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Blunt traumatic innominate artery injuries occur in polytrauma victims who have suffered high-speed motor vehicle collisions. Their associated injuries may preclude the use of heparin and affect surgical management and perioperative neurological risk. The uniqueness of this case is combining the arterial injury repair with a severe progressive neurological injury that prohibited standard perioperative antiplatelet or anticoagulent use.

We present a unique case of late diagnosis of coarctation of the aorta in an adult, presenting with congestive heart failure associated with severe aortic and mitral valve insufficiency. To minimize operative risk, staged endovascular repair of the coarctation was initially performed, followed by aortic valve replacement and mitral valve repair. Six months postoperatively, the 41-year-old patient remains completely asymptomatic.

To simulate the hemodynamic effects in the feet in response to a thigh cuff occlusion, we have developed a multi-compartmental model in which the circulatory system for the leg is represented by its electrical equivalents. Dynamic vascular optical tomographic imaging data previously obtained from 20 patients with peripheral artery disease (PAD) and 20 healthy subjects is used to test the model. Analyzing the clinical data with the support of the model yields diagnostic specificity and sensitivity in the 90-95% range, significantly higher than previously reported.

Objective Vascular optical tomographic imaging (VOTI) is a novel imaging modality that is capable of detecting hemoglobin concentrations in tissue. VOTI is non-invasive, non-ionizing and does not require contrast injection. This technology was applied to the diagnosis of peripheral arterial disease (PAD) within lower extremities of diabetic patients with calcified arteries. This could be of substantial benefit as these patients suffer from comorbidities such as arterial incompressibility, which complicates diagnosis and monitoring. Methods Forty individuals (10 non-diabetic patients with PAD, 10 diabetic patients with PAD, and 20 healthy volunteers) were enrolled in a diagnostic pilot study using the VOTI system. The patients were imaged during a thigh pressure cuff occlusion. Results The VOTI system was capable of quantifying the blood volume changes within the foot during the thigh cuff occlusion and outputting diagnostic parameters, such as change in hemoglobin concentration, enabling the assessment of foot perfusion. This study resulted in a statistically significant difference between the healthy cohort and both the non-diabetic and the diabetic PAD cohorts ( p = .006, p = .006). Receiver operating characteristic (ROC) curve analysis showed that PAD diagnosis could be made with over 80% sensitivity or specificity depending on the characteristic cutoff point. In addition, VOTI was capable of providing the locations of under-perfused regions within the foot and evaluating the severity of arterial disease, even within diabetic patients with calcified arteries, who are traditionally difficult to diagnose. Conclusion VOTI can effectively diagnose PAD independently of arterial compressibility, making it very useful for assessing vascular disease in diabetic patients.

Ehlers-Danlos Syndrome (EDS) type IV is a connective tissue disorder with autosomal dominant inheritance. It can be potentially life-threatening due to increased risk of arterial rupture. The diagnosis is based on clinical findings including thin, translucent skin; bleeding propensity, rupture of vessels, and viscera. Isolated peripheral vascular injury may be the first presenting complaint, leading to eventual diagnosis in patients who often experience minimal trauma. We present a case of a brachial artery rupture requiring surgical reconstruction, eventually leading to the diagnosis of EDS type IV after a non-contact, low-energy injury to the arm of an adolescent.

Modeling the foot vasculature during a thigh cuff inflation provided a better understanding of the reconstruction results from Vascular Optical Tomography. Effects of posture and heart rate changes were modeled and compared to experimental results.

Introduction La simulation endovasculaire a ete promue en tant qu'outil educatif pour les chirurgiens en formation desirant s'entrainer a pratiquer les procedures dans un environnement sur, et ameliorer leurs competences techniques de base. Nous souhaitions determiner si un cours dedie aux procedures endovasculaires pouvait ameliorer les aptitudes techniques, augmenter l'interet pour la chirurgie vasculaire et etre mis en place dans une autre institution academique. Methodes Dans le Centre A, les etudiants en medecine participaient a un cours planifie sur huit semaines avec un parcours structure incluant des sessions encadrees sur simulateurs et des enseignements didactiques. Un cours similaire etait developpe au Centre B pour entrainer une cohorte comparable d'etudiants utilisant le meme simulateur haute-fidelite. Les donnees demographiques et les reponses aux questionnaires, incluant l'interet pour la chirurgie vasculaire, etaient obtenues, et des sessions sur simulateur avant et apres le cours planifie concernant le stenting renal ou iliaque/femoral superficiel etaient proposees. Les performances etaient jugees par des observateurs experts en utilisant une echelle de score endovasculaire globale standardisee et des mesures objectives sur la procedure collectees a partir du simulateur. Resultats Soixante-dix-sept etudiants en medecine (41 dans le Centre A et 36 dans le Centre B ; 56 hommes et 21 femmes) suivaient le cours entre 2007 et 2009. Les parametres mesures sur echelle de score endovasculaire globale standardisee, dont les competences angiographiques, la manipulation des guides, et les criteres interventionnels ainsi que les mesures objectives sur la procedure, etaient significativement ameliores apres le cours dans les deux groupes d'etudiants en medecine au sein des deux institutions (p < 0,05). Plus de 94% des etudiants etait plutot accord ou franchement d'accord pour dire que le cours de simulation augmentait leur interet pour la chirurgie vasculaire. Conclusion Un cours de simulation endovasculaire constitue un outil educatif qui ameliore les performances techniques basiques et augmente l'interet pour la chirurgie vasculaire chez les etudiants en medecine. Ce module educatif simple semble etre transferable et adaptable dans une autre institution avec des modifications mineures pour produire des resultats similaires.

Endovascular simulation has been promoted as an educational tool for trainees to practice procedures in a safe environment and improve basic technical skills. We sought to determine whether an established endovascular training course for medical students could increase technical proficiency, enhance interest in vascular surgery, and be implemented at another academic institution.At Center A, medical students participated in an eight-week elective course with a structured curriculum comprised of weekly mentored simulator sessions and didactic teachings. A similar course was developed at Center B to train a similar cohort of students using the same high-fidelity simulator. Demographics and survey data, including interest in vascular surgery, were obtained, and pre- and postcourse graded simulator sessions on renal stent or iliac/superficial femoral artery stent modules were conducted. Performance was assessed by expert observers using a standardized global endovascular rating scale and objective procedural metrics collected from the simulator.Seventy-seven medical students (41 at Center A and 36 at Center B; 56 men and 21 women) completed the course from 2007 to 2009. Parameters measured on the standardized global endovascular rating scale, including angiography skills, wire handling, and interventional criteria as well as simulator-generated metrics, significantly improved from pre- to postcourse values for both groups of medical students at the two institutions (p0.05). More than 94% of the students agreed or strongly agreed that the simulation course increased their interest in vascular surgery.A simulation-based endovascular course provides an educational tool that improves basic technical performance and increases interest in vascular surgery among medical students. This simple educational module appears to be transferable and adaptable at another institution with minimal modification to produce similar results.

To evaluate the role of endovascular therapy in the management of infrainguinal arterial chronic total occlusions (CTOs).Data on all patients with CTOs treated at a single center from 2004 to 2010 were extracted from a prospectively maintained database for retrospective analysis. Patient demographics, angiographic studies, noninvasive vascular test results, and clinical outcomes were evaluated. In this time frame, 481 patients (283 men; mean age 71.7±11.5 years, range 52-85) with claudication (n = 177) or critical limb ischemia (CLI, n = 304) were treated for 688 CTOs. Lesions were segregated according to location [SFA (n = 193), popliteal (n = 67), tibial (n = 217), and multilevel (n = 211)] and analyzed based on treatment mode (angioplasty, angioplasty with stenting, or atherectomy) and clinical indication. Primary patency, assisted primary patency, and secondary patency, as well as limb salvage rates for CLI patients, were calculated.At 2 years in claudicants with CTOs confined to the SFA, primary patency ranged from 44% to 58% and secondary patency to 92% depending on treatment type; there were no significant differences among the treatments. However, in CLI patients with SFA CTOs, atherectomy produced better outcomes at 2 years (p = 0.002 for primary and p = 0.012 for secondary patency) than angioplasty alone. The limb salvage rates ranged from 73% to 91% (no differences among treatment types). In diabetics, CTOs treated with angioplasty and stent had improved secondary patency rates over angioplasty alone.The endovascular management of CTO results in reasonable primary patency; moreover, secondary patency at 2 years is excellent. Endovascular therapy should be the first-line option for many patients with peripheral artery disease, including those with CLI, claudicants with poor bypass conduit, or patients at high medical risk for surgery. The presence of CTOs does not appear to change these recommendations. Although multiple reinterventions may be required, endovascular therapies can be considered a primary therapy for many patients with CTO.

Background Studies examining duplex surveillance of lower extremity bypass grafts have defined a role for guiding graft re-intervention. The goal of this study is to determine the utility of duplex scanning to detect angiographic restenosis after endovascular therapy in patients with infrainguinal arterial disease. Methods A prospective registry including all patients treated for lower extremity atherosclerotic disease between February 2004 and September 2008 was established. Patients were followed up with duplex ultrasound at 1, 3, 6, 12 months, and then annually. Patients receiving repeat angiograms were identified and angiogram and duplex data were abstracted. Velocity ratios (Vr) were calculated for each lesion by dividing the peak velocity within the lesion by the peak velocity proximal to the lesion. Logarithmic regression and receiver operator characteristic (ROC) curve analyses were used. Results Repeat angiograms were performed on 345 lesions in 143 patients, and 254 lesions in 103 patients had a corresponding duplex ultrasound. Indications for the initial intervention were claudication (n = 62, 43.4%), rest pain (n = 23, 16.1%), and tissue loss (n = 58, 40.5%). A total of 178 superficial femoral artery (SFA) lesions, 59 popliteal lesions, and 17 tibial lesions were identified by surveillance duplex in 103 patients. In all, 70.5% of the intervened vessels that were studied were nonstented and the remaining 29.5% were stented. A total of 65% of the patients had diabetes. On determining correlations for peak systolic velocity (PSV) as measured by duplex ultrasound with degree of angiographic stenosis, strong correlation coefficients for SFA disease (R2 = 0.84) and popliteal disease (R2 = 0.88) were found. However, poor correlation was found in patients with tibial disease. When analyzing the lesions on the basis of Vr 70% angiographic stenosis. In lesions with ratios from 2 to 2.5, 12 of 13 (92.3%) had >70% angiographic stenosis and in lesions with ratios >2.5, 69 of 75 (92.0%) had >70% angiographic stenosis. ROC curve analysis showed that to detect ≥70% stenosis in the SFA, a PSV ≥204 cm/sec had a sensitivity of 97.6% and specificity of 94.7%. To detect ≥70% stenosis in the overall femoropopliteal region, a PSV ≥223 cm/sec had a sensitivity of 94.1% and specificity of 95.2%. Conclusions Duplex ultrasound surveillance correlates to the degree of angiographic stenosis on the basis of PSV in the SFA and popliteal region. Correlation in the tibial vessels is poor. Vr>2.0 appear to correlate to angiographic stenosis of >70%. ROC analysis shows that PSV can have sufficiently high sensitivity and specificity to predict angiographic stenosis in the femoropopliteal region.

Introduction Les etudes examinant la surveillance echodoppler des pontages des membres inferieurs ont defini un role afin de guider la reintervention pour pontage. Le but de cette etude est de determiner l’utilite de l’echodoppler pour detecter la restenose angiographique apres traitement endovasculaire chez les patients presentant une maladie arterielle sous-inguinale. Methodes Un enregistrement prospectif comprenant tous les patients soignes pour une maladie atherosclerotique des membres inferieurs entre fevrier 2004 et septembre 2008 a ete etabli. Les patients etaient suivis par echodoppler a 1, 3, 6, 12 mois, et puis annuellement. Les patients recevant des angiographies a repetition ont ete identifies et l’angiographie et les donnees echodoppler ont ete analysees. Les rapports de vitesse (Vr) ont ete calcules pour chaque lesion en divisant la vitesse maximale sur la lesion par la vitesse maximale en amont de la lesion. Les analyses de regressions logarithmiques et de caracteristique de l’operateur receveur (ROC) ont ete utilisees. Resultats Des angiographies iteratives ont ete realisees sur 345 lesions chez 143 patients, et 254 lesions chez 103 patients ont eu un echodoppler correspondant. Les indications pour l’intervention initiale etaient la claudication ( n = 62, 43,4%), la douleur de repos ( n = 23, 16,1%), et la perte de tissu ( n = 58, 40,5%). Un total de 178 lesions de l’artere femorale superficielle (AFS), 59 lesions poplitees, et 17 lesions tibiales ont ete identifiees par l’echodoppler de surveillance chez 103 patients. En tout, 70,5% des vaisseaux operes qui ont ete etudies etaient non stentes et les autres 29, 5% etaient stentes. Un total de 65% des patients avaient un diabete. A la determination des correlations entre la vitesse systolique maximale (PSV) mesuree par echodoppler et le degre de stenose angiographique, les coefficients de correlation forts pour l’atteinte de l’AFS ( R2 = 0,84) et de la poplite ( R2 = 0,88) ont ete trouves. Cependant, une correlation pauvre a ete trouvee chez les patients presentant une atteinte tibiale. En analysant les lesions sur la base de la Vr 70%. Parmi les lesions avec des rapports de 2 a 2,5, 12 sur 13 (92,3%) avaient une stenose angiographique >70% et parmi les lesions avec des rapports >2,5, 69 sur 75 (92,0%) avaient une stenose angiographique >70%. L’analyse de courbe de ROC a montre que pour detecter une stenose de ≥70% dans l’AFS, un PSV ≥204 centimetre-seconde avait une sensibilite de 97,6% et une specificite de 94,7%. Pour detecter une stenose ≥70% a l'etage femoropoplite, un PSV ≥223 cm/sec avait une sensibilite de 94,1% et une specificite de 95,2%. Conclusions La surveillance echodoppler est correlee avec le degre de stenose angiographique sur la base de la PSV dans l’AFS et la region poplitee. La correlation dans les vaisseaux tibiaux est pauvre. Vr>2,0 semblent etre correle a une stenose angiographique >70%. L’analyse de ROC prouve que la PSV peut avoir une sensibilite et une specificite suffisamment elevees pour prevoir la stenose angiographique dans la region femoropoplitee.

Introduction Le Gadolinium (Gd) est traditionellement utilise comme une alternative non nephrotoxique aux produits de contraste iodes pour la realisation d'arteriographies numerisees de soustraction (ANS) chez les patients presentant une insuffisance renale chronique. Neanmoins, son utilisation a ete remise en cause en raison de sa potentielle nephrotoxicite et de son association recemment decrite avec des cas de fibrose nephrogenique systemique (FNS), complication potentiellement lethale. Les donnees actuellement disponibles sur l'innocuite du Gd sont donc incertaines. L'objectif de cette etude a ete d'evaluer le risque de nephropathie induite par le produit de contraste et de FNS apres exposition au Gd dans une large population de patients azotemiques et ayant beneficie d'une ANS. Methode Un registre complet comprenant les donnees de tous les patients beneficiant d'une ANS entre Juin 2003 et Decembre 2007 a l'hopital Presbyterian a ete analyse retrospectivement. Les patients recevant soit du Gd seul soit une combinaision de Gd et de produit de contraste iode au cours d'une ANS ont ete identifies et leurs donnees analysees. L'insuffisance renale aigue (IRC) a ete definie comme une elevation de la cretininemie (Cr) > >0.5 mg/dL dans les 48 premieres heures suivant l'exposition. Le suivi clinique a ete effectue par analyse des dossiers et par interviews telephoniques des patients et des medecins traitants. Resultats Au total, 153 patients ont ete exposes a 179 injections de Gd seul (33%) ou a une combinaison de Gd et de produit de contraste iode (67%). La duree moyenne du suivi a ete de 27,1 mois. La Cr moyenne a ete de 1,94 ± 0,78 mg/dL et 1,96 ± 1,1 mg/dL avant et apres ANS, respectivement. Il y a eu 20(11,2%) cas d'IRA. La Cr moyenne avant ANS etait plus elevee chez les patients ayant presente une IRA en comparaison au groupe sans IRA (2,7 ± 1,1 mg/dL vs. 1,9 ± 0,7 mg/dL, p = 0,004). Dans le group IRA, 12 patients ont retrouve une Cr equivalente a celle de la periode ayant precede l'ANS, quatre ont presente une deterioration irreversible de leur fonction renale, et quatre ont necessite une dialyse (incidence de l'insuffisance renal chronique: 4,5%). Durant la periode de l'etude, 19 deces sont survenus (12,4%). Le risque le plus eleve de developper une IRA apres exposition au Gd a ete observe chez les patients ayant une Cr >3.0 mg/dL avant ANS et chez ceux recevant des doses >0.4 mmol/kg de Gd. Chez les patients ayant recu une combinaison de Gd et de produit de contraste iode, il existait une tendance a un risque accru de developper une IRA en comparaison au groupe ne recevant que du Gd. Aucun cas de FNS n'a ete observe chez les patients recevant du Gd en intra-arteriel. Conclusions De facon similaire aux produits de contraste iodes, l'administration de Gd est associee a un risque de toxicite renale, mais les risques d'insuffusance renale irreversible et de dialyse sont peu eleves. Les interventions pour menace vitale ou sauvetage de membre ne doivent pas etre evitees meme en presence d'une elevation de la Cr. Nos resultats devraient aider a guider la bonne utilisation du Gd chez les patients insuffisants renaux.

The purpose of this study was to evaluate the effect of carotid cell design on duplex ultrasound velocity readings in the immediate postoperative period and over time.A prospective database encompassing all patients treated with carotid artery stents between 2003 and 2008 was established and analyzed for stent type (closed-cell vs. open-cell), indications, and comorbidities. Patients were followed up clinically and with duplex ultrasound immediately after surgery, and every 6 months thereafter. Peak systolic velocities (PSV), end diastolic velocities (EDV), and internal carotid artery (ICA) to common carotid artery (CCA) ratios of PSV were recorded.A total of 214 interventions with 157 (73.3%) open-cell and 57 (26.7%) closed-cell types of carotid stents were performed in 205 patients. Two groups were similar regarding demographics, comorbidities, lesions characteristics, and stent length and diameter. The only difference was a significantly higher mean age (74.4 ± 10.1 vs. 70.9 ± 9.7 years; p = 0.027) and a history of myocardial infarction (34.5% vs. 15.6%; p = 0.004) in the closed-cell group versus open-cell group. Immediately after surgery PSV (115.9 ± 66.1 vs. 93.1 ± 38.7 cm/s; p = 0.003) and ICA/CCA ratio (2.08 ± 1.66 vs. 1.45 ± 0.52; p = 0.001) were significantly higher in closed-cell compared with open-cell group. This difference persisted during the follow-up period of 20.2 +/- 16.4 months; PSV (147.2 ± 108.8 vs. 110.0 ± 51.9; p = 0.003) and ICA/CCA ratio (2.61 ± 2.31 vs. 1.76 ± 0.81; p = 0.001). Patients with diabetes and calcified lesions had higher PSV and ICA/CCA ratio immediately after surgery (p0.05 and p0.05 for those with diabetes and calcified lesions, respectively) and over time. The number of readings showing significant restenosis (PSV300 cm/s) over time were significantly higher in closed-cell 5 (8.7%) versus open-cell 1 (0.06%). EDV was not statistically different in the two groups (p0.05).Our study suggests that duplex criteria to screen for poststent restenosis may require modification according to stent-type. However, long-term effect of stent design on restenosis is still to be established.

Endovascular repair of a descending thoracic aortic aneurysm may result in covering the ostia of the left carotid or left subclavian artery for proper proximal landing zones, and the celiac artery or superior mesenteric artery ostia in the abdomen for distal landing zones. To prevent possible complications of occluding the ostia of these vessels, the authors performed an innominate to left common carotid and left subclavian artery bypass as the first procedure in one patient. In the second patient they performed an aortoceliac and aortomesenteric bypass before stent graft placement. The stent graft repair of the descending thoracic aortic aneurysm was performed subsequently in both patients. This aortic debranching provides subsequent proper placement of thoracic stent grafts.

Peripheral Arterial Disease (PAD) is caused by a reduction of the internal diameters of the arteries in the upper or lower extremities mainly due to atherosclerosis. If not treated, its worsening may led to a complete occlusion, causing the death of the cells lacking proper blood supply, followed by gangrene that may require chirurgical amputation. We have recently performed a clinical study in which good sensitivities and specificities were achieved with dynamic diffuse optical tomography. To gain a better understanding of the physiological foundations of many of the observed effects, we started to develop a mathematical model for PAD. The model presented in this work is based on a multi-compartment Windkessel model, where the vasculature in the leg and foot is represented by resistors and capacitors, the blood pressure with a voltage drop, and the blood flow with a current. Unlike existing models, the dynamics induced by a thigh-pressure-cuff inflation and deflation during the measurements are taken into consideration. This is achieved by dynamically varying the resistances of the large veins and arteries. By including the effects of the thigh-pressure cuff, we were able to explain many of the effects observed during our dynamic DOT measurements, including the hemodynamics of oxy- and deoxy-hemoglobin concentration changes. The model was implemented in MATLAB and the simulations were normalized and compared with the blood perfusion obtained from healthy, PAD and diabetic patients. Our preliminary results show that in unhealthy patients the total system resistance is sensibly higher than in healthy patients.

ObjectiveThis study used a canine model of abdominal aortic aneurysms (AAAs) to compare intra-aneurysmal pressure and thrombus formation after exclusion with Dacron and expanded polytetrafluoroethylene (ePTFE) stent-grafts.MethodsProsthetic AAAs with implanted strain-gauge pressure transducers were treated by stent-graft exclusion using Food and Drug Administration-approved devices in 10 mongrel dogs: five Dacron (AneuRx) and five ePTFE (original Excluder). Intra-aneurysmal pressure was measured over 4 weeks after AAA exclusion and indexed to the systemic pressure, represented as a percentage of a simultaneously obtained systemic pressure (value = 1.0). Magnetic resonance imaging (MRI) of the intra-aneurysmal thrombus was performed at 1, 2, and 4 weeks after exclusion and expressed as a signal-to-noise ratio (S:N) to control for background signal intensity. Comparisons of pressures and S:N between the two stent-grafts was analyzed with the Student’s t test. Intra-aneurysmal thrombus was characterized histologically.ResultsIn animals excluded with both Dacron and ePTFE stent-grafts, the intra-aneurysmal pressure was nonpulsatile and reduced to

A renal artery aneurysm with an associated arteriovenous fistula in a native kidney has been reported infrequently in the literature. Management depends on size, location, and the patient's physiological condition. We describe a case in which endovascular therapy was used to successfully exclude both aneurysm and fistula. This report describes a 13-centimeter renal artery aneurysm with arteriovenous fistula originating from an isolated branch of the renal artery. Coil-embolization resulted in thrombosis of the aneurysm and fistula while preserving parenchymal perfusion. Coil embolization is an alternative to surgery for coexistent renal artery aneurysm and arteriovenous fistula arising from a branch of adequate length for placement of embolic coils. Successful treatment is not limited by aneurysm size or presence of arteriovenous connection.

ObjectiveThe clinical significance and treatment of retrograde collateral arterial perfusion of abdominal aortic aneurysms after endovascular repair (type II endoleak) have not been completely characterized. A canine abdominal aortic aneurysm model of type II endoleak with an implanted pressure transducer was used to evaluate the use of polyurethane foam to induce thrombosis of type II endoleaks. The effect on endoleak patency, intra-aneurysmal pressure, and thrombus histology was studied.MethodsProsthetic aneurysms with an intraluminal, solid-state, strain-gauge pressure transducer were created in the infrarenal aorta of 14 mongrel dogs. Aneurysm side-branch vessels were reimplanted into the prosthetic aneurysm of 10 animals by using a Carrel patch. Type II (retrograde) endoleaks were created by excluding the aneurysm from antegrade perfusion with an impermeable stent graft. Thrombosis of the type II endoleak was induced by implantation of polyurethane foam into the prosthetic aneurysm sac of four animals. Six animals with type II endoleaks were not treated. In four control animals, no collateral side branches were reimplanted, and therefore no endoleak was created. Intra-aneurysmal and systemic pressures were measured daily for 60 to 90 days after the implantation of the stent graft. Endoleak patency and flow were assessed during surgery and at the time of death by using angiographic imaging and duplex ultrasonography. Histologic analysis of the intra-aneurysmal thrombus was also performed.ResultsIntra-aneurysmal pressure values are indexed to systemic pressure and are represented as a percentage of the simultaneously obtained systemic pressure, which has a value of 1.0. All six animals with untreated type II endoleaks maintained patency of the endoleak and side-branch arteries throughout the study period. Compared with control aneurysms that had no endoleak, animals with patent type II endoleaks exhibited significantly higher intra-aneurysmal pressurization (systolic pressure: patent type II endoleak, 0.702 ± 0.283; control, 0.172 ± 0.091; P < .001; mean pressure: endoleak, 0.784 ± 0.229; control, 0.137 ± 0.102; P < .001; pulse pressure: endoleak, 0.406 ± 0.248; control, 0.098 ± 0.077; P < .001; P < .001 for comparison for all groups by analysis of variance). Treatment of the type II endoleak with polyurethane foam induced thrombosis of the endoleak and feeding side-branch arteries in all four animals with type II endoleaks. This resulted in intra-aneurysmal pressures statistically indistinguishable from the controls (systolic pressure, 0.183 ± 0.08; mean pressure, 0.142 ± 0.09; pulse pressure, 0.054 ± 0.04; not significant). Angiography and histology documented persistent patency up to the time of death (mean, 64 days) for untreated type II endoleaks and confirmed thrombosis of polyurethane foam-treated endoleaks in all cases.ConclusionsUntreated type II endoleaks were associated with intra-aneurysmal pressures that were 70% to 80% of systemic pressure. Treatment with polyurethane foam resulted in a reduction of intra-aneurysmal pressure to a level that was indistinguishable from control aneurysms that had no endoleak.Clinical RelevanceEndovascular repair of abdominal aortic aneurysms is dependent on the successful exclusion of the aneurysm from arterial circulation. Type II endoleaks originate from retrograde flow into the aneurysm sac. This study demonstrates the use of polyurethane foam to induce thrombosis in a canine model of a type II endoleak, thereby reducing intra-aneurysmal pressure to levels similar to levels in animals without endoleaks. This approach may be a strategy for future treatment of type II endoleaks.

This study analyzed clinical success, patency, and limb salvage after endovascular repair in patients treated for chronic limb ischemia presenting with claudication versus critical limb ischemia. Between October 2001 and August 2004, 115 patients (mean age 71) underwent endovascular treatment for infrainguinal arterial disease. Techniques included subintimal angioplasty and transluminal angioplasty with or without stents. Lesions were classified according to Transatlantic InterSociety Consensus. Follow-up (mean 11 months) included physical exam, ankle-brachial index, and duplex ultrasound. Patency rates were determined using Kaplan-Meier and compared by log-rank analysis. One hundred ninety-nine lesions were treated in 121 limbs using percutaneous techniques. Comorbidities were similar except higher rates of diabetes mellitus (67% vs 41%, P < 0.001) and chronic renal insufficiency (22% vs 7%, P < 0.05) were found in critical limb ischemia patients. Primary patency for claudicants was 100 per cent, 98 per cent, and 85 per cent at 3, 6, and 12 months and 89 per cent, 80 per cent, and 72 per cent for critical limb ischemia, respectively ( P = 0.06). Limb salvage was 91 per cent at 12 months for critical limb ischemia patients. Morbidity was similar between groups, and there was no perioperative mortality. Percutaneous intervention for both claudication and critical limb ischemia provides acceptable 12-month patency with limited morbidity.

ObjectiveWe compared the physiologic effect of selective atropine administration for bradycardia with routine prophylactic administration, before balloon inflation, during carotid angioplasty and stenting (CAS). We also compared the incidence of procedural bradycardia and hypotension for CAS in patients with primary stenosis vs those with prior ipsilateral carotid endarterectomy (CEA).MethodsA total of 86 patients were treated with CAS at 3 institutions. Complete periprocedural information was available for 75 of these patients. The median degree of stenosis was 90% (range, 60%-99%). Indications for CAS were severe comorbidities (n = 49), prior CEA (n = 21), and prior neck radiation (n = 5). Twenty patients with primary lesions were treated selectively with atropine only if symptomatic bradycardia occurred (nonprophylactic group). Thirty-four patients with primary lesions received routine prophylactic atropine administration before balloon inflation or stent deployment (prophylactic group). The 21 patients with prior CEA received selective atropine treatment only if symptomatic bradycardia occurred (prior CEA group) and were analyzed separately. Mean age and cardiac comorbidities did not vary significantly either between the prophylactic and nonprophylactic atropine groups or between the primary and prior CEA patient groups. Outcome measures included bradycardia (decrease in heart rate >50% or absolute heart rate

Phlegmasia cerulea dolens is a limb-threatening form of deep venous thrombosis and should be treated aggressively. The authors report a patient who presented with iliocaval and femoral deep venous thrombosis and posed an additional therapeutic challenge based on a recent history of heparin-induced thrombocytopenia. Catheter-directed pharmacologic thrombolysis and balloon venoplasty were applied in treatment. The direct thrombin inhibitor argatroban was used in place of heparin for concurrent anticoagulation. This multimodality endovascular approach (chemical and mechanical interventions) was successful in relieving the venous occlusion and salvaging the limb, while maintaining appropriate treatment for heparin-induced thrombocytopenia.

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA); however, its occurrence is associated with significant risk of morbidity. The patient in this report presented 2 years following CEA with headache and lateral neck mass. The diagnosis of a 3.5 x 3.0 cm carotid artery bifurcation pseudoaneurysm was made by using magnetic resonance angiography (MRA). Endovascular exclusion of the aneurysm was accomplished with coil embolization of the external carotid artery followed by deployment of a 7 x 50 mm wall stent graft into the common carotid artery-internal carotid artery (CCA-ICA). The patient's symptoms improved and at 6-months postexclusion, duplex ultrasound demonstrated a significant reduction in pseudoaneurysm size. This case highlights the feasibility and safety of using endovascular techniques in the treatment of post-CEA pseudoaneurysm.

Objective The clinical significance of Type 2 endoleak after endovascular repair of abdominal aortic aneurysms (AAA) remains incompletely delineated. This study describes the development of a novel canine model that allows for continuous monitoring of intraaneurysmal pressure in the setting of Type 2 endoleak. Methods Infrarenal AAA were created in 10 mongrel dogs by implanting a prosthetic aneurysm containing an intraluminal, solid-state, strain gauge pressure transducer which is able to measure pressures in both solid and liquid media. A segment of native aorta with two or more patent side branch vessels was reimplanted into the prosthetic aneurysm using a Carrel patch. Four animals had two lumbar vessels implanted; two had two lumbar vessels and the caudal mesenteric artery implanted, and four control animals had no vessels reimplanted. Retrograde flow in the aneurysmal side branches caused a Type 2 endoleak after the aneurysm was excluded from antegrade flow by deploying a stent graft. Both systemic and intra-sac pressures were measured daily for up to 90 days after endovascular exclusion and indexed to systemic pressure. Endoleak patency and flow were assessed with digital subtraction angiography, duplex ultrasound, and cine-magnetic resonance angiography (MRA). Histological characterization of the intraaneurysmal contents was performed. Results Before endovascular exclusion, the systolic, mean arterial, and pulse pressure within the aneurysmal sac closely matched that of the systemic circulation (systolic, 0.96 ± 0.22; mean, 0.94 ± 0.21; pulse pressure, 0.97 ± 0.22) ( R value, 0.97). Endovascular exclusion in animals with no collateral side branch vessels resulted in no endoleak and significantly reduced intraaneurysmal pressure when compared to systemic pressure, with systolic, mean arterial, and pulse pressure 0.172 ± 0.05, 0.137 ± 0.05, and 0.098 ± 0.02, respectively ( P P Conclusion Intraaneurysmal pressure in the setting of Type 2 endoleaks may be accurately determined using this canine model. Intraaneurysmal pressure is maintained at a significant level in the context of this retrograde collateral perfusion, suggesting that persistent Type 2 endoleaks are of clinical significance. This model may serve to allow further evaluation and characterization of Type 2 endoleaks.

This study evaluated the potential for transvenous ultrasonography to assess renal artery stenosis (RAS), the most common correctable cause of hypertension in the United States. We developed a porcine model for studying RAS using TVUS. An endovascular ultrasound probe was placed into the inferior vena cava and renal veins to image renal arteries in which stenoses had been surgically created in varied locations and to varied degrees. TVUS was then used to identify and assess these stenotic lesions. The accuracy of TVUS for determining the degree and location of the stenoses was then determined using contrast arteriography as the standard. When compared with arteriography, TVUS identified and properly located all six lesions and correctly quantified the degree of stenosis in five of the six lesions. TVUS is an effective means of assessing the presence, degree, and location of stenotic lesions of the renal arteries in this animal model. Study of this method in humans may be warranted.

The thyrocervical trunk is the second superior branch off the subclavian artery. Pseudoaneurysm of the thyrocervical trunk has been reported after attempted internal jugular vein cannulation for central venous or hemodialysis access. The treatment of pseudoaneurysms of the thyrocervical trunk depends on the findings from color flow Doppler ultrasonography and angiography. Although pseudoaneurysms of the thyrocervical trunk are rare, the treatment options should be clear. Surgical ligation is an effective technique that is safe and well-defined, but control through a cervical incision may be difficult. Endovascular treatment of the pseudoaneurysm may be accomplished with coil embolization of the artery, which is described.

Peripheral Arterial Disease (PAD) is the narrowing of the functional area of the artery generally due to atherosclerosis. It affects between 8-12 million people in the United States and if untreated this can lead to ulceration, gangrene and ultimately amputation. The current diagnostic method for PAD is the ankle-brachial index (ABI). The ABI is a ratio of the patient’s systolic blood pressure in the foot to that of the brachial artery in the arm, a ratio below 0.9 is indicative of affected vasculature. However, this method is ineffective in patients with calcified arteries (diabetic and end-stage renal failure patients), which falsely elevates the ABI recording resulting in a false negative reading. In this paper we present our results in a pilot study to deduce optical tomography’s ability to detect poor blood perfusion in the foot. We performed an IRB approved 30 patient study, where we imaged the feet of the enrolled patients during a five stage dynamic imaging sequence. The patients were split up into three groups: 10 healthy subjects, 10 PAD patients and 10 PAD patients with diabetes and they were imaged while applying a pressure cuff to their thigh. Differences in the magnitude of blood pooling in the foot and rate at which the blood pools in the foot are all indicative of arterial disease.

To examine the outcomes following interventions for type II endoleaks in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR).A retrospective review was conducted of all patients who underwent treatment for type II endoleak from July 2001 to September 2010 in a single center. In this time period, 29 (4.7%) patients (22 men; mean age 78.6 years, range 54-87) were identified as having a type II endoleak and enlargement of the aneurysm sac, meeting the criterion for treatment. All patients had at least one attempted percutaneous intervention. Patients were followed both clinically and radiographically, with computed tomographic angiography every 3 to 12 months, over a follow-up period that ranged from 1 to 10 years (mean 3.5).Forty-eight interventions were performed on the 29 patients. Of these, 15 (56%) patients underwent multiple (2-4) procedures. Of the 11 endoleaks with an isolated inferior mesenteric artery identified as the source, initial success for transarterial embolization at 2 years was 72%, with 2 of the failures having successful secondary interventions. For the 18 endoleaks with a lumbar source, the success of the initial intervention was 17% at 2 years; repeated embolization attempts produced a 40% secondary success rate. Seven (24%) patients had continued endoleak despite multiple treatment attempts; 3 ultimately required elective aortic graft explantation. There were no ruptures or deaths during the study period. In a comparison of type II endoleak patients who had stable aneurysm sacs and those who had persistent sac expansion, the only significant differences in preoperative anatomical characteristics were a lower prevalence of mural thrombus (p = 0.036) and longer right iliac arteries (p = 0.012) in the group with sac expansion. Independent predictors of type II endoleak were mural thrombus (p0.001), patent lumbar arteries (p = 0.004), aneurysm length (p = 0.011), and iliac artery length (p = 0.004).This study demonstrates that most patients require multiple reinterventions to treat type II endoleaks; specifically, lumbar artery embolization carries a low midterm success rate.

We present case studies using dynamic diffuse optical tomographic imaging to view the vascular perfusion of patients with Peripheral Arterial Disease with and without calcifications as well as a healthy control group.

Aortoiliac atherosclerotic disease has a unique disease process, presentation, progress, and treatment and should be viewed as a distinct entity from the infrainguinal and infrapopliteal atherosclerosis. At a cursory look, diabetes appears to mainly affect the tibial vessels. Although not as well described, diabetes has a large impact on the proximal vessels at multiple levels. This chapter reviews the pathogenesis, epidemiology, diagnosis, and treatment of aortoiliac disease as it pertains to the diabetic population.

Objectifs Le but de cette etude est d’evaluer l’effet de l’architecture des « cellules » des stents carotidiens sur les vitesses mesurees a l’echographie doppler dans la periode postoperatoire immediate et au cours du suivie. Methodes Une base de donnees prospectives englobant tous les patients traites avec des stents carotidiens entre 2003 et 2008 a ete etabli et analysee en fonction du type de stent (a cellules fermees vs cellules ouvertes), des indications et des comorbidites. Les patients ont ete suivis cliniquement et par echographie doppler immediatement apres la chirurgie, et tous les 6 mois par la suite. Les pics de vitesses systolique (PSV), les vitesses en fin de diastole (EDV), et le rapport des PSV entre l’artere carotide interne (ACI) de l’artere carotide primitive (ACP) ont ete etudies. Resultats Un total de 214 stentings carotidien a ete effectue chez 205 patients avec 157 (73,3%) stentings avec des stents a cellules ouvertes et 57 (26,7%) a cellules fermees. Les deux groupes etaient similaires en ce qui concerne la demographie, les comorbidites, les caracteristiques des lesions ainsi que la longueur du stent et son diametre. Les seules differences etaient : un âge significativement plus elevee (74,4 ± 10,1 vs 70,9 ± 9,7 ans ; p = 0,027) ainsi que des antecedents d’infarctus plus frequents (34,5% vs 15,6%, p = 0,004) dans le groupe « cellules fermees ». Immediatement apres la chirurgie, la mesure de la PSV (115,9 ± 66,1 vs 93,1 ± 38,7 cm/s ; p = 0,003) et le rapport ACI/ACP (2,08 ± 1,66 vs 1,45 ± 0,52, p = 0,001) etaient significativement plus eleves dans le groupe « cellule fermee ». Cette difference a persiste tout au long du suivi de 20,2 ± 16,4 mois (PSV (147,2 ± 108,8 vs 110,0 ± 51,9, p = 0,003), rapport ACI/ACP (2,61 ± 2,31 vs 1,76 ± 0,81, p = 0,001). Les patients diabetiques et ceux presentant des lesions calcifiees ont eu des PSV et un rapport ACI/ACP plus eleves immediatement apres la chirurgie (p > 0,05 et p 300 cm/s) au cours du suivi a ete significativement plus eleves dans le groupe cellules fermees 5 (8,7%) par rapport eu groupe cellules ouvertes 1 (0,06%). La mesure de l’EDV n’etait statistiquement pas differente dans les deux groupes (p > 0,05). Conclusion Notre etude suggere que les criteres en echographie doppler de restenose post stenting necessitent des modifications en fonction du type de stent. Toutefois, a long terme l’effet de l’architecture du stent sur la restenose reste encore a etablir.

BackgroundDigital subtraction angiography (DSA) is the gold standard for diagnosing lower extremity (LE) arterial lesions. However, duplex ultrasound (DUS) is a widely used, safe, and noninvasive method of detecting LE lesions. The purpose of this study was to establish DUS criteria for detecting and grading de novo stenotic lesions in the femoropopliteal arterial segment.MethodsA prospective database was established including all patients who underwent LE endovascular interventions between 2004 and 2009. Patients with de novo stenotic lesions in the femoropopliteal segment were selected. DUS and DSA data pairs ≤30 days apart were analyzed. Peak systolic velocity (PSV; cm/s), velocity ratio (Vr), and DSA stenosis were noted. Linear regression and receiver operator characteristic (ROC) curves were used.ResultsTwo hundred seventy-five lesions in 200 patients were analyzed. Indications were claudication (50.5%), rest pain (12.5%), and tissue loss (37.0%). Mean time interval between DUS and DSA was 24 days. Both PSV (R = .80, R2 = .641; P < .001) and Vr (R = .73, R2 = .546; P < .001) showed strong correlation with the degree of angiographic stenosis. ROC analysis showed that to detect ≥70% stenosis, a PSV of 200 cm/s had 89.2% sensitivity and 89.7% specificity, and a Vr of 2.0 had 88.7% sensitivity and 90.2% specificity. Similarly, to differentiate between

Peripheral Artery Disease (PAD) affects over 10 million Americans and is associated with significant morbidity and mortality. While in many cases the ankle-brachial index (ABI) can be used for diagnosing the disease, this parameter is not dependable in the diabetic and elderly population. These populations tend to have calcified arteries, which leads to elevated ABI values. Dynamic optical tomography (DDOT) promises to overcome the limitations of the current diagnostic techniques and has the potential to initiate a paradigm shift in the diagnosis of vascular disease. We have performed initial pilot studies involving 5 PAD patients and 3 healthy volunteers. The time traces and tomographic reconstruction obtained from measurements on the feet show significant differences between healthy and affected vasculatures. In addition, we found that DOT is capable of identifying PAD in diabetic patients, who are misdiagnosed by the traditional ABI screening.

Diffuse optical imaging of the peripheral vascular reactivity is implemented at the major arteries of the foot. Transmitted light intensities are recorded in response to vascular occlusions induced by pressure cuffs. These dynamic measurements promise to help identify various peripheral vascular diseases.

Background Gadolinium (Gd) has been traditionally used as a non-nephrotoxic alternative to iodinated contrast for digital subtraction angiography (DSA) in patients with chronic renal insufficiency. However, its use has been questioned on the basis of reports of nephrotoxicity and its recent association with nephrogenic systemic fibrosis (NSF), a potentially lethal complication. Recently available data are conflicting with respect to the true safety profile of intra-arterial Gd. The purpose of this study was to examine the risk of contrast nephropathy and NSF after Gd exposure in a large population of azotemic patients undergoing DSA. Methods A comprehensive database encompassing data on all patients who underwent DSA between June 2003 and December 2007 at the New York Presbyterian Hospital was retrospectively reviewed. Patients receiving Gd either alone or in combination with iodinated contrast during DSA were identified and further analyzed. Acute renal failure (ARF) was defined as an elevation in serum creatinine (Cr) by >0.5 mg/dL within 48 hours of exposure. Clinical follow-up was conducted through chart reviewing as well as telephonic interviews with patients and their primary care physicians. Results A total of 153 patients underwent 179 exposures to Gd either alone (33%) or in combination (67%) with iodinated contrast. Mean follow-up duration was 27.1 months. The mean Cr level was 1.94 ± 0.78 mg/dL and 1.96 ± 1.1 mg/dL before and after DSA, respectively. There were 20 (11.2%) instances of ARF. The mean Cr level before DSA was higher in patients who developed ARF versus those in the non-ARF group (2.7 ± 1.1 mg/dL vs. 1.9 ± 0.7 mg/dL, p = 0.004). In the ARF group, 12 patients had a return to baseline renal function, four experienced irreversible renal deterioration, and four needed dialysis (4.5% incidence of irreversible renal failure). There were 19 deaths at the time of this study (12.4%). The highest risk for the development of ARF after Gd exposure occurred in patients with Cr levels of >3.0 mg/dL before DSA and in those receiving >0.4 mmol/kg of Gd. For patients who received iodinated contrast in combination with Gd, there was a trend toward a higher risk for developing ARF as compared with those receiving only Gd. Finally, there were no instances of NSF identified in any of the patients who received intra-arterial Gd. Conclusions Although Gd has the potential to cause kidney injury similar to iodinated contrast, the risk of irreversible renal failure and the requirement for dialysis is low. Life- or limb-threatening interventions should not be avoided in this patient cohort because of preexisting elevations in Cr. These data should help guide the use of Gd in patients with chronic renal insufficiency.

The upper extremity arterial system shows a large number of variations in the adult human body. Most of these variations occur in either the radial or ulnar artery; brachial artery variations are less common. Because the upper extremity is a frequent site of injury and various surgical and invasive procedures are performed in this region, it is of utmost importance to be aware of arterial variations. We report a case of a high bifurcation of the brachial artery presenting with acute ischemia secondary to an embolic event. The anomaly was identified, and the ischemia was successfully resolved with embolectomy.

Endovascular repair of a descending thoracic aortic aneurysm may result in covering the ostia of the left carotid or left subclavian artery for proper proximal landing zones, and the celiac artery or superior mesenteric artery ostia in the abdomen for distal landing zones. To prevent possible complications of occluding the ostia of these vessels, the authors performed an innominate to left common carotid and left subclavian artery bypass as the first procedure in one patient. In the second patient they performed an aortoceliac and aortomesenteric bypass before stent graft placement. The stent graft repair of the descending thoracic aortic aneurysm was performed subsequently in both patients. This aortic debranching provides subsequent proper placement of thoracic stent grafts.

Phlegmasia cerulea dolens, a rare complication of deep venous thrombosis, has traditionally been difficult to treat. The patient described in this report posed additional therapeutic challenges based on a history of heparin-induced thrombocytopenia. She presented with severe leg pain and swelling, and a venogram showed occlusion of both her inferior vena cava and right iliac vein. The use of a multimodality approach, both chemical and mechanical, was successful in removing the venous occlusion, thereby preventing further complications, such as circulatory shock, postphlebitic syndrome, and venous gangrene.

Recent data suggest that patient age80 years may be associated with increased risk of periprocedural complications from carotid angioplasty and stenting (CAS). In this study, we analyzed anatomic risk factors in patients undergoing CAS based on age80 or80 years. Our hypothesis was that patients80 would have more challenging anatomy. Between February 2003 and August 2004, 82 patients underwent CAS. Images for 57 lesions were available for review. Eighteen patients wereor =80 years old and 39 were80. Cerebral protection devices, including EPI Filterwire, Percusurge, Accunet, and Angioguard, were used in all but two cases; and self-expanding stents (Wallstent, NexStent, Acculink, Precise) were placed in all. Arterial anatomic characteristics were assigned a score based on complexity and associated procedural risk. Characteristics evaluated using angiographic images were aortic arch elongation classification, arch calcification, common carotid/innominate stenosis, common carotid tortuosity, internal carotid tortuosity, index lesion length, index lesion calcification, and index lesion stenosis. Statistical analysis was performed using Fisher's exact test. CAS was successfully completed in 98% of cases. The two patients in whom we could not perform CAS were 79 and 83 years old. The anatomic characteristics that were statistically significantly more complex/severe in patientsor =80 were arch calcification (p = 0.045), common carotid/innominate stenosis (p = 0.023), common carotid tortuosity (p = 0.049), and internal carotid tortuosity (p = 0.032). There was no statistically significant difference in arch elongation classification, lesion length, lesion calcification, or stenosis severity (p = nonsignificant). Overall, patientsor =80 years had an increased incidence of complex anatomic risk factors compared to younger patients (p0.001). Cerebrovascular accident without residual deficits occurred in two patients; both were80 years old. Complex arterial anatomy is more often present in patients80 years and may explain the increased complication rates associated with CAS. Pre- or intraoperative consideration of these characteristics may help provide better risk assessment in candidates for CAS.

Critical deep venous thrombosis and occlusion constitutes a small percentage of patients with venous disease. However, these patients exhibit severe symptomatology including pain and extensive edema that may progress to limb-or life-threatening complications such as phlegmasia cerulea dolens and superior vena cava syndrome. This paper reviews the different multimodal percutaneous interventions currently available for the treatment of complex critical venous thrombotic and occlusive disease.

Percutaneous transluminal methods of revascularization for chronic limb ischemia have traditionally been used as an adjunctive or secondary mode of treatment. This study examines the outcomes of patients treated via endovascular methods as the primary form of treatment. The records of 66 patients (average age, 71.3 years; range, 53 to 92) with chronic limb ischemia treated from November 2000 to January 2002 at a single institution with endovascular methods were retrospectively reviewed. Thirty-one patients had disabling claudication, 15 had rest pain, 17 had minor tissue loss, and 3 had major tissue loss. There were 94 lesions in the 66 limbs: 45 lesions in the superficial femoral artery, 28 lesions in the popliteal artery, and 21 lesions in tibial arteries. Occlusive lesions were treated by subintimal angioplasty. Stenoses were treated by percutaneous transluminal angioplasty (PTA). The median length of the lesions was 12 cm. Forty-six stents were placed in 32 patients; 34 patients did not receive stents. The approach was contralateral in 71% (47/66) and ipsilateral in 29% (19/66) of cases. Patients were followed up with physical exam, anklebrachial index (ABI), and duplex ultrasonography. Post-intervention medical treatment included aspirin and clopidogrel. Long-term patency was correlated with age, comorbidities, risk factors, and the use of stents in addition to angioplasty. Endovascular treatment was technically successful in 65 of 66 patients (98%). Residual stenosis (30%) was found in three cases, two in patients with PTA alone and one patient with PTA and a stent. Mean length of follow-up was 6.3 months (range, 6 weeks to 15 months). Post-intervention ABI improved from a mean of 0.65 to a mean of 1.01 (p30.05). The perioperative complication rate was 9% and included three cases of hematoma and one case each of thrombosis, lymphocele, and rash reaction to medications. Outcome measures included primary patency (89%), assisted primary patency (96%), and limb salvage (97%) at 6 months. Restenosis of50% occurred in four patients and occlusion occurred in two. At 6 months, patients with one or more stents had a patency rate of 84% (27/32), whereas those without a stent had a patency rate of 94% (32/34) (p = NS). Endovascular treatment is a safe, feasible, and effective method with a high short-term patency rate and may be used as an alternative to bypass for chronic limb ischemia.

Critical deep venous thrombosis and occlusion constitutes a small percentage of patients with venous disease, who exhibit severe symptomatology. This study examined the results of multimodal percutaneous therapy for the treatment of complex critical venous thrombotic and occlusive disease. Twenty-five patients presented with critical venous thromboses or occlusions (11 with debilitating unilateral lower extremity edema causing ambulatory impairment, 2 with debilitating bilateral lower extremity edema, 3 with phlegmasia cerulea dolens, 2 with venous claudication, 2 with superior vena cava (SVS) syndrome with respiratory compromise, 4 with debilitating upper extremity edema, and 1 with renal insufficiency). Therapeutic modalities including thrombolysis, mechanical thrombectomy, percutaneous venoplasty and stent placement, temporary inferior vena cava filtration, and ultrasound guidance were used in all cases in conjunction with long-term systemic anticoagulation. The venous access site was determined by the anatomic location of the lesion and included popliteal, femoral, brachial, and lesser saphenous. Patients were followed with clinical exam and duplex surveillance. Resolution of symptoms was achieved in 18 of 25 patients (72%) and partial resolution occurred in 4 of 25 (16%). Failure of treatment identified as both lack of clinical response and evidence of continued venous thrombosis occurred 3 of 25 patients (12%). Restoration of arterial pulses and limb salvage was achieved in the three patients with phlegmasia cerulea dolens and acute limb-threatening ischemia. Both patients with SVC syndrome experienced resolution of respiratory compromise and facial edema. The mean length of follow-up was 11 +/- 2.7 months. Complications included transfusion requirement (2), hematuria (2), retroperitoneal hematoma (1), and cellulitis (1). Acute critical venous thrombotic and occlusive disease is responsive to multimodal percutaneous treatment. The relief of pain and resolution of acutely life and limb-threatening conditions in this most severely symptomatic subset of patients represents the immediate goal of treatment.

The purpose of this study was to assess the technical feasibility and early outcome of tibial angioplasty for a subset of patients with limb-threatening ischemia who were not candidates for bypass grafting. A retrospective analysis was conducted of 19 patients (7 male, 12 female) who underwent crural angioplasty for limb-threatening ischemia using 0.018- or 0.014 inch-based systems. Contraindications to bypass were insufficient conduit in 7 patients and severe comorbid illness in 12. Concurrent treatment of inflow lesions was performed in 12 of 20 limbs via either angioplasty alone (5) or combined with stenting (12). Outcome measures were ankle-brachial indices (ABI), relief of rest pain, and healing or healed wounds. Twenty-three vessels were treated, including 14 tibial occlusions and 9 stenoses. The average length of diseased segment was 11 cm (range, 3-25 cm). Thirteen of 14 occlusions were treated with subintimal recanalization, the remainder with laser recanalization. Technical success was achieved in 22 of 23 treated vessels. Mean preoperative ABI was 0.53 and mean postoperative ABI was 0.85. Palpable pulses were present in 11 of 20 limbs (55%). There was one perioperative mortality (5.2%). Mean follow-up was 3 months. Three failures occurred requiring amputation (15.8%). The remaining 16 patients were improved with healing (8) or healed (4) wounds and relief of rest pain (4). These results indicate that technical success may be achieved with outflow lesion angioplasty in the majority of patients encountered. The durability of this method of therapy is unknown, and our length of follow-up is not sufficient to answer this question. However, an attempt at angioplasty appears justified before primary amputation and before surgical bypass in those patients at high risk for intervention.

The treatment of carotid artery stenosis currently constitutes a major component of vascular surgical practice. Carotid angioplasty and stenting (CAS), however, is mainly performed by nonvascular surgeon interventionalists with cerebral protection devices available only through investigational protocols. This study reports the initial results of a CAS program initiated and performed by vascular surgeons using commercially available cerebral protection devices. Fifty-seven patients were enrolled in the study over a 14-month period. All patients were at high risk for conventional endarterectomy (7 resentosis, 4 irradiation, and 46 medically high-risk ASA III). Mean age was 75.7 years (range, 45-93 years). High-grade stenosis of the carotid artery was present in all cases (mean stenosis, 85%; range, 80-99%). Twenty-four percent of patients were symptomatic. Cerebral protection was performed with an occlusion balloon-wire in 32 cases and with a filter-wire device in 24; no cerebral protection was used in 1 patient with restenosis after endarterectomy. Initially in the study, atropine was administered selectively for the development of bradycardia. Currently atropine is administered routinely prior to the initial balloon angioplasty of the carotid bulb. Clopidogrel (75 mg/day) was administered for 5 days prior to CAS and for 30 days after CAS. All 57 patients underwent successful dilatation of their carotid stenoses without occlusion or dissection. Ten of 32 patients in whom balloon occlusion was used for cerebral protection exhibited transient evidence of cerebral ischemia during protection balloon occlusion. These symptoms resolved completely without permanent neurological deficit in all cases. Development of bradycardia with a heart rate