Faculty Bibliography

Aberrant left vertebral artery (LVA) origin off the aortic arch is an uncommon anatomic variant. Treatment of the thoracic aortic pathology that necessitates its coverage has not been described. We present a patient with an acute intramural hematoma with a dominant LVA originating from the aortic arch. A LVA-to-carotid artery transposition with shunt placement, carotid-to-subclavian bypass, and thoracic endovascular aortic repair were performed. The patient recovered uneventfully, without any evidence of stroke. This case study shows that aberrant left vertebral anatomy presents a unique and interesting challenge and that vertebral shunt techniques during revascularization can be performed without stroke.

The purpose of the current study was to investigate the association between bone mineral density (BMD) scores and the prevalence of peripheral artery disease (PAD) in a large cohort of subjects who underwent arterial Doppler assessments and calcaneal bone densitometry. The study was performed using data obtained from Life Line Screening Inc. Subjects were self-selected and paid for screening tests. The prevalence of PAD was significantly higher in men with osteopenia (4.5%) and osteoporosis (10.9%) compared to men with normal BMD (3.0%) (p<0.001). Osteopenia (odds ratio (OR) 1.3) and osteoporosis (OR 2.3) were found to be independent risk factors for the presence of PAD in men. The prevalence of PAD was significantly higher in women with osteopenia (4.8%) and osteoporosis (11.8%) compared to women with normal BMD (3.3%) (p<0.001). Osteopenia (OR 1.15) and osteoporosis (OR 1.8) were found to be independent risk factors for the presence of PAD in women. The current study reports a strong association of abnormal BMD analysis with the prevalence of PAD, which persists even when controlling for age and associated atherosclerotic risk factors. Although the mechanism by which these two disease processes is related is not completely elucidated, the presence of osteoporosis should make clinicians aware of the possibility of occult PAD or associated atherosclerotic disease in appropriate patients.

OBJECTIVE: The goal of this study is to determine if compression therapy after endovenous ablation (EVA) of the great saphenous vein (GSV) improves efficacy and patient reported outcomes of pain, ecchymosis and quality of life. METHODS: This was a prospective randomized controlled trial from 2009 to 2013 comparing the use of thigh-high 30-40mmHg compression therapy for 7 days vs no compression therapy following endovenous ablation of the GSV. Severity of venous disease was measured by CEAP scale and the venous clinical severity score (VCSS). Quality of life assessments were carried out with a CIVIQ-2 questionnaire at days 1, 7, 14, 30 and 90, and the visual analog pain scale daily for the first week. Bruising score was assessed at 1 week post procedure. Post ablation venous duplex was also performed. RESULTS: 70 patients and 85 limbs with EVA were randomized. EVA modalities included radiofrequency ablation (91%) and laser ablation (9%). CEAP class and VCSS scores were equivalent between the two groups. There was no significant difference in patient reported outcomes of post-procedural pain scores at day 1 (mean 3.0 vs. 3.12, p =0.948) and at day 7 (mean 2.11 vs 2.81,p =0.147), CIVIQ-2 scores at 1 week (mean 36.9 vs 35.1, p=0.594), at 90 days (mean 29.1 vs 22.5, p =0.367) and bruising score (mean 1.2 vs 1.4,p=0.561) in the compression vs. no compression groups respectively. Additionally, there was a 100% rate of GSV closure in both groups and no endothermal heat-induced thrombosis (eHIT) as assessed by post-ablation duplex. CONCLUSION: Compression therapy does not significantly affect both patient reported and clinical outcomes after GSV ablation in patients with non-ulcerated venous insufficiency. It may be an unnecessary adjunct following GSV ablation.

OBJECTIVE: Peripheral arterial disease (PAD) disproportionally affects racial groups in the United States. Few studies have analyzed the rates of PAD in the American Indian (AI)/ Alaskan Native (AN) population. In this paper we compare the prevalence of PAD in the AI/AN as compared to white and non-white Americans. METHODS: The study data were provided by Life Line Screening (Independence, Ohio). The cohort consists of self-referred individuals who paid for vascular screening tests. Mild to moderate and severe PAD were defined as having an ankle brachial index (ABI) in at least one extremity of < .9 and <.5 respectively. Univariate and multivariate analysis were performed to compare the rates of PAD between AI/AN, Caucasians, and non-whites. RESULTS: The original sample for which this study was obtained included 3,444,272 people. Of this group there was a predominance of females 64.5% (2,221,555) compared to 35.5% (1,222,716) males. The Native American/ Alaskan Native population was 2.8% of the sample (96,440). In our univariate analysis AI/AN had the highest rates of mild-moderate and severe PAD when compared to whites (OR 1.78 and 2.14 respectively) and non-whites (OR 1.52 and 1.82 respectively). We then controlled for atherosclerotic risk factors in our multivariate analysis and the AI/NA cohort had persistently higher rates of both moderate and severe PAD compared to whites (OR 1.32 and 1.40) but not compared to non-whites (OR .95 and .92). CONCLUSIONS: Here we present the largest epidemiology study of PAD in AI/NA to date. AI/NA people have disproportionately high rates of both mild-to moderate and severe PAD when compared to whites and non-white Americans. After controlling for atherosclerotic risk factors the rates of PAD remain high for AI/NA when compared to whites but not when compared to non-whites. While it is possible that a combination of diet and lifestyle choices are responsible for the high rates of PAD in this population, genetic factors may be involved as well, and deserve further investigation. Optimal medical management may help to prevent the complications of PAD in this patient population.

OBJECTIVE: To report the 5-year outcomes from the Endurant Stent Graft System in the U.S. regulatory trial (bifurcated Endurant; Medtronic Santa Rosa, Calif). METHODS: The study was a prospective, multicenter, regulatory trial performed at 26 U.S. sites. From June 2008 to April 2009, 150 patients with abdominal aortic aneurysms (AAAs) were treated with the Endurant bifurcated graft. The main inclusion criteria included AAA diameter >5 cm (or 4-5 cm in diameter where the size increased more than 5 mm within the previous 6 months), neck length >/=10 mm, and neck angulation 5 mm in 5/83 (6.0%). Eighteen AAA-related secondary interventions were required in 15 patients (11%): 12 for endoleak management, 4 for limb occlusions, 1 for stenosis, and 1 for thromboembolism. Four of 5 limb occlusions reported were in the first 6 months. Survival and reintervention rates were better than the Talent eLPS study, which was conducted under similar inclusion exclusion criteria. CONCLUSIONS: The 5-year outcomes of the Endurant Stent Graft System in the U.S. regulatory trial continue to be positive. The device appears to be durable with limited adverse events through 5 years. Comparison with an older generation device suggests improving outcomes with newer devices.

Pulmonary embolism (PE), a potentially life-threatening entity, can be treated medically, surgically, and percutaneously. In patients with right ventricular dysfunction (RVD), anticoagulation alone may be insufficient to restore cardiac function. Because of the morbidity and mortality associated with surgical embolectomy, clinical interest in catheter-directed interventions (CDI) has resurged. We describe specific catheter-directed techniques and the evidence supporting percutaneous treatments.

OBJECTIVE: This review explores the current literature on the natural history, diagnosis, and management of mesenteric venous thrombosis (MVT) in the modern era. METHODS: A review of the contemporary literature from 1997 to 2016 on MVT and its pathogenesis, diagnosis, and treatment was performed. RESULTS: MVT is an insidious and lethal disease associated with acute mesenteric ischemia. The prevalence of MVT has increased sharply during the past two decades commensurate with an increase in radiographic imaging for abdominal complaints. The optimal treatment of and approach to MVT is controversial, given the poorly understood natural history of this rare disease. Both endovascular and open surgical strategies in addition to systemic anticoagulation have been used as adjuncts to treat MVT with limited success. Despite advances in treatment, mortality associated with MVT is still high. Furthermore, recent studies have shown that failure to recanalize the portomesenteric venous system leads to an increased risk for development of sequelae of portal hypertension. CONCLUSIONS: MVT is a challenging disease to treat, given the difficulty in establishing a prompt initial diagnosis and the inability to reliably monitor patients for evidence of impending bowel infarction. Careful selection of patients for endovascular, open, or hybrid approaches is key to achieving improved outcomes. However, the paucity of prospective data and our evolving understanding of the natural history of MVT make consensus treatment strategies difficult to ascertain.

BACKGROUND: Mesenteric venous thrombosis (MVT) is a relatively uncommon but potentially lethal condition associated with bowel ischemia and infarction. The natural history and long-term outcomes are poorly understood and under-reported. METHODS: A single-institution retrospective review of noncirrhotic patients diagnosed with MVT from 1999 to 2015 was performed using International Classification of Diseases, Ninth Revision and radiology codes. Patients were excluded if no radiographic imaging was available for review. Eighty patients were identified for analysis. Demographic, clinical, and radiographic data on presentation and at long-term follow-up were collected. Long-term sequelae of portal venous hypertension were defined as esophageal varices, portal vein cavernous transformation, splenomegaly, or hepatic atrophy, as seen on follow-up imaging. RESULTS: There were 80 patients (57.5% male; mean age, 57.9 +/- 15.6 years) identified; 83.3% were symptomatic, and 80% presented with abdominal pain. Median follow-up was 480 days (range, 1-6183 days). Follow-up radiographic and clinical data were available for 50 patients (62.5%). The underlying causes of MVT included cancer (41.5%), an inflammatory process (25.9%), the postoperative state (20.7%), and idiopathic cases (18.8%). Pancreatic cancer was the most common associated malignant neoplasm (53%), followed by colon cancer (15%). Twenty patients (26%) had prior or concurrent lower extremity deep venous thromboses. Most patients (68.4%) were treated with anticoagulation; the rest were treated expectantly. Ten (12.5%) had bleeding complications related to anticoagulation, including one death from intracranial hemorrhage. Four patients underwent intervention (three pharmacomechanical thrombolysis and one thrombectomy). One patient died of intestinal ischemia. Two patients had recurrent MVT, both on discontinuing anticoagulation. Long-term imaging sequelae of portal hypertension were noted in 25 of 50 patients (50%) who had follow-up imaging available. Patients with long-term sequelae had lower recanalization rates (36.8% vs 65%; P = .079) and significantly higher rates of complete as opposed to partial thrombosis at the initial event (73% vs 43.3%; P < .005). Long-term sequelae were unrelated to the initial cause or treatment with anticoagulation (P = NS). CONCLUSIONS: Most cases of MVT are associated with malignant disease or an inflammatory process, such as pancreatitis. A diagnosis of malignant disease in the setting of MVT has poor prognosis, with a 5-year survival of only 25%. MVT can be effectively treated with anticoagulation in the majority of cases. Operative or endovascular intervention is rarely needed but important to consider in patients with signs of severe ischemia or impending bowel infarction. There is a significant incidence of radiographically noted long-term sequelae from MVT related to portal venous hypertension, especially in cases of initial complete thrombosis of the mesenteric vein.

OBJECTIVES: Nutcracker syndrome, or mesoaortic compression of the left renal vein (LRV), with associated symptoms related to venous hypertension in the left kidney, is a rare entity that may result in severe symptoms requiring operative intervention. We report on three patients who presented with nutcracker syndrome, including one patient with a circumaortic LRV resulting in posterior nutcracker syndrome, who underwent successful endovascular treatment with renal vein stenting. A review of existing literature on endovascular management of nutcracker syndrome follows. METHODS: Three women (age range 28 to 43 years) presented with symptoms and imaging studies consistent with nutcracker syndrome. Symptoms included pelvic and flank pain in all three patients, and episodes of hematuria in two. Imaging studies demonstrated compression of the LRV between the superior mesenteric artery and aorta in two of the patients. The third patient was noted to have a circumaortic LRV. RESULTS: All three patients underwent venography and LRV stenting. Stents included a 12 x 40 mm self-expanding nitinol stent, 14 x 60 mm Wallstent, and 16 x 40 mm Wallstent. All patients were placed on clopidogrel post-operatively. The duration of follow-up ranged from six to twenty-seven months. At follow up, all three patients reported significant symptomatic improvement, and duplex ultrasonography demonstrated stent patency in all. CONCLUSIONS: Nutcracker syndrome is a rare condition that can be successfully treated with renal vein stenting via an endovascular approach. Results are encouraging at follow-up periods beyond two years.