Faculty Bibliography

PURPOSE: To report preliminary experiences with the treatment of aortic aneurysm sac abscesses following prior endovascular aortic aneurysm repair (EVAR) using computerized tomography (CT)-guided percutaneous drainage. CASE REPORTS: Three patients aged 73 to 78 years with aortic aneurysm sac infections following prior EVAR, 2 of which were associated with aortoduodenal fistula, underwent CT-guided percutaneous drainage and catheter placement. One patient had complete resolution of the aortic aneurysm sac abscess following percutaneous drainage; 1 patient was stabilized to eventual extraanatomic bypass, graft explantation, and fistula repair; and 1 patient was temporized to debridement and fistula repair with endograft preservation. CONCLUSION: CT-guided percutaneous drainage may be a helpful therapy in selected patients for the treatment of aortic aneurysm sac infections following EVAR

OBJECTIVE: To examine the efficacy of dexmedetomidine (DEX) as a primary sedative during vascular procedures performed under monitored anesthesia care (MAC). A total of 55 patients were randomized in a 2:2:1 ratio to receive either DEX 1.0 microg/kg load or DEX 0.5 microg/kg load versus midazolam (MDZ) boluses, the current standard of care. This was followed by a maintenance infusion of DEX versus a normal saline infusion for the control group. Midazolam was given in 0.5 mg increments to maintain an equivalent target level of sedation among the 3 study groups. Fentanyl was given in 25 microg increments to treat pain as needed. The percentage of DEX patients not requiring MDZ and the total dose of MDZ and fentanyl were compared to the control. Dexmedetomidine was efficacious as a sole sedative for 50% of patients. The total dose of MDZ and fentanyl was significantly less during the DEX infusions. Patient satisfaction was superior with DEX

OBJECTIVES: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries. METHODS: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. RESULTS: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. DISCUSSION: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair

BACKGROUND: Spontaneous dissection of the superior mesenteric artery (SMA) is exceedingly rare. Treatment options range from observation to anticoagulation to open surgery or endovascular repair. We present our experience to date in the management of isolated SMA dissections. METHODS: A retrospective review of the vascular surgery and radiology databases from 1998 to 2008 was performed. In general, incidental radiologic findings of a dissection were managed expectantly. The decision to intervene was based on anatomic suitability, patient comorbidities and symptoms, and physician preference. Endovascular stents were placed using a brachial approach, with the choice of stent determined by physician preference. Patients who underwent endovascular stent placement (ESP) were maintained on antiplatelet therapy for 6 months postoperatively. Follow-up consisted of yearly office visits and adjunctive computerized tomography (CT) or magnetic resonance imaging (MRI) when clinically indicated. RESULTS: CT or MRI imaging identified nine patients (7 men, 2 women) with an isolated SMA dissection. One patient also had a concomitant celiac artery dissection. Median age was 70 years (range, 46-73 years). Median follow-up time was 32 months (range, 13.8-62.5 months). Presentations included an incidental radiologic finding in three patients and acute onset abdominal pain in six. Treatment included expectant management in four patients, anticoagulation in two, and ESP in three. ESP was performed primarily in two patients and in a third patient after initial management with anticoagulation failed. The reduction in the diameter of the true lumen was significantly greater in patients treated with ESP vs patients who were successfully managed expectantly or with anticoagulation (F = 15.59, P < .005). No procedural complications were associated with ESP. CONCLUSIONS: An isolated SMA dissection is a rare entity that may be managed successfully in a variety of ways based on clinical presentation. Endovascular stenting can be performed with good results and may be the preferred treatment in patients with symptomatic isolated SMA dissections

In patients who require lower extremity revascularization, prosthetic graft is a reasonable alternative in the absence of a suitable autologous vein conduit. However, prosthetic bypass grafts have limited patency, especially for infrageniculate reconstruction. Polytetrafluoroethylene grafts were geometrically modified at the distal end to increase their patency. The authors reviewed their experience with the Distaflo graft in patients who required lower extremity below-knee popliteal and tibial bypasses when no suitable autologous vein conduit was available. Chart review was conducted of the 57 patients who underwent 60 lower extremity bypasses over a 3-year period between June 2003 and April 2006. Twenty-four revascularizations were constructed to the tibial outflow sites, whereas the remaining grafts were placed to the below-knee (28) and above-knee (8) popliteal artery, respectively. Study endpoints were primary, assisted primary, secondary patency, and limb salvage at the time of follow-up. Distaflo bypass was performed at the infrageniculate level in 86.7% of cases (28 below-knee popliteal, 24 tibial). Mean follow-up time was 12 months (range, 0.5-37.5 months). At 1 year, primary, assisted primary, and secondary patencies and limb salvage rates for below-knee popliteal bypasses were 83.5%, 89.5%, 94.7%, and 94.4%, respectively. Primary, assisted primary, and secondary patencies and limb salvage rates for tibial bypasses were 44.4%, 44.4%, 63.2%, and 74.9%, respectively. Distaflo precuffed graft is a good alternative conduit for below-knee popliteal and tibial lower extremity reconstructions in the absence of an autologous vein and appears to have promising early patency and limb salvage rates even when used for tibial bypasses

Over the post ten years endoveous treatment options for varicose veins have evovled considerably,offering clinicians a multitude of options to meet the needs of their patients. The endothermal oblation procedures have moved to the forefront as the choice modality for treating truncal reflux. Both radiofrequency ablation and endovenous loser ablation are widely accepted and interchangeable, showing comparable efficacy and safety. Although numerous endovenous loser wavelengths exist, the data indicates that the differences do not affect the efficacy or postoperative recovery of the procedure. The endovenous laser innovation that has shown early evidence of improved patient outcome is the jacket-tip fiber. The versatility of sclefotheropy makes it a critical component in the endovenous treatment of varicosities. Although not approved by the Food and Drug Administration (USA), the use of a foamed sclerosing agent is the fastest growing segment of sclerotherapy and an important treatment modality in the future of varicose vein treatment. Cutaneous losers and intense pulse light devices contribute a crucial element, enabling clinicians to treat minute veins that may be impossible to treat with other therapies

PURPOSE: Clinical decision making for carotid surgery depends largely upon stenosis grade. While digital subtraction angiography remains the gold standard for stenosis grading, many physicians use less invasive modalities. The purpose of this study was to compare the results of multidimensional Computed tomography (CTA) with ultrasound (US) grading and peak flow velocity (PSV). METHODS: 37 stenosed carotid arteries were studied retrospectively in 36 consecutive patients. US grading and PSV were compared to multidimensional CTA analysis (diameter, area and volumetric measurements), performed by a medical software company. Calculations of stenosis percentage on CTA were made using the NASCET and ECST methodology. Diameter measurements were also performed by a neuroradiologist. RESULTS: All CTA diameter, area and volume measurements had only modest correlation with PSV (r<0.5) and ultrasound grading (p<0.5). There was concordant classification of stenosis grades in only 40-60% of cases. CTA diameter, area and volume measurements had good correlation (0.69<r<0.87) with one another using ECST methodology. Using NASCET methodology on CTA, correlation between diameter and area was insignificant (r=0.32). CTA volumetric analysis with the NASCET method yielded 27 negative stenosis grades. Repeatability coefficient for selecting the normal distal ICA 20 mm more distally was 20% for diameter and 43% for area. CTA diameter interobserver repeatability coefficients were 22.9% (NASCET) and 17.8% (ECST) and 0.7 mm (lumen) and 1.9 mm (vessel). CONCLUSIONS: All CTA measurements showed moderate correlation with both ultrasound grading and PSV. Selection of the level of the normal distal ICA influences the NASCET calculations and can produce discrepant stenosis grades. Multidimensional CTA analysis seems to have no additional value for stenosis grading, but provides other useful anatomic information

The goal of endovascular repair of an abdominal aortic aneurysm is to exclude the aneurysm from systemic arterial pressure, thereby preventing rupture. However, the long-term durability of endovascular repair continues to be in question, as aneurysm rupture after endovascular repair continues to be reported. We report the case of an 89-year-old patient who underwent endovascular repair of a 7.1-cm abdominal aortic aneurysm with an Ancure endograft 5 years earlier. Despite close follow-up and a shrinking aneurysm sac on annual contrast-enhanced computed tomography, he presented with aneurysm rupture and a new proximal type I endoleak. The endoleak and rupture were successfully repaired with endovascular placement of a main body extension