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Background Multiple studies have demonstrated the benefits of creating arteriovenous fistulas (AVFs) under regional anesthesia. This is most likely because of the avoidance of hemodynamic instability and stress response of general anesthesia, as well as the sympathectomy associated with brachial plexus blockade. As vein diameter is the major limiting factor for primary AVF creation and maturation, our aim is to investigate if the vasodilation that accompanies regional anesthesia leads to improved patency and maturation rate of autologous AVF and improved patency of arteriovenous graft (AVG) compared with those placed under general anesthesia. Methods This retrospective study was approved by the institutional review board. A total of 238 patients who had either an AVF or an AVG placed at the Mayo Clinic, Florida, between 2012 and 2017 were analyzed. Demographics, access type, preoperative vein diameter, anesthesia type, change of plan after regional versus general anesthesia, and outcomes were assessed. All statistical tests were 2 sided, with the alpha level set at 0.05 for statistical significance. Results Among 238 patients, 120 (50.4%) had regional anesthesia. Differences between the 2 groups in risk factors and 30-day or long-term outcomes (failure, abandonment, or reoperation) were not statistically significant. Of the accesses placed under general anesthesia, 58.5% were abandoned compared with 45.2% of those placed under regional anesthesia. Owing to loss of patency, 25.8% of accesses placed under general anesthesia were abandoned compared with 19.2% of those placed under regional anesthesia. Two-month failure was higher in the general anesthesia group than that in the regional anesthesia group (P = 0.076). After preoperative vein mapping, 22 patients were originally intended to have an AVG placed under regional anesthesia. After brachial plexus blockade, 9 of these patients (41%) were successfully switched to AVF, while the other 13 followed the original surgical plan and received an AVG. Of these, 0 failed and 0 were abandoned because of loss of patency. Conclusions This study showed possible improvements in failure rates for vascular accesses placed under regional anesthesia compared with those placed under general anesthesia. In addition, we showed an impact of regional anesthesia on the surgical plan by transitioning from a planned AVG to an AVF, intraoperatively. Giving patients with originally inadequate vein diameter the chance to have the preferred hemodialysis access method by simply switching anesthesia type could reduce the number of grafts placed in favor of fistulas.

BACKGROUND: Major vascular reconstruction during a pancreaticoduodenectomy (PD), also known as a Whipple procedure, leads to controversial postoperative outcomes compared to conventional Whipple. Discussion with the patient regarding postoperative expectations is a crucial component of holistic surgical healthcare. The aim of this study was to report our 8-year experience of Whipple procedures involving vascular reconstruction and to review relevant literature to further evaluate expectant outcomes, therefore leading to more accurate discussion. METHODS: A retrospective review of patients undergoing Whipple procedures from January 2010, through December 2017 was performed. Patch, graft, and primary anastomosis during Whipple procedures were considered major vascular reconstruction. Literature on the current understanding of the outcomes associated with vascular reconstruction during Whipple procedures was reviewed. RESULTS: Twenty-nine from a total of 405 patients that met inclusion criteria had a Whipple procedure that involved major vascular reconstruction. Twelve patients were male and 17 were female (mean age, 65.2 years). Median hospital and intensive care unit (ICU) stay [range] of patients with vascular reconstruction was 12 [5–92] days and 3 [0–59] days, respectively. Thirty-day survival and 1-year survival of patients with vascular reconstruction was 93.1% and 55.2%, respectively, compared to non-vascular reconstruction patients 96.0% and 83.5%, respectively (P=0.35, P

Parallel endografts were introduced as a way to expand endovascular repair of aneurysms involving branch vessels. However, endoleaks as a result of the gutters between the parallel endografts made this technique less favorable. The "eye of the tiger" technique was introduced to reduce the gutters between the parallel endografts proximally in the aorta. We report endovascular repair of infrarenal abdominal aortic aneurysm using eye of the tiger technique distally to preserve the internal iliac arteries.

Mycotic aneurysms, especially those of the upper extremity, are rarely reported in literature. These aneurysms are caused by bacterial endocarditis and, therefore, are more commonly seen in patients who are in an immunocompromised state, including those requiring bacillus Calmette-Guerin (BCG) therapy for bladder cancer. Owing to the inevitable rupture of mycotic aneurysms, the standard treatment is surgical repair with appropriate secondary antibiotics. We present a unique case of a mycotic ulnar artery aneurysm following BCG therapy and repetitive hand trauma in a patient with bladder cancer that was successfully repaired with microsurgical techniques and secondary antibiotics.

Aortic disease becomes more prevalent with age and can result in acute aortic conditions including aneurysm, dissection, intramural hematoma and penetrating ulcers. Repair techniques for these conditions remain controversial due to the varying outcomes of studies. This retrospective study collected and analyzed data from twenty-three (23) patients with complex aortic aneurysms repaired using hybrid open-endovascular techniques. A high percentage of patients (82.6%) suffered from multiple comorbidities, including hypertension, hyperlipidemia, renal disease, coronary artery disease, congestive heart failure and prior aortic procedures. All patients presented with ASA scores 3 or 4. Eleven patients (47.8%) presented with aneurysms of the ascending, transverse and descending arch, and seven patients (30.4%) with thoracoabdominal aneurysm. 78.3% of patients underwent thoracic vessel debranching, while the remainder underwent visceral vessel debranching (13.0%) or thoracic and visceral debranching (8.7%). No patients suffered visceral ischemia, spinal cord injury, extremity amputation or reoperation for bleeding post-operatively. Two patients suffered minor stroke (8.7%) and one patient (4.3%) had major stroke. Three patients (13.0%) suffered temporary kidney injury and one patient (4.3%) developed renal failure requiring dialysis. Four patients (17.4%) developed Type II stent graft endoleaks. All patients had patent grafts. Reintervention occurred in two patients (8.7%). Thirty-day mortality occurred in three patients (13.0%). These results are within the range reported in other studies involving hybrid repair of aortic conditions, and show that hybrid open-endovascular repair is a feasible alternative in high-risk patients.

Background: Ferumoxytol is an Ultrasmall Superparamagnetic Iron Oxide (USPIO) which has demonstrated promise as a novel contrast agent with an excellent safety profile in patients with CKD. Our aim was to evaluate the safety and utility of this agent for diagnosis and operative planning in the setting of PAD and CKD. A comparison with digital subtraction angiography is also provided. Methods: Between April, 2013 and September, 2014 seven patients with renal insufficiency (CKD ≥ Stage 3) and symptomatic PAD underwent Fe-MRA. This was followed by DSA limited to the vascular bed with significant stenosis as detected by Fe-MRA. Renal function was assessed before and after each procedure. Images were qualitatively scored at the iliac, femoral, popliteal and tibial levels by two interventional radiologists. Degree of stenosis was also scored for comparison. Results: Seven male patients were studied with a mean age of 75 years (64-92). 5 therapeutic procedures (4 endovascular and 1 open) were performed. There were no statistically significant differences in creatinine or GFR after Fe-MRA or DSA. Iodinated contrast load (mg I) for DSA was reduced in comparison with age and disease matched controls (8240 ± 5206 vs. 29320 ± 15605, p=0.001). No statistically significant differences were found for degree of stenosis or mean image quality score below the iliac level. There were no adverse events in response to Ferumoxytol administration. Conclusion: Fe-MRA provides image quality and estimation of degree of stenosis comparable to DSA. Fe-MRA may serve as an alternative to CTA or gadoliniumbased MRA for patients with end-stage renal disease.

Purpose: Mycotic aortic aneurysms are rare but are associated with high morbidity and mortality due to their propensity for rupture. Traditional therapy consists of open surgical repair with resection and aortic reconstruction or extra-anatomic bypass combined with long-term antibiotic therapy. Case report: An 85-year-old male with persistent bacteremia was found to have a descending mycotic aortic aneurysm. Surgical options were discussed and endovascular treatment was recommended with stent-graft placement followed by intra-aortic rifampin infusion. This approach led to resolution of the aneurysm and eradication of bacteremia at 4-month follow-up. Conclusion: By combining traditional surgical strategies with a contemporary endovascular approach, the perioperative mortality and long-term risk of infection associated with mycotic thoracic aneurysms can potentially be decreased.

Examinamos las alteraciones subclinicas de la funcion cerebral y la incidencia de lesiones cerebrales tras la endarterectomia carotidea (EAC), y su relacion con las concentraciones perioperatorias de marcadores bioquimicos de lesion cerebral (S100B y enolasa neuroespecifica [ENE]). Participaron 20 pacientes consecutivos con una estenosis carotidea asintomatica ≥ 70% sometidos a EAC programada. Las pruebas pre y postoperatorias incluyeron resonancia magnetica nuclear (RMN) cerebral, examen neurologico estandarizado, bateria de pruebas neuropsicologicas, y determinacion de las concentraciones sericas de S100B y ENE. No se produjeron ictus isquemicos mayores. Durante el examen neurologico de un paciente se descubrio una debilidad leve de la extremidad inferior contralateral; en otro individuo, la RMN postoperatoria revelo dos nuevas lesiones subcorticales de pequeno tamano sin correlacion clinica. Si bien la proteina S100B aumento de forma significativa tras la apertura del clampaje carotideo (p = 0,015), el aumento de la ENE no fue estadisticamente significativo. La puntuacion neuropsicologica global media aumento significativamente durante el seguimiento (p

Nous avons etudie les alterations infracliniques de la fonction cerebrale au cours de l'endarteriectomie carotidienne (EC) et la predictabilite de lesions cerebrales mineures en etudiant les taux de marqueurs biochimiques de lesions cerebrales S100B et enolase neurone specific (ENS). Vingt malades consecutifs ayant des stenoses carotidiennes asymptomatiques superieures ou egales a 70% et subissant une EC elective ont ete enroles. Les tests pre et post-operatoires comportaient une imagerie par resonance magnetique (IRM) cerebrale, un examen neurologique standard, une batterie de tests neuro-psychologiques et des mesures des taux seriques de S100B et d'ENS. Il n'y a pas eu d'accident vasculaire cerebral ischemique majeur. Chez un malade, une legere faiblesse du membre inferieur controlateral a ete decouverte par l'examen neurologique. Chez un autre malade, l'IRM post-operatoire a revele deux nouvelles petites lesions sous-corticales sans correlation clinique. Alors que le S100B augmentait de facon significative immediatement apres le declampage carotidien (p = 0,015), l'augmentation de l'ENS n'atteignait pas la signification statistique. Globalement, les participants ont eu un score neuropsychologique global moyen significativement plus important lors du testing de controle (p

Acute mesenteric ischemia is caused by a critical reduction in intestinal blood flow that frequently results in bowel necrosis and is associated with a high mortality. Clinicians must maintain a high index of suspicion because a prompt diagnosis and early aggressive treatment before the onset of bowel infarction results in reduced mortality. Medical management includes aggressive rehydration and the use of antibiotics, anticoagulation, vasodilators, and inhibitors of reperfusion injury. If acute mesenteric ischemia is suspected, early angiography is imperative, as it permits accurate diagnosis and possible therapeutic intervention. Therapeutic options during angiography depend on the cause of ischemia and include administering intra-arterial vasodilators and/or thrombolytic agents and angioplasty with or without stent placement. If interventional techniques are not possible or if the patient presents with suspicion of bowel infarction, surgery is warranted. Surgical techniques include superior mesenteric artery embolectomy or visceral artery bypass, which should be used before bowel resection to ensure only resection of nonviable bowel.

Purpose: To investigate the natural history of dilated common iliac arteries (CIA) exposed to pulsatile blood flow after endovascular abdominal aortic aneurysm repair (EVAR) and the suitability of ectatic iliac arteries as sealing zones using flared iliac limbs. Methods: Follow-up computed tomograms of 102 CIAs in 60 EVAR patients were investigated. Diameter changes in CIAs ≤16 mm (group 1) were compared with changes in vessels where a dilated segment >16 mm in diameter continued to be exposed to pulsatile blood flow (group 2). Within group 2, cases in which the stent terminated proximal to the dilated artery segment (2a) were compared with those that had been treated with a flared limb (2b). Results: The mean CIA diameter increased by 1.0±1.0 mm in group 1 (pConclusion: Dilatation of the CIA is significant after EVAR, and it is more pronounced in ectatic iliac arteries. Although ectatic iliac arteries appear to be suitable sealing zones in the short term, continued follow-up is mandatory.

The purpose of the present study was to compare surgical and endovascular revascularization for chronic mesenteric ischemia (CMI).Forty-nine patients underwent surgical (SG) or endovascular (EG) treatment. Relief of symptoms was considered the primary endpoint; patency, morbidity, and mortality were secondary endpoints. For statistical analysis, significance was assumed if P valuesor = 0.05.Twenty-six patients (53%) underwent surgical revascularization; 23 patients (47%), endovascular repair. Mean follow-up was 25 +/- 21 months (SG) versus 10 +/- 10 (EG) months (P = 0.07). Except for body mass indices (SG 18.9 +/- 2.7 versus EG 23.6 +/- 4.8; P = 0.001), preoperative data were comparable. Freedom from symptoms was 100% (SG) versus 90% (EG) after intervention (P = 0.194), and 89% (SG) versus 75% (EG) at the end of follow-up. Reocclusion or re-stenosis occurred in 8% (SG) versus 25% (EG) (log-rank test: P = 0.003), and mesenteric ischemia developed in 0% (SG) versus 9% (EG) (P = 0.04). Reintervention for CMI was required in 0% (SG) versus 13% (EG) (P = 0.01). Surgical patients experienced more early complications (42% versus EG 4%; P = 0.02) and longer hospital stays (11.6 +/- 10.9 days versus EG 1.3 +/- 0.5 days; P0.001). Overall mortality at the end of follow-up was 31% (SG) versus 4% (EG) (log-rank test: P = 0.08), including all patients with combined open mesenteric and aortic reconstruction (P = 0.001).Surgical treatment has superior long-term patency and requires fewer reinterventions, but it is also more invasive with greater morbidity and mortality compared to endovascular treatment. Endovascular techniques may be preferable in patients with significant co-morbidities, concomitant aortic disease, or indeterminate symptoms.

Bowel ischemia can complicate treatment of type II endoleak with liquid or semiliquid agents such as n-butyl cyanoacrylate (NBCA) if nontarget embolization of the inferior mesenteric artery (IMA) occurs. The current report describes four cases of type II endoleak in which the IMA was the main outflow vessel and was prophylactically occluded with embolization coils before NBCA injection into the endoleak nidus. The purpose was to prevent unintentional embolization of the NBCA into IMA branches. If feasible, protective IMA coil occlusion should be considered in type II endoleaks with IMA outflow in cases of NBCA embolization.

Several studies have suggested that the benefits of CEA may be gender-dependent. The purpose of this study was to focus on age and gender outcomes after CEA. Three hundred seventy-two CEAs were performed in 344 patients (115 females, 229 males; mean age 72.9 years). Mean follow-up was 25.8 months. Data were collected retrospectively by chart review, and follow-up data were obtained by clinical examination and duplex ultrasound. Recurrent stenosis was defined as >50% and/or occlusion. Three hundred and seventy-two CEAs were performed in 120 female and 252 male carotid arteries: 97.3% of patients underwent patch angioplasty (bovine pericaridium 71.5%, Dacron 21.8%, vein 3.8%, and polytetrafluoroethylene 0.3%) and 2.7% of patients underwent eversion endarterectomy. Perioperative mortality rate (30-day) was 0.8% (0% of females vs. 1.2% of males), and stroke rate was 0.5% (1.7% of females vs. 0% of males), with no significant gender difference (p = 0.554 and p = 0.103, respectively). Follow-up ultrasound revealed 21 (7%) restenoses (>50%) and/or occlusions, with a significantly higher rate of restenosis in females (14% vs. 3.9% in males, p = 0.008) and in patients

The purpose of this study was to review the outcome of endovascular abdominal aortic aneurysm repair (EVAR) using custom-made aortouni-iliac (AUI) devices with femorofemoral bypass. Between June 1999 and March 2001, 23 consecutive patients (1 female, 22 male) at high risk of open aortic aneurysm repair underwent EVAR with custom devices in an AUI configuration. The mean follow-up was 37 months (range 2–72 months), and the mean age was 76.8 years (range 67.5–88.7 years). Increased surgical risk was evidenced by 92% and 69% of patients with significant pulmonary or cardiac disease, respectively. The preoperative mean aneurysm diameter ( n = 23) 62 ± 8.2 mm was significantly greater than the postoperative diameter, ( n = 23) 54 ± 16.4 mm. Ten endoleaks occurred. Migration of the stent graft occurred in 9% ( n = 2). Secondary interventions were necessary in 23%, whereas tertiary interventions were required in 9%. Patients at high risk of open aneurysm repair received sufficient protection from aneurysm rupture with custom-made AUI devices.

The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.

Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization or with angioplasty and stenting. As experience has been gained, endovascular treatment appears safe and effective in selected patients. Currently, surgical revascularization has better success and patency rates but also a higher short- and midterm mortality and morbidity, especially in patients at high surgical risk. A 72-year-old female with severe respiratory dysfunction presented with CMI resulting in profound malnutrition. Serial percutaneous interventions averted urgent surgery and reversed the mesenteric ischemia. Nine months later, after repeated angioplasty and stenting had failed, elective uncomplicated iliomesenteric bypass, in a medically optimized patient, resolved the ischemia. At an 18-month follow-up, the graft remained widely patent and the patient asymptomatic with a body weight corresponding to her ideal body weight. Compared to surgical revascularization, reocclusion or restenosis occurs more frequently after endovascular treatment of CMI, and reintervention may be necessary. Nevertheless, percutaneous intervention effectively provides relief from mesenteric ischemia and has lower perioperative complication rates compared to surgery in patients at high surgical risk. After initial relief of the CMI, the patient's condition may improve, allowing for more definitive secondary surgical revascularization, if needed.

The aim of this study was to determine the maximal aneurysm diameter (MAD), the total aneurysm volume (TAV), the intra-aneurysm vascular channel (IAVC), and total thrombus volume (TTV) and compare changes in those parameters during a 12-month time period. In addition, these parameters for three different endovascular grafts were compared. A retrospective review of 42 patients who had undergone endovascular aneurysm repair (EVAR) between July 1999 and March 2001, and without evidence of an endoleak or migration, was performed. The minimum follow-up in this group was 12 months. The three grafts deployed were Dacron-stainless steel bifurcated grafts with suprarenal fixation [Zenith; Cook, Inc. ( n = 14)], Dacron stainless steel aorto uni-iliac grafts with suprarenal fixation [custom-made ( n = 10)], and externally supported Dacron nitinol bifurcated grafts [AneuRx; Medtronic, Inc. ( n = 18)]. Volumetric measurements were obtained from CT images performed preoperatively, at 1 month and 12 months thereafter, using a 3-D Magicview 1000 workstation (Siemens, Inc.). Regardless of the type of endograft, a significant Change in MAD and TAV ( P = 0.008), IAVC ( P = 0.031), and TTV ( P = 0.001) was observed over the 12-month postoperative period. Both maximum diameter and total aneurysm volume appear to reflect accurately successful aneurysm exclusion. We conclude that both two-dimensional, maximal aneurysm diameter and three-dimensional, total aneurysm volume accurately reflect changes in morphology after endovascular aneurysm repair.

Carotid-carotid bypass grafting is a procedure only rarely performed. However, in selected cases it may provide an excellent treatment alternative. The authors report on two patients who were treated by carotid-carotid bypass. The first patient had recurrent cerebral emboli from a chronic aortic dissection extending into the right innominate, common carotid, and internal carotid artery. The second patient was symptomatic from a recurrent high-grade internal carotid artery stenosis and an ulcerated plaque in the right common carotid artery following radical neck dissection and radiotherapy. The indications for this procedure are described and the related literature is reviewed.

Objective: To evaluate the early and late outcome of mesenteric revascularisation in patients who had had elective mesenteric revascularisation for chronic intestinal ischaemia. Design: Retrospective review. Setting: Academic clinic, United States. Subject: 19 consecutive patients (7 men, 12 women; mean age 70 years, range 53–83). Results: Angiography showed that 2 mesenteric vessels were affected in 7 patients and 3 in 12. Four patients had coexisting symptomatic aortoiliac occlusive disease and 1 patient had bilateral renal artery stenosis. A total of 36 visceral arteries were revascularised. One patient died postoperatively, and 8 developed serious complications. Morbidity and mortality were significantly higher in patients who had simultaneous infrarenal aortic or renal artery reconstructions (p = 0.01). Patients whose body weight before operation was less than 90% of ideal had more complications (8/11) than patients who were within 10% of their ideal body weight (1/8) (p = 0.02). Cumulative survival was 89% at 1 year, 72% at 3 years, and 57% at 5 years. The cumulative graft patency rate was 92% at 3 years and 66% at 5 years. Conclusions: Mesenteric bypass procedures for chronic mesenteric ischaemia are durable. Long-term survival and graft patency rates are excellent even in older patients. Simultaneous aortic surgery should be avoided because of the associated morbidity. More than 10% below ideal body weight was associated with higher morbidity. For these patients, early total parenteral nutrition postoperatively, or a period of total parenteral nutrition preoperatively may reduce postoperative morbidity and mortality. Copyright © 2000 Taylor and Francis Ltd.

Ureteral obstructions following aortoiliac or aortofemoral bypass grafting for aortoiliac occlusive and aneurysmal disease are infrequently reported. Ureteral obstructions can be self-limiting and resolve without further treatment or can signify a more serious underlying complication such as graft infection or a pseudoaneurysm formation. The authors present a series of five patients with ureteral obstruction secondary to aortobifemoral bypass grafting. Different treatment options are described and an algorithm for the management of these complications is presented.

Endovascular repair of abdominal aortic aneurysms has evolved dramatically within the past few years. In light of the potential to reduce morbidity and mortality associated with open surgical repair, endoluminal grafting offers therapeutic options to patients who are not surgical candidates because of comorbidities. With the development of bifurcated devices, more complex aneurysms may be treated by endovascular grafting. Although successful placement of endovascular grafts requires a pronounced learning curve, including appropriate patient selection, midterm results seem consistent with those of traditional open repair of aneurysms. This review describes the current indications, minimal requirements, different devices and associated techniques, and potential complications of endoluminal repair of abdominal aortic aneurysms. Future aspects of endoluminal grafting are also discussed.

Ischemic colitis is a devastating complication of aortic reconstruction. Its diagnosis is often delayed or overlooked, resulting in significant patient morbidity and mortality. To avoid this complication, the vascular surgeon must be aware of the preoperative, intraoperative, and postoperative risk factors. The vascular surgeon must be knowledgeable of the vascular anatomy and protective of the many vascular collaterals that may protect the colon when blood flow is reduced. Reviewed are the many intraoperative techniques to assess the adequacy of colonic perfusion during aortic reconstruction. Introduced is a new technique of assessing colonic perfusion: inferior mesenteric vein blood gas sampling. This technnique is compared to laser Doppler flowmetry and photoplethysmography in patients undergoing aortic reconstruction.

Mobilization of a tortuous carotid artery during endarterectomy may produce redundancy of the carotid artery, and kinking. We reviewed our experience with common carotid artery (CCA) imbrication as a technique to shorten the common and internal carotid artery postendarterectomy and to avoid carotid kinking. A retrospective chart review of 163 patients who underwent carotid endarterectomy by the same surgeon between August 1998 and February 2006 was performed. All patients underwent conventional endarterectomy via a longitudinal arteriotomy with an indwelling shunt and patch angioplasty. Patients undergoing concomitant carotid artery imbrication were identified. Twelve patients who underwent carotid imbrication were identified. The mean age was 74.9 ± 8.8 years. Nine patients underwent imbrication of the CCA, and in three cases, the internal carotid artery was plicated. Follow-up duplex ultrasound examinations were available for 10 individuals and mean follow-up time was 10.7 months (range, 1–58 months). There were no cases of peri- or postoperative cerebral accidents and there was no case of restenosis. CCA imbrication as an adjunct to carotid endarterectomy is a feasible technique in preventing postoperative carotid kinking.

The development of postoperative leaks of the thoracic duct after neck dissection or vascular surgery of the subclavian and vertebral artery is a well-known but rare complication. Usually, an injury of the duct manifests immediately after the operation with chylous drainage. Presentation as a postoperative lymphocele is rare. Operative treatment may be an option, but identification of the leak often is impossible, resulting in a high rate of failure. Percutaneous catheter drainage in combination with sclerosis with povidone-iodine has proved to be highly effective in obliterating pelvic lymphoceles but has not been reported in patients who have undergone vascular surgery in the neck. We present a case in which a povidone-iodine solution was used successfully in percutaneous sclerosis of a cervical lymphocele after transposition of the left subclavian artery to the left common carotid artery.

Increasingly, endovenous ablation of the greater saphenous vein (GSV) is used for the treatment of symptomatic varicose veins. The propagation of thrombus can result in a “tail of thrombus” within the common femoral vein (CFV). In two cases, patients were treated with low molecular weight heparin and re-imaged within 1 week. In both cases, complete resolution of the thrombus was confirmed, and anticoagulation was discontinued. Thrombus extension into the CFV after endovenous ablation may be safely treated with short-term anticoagulation and followed by duplex ultrasound. If unresolved, standard deep vein thrombosis anticoagulation is indicated.

Background Long-term follow-up of patients with aortouniiliac (AUI) grafts is lacking in the current literature. The purpose of this study was to review the outcomes of endovascular aneurysm repair (EVAR) using commercially available AUI devices with femorofemoral bypass in patients whose aortoiliac anatomy was unfavorable for bifurcated repair. Methods A retrospective review of 35 patients from September 2000 to February 2012, who underwent EVAR with commercially manufactured AUI devices, was performed. These comprised 35 of 372 (9.4%) patients who underwent EVAR during that period. Patient records were reviewed to determine morbidity, mortality, and survival after AUI repair. Patients were followed at 1-, 3-, 6-, and 12-month intervals with computed tomography (CT) scans during each visit. Median follow-up was 40 months (range: 2–135 months). Results Median age at surgery was 76 years (range: 60–93). The median preoperative aneurysm diameter was 57 mm (range: 45–71) and the median postoperative diameter was 53 mm (range: 29–80). Two type II endoleaks occurred on 1-month CT, whereas 10 endoleaks (type I [3], II [6], and III [1]) occurred during follow-up after 1 month. Migration of the stent graft occurred in 9% ( n = 3). Secondary procedures were required in 26% ( n = 9), whereas tertiary procedures were required in 3% ( n = 1). One patient required treatment for thrombosis of the iliac extension and 2 required treatment for thrombosis of the femorofemoral component. Mortality over the follow-up period was 34% ( n = 12) with no deaths occurring within 30 days. Conclusions High-risk patients who present with aortoiliac anatomy unsuitable for bifurcated stent graft placement should be offered AUI graft placement as a potential alternative to open repair.

Objective Inflammatory abdominal aortic aneurysms (IAAAs) have been traditionally managed with open repair. Endovascular aneurysm repair (EVAR) was approved September of 1999. Some authors have suggested that EVAR is not an acceptable option for management of an IAAA. However, several recent reports have suggested EVAR is a reasonable management option in these patients. The purpose of our study was to review our experience with the contemporary management of IAAA involving both open and endovascular approaches. Methods A retrospective review of all patients undergoing repair of IAAAs from 1999 to 2011 was conducted at three geographically separate institutions. Basic demographics, diagnostic workup, treatment, and outcomes were reviewed. Results Between 1999 and 2011, 69 patients underwent surgical repair of IAAAs, 59 by open repair and 10 by EVAR. Eighty-three percent of patients were men with a mean age of 67. Aneurysm size was similar in both groups (6.3 cm open repair vs 5.9 cm EVAR). Follow-up for the open group was a mean of 42.6 months and 33.6 months for the EVAR group. Periaortic fibrosis decreased from a mean of 5.4 mm to 2.7 mm after EVAR. Hydronephrosis was present preoperatively in one patient and did not change after EVAR. Aneurysm size decreased in seven patients (70%) who underwent EVAR. Two patients had no change with one lost to follow-up. Mean aneurysm size decrease after EVAR was 1.12 cm (17.8%). There were no aneurysm-related deaths or major morbidities in the EVAR group. Twenty-two patients (37%) in the open surgical group suffered major complications, including myocardial infarction, renal failure, lower extremity amputation, sepsis, and prolonged ventilation. Conclusions Endovascular repair for IAAA results in successful management with improvement of periaortic inflammation. EVAR should be considered as first-line therapy in which anatomic parameters are favorable.

A 71-year-old man had painful blue toes after an episode of protracted vomiting. Abdominal, cardiac, and transesophageal ultrasound studies were performed before angiography was considered. A large mobile mass in the proximal descending thoracic aorta, which suggested thrombus, was identified by transesophageal echocardiography. With no further evaluation, anticoagulant therapy with heparin and warfarin was initiated. Three months later, repeated transesophageal echocardiography demonstrated only a tiny vestige of the plaque-related mass. The pain and discoloration of the toes resolved completely. The advantages and disadvantages of the various diagnostic and therapeutic approaches to peripheral embolization are discussed.

We examined subclinical alterations of cerebral function during carotid endarterectomy (CEA) and predictability of minor cerebral damage by perioperative levels of biochemical markers of brain damage (S100B and neuron-specific enolase [NSE]). Twenty consecutive patients with > or =70% asymptomatic carotid stenosis undergoing elective CEA were enrolled. Pre- and postoperative testing included magnetic resonance imaging (MRI) of the head, a standardized neurological exam, a battery of neuropsychological tests, and measurement of serum levels of S100B and NSE. There were no major ischemic strokes. In one patient, a mild weakness of the contralateral lower extremity was discovered on neurological examination; in another individual, postoperative MRI revealed two new small subcortical lesions without clinical correlate. While S100B increased significantly early after opening of the carotid clamp (p = 0.015), the NSE increase did not reach statistical significance. As a group, participants obtained a significantly higher mean overall neuropsychological score at follow-up testing (p < 0.05). In one patient, a significant decline of cognitive function was observed. This was the only individual to obtain a consistently high S100B and NSE increase. Neuropsychological testing combined with measurements of S100B and NSE may improve sensitivity when assessing subtle cerebral damage following CEA.

Purpose: To analyze the 2-year outcomes of female patients after endovascular aortic aneurysm repair (EVAR) with the Zenith AAA Endovascular Graft. Methods: A retrospective analysis was conducted of data from the US Zenith multicenter trial and the Zenith female registry on 40 women (10.9%, study group) and 326 men (89.1%, control group) enrolled. All patients had completed their 2-year follow-up. Primary study endpoints were survival, aneurysm rupture, and conversion rate. Significance was assumed if pResults: Overall rates of mortality (12.5% for women versus 13.2% for men, p=0.94) and aneurysm rupture (2.5% for women versus 0% for men, p=0.11) were comparable between groups. Conversion to open repair within 2 years was significantly more frequent in women compared to men (7.5% versus 0.6%, p=0.01). The incidence of endoleaks of any type was equivalent between groups at 2 years (13.3% for women versus 6.9% for men, p=0.30). No difference was observed in the need for secondary interventions (15% for women versus 13.5% for men, p=0.81) or aneurysm dilatation >5 mm (10.5% for women versus 2.3% for men, p=0.10). None of the patients developed device migration .10 mm or required intervention for migration. Conclusion: While women underwent conversion to open repair more frequently compared to men at 2 years post EVAR, there was no difference in survival, freedom from aneurysm rupture, or need for secondary interventions between groups. As in men, the Zenith AAA Endovascular Graft provides reliable protection from aneurysm rupture and aneurysm-related death in women in a midterm follow-up.

Erectile dysfunction (ED) is frequently associated with cardiovascular disease. Epidemiological data on the frequency of ED in vascular surgery patients is rarely reported. We evaluated the prevalence of this comorbidity in patients consulting the vascular surgery outpatient clinic. Over a 6-month period, a short version of the International Index of Erectile Function (IIEF) questionnaire consisting of six EDrelevant questions was handed out to 440 vascular surgery outpatients. Clinical data were collected from patients' records. Linear regression models with forward selection were used to investigate associations between erectile function score and possible risk factors. The return rate was 31% (137 patients). Eight patients (6%) were taking phosphodiesterase inhibitors. ED, as defined by an erectile function score of 25 or less and/or use of phosphodiesterase inhibitors, was found in 90% (95% CI: 84% to 95%) of cases. Moderate or severe ED, as defined by an erectile function score of 16 or less and/or use of phosphodiesterase inhibitors, was found in 70% (95% CI: 62% to 78%) of cases. Increased age, abdominal aortic aneurysm, peripheral arterial disease, urologic disease, insulin-dependent diabetes mellitus, and use of beta-blockers were significantly associated with a lower erectile function score. In conclusion, erectile dysfunction is a frequent and often missed comorbidity in vascular surgery patients. While ED may have a profound impact on the patient's quality of life, attention should also be paid to the patient's preoperative sexual function, considering the availability of oral pharmacotherapies and possible consequences concerning liability in postoperative patients in whom pre-existing ED was not identified properly.

Mobilization of a tortuous carotid artery during endarterectomy may produce redundancy of the carotid artery, and kinking. We reviewed our experience with common carotid artery (CCA) imbrication as a technique to shorten the common and internal carotid artery postendarterectomy and to avoid carotid kinking. A retrospective chart review of 163 patients who underwent carotid endarterectomy by the same surgeon between August 1998 and February 2006 was performed. All patients underwent conventional endarterectomy via a longitudinal arteriotomy with an indwelling shunt and patch angioplasty. Patients undergoing concomitant carotid artery imbrication were identified. Twelve patients who underwent carotid imbrication were identified. The mean age was 74.9 +/- 8.8 years. Nine patients underwent imbrication of the CCA, and in three cases, the internal carotid artery was plicated. Follow-up duplex ultrasound examinations were available for 10 individuals and mean follow-up time was 10.7 months (range, 1-58 months). There were no cases of peri- or postoperative cerebral accidents and there was no case of restenosis. CCA imbrication as an adjunct to carotid endarterectomy is a feasible technique in preventing postoperative carotid kinking.

Although the causes of digital ischemia and necrosis are diverse in women, the most common etiology is connective tissue disease. We describe a patient with scleroderma who presented with arm ischemia secondary to arterial embolization from thoracic outlet syndrome. Her sublavian artery was compressed by the anterior scalene muscle and a cervical rib, leading to a stenosis with poststenotic dilation of the artery. Within the aneurysmal formation was a thrombus, which was probably the source of the distal embolization. The patient underwent surgical resection of the cervical and first rib. The abnormal portion of the subclavian artery was resected and replaced with an interposition graft.

The middle mesenteric artery is a rare anomalous mesenteric vessel that may supply variable segments of the colon. Occlusion of this artery during endovascular aortic aneurysm repair may bear a significant risk of bowel ischemia. We report the successful interventional treatment of a patient with a 5.3 cm infrarenal abdominal aortic aneurysm, sparing a dominant middle mesenteric artery.

To review the outcome of endovascular abdominal aortic aneurysm repair (EVAR) using commercial stent graft devices.Retrospective review of 167 EVAR procedures using different commercial devices at a single center between 1999 and 2003. Analysis included preoperative patient morbidities, operative and hospitalization data, postoperative complications, procedural outcome and midterm patient survival. Data are expressed as mean +/- SD and total number (%). P-values = 0.05 were considered significant.A total of 153 men and 14 women (mean age 75.0 +/- 7.3 years, range 53.1-89.2 years) underwent EVAR. Technical success rate was 97.0%. Postoperative intensive care unit stay was 0.05 +/- 0.24 days and hospital stay was 4 +/- 1.84 days. Postoperative complications occurred in 25 patients (15.0%). Two patients had to be readmitted within 30 days. Median follow-up time was 16.0 months (0-48 months). Overall mortality rate was 9.6% and did not depend on the type of endograft used (p=0.287). No early or aneurysm-related deaths or aneurysm ruptures occurred. Clinical success rate was 91.6% (153 patients). Graft limb thrombosis occurred in 5 patients (3.0%), all with the AneuRx device (p=0.041). Graft migration was seen in 3 devices (1.8%). There were 36 endoleaks (20.4%), specifically 30 branch vessel (type II) and 6 junctional (type I) endoleaks. Early endoleaks occurred in 21 patients (12.5%) and late endoleaks in 15 (9.0%). Twenty-two patients (13.0%) required secondary procedures (75.0% catheter-based vs. 25.0% surgical). Three patients (1.8%) underwent conversion to open aortic repair, 2 (1.0%) within the first year after EVAR. Aneurysm sac stabilization or shrinkage (or = 5 mm reduction in transverse aneurysm diameter) occurred in 98.2% of patients; aneurysm shrinkage rate was 39.6% at 1 year, 68.74% at 2 years and 79.96% at 3 years after the procedure. Time to aneurysm shrinkage was longest with the AneuRx (1.96 +/- 0.18 years) and Talent (1.67 +/- 0.53 years) devices, compared to the Zenith (1.01 +/- 0.13 years), Ancure (0.95 +/- 0.14 years) and Excluder (0.25 +/- 0.17 years) stent grafts (p=0.0001).Endovascular aortic aneurysm repair using commercially manufactured devices is safe and effective, especially in patients at high risk for open aneurysm resection. While evolving endovascular experience has significantly decreased complication and secondary intervention rates, close long-term follow-up remains mandatory to detect late complications. Elective and unbiased use of all available surgical and interventional procedures is required to maintain long-term clinical success after EVAR.

Purpose To evaluate the effect of oral anticoagulation on durability of endovascular aortic aneurysm repair (EVAR). Methods Retrospective review was conducted of 182 consecutive EVAR patients (169 men; mean age 75.3 years, range 53-89) between 1999 and 2003. Patients on warfarin anticoagulation (WA, n=21; International Normalized Ratio of 2 to 3) were compared against a control group (CG) with no postoperative anticoagulation (n=161). Death, aneurysm rupture, and reintervention were considered primary endpoints; endoleaks, endograft migration, and aneurysm remodeling were secondary endpoints. Results Mean follow-up was 16.3+/-12.6 months. One-year mortality was 6.6% (9.5% WA versus 6.2% CG); overall mortality was 14.3% (p=0.414). No aneurysm rupture occurred. At 1, 2, and 3 years, respectively, cumulative reinterventions (20%/20%/20% WA versus 12%/15%/20% CG; p=0.633) and endoleak rates (25%/25%/25% WA versus 17%/22%/34% CG; p=0.649) were comparable. In both groups, most completion endoleaks resolved (42.9% WA versus 74.4% CG; p=0.474), but few de novo endoleaks did (0% WA versus 12.8% CG; p=0.538). Anticoagulation did not affect mean time to aneurysm sac shrinkage (1.3+/-0.3 WA versus 1.4+/-0.1 years CG; p=0.769). Conclusions After EVAR, anticoagulation appears safe and does not significantly alter mortality, risk for rupture, or the incidence of reintervention. Early endoleaks appear more common in anticoagulated patients, but anticoagulation does not preclude spontaneous endoleak resolution nor does it increase late endoleak rates. Irrespective of the anticoagulation status, early but not late endoleaks usually sealed spontaneously. Observing type II endoleaks appears safe in the absence of aneurysm enlargement.

Stent-grafts are ideally terminated within the common iliac artery (CIA). However, CIA ectasia may require hypogastric artery occlusion, with stent-graft extension to the external iliac artery. Alternatively, the diameter of the distal stent-graft may be increased, or flared, to allow exclusion of the abdominal aortic aneurysm. This report details the authors’ experience with this technique. Forty-one patients received bifurcated stent-grafts (BSG): 20 received an AneuRx device, and 21 received a Zenith device. CIA ectasia (diameter 15–25 mm) was treated with a distal flare of 2–4 mm greater than the CIA diameter. Patients were followed up with computed tomography scan at 1, 6, and 12 months. Statistical analysis was performed using ANOVA within groups and unpaired two-tailed t test between groups. A p value of

PurposeThe aim of this report was to compare polyester vs. bovine pericardial patching during CEA with regards to the incidence of early neurologic events and recurrent stenosis.Patients and methodsOne hundred and twenty-five consecutive patients with high grade symptomatic (14%) or asymptomatic (86%) carotid artery stenosis (>70%) who underwent 139 CEAs by a single surgeon between January 1997 and April 2001 were retrospectively reviewed. Patients were assessed postoperatively clinically and with routine follow-up duplex scanning. Recurrent stenosis was defined as a narrowing in the common or internal carotid artery of more than 50% by duplex ultrasound examination.ResultsFrom January 1997 to May 1999, a polyester patch was routinely used in 81 (58%) patients, while between June 1999 and April 2001, a bovine pericardium patch was exclusively used in 59 (42%) patients. There were no ipsilateral postoperative TIAs or strokes in either group. The combined 30-day mortality rate for both groups was 0.8%. One patient in the polyester patch group died from cardiopulmonary complications 10 days after discharge. The length of follow-up in the bovine pericardial patch group was 3–28 months (mean 12 months), while in the polyester patch group was 1–50 months (mean 24.5 month). One patient developed a carotid pseudoaneurysm of the suture line in the bovine pericardium patch group caused by a local infection after previous neck dissection and radiation. The incidence of recurrent stenosis was two patients (4%) in the bovine pericardium group as opposed to six patients (7.6%) in the polyester patch group.ConclusionAlthough this is a preliminary report, it is concluded that bovine pericardium provides excellent perioperative results and is at least comparable to polyester patching in terms of safety. Our study with short term follow up suggests that bovine pericardium patching during carotid endarterectomy may have a lower restenosis rate compared to knitted polyester patching. Clear superiority of bovine pericardium as a patch material awaits a prospective randomised study with long-term follow-up.