Faculty Bibliography

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

BACKGROUND: Open abdomen treatment (OAT) is considered a lifesaving procedure in patients with abdominal compartment syndrome (ACS) after endovascular or open intervention for ruptured abdominal aortic aneurysms (RAAA). Standardized treatment methods and algorithms for its use are still lacking. The high, published mortality rates may reflect difficulties in detecting and treating ACS, especially in patients treated by emergency endovascular aneurysm repair (eEVAR). Presented are standardized algorithms for OAT, including a new technique using the vacuum-assisted closure (VAC) system developed during 10 years of experience with eEVAR for RAAA. METHODS: We retrospectively analyzed 102 patients with RAAA treated by eEVAR from January 1998 to April 2008. Abdominal decompression was done when intravesical pressure >20 mm Hg or when abdominal perfusion pressure was <50 to 60 mm Hg and concomitant organ deterioration occurred. OAT was initially done with a subcutaneously sutured plastic bag or with a nonsutured zipper drape combined with a VAC device (VAC/ETHIZIP; KCI International Inc, Amstelveen, The Netherlands; Ethicon, Somerville, NJ). All patients were switched to VAC/ETHIZIP as soon as possible. Dressings were generally changed every 3 to 5 days. Intra-abdominal pressure was monitored until stability was observed after delayed direct abdominal closure. RESULTS: Overall 30-day mortality for eEVAR was 13% (13 of 102); 8% (7 of 82) for patients without ACS and 30% (6 of 20) for those with ACS. Decompression for ACS was needed in 20 patients (20%) primarily during the intervention (n = 14) or secondarily in the intensive care unit (n = 6). Six of 20 (30%) patients requiring OAT died <or=30 days (4 primary, 2 secondary). A mean of 3.6 (range, 1-12) planned second-look interventions were done per patient at an interval of 3 to 5 days. No bowel lesions were observed. Four patients required antibiotic therapy for abdominal infection, and all infections resolved. Delayed abdominal wall closure (direct closure, 11; closure with polypropylene mesh, 3; bilateral anterior rectus abdominis sheath turnover flap, 1) was achieved after a median of 6 days (range, 1-47 days). CONCLUSION: The use of standardized novel techniques and a treatment protocol and algorithm for OAT after eEVAR for RAAA were feasible and safe. It decreased the workload of the medical and nursing staff, enhanced patient comfort because the need for dressing changes was minimized, and likely contributed to lower overall mortality in RAAA patients. Delayed direct fascial closure was possible in most patients

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

Carotid artery stenting (CAS) has emerged as a potential alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. The purpose of this article is to provide an evaluation and critical overview of the trials comparing the early and later results of CAS with CEA for symptomatic carotid stenosis. The CochraneControlled Trials Register, PubMed/Medline, and EMBASE databases were searched up to February 1, 2009, to identify trials comparing the long-term outcomes of CAS with CEA. The MeSH terms used were 'carotid artery stenting,' 'carotid endarterectomy,' 'symptomatic carotid artery stenosis,' 'treatment,' 'clinical trial,' 'randomized,' and 'long-term results,' in various combinations. One single-center and three multicenter randomized studies reporting their long-term results from the comparison of CAS with CEA for symptomatic carotid stenosis were identified. All four studies independently reached the conclusion that CAS may not provide results equivalent to those of CEA for the management of symptomatic carotid stenosis. A higher incidence of recurrent stenosis and peri- and postprocedural events accounted for the inferior results reported for CAS compared with CEA. Current data from randomized studies indicate that CAS provides inferior long-term results compared with CEA for the management of symptomatic carotid artery stenosis. However, it can be argued that all of these trials were performed when both CAS equipment and CAS operators had not evolved to their current status. Given that current equipment and mature experience are required for CAS before comparing it with the current 'gold standard' procedure (CEA), the results of soon-to-be reported trials (Carotid Revascularization Endarterectomy vs Stenting Trial [CREST], International Carotid Stenting Study [ICSS], or others) may alter the current impression that CAS is inferior to CEA for the treatment of symptomatic carotid stenosis

INTRODUCTION: Endovascular replacement of failed Vanguard endoprosthesis with a newly inserted bifurcated Excluder endograft in 6 selected patients over a 10-year period is reported. REPORT: Six male patients were treated by secondary EVAR procedures for endograft failure (type I and/or III endoleaks caused by endograft disintegration and/or migration). All failed endografts (1 tube, 5 bifurcated) were Vanguard prostheses. Technically, a new bifurcated Excluder endograft was placed within the old failing Vanguard endograft. All reinterventions were performed under local anesthesia supplemented by systemic analgesia/sedation. In 3 patients, insertion of the new Excluder endograft was possible without any additional technical measure as the failing Vanguard endograft trunk had migrated distally. In another 3 patients, the failed Vanguard endograft trunk was still in place. In these patients, the Vanguard main body was pulled caudally with a transfemoral cross-over guide wire in order to gain sufficient length to allow the short limb of the Excluder endograft to open within the trunk of the failed Vanguard endoprosthesis. This guide wire was introduced through a second femoral 5F in the main access and exeteriorized with a snare through the contralateral 12 Fr sheath. The main body and short limb of the Excluder was then deployed whilst pulling on the cross-over wire. RESULTS: Six patients initially treated by a Vanguard endograft underwent complete relining with a newly inserted Excluder bifurcated stentgraft. The mean interval from the first EVAR procedure to the described replacement procedure was 75+/-20.2 months (range: 53-109). The new bifurcated Excluder endografts were successfully deployed in all patients (technical success: 100%). Primary sealing (defined as absence of endoleaks type I, III or IV in the postoperative contrast enhanced CT scan) was achieved in 6 of the 6 patients. There was no operative mortality. No further endovascular or open treatment was needed in the other 5 patients. During the mean follow-up period of 26+/-20.1 months (range 2.5-50 months), 2 patients died from unrelated causes. CONCLUSION: Secondary endovascular replacement of failed Vanguard endografts with a bifurcated Excluder endograft proved to be feasible and safe with no 30-day mortality. Technical detail requires traction on a cross-over wire to pull the old graft caudally and create enough space for the new bifurcated graft to be deployed

This article describes a new, less invasive prosthetic graft anastomotic technique that uses self-expanding stent grafts that are 'telescoped' into aortic branches. This method, the VORTEC (Viabahn Open Revascularization TEChnique), obviates the need for potentially difficult complete vessel exposure and graft anastomoses, thereby reducing the duration of flow interruption and simplifying the performance of complex aortic reconstructions and so-called debranching procedures requiring reconstruction of major branches such as renal arteries. Minimal exposure of one surface of the renal artery allowed introduction and deployment of a self-expanding Viabahn (W.L. Gore & Associates, Flagstaff, AZ) device using the Seldinger technique. The Viabahn devices used were 5 to 8 mm in diameter and 5 to 15 cm in length depending on individual anatomy (assessed by preoperative computed tomographic angiography). Overall, 82 renal arteries have been revascularized in 58 patients using the VORTEC. The technical success rate was 100%, with all of the stent grafts implanted as intended with maintenance of flow. The patency rates were 97% after 30 days and 96% after a mean follow-up of 18 months (range 1-38 months). The VORTEC allows performance of safe and expeditious revascularization of renal arteries. This new technique may represent significant improvement over the standard approach of surgical exposure and sutured anastomosis

OBJECTIVE: This study examined the frequency and nature of incidental findings seen on computed tomography (CT) scans during preoperative and postoperative follow-up in patients undergoing endovascular aortic aneurysm repair (EVAR). METHODS: Between January 1, 2000, and March 1, 2006, 176 consecutive patients who underwent EVAR at our institution were retrospectively reviewed. Patients were included in the study if all preoperative and postoperative surveillance CT scans were performed at our institution. Eighty-two patients, 26 women (32%) and 56 men (68%), met this criterion. Their mean age was 76 years (range, 51-103 years). Official CT scan reports were reviewed. Findings were considered primary incidental if they were noted on preoperative CT scans and secondary incidental if they appeared on surveillance CT scans but not on the preoperative study. Primary and secondary incidental findings were considered either benign (eg, gallstones, diverticulosis) or clinically significant if they warranted further workup (eg, suspicious masses or changes suggestive of malignancy, internal or diaphragmatic hernias, and diverticulitis). The median follow-up was 29 months (range, 3-60 months). Each incidental finding was counted only once, on the first scan in which it appeared. RESULTS: Of the 82 patients, 73 (89%) had at least one primary incidental finding, and 14 (19%) of these were clinically significant. Secondary incidental findings, many of which were clinically significant, continued to appear throughout the follow-up period. The most common clinically significant primary incidental finding was the presence of a lung mass (n = 4). The most common clinically significant secondary incidental findings were lung mass (n = 6), liver mass (n = 6), and pancreas mass (n = 3). There was a significant difference in the proportion of men to women in the group with clinically significant incidental findings vs the group without clinically significant incidental findings (P = .03959). Differences between the groups with respect to age or aneurysm size were not significant. CONCLUSION: CT scans yielded surprisingly large numbers of both primary and secondary incidental findings, many of which were clinically significant. Primary incidental findings were more common than secondary incidental findings; however, clinically significant findings were found at a consistent rate throughout the study period