Faculty Bibliography

Endovascular aneurysm repair (EVAR) of ruptured thoracoabdominal aortic aneurysms may be compromised or even impossible due to short proximal and/or distal necks or landing zones, respectively. Supra-aortic branches may limit the proximal anchorage and visceral or renal arteries the distal anchorage of endografts. While solutions have been proposed to overcome the problem of a short proximal neck, no technique has been described that solves the problem of a short distal neck. We present the 'periscope technique,' which allows extension of the distal landing zone and complete endovascular treatment of ruptured thoracoabdominal aneurysms with short distal necks using devices already stocked in most centers performing EVAR procedures

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

PURPOSE: To describe a new technique to assist aortoiliac stent-graft implantation in the presence of severe and extensive calcification. TECHNIQUE: The use of an aortic stent-graft telescoped into the aorta and deployed partly within and partly outside the aorta is illustrated in 2 cases. In the first, the bifurcated stent-graft was deployed with the proximal end and body intraluminally within the aorta; the distal ends (legs) were extended in an extravascular fashion with surgical grafts to reach the femoral bifurcation. In the second case, a tapered tubular stent-graft was deployed through the aortic wall to land partially inside the aortic lumen and partly inside a bifurcated standard surgical graft; the distal ends of the surgical graft were anastomosed to the iliac arteries by a standard anastomosis on the left and by an intraluminal telescoped stent-graft anastomosis on the right. Follow-up was uneventful in both patients. The sutureless telescoping anastomosis was stable at 5 years and 6 months, respectively, on computed tomographic angiography. CONCLUSION: These favorable outcomes underscore that this technique should be considered in patients with aortoiliac occlusive disease in whom aortic cross-clamping and/or a standard aortic anastomosis is expected to be difficult or impossible

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: Preoperative evaluation and perioperative management of cardiac disease in patients undergoing vascular surgery (VS) is important for patients and vascular surgeons. Recent evidence has emerged that has allowed us to develop contemporary paradigms for evaluating and managing coronary artery disease in VS patients perioperatively. METHODS: The utility of stress testing, the role of preoperative coronary revascularization, the optimal use of beta-blockers and statins, and the role of antiplatelet therapy in VS patients were reviewed in the literature. RESULTS: The revised Lee cardiac risk index, based on the number of risk factors (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, renal failure, hypertension, and age >75) quantitates cardiac risk. Stress testing is not predictive of myocardial ischemia/infarction (MI) or death and is only recommended in patients with unstable angina or an active arrhythmia. Stress testing for patients with 0 to 2 risk factors delays VS up to 3 weeks. In high-risk patients (>or=3 risk factors), it helps to identify patients who may develop myocardial ischemia and would benefit from a 30-day period to optimize medical therapy before VS. Stress testing and coronary catheterization do not predict which coronary artery to revascularize to prevent MI or death. Revascularization does not decrease MI or death rates at 1 month or 6 years. Although beta-blocker treatment decreases cardiac risk with VS, timing and dosage (titration) influence outcomes, improper usage may increase stroke and death rate, and not all VS patients should be taking these drugs. Patients with >or=1 risk factor should be considered to begin a low dose beta-blocker 1 month before VS. Preoperative statin use sharply decreases MI, stroke, and death perioperatively and long-term postoperatively. CONCLUSION: Routine stress testing should not be performed before VS. The Lee index should be used to stratify risk in patients undergoing VS. Patients with >or=3 risk factors or active cardiac conditions should undergo stress testing, if VS can be delayed. All VS patients, except those with 0 risk factors, should be considered for a beta-blocker (bisoprolol, 2.5-5 mg/d started 1 month before VS, titrated to a pulse <70 beats/min and a systolic blood pressure >or=120 mm Hg). Intermediate risk factors may not require aggressive heart rate control but simply maintenance on a low-dose beta-blocker. Statins should be started (ideally 30 days) before all VS using long-acting formulations such as fluvastatin (80 mg/d) for patients unable to take oral medication

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