Faculty Bibliography

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

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

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

Endovascular repair is becoming the mainstay of treatment for aneurysmal disease of the abdominal and thoracic aorta. Access related issues comprise a major reason for failure or conversion to open repair and can contribute to a significant amount of morbidity and mortality. This article will discuss a multitude of access related complications and their treatment. Preoperative imaging is paramount to the success of endovascular procedures. Intraoperative adjuncts, such as iliac artery angioplasty/stenting, the 'pull-down' technique, and aorto mono iliac/femoral systems will be discussed. Occasionally, challenging iliac or femoral anatomy may preclude access through these vessels and the endovascular specialist may need to gain direct access through the aorta or via the carotid artery. In addition, the advantages and disadvantages of an entirely percutaneous technique will be discussed. Finally, peri-operative complications such as rupture, dissection, pseudoaneurysm and infection will be discussed and various treatment modalities reviewed. As stent graft technology and our own skill sets and experience continue to improve, fewer patients will be refused an endovascular repair based on access issues alone

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

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

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

BACKGROUND: To evaluate the effectiveness of the Viabahn Open Revascularization Technique (VORTEC) in the treatment of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PAAAs) by hybrid procedures. METHODS: Between December 2004 and March 2009, 58 patients (45 male, mean age, 74 years) were diagnosed with TAAA (n = 30) and PAAA (n = 28) and treated electively by combined hybrid techniques. Hybrid procedure includes bypass surgery of the visceral and renal arteries (debranching or rerouting), followed by endovascular exclusion of the aortic aneurysm. One hundred thirteen renovisceral vessels were revascularized in a retrograde fashion (ie, 98 renal and 15 visceral arteries), using VORTEC. The novel technique consists of the placement of self-expanding stent-grafts (Viabahn graft, Gore and Associates, Flagstaff, Ariz) in Seldinger technique into the renal and visceral arteries after surgical identification of the origin of the arteries. The end of the stent outside of the renal artery was sutured end to side directly with the main feeding graft, bypassing the aneurysm, or was fixed into an interposition branch graft on the main bypass. All cases were treated by two-staged approach (endovascular aneurysm repair [EVAR] performed after recovery from the debranching procedure). Computed tomography angiography and clinical follow-up were obtained before discharge, at six weeks, and three, six, and 12 months after the procedure and then annually. RESULTS: Primary technical success of VORTEC was achieved in all patients. Overall primary patency rate of the novel technique was 97% during a mean follow-up of 22.1 +/- 12.9 months (range, 1-52 months); the primary patency of the subgroups PAAAs and TAAAs was 97.7% and 96.4%, respectively; the assisted primary patency rate was 98%, as two occluded Viabahn grafts were reopened by thrombolysis and thrombus aspiration. No patient required long-term hemodialysis. Thirty-day mortality rate was 8.6% (5/58) and 25.8% (15/58) for the entire follow up. Permanent neurologic deficit occurred in two cases (3.4%; paraplegia, n = 1; paraparesis, n = 1). The overall endoleak rate was 17.1% as three patients presented early (30-day) type I endoleak, treated by cuff-implantation, and six patients presented type II endoleak, three of them treated by coil embolization of the patent vessel and the others treated conservatively with radiological surveillance. CONCLUSION: VORTEC allows performance of easy, safe, and minimally invasive revascularization of renal and visceral arteries and may represent a significant technical advance in the hybrid repair of TAAAs and PAAAs. However, the questions of reproducibility by other centers and long-term results are mandatory to establish this alternative revascularization option

BACKGROUND: Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial. OBJECTIVE: To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers. METHODS: Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR). RESULTS: Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients. CONCLUSION: These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed

A floating thrombus within the aortic arch is a rare condition that is generally detected after cerebral, visceral, or peripheral embolization. Endovascular exclusion of such mobile thrombus has been described but exclusively involved the descending aorta, or debranching of the supra-aortic trunk was done by open surgical bypass procedure. We present a case with a floating thrombus that extended throughout the whole aortic arch and involved all of the supra-aortic trunks. The pathology was treated by debranching the supra-aortic trunks using a new nonsutured Viabahn-based (W. L. Gore & Associates, Flagstaff, Ariz) technique (Viabahn Open Revascularization TEChnique [VORTEC]) for revascularization of the left common carotid artery and performing an antegrade endograft implantation from the ascending aorta, distal to the origin of the feeding graft for debranching, to the descending aorta in one procedure