). Conclusion In patients undergoing IAS with poor distal runoff, CIAR does not improve iliac artery stent patency. Infrainguinal bypass procedures should therefore be reserved for patients who do not demonstrate clinical improvement and possibly for those with limb-threatening ischemia.

Standard surgical treatment for ruptured abdominal aortoiliac aneurysms (AAAs) has achieved some dramatic individual results but is generally associated with substantial morbidity and an in-hospital mortality which ranges from 35-70% (1-8). Recent efforts to improve these poor results have not changed this bleak outlook significantly. Since 1994, we have evaluated the possibility that endovascular grafts coupled with other interventional techniques might help to improve the treatment outcomes of ruptured AAAs (9). Although we first used these grafts and techniques in a selected group of high-risk patients in whom pretreatment computerized tomographic (CT) scans could be obtained, we presently believe that they should be applied more widely to treat most patients with ruptured AAAs. The present chapter describes our experience to date with the use of endovascular grafts and other catheter-based techniques to treat ruptured AAAs. Obstacles to use of endovascular grafts in the ruptured aneurysm setting

Objective: Patients with infrainguinal occlusive disease may experience spontaneous symptomatic improvement. This is generally thought to be from augmented collateral circulation. This study reports another mechanism. Methods: Over a 20-year period, 4123 paients underwent lower extremity arteriography for limb ischemia. For a variety of reasons, 451 patients had repeat arteriography. Results: Five patients were identified as having conclusive arteriographic evidence of spontaneous recanalization of occluded arterial segments without having undergone any surgical or thrombolytic interventions. Repeat contrast arteriography was performed on these patients for failing grafts (n = 2) or contralateral lower extremity ischemia (n = 3). Three other patients had magnetic resonance arteriographic or duplex arteriographic evidence of spontaneous arterial recanalization. Spontaneous recanalizaton occurred in ileofemoral (n = 2), superficial femoral (n = 2), popliteal (n = 3), and peroneal (n = 1) arterial segments. The average time interval of occlusion to recanalization was 21 weeks (2 weeks to 2 years). Two of the eight patients had failed revascularization procedures before spontaneous recanalization. All eight patients had restoration of pulses distal to the recanalized segments and significant symptomatic improvement as defined with the Society for Vascular Surgery/American Association for Vascular Surgery categories for limb ischemia. Conclusion: Spontaneous recanalization of arterial segments can occur and must be considered when evaluating other proposed treatments of critical limb ischemia, including cilostazol, lytic agents, and angiogenic agents, such as vascular endothelial growth factor. Although its true incidence is unknown, this represents another mechanism for spontaneous symptomatic improvement without treatment in patients with severe limb ischemia. (J Vasc Surg 2002;36:1161-6.)

Objective: Carotid artery stenting (CAS) for treatment of carotid stenosis has not received wide acceptance because of the availability of carotid endarterectomy (CEA) with its excellent results and because of the risk of embolic stroke associated with CAS. The feasibility and efficacy of cerebral protection devices that may prevent such embolic complications have yet to be shown. We report our initial results with CAS performed with cerebral protection. Methods: For a period of 28 months, 31 patients with carotid artery stenosis, most of whom were considered at high risk for CEA (87%), underwent treatment with CAS in conjunction with either the PercuSurge GuardWire (n = 19; Medtronic, Minneapolis, Minn), the Cordis Angioguard filter (n = 7; Cordis, Warren, NJ), or the ArteriA Parodi Anti-embolization catheter (n = 4; ArteriA, San Francisco, Calif) with US Food and Drug Administration-approved investigational device exemptions. Factors that made CEA high risk included restenosis after CEA (n = 6), hostile neck (n = 6), high or low lesions (n = 4), and severe comorbid medical conditions (n = 11). Preoperative neurologic symptoms were present in 58%, and the mean stenosis was 85% ± 12%. Data were prospectively recorded and analyzed on an intent-to-treat basis. Neurologic evaluation was performed before and after CAS by a protocol neurologist. Results: CAS was performed with local anesthesia with the Wallstent (n = 23; Boston Scientific Corp, Natick, Mass) or the PRECISE carotid stent (n = 7; Cordis) in conjunction with one of the protection devices in an operating room with a mobile C-arm. Each patient received dual antiplatelet therapy before surgery. The overall technical success rate was 97% (30/31). In one patient, the lesion could not be crossed with a guidewire because of a severely stenosed and tortuous lesion. This patient was not a candidate for CEA and was treated conservatively. In the remaining 30 cases, CAS had a good angiographic result (residual stenosis

Endovascular interventions have gained widespread acceptance as primary and secondary treatments for critical lower extremity ischemia (CLI), and many believe there is little need for open bypasses for CLI. Despite this, some patients presenting with CLI require traditional lower extremity bypass procedures at some point for successful limb salvage. To determine the proportion of patients requiring an open procedure, we reviewed our 1-year experience with CLI patients at a center committed to endovascular approaches whenever possible. We reviewed all patients presenting with CLI from January 1, 2007 to December 31, 2007. CLI was defined as ischemic rest pain, nonhealing ulceration, or gangrene for which a major amputation was imminently required. All patients underwent duplex and conventional angiography before intervention. Endovascular treatments were favored as primary, secondary, or tertiary treatments, if possible. If these failed or were impossible, standard lower extremity bypasses were performed. One hundred and forty-eight patients presented with primary, secondary, or tertiary CLI over this 1-year period. Of these, 63 (42%) were treated successfully with an endovascular intervention, and 69 (47%) required standard lower extremity bypass, and 16 (11%) required a combined endovascular and open procedure (i.e., hybrid procedure). Of these 148 patients, 46 (31%) were presenting with secondary, tertiary, or more CLI after failed previous (1-5) procedures. Despite the initial enthusiasm that the majority of patients presenting with CLI may be treated with endovascular procedures, there exists a significant cohort of patients that will ultimately require standard open surgical procedures.

Background There is increasing pressure for the rapid development and implementation of new techniques and procedures. This study examined whether or not there has been a trend toward increasingly short follow-up times for studies evaluating the treatment of lower-extremity occlusive disease. Methods A search was performed of PubMed using the term “femoropopliteal occlusive disease” from 1976 to 2006. Reports describing the open and/or endovascular treatment of femoropopliteal occlusive disease were classified according to the number of patients, method of treatment, and follow-up time. Results A total of 103 of the 435 reports met the inclusion criteria. Average follow-up times from 1976 to 1986 were a mean of 43.3 months and a median of 38.8 months, from 1986 to 1996 were a mean of 32.4 months and a median of 16.9 months, from 1996 to 2006 were a mean of 22.6 months and a median of 16.5 months. Conclusions The number of reports on femoropopliteal occlusive disease treatment has increased. The length of follow-up period was 2- to 3-fold longer for reports on open procedures compared with those on endovascular procedures. Whether length of follow-up evaluation and reporting intervals should be standardized warrants further investigation.

Background It has been well established that inferior vena cava (IVC) filter placement at the time of open gastric bypass (OGB) surgery in patients with a body mass index of more than 55 kg/m 2 reduces both the pulmonary embolism rate and the perioperative mortality. However, little is known about the long-term effects of IVC filter placement in this particular group of patients. Methods Over an 8-year period, a total of 571 morbid obese patients underwent OGB procedures, and 58 (10%) of them required placement of an IVC filter before their procedure. All IVC filters were placed percutaneously through a femoral vein approach using a portable OEC fluoroscope. Types of IVC filters used in our study included the TrapEase ( n = 35), Simon-Nitinol ( n = 9), Greenfield ( n = 2), and Bard Recovery ( n = 12). Results Of the 58 patients who required an IVC placement, 56 remained free of any thromboembolic phenomena over the 8-year period (range, 1-8 years). The remaining two patients developed deep venous thrombosis. One patient was successfully treated with intravenous heparin and a 6-month course of Coumadin. She had complete resolution of her deep venous thrombosis and was incidentally noted to have a prothrombin 20210 gene mutation. The other patient, who had multiple gastric bypass complications, could not be successfully treated with intravenous heparin and thus progressed on to complete IVC thrombosis. She developed phlegmasia cerulea dolens and required bilateral above-the-knee amputations. She subsequently died 3 months after her procedures. Conclusion It appears that IVC filter placement at the time of OGB surgery is a relatively benign intervention with a maximal benefit. A note of caution should be exerted for those obese patients who have a hypercoagulable disorder and for those who have complications related to the gastric bypass. An aggressive posture, which may consist of immediate anticoagulation after their procedures (only when it is deemed safe), should be advocated in this small sub-group of morbid obese patients.

When ruptured abdominal aortic aneurysms (AAAs) are not treated, they cause death. In addition, ruptured abdominal aortic aneurysms (RAAAs) have high mortality (35%-70%) and morbidity rates when treated by standard open surgical methods. These high perioperative mortality and morbidity rates have not been substantially reduced despite the introduction of many improvements in open operative technique or perioperative care. Endovascular approaches to treat AAAs introduced in the early 1990s provided an opportunity to substantially alter treatment outcomes when rupture occurred. This article details how these endovascular approaches, which include endovascular stented grafts, can be applied to the treatment of RAAAs, and what advantages these new catheter-based approaches to treatment offer.

Obesity independently increases the risk of pulmonary embolism (PE). We compare a superobese population (body mass index [BMI]55 kg/m(2)) undergoing open gastric bypasses (OGBs) with a similarly matched group of laparoscopic gastric bypasses (LGB) to see if the incidence of PE differs. We included all patients undergoing OGB (n = 193, average BMI = 51 kg/m(2)) at our institution by a single surgeon between July 1999 and April 2001. Thirty-one patients were superobese (BMI55 kg/m(2)). LGB was started at our institution in April 2001. Since that time 213 patients (average BMI = 52 kg/m(2)) have undergone the procedure. One hundred and nine patients were superobese. Pre- and postoperative prophylaxis included sequential compression stockings and subcutaneous heparin. Postoperatively, patients who developed signs of hypoxia, tachypnea, or tachycardia underwent a chest X-ray and spiral computed tomography. In addition, all patients who expired in the 30-day postoperative period underwent postmortem examination. Data were analyzed using the chi-squared test. In the OGB group, four patients (2.1%) developed PE. All occurred in superobese patients with a BMI55 kg/m(2). Three were fatal PEs and one was nonfatal. None of these patients had a prior history of deep vein thrombosis, PE, venous stasis disease, or pulmonary hypertension. In the LGB group, one patient (0.9%) had a nonfatal PE. This patient had a history of deep vein thrombosis. The incidence of PE was statistically higher in the superobese OGB group (P0.01). Despite the theoretical hindrance to venous return and vena caval compression observed with pneumoperitoneum, fewer PEs occurred in the laparoscopic group. Our data, however, suggest that patients with a BMI55 kg/m(2) might be at an increased risk for PE independent of operative approach.

To evaluate the fate of collateral vessels adjacent to and within the target lesion following subintimal angioplasty (SIA).Pre and postprocedural angiograms were reviewed for 29 patients undergoing SIA of the lower extremity arteries over a 3-year period. The number of patent collateral vessels/=5 cm proximal to the occlusion (proximal segment) and/=5 cm distal to the occlusion (distal segment) were recorded pre and postprocedurally and compared. In addition, the number of collateral vessels that were re-opened within the recanalized segment following SIA was counted.The mean number of patent collaterals in the proximal segment was 1.9 (range 0-4) preprocedurally and 1.4 (range 0-4) postprocedurally (p0.002). The mean number of patent collaterals in the distal segment was 1.9 (range 0-4) pre-procedurally and 1.0 (range 0-4) postprocedurally (p0.0001). Previously absent collaterals within the recanalized segment were observed in 4 (14%) of 29 patients post-SIA. The mean number of collateral vessels within all 3 segments (proximal, treated, and distal) was 3.9 collaterals preprocedurally and 2.9 collaterals postprocedurally.Some collateral vessels are sacrificed during SIA, but the majority are preserved. In addition, SIA has the potential to open new collaterals within the occluded segment. These collaterals may play an important role should restenosis develop within the target segment.

Objectives The purpose of this study was to review our experience with delayed open conversion (>30 days) following endovascular aortoiliac aneurysm repair (EVAR) and to introduce the concept and advantages of endograft retention in this setting. Methods From January 1992 to January 2003, a total of 386 EVARs using a variety of endografts were successfully deployed. Eleven (2.8%) patients required delayed conversion to open repair at an average of 30 months (range, 10-64). Data from all patients undergoing both EVAR and open conversion were prospectively collected. Results EVARs were performed using grafts made by Talent (4), Vanguard (2,) AneuRx (1), and Surgeon (4). Conversion to open repair (9 transabdominal, 1 retroperitoneal, 1 transabdominal plus thoracotomy) was performed for aneurysm rupture in 7 patients (4 type 1 endoleak, 2 type 2 endoleak, 1 aortoenteric fistula) and aneurysm enlargement in 4 patients (1 type 1 endoleak, 1 type 2 endoleak, 1 type 3 endoleak, 1 endotension). Patients with aneurysm rupture were treated on an emergent basis. Complete removal of the endograft with supraceliac cross-clamping was performed in two cases. One patient (rupture) did not survive the operation, and one patient (aortoenteric fistula) died 2 weeks postoperatively. In the remaining nine cases, the endograft was either completely (1) or partially (6) removed, or left in situ (2). Supraceliac balloon control (2), supraceliac clamping (1), suprarenal clamping (1), or infrarenal clamping (5) was used in these cases. All nine of these patients survived the operation. In one procedure in which the endograft was left intact (endotension), repair was accomplished by exposing the endograft and by placing a standard tube graft over it as a sleeve. In the second procedure in which the graft was left in situ (rupture), the graft was well incorporated, and bleeding lumbar arteries were oversewn and the sac was closed tightly over the endograft. In the remaining 7 cases, the endograft was transected and the proximal portion only (6) or the proximal and distal portions (1) were excised. All surviving patients continue to do well and remain without complications associated with the endograft remnant at a mean follow-up of 22 months (range, 3-56) from the time of open conversion and 46 months (range, 10-73) from the time of original EVAR. Conclusions Open repair in the setting of a long-standing endograft offers several unique technical challenges but can be successfully accomplished in most patients. Preservation of all or part of the endograft is possible in many patients. This technique simplifies the operative approach and is preferred over complete endograft removal if possible.

ObjectiveThis study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center.MethodsWe reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short ( .2).ConclusionIn the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.