Faculty Bibliography

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

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

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

OBJECTIVES: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries. METHODS: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. RESULTS: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. DISCUSSION: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair

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: 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 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

PURPOSE: To present a technique for renal and visceral revascularization allowing complete endovascular treatment of a ruptured type IV thoracoabdominal aneurysm using devices already stocked in most centers performing endovascular aneurysm repair. TECHNIQUE: Open arterial access is obtained to both common femoral arteries and the left subclavian artery (LSA). Access to the visceral and renal arteries is obtained through separate 8-F sheaths for each visceral and renal branch. Both visceral arteries (celiac trunk and superior mesenteric artery) are accessed through 2 separate sheaths placed into the LSA, and both renal arteries are accessed through 2 separate sheaths placed into the left common femoral artery. Corresponding covered stents are introduced and positioned in the celiac trunk, superior mesenteric artery, and both renal arteries but not deployed. The aortic stent-graft is then introduced and deployed through the right common femoral artery. Once the aneurysm exclusion is completed, the stent-grafts to the branches are deployed so that they are positioned between the aortic wall and the aortic stent-graft. Finally, the branch stent-grafts as well as the aortic stent-graft are fully expanded with balloon catheters inflated simultaneously as in the kissing balloon technique. CONCLUSION: To our knowledge, no one has reported using this technique to successfully treat a ruptured thoracoabdominal aneurysm and revascularize all 4 major renovisceral arteries. A main advantage of this technique over use of branched stent-grafts is that it can be performed even in the emergency setting with devices that are in stock in most institutions performing endovascular aneurysm exclusion

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

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