Faculty Bibliography

This article defines disruptive technology and discusses such technologies in Vascular Surgery. It considers the question: Is carotid artery stenting (CAS) a disruptive technology? Although CAS will impact positively on the treatment of carotid bifurcation disease, it will probably never displace carotid endarterectomy in the majority of patients. The precise role of CAS remains to be determined

PURPOSE: To present a technique for vascular access that features minimal surgical visualization of the target vessel, fast and safe access using an open Seldinger technique under tactile and visual control, and suture closure. TECHNIQUE: After minimal surgical access to the target vessel, exposing only the anterior wall, 4 preliminary 5-0 polypropylene transmural single sutures are placed in the horizontal plane, 2 on either side of the proposed entry point. If the anterior wall is calcified, the sutures are placed more laterally or medially in a suitable plaque-free area. The vessel is then accessed via an open Seldinger technique in the midline between the 4 sutures, and the corresponding sheaths are inserted over the wire. At the end of the procedure, the sheath and wire are removed, and with digital pressure on the vessel distally, the access site is washed out in antegrade fashion. All 4 sutures are then pulled tight by an assistant, and the surgeon ties all the sutures sequentially. Over a 4-year period, this technique has been used in 536 accesses involving the common femoral (n = 500) and iliac (n = 32) arteries and the abdominal aorta (n = 4). Up to 24-F sheaths were introduced. Mean time for vascular access was 9.0+/-3.3 minutes. There were no access-related early complications detected in routine postprocedural imaging and clinical evaluation. CONCLUSION: The 'Surgiclose' technique, which is easy to learn and applicable to all vessels, provides a fast, easy, and reliable remote vascular access. It combines the best of both surgical and interventional access techniques, affording minimal surgical access and maximal safety

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

Carotid artery interventions can be associated with adverse hemodynamic changes, including bradycardia and hypotension. These hemodynamic changes are believed to be caused by direct stimulation of the carotid sinus baroreceptors, mimicking normal physiological response to rises in blood pressure. During open carotid surgery, these hemodynamic changes can be controlled by direct injection of medications that block fast voltage gated sodium channels in the neuron cell membrane, thus preventing depolarization of the presynaptic neuron in the carotid sinus. This form of control is difficult or impossible during percutaneous carotid interventions because direct access to the carotid artery and carotid sinus is not available. This discussion focuses on the cause, effects, and possible treatments for the hemodynamic changes associated with carotid artery stenting procedures

Graft migration and other device-related problems are more frequent in abdominal aortic aneurysm (AAA) patients with a complicated neck. We wanted to evaluate the performance of a balloon-expandable stent graft in these cases. Complicated aortic neck morphology was defined as a combination of short (<15 mm) and angulated (>45 degrees) necks with or without circumferential thrombus. Severe aortic angulation was defined as less than 120 degrees. During a 24-month period, 18 consecutive patients with complicated neck anatomy were treated with the Vascular Innovations (VI)-Datascope balloon-expandable endograft. In two patients, a balloon-expandable cuff was implanted to remodel the neck prior to insertion of a bifurcated endograft (Excluder, W.L. Gore & Associates, Flagstaff, AZ). Demographic, procedural, and outcome data were collected prospectively and retrospectively analyzed. All patients had preoperative computed tomographic (CT) angiography to determine aortic neck angulation and were followed with duplex ultrasonography and CT every 3 and 6 months postoperatively to assess aortic neck and sac dilatation, as well as device migration. The VI-Datascope graft consists of an aortounifemoral polytetrafluoroethylene (PTFE) graft sutured to a proximal balloon-expandable stent. The length of the graft is 40 cm; thus, the distal end of the graft always protrudes through the ipsilateral arteriotomy and can be cut to an appropriate length for each patient. The covered portion of the graft was deployed just below the level of the lowest renal artery. The proximal bare metal stent was deployed in the suprarenal area. An endoluminal hand-sewn anastomosis was performed between the aortounifemoral limb and the distal external iliac or the common femoral arteries. An occluder device was placed in the contralateral common iliac artery to prevent retrograde perfusion of the aneurysm. A femorofemoral 8 mm Dacron graft bypass was then performed to establish flow to the contralateral extremity and pelvis. Using this approach, remodeling and straightening of angulated aortic neck morphology were achieved in all cases, including in 44% of patients with severe aortic neck angulation. The average follow-up period was 11.5 months (4-21 months). There was one early occlusion (<30 days after implantation) of the PTFE limb requiring thrombectomy and one late occlusion (6 months after implantation) requiring thrombectomy and implantation of a Viabahn stent graft (W.L. Gore & Associates). Scheduled CT scans did not show any graft migration or proximal neck dilatation. Neither neck dilatation nor endograft migration was observed with the balloon-expandable stent graft. In patients with complicated aortic neck morphology, balloon-expandable stent grafts such as the VI-Datascope graft provide more secure fixation and better long-term outcomes compared with the more commonly used self-expanding endografts

When ruptured abdominal aortic aneurysms (AAAs) are not treated, they cause death. In addition, ruptured abdominal aortic aneurysms (RAAAs) have high mortality (35%-70%) and morbidity rates when treated by standard open surgical methods. These high perioperative mortality and morbidity rates have not been substantially reduced despite the introduction of many improvements in open operative technique or perioperative care. Endovascular approaches to treat AAAs introduced in the early 1990s provided an opportunity to substantially alter treatment outcomes when rupture occurred. This article details how these endovascular approaches, which include endovascular stented grafts, can be applied to the treatment of RAAAs, and what advantages these new catheter-based approaches to treatment offer

BACKGROUND: A randomized clinical trial from the United Kingdom (EVAR trial 2) comparing endovascular aortic aneurysm repair (EVAR) with no intervention found no advantage for EVAR in patients with high risk. This finding was predominantly caused by the substantial in-hospital mortality after EVAR (9%). HYPOTHESIS: The nationwide in-hospital mortality for patients with the highest risk undergoing EVAR in the United States is lower than that reported in EVAR trial 2. DESIGN: Population-based, cross-sectional study. SETTING: The 2001-2004 Nationwide Inpatient Sample. PATIENTS AND METHODS: The Nationwide Inpatient Sample identified EVAR procedures for nonruptured abdominal aortic aneurysms. Risk stratification was based on comorbidities and the Charlson comorbidity index, a validated predictor of in-hospital mortality after abdominal aortic aneurysms repairs. Weighted univariate and logistic regression analyses were used to determine the association between comorbidity measures and risk-adjusted in-hospital mortality. RESULTS: During the 4-year period, 65 502 EVARs were performed with an in-hospital mortality of 2.2%. Risk-adjusted in-hospital mortality rates ranged from 1.2% to 3.7%. Stratified analyses, including only elective EVAR procedures, revealed that in-hospital mortality was significantly higher in patients with the most severe comorbidities (1.7%) vs those with lower comorbidity (0.4%; P<.001). Patients with high risk had only a 1.6-fold increased risk of adjusted in-hospital mortality (odds ratio, 1.6; 95% confidence interval, 1.2-2.2) compared with patients with low risk. CONCLUSIONS: The EVAR procedure is currently being performed in the United States with low in-hospital mortality, even in patients with the highest risk. Therefore, EVAR should not be denied to high-risk patients with abdominal aortic aneurysms in the United States on the basis of the level I evidence from the United Kingdom study