Faculty Bibliography

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

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

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

Ruptured abdominal aortic aneurysms historically have high mortality rates. Despite improvements in many open surgical techniques and perioperative care, these mortality rates have not significantly changed. Some of the reasons for the high mortality rates include the excessive blood loss and hypothermia that occur during open operative repair. The blood loss and hypothermia, combined with resuscitative dilutional coagulopathy, can lead to an irreversible spiraling coagulopathy that ultimately ends in the patient's demise. The availability of endovascular approaches to treat abdominal aortic aneurysms in the early 1990s offered an opportunity to substantially alter the treatment outcomes of ruptured abdominal aortic aneurysms. Endovascular repair offers many advantages, including rapid aortic control under local anesthesia, as well as an opportunity to limit the hypothermia and blood loss that occur with an open abdomen. This article will review the endovascular management of ruptured abdominal aortic aneurysms and describe the endovascular techniques for safe and effective treatment. Mt Sinai J Med 77:250-255, 2010. (c) 2010 Mount Sinai School of Medicine

Most symptomatic patients should not be candidates for carotid artery stenting (CAS); at least not at present. In these patients, CAS is associated with higher stroke, as well as recurrent stenosis rates compared with carotid endarterectomy (CEA). Furthermore, CAS is considerably more expensive than CEA. These facts raise the question, why perform CAS in symptomatic patients when you have CEA, which is associated with lower stroke and recurrent stenosis rates, and is also a more cost-effective option. This article supports the theory that currently most symptomatic patients are not appropriate candidates for CAS

When abdominal aortic aneurysms (AAAs) rupture and are untreated, they cause death. In addition, ruptured AAAs have high mortality (35-55%) and morbidity rates when treated by standard open surgical methods. These high rates have not been substantially reduced despite the introduction of many improvements in open operative technique and perioperative care. Endovascular approaches to treat AAAs introduced in the early 1990s provided an opportunity to alter substantially treatment outcomes when rupture occurred. This article details how these endovascular approaches, which include endovascular stent-grafts, can be applied to the treatment of RAAAs, and what advantages these new catheter based approaches to treatment offer

The value of emergency endovascular aneurysm repair (EVAR) in the setting of ruptured abdominal aortic aneurysm remains controversial owing to differing results. However, interpretation of published results remains difficult as there is a lack of generally accepted protocols or standard operating procedures. Furthermore, such protocols and standard operating procedures often are reported incompletely or not at all, thereby making interpretation of results difficult. We herein report our integrated logistic system for the endovascular treatment of ruptured abdominal aortic aneurysms. Important components of this system are prehospital logistics, in-hospital treatment logistics, and aftercare. Further studies should include details about all of these components, and a description of these logistic components must be included in all future studies of emergency EVAR for ruptured abdominal aortic aneurysms