Faculty Bibliography

OBJECTIVE: Patients undergoing open gastric bypass (OGB) for morbid obesity are at significant risk for pulmonary embolism (PE) despite the use of subcutaneous heparin injections and sequential compression devices. Prophylactic preoperative inferior vena cava (IVC) filter placement may reduce this risk. We report our experience with simultaneous IVC filter placement and OGB in an operating room setting. METHODS: From July 1999 to April 2001, 193 patients (group 1) underwent OGB. Eight patients had prophylactic intraoperative IVC filters placed for deep vein thrombosis, PE, or pulmonary hypertension. From May 2001 to January 2003, 181 patients (group 2) underwent OGB. There were 33 IVC filters placed for body mass index (BMI) greater than 55 kg/m2 in addition to the above-mentioned criteria. To confirm observations made in group 1 and 2 patients, from July 2003 to May 2005, 197 patients (group 3) underwent OGB, and patients with a BMI greater than 55 kg/m2 (n = 35) were offered IVC filter placement. Group 3A (n = 17) consented to IVC filter placement, and group 3B (n = 18) did not. RESULTS: Fifty-eight IVC filters were placed (100% technical success rate) with an increase in operating room time of 20 +/- 5 minutes. In group 1, the eight patients with IVC filters had a BMI greater than 55 kg/m2. There were four PEs (3 fatal and 1 nonfatal) in the other 185 patients, all which occurred in patients with BMIs greater than 55 kg/m2. In group 2, there were no PEs. The perioperative PE rate in these patients was reduced from 13% (4/31; 95% confidence interval [CI], 1.1%-25.7%) to 0% (0/33; 95% CI, 0%-8.7%). Perioperative mortality was reduced from 10% (3/31; 95% CI, 0%-20.0%) to 0% (0/33; 95% CI, 0%-8.7%). There were no pulmonary emboli or deaths related to PE in group 3A patients. Group 3B patients had a 28% PE rate (two fatal and three nonfatal) and an 11% PE-related death rate. None of the remaining patients in group 3 had a PE. CONCLUSIONS: Intraoperative IVC filter placement for the prevention of PE in morbidly obese patients undergoing OGB is feasible. We observed a significant reduction in the perioperative PE rate when a BMI greater than 55 kg/m2 was used as an indication for IVC filter placement despite the use of subcutaneous heparin injections and sequential compression devices

PURPOSE: To retrospectively assess endoleak shapes and locations within aneurysms to differentiate type II from type I and type III endoleaks. MATERIALS AND METHODS: The institutional review board granted an exemption for this HIPAA-compliant study; patient informed consent was not required. A retrospective review of arterial phase helical computed tomographic (CT) studies and medical records was performed for 39 patients (29 men, 10 women; age range, 60-89 years; mean, 78.5 years) who had an endoleak after endoaortic graft implantation for treatment of abdominal aortic aneurysm and who subsequently underwent angiography (n = 25), surgery (n = 8), or long-term follow-up (n = 6) to classify their endoleak into a specific type. At CT, endoleak shape (tubular or nontubular) and location (central or peripheral) were recorded. An endoleak was classified as type II if it contained a peripheral tubular component (PTC) near the aortic wall, with or without an identifiable feeding vessel. Endoleaks without these features were classified as type I or III. The Fisher exact test was used to assess associations between CT findings and endoleak type. RESULTS: There were 22 type II and 17 type I or III endoleaks. CT enabled correct identification of 22 (100%) of 22 type II endoleaks, all of which contained a PTC. Of 17 type I or III endoleaks, only two (12%) contained a PTC and were misclassified as type II endoleaks; the remaining 15 (88%) were correctly classified. Overall, CT enabled correct identification of endoleaks as type II or type I or III in 37 (95%) of 39 patients. PTCs were significantly more common (P < .001) in type II than in type I or III endoleaks, with a sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of 100%, 88.2%, 94.9%, 100%, and 91.7%, respectively. CONCLUSION: A PTC is a statistically significant predictor of type II endoleak in most patients

A 66-year-old man had foot gangrene and a fixed contracture of the knee following two failed femoropopliteal bypasses, one with vein and one with polytetrafluoroethylene (PTFE). An external iliac to anterior tibial artery bypass and skeletal traction via the os calcis resulted in limb salvage and successful normal ambulation. After 3 months, he ruptured the infected femoral anastomosis of the failed PTFE femoropopliteal bypass with external bleeding. The use of arteriography and a balloon catheter to obtain proximal control allowed arterial repair, removal of the graft, and preservation of flow within a patent common and deep femoral artery. This flow preservation maintained the viability and function of the limb when the anterior tibial bypass closed 4 years later, and the limb continues to be fully functional 3 years later. Aggressive secondary attempts at limb salvage are worthwhile even in unfavorable circumstances

OBJECTIVE: Proximal neck dilatation (PND) and/or endograft migration with the subsequent development of type I endoleak is a significant cause of late endograft failure after endovascular abdominal aortic aneurysm repair (EVAR). Although there are numerous reports examining PND in patients receiving endografts that use self-expanding stents (SES) for proximal fixation, there are no such reports for patients treated with endografts that use balloon-expanding stents (BES). The purpose of this study was to investigate PND and endograft migration after EVAR with BES endografts. METHODS: We retrospectively reviewed all charts and all serial computed tomographic scans available for patients who underwent EVAR with a BES endograft (surgeon-made, aortounifemoral polytetrafluoroethylene graft with a proximal Palmaz stent) between August 1997 and October 2002. Only patients with longer than a 12-month follow-up were analyzed. Neck diameter was measured at the level of the lowest renal artery and at 5 mm below it. PND was defined as neck enlargement of 2.5 mm or more. To assess endograft migration, the distance between the superior mesenteric artery and the cranial end of the BES was measured. Stent migration was defined as a change of 5 mm or more. RESULTS: A total of 77 patients received this device during the study period. The technical success rate was 99%. The 1-, 3-, and 5-year survival was 66%, 48%, and 29.5%, respectively. Complete serial computed tomographic scans were available in 41 of the 48 patients who survived 12 months or longer after the operation. The mean follow-up period for these patients was 31 months (range, 12-66 months). The maximum aneurysm diameter was either unchanged or decreased in 35 patients (85%). The immediate postoperative proximal neck diameter was 19 to 29 mm (median, 24 mm). This was unchanged at the latest follow-up. None of the patients had significant PND. The cranial end of the BES was located in the area between 14 mm proximal and 36 mm distal to the superior mesenteric artery (median, 6 mm). None of the patients developed significant endograft migration. CONCLUSIONS: Neither PND nor endograft migration was observed with the BES endograft. The nature of the SES may be responsible for the observed neck dilatation and device migration after EVAR with SES endografts. This study suggests that BES may be a better fixation method for EVAR

PURPOSE: To describe a technique of aortic clamping during endovascular aneurysm repair (EVAR) in patients with ruptured abdominal aortic aneurysms (AAA) and circulatory collapse. TECHNIQUE: A balloon catheter is inserted percutaneously from the femoral artery and inflated in the suprarenal aorta. An introducer sheath must support the balloon. The stent-graft is passed from the contralateral groin and deployed beneath the balloon. The sheath makes it possible to retrieve the balloon after the endograft has been deployed. Carbon dioxide facilitates angiography while the aortic blood flow is arrested. CONCLUSIONS: The aortic stent-graft can be deployed while the aorta is continuously 'clamped' from a transfemoral approach. This may allow EVAR in patients with circulatory collapse due to aneurysm rupture

In 1990 Juan C. Parodi performed the first endovascular abdominal aortic aneurysm (AAA) repair in Buenos Aires. Two years later, in 1992, Parodi and Claudio Schonholz visited Montefiore Medical Center in New York to perform with us the first endovascular AAA repair to be done in the United States. Since then the Montefiore/Einstein vascular group has performed 1522 endovascular grafts in 674 patients for many types of vascular lesions using a variety of both surgeon-made and industry-made devices. The purpose of the present article is to describe the events that surrounded the performance of the first seminal endovascular AAA repair at our institution on November 23, 1992