Faculty Bibliography

Purpose : To present early and midterm results of the periscope endograft (PG) technique to maintain left subclavian artery (LSA) blood flow in thoracic endovascular aortic repairs (TEVAR) involving zone 3. Methods : From April 2010 to January 2013, 14 consecutive high-risk patients (11 men; mean age 70+/-8 years, range 56-87) underwent TEVAR with the PG technique for 10 thoracic aortic aneurysms (TAA), 2 traumatic aortic ruptures, and 2 aortic dissections without a suitable landing zone (>2 cm distal to the LSA). Five procedures were performed emergently for rupture (3 TAAs and the 2 trauma cases). Two patients had a periscope deployed in an aberrant right subclavian artery. The periscope endografts were sized 1 to 2 mm larger than the branch artery at the intended landing zone. The caudal end was extended distal to the intended distal landing site of the thoracic stent-graft, which was usually deployed after the PG. Both the PG and thoracic stent-grafts were generally molded using the kissing balloon technique. Outcomes analyzed were immediate technical success, perioperative mortality and morbidity, aneurysm diameter change, and periscope endograft patency. Results : Immediate technical success was 100%, with all procedures completed as planned. Perioperatively, one periscope occluded and one of the ruptured TAA patients died. One percutaneous access site hematoma required only conservative management. At a mean follow-up of 26+/-9 months (range 9-37), there was no additional PG occlusion. The Kaplan-Meier estimate of PG patency was 93% at 2 years. Conclusion : The periscope endograft is a simple technique to maintain perfusion to the LSA in cases where the aortic stent-graft crosses its ostium. The PG technique can be performed transfemorally and even percutaneously, and it can be applied to all supra-aortic branches. Early and midterm results are encouraging, but more experience and long-term results are mandatory before this technique can be widely recommended.

Purpose : To describe the endovascular treatment of intra-abdominal perigraft seromas associated with small-caliber expanded polytetrafluoroethylene (ePTFE) grafts. Case Reports : Two patients who underwent hybrid repair of thoracoabdominal aortic aneurysms in which renovisceral bypass grafts were implanted presented with large, symptomatic perigraft seromas. The 5- to 8-mm-diameter ePTFE bypass grafts believed to be involved in the seromas were successfully relined with self-expanding Viabahn stent-grafts in percutaneous procedures. The patients' symptoms were relieved, and imaging follow-up (18 and 10 months, respectively) has shown near complete resorption of the seromas. Conclusion : It is expected that this minimally invasive technique could be very valuable in treating aortic, renovisceral, and peripheral perigraft seroma.

BACKGROUND: Femoro-femoral veno-arterial perfusion is an established circulatory support and cooling method for thoracic- and/or thoracoabdominal aortic aneurysm repair. However, retrograde perfusion through femoral arteries can lead to retrograde cerebral embolization and neurologic dysfunction after surgery. To avoid these complications, we have established a femoro-femoral veno-venous perfusion technique and evaluated its safety and effectiveness in elective and nonelective patients. METHODS: Common femoral veins were cannulated bilaterally percutaneously following systemic low-dose heparinization (100 IU/kg body weight). Venous blood was drained from drainage of the inferior vena cava, and venous return followed through the superior vena cava. After proximal aortic cross-clamping, veno-venous perfusion was switched to veno-arterial antegrade perfusion through the distal descending thoracic aorta to achieve spinal and visceral perfusion or through iliac arteries for distal perfusion combined with selective renovisceral blood perfusion. After completion of aortic repair, the arterial cannula was removed and the patient rewarmed just by switching back to veno-venous perfusion. Gas and temperature exchange as well as relevant hemodynamic parameters were recorded prospectively and analyzed retrospectively in 25 consecutive patients including 15 nonelective cases. RESULTS: Percutaneous insertion of outflow (28F cannula) and inflow (18F cannula) venous cannulae was complication-free and allowed unrestricted perfusion in all 25 patients. Veno-venous perfusion allowed effective cooling (mean body temperature 36.6 +/- 0.6 degrees C to 31.6 +/- 2.1 degrees C, P = .001 compared with start of cooling) and re-warming (mean body temperature 30.5 +/- 3 degrees C to 36.3 +/- 0.8 degrees C, P = .03 compared with start of re-warming). Hemodynamic as well as pulmonary parameters remained remarkably stable during surgical dissection and single lung ventilation even in nonelective cases. There was no complication associated with the perfusion technique during surgery. CONCLUSIONS: Transfemoral veno-venous cooling and re-warming results in remarkable hemodynamic stability during open repair of thoracic- and/or thoracoabdominal aortic aneurysms and eliminates the need for retrograde arterial perfusion and its inherent risks.

OBJECTIVES: To present the safety, feasibility, costs, and patient satisfaction of outpatient endovascular aneurysm repair (EVAR). BACKGROUND: Our experience in more than 1000 patients indicated that in technically uncomplicated EVAR procedures, the only need for hospitalization was for access vessel complications (bleeding or occlusion) requiring secondary procedures. These complications could always be identified within the first 3 hours after EVAR. METHODS: Two-center retrospective analysis of prospectively gathered data on 100 consecutive elective outpatient EVAR cases (Outpt EVAR). Inclusion criteria for Outpt EVAR were as follows: asymptomatic clinical state, informed consent, travel time to the hospital if readmission was required of less than 60 minutes, adult observer assistance for the first 24 hours, and a technically uncomplicated EVAR procedure. EVAR was mostly performed under local anesthesia and with percutaneous access. Patients were discharged home after 4 to 6 hours of observation and checked the next morning and on the fifth postoperative day in the outpatient clinic. RESULTS: From 104 patients selected, 4 (3.8%) preferred primary hospitalization and were excluded from further analysis. Four patients (4%) with access vessel complications required additional procedures and had to be hospitalized overnight. The 30-day readmission rate was 4% (4), all due to access vessel stenosis (2) or false aneurysm (2). There was no 30-day mortality. From the 96 outpatients who completed Outpt EVAR, 93 (97%) would undergo Outpt EVAR again and would recommend it to others. Cost comparison showed in 42 matched contemporary patients treated with just a standard stent graft that costs were significantly lower in 21 Outpt EVAR patients than in 21 inpatient EVAR. CONCLUSIONS: Elective Outpt EVAR can be performed safely, provided certain criteria are fulfilled and specific precautions are taken. In this series, Outpt EVAR morbidity was minimal, especially delirium common in elderly patients recovering from inpatient vascular surgery and nosocomial infections did not occur. Finally, patient satisfaction was high and costs were less than with standard inpatient EVAR.

INTRODUCTION/AIM: We reviewed the literature for studies evaluating the effects of statins on vascular patients undergoing open surgical or endovascular procedures. METHODS: MEDLINE was searched using the search terms "statins and vascular surgery", "statins and endovascular procedures", "statins and perioperative effects" and "statins and postoperative complications". RESULTS: Preoperative statin use is associated with lower perioperative/periprocedural death, myocardial infarction and stroke rates. Statins may also reduce postoperative complications as well as hospitalization rates and costs. Statins reduce the incidence of postoperative/postprocedural renal insufficiency and help the earlier recovery of complete kidney function in vascular patients. A loading dose of statins prior to a procedure may be associated with improved cardiovascular outcomes. CONCLUSIONS: Statins are associated with several beneficial actions in patients undergoing open surgical or endovascular procedures. Nevertheless, statin use in vascular patients still remains underutilized and suboptimal. Ideally, statins should be initiated a minimum of 2 weeks before the procedure. Extended-release formulas may be preferable perioperatively to cover the first 1-2 days after the procedure when oral intake may not be feasible. Statins should be administered to all vascular disease patients, whether they are managed conservatively or are undergoing open surgical or endovascular procedures.

Purpose : To evaluate the performance of periscope and/or chimney grafts (CPGs) in the endovascular treatment of pararenal or thoracoabdominal aneurysms using off-the-shelf devices. Methods : Between February 2002 and August 2012, 77 consecutive patients (62 men; mean age 73+/-9 years) suffering from pararenal aortic (n=55), thoracoabdominal (n=16), or arch to visceral artery aneurysms (n=6) were treated with aortic stent-graft implantation requiring chimney and/or periscope grafts to maintain side branch perfusion. CPGs were planned in advance and were not used as bailout. A standardized follow-up protocol including computed tomographic angiography, laboratory testing, and clinical examination was performed at 6 weeks; 3, 6, and 12 months; and annually thereafter. Results : Technical success was achieved in 76 (99%) patients; 1 branch stent-graft became dislocated from a renal artery, which could not be re-accessed. Overall, 169 target vessels (121 renal arteries, 30 superior mesenteric arteries, 17 celiac trunks, and 1 inferior mesenteric artery) were addressed with the chimney graft configuration in 111 and the periscope graft configuration in 58. In total, 228 devices were used for the CPGs: 213 Viabahn stent-grafts and 15 bare metal stents. Over a mean 25+/-16 months (range 1-121), 9 patients died of unrelated causes. Nearly all (95%) of the patients demonstrated a decreased or stable aneurysm size on imaging; there was a mean 13% shrinkage in aneurysm diameter. Twenty patients had primary type I/III endoleaks at discharge; in follow-up, only 3 of these were still present (no secondary or recurrent endoleaks were noted). Additional endovascular maneuvers were required for CPG-related complications in 13 patients from intervention throughout follow-up. Overall, 4 CPGs occluded (98% target vessel patency); no stent-graft migration was observed. Renal function remained stable in all patients. Conclusion : In this series, the use of CPGs has proven to be a feasible, safe, and effective way to treat thoracoabdominal and pararenal aneurysms with maintenance of blood flow to the renovisceral arteries. Nearly all of the aneurysms showed no increase in diameter over a >2-year mean follow-up, which supports the midterm adequacy of the CPG technique as a method to effectively revascularize branch vessels with few endoleaks or branch occlusions.

BACKGROUND: Endoleak and sac growth remain unpredictable occurrences after EVAR, necessitating regular surveillance imaging, including CT angiography. This study was designed to identify preoperative CT variables that predict AAA remodeling and sac behavior post-EVAR. METHODS: Pre- and postoperative CT scans from 136 abdominal aortic aneurysms treated with EVAR were analyzed using M2S (West Lebanon, NH) software for size measurements. Preoperative total sac volume and proportion of thrombus and calcium in the sac were assessed. Sac change was defined as a 3-mm difference in diameter and a 10-mm(3) difference in volume when compared with preoperative measurements. Univariate analysis was performed for age, gender, AAA size, relative thrombus/calcium volume, device type, presence of endoleak, and the effects on sac size. RESULTS: Gender, device type, age, AAA size, and percent calcium were not predictive of sac change post-EVAR. Increased proportion of thrombus on pre-EVAR resulted in a greater likelihood of sac shrinkage (P = 0.002). Patients with aneurysms that grew on postoperative CT scan had less sac thrombus on pre-EVAR (mean 27.5%) than patients without evidence of endoleak (mean 41.9%, P < 0.0001). Only 2 of 30 patients with >50% pre-EVAR thrombus developed endoleak. A >50% thrombus burden resulted in endoleak in significantly fewer patients (6.7%) compared with those who had <50% thrombus (43.1%). CONCLUSIONS: The proportion of thrombus on preoperative CT may predict sac behavior after EVAR and development of an endoleak. Greater than 50% thrombus appears to predict absence of endoleak after EVAR. Aneurysms with large thrombus burden are less likely to grow and may require less vigilant postoperative surveillance than comparable AAA with relatively little thrombus.

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) has been used to support the equivalence of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in the treatment of carotid stenosis in both symptomatic and asymptomatic patients. This inclusion of two different forms of the disease decreased the power and significance of the CREST results and weakened the trial. Other flaws in CREST were the equal weighting of mostly minor myocardial infarctions (MIs) with strokes and death in the peri-procedural, composite 'end' point, but not in the 4-year, long-term 'end' point. Although CAS was associated with 50% fewer peri-procedural MIs compared with CEA, there were >2.5-fold more MIs after CAS than CEA at 4 years. The 4-year MI rate, however, was not a component of the primary 'end' point. Additionally, although the initial CREST report indicated that there was no difference in the outcomes of CAS and CEA according to symptomatic status or sex, subsequent subgroup analyses showed that CAS was associated with significantly higher stroke and death rates than CEA in symptomatic patients, in females and in individuals >/= 65 years of age. The present article will examine these and other flaws and the details of CREST's results derived from the trial's preplanned subanalyses to show why the claims that CREST demonstrates equivalence of the two therapeutic procedures are unjustified.