Faculty Bibliography

OBJECTIVES: Aortic surgery involving major aortic branches (supraaortic trunks, visceral, renal arteries, and iliac arteries) is complicated by the requirement to dissect and occlude them during revascularization. We report an 8-year experience with a sutureless telescoping anastomotic technique to revascularize these branches with minimal branch dissection and organ ischemia. METHODS: Over an 8-year period, 246 major aortic branches in 142 patients were revascularized by the following technique: After limited dissection of the most easily accessible wall of the target artery, a self-expanding but unexpanded stent graft, Viabahn (5-13 mm in diameter; 5-15 cm long) was introduced into a standard vascular graft (SVG) 1 mm less in diameter than the expanded stent graft. The target artery was punctured and over a guide wire the unexpanded stent graft was introduced 1 to 2 cm in artery. The SVG was advanced over the nondeployed stent graft up to the artery puncture site. Then the stent graft was deployed (partly in the branch and partly in the SVG). After balloon dilatation of the stent graft, the balloon and guide wire were removed and 2 stitches placed to penetrate the arterial wall and stent graft to fix it in the artery. Usually the proximal end of the SVG was already anastomosed to an aortic replacement graft, the aorta or an iliac artery before stent-graft branch revascularization was performed so that ischemia to the organs supplied by the aortic branch was minimized. RESULTS: This technique was used for revascularization of supraaortic trunks (45 target vessels), and renal and/or visceral arteries and/or hypogastric arteries (201 target vessels), mostly in debranching procedures to allow endovascular aneurysm repair. The immediate technical success rate was 98%. Overall mean ischemia time was less than 4 minutes. The 30-day patency rate was 94%, and the mid-term (4-5 year) patency rate was 91%. CONCLUSIONS: This technique simplifies and shortens performance of aortic branch revascularization during aortic reconstructions for aneurysmal or occlusive disease. It minimizes vessel dissection and ischemia time and is of particular value in hybrid procedures, anatomically challenging situations, and in extensive scarring encountered in redo surgery

BACKGROUND: Composite sequential femoro-popliteal-distal bypass is a valuable option for treatment of critical limb ischemia when autogenous vein is limited and an isolated popliteal or distal arterial segment exists. We report a modified technique for composite sequential bypass and the results with its use over a 14-year period. METHODS: Twenty-five modified composite sequential bypass procedures were performed on 24 patients to treat gangrene, ischemic ulceration, and severe rest pain. Vein grafts were anastomosed from blind popliteal or blind distal arterial segments above-knee (7) or below-knee (18) to a distal outflow vessel including the below-knee popliteal (1), posterior tibial (5), anterior tibial (7), or peroneal (12) artery. Polytetrafluoroethylene bypass grafts were then placed from a suitable inflow artery to the proximal hood of the vein graft. RESULTS: Cumulative primary patency rates were 80% at 3 years, and 65% at 5 years. The limb-salvage rate was 85% at 4 years. Occlusion of the prosthetic segment with a patent distal vein segment was recognized in two patients who presented with less severe recurrent ischemia. Limb-salvage in these patients was achieved by a secondary prosthetic graft to the patent vein graft. CONCLUSION: Our modified configuration of the prosthetic-vein anastomosis for composite sequential bypass is an alternative to the conventional procedure and may help preserve vein graft patency should the polytetrafluoroethylene graft thrombose

BACKGROUND: Carotid artery stenting (CAS) is considered by many as an alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. However, recent trials demonstrated inferior results for CAS in symptomatic patients compared with CEA. We reviewed the literature to evaluate the appropriateness of CAS for symptomatic carotid artery stenosis and to determine the pathogenetic mechanism(s) associated with stroke following the treatment of such lesions. Based on this, we propose steps to improve the results of CAS for the treatment of symptomatic carotid stenosis. METHODS: PubMed/Medline was searched up to March 25, 2010 for studies investigating the efficacy of CAS for the management of symptomatic carotid stenosis. Search terms used were 'carotid artery stenting,' 'symptomatic carotid artery stenosis,' 'carotid endarterectomy,' 'stroke,' 'recurrent carotid stenosis,' and 'long-term results' in various combinations. RESULTS: Current data suggest that CAS is not equivalent to CEA for the treatment of symptomatic carotid stenosis. Differences in carotid plaque morphology and a higher incidence of microemboli and cerebrovascular events during and after CAS compared with CEA may account for these inferior results. CONCLUSIONS: Currently, most symptomatic patients are inappropriate candidates for CAS. Improved CAS technology referable to stent design and embolic protection strategies may alter this conclusion in the future

Carotid artery stenting (CAS) remains a viable option for treating carotid artery lesions in high surgical risk patients. We retrospectively reviewed our experience in performing CAS in patients with complex aortic arch anatomy. The ''coronary technique'' uses an AL1 guiding catheter to engage the origin of the common carotid artery permitting delivery of protection device and stent. In total, 12 patients had complex arch anatomy which precluded access using the standard technique as determined on preoperative imaging. A total of 8 patients with such anatomy underwent femoral artery catheterization with placement of an Amplatz AL1 guide catheter into the common carotid artery. All were able to be successfully treated, with no dissection, neurovascular deficit, or other major complication. Based on this case series, we describe the coronary technique as a safe and viable method for CAS in the setting of complex anatomy which might otherwise preclude CAS

Mortality rates following repair of ruptured abdominal aortic aneurysms have remained depressingly high over the last number of decades despite advances in anesthesia and perioperative care. Prior to the introduction of endovascular repair, refinements in surgical technique had been few and far between. It was not until fairly recently that we finally observed a reduction in mortality coinciding with the wider adoption of endovascular repair. So, the case is closed, right? Endovascular repair should be widely adopted in all suitable patients? Well, not exactly. The following debate centers around what level of evidence is required to answer this question. Frank Veith argues that we're already there. He was an early adopter and innovator of endovascular techniques and feels that we have enough information to widely adopt endovascular repair of ruptured aneurysms. Janet Powell and Robert Hinchliffe, innovators in their own right, feel that the generalizability and applicability of endovascular repair require further evaluation with a randomized trial. Both offer clear and reasoned arguments

BACKGROUND: It has been well established that inferior vena cava (IVC) filter placement at the time of open gastric bypass (OGB) surgery in patients with a body mass index of more than 55 kg/m(2) reduces both the pulmonary embolism rate and the perioperative mortality. However, little is known about the long-term effects of IVC filter placement in this particular group of patients. METHODS: Over an 8-year period, a total of 571 morbid obese patients underwent OGB procedures, and 58 (10%) of them required placement of an IVC filter before their procedure. All IVC filters were placed percutaneously through a femoral vein approach using a portable OEC fluoroscope. Types of IVC filters used in our study included the TrapEase (n = 35), Simon-Nitinol (n = 9), Greenfield (n = 2), and Bard Recovery (n = 12). RESULTS: Of the 58 patients who required an IVC placement, 56 remained free of any thromboembolic phenomena over the 8-year period (range, 1-8 years). The remaining two patients developed deep venous thrombosis. One patient was successfully treated with intravenous heparin and a 6-month course of Coumadin. She had complete resolution of her deep venous thrombosis and was incidentally noted to have a prothrombin 20210 gene mutation. The other patient, who had multiple gastric bypass complications, could not be successfully treated with intravenous heparin and thus progressed on to complete IVC thrombosis. She developed phlegmasia cerulea dolens and required bilateral above-the-knee amputations. She subsequently died 3 months after her procedures. CONCLUSION: It appears that IVC filter placement at the time of OGB surgery is a relatively benign intervention with a maximal benefit. A note of caution should be exerted for those obese patients who have a hypercoagulable disorder and for those who have complications related to the gastric bypass. An aggressive posture, which may consist of immediate anticoagulation after their procedures (only when it is deemed safe), should be advocated in this small sub-group of morbid obese patients