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Recent vascular societal guidelines have recommended an abdominal aortic aneurysm (AAA) size threshold for elective intervention; however, limited data have documented how well these AAA diameter benchmarks are being met. The objective of this study was to analyze variation in management of AAAs based on diameter and to determine the physician's rationale for intervention on small AAAs in relation to recommended treatment guidelines.A retrospective review of a statewide vascular surgery registry of all elective endovascular or open surgical AAA repairs from January 2012 to January 2016 was performed. Patients were dichotomized on the basis of aortic diameter at time of intervention into either guideline size AAAs or small AAAs, which were defined as 5.5 cm in men, 5.0 cm in women, or with growth 1.0 cm/y. An internal review was conducted of all small AAAs to determine the physician's rationale for intervention. The primary outcomes were variation in adherence to recommended treatment guidelines and the physician's rationale for treatment of small AAAs. Risk-adjusted major complication and mortality rates were calculated at 30 days and 1 year using a propensity score matching analysis.Among the 3932 patients who underwent an elective AAA repair, 485 (12.3%) were repaired at diameters smaller than recommended by guidelines. The median AAA size in the small AAA cohort was 5.1 cm (interquartile range, 4.7-5.3 cm) vs 5.6 cm (interquartile range, 5.2-6.1 cm) in the guideline-based group. Percentage of small AAA repairs varied widely between hospitals from 1.4% to 44.4%. The physician's rationale for the majority of early interventions included the patient's anxiety (12.0%), combined aortoiliac occlusive disease (14.8%), aneurysm anatomy (28.2%), and does not adhere to guidelines (30%). The small AAA cohort had no significant difference in the 30-day or 1-year risk-adjusted mortality in comparison to guideline size AAAs.Despite well-established aortic diameter threshold guidelines, marked variation exists both at the hospital level and in terms of the physician's rationale for the management of elective AAA repairs. These findings demonstrate the challenge of providing uniform care for patients with AAAs despite established guidelines.

Isolated dissection of the mesenteric vessels is rare but increasingly recognized. This study aimed to evaluate patient characteristics, primary treatment, and subsequent outcomes of mesenteric dissection using multi-institutional data.All patients at participant hospitals between January 2003 and December 2015 with dissection of the celiac artery (or its branches) or dissection of the superior mesenteric artery (SMA) were included. Patients with an aortic dissection were excluded. Demographic, treatment, and follow-up data were collected. The primary outcomes included late vessel thrombosis (LVT) and aneurysmal degeneration (AD).Twelve institutions identified 227 patients (220 with complete treatment records) with a mean age of 55 ± 12.5 years. Median time to last follow up was 15 months (interquartile range, 3.8-32). Most patients were men (82% vs 18% women) and symptomatic at presentation (162 vs 65 asymptomatic). Isolated SMA dissection was more common than celiac artery dissection (n = 158 and 81, respectively). Concomitant dissection of both arteries was rare (n = 12). The mean dissection length was significantly longer in symptomatic patients than in asymptomatic patients in both the celiac artery (27 vs 18 mm; P = .01) and the SMA (64 vs 40 mm; P .001). Primary treatment was medical in 146 patients with oral anticoagulation or antiplatelet therapy (n = 76 and 70, respectively), whereas 56 patients were observed. LVT occurred in six patients, and 16 patients developed AD (3% and 8%, respectively). For symptomatic patients without evidence of ischemia (n = 134), there was no difference in occurrence of LVT with medical therapy compared with observation alone (9% vs 0%; P = .35). No asymptomatic patient (n = 64) had an episode of LVT at 5 years. AD rates did not differ among symptomatic patients without ischemia treated with medical therapy or observed (9% vs 5%; P = .95). Surgical or endovascular intervention was performed in 18 patients (3 ischemia, 13 pain, 1 AD, 1 asymptomatic). Excluding the patients treated for ischemia, there was no difference in LVT with surgical intervention vs medical management (one vs five; P = .57).Asymptomatic patients with isolated mesenteric artery dissection may be observed and followed up with intermittent imaging. Symptomatic patients tend to have longer dissections than asymptomatic patients. Symptomatic isolated mesenteric artery dissection without evidence of ischemia does not require anticoagulation and may be treated with antiplatelet therapy or observation alone.

Objective This study evaluated the morbidity of endovascular abdominal aortic aneurysm repair (EVAR) in patients with concomitant common iliac artery aneurysm (CCIAA). Methods This was a retrospective review of all patients who underwent elective EVAR from June 2006 through June 2012 at a single institution. Demographics, comorbidities, preoperative presentation, intraoperative details, and postoperative complications were tabulated. Patients with CCIAA were categorized into three groups according to the distal extent of their iliac limb: iliac limb extension into the external iliac artery with internal iliac artery coil embolization (EE); flared iliac limb ≥20 mm in diameter to the iliac bifurcation (FL); and iliac limb ≤20 mm ending proximal to the CCIAA (no-FL). Results During this period, 627 consecutive patients underwent elective EVAR and preoperative computed tomographic angiograms were available for 523 patients to evaluate the presence of CCIAA. Of these, 211 patients (40.2%) had a CCIAA in at least one common iliac artery, with a total of 307 aneurysmal arteries. Of these 307 aneurysmal arteries, 62 (20.2%) were treated with EE, 132 (43.0%) were treated with FL, and 113 (36.8%) had a sufficient landing zone in the proximal common iliac artery to use an iliac limb ≤20 mm in diameter (no-FL). The overall reintervention rate was 12.4% of patients, with a higher reintervention rate between patients with CCIAA compared with those without (15.2% vs 10.9%; P = .039). There were no significant differences in reintervention rates between the EE, FL, and no-FL techniques (4.5% vs 4.8% vs 6.2%; P = .802) over a mean 59.8 months follow-up. The FL and EE techniques had a lower risk of distal endoleak than the no-FL technique, but the difference was not statistically significant (3.2% vs 2.3% vs 5.3% compared with 4.23% in the entire cohort). Conclusions Patients with CCIAA had a higher reintervention rate after EVAR for abdominal aortic aneurysm compared with non-CCIAA patients. Of the techniques studied (EE, FL, and no-FL), there was no significant difference in reintervention rates between the three. All three techniques remain viable options for the endovascular repair of CCIAA.

Objective To determine the predictors of periprocedural blood transfusion and the association of transfusion on outcomes in high risk patients undergoing endoluminal percutaneous vascular interventions (PVI) for peripheral arterial disease. Methods/Results Between 2010–2014 at 47 hospitals participating in a statewide quality registry, 4.2% (n = 985) of 23,273 patients received a periprocedural blood transfusion. Transfusion rates varied from 0 to 15% amongst the hospitals in the registry. Using multiple logistic regression, factors associated with increased transfusion included female gender (OR = 1.9; 95% CI: 1.6–2.1), low creatinine clearance (1.3; 1.1–1.6), pre-procedural anemia (4.7; 3.9–5.7), family history of CAD (1.2; 1.1–1.5), CHF (1.4; 1.2–1.6), COPD (1.2; 1.1–1.4), CVD or TIA (1.2; 1.1–1.4), renal failure CRD (1.5; 1.2–1.9), pre-procedural heparin use (1.8; 1.4–2.3), warfarin use (1.2; 1.0–1.5), critical limb ischemia (1.7; 1.5–2.1), aorta-iliac procedure (1.9; 1.5–2.5), below knee procedure (1.3; 1.1–1.5), urgent procedure (1.7; 1.3–2.2), and emergent procedure (8.3; 5.6–12.4). Using inverse weighted propensity matching to adjust for confounders, transfusion was a significant risk factor for death (15.4; 7.5–31), MI (67; 29–150), TIA/stroke (24; 8–73) and ARF (19; 6.2–57). A focused QI program was associated with a 28% decrease in administration of blood transfusion (p = 0.001) over 4 years. Conclusion In a large statewide PVI registry, post procedure transfusion was highly correlated with a specific set of clinical risk factors, and with in-hospital major morbidity and mortality. However, using a focused QI program, a significant reduction in transfusion is possible.

Objectives This study sought to evaluate the effect of age on procedure type, periprocedural management, and in-hospital outcomes of patients undergoing lower-extremity (LE) peripheral vascular intervention (PVI). Background Surgical therapy of peripheral arterial disease is associated with significant morbidity and mortality in the elderly. There are limited data related to the influence of advanced age on the outcome of patients undergoing percutaneous LE PVI. Methods Clinical presentation, comorbidities, and in-hospital outcomes of patients undergoing LE PVI in a multicenter, multidisciplinary registry were compared between 3 age groups: Results In our cohort, 7,769 patients underwent LE PVI. The elderly patients were more likely to be female and to have a greater burden of comorbidities. Procedural success was lower in the elderly group (74.2% for age ≥80 years vs. 78% for age 70 to Conclusions Contemporary PVI can be performed in elderly patients with high procedural and technical success with low rates of periprocedural complications including mortality. These findings may support the notion of using PVI as a preferred revascularization strategy in the treatment of severe peripheral arterial disease in the elderly population.

Purpose: There continues to be debate regarding optimal management of type II endoleaks following endovascular abdominal aortic aneurysm repair. Case Report: We present an intraoperative treatment approach to type II endoleaks using components of the EndoSure Intrasac Pressure Monitor System. Our technique can easily be reproduced with commercially available guidewires and catheters. We also present a literature review that identifies type II endoleak characteristics associated with a high rate of persistence (high-risk endoleaks) and could benefit from early treatment. Conclusions: If a high-risk type II endoleak is identified intraoperatively, those patients may benefit from our model of an early intervention strategy. Early definitive treatment of the endoleaks could result in lower morbidity and reintervention rates.

In comparison to endovascular repair of fusiform iliac aneurysms, endovascular repair of large iliac anastomotic aneurysms can be difficult because of their saccular nature and redundancy of the iliac limb of the prosthetic graft. Iliac anastomotic aneurysms may have patency of ipsilateral hypogastric artery branches necessitating coil embolization. We report technical challenges incurred in two patients during endovascular repair of large symptomatic iliac anastomotic aneurysms.

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

It remains a significant technical challenge for duplex ultrasound to accurately differentiate between total and near total internal carotid artery (ICA) occlusions. We have evaluated the efficacy of an ultrasound contrast agent combined with improved imaging techniques in patients with suspected carotid artery occlusions. Patients identified by conventional duplex ultrasound between January and August 2003 as having a possible ICA occlusion were eligible for study. A 1 mL bolus of ultrasound contrast agent was injected into a 50 mL bag of normal saline and given intravenously at a rate of approximately 4–5 mL/minute. Ultrasound imaging and spectral Doppler analysis were done using tissue harmonic imaging for optimum contrast agent to soft tissue discrimination, or with the direct B-mode imaging of blood flow to maximize the brightness of the circulating contrast agent. Ten patients were identified, 6 men and four women with a mean age of 68.3 years. Nine suspected total ICA occlusions were unilateral and 1 was bilateral. Imaging with contrast agent confirmed occlusion of the ICA in 7 of 10 patients; 3 patients had near-total occlusion with flow detected in the distal ICA by spectral and color Doppler. All 3 of these near-total occlusions were ultimately confirmed by either conventional or magnetic resonance carotid angiography. The contrast agent was most beneficial in improving the detection of minimal flow beyond a severe stenosis and in evaluating flow dynamics in the presence of severely calcified plaque. We conclude that the use of an ultrasound contrast agent with newer duplex ultrasound imaging techniques can reliably distinguish total from near-total internal carotid artery occlusions. Future prospective studies should be able to define the efficacy of ultrasound contrast agents in improving the overall diagnostic accuracy of duplex ultrasound in technically difficult cases and in patients with complex peripheral vascular disease.

Gastrointestinal complications are known to occur after open elective aortic aneurysm repair. This leads to increased morbidity, mortality, length of stay, and hospital costs. The authors hypothesize a change in the character and/or frequency of early postoperative gastrointestinal complications after endovascular aneurysm repair as compared to open abdominal aortic repair. This is a retrospective cohort study in which the medical records of 153 consecutive patients who underwent endovascular infrarenal aneurysm repair from November 1998 to August 2001 were reviewed for gastrointestinal complications. Of these 153 patients, 9 (5.9%) had postoperative gastrointestinal complications. Three patients (1.9%) underwent exploratory laparotomy for small bowel obstruction. One patient had had a right hemicolectomy for cancer 2 years before stent graft placement. This patient needed a partial small bowel resection. One patient had had a right hemicolectomy 4 months before stent graft placement; he had lysis of adhesions with no bowel resection. A third patient underwent operative repair of an incarcerated inguinal hernia. Six patients (3.9%) had paralytic ileus that was treated by nasogastric tube or observation resulting in an extended hospital length of stay. All cases of ileus resolved without any operative intervention. No patients in this series developed any intestinal ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding. After endovascular aneurysm repair, gastrointestinal complications such as ileus and postoperative small bowel obstruction are seen with a similar frequency as after open aortic repair. This occurs despite the absence of a laparotomy with mesenteric dissection and evisceration. In this series, these complications are associated with longer hospital length of stay but no increased mortality rate. No instances of colonic ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding were seen in this series.

Objectives The purpose of this study was to evaluate the reliability of carotid duplex ultrasound scanning performed by nonaccredited vascular laboratories and to assess the clinical effect on patient management. Methods We retrospectively reviewed concordance of findings of carotid duplex ultrasound scanning between laboratories accredited by the Intersocietal Commission for Accreditation of Vascular Laboratories and nonaccredited laboratories in 174 patients with asymptomatic disease referred to tertiary care community hospitals for surgical evaluation for carotid endarterectomy (CEA) between January 2001 and December 2002, and evaluated changes in clinical management made on the basis of repeat examinations. Results Concordant findings were noted in 171 of 348 arteries (49%), predominantly those with minimal or mild disease (114 arteries; 67%). Discordant findings of no clinical significance were found in 54 arteries (16%). Clinically significant discordant findings were noted in 123 arteries (35%) in 107 patients (61%). In 104 arteries (88 patients) stenosis was overestimated by the nonaccredited laboratory secondary to technical error (19 arteries), use of B-mode imaging data alone (36 arteries), and use of inappropriate velocity criteria (49 arteries). None of these patients underwent CEA. Stenosis was significantly underestimated in 19 arteries (19 patients); all of these patients underwent uncomplicated CEA. Conclusions Incorrect physician interpretation of data is the most common cause of error in carotid duplex ultrasound scanning performed in nonaccredited vascular laboratories. Results of carotid duplex ultrasound scanning from nonaccredited laboratories should be considered with extreme caution, and do not appear reliable in planning treatment of obstructive disease.

The use of endovascular stent graft repair for aortic aneurysmal disease has become increasingly common, with the added requirement for close postoperative surveillance to detect the presence of endoleaks or graft migration. The most commonly used technique for surveillance is computed tomography (CT) angiography, with the need for intravenous contrast posing 1 limitation in those patients with renal dysfunction and the cost of this testing presenting an economic limitation. Early results of duplex imaging in the authors' Vascular Laboratory using an intravenous ultrasound contrast agent have shown sensitivity and specificity equivalent to those of CT angiography, with no evidence of any related morbidity. They have evaluated the cost effectiveness of using duplex ultrasound imaging as the primary surveillance technique for postoperative follow-up in aortic stent graft patients. Surveillance protocols now require that 8 follow-up examinations be performed in the first 3 years after stent graft placement. The charges for CT angiography in their institution average 2,779 dollars per study, for a 3-year total of 22,232 dollars per patient. The charges for aortic duplex ultrasound average 525 dollars per study, with a 3-year total of 4,200 dollars per patient. Adding the cost of routine abdominal radiographs to confirm stent graft position (147 dollars per study) would bring this 3-year total to 5,376 dollars, a savings of 16,856 dollars per patient. For every 100 patients who are followed up after stent graft placement, this represents a 3-year savings of more than 1.6M dollars. Promising early results of duplex ultrasound imaging with an intravenous contrast agent show sensitivity and specificity equivalent to those of CT angiography in detecting aneurysm size and graft endoleaks or other hemodynamic abnormalities. If these results can be demonstrated in larger patient series, this technique should become the method of choice for stent graft surveillance, for it offers very significant economic advantages and avoids the complications of intravenous contrast-induced renal dysfunction.

Purpose: To describe a technique for concomitant endovascular stent-graft repair of thoracic and infrarenal abdominal aortic aneurysms. Case Report: A 68-year-old man was found to have concomitant thoracic and abdominal aortic aneurysms. Both of the aneurysms were excluded successfully in one procedure using Talent stent-grafts. The patient tolerated the procedure well and was discharged on postoperative day 4. Aside from an infected groin wound, the patient did not have any complications. Computed tomographic scans at 6, 12, and 18 months showed proper position of both stents without evidence of endoleak. Conclusions: Simultaneous endovascular treatment of thoracic and infrarenal abdominal aortic aneurysms may represent a viable alternative for therapy in some patients.

calf veins that previously were not visualized and seven were seen in femoral veins or calf veins that previously were visualized and did not have clot (Table). Conclusions: Nonvisualized calf veins are common in DUS imaging. Almost half of patients with nonvisualized veins on the initial DUS imaging had successful visualization on subsequent DUS scans. Lower body weight, whole leg swelling, single vein nonvisualization, and single limb nonvisualization on the initial DUS scan were associated with successful visualization on subsequent DUS scans. Of patients with nonvisualized veins on the initial DUS scan, 4.8% go on to develop VTE, and 8.8% of patients who have subsequent DUS scans are found to have DVT. When the initial DUS scan is unable to visualize calf veins, a repeat DUS scan may be useful to identify new or initially unseen DVT.

Background: We have evaluated the efficacy of using three-dimensional reconstruction of amplitude Doppler imaging data to quantitatively assess carotid artery bifurcation stenoses. Methods: Sixty-four consecutive frames of amplitude (power) Doppler images are stored to be reassembled into a three-dimensional image representing the patent lumen. These images can then be rotated by any angle necessary to clearly view the vascular anatomy and to make quantitative ultrasound caliper measurements of the stenotic lumen and normal vessel caliber. Results: Three-dimensional Doppler images accurately classified 53 of 61 vessels (87%) into categories of stenosis compared with angiography. All stenoses with >60% diameter reduction were detected and classified as such, for a sensitivity of 100%. Conclusions: Three-dimensional vascular imaging based on amplitude (power) Doppler data provides an accurate noninvasive technique for quantitative diagnosis of carotid bifurcation atherosclerotic disease, with selectable viewing projections that eliminate vessel overlap and other artifacts, and complements the hemodynamic data already available with two-dimensional duplex ultrasound.183

Background— Peripheral arterial disease is a manifestation of systemic atherosclerosis and is predictive of future cardiovascular events. Clinical trial data have demonstrated that medical therapy can attenuate cardiovascular morbidity and mortality in patients with peripheral arterial disease. The utilization and impact of recommended medical therapy in a contemporary population of patients who undergo percutaneous interventions for lifestyle-limiting peripheral arterial disease is unknown. Methods and Results— Using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention (BMC2 PVI) database, we identified 1357 peripheral vascular intervention encounters between January 2007 and December 2009 for the purpose of treating claudication. Before the intervention, 85% of these patients used aspirin, 76% used statin, 65% abstained from smoking, and 47% did all 3. There was no difference in cardiovascular events among those taking an aspirin and a statin on admission and those who were not. However, in both an unadjusted and a multivariable analysis, the odds of an adverse peripheral vascular outcome (repeat peripheral intervention, amputation, or limb salvage surgery) within 6 months decreased by more than half in patients receiving aspirin and statin therapy before peripheral vascular intervention as compared with those who received neither (odds ratio, 0.45; 95% CI, 0.29–0.71). Conclusions— The fundamental elements of medical therapy in patients with lifestyle-limiting claudication are often underutilized before referral for revascularization. Appropriate medical therapy before percutaneous revascularization is associated with fewer peripheral vascular events at 6 months.

Clostridium septicum aortitis is a rare infection that has a strong association with occult colonic malignancy. To our knowledge, we report the 25th and 26th cases of C septicum aortitis in the English literature and make recommendations for its management. The first patient was a 75-year-old man who presented with abdominal pain. Computed tomography showed the presence of periaortic gas. He underwent aortic debridement and extra-anatomic bypass after blood cultures revealed C septicum. Four months after the initial presentation, he was readmitted with lethargy, found to have recurrent periaortic gas, and died. The second patient was a 76-year-old woman who presented with a 5-cm abdominal aortic aneurysm with surrounding retroperitoneal gas. She underwent emergency aortic ligation and retroperitoneal debridement. Her blood and intraoperative tissue cultures also grew C septicum. She had a prolonged postoperative course and ultimately died on hospital day 94. Both patients were found to have concurrent colon adenocarcinomas. C septicum aortitis is a lethal disease that necessitates prompt surgical intervention and appropriate antibiotic therapy. The strong association of C septicum with occult malignancy should prompt the astute clinician to undertake an exhaustive search for a neoplastic process.

Objective There is abundant evidence linking hostile proximal aortic neck anatomy to poor outcome after endovascular aortic aneurysm repair (EVAR), yet the definition of hostile anatomy varies from study to study. This current analysis was undertaken to identify anatomic criteria that are most predictive of success or failure at the aortic neck after EVAR. Methods The study group comprised 221 patients in the Aneurysm Treatment using the Heli-FX Aortic Securement System Global Registry (ANCHOR) clinical trial, a population enriched with patients with challenging aortic neck anatomy and failure of sealing. Imaging protocols were not protocol specified but were performed according to the institution's standard of care. Core laboratory analysis assessed the three-dimensional centerline-reformatted computed tomography scans. Failure at the aortic neck was defined by type Ia endoleak occurring at the time of the initial endograft implantation or during follow-up. Receiver operating characteristic curve analysis was used to assess the value of each anatomic measure in the classification of aortic neck success and failure and to identify optimal thresholds of discrimination. Binary logistic regression was performed after excluding highly intercorrelated variables, creating a final model with significant predictors of outcome after EVAR. Results Among the 221 patients, 121 (54.8%) remained free of type Ia endoleak and 100 (45.2%) did not. Type Ia endoleaks presented immediately after endograft deployment in 58 (58.0%) or during follow-up in 42 (42.0%). Receiver operating characteristic curve analysis identified 12 variables where the classification of patients with type Ia endoleak was significantly more accurate than chance alone. Increased aortic neck diameter at the lowest renal artery (P = .013) and at 5 mm (P = .008), 10 mm (P = .008), and 15 mm (P = .010) distally; aneurysm sac diameter (P = .001), common iliac artery diameters (right, P = .012; left, P = .032), and a conical (P = .049) neck configuration were predictive of endoleak. By contrast, increased aortic neck length (P = .050), a funnel-shaped aortic neck (P = .036), and neck mural thrombus content, as measured by average thickness (P = .044) or degrees of circumferential coverage (P = .029), were protective against endoleak. Binary logistic regression identified three variables independently predictive of type Ia endoleak. Neck diameter at the lowest renal artery (P = .002, cutpoint 26 mm) and neck length (P = .017, cutpoint 17 mm) were associated with endoleak, whereas some mural neck thrombus content was protective (P = .001, cutpoint 11° of circumferential coverage). Conclusions A limited number of independent anatomic variables are predictive of type Ia endoleak after EVAR, including aortic neck diameter and aortic neck length, whereas mural thrombus in the neck is protective. This study suggests that anatomic measures with identifiable threshold cutpoints should be considered when defining the hostile aortic neck and assessing the risk of complications after EVAR.

Objective Blood transfusions are common among patients undergoing major vascular surgery. Prior studies suggest an association between blood transfusion and increased morbidity and mortality among patients undergoing cardiac surgery. The predictors of perioperative transfusion and its impact on patients undergoing vascular surgery have been poorly defined. Methods We examined data from a large multicenter quality improvement vascular surgical registry of all patients undergoing elective or urgent open peripheral arterial disease procedures, endovascular aneurysm repair, or open abdominal aortic aneurysm (AAA) repair between January 2012 and December 2013. Emergency cases, carotid endarterectomy, and carotid artery stenting were excluded. Univariate and multivariate logistic regression modeling was used to identify predictors of transfusion and association of transfusion with outcomes. All regression models had Hosmer-Lemeshow P > .05 and area under the receiver operating characteristic curve of >0.8, confirming excellent goodness of fit and discrimination. Results Our study population comprised 2946 patients who underwent open peripheral arterial disease procedures (n = 1744), open AAA repair (n = 175), or endovascular aneurysm repair (n = 1027) at 22 hospitals. The overall transfusion rate was 25%, at a median nadir hemoglobin level of 7.7 g/dL. Independent factors predicting transfusion included female gender (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.1-3.2), nonwhite race (OR, 2.7; 95% CI, 1.4-5.2), preoperative admission status (ie, acute care hospital) (OR, 2.6; 95% CI, 1.3-5.3), preoperative anemia (OR, 4.2; 95% CI, 3.3-5.1), congestive heart failure (OR, 1.4; 95% CI, 1.1-1.9), prior myocardial infarction (OR, 1.3; 95% CI, 1.01-1.6), clopidogrel (OR, 1.4; 95% CI, 1.2-1.8), open AAA repair (OR, 25; 95% CI, 17-39), open bypass (OR, 3.5; 95% CI, 2.7-4.6), and urgent procedures (OR, 1.4; 95% CI, 1.1-1.8). With adjustment for major covariates, perioperative transfusion was independently associated with death (OR, 6.9; 95% CI, 3.2-15), myocardial infarction (OR, 8; 95% CI, 3.7-17), and pneumonia (OR, 7.4; 95% CI, 3.3-17). Conclusions Perioperative transfusion in vascular surgical patients is independently associated with increased 30-day morbidity and mortality. Given indeterminate causation, these data suggest the need for a prospective transfusion threshold study in vascular surgical patients.

Background Renal artery aneurysms (RAAs) are rare, with little known about their natural history and growth rate or their optimal management. The specific objectives of this study were to (1) define the clinical features of RAAs, including the precise growth rate and risk of rupture, (2) examine the current management and outcomes of RAA treatment using existing guidelines, and (3) examine the appropriateness of current criteria for repair of asymptomatic RAAs. Methods A standardized, multi-institutional approach was used to evaluate patients with RAAs at institutions from all regions of the United States. Patient demographics, aneurysm characteristics, aneurysm imaging, conservative and operative management, postoperative complications, and follow-up data were collected. Results A total of 865 RAAs in 760 patients were identified at 16 institutions. Of these, 75% were asymptomatic; symptomatic patients had difficult-to-control hypertension (10%), flank pain (6%), hematuria (4%), and abdominal pain (2%). The RAAs had a mean maximum diameter of 1.5 ± 0.1 cm. Most were unilateral (96%), on the right side (61%), saccular (87%), and calcified (56%). Elective repair was performed in 213 patients with 241 RAAs, usually for symptoms or size >2 cm; the remaining 547 patients with 624 RAAs were observed. Major operative complications occurred in 10%, including multisystem organ failure, myocardial infarction, and renal failure requiring dialysis. RAA repair for difficult-to-control hypertension cured 32% of patients and improved it in 26%. Three patients had ruptured RAA; all were transferred from other hospitals and underwent emergency repair, with no deaths. Conservatively treated patients were monitored for a mean of 49 months, with no acute complications. Aneurysm growth rate was 0.086 cm/y, with no difference between calcified and noncalcified aneurysms. Conclusions This large, contemporary, multi-institutional study demonstrated that asymptomatic RAAs rarely rupture (even when >2 cm), growth rate is 0.086 ± 0.08 cm/y, and calcification does not protect against enlargement. RAA open repair is associated with significant minor morbidity, but rarely a major morbidity or mortality. Aneurysm repair cured or improved hypertension in >50% of patients whose RAA was identified during the workup for difficult-to-control hypertension.

PURPOSE To describe the efficacy and morbidity of intentionally covering a main renal artery during symptomatic juxtarenal endovascular aneurysm repair (EVAR). CASE REPORTS Two patients with symptomatic juxtarenal abdominal aortic aneurysm (AAA) were felt to be at prohibitive risk for open repair. Each underwent EVAR with intentional coverage of 1 main renal artery to achieve adequate proximal hemostatic seal. One patient died at 24 months; the second is symptom-free at 10 months. Both aneurysms initially decreased in diameter. Both patients had increased serum creatinine and required increased therapy for hypertension, but neither required hemodialysis. Renal volume decreased 48.7% and 68.0%, respectively. CONCLUSION Intentional coverage of a main renal artery during EVAR for a symptomatic juxtarenal aneurysm resulted in effective short-term AAA repair with no need for dialysis. Despite the increased requirement for antihypertensive medications and the observed decline in renal function, this technique provides an option for treatment of this difficult patient subset.

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS) demonstrated the efficacy of carotid endarterectomy (CEA), but these studies were published 15 and 11 years ago, respectively. We hypothesized that present clinical results of CEA have improved compared with those reported by NASCET/ACAS. Every patient having CEA from January 1999 through December 2003 was reviewed as part of a continuous quality-assurance program. Patient demographics and risk factors were recorded; high-risk patients were identified using inclusion criteria for high-risk carotid stent trials. Primary end points recorded were all neurologic events, deaths, and myocardial infarctions (MIs). Outcomes were reported individually or as combined neurologic events and deaths (traditional NASCET/ACAS methodology) and, similar to recent carotid stent trials, individually, combined, and as a composite that included MI. A total of 1,927 CEAs were performed, 1,140 in men (59%) and 787 in women (41%). The average age was 72 +/- 9 years; 21% of patients were age 80 or older. Symptomatic patients accounted for 717 procedures (37%). Perioperative neurologic event, death, and MI occurred in 1.0%, 0.5%, and 1.3% of patients, respectively. The combined neurologic event and death rate was 1.3% (symptomatic = 1.8%, asymptomatic = 1.1%). High-risk patients comprised 54% of the cohort; the neurologic event and death rate for this group was 1.6%. The composite end point including MI was 3.4%. Severe coronary artery disease and prior ipsilateral CEA significantly correlated with a higher incidence of primary end point complications. In contemporary practice, the perioperative neurologic event rate is significantly less than reported in NASCET/ACAS. Perioperative death and MI rates were similar to those seen in NASCET/ACAS. Neurologic events and death rates were not different between high- and low-risk groups. These data may serve as a guide for the modern vascular specialist weighing open and endovascular options for treatment of carotid artery occlusive disease in both high- and low-risk patients.

Objective: Computed tomographic angiography (CTA) is currently the most commonly used technique for postoperative surveillance to detect endoleaks after endovascular stent graft repair of abdominal aortic aneurysms. We have evaluated the efficacy of duplex ultrasound scan with the addition of an ultrasound scan contrast agent in documenting endoleaks and compared these results with CTA. Methods: Conventional duplex ultrasound scan with color Doppler imaging (CDI) was first done as part of routine postoperative surveillance. After the CDI study, a 1-mL bolus of ultrasound scan contrast was given via an antecubital vein, followed by a 5-mL flush with normal saline solution. The duplex ultrasound scan evaluation of the stent graft was repeated once the contrast agent was circulating throughout the blood pool, with tissue harmonic imaging to optimize visualization of the contrast agent. Status of the stent graft, the presence or absence of any endoleak, and whether these endoleaks were graft related (group I) or arterial branch related (group II) were recorded. Findings were compared with CTA studies done within a 2-week period of the ultrasound scan examination. Results: Twenty patients were evaluated, 18 with modular stent grafts and two with unibody bifurcated stent grafts. Patients had a mean age of 74.5 ± 7.6 years; 19 were male, with only one female. All stent grafts remained widely patent with normal aortoiliac flow hemodynamics. Duplex ultrasound scan with contrast identified all eight of the endoleaks seen with CTA and was able to determine whether they were group I or group II leaks. In two patients, ultrasound scan with contrast detected small endoleaks at the proximal graft attachment site, with extravasation of contrast into the aneurysm sac during systole. These endoleaks were not seen with CTA but were confirmed with conventional angiography at the time of endovascular closure. Standard duplex ultrasound scan with CDI failed to identify four of the 10 endoleaks in patients with technically difficult conditions. Conclusion: Duplex ultrasound scan, when used with an intravenously administered ultrasound scan contrast agent in the noninvasive follow-up of patients with aortic stent grafts, appears to provide good sensitivity to the presence and type of endoleaks, even in patients with technically difficult conditions not amenable to conventional duplex ultrasound scan with CDI. (J Vasc Surg 2003;37:381-5.)

ObjectiveProximal attachment site complications continue to occur after endovascular repair of abdominal aortic aneurysms (EVAR), specifically type Ia endoleak and endograft migration. EndoAnchors (Aptus Endosystems, Sunnyvale, Calif) were designed to enhance endograft proximal fixation and sealing, and the current study was undertaken to evaluate the potential benefit of this treatment.MethodsDuring the 23-month period ending in December 2013, 319 subjects were enrolled at 43 sites in the United States and Europe. EndoAnchors were implanted in 242 patients (75.9%) at the time of an initial EVAR procedure (primary arm) and in 77 patients with an existing endograft and proximal aortic neck complications (revision arm). Technical success was defined as deployment of the desired number of EndoAnchors, adequate penetration of the vessel wall, and absence of EndoAnchor fracture. Procedural success was defined as technical success without a type Ia endoleak at completion angiography. Values are expressed as mean ± standard deviation and interquartile range.ResultsThe 238 male (74.6%) and 81 female (25.4%) subjects had a mean age of 74.1 ± 8.2 years. Aneurysms averaged 58 ± 13 (51-63) mm in diameter at the time of EndoAnchor implantation (core laboratory measurements). The proximal aortic neck averaged 16 ± 13 (7-23) mm in length (42.7%

Primary angiosarcoma of the aorta is a rare malignancy that is characterized by rapid proliferation and propensity for metastasis. It has been reported only 35 times in the surgical literature. This case report presents a 66-year-old man diagnosed with angiosarcoma of his native aorta 7 years after endograft repair of an abdominal aortic aneurysm. We then reviewed the world surgical literature for occurrence, tumorigenic studies, prognosis, and management of aortic angiosarcoma. Because native aortic tissue is retained after endovascular repair of an abdominal aortic aneurysm, the treating physician should have an awareness of this pathology and entertain the diagnosis as appropriate.

PURPOSE: This study was undertaken to assess colorectal complications following cardiopulmonary bypass surgery. METHOD: This is a retrospective review of 5,801 patients who underwent 5,801 cardiopulmonary bypass procedures from 1985 to 1991. Patients were evaluated for type of bypass procedure, postoperative colorectal complications, age, sex, bypass time, aortic cross-clamp time, electivevs.emergency cases, uses of intra-aortic balloon pump, perioperative hypotension, and use of vasopressors. Statistical analysis was performed using chi-squared analysis and Student'st-test. RESULTS: Nineteen of the 5,801 patients developed 19 colorectal complications, a prevalence of 0.3 percent for the initial hospital stay following bypass surgery. Mortality in those with complications was 37 percent (7/19). Of the 19 complications, 9 (47 percent) followed coronary artery bypass grafting, whereas 10 (53 percent) followed valve replacement or combined coronary artery bypass grafting with other cardiac procedures. Five (26 percent) of the complications followed emergency cases, whereas 14 (74 percent) followed elective cases. Average age of those with complications was 698 years, compared with 63.2 years for those without complications. Average aortic cross-clamp time for those with complications was 71 ±25 minutes; pump time was 106±34 minutes. That was significantly higher than in those without complications. Nine (47 percent) patients with complications required vasopressors during the perioperative period, whereas eight (42 percent) suffered prolonged hypotension (systolic blood pressure

The hemodynamic effects of combined venoarterial injury and stasis were studied in the hindlimbs of 10 dogs. Femoral arterial blood flow and pressure, peripheral venous pressure, and peripheral resistance were measured after the restoration of blood flow following venoarterial injury and a 4-hour period of occlusion for up to 72 hours. In one limb of each animal both the artery and vein were repaired, whereas only the artery was repaired in the other limb and the vein was ligated. Arterial blood flow was similar in both groups but was significantly diminished from baseline for the first 30 minutes after restoration of blood flow, but then it became significantly reduced in the limbs with venous ligation when compared with values in those with venous repair. By 72 hours the flow on both sides returned to control values. Peripheral venous hypertension and edema occurred in all 10 limbs with venous ligation and persisted for the 72-hour experimental period. In the 10 limbs with venous repair, edema occurred in four and venous hypertension in none. The peripheral resistance was elevated on both sides; this elevation persisted for 75 minutes and then dropped to control values. None of the repaired arteries and only one repaired vein thrombosed during the experiment. Combined venous and arterial occlusion for 4 hours reduced both the amount of arterial flow and its subsequent rate of increase compared with changes seen after release of an actue venous occlusion. The rate of increase was enhanced by repair of the affected venous segment compared with simple venous ligation.

Purpose: We evaluated our early experience with the transrenal fixation of aortic stent-grafts to determine the efficacy of this procedure and its effects on renal artery patency and hemodynamics. Methods: Twenty-eight patients (22 men) had endoluminally placed modular bifurcated stent-grafts with a bare spring structure at the proximal end crossing the origin of both renal arteries; no patient with infrarenal fixation was included for analysis. The mean age of the patients was 75 ± 7 years (range, 58-86 years); the mean aneurysm size was 5.8 ± 0.8 cm (range, 4.7-7.2 cm). Eight patients had preoperative or intraoperative angiographic evidence of renal artery atherosclerotic disease, but only four vessels had luminal narrowing of 50% or greater. No complications were noted during stent-graft placement, and all patients have returned for follow-up visits, ranging from 1 to 12 months (mean follow-up, 6 ± 4 months). Follow-up evaluations included clinical assessment, duplex ultrasound scan of the renal arteries and kidneys, and computed tomographic angiography. Results: No evidence of lobular or sublobular perfusion defects of the renal parenchyma was detected postoperatively. Two patients exhibited postoperative changes in renal artery hemodynamics—one progressing from a 30% diameter reduction to a greater than 60% diameter stenosis at the 12-month follow-up visit and one with a normal renal artery preoperatively having elevated flow velocities indicative of a greater than 60% stenosis at the 1-month visit. Of 19 patients with normal preoperative renal function, only one has had persistently elevated serum creatinine levels. Conclusion: We conclude from this experience that the transrenal placement of open stents is safe and effectively excludes the aneurysm, potentially expanding the availability of this technique to more patients with a short infrarenal aortic neck. Long-term follow-up is essential to determine the overall efficacy of this technique and to identify potential effects on renal artery hemodynamics or kidney function. (J Vasc Surg 2000;32:697-703.)

Purpose: This study was undertaken to determine the relationship of residual intraluminal aneurysmal sac pressure (ILASP) to intrathrombic aneurysm sac pressure (ITASP) and to define the relationship between abdominal aorta aneurysm (AAA) size (anteroposterior or transverse diameter), volume of intraluminal thrombus, and residual ITASP. Methods: We measured ILASP and ITASP after proximal aortic neck and distal iliac clamping by placing angiocatheters into the lumen and thrombus of an excluded aneurysm sac in 41 consecutive patients. Simultaneously, mean blood pressure was recorded and aneurysm sac pressure ratio was calculated. Changes in ILASP and ITASP after clamping of the inferior mesenteric artery were recorded. In addition, correlation between AAA size, volume of intraluminal thrombus in AAA, and residual ITASP was determined. Results: Mean ILASP/blood pressure ratio was 0.40 (SD, 0.20). Mean ITASP/blood pressure ratio was 0.37 (SD, 0.23). There was a significant positive correlation of 0.47 between ITASP and ILASP ( P =.002). Clamping of the inferior mesenteric artery resulted in markedly decreased ITASP in 2 patients (n = 40) and ILASP in 4 patients (n = 41). Each centimeter increase in AAA size resulted in a 47 mL increase in thrombus volume. Conclusion: Increased ILASP results in corresponding increase in ITASP, and increased AAA size is associated with increased thrombus volume. However, neither thrombus volume nor AAA size has any relationship to ITASP. (J Vasc Surg 2003;37:949-53.)

Objective The proximal aortic neck remains one of the challenges of endovascular aneurysm repair (EVAR), and the risk of type Ia endoleak and endograft migration is increased in patients with short, large-diameter, or highly angulated necks. EndoAnchors have been used as an adjunct to EVAR in such patients, and the aim of this study was to assess their benefit analyzed by indication for use. Methods During a 2-year period, 319 patients were enrolled at 43 sites in the Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR) study. This prospective, multinational, real-world analysis of EndoAnchors comprised two groups of patients, those undergoing first-time EVAR (primary arm, 242) and those with proximal neck complications remote from the time of an initial endograft implantation (revision arm, 77). The primary arm was further subdivided into patients undergoing prophylactic EndoAnchor use for hostile proximal neck anatomy (178), with a type Ia endoleak evident during initial endograft deployment (60), and in conjunction with extender cuffs after unsatisfactory endograft deployment distally in the neck (four). The revision arm was subdivided into patients presenting with a type Ia endoleak alone (45), endograft migration alone (11), and migration with endoleak (21). Technical success was site reported as satisfactory deployment of the desired number of EndoAnchors without fracture or loss of integrity. Procedural success was defined as technical success without type Ia endoleak at completion arteriography. Core laboratory analysis was performed on 249 baseline and 192 follow-up computed tomographic studies, 66 of which were available within the 1-year window. Results Technical and procedural success rates were highest in the prophylactically treated subset (172 of 178; 96.6%). Whereas the technical success of EndoAnchor deployment was also high in the other subsets, residual type Ia endoleaks were more frequent at completion angiography when the indication for EndoAnchor use was type Ia endoleak, both in the primary arm (17 of 60; 28%) and in the revision arm (9 of 45; 20%). During a median imaging follow-up of 7 months, 183 of 202 patients (90.1%) remained free of type Ia endoleaks. Primary prophylactic patients were free from type Ia endoleak in 110 of 114 cases (96.5%). The most challenging subset was revision patients treated for type Ia endoleak; type Ia endoleaks were evident during follow-up in 10 of 29 of the cases (34%). Sac regression >5 mm in patients with 1-year imaging was observed in 26 of 66 patients (39%) and was highest in the primary prophylaxis subset (20 of 43; 47%). Conclusions EndoAnchor implantation can be a useful adjunct to EVAR as prophylaxis against proximal attachment site complications in patients with hostile aortic neck anatomy, as treatment for early and late type Ia endoleaks, or, in conjunction with aortic extension cuffs, for endograft migration. Whereas the most challenging patients are those who present with type Ia endoleaks remote from initial EVAR, EndoAnchors are still effective in treating the majority of these cases.