Faculty Bibliography

INTRODUCTION:: Iatrogenic arterial injury is an uncommon but recognized complication of posterior spinal surgery. The spectrum of injuries includes vessel perforation leading to hemorrhage, delayed pseudoaneurysm formation, and threatened perforation by screw impingement on arterial vessels. Repair of these injuries traditionally involved open direct vessel repair or graft placement, which can be associated with significant morbidity. METHODS:: We identified five cases of iatrogenic arterial injury during or after posterior spinal surgery between July 2004 and August 2009 and describe the endovascular treatment of these five patients. RESULTS:: In two patients, intraoperative arterial bleeding was encountered during posterior spinal surgery. The posterior wounds were packed, temporarily closed, and the patients were placed supine. Angiography in both patients demonstrated arterial injury necessitating repair. Covered stent grafts were deployed through femoral cutdowns to exclude the areas of injury. In three additional patients, postoperative computed tomography imaging demonstrated pedicle screws abutting or penetrating the thoracic or abdominal aorta. In all three patients, angiography or intravascular ultrasound (IVUS), or both, confirmed indention or perforation of the aorta by the screw. Aortic stent graft cuffs were deployed through femoral cutdowns to cover the area of aortic contact before hardware removal. All five patients did well and were discharged home in good condition. CONCLUSIONS:: Endovascular repair of arterial injuries occurring during posterior spine procedures is feasible and can offer a safe and less invasive alternative to open repair

This article summarizes a differing interpretation of the long-term results of the Endovascular Aneurysm Repair (EVAR) 1 Trial. The EVAR 1 Trialists' conclusions regarding the equivalence of long-term outcomes of endovascular aneurysm repair (EVAR) with those of open repair (OR) are misleading and not applicable to patients currently treated by EVAR. The reasons that the EVAR 1 Trial is misleading and casts an unfairly negative light on the superiority of EVAR are as follows: (1) The convergence of all-cause mortality curves or the "catch-up" phenomenon; (2) old technology, inexperience, and outdated secondary treatment; (3) complications were not well-defined in EVAR 1 and are not applicable to current practice; and (4) the unfair cost comparison between EVAR and OR. The implication that OR is equivalent or superior to EVAR is, therefore, a misrepresentation. EVAR is a better treatment for infrarenal aortic aneurysms in anatomically suitable patients. We believe that current standards of practice should be altered accordingly, rather than preserving the nostrums that EVAR and OR are equivalent and that EVAR has more intrinsic disadvantages.

This commentary addresses the issue of optimal contemporary management of symptomatic and asymptomatic carotid artery stenosis. Based on current data, carotid endarterectomy (CEA) should be performed in the majority of patients with symptomatic carotid artery stenosis. Carotid artery stenting (CAS) should be reserved for a minority of these symptomatic patients, in whom CEA is contraindicated. In asymptomatic patients, all should be placed on best medical treatment (BMT). With the use of one or more of the proposed stroke risk stratification models or some as yet undetermined method, the identification of those asymptomatic individuals may be possible in whom stroke risk is higher than usual with BMT. This asymptomatic subgroup, which may be small and is yet to be determined with certainty, could be offered an invasive carotid procedure (either CAS or CEA)

The recent guidelines by the American Heart Association/American Stroke Association (AHA/ASA) and several other associations recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients (Class I; Level of Evidence: B). The term 'alternative' may easily be misinterpreted as 'equivalent' to justify the widespread use of CAS. However, current evidence indicates that for symptomatic patients, CAS produces inferior outcomes compared with CEA. It is likely that with technical improvements, better patient selection, and better physician experience, CAS outcomes will improve in the future. CAS may then become a fair alternative to CEA, at least in certain patient subgroups. Based on current evidence, however, we are not there yet and it seems unfair to spin the AHA/ASA guidelines to conclude that we are

OBJECTIVE:: To present the first long-term results of Szilagyi III vascular infections treated by negative pressure wound therapy (NPWT) with graft preservation. BACKGROUND DATA:: Szilagyi III infections are usually treated by graft/artery excision and secondary vascular/plastic reconstruction. Small series treated with NPWT without graft removal are reported with good short-term to midterm results. METHODS:: The outcomes of 44 polymorbid patients (mean age = 62 years) with Szilagyi III infections from 2002 to 2009 were analyzed. Thirteen of forty-four required intensive care unit treatment. Forty grafts (prosthetic = 24, vein = 3, biological = 13) and 9 native arteries were involved. Negative pressure wound therapy (VAC; KCI International, Amstelveen, Netherlands) was applied directly on grafts/arteries (negative pressure = 50-125 mm Hg) after radical debridement of infected tissue. Antibiotic treatment was initiated and adapted according to microbiology. RESULTS:: Median duration of NPWT was 33 days (IQR: 20-78), of hospital stay 32 (IQR: 20-82) days. All patients survived 30 days. One-year mortality was 16% (7/44). Long-term mortality after a mean follow-up of 43 months (SD: 21) was 41% (18/44).Complete wound healing was achieved in 91% (40/44). In 37 of 44 patients, grafts were preserved long-term without reinfection. There was no statistically significant difference in outcome between the various graft types involved. CONCLUSIONS:: Vascular graft/arterial preserving treatment with NPWT in Szilagyi III infections was safe and effective with a very low short-term mortality. The majority of infected grafts were preserved without reinfection during a mean long-term follow-up of 4 years. This new treatment algorithm avoids major reconstructive surgery and should be used when dealing with Szilagyi III vascular infections

Abstract Purpose: To report midterm outcomes after urgent endovascular repair of ruptured pararenal or thoracoabdominal aortic aneurysms using multiple periscope and chimney grafts to preserve renovisceral branch perfusion and facilitate aneurysm exclusion. Methods: Nine consecutive men (mean age 72+/-14 years, range 40-88) presenting with ruptured thoracoabdominal (n = 6), pararenal (n = 2), or infrarenal (n = 1) aortic aneurysm underwent urgent endovascular repair with at least 1 periscope graft delivered via a transfemoral access; chimney grafts were installed from an axillary access. In all, 17 periscope and 7 chimney grafts were used to reperfuse 11 renal and 13 visceral arteries in the 9 patients. The aortic aneurysms were excluded using thoracic devices (n = 7), an aortic extension cuff (n = 1), and bifurcated stent-grafts (n = 2). Results: All procedures were completed without technical complications except for a dislocated stent-graft from the right renal artery; the artery could not be re-accessed, and the right kidney was sacrificed. One patient died of multiple organ failure (11% 30-day mortality). At a mean follow-up of 10 months (range 3-24), 5 of the 9 patients had recovered completely; 3 patients died of unrelated causes. Imaging showed no aneurysm growth in any patient, with a mean 20% shrinkage in aneurysm size. All periscope and chimney grafts remained patent, and no aortic stent-graft migration was observed. Renal function and the glomerular filtration rate remained stable in all patients. Conclusion: The periscope and chimney graft technique provides a simpler, less invasive way to maintain blood flow to the renovisceral arteries during urgent endovascular aortic repairs. The very low 30-day mortality rate and the stability of the repairs in the midterm are encouraging. This technique has the potential to profoundly influence the treatment of acute aortic pathologies