Faculty Bibliography

OBJECTIVE: Patients with infrainguinal occlusive disease may experience spontaneous symptomatic improvement. This is generally thought to be from augmented collateral circulation. This study reports another mechanism. METHODS: Over a 20-year period, 4123 patients underwent lower extremity arteriography for limb ischemia. For a variety of reasons, 451 patients had repeat arteriography. RESULTS: Five patients were identified as having conclusive arteriographic evidence of spontaneous recanalization of occluded arterial segments without having undergone any surgical or thrombolytic interventions. Repeat contrast arteriography was performed on these patients for failing grafts (n = 2) or contralateral lower extremity ischemia (n = 3). Three other patients had magnetic resonance arteriographic or duplex arteriographic evidence of spontaneous arterial recanalization. Spontaneous recanalizaton occurred in ileofemoral (n = 2), superficial femoral (n = 2), popliteal (n = 3), and peroneal (n = 1) arterial segments. The average time interval of occlusion to recanalization was 21 weeks (2 weeks to 2 years). Two of the eight patients had failed revascularization procedures before spontaneous recanalization. All eight patients had restoration of pulses distal to the recanalized segments and significant symptomatic improvement as defined with the Society for Vascular Surgery/American Association for Vascular Surgery categories for limb ischemia. CONCLUSION: Spontaneous recanalization of arterial segments can occur and must be considered when evaluating other proposed treatments of critical limb ischemia, including cilostazol, lytic agents, and angiogenic agents, such as vascular endothelial growth factor. Although its true incidence is unknown, this represents another mechanism for spontaneous symptomatic improvement without treatment in patients with severe limb ischemia

OBJECTIVE: To analyze the late complications after endovascular graft repair of elective abdominal aortic aneurysms (AAAs) at the authors' institution since November 1992. SUMMARY BACKGROUND DATA: Recently, the use of endovascular grafts for the treatment of AAAs has increased dramatically. However, there is little midterm or long-term proof of their efficacy. METHODS: During the past 9 years, 239 endovascular graft repairs were performed for nonruptured AAAs, many (86%) in high-risk patients or in those with complex anatomy. The grafts used were Montefiore (n = 97), Ancure/EVT (n = 14), Vanguard (n = 16), Talent (n = 47), Excluder (n = 20), AneuRx (n = 29), and Zenith (n = 16). All but the AneuRx and Ancure repairs were performed as part of a U.S. phase 1 or phase 2 clinical trial under a Food and Drug Administration investigational device exemption. Procedural outcomes and follow-up results were prospectively recorded. RESULTS: The major complication and death rates within 30 days of endovascular graft repair were 17.6% and 8.5%, respectively. The technical success rate with complete AAA exclusion was 88.7%. During follow-up to 75 months (mean +/- standard deviation, 15.7 +/- 6.3 months), 53 patients (22%) died of unrelated causes. Two AAAs treated with endovascular grafts ruptured and were surgically repaired, with one death. Other late complications included type 1 endoleak (n = 7), aortoduodenal fistula (n = 2), graft thrombosis/stenosis (n = 7), limb separation or fabric tear with a subsequent type 3 endoleak (n = 1), and a persistent type 2 endoleak (n = 13). Secondary intervention or surgery was required in 23 patients (10%). These included deployment of a second graft (n = 4), open AAA repair (n = 5), coil embolization (n = 6), extraanatomic bypass (n = 4), and stent placement (n = 3). CONCLUSION: With longer follow-up, complications occurred with increasing frequency. Although most could be managed with some form of endovascular reintervention, some complications resulted in a high death rate. Although endovascular graft repair is less invasive and sometimes effective in the long term, it is often not a definitive procedure. These findings mandate long-term surveillance and prospective studies to prove the effectiveness of endovascular graft repair