Faculty Bibliography

The principle findings of the Carotid Revascularization Endarterectomy Versus Stenting Trial and the International Carotid Stenting Study are reviewed and discussed. Flaws and possible weaknesses in both trials are highlighted. The possibility that some Carotid Revascularization Endarterectomy Versus Stenting Trial conclusions have been misinterpreted in ways not justified by the trial's data is considered. This possibility may have prompted one conclusion of a recent American Heart Association Guideline on the management of carotid artery disease to be misleading

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

Aortoesophageal fistula (AEF) as a result of prolonged nasogastric intubation is rare and certainly fatal, without prompt surgical intervention. We report the case of a 41-year-old man with morbid obesity who was admitted after suffering 55% of total body surface area burns. After several skin graft operations over the course of 12 weeks, he was rushed into surgery because of the acute onset of severe upper gastrointestinal bleeding. Exploratory laparotomy and esophagogastroduodenoscopy (EGD) suggested an AEF, which was then quickly confirmed by a diagnostic angiogram. An endovascular aortic stent graft repair was performed that successfully stopped the bleeding. We include a review of the literature pertaining to cases of AEF treated by endovascular surgery, which appears to be a promising alternative to open surgery in the unfit patient

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

Complications of surgical and percutaneous vascular access are well known and can lead to considerable morbidity and even mortality. This article describes a technique which combines the advantages of surgical open and percutaneous access approaches: minimal surgical exposure of the target vessel followed by fast and safe access by a modified open Seldinger technique under direct tactile and visual control. This unique combination of techniques enhances the safety of vascular access such that local complications can be almost totally avoided. Economic and safety considerations are discussed and a balanced view on the advantages of the described technique will be given

The current size threshold for elective abdominal aortic aneurysm (AAA) repair is 5.5 cm. Over this diameter limit, the AAA rupture rate exceeds the perioperative mortality of open surgical repair. Endovascular aneurysm repair (EVAR) is associated with lower perioperative mortality rates, so it seems logical to hypothesize that the size threshold for endovascular AAA repair should be lowered. The arguments supporting this proposal are: (1) the EVAR-associated mortality rises several fold with increasing age, (2) larger AAAs have more complex anatomy that may not be suitable for EVAR, and (3) smaller AAAs treated with EVAR have lower perioperative and long-term mortality and fewer secondary interventions. Future guidelines may need to consider lowering the size threshold for elective AAA repair in the endovascular era in certain patient subgroups. The reduction of the size threshold should be counterbalanced against the cost of the procedures, as well as the age, life expectancy, and general condition of the patient