Faculty Bibliography

This paper describes the present status of the initiative to obtain American Board of Medical Specialties (ABMS) approval of an independent American Board of Vascular Surgery (ABVS). The need for such a board arises from the evolution of vascular surgery into a distinct, well-defined specialty that deals with all aspects of vascular disease, including knowledge of its natural history, all methods of noninvasive and invasive diagnosis, conservative and medical treatment, open operative treatment, endovascular treatment, and periprocedural care. Because of the greater skill requirements and increased complexity of vascular surgery, its paradigms of training must be changed. Longer periods of vascular training are required with a reciprocal 2- to 3-year shortening of training in general surgery. This cannot be done without an independent ABVS. The effort to obtain ABVS approval has elicited opposition from the American Board of Surgery (ABS) and from some vascular surgery leaders associated with it, making the ABVS a contentious issue. A successful effort was made to reach consensus within vascular surgery, and the ABVS application was submitted to the ABMS. As a result of an ABS campaign that combined pressure and dire warnings, this application encountered intense opposition within the ABMS and its Liaison Committee for Specialty Boards (LCSB). Institutional and professional self-interest, rather than quality of patient care, appeared to be the overriding considerations in the ABS argument. Measures to overcome this ABS opposition and obstructionism are proposed. They require unity, action, and tangible support from all vascular surgeons. If this call to arms goes unheeded, vascular surgery will not continue to be the self-sufficient specialty it has become and, most importantly, patient care will suffer

OBJECTIVE: The lack of aneurysm pulsatility after endovascular aneurysm repair (EVAR) is deemed by some an important guide to the effectiveness of exclusion. However, factors that contribute to aneurysm pulsatility after EVAR have not been elucidated. This study quantitatively analyzed the effects of systemic pressure, aneurysm sac pressure, endoleak, branch outflow from aneurysm sac, and intra-sac thrombus on aneurysm pulsatility after EVAR. METHODS: In an ex vivo model, an artificial aneurysm sac was incorporated within a mock circulation comprised of rubber tubing and a pulsatile pump. The aneurysm sac was then completely excluded from the circulatory circuit with two types of stent-grafts, ie, supported and unsupported, and heparinized canine blood was circulated. Systemic circulation and aneurysm sac pressure was recorded in the absence and presence of endoleaks, and simulated open and closed lumbar branch outflow from the aneurysm sac. The aneurysm sac was then filled with organized human thrombus, and all pressure measurements were repeated. Two observers blinded to the above-mentioned variables independently evaluated aneurysm sac pulsatility with palpation in five separate experiments. Analysis of variance was performed, with significance accepted at P =.05. RESULTS: Systemic pressure was simulated in the artificial circulation to range from 100/60 to 180/60 mm Hg. Regardless of the simulated lumbar branch outflow from the aneurysm, sac pressure was directly related to the presence of endoleak (P <.001). Aneurysm sac pulsatility was present only when the lumbar branch outflow was patent and not dependent on sac pressures. Aneurysm sac thrombosis or type of stent-graft did not influence sac pressure and pulsatility. CONCLUSIONS: In this model, after EVAR pulsatility depends on aneurysm sac outflow, regardless of endoleak, sac thrombosis, sac pressure, or stent-graft. Furthermore, persistent pulsatility does not predict systemic intra-sac pressure, nor does lack of pulsatility reflect freedom of the aneurysm sac from systemic pressurization. This ex vivo model suggests that aneurysm pulsatility is an unreliable guide for predicting aneurysm sac pressurization after EVAR. Other diagnostic methods must be used to assess successful aneurysm exclusion

OBJECTIVE: Subintimal angioplasty (SIA) has been advocated to treat long segment lower extremity arterial occlusions, but many question its value. We evaluated the role of SIA in a group of patients with severe lower extremity arterial occlusive disease. METHODS: During a 2.5-year period, 39 patients with arterial occlusions (median length, 8 cm; range, 2 to 31 cm) were treated on an intention-to-treat basis with SIA. Twenty-five patients had gangrene, five had rest pain, and nine had disabling (<one block) claudication. There were 24 superficial femoral, two superficial-femoral-popliteal, four popliteal, two popliteal-tibial, five tibial, and two external iliac artery lesions. With fluoroscopic guidance, via a prograde common femoral artery puncture (n = 29) or a contralateral common femoral artery puncture (n = 9), a subintimal dissection plane was created across the occlusion with a standard guidewire and catheter. The arterial lumen was reentered distal to the occlusion, and the recanalized segment balloon was dilated. All patients were followed prospectively with arterial duplex scan. RESULTS: SIA was technically successful in 34 of 39 patients (87%). All five failures were from an inability to reenter the patent lumen distally. These five patients underwent successful bypasses that in no case were more distal than would have been required before SIA. In the 34 technically successful SIAs, pain completely resolved (14/14) and areas of gangrene (21/25) healed. The cumulative patency rate in patients who underwent successful SIA was 74% +/- 10% at 12 months. The mean increase in ankle-brachial index after SIA was 0.34 (range, 0.1 to 0.69). There were two distal embolic events, successfully treated surgically (n = 1) or with catheter-directed techniques (n = 1). Three patients underwent subsequent bypass, and the remaining five patients remain asymptomatic. CONCLUSION: SIA is feasible and can be effective in some patients with lower extremity arterial occlusions and threatened limbs. These results, plus SIA's many advantages, support an increasing role for it in the treatment of lower extremity arterial occlusive disease

OBJECTIVE: Carotid artery stenting (CAS) for treatment of carotid stenosis has not received wide acceptance because of the availability of carotid endarterectomy (CEA) with its excellent results and because of the risk of embolic stroke associated with CAS. The feasibility and efficacy of cerebral protection devices that may prevent such embolic complications have yet to be shown. We report our initial results with CAS performed with cerebral protection. METHODS: For a period of 28 months, 31 patients with carotid artery stenosis, most of whom were considered at high risk for CEA (87%), underwent treatment with CAS in conjunction with either the PercuSurge GuardWire (n = 19; Medtronic, Minneapolis, Minn), the Cordis Angioguard filter (n = 7; Cordis, Warren, NJ), or the ArteriA Parodi Anti-embolization catheter (n = 4; ArteriA, San Francisco, Calif) with US Food and Drug Administration-approved investigational device exemptions. Factors that made CEA high risk included restenosis after CEA (n = 6), hostile neck (n = 6), high or low lesions (n = 4), and severe comorbid medical conditions (n = 11). Preoperative neurologic symptoms were present in 58%, and the mean stenosis was 85% +/- 12%. Data were prospectively recorded and analyzed on an intent-to-treat basis. Neurologic evaluation was performed before and after CAS by a protocol neurologist. RESULTS: CAS was performed with local anesthesia with the Wallstent (n = 23; Boston Scientific Corp, Natick, Mass) or the PRECISE carotid stent (n = 7; Cordis) in conjunction with one of the protection devices in an operating room with a mobile C-arm. Each patient received dual antiplatelet therapy before surgery. The overall technical success rate was 97% (30/31). In one patient, the lesion could not be crossed with a guidewire because of a severely stenosed and tortuous lesion. This patient was not a candidate for CEA and was treated conservatively. In the remaining 30 cases, CAS had a good angiographic result (residual stenosis, <10%). All patients tolerated the protection device well, and no intraprocedural neurologic complications occurred. Macroscopic embolic particles were recovered from each case. One patient (3%) with a severely tortuous vessel had a major stroke immediately after CAS, and no deaths occurred. The combined 30 day stroke/death rate was 3%. During a mean follow-up period of 17 months, one subacute occlusion of the stent occurred but did not result in a stroke. Three other patients had duplex scan-proven in-stent restenosis, and two underwent treatment with repeat percutaneous transluminal angioplasty with a good result. No patient had a stroke during the follow-up period. CONCLUSION: CAS with cerebral protection devices can be performed safely with a high technical success rate. Although many patients who underwent treatment with CAS were at high risk, the neurologic complication rate was low and CAS appears to be an acceptable treatment option for select patients at high risk for CEA. Tight lesions and tortuous anatomy may make the use of distal protection devices difficult. Further study is warranted