Faculty Bibliography

Introduction and Objectives: Prior studies have alluded to gender differences in aortic neck morphology resulting in anatomic exclusion of some women from EVAR. The objective of this study is to correlate gender differences in aortic neck morphology and changes in the neck and aneurysm sac after EVAR. Methods: A retrospective review of consecutive EVARs performed for infrarenal AAA was conducted from 2004 to 2013 at a single institution. Pre- and post-operative imaging studies were utilized to measure aortic neck length and diameter, shape, and angulation, aneurysm sac diameter. Volumetric analysis of neck thrombus burden was performed using TeraRecon. Results: 146 patients met inclusion criteria 21% were women with a mean age of 75.5 (p=0.724) with comparable baseline comorbidities to men. Neck angulation was greater in women 23.9degreevs 13.5degree (P<0.028). The percent thrombus of the aortic neck was greater in female patients at 35.7% vs 30%(P=0.02). Preoperative AAA diameter was 5.8 in female and 5.5 in males (p=0.348). Abdominal aneurysm sacs were smaller in women at 1 year follow up (4.2cm vs. 5.1cm, P<0.002). In addition, although not statistically significant, reintervention rates post-EVAR for type 1 leaks were higher in men (3.5% vs. 0% P=0.27). Neck shape, changes in neck diameter, neck length, percent oversizing of graft where not significantly different between gender (table 1). Conclusions: Although female patients have more hostile aortic neck morphology compared to males, AAAs post-EVAR have acceptable sac regression and reintervention rates. Long term follow up is necessary to further validate findings

Introduction and Objectives: Lymphedema is an incurable and disfiguring disease secondary to excessive fluid and protein in the interstitium as a result of lymphatic obstruction. Pneumatic compression (PC) offers a novel modality for treatment of lymphatic obstruction through targeting lymphatic beds and mimicking a functional drainage system. The objective of this study is to demonstrate improved quality of life in patients with lower extremity lymphedema. Methods: Consecutive patients presenting to a single institution for treatment of lymphedema were all treated with PC for at least three months. All patients underwent a pre-and post-PC assessment of episodes of cellulitis, number of ulcers, and venous insufficiency. Post-PC symptom questionnaires were administered. Symptom improvement was the primary outcome for analysis. Results: 100 patients met inclusion criteria. At presentation, 70 % were female with a mean age of 57.5 years. Secondary lymphedema was present in 78%. Mean length of PC use was 12.7 months with a mean of 5.3 treatments per week. The number of episodes of cellulitis and ulcers pre- and post-PC decreased from mean of 0.26 to 0.05 episodes (p=0.002) and 0.12 to 0.02 ulcers (p=0.007) respectively. 14 % had concomitant superficial venous insufficiency, all of whom underwent venous ablation. 100% of patients reported symptomatic improvement post-PC with 54% greatly improved. 90% would recommend the treatment to others. Conclusions: PC improves symptom relief and reduces episodes of cellulitis and ulceration in lower extremity lymphedema. It is well tolerated by patients and should be recommended as an adjunct to standard lymphedema therapy. Screening for venous insufficiency is recommended

Objective: Thoracic endovascular aortic repair (TEVAR) for acute uncomplicated type B aortic dissection (TBAD) remains controversial. This study aims to evaluate the impact of TEVAR on mortality, morbidity, length of stay (LOS), and discharge status in patients with acute uncomplicated TBAD.Methods: We analyzed the National Inpatient Sample from 2009 and 2010. Patients were categorized according to the type of treatment: TEVAR or medical management. Outcomes, including mortality, stroke, myocardial infarction (MI), acute renal failure, discharge disposition, and LOS, were compared between the treatment groups.Results: We identified 4706 patients with TBAD. Mean age was 67 years and 55% were male. Treatment options included TEVAR in 504 and medical management in 4202. The overall adjusted in-hospital mortality was similar for both the groups (8.5% for TEVAR vs 10.3% for medical management, P = .224). The TEVAR carried higher risk of stroke (odds ratio [OR] = 1.61, 95% confidence interval [CI] = [1.14-2.27]; P = .0073). The TEVAR was associated with prolonged LOS (12 vs 5.6 days, P < .0001) and patients were less likely to be discharged home (OR 0.73, 95% CI 0.54-0.99; P = .013). When stratified by age, all outcomes were similar between the 2 groups, with the exception of longer LOS with TEVAR.Conclusions: Thoracic endovascular aortic repair for acute uncomplicated TBAD was associated with similar in-hospital mortality, MI, and renal failure as compared to medical management. The TEVAR had higher rate of stroke up to the age 70 years and longer LOS. Because extending TEVAR to less complicated patients could only decrease TEVAR mortality rates, these findings support the more widespread use of TEVAR to treat patients with uncomplicated TBAD.

OBJECTIVE: Endovascular interventions for critical limb ischemia are associated with inferior limb salvage (LS) rates in most randomized trials and large series. This study examined the long-term outcomes of selective use of endovascular-first (endo-first) and open-first strategies in 302 patients from March 2007 to December 2010. METHODS: Endo-first was selected if (1) the patient had short (5-cm to 7-cm occlusions or stenoses in crural vessels); (2) the disease in the superficial femoral artery was limited to TransAtlantic Inter-Society Consensus II A, B, or C; and (3) no impending limb loss. Endo-first was performed in 187 (62%), open-first in 105 (35%), and 10 (3%) had hybrid procedures. RESULTS: The endo-first group was older, with more diabetes and tissue loss. Bypass was used more to infrapopliteal targets (70% vs 50%, P = .031). The 5-year mortality was similar (open, 48%; endo, 42%; P = .107). Secondary procedures (endo or open) were more common after open-first (open, 71 of 105 [68%] vs endo, 102 of 187 [55%]; P = .029). Compared with open-first, the 5-year LS rate for endo-first was 85% vs 83% (P = .586), and amputation-free survival (AFS) was 45% vs 50% (P = .785). Predictors of death were age >75 years (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.7-6.6; P = .0007), end-stage renal disease (ESRD) (HR, 3.4; 95% CI, 2.1-5.6; P < .0001), and prior stroke (HR, 1.6; 95% CI, 1.03-2.3; P = .036). Predictors of limb loss were ESRD (HR, 2.5; 95% CI, 1.2-5.4; P = .015) and below-the-knee intervention (P = .041). Predictors of worse AFS were older age (HR, 2.03; 95% CI, 1.13-3.7; P = .018), ESRD (HR, 3.2; 95% CI, 2.1-5.11; P < .0001), prior stroke (P = .0054), and gangrene (P = .024). CONCLUSIONS: At 5 years, endo-first and open-first revascularization strategies had equivalent LS rates and AFS in patients with critical limb ischemia when properly selected. A patient-centered approach with close surveillance improves long-term outcomes for both open and endo approaches.

BACKGROUND: A 61-year-old man with a previous endovascular repair and stage 5 chronic kidney disease presented with a symptomatic 4.5-cm left internal iliac artery aneurysm. The decision was made to proceed with endovascular repair. METHODS: The preoperative magnetic resonance angiography (MRA) scan was linked to on-table rotational imaging using the Artis zeego Fusion program (Siemens AG, Forchheim, Germany). Using the fused image as a road map, we undertook coil embolization of the left internal iliac artery, and a tapered stent graft was extended from the previous graft into the external iliac artery. RESULTS: Completion angiography revealed exclusion of the aneurysm sac. Three milliliters of contrast were used throughout the procedure. A follow-up magnetic resonance angiography scan at 1 month and duplex ultrasonography at 1 year revealed continued exclusion of the aneurysm sac. The patient's renal function remained unchanged. CONCLUSIONS: This case shows that in a patient with severe chronic kidney disease, fusion of preoperative imaging with intraoperative rotational imaging is feasible and can limit significantly the amount of contrast used during a complex endovascular procedure.

BACKGROUND: The incidence of concomitant carotid artery stenosis and unruptured intracranial aneurysms (UIAs) has been reported at between 0.5% and 5%. In these patients, treatment strategies must balance the risk of ischemic stroke with the risk of aneurysmal rupture. Several studies have addressed the natural course of UIAs in the setting of carotid revascularization; however, the final recommendations are not uniform. The purpose of this study was to review our institutional experience with concomitant UIAs and carotid artery stenosis. METHODS: We performed a retrospective review of all patients with carotid artery stenosis who underwent carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) at our institution between 2003 and 2010. Only patients with preoperative imaging demonstrating intracranial circulation were included. Charts were reviewed for patients' demographic and clinical data, duration of follow-up, and aneurysm size and location. Patients were stratified into 2 groups: carotid artery stenosis with unruptured intracranial aneurysm (CS/UIA) and carotid artery stenosis without intracranial aneurysm (CS). RESULTS: Three hundred five patients met the inclusion criteria and had a total of 316 carotid procedures (CAS or CEA) performed. Eleven patients were found to have UIAs (3.61%) prior to carotid revascularization. Male and female prevalence was 2.59% and 5.26% (P = 0.22), respectively. Patients' demographics did not differ significantly between the 2 groups. The average aneurysm size was 3.25 +/- 2.13 mm, and the most common location was the cavernous segment of the internal carotid artery. No patient in the study had aneurysm rupture, and the mean follow-up time was 26.5 months for the CS/UIA group. CONCLUSIONS: Concomitant carotid artery stenosis and UIAs is a rare entity. Carotid revascularization does not appear to increase the risk of rupture for small aneurysms (<10 mm) in the midterm. Although not statistically significant, there was a higher incidence of aneurysms found in females in our patient population.