Faculty Bibliography

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are frequently encountered in critically ill patients and carry a high morbidity and mortality risk. Despite these facts, IAH/ACS are still overlooked by many physicians and therefore timely diagnosis is not made and treatment is often inadequate. All clinicians should be aware of the risk factors predicting IAH/ACS, the profound implications and derangements on all organ systems, the clinical presentation, the appropriate measurement of intra-abdominal pressure to detect IAH/ACS and the current treatment options for these detrimental syndromes. This comprehensive review provides knowledge about known facts, unresolved issues and future directions for research to improve patient survival and long-term outcome

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

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

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

BACKGROUND: We report our clinical experience with the use of a sutureless telescoping anastomosis, initially described as the VORTEC (Viabahn Open Rebranching TEChnique) revascularization technique, for debranching of supra-aortic vessels. METHODS: Between May 2005 and December 2008, 20 patients (15 men) with an aortic arch lesion underwent trans-sternal debranching with sutureless telescoping anastomosis performed with a Viabahn (diameter, 5-8 mm; length, 5-15 cm) or Hemobahn (diameter, 9-13 mm; length, 10-15 cm), followed by endovascular aneurysm repair. Initially, the Viabahn/Hemobahn was sutured to a feeding graft after deployment. Since 2008, the Viabahn/Hemobahn has been deployed within an interposition graft, rendering unnecessary the anastomosis. The underlying aortic pathology was (1) isolated aortic arch aneurysm in 10, (2) aortic arch aneurysm extending to the ascending or descending aorta in 6, (3) floating thrombus within the aortic arch in 1, (4) acute aortic arch dissection in 1, and (5) Crawford II thoracoabdominal aortic aneurysm extending into the aortic arch in 2. Postprocedural duplex ultrasound imaging showed normal flow profiles in all patients. Follow-up included computed tomography angiography at 1, 3, and 6 months postoperatively, and then annually. RESULTS: Overall, 56 supra-aortic vessels in the 20 patients were debranched by sutureless telescoping anastomosis, including the carotid artery in 18, subclavian artery in 13, and left vertebral artery in 1. Technical success was 100%. The mean ischemia time was 3 minutes (range, 1-9 minutes) for the debranching procedure vs 6 minutes (range, 5-16 minutes) for a conventional suture anastomosis. The 30-day mortality rate was 15% (3 if 20); 28.5% (2 of 7) in urgent cases and 7.6% (1 of 12) in elective patients. Three patients (15%) had neurologic deficits after debranching in the conventionally-sutured anastomosis territories. No early (<30 days) occlusion occurred. During a mean follow-up of 14 +/- 9 months (range, 1-39 months), one patient with Takayasu disease showed asymptomatic occlusion of a Viabahn implanted into the left common carotid artery. Stenosis in the aortic anastomosis of the bypass graft in another patient was successfully treated by angioplasty and stent placement through the right brachial artery. CONCLUSIONS: Sutureless telescoping anastomosis with a Viabahn or a Hemobahn in supra-aortic debranching seems to be a safe and reliable alternative to sutured anastomosis. It enables safe and fast-track revascularizations, especially in anatomically challenging situations, and requires a very short ischemia time. Questions about long-term results and the technique reproducibility must be addressed

PURPOSE: To evaluate the outcomes of atherectomy versus subintimal angioplasty (SIA) in patients with lower extremity arterial occlusive disease. METHODS: From September 2005 through July 2006, 27 patients (17 women; mean age 65 years, range 37-85) underwent atherectomy of 46 lesions (11 TASC C/D occlusions) with the SilverHawk device. Results were compared to 67 patients (34 men; mean age 69 years, range 46-92) undergoing SIA for 67 lower extremity arterial occlusions from July 1999 through June 2004. RESULTS: Technical success in the atherectomy cohort was 100%. In the 11 patients with occlusions, symptoms improved in 10 and worsened in 1, but 9 (82.0%) of the 11 patients required reintervention, and 8 (72.7%) patients with occlusive lesions re-occluded. Endovascular reintervention was required to maintain primary patency in only 2 (12.5%) of 16 patients treated for stenotic lesions. At 1 year, the assisted primary patency was 37.7% in the atherectomy group. In the 11 patients with occlusive lesions, the patency rates were 36.8% and 12.3% at 6 and 9 months, respectively, versus 100% and 83.3% at the same time intervals in patients with stenotic lesions. SIA was technically successful in 56 (83.6%) of 67 occlusions. The assisted primary patency and limb salvage rates of the entire group (intention-to-treat) at 12 and 24 months were 59.2% and 45.0%, respectively, while the assisted primary patency of the 56 technically successful SIAs at 12 and 24 months were 70.7% and 53.8%, respectively. Limb salvage for the entire group (intention-to-treat) was 90.6% and 87.9% at 12 and 24 months, respectively. CONCLUSION: Atherectomy may yield acceptable primary patency and limb salvage in patients with stenotic lesions. Many of the patients treated for occlusive lesions require reintervention. Based on patency and limb salvage, SIA appears superior to atherectomy for the treatment of lower extremity occlusive disease