Faculty Bibliography

OBJECTIVE: The utilization of endovascular abdominal aortic aneurysm repair (EVAR) in suitable patients has resulted in decreased perioperative morbidity and mortality. Octogenarians as a subgroup have been more readily offered EVAR, as it is less invasive, and therefore presumably better tolerated than conventional open aortic repair. The purpose of this study is to investigate periprocedural and late EVAR outcomes in octogenarians compared with patients less than 80 years of age. METHODS: From January 2003 to May 2008, 322 patients underwent EVAR. A total of 117 octogenarians were compared with 205 patients less than 80 years of age. A retrospective review of the demographic data, aneurysm details, perioperative morbidity, mortality, and late outcomes were analyzed. RESULTS: Octogenarians were significantly more likely to have a history of diabetes mellitus (51% vs 23%; P < .001), coronary artery disease (45% vs 32%; P = .0165), chronic obstructive pulmonary disease (44% vs 30%; P = .0113), and renal insufficiency (57% vs 31%; P < .0001). There were no significant differences in the rates of perioperative myocardial infarction, stroke, death, intestinal, or arterial ischemic complications between the two groups. Octogenarians had a significant higher rate of pulmonary complications (5.1% vs 1%; P < .03) and access-site hematomas (12% vs 2.4%; P = .001) than younger patients. When all significant perioperative morbidity was combined, octogenarians were twice as likely to develop complications following EVAR than younger patients (27.4% vs 11.7%; P = .001). At 5-year follow-up, younger patients were twice as likely to develop type II endoleaks. CONCLUSIONS: EVAR can be performed safely and effectively in octogenarians, and the incidence of major complications including myocardial infarction, stroke, and death is unchanged compared with younger patients. However, there is a significantly increased rate of access-site hematomas, pulmonary, and perioperative complications in octogenarians as a whole. Our findings suggest EVAR remains a suitable form of therapy in the elderly group provided there is an appropriate preoperative evaluation and perioperative monitoring following repair

BACKGROUND: Preoperative evaluation and perioperative management of cardiac disease in patients undergoing vascular surgery (VS) is important for patients and vascular surgeons. Recent evidence has emerged that has allowed us to develop contemporary paradigms for evaluating and managing coronary artery disease in VS patients perioperatively. METHODS: The utility of stress testing, the role of preoperative coronary revascularization, the optimal use of beta-blockers and statins, and the role of antiplatelet therapy in VS patients were reviewed in the literature. RESULTS: The revised Lee cardiac risk index, based on the number of risk factors (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, renal failure, hypertension, and age >75) quantitates cardiac risk. Stress testing is not predictive of myocardial ischemia/infarction (MI) or death and is only recommended in patients with unstable angina or an active arrhythmia. Stress testing for patients with 0 to 2 risk factors delays VS up to 3 weeks. In high-risk patients (>or=3 risk factors), it helps to identify patients who may develop myocardial ischemia and would benefit from a 30-day period to optimize medical therapy before VS. Stress testing and coronary catheterization do not predict which coronary artery to revascularize to prevent MI or death. Revascularization does not decrease MI or death rates at 1 month or 6 years. Although beta-blocker treatment decreases cardiac risk with VS, timing and dosage (titration) influence outcomes, improper usage may increase stroke and death rate, and not all VS patients should be taking these drugs. Patients with >or=1 risk factor should be considered to begin a low dose beta-blocker 1 month before VS. Preoperative statin use sharply decreases MI, stroke, and death perioperatively and long-term postoperatively. CONCLUSION: Routine stress testing should not be performed before VS. The Lee index should be used to stratify risk in patients undergoing VS. Patients with >or=3 risk factors or active cardiac conditions should undergo stress testing, if VS can be delayed. All VS patients, except those with 0 risk factors, should be considered for a beta-blocker (bisoprolol, 2.5-5 mg/d started 1 month before VS, titrated to a pulse <70 beats/min and a systolic blood pressure >or=120 mm Hg). Intermediate risk factors may not require aggressive heart rate control but simply maintenance on a low-dose beta-blocker. Statins should be started (ideally 30 days) before all VS using long-acting formulations such as fluvastatin (80 mg/d) for patients unable to take oral medication

OBJECTIVE: Prophylactic atropine traditionally has been used to prevent CAS-associated hemodynamic depression. Glycopyrrolate may serve as an alternative with decreased cardiac effects. This study aims to compare the efficacy of prophylactic glycopyrrolate to atropine in preventing CAS-induced hemodynamic instability and cardiac complications. METHODS: 115 consecutive CAS patients from 2004-2010 were evaluated. Primary endpoints were stroke, MI, bradycardia (HR<60 beats/min), and hypotension (systolic BP <90 mm Hg). Additional outcomes included tachycardia (HR >100 beats/min), hypertension (systolic BP >160 mm Hg), pre- and postoperative systolic BP difference, vasopressor use, arrhythmias, cardiac enzyme elevations, and access site complications. RESULTS: Of 115 patients, 65 (56.5%) patients who received atropine or glycopyrrolate prior to CAS were analyzed [40 (61.5%) patients received glycopyrrolate, 25 (38.5%) received atropine]. Mean age was 70.0 +/- 8.5 years (range, 48-86 years). Mean stenosis was 86.2 +/- 7.4% (range, 70-99%). No MI, major stroke, or death was observed in the 30-day postoperative period. Baseline systolic BP and HR were equivalent between groups. Postoperative bradycardia and hypotension were significantly lower in glycopyrrolate patients compared with atropine patients (30% vs 72%, P = .002; 2.5% vs 36%, P < .001, respectively). Postoperative hypertension was also significantly lower in the glycopyrrolate cohort (2.5% vs 16%, P = .047), whereas tachycardia, pressure changes, vasopressor use, and cardiac complications did not differ significantly. No significant differences in neurologic and access site complications were observed. CONCLUSIONS: Prophylactic glycopyrrolate, compared with atropine, reduces hemodynamic instability during CAS. The authors recommend glycopyrrolate use to prevent CAS-induced bradycardia and hypotension

We reviewed our experience with urgent carotid intervention in the setting of acute neurological deficits. Between June 1992 and August 2008, a total of 3145 carotid endarterectomies (CEA) were performed. Twenty-seven patients (<1.0%) were categorized as urgent. The mean age was 74.1 years (range 56-93 years) with 16 (60%) men, and 11 (40%) women, Symptoms included extremity weakness or paralysis (n = 13), amaurosis fugax (n = 6), speech difficulty (n = 2), and syncope, (n = 3). Three patients exhibited a combination of these symptoms. Three open thrombectomy were performed. Regional anesthesia was used in 13 patients (52%). Seventeen patients (67%), required shunt placement. At 30-days, 2 patient (7%) suffered a stroke, and 1 (4%) died. Urgent CEA can be performed safely. A stroke rate of 7% is acceptable in those who may otherwise suffer a dismal outcome without intervention

Improvements in the design of endovascular grafts are based on lessons learned from difficulties encountered with prior-generation devices. The most common difficulties in device design relate to how the device is delivered and how it can safely and durably fix the aneurysm. This concept is especially true in patients with difficult anatomy. Difficult anatomy, such as small, calcified, tortuous access vessels and short angulated sealing zones, continue to challenge engineers. Currently, the US Food and Drug Administration has approved eight endovascular devices for the treatment of aortic aneurysms: five for abdominal aortic aneurysms and three for thoracic aortic aneurysms. Compared to the first-generation devices approved in 1999, current devices have smaller and more flexible delivery systems. The devices themselves are more flexible and have better fixation than prior-generation devices. This article will focus on the next generation of devices that are not yet approved, but currently under investigation in the United States

INTRODUCTION: Prior neck irradiation may induce atherosclerosis in the carotid artery and is considered an indication for carotid angioplasty and stenting (CAS). This study sought to evaluate the effect of neck radiation therapy (XRT) on the rate of restenosis and embolic potential in patients undergoing CAS. METHODS: Two hundred ten CAS procedures were performed on 193 patients (XRT [N = 28], non-XRT [N = 182]). Mean follow-up was 347 +/- 339 days (median, 305 days; range, 16-1354 days). Duplex velocity criteria for restenosis after CAS were: >50% restenosis (peak systolic velocity [PSV] > 125 cm/sec, end diastolic velocity [EDV] 40-99 cm/sec, and internal carotid artery to common carotid artery systolic ratio [ICA/CCA] > 2.0); >70% restenosis (PSV>230 cm/sec, EDV>100 cm/sec, and ICA/CCA ratio >4.0). Restenosis >70% was confirmed by digital subtraction angiography. Additional endpoints included groin hematoma, groin pseudoaneurysm, myocardial infarction, stroke, mortality, and the combined myocardial infarction/stroke/mortality rate. Captured particulate data was obtained from microporous filters used during CAS. Nineteen XRT and 128 non-XRT consecutive filters were analyzed. Photomicroscopy was performed along three axes for each filter, and the quantity and size of the captured particles were analyzed using video image analysis software. RESULTS: There were more men (XRT: 85.7% vs. non-XRT: 52.8%, P < .001) and prior surgical neck dissections in the XRT patients (XRT: 82.1% vs. non-XRT: 4.7%, P < .001). Pre-procedural stenosis did not differ significantly betweeen the two groups (XRT: 86.5% +/- 8.9% [range, 70%-99%] vs. non-XRT: 85.5% +/- 8.7% [range 70%-99%], P = NS). Perioperative outcomes, including the composite 30 day stroke/myocardial infarction/mortality rate did not differ significantly between the two groups (XRT: 0% vs. non-XRT: 3.2%, P = NS). Twelve-month freedom from restenosis rates did not differ significantly at the 50% threshold (XRT: 95.5% vs. non-XRT: 90.3%, P = NS) or at the 70% threshold (XRT: 95.5% vs. non-XRT: 96.5%, P = NS). Target lesion revascularization did not differ significantly (XRT: 0% vs. non-XRT: 0.5%, P = NS). Photomicroscopy demonstrated a trend towards increased particle number and size in the XRT filters, however the results did not achieve statistical significance: particle number (XRT: 9.8 +/- 8.4 vs. non-XRT: 9.6 +/- 11.7, P = NS), %patients with particle size >1000 microm (XRT: 47.4% vs. non-XRT: 30.5%, P = NS). CONCLUSIONS: This study suggests that the durability of CAS and the characteristics of captured embolic particles are not altered by a history of neck XRT. This supports the safety and efficacy of CAS for the treatment of patients with a history of neck XRT. Prior neck XRT may predispose the patient to the de novo development of stenoses at locations that were not previously treated

BACKGROUND: Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial. OBJECTIVE: To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers. METHODS: Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR). RESULTS: Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients. CONCLUSION: These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed