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Background: The “crescent sign” is a hyperattenuating crescent-shaped region on CT within the mural thrombus or wall of an aortic aneurysm. Although it has previously been associated with aneurysm instability or impending rupture, the literature is largely based on retrospective analyses of urgently repaired aneurysms. We strove to more rigorously assess the association between an isolated “crescent sign” and risk of impending aortic rupture. Methods: Patients were identified by querying a single health system PACS database for radiology reports noting a crescent sign. Adult patients with a CT demonstrating a descending thoracic, thoracoabdominal, or abdominal aortic aneurysm and “crescent sign” between 2004 and 2019 were included, with exclusion of those showing definitive signs of aortic rupture on imaging. Results: A total of 82 patients were identified. Aneurysm size was 7.1 ± 2.0 cm. Thirty patients had emergent or urgent repairs during their index admission (37%), 19 had elective repairs at a later date (23%), and thirty-three patients had no intervention due to either patient choice or prohibitive medical comorbidities (40%). Patients without intervention had a median follow up of 275 days before death or loss to follow up. In patients undergoing elective intervention, 6,968 patient-days elapsed between presentation and repair, with zero episodes of acute rupture (median 105 days). Patients undergoing elective repair had smaller aneurysms compared to those who underwent emergent/urgent repair (6.2 ± 1.3 vs 7.7 ± 2.1 cm, p = 0.008). No surgical candidate with an aneurysm smaller than 8 cm ruptured. There were 31 patients with previous axial imaging within 2 years prior to presentation with a “crescent sign”, with mean aneurysm growth rate of 0.85 ± 0.62 cm per 6 months [median 0.65, range 0 – 2.6]. Those with aneurysms sized below 5.5 cm displayed decreased aneurysm growth compared to patients with aneurysm's sized 5.5 – 6.5 cm or patients with aneurysms greater than 6.5 cm (0.12 vs 0.64 vs 1.16 cm per 6 months, p = 0.002). Conclusions: The finding of an isolated radiographic “crescent sign” without other signs of definitive aortic rupture (i.e. hemothorax, aortic wall disruption, retroperitoneal bleeding) is not necessarily an indicator of impending aortic rupture, but may be found in the setting of rapid aneurysm growth. Many factors, including other associated radiographic findings, aneurysm size and growth rate, and patient symptomatology, should guide aneurysm management in these patients. We found that patients with minimal symptoms, aneurysm sizes below 6.5 cm, and no further imaging findings of aneurysm instability, such as peri-aortic fat stranding, can be successfully managed with elective intervention after optimization of comorbid factors with no evidence of adverse outcomes.

Intravascular ultrasound (IVUS) examination is an integral technique used for treating type B aortic dissection (TBAD) because it verifies true lumen access. The purpose of this study was to evaluate the use of IVUS, to determine factors associated with IVUS use, and to investigate the potential survival benefit associated with IVUS in the treatment of TBAD.A retrospective review of TEVARs performed for TBAD in the national Vascular Quality Initiative was performed from January 2010 to August 2018. Data collected included demographics, intraoperative and postoperative variables, and long-term mortality. Multivariable logistic regression evaluated variables associated with IVUS the use and mortality, and Cox regression was performed for adjusted survival analysis.In this study of 2686 patients, the average age was 60.4 years, 69.3% were male, and IVUS examination was used in 74.6% of cases. IVUS patients were younger (60.0 years vs 61.7 years; P = .004), more often male (72.1% vs 61.3%; P .001), exhibited less coronary disease, but had higher preoperative creatinine (1.27 ± 0.89 mg/dL vs 1.14 ± 0.68 mg/dL; P .001) and were more often treated in the acute setting (55.2% vs 49.7%; P = .03). Interestingly, there were no differences in contrast use (117.4 ± 77.6 mL vs 123.0 ± 81.90.1 mL; P = .11) or fluoroscopy time (20.3 ± 16.5 minutes vs 19.0 ± 22.1 minutes; P = .10). However, IVUS cases had a greater number of devices implanted (1.84 vs 1.65; P .001), higher rates of Zone 0 to 2 proximal seal (43.9% vs 30.7%; P .001), higher rates of distal seal zones beyond the diaphragm (53.9% vs 37.4%; P = .001), and larger proximal and distal graft diameters, with no differences in postoperative renal function. IVUS patients notably also had higher rates of follow-up imaging (61.3% vs 54.8%; P = .003), larger maximum aortic diameters at follow-up, and more reinterventions over time. The number of aortic devices (odds ratio [OR] 1.56; 95% confidence interval [CI], 1.24-1.97; P .001), malperfusion indication (OR, 1.68; 95% CI, 1.17-2.42; P = .005) and distal seal zone beyond the diaphragm (OR, 1.64; 95% CI, 1.30-2.07; P .001) were independently associated with IVUS use, whereas female gender showed a trend towards less IVUS use (OR, 0.79; 95% CI, 0.62-1.01; P = .063). Even after controlling for age, preoperative comorbidities, and postoperative complications like spinal cord ischemia, IVUS was associated with a 61% decrease in the odds of mortality (OR, 0.39; 95% CI, 0.20-0.78; P = .008), with a clear survival advantage shown in adjusted survival curves.IVUS examination was used in the majority of TBAD, although not universally. IVUS examination was used more often in acute TBAD and more complex aortic repairs, and was independently associated with improved long-term survival. Further study is needed to understand these patterns.

This case describes a patient who underwent endovascular repair for an extent V thoracoabdominal aneurysm with planned coverage of the celiac artery. Following deployment of the stent graft, the superior mesenteric artery was shuttered, and the patient subsequently developed signs and symptoms of bowel ischemia. The patient underwent successful retrograde open superior mesenteric artery stenting with resolution of her symptoms. Although retrograde open mesenteric artery stenting (ROMS) has been primarily shown to be effective in acute mesenteric ischemia, this case demonstrates that ROMS can be used as a salvage option for shuttering during endovascular procedures.

Length of stay (LOS) is a commonly used metric to optimize value in medical care. Although pathways have been developed for some procedures in vascular surgery to reduce LOS, they do not yet exist for thoracic endovascular aortic repair (TEVAR). The purpose of this study is to identify and define the risk factors for prolonged LOS in patients undergoing TEVAR to facilitate pathway development.We included TEVAR patients in the National Surgical Quality Improvement Program database from 2005 to 2015. Prolonged LOS was defined as LOS75th percentile of the overall cohort (11 days). Because initial analysis revealed the distinct clinical differences between dissection and aneurysm patients, further analysis was stratified by aortic pathology. Student's t-test and Chi-square tests were used to compare demographic and perioperative variables between dissection and aneurysm patients, respectively. Multivariable logistic regression was used to evaluate the predictors for prolonged LOS.A total of 3,021 patients underwent TEVAR, with 858 patients (28.4%) undergoing TEVAR for dissection and 2,163 (71.6%) undergoing TEVAR for aneurysm. An initial analysis with logistic regression identified dissection indication (odds ratio [OR], 2.87; 95% confidence interval [CI], 1.1-7.3) as an independent predictor of prolonged LOS. Further analysis for prolonged LOS was subsequently performed separating dissection and aneurysm patients. Aneurysm patients were older (71.2 ± 11.7 vs. 63.1 ± 13.6 years, P 0.001), more often Caucasian (76.8% vs. 61.8%, P 0.001), and had more medical comorbidities (chronic obstructive pulmonary disease, cardiac history, diabetes, peripheral vascular disease, transient ischemic attack [TIA], P 0.001). In contrast, dissection patients had higher American Society of Anesthesiology (ASA) classification score (58.5% had3 ASA vs. 45.5%, P 0.001), longer hospitalizations (10.2 ± 9.3 vs. 8.5 ± 10.4 days, P 0.001), were more likely to have been transferred from another hospital or emergency room (58.4% vs. 48.3%, P 0.001), and were more often emergent (32.4% vs. 15.4%, P 0.001). In dissection patients, ASA classification score (OR, 1.49; 95% CI, 1.1-2.1) and dialysis (OR, 1.98; 95% CI, 1.0-3.9) were independent predictors for prolonged LOS. In aneurysm patients, dependent functional status (OR, 2.03; 95% CI, 1.4-2.8), diabetes (OR, 1.75; 95% CI, 1.1-2.8), cardiac history (OR, 1.37; 95% CI, 1.0-1.9), emergency status (OR, 1.98; 95% CI, 1.4-2.8), and dialysis (OR, 2.08; 95% CI, 1.2-3.7) predicted prolonged LOS. Postoperative complications including stroke/TIA; failure to wean from ventilator, sepsis, and pneumonia; and need for reoperation similarly increased LOS in both dissection and aneurysm patients.Dissection and aneurysm patients undergoing TEVAR are comprised of different patient populations, with dissection patients more often enduring prolonged hospitalizations. In contrast, TEVAR performed for nonemergent aneurysm repair had the shortest LOS. These data support the development of separate pathways defined by indication and acuity for patients undergoing TEVAR.

Type B aortic dissection (TBAD) complicated by malperfusion carries high morbidity and mortality. The present study was undertaken to compare the characteristics of malperfusion and uncomplicated cohorts and to evaluate the long-term differences in survival using a granular, national registry.Patients with TBAD entered into the thoracic endovascular aortic repair/complex endovascular aortic repair module of the Vascular Quality Initiative from 2010 to 2019 were included. The demographic, radiographic, operative, postoperative, in-hospital, and long-term reintervention data were compared between the malperfusion and uncomplicated TBAD groups using t tests and χOf the 2820 included patients, 2267 had uncomplicated TBAD and 553 had malperfusion. The patients with malperfusion were younger (age, 55.8 vs 61.2 years; P .001), were more often male (79.7% vs 68.1%; P .001), had a higher preoperative creatinine (1.8 vs 1.1 mg/dL; P .001), had more often presented with an American Society of Anesthesiologists class of 4 or 5 (81.9% vs 58.4%; P .001), and had more often presented with urgent status (77.4% vs 32.8%; P .001). In contrast, the uncomplicated TBAD group had had more medical comorbidities, including coronary artery disease and chronic obstructive pulmonary disease, and a larger aortic diameter (4.0 cm vs 4.9 cm; P .001). The malperfusion group more frequently had proximal zones of disease in zones 0 to 2 (38.6% vs 31.5%; P = .002) and distal zones of disease in zones 9 and above (78.7% vs 46.2%; P .001), with a greater number of aortic zones traversed (7.7 vs 5.1; P .001) and a greater frequency of dissection extension into branch vessels (61.8% vs 23.1%; P .001). Patients with malperfusion also exhibited greater case complexity, with a greater need for branch vessel stenting and longer procedure times. The overall incidence of postoperative complications was greater in the malperfusion group (39.4% vs 17.1%; P .001) and included a greater rate of spinal cord ischemia (6.3% vs 2.2%; P .001), acute kidney injury (10.4% vs 0.9%; P .001), and in-hospital mortality (11.6% vs 5.6%; P .001). In-hospital reintervention was also greater for the malperfusion patients (14.5% vs 7.4%; P .001), although the incidence of long-term reinterventions was similar between the two groups (8.7% vs 9.7%; P = .548). A proximal zone of disease in zone 0 to 2 was associated with decreased survival. In contrast, a distal zone of disease in 9 and above, in-hospital reintervention, and long-term follow-up were associated with increased survival. Despite these differences, long-term survival did not differ between the malperfusion and uncomplicated groups (P = .320.) CONCLUSIONS: Patients presenting with TBAD and malperfusion represent a unique cohort. Despite the greater need for branch vessel stenting and in-hospital reintervention, they had similar long-term reintervention rates and survival compared with those with uncomplicated TBAD. These data lend insight with regard to the observed differences between uncomplicated and malperfusion TBAD.

Current guidelines recommend single-agent antiplatelet therapy for patients with symptomatic peripheral artery disease and consideration of dual antiplatelet therapy (DAPT) after surgical revascularization. The objective of this study was both to explore prescribing patterns of single antiplatelet therapy vs DAPT after lower extremity bypass surgery and to investigate the effects of antiplatelet therapy on bypass graft patency.A retrospective analysis of prospectively collected nonemergent infrainguinal lower extremity bypass operations entered in the national Vascular Quality Initiative (2003-2018) with captured long-term follow-up was performed. Patients discharged on aspirin monotherapy or DAPT were identified. Linear regression investigated temporal trends in antiplatelet use. Multivariable Cox regression investigated predictors of primary, primary assisted, and secondary patency.Of the 13,020 patients investigated, 52.2% were discharged on aspirin monotherapy and 47.8% on DAPT. The proportion of patients discharged on DAPT increased from 10.6% in 2003 to 60.6% in 2018 (P .001). The DAPT cohort was younger, had higher rates of medical (hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease) and atherosclerotic (coronary artery disease, prior coronary artery bypass graft or percutaneous coronary intervention, prior lower extremity intervention) comorbidities, and had higher risk bypass procedures (more distal targets, prior inflow bypass procedure, prosthetic conduit use). Multivariable Cox regression analysis did not show any difference between the DAPT and aspirin cohorts in primary patency (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.88-1.10; P = .78), primary assisted patency (HR, 0.93; 95% CI, 0.80-1.07; P = .30), or secondary patency (HR, 0.88; 95% CI, 0.74-1.06; P = .18). On subgroup analysis based on bypass conduit, DAPT was found to have a protective effect on patency only in the prosthetic bypass cohort (primary patency: HR, 0.81 [95% CI, 0.66-1.00; P = .05]; primary assisted patency: HR, 0.74 [95% CI, 0.58-0.94; P = .01]; and secondary patency: HR, 0.60 [95% CI, 0.44-0.82; P .001]). No patency differences were observed on adjusted subgroup analysis for the other bypass conduits.A significant and increasing proportion of patients are discharged on DAPT after lower extremity bypass revascularization. These patients represent a higher risk cohort with more medical comorbidities and higher risk bypass features. After controlling for these differences, DAPT therapy had no beneficial effect on overall bypass graft patency or major adverse limb events. However, on subgroup analysis, DAPT was associated with improved bypass graft patency in patients receiving prosthetic bypass conduits. Further study is warranted to investigate optimal duration of DAPT therapy and its possible bleeding complications in prosthetic bypass patients.

Published rates of reintervention after endovascular aneurysm repair (EVAR) range from 10% to 30%. We evaluated a single university center's experience with reinterventions in the context of Food and Drug Administration (FDA)-approved and trial devices.Retrospective data collection was performed for patients who underwent infrarenal EVAR and required reintervention from 2000 to 2016. Trial devices included those used in FDA feasibility and pivotal trials. Time-to-event analysis was performed using Cox regression. Predictors of mortality and explantation were evaluated using logistic regression; survival analysis was performed using Kaplan-Meier methods.From 2000 to 2016, there were 1835 EVARs performed, and 137 patients (116 men; mean age, 72.2 ± 10.0 years) underwent reintervention with a mean aneurysm size of 5.9 ± 1.2 cm. The median follow-up was 5 years with an overall survival of 70.1%. The overall reintervention rate was 7.5%. FDA-approved devices had a reintervention rate of 6.4%, whereas trial devices had a rate of 14.4% (P .001). For all devices, the most common cause of reintervention was type II endoleak (52.5%), followed by type I endoleak (18.2%), type III endoleak (9.5%), limb kink (7.3%), iliac occlusive disease (5.8%), endotension (1.5%), and other. The overall mean time to first reintervention was 2.3 ± 2.5 years, and univariate Cox regression identified male gender (hazard ratio, 1.91; 95% confidence interval [CI], 1.17-3.10; P = .010) and age at the time of EVAR (hazard ratio, 1.03; 95% CI, 1.01-1.05; P = .006) as risk factors for time to first reintervention. Among patients requiring reintervention, the mean number of reinterventions for trial devices was significantly greater than that for FDA-approved devices (2.18 vs 1.65; P = .01). Trial devices requiring reintervention had a nearly threefold higher odds for the need for more than two reinterventions (odds ratio, 2.88; 95% CI, 1.12-7.37; P = .034). Trial device, cause of reintervention, and type of reintervention were not predictive of the need for explantation or mortality, but the number of reinterventions was significantly associated with the need for explantation (odds ratio, 1.86; 95% CI, 1.17-2.96; P = .012). EVAR device and the need for explantation did not have an impact on mortality.Despite the rigorous nature of patient enrollment in clinical trials and the development of newer iterations of investigational devices, patients undergoing EVAR with trial devices are more likely to undergo a greater number of reinterventions than with FDA-approved devices. Although mortality and the need for explantation were not significantly associated with trial devices, the finding of a greater number of reinterventions highlights the need to properly inform patients willing to partake in investigational device trials.

There has been growing scrutiny in the treatment of patients with peripheral artery disease due to the utilization of resources to manage this complex patient population. The purpose of this study was to determine the factors associated with prolonged length of stay (LOS7 days) following lower extremity bypass using data from the Vascular Quality Initiative as well as to define the additional costs incurred due to prolonged LOS in our health system.Summary statistics were performed of patients undergoing lower extremity bypass from 2010 to 2015. Student's t-tests and χThis study included 334 patients with a mean age of 66.4 ± 12.4 years, 64.7% males, 58.5% of white race, 11.1% on dialysis, 80.5% smokers, and 53.6% with diabetes. The mean LOS was 15.7 ± 12.2 days. Prolonged LOS was associated with transfer (15.4% vs. 2.3%, P = 0.001), diabetes (58.3% vs. 40.2%, P = 0.004), critical limb ischemia (71.3% vs. 49.4%, P 0.001), preoperative need for ambulatory assistance (44.5% vs. 16.1%, P 0.001), prior ipsilateral bypass (6.9% vs. 1.1%, P = 0.042), urgent surgery (39.7% vs. 9.8%, P 0.001), tibial or distal target vessel (52.7% vs. 28.0%, P 0.001), use of vein (65.4% vs. 46.3%, P = 0.002), return to operating room (42.6% vs. 1.2%, P 0.001), ambulatory assistance (65.0% vs. 34.1%, P 0.001) as well as discharge anticoagulant (22.8% vs. 9.8%, P = 0.010). Multivariable logistic regression identified urgency (odds ratio [OR] = 5.09, 95% confidence interval [CI] 2.16-12.02, P 0.001), critical limb ischemia (OR = 3.12, 95% CI 1.65-5.90, P 0.001), return to OR (OR = 40.30, 95% CI 5.36-303.20, P 0.001), use of vein (OR = 2.19, 95% CI 1.18-4.07, P = 0.013), and the need for anticoagulation at discharge (OR = 2.56, 95% CI 1.03-6.33, P = 0.043) as independent predictors of LOS7 days. Prolonged hospital stays accounted for an additional $40,561.64 in total cost and $26,028 in direct costs incurred. Despite these increased costs, limb salvage and overall survival were not adversely impacted in the prolonged LOS group in follow-up.Lower extremity bypass is associated with a longer than expected LOS in our health system, much of which can be attributed to return to the OR for minor amputations and wound issues. This led to added total and direct costs, where the majority of this increase was attributable to prolonged LOS. Limb salvage and overall survival were preserved, however, in this subset of patients in follow-up. These findings suggest that lower extremity bypass patients are a resource-intensive population of patients, but that these costs are worthwhile in the setting of preserved limb salvage and overall survival.

Background The morbidity and mortality of thoracic blunt aortic injury (BAI) has been both diminished and revolutionized by the advent of endovascular repair. Nevertheless, the question remains as to what severity of injury requires endovascular repair. We therefore conducted a retrospective analysis of our experience with nonoperative grade II BAI of the thoracic aorta. Methods The records of patients with BAI from 2007 to 2017 at a Level I trauma center were retrospectively reviewed. Images were reviewed and graded by a radiologist according to the Society of Vascular Surgery Guidelines (grade I–IV). Demographics, injury severity, and outcomes were recorded. Results We identified 111 patients with BAI. Of these, 15 were deemed grade II injuries and were managed nonoperatively. Mean patient age was 45 ± 21 years; 60% of patients were male. The mean injury severity scale was 36 ± 13. No patients had progression of BAI to a more severe grade requiring intervention. Until now, the survival rate is 86.7% with a mean follow-up of 69 months (range 7–138). Conclusions Within the grade II BAI cohort, injury progression did not occur, nor were any operative interventions performed. We conclude that grade II BAI can be managed nonoperatively. However, given that progression of the BAI is possible, follow-up aortic imaging is encouraged as well as appropriate blood pressure control and exercise restriction.

Objective: To review the current use of endovascular techniques in trauma. Summary Background Data: Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma. Methods: The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines. Results: Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability. Conclusions: The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.

The aim of this study was to examine practice patterns of inferior vena cava (IVC) filter insertion and retrieval at a tertiary care institution.A retrospective review of all IVC filter procedures performed at the University of Pennsylvania and entered into the Penn cohort of the Vascular Quality Initiative registry between January 2013 and September 2017 was performed. Data collected included demographics, venous thromboembolism risk factors, indications for filter placement, and presence and timing of retrieval. Trend analysis and multivariable logistic regression were performed to evaluate factors associated with failure to retrieve the filter.During the study period, 627 IVC filters were inserted. The mean age was 52.8 ± 16.9 years, and 49.3% were male; 39.2% were placed for a major indication, whereas 58.1% were placed for prophylaxis. There was a significant decline in overall frequency of filter placement during the period observed, with a 33% decrease from 2015 to 2016 and a 26% decrease from 2016 to 2017 (P .001), with an overall retrieval rate of 44.9%. In contrast, there was a corresponding increase in filter retrieval, with a 20% increase in 2015 and a 68% increase in 2016 (P = .02). In evaluating trends separated by indication, there was a significant decline in prophylactic filter placement (P .001) and a trend toward an increase in retrieval of prophylactic filters (P = .09). Whereas there was not a significant change in number of filter insertions for major indication (P = .06), filter retrievals for major indication filters increased (P = .01). Multivariable regression analysis revealed that longer time to follow-up (odds ratio [OR], 1.08; P .001) and discharge to rehabilitation facility (OR, 6.14; P .001) were predictive of failure to retrieve the filter. In contrast, filter placement at a later date within our study period (OR, 0.90; P .001) and prophylactic indication for filter placement (OR, 0.36; P .001) were protective from filter nonretrieval.These results show both a decline in overall IVC filter placement and an increase in overall IVC filter retrieval at our institution. These trends are predominantly due to a decrease in prophylactic filter placement as well as an overall increase in filter retrieval. Further study should be dedicated to increasing the retrieval rate in this population of patients.

Fistula first initiative is the recommended guideline for hemodialysis access. The creation of distal radiocephalic fistula often is not an option; additionally, non-maturation of created fistula leads to use of arm vessels which increases the risk of complications. Proximal forearm fistula even though overlooked may be a viable option with reasonably good outcomes and patency. The case describes proximal radiocephalic fistula (pRCF), ulnar-basilic AVF (UBAVF), and transposed radio-basilic fistula (tRBF) of the forearm and techniques and outcomes.

Cerebral hyperperfusion syndrome represents a clinical spectrum characterized by severe unilateral headache, acute changes in mental status, vomiting, seizures, focal neurologic deficits, and, in its most severe form, intracranial hemorrhage. With the exception of one early case report, reperfusion injury to the brain following carotid endarterectomy has been reported only ipsilateral to the side of surgery. We report the unique case of a patient with symptomatic severe right internal carotid artery stenosis and contralateral carotid occlusion who underwent carotid endarterectomy complicated by cerebral hyperperfusion syndrome and associated bilateral intracranial hemorrhage.

Low-grade endometrial stromal sarcoma with intracaval and intracardiac extension represents a complex and often lethal condition. A case of a 40-year-old woman, who underwent hysterectomy for endometrial stromal sarcoma 4 years previously and developed recurrence with intracaval and intracardiac metastases, is presented. Operative management of resection of the intracaval and intracardiac tumor is described. The literature is reviewed in order to highlight the data on diagnosis and management of recurrent endometrial stromal sarcoma with vascular involvement, including the multimodality approach required in treating this disease.

Ischemia monomelic neuropathy is rare and underrecognized complication of hemodialysis access (HA), characterized by diffuse multiple mononeuropathies in the absence of significant clinical ischemia. It is important to diagnose this syndrome early because ligation of the HA is the most accepted treatment to prevent or at least halt irreversible neural dysfunction and therefore, chronic pain and disability. Literature describing this fistulae-related pathology is rare, and we attempt to increase its awareness.

Background The neoaortoiliac system (NAIS) has gained popularity as a durable procedure for treating aortic graft infections. However, one of the disadvantages has been a long operation that can take up to 10 hours. The goal of this study was to assess the feasibility of staging the NAIS procedure with deep vein harvest a day before the aortofemoral bypass and evaluate if staging had any effect on graft patency or morbidity and mortality, or both. Methods We reviewed data for all the NAIS procedures performed for aortic graft infections at a tertiary care university hospital. The femoral popliteal veins of patients undergoing the staged NAIS were harvested a day in advance and left in situ. The next day patients underwent the prosthetic graft excision with reconstruction using the femoral popliteal veins. Patients with aortic occlusion on presentation were not candidates for vein harvest in advance and underwent a unilateral bypass with a subsequent femorofemoral bypass as a second stage. Results In the last 8 years, 26 patients (17 men, 9 women; mean age, 62.6 ± 8.3 years) underwent the NAIS procedure for aortic graft infections. Mean follow-up was 15.7 months. Primary assisted graft patency was 100%. There were 11 patients in the staged group and 10 patients in the nonstaged group. All the staged patients underwent vein mobilization a day before excision of aortic prosthesis. Despite undergoing a separate procedure for vein harvesting at a different time, there was no difference in total operative time (12.0 ± 1.8 vs 11.9 ± 2.2 hours), operative blood loss (2.6 ± 1.2 vs 3.4 ± 2.4 L), and requirements for transfusion for blood products (6.7 ± 3.7 vs 6.0 ± 5.4 U) or crystalloid (11.3 ± 3.1 vs 10.9 ± 2.4 L) between the staged group and nonstaged groups. One amputation occurred in each group. The perioperative mortality was 18% for the staged group and 20% for nonstaged group. The 12-month survival was 72% for staged and 70% for nonstaged NAIS. No graft-related complications were observed from the preoperative vein harvest. Conclusion The NAIS can be staged without compromising the efficacy of the procedure as evident by excellent long-term patency and control of the infection. By reducing the duration of the primary procedure, staging may be beneficial to both the patient and the surgeon.

The diagnosis of median arcuate ligament (MAL) syndrome and its correlation with symptoms has been controversial since the disease entity was described. The authors describe a technique that will identify patients who will benefit from intervention. Eight patients with isolated celiac artery compression from MAL were identified by the authors. Their technique involved selective cannulation of the superior mesenteric artery (SMA) and injection of a vasodilator during angiography. Symptom reproduction and loss of collateral filling of the celiac territory represented a positive test: 4 of the 8 patients had a positive test and underwent successful surgical treatment of the condition; 3 of them remained asymptomatic at follow-up; 1 patient continues to have mild abdominal discomfort. Of the 4 patients with a negative test, 2 were found to have other conditions causing their symptoms. Vasodilator injection into the SMA is a useful diagnostic test to identify patients with symptomatic MAL syndrome.

Carotid endarterectomy (CEA) and more recently carotid artery stenting are the treatments of choice for atherosclerotic disease of the extracranial carotid arteries; however, early restenosis caused by neointimal hyperplasia confounds surgical therapy. Oxidative stress has been implicated in the progression of intimal hyperplasia. The authors hypothesized that ketorolac tromethamine (Toradol), a nonsteroidal antiinflammatory drug that is a potent cyclooxygenase inhibitor, would decrease oxidative stress and thereby reduce intimal hyperplasia in a rat CEA model. Twenty-nine male Sprague-Dawley rats underwent CEA and were divided into 3 treatment groups as follows: (1) control (placebo), (2) 7.5 mg/kg Toradol, and (3) 10 mg/kg Toradol. Toradol treatment began 2 days before CEA and continued for 2 weeks. Two weeks after endarterectomy, carotid arteries were fixed, harvested, and examined for platelet activity (platelet reactive units), oxidative stress (malondialdehyde and glutathione), and intimal hyperplasia (measured as percentage of luminal stenosis). Platelet activity, malondialdehyde and glutathione, and intimal hyperplasia were all significantly lowered in both 7.5- and 10-mg/kg doses of Toradol versus control. Toradol given daily beginning 2 days before CEA and ending 2 weeks after the procedure was effective at significantly reducing platelet activity, oxidative stress, and intimal hyperplasia development in the rat without any increase in bleeding. Although the mechanism of action of this reduction is not completely understood, one possible explanation may be through the inhibition of reactive oxygen species production.

Endovascular treatment for Transatlantic Inter-Society Consensus (TASC) D lesions of the superficial femoral artery has been disappointing. This has been attributed to a bulking atheromatous plaque. Debulking the superficial femoral artery allows for a larger lumen, whereas covering the lumen with an endograft provides in-line flow. We evaluated the intermediate results of remote superficial femoral artery endarterectomy with covered endograft placement in 18 patients. Patient demographic, vascular laboratory, and preoperative data were gathered retrospectively. The procedure was technically successful in all the patients. The mean age was 62.2 ± 9.9 years. Ankle brachial index improved from 0.35 ± 0.1 to 0.86 ± 0.1. The cumulative 12-month primary patency was 42.2%, whereas assisted primary or secondary patency was 70.8%. Five endografts occluded within the 12 months. Two of those patients underwent subsequent femoral-to-below-knee bypass, whereas 2 had major amputations. Remote superficial femoral artery endarterectomy can be reasonably offered if an autogenous conduit is not available for revascularization of the superficial femoral artery.

According to data reported by the American Heart Association, more than 5 million diagnostic and therapeutic catheterizations are performed each year in the United States. The number of catheterizations has tripled since 1979. It has been estimated that complications related to the access site result in more than 75,000 surgical procedures annually. Thus, improved management of the access site itself is essential to achieve the greater goals of improved care and reduced cost. Manual compression directly over the site of arterial puncture usually results in adequate hemostasis but has several significant drawbacks. Manual compression is uncomfortable for the patient, is fatiguing and time-consuming for staff, and necessitates several hours of costly in-hospital observation. In addition, it may be ineffective in achieving hemostasis, especially in the setting of systemic anticoagulation or following the use of large-bore devices. Based on the perceived need for an improved method of managing the arterial access site following catheterization, various vascular sealing devices have been developed. There are at least 8 (and the number is increasing) hemostatic vascular closure devices that are currently approved by the FDA for access site closure after femoral arterial catheterization. The chief advantage attributed to vascular sealing devices is accelerated access site hemostasis, even in the setting of anticoagulation, leading to earlier ambulation and hospital discharge following arterial catheterization. The most important drawbacks related to vascular sealing devices include the cost of the devices and the possibility of increased access site complications. Despite the paucity of properly designed studies supporting their use, it is estimated that over one million vascular sealing devices are used annually in the United States, a number that has increased dramatically in the past 5 years.In this review, we present a brief description of the design and function of the most widely used devices, describe the most common mechanisms of failure, and recommend strategies for management of access site complications including hemorrhage, arterial obstruction, and infection.

Patients with severe tibioperoneal disease are poor candidates for a distal bypass. Absence of a distal target, lack of conduit, or multiple medical problems can make these patients a prohibitive risk for revascularization. Acute on chronic ischemia in this group poses a greater challenge. Thrombolytic therapy for acute ischemia can be prolonged and carries a significant risk of bleeding if continued beyond 24 hours. However, if the ischemic limbs can be isolated from the systemic circulation, a higher dose of the lytic agent can be given with lower risk. These are the initial results of a series of 10 patients who underwent percutaneous isolated limb perfusion with a high dose of thrombolytics for severe ischemia. Ten patients (lower extremity 8 and upper extremity 2) presented with severe limb-threatening ischemia. Mean ankle/brachial index (ABI) was 0.15 for the lower extremity, and there were no recordable digital pressures in patients with upper extremity ischemia. No distal target was visible on the initial arteriogram. These patients were then taken to the operating room, and under anesthesia, catheters were placed in an antegrade fashion via femoral approach in the popliteal artery and vein percutaneously. For upper extremity, the catheters were placed in the brachial artery and vein. A proximal tourniquet was then applied. This isolated the limb from the systemic circulation. Heparinized saline was infused through the arterial catheter while the venous catheter was left open. A closed loop or an isolated limb perfusion was confirmed when effluent became clear coming out of the venous port. A high dose of thrombolytic agent (urokinase 500,000 to 1,000,000 U) was infused into the isolated limb via the arterial catheter and drained out of the venous catheter. After 45 minutes, arterial flow was reestablished. In 4 patients, Reopro ® was used in addition to thrombolytics. Postprocedure angiograms showed minimal changes, but patients exhibited marked clinical improvement. The ABI changed from 0.15 to 0.5 in the lower extremity and near-normal digital pressures in upper extremity ischemia. Limb salvage and symptomatic relief at 6 months was 90%. All patients except one were kept on anticoagulation postoperatively. No bleeding complications were observed from the procedure. Percutaneous isolated limb perfusion brought symptomatic relief to patients presenting with acute on chronic limb ischemia. This can be an alternate option for patients facing amputation with no revascularization options.

Objectives: The role of carotid stenting in the management of extracranial carotid artery occlusive disease remains controversial. Whether the results of randomized controlled trials of select patient groups can be generalized to the population at large remains uncertain. Methods: A retrospective case-control study was performed of all consecutive patients undergoing carotid artery stenting (CAS) and carotid endarterectomy (CEA) within a large rural tertiary health care system. Each CAS patient was matched with two CEA patients. Postoperative outcomes of stroke, acute myocardial infarction (AMI), and death were analyzed at 30 days, 60 days, and long-term (median follow-up 647 days; range, 0-2473 days). Hazard ratios (HR) were calculated with CEA as the reference group, and results were expressed in models adjusted for gender and stratified by age 70 years. Life-table survival estimates were generated and compared with log-rank testing.