Faculty Bibliography

This report describes the treatment of bilateral common iliac artery aneurysms in a patient with a pelvic horseshoe kidney. Anomalous renal arteries arising from the aorta, the common iliac arteries, and the left hypogastric artery were identified precisely by selective angiography. These multiple renal artery anomalies and the presence of a large pelvic horseshoe kidney complicated the surgical treatment of the aneurysms. The repair of the aneurysms was successfully accomplished by staged retroperitoneal procedures. This technique allowed excellent visualization of the iliac aneurysms and preservation of all renal arteries with intact renal function

PURPOSE: This report describes our 5-year experience with the endovascular repair of isolated iliac aneurysms and pseudoaneurysms. METHODS: Between June 1993 and July 1998, 40 isolated iliac aneurysms and pseudoaneurysms were treated with endovascular grafts in 39 patients. Thirty-seven aneurysms were treated with endovascular grafts composed of polytetrafluoroethylene grafts and balloon expandable stents, and the other three underwent repair with a polycarbonate urethane endoluminal graft. RESULTS: All the patients underwent initially successful endovascular treatment of isolated iliac aneurysms and pseudoaneurysms and were followed from 1 to 51 months (mean, 18 months). The 4-year primary patency rate was 94.5% +/- 10%. The perioperative complications included one episode of distal embolization, an episode of colonic ischemia, five episodes of kinking or compression of the endovascular graft, and one early postoperative graft thrombosis. There was only one perioperative death in a patient whose aneurysm ruptured in the operating room just before endovascular repair. The median postoperative length of hospital stay was 3.0 +/- 1.3 days in this group of patients at moderate and high risk. The long-term complications included one graft thrombosis and two endoleaks. One small endoleak was followed until the patient died of unrelated causes, and the other one led to aneurysm rupture in the only patient temporarily lost to follow-up examination. This patient successfully underwent treatment in the standard open surgical fashion. To date, all the other aneurysms have remained stable or have decreased in size during the follow-up examinations with duplex or contrast-enhanced computed tomographic scans. CONCLUSION: Endovascular repair of iliac aneurysms and pseudoaneurysms is a safe and effective technique with good midterm results in patients at standard and high risk. These grafts are particularly beneficial for patients with medical, surgical, or anatomic contraindications for open surgical repair

PURPOSE: Isolated aneurysms of the iliac arteries are uncommon lesions that require surgical repair to prevent rupture. METHODS: During a 4-year period, we used endovascular stented grafts (EGs) to treat 28 iliac artery aneurysms that were not associated with aortic aneurysms. Twenty-five patients, with a total of 24 common iliac (15 right, nine left) and four internal iliac (two right, two left) artery aneurysms, underwent endovascular grafting. There were 24 men and 1 woman, with a mean age of 74 years (range, 51 to 88 years). Combined common and internal iliac artery aneurysms were present in three patients. Nineteen patients who underwent treatment with EGs were administered epidural anesthesia (22 epidural, two local, one general). Before surgery, one patient had lower extremity embolization and ischemia from the aneurysm, three had abdominal or back pain, and the remaining were asymptomatic. The EGs were constructed of polytetrafluoroethylene grafts and balloon expandable stents. RESULTS: Four procedure-related complications (12%) occurred (distal extremity embolization, n = 1; wound complications, n = 2; colonic mucosal ischemia, n = 1). Only a minimal reduction in the aneurysmal diameter was seen in 90% of the iliac artery aneurysms treated. The remaining lesions showed no change in size, and no aneurysm had an increase in cross-sectional diameter on computed tomographic images enduring a follow-up period up to 4 years (mean, 24 months). One aneurysm ruptured after successful endovascular exclusion, and the patient underwent treatment with open repair. The 3-year primary patency rate of iliac EGs was 86%. CONCLUSION: EGs appear to show satisfactory safety and efficacy for the repair of isolated aneurysms of the iliac arteries

OBJECTIVE: Although percutaneous angioplasty and stenting (PTAS) of carotid bifurcation lesions is feasible and appropriate for surgically inaccessible lesions, its general role and comparative value remain unclarified. Moreover, the acceptance of carotid PTAS has been limited by its potential for producing embolic debris. This study used an ex vivo model to evaluate the efficacy of a novel filter device to entrap emboli during PTAS of human carotid plaques. METHODS: Eight carotid bifurcation plaques were obtained from patients who underwent carotid endarterectomy for high-grade atherosclerotic stenosis (>90%). The mean age of the patients was 63 years, and six patients were symptomatic. Each plaque was encased with polytetrafluoroethylene material to simulate adventitia and was connected to a perfusion circuit, which provided continuous flow through the plaque. The filter device consisted of an expandable polymeric membrane with multiple micro pores that was attached to the distal end of a 0.014-in wire with a shapeable tip. This filter was encased in a delivery catheter. With fluoroscopic guidance, the filter wire was passed through the stenosis and the delivery catheter was then retracted to open the filter to capture particles released into the distal internal carotid artery. PTAS with a self-expandable stent then was carried out over the filter wire. The particles released during the initial filter passage, those captured in the filter, and those that flowed through or around the filter (missed) were collected and analyzed with light microscopy. RESULTS: Filter deployment, PTAS, and filter retrieval were achieved successfully with each lesion. Because the filter has a low crossing profile, it passed through the stenoses smoothly and only produced occasional small particles. PTAS improved the angiographic stenosis from 96.2% +/- 3.7% to 1.3% +/- 1.6%. The mean number and the maximum size of the particles that were released during initial filter passage, missed, and captured by the filter device were 3.1 and 500 microm, 2.8 and 360 microm, 20.1 and 1100 microm, respectively. Most of the particles and those of large size were released during PTAS. The filter captured 88% of these particles. CONCLUSION: These study results show that this filter device, at least in this model, did not add complexity to the interventional procedure itself. Furthermore, the filter may markedly decrease embolic events during carotid PTAS and expand the indications for this procedure

The mortality rate following rupture of an abdominal aortic aneurysm (AAA) is 80-90% and the main goal of treatment is to prevent rupture. Treatment of the aneurysm is generally recommended for patients with an aneurysm larger than 5 cm in diameter, and the only effective treatment has been to replace the aneurysm with a prosthetic graft. Traditionally, this is performed through a major laparotomy; that is, open surgical repair, which itself carries a mortality rate of 4-8% and requires a hospital stay of 7-10 days. In addition, some sick patients are deemed a prohibitive risk for such major surgery and, therefore, treatment may be deferred. Endovascular grafts (EVGs) that enable treatment of patients with AAA without the need for laparotomy were developed in the hope of improving on the shortcomings of the standard repair technique. In addition to the various industry-made EVGs the authors have been using a surgeon-made Montefiore Endovascular Grafting System (MEGS). The recent introduction of several industry-made devices has prompted some to postulate that MEGS is no longer required. The 60 patients with AAA treated from 1 July 1997 to 30 June 1998 were evaluated for the inclusion criteria for industry-made EVG protocols. Those excluded from these protocols were evaluated for the MEGS. Open surgical repair was reserved for those unsuitable for any EVG repair or those not consenting to EVG repair. Thirty-seven percent of all cases could be treated with an industry-made device. By using the MEGS, an additional 43% of the cases could be treated endovascularly. In total, 80% of AAAs were able to be treated endovascularly. The reasons for excluding patients from industry-made devices were a combination of the following factors: (1) Short (<1.5 cm) or angulated (>60) proximal necks, (2) iliac artery aneurysms, (3) small, diseased or tortuous access arteries, and (4) small distal aortas. The mean length of stay for those treated endovascularly was 2.3 days, whereas it was 9 days for those treated by open surgery. There was no difference in the morbidity and mortality rates. EVG repair is feasible and safe for the majority of patients with AAAs; however, long-term durability is yet to be shown. Despite the availability of industry-made devices, there appears to be a continuing role for MEGS, especially for difficult aneurysms including those patients with complex anatomy and those with ruptured AAAs

The mortality rate after the rupture of an abdominal aortic aneurysm is 80% to 90%; therefore, the main goal of treatment is to prevent rupture. Patients with abdominal aortic aneurysms smaller than 5 cm in diameter should be managed conservatively under close surveillance with either computed tomography or sonography every 3 to 12 months. Patients should be informed that most aneurysms continue to enlarge at an average rate of 2 to 4 mm per year and that there is a 1% to 5% annual risk for sudden rupture. Treatment of the aneurysm is generally recommended if it is larger than 5 cm in diameter, and the only effective treatment is replacement of the aneurysm with a prosthetic graft. This can be performed through a laparotomy or a groin incision using an endovascular graft. Open surgical repair carries a mortality rate of 2% to 8% and requires a hospital stay of 7 to 10 days. Patients receiving endovascular grafts can be discharged within 1 to 3 days. Long-term durability has yet to be proven, however

The superior mesenteric artery (SMA) is an uncommon location for spontaneous peripheral arterial dissections. In the past, most symptomatic SMA dissections were treated surgically. However, the authors recently treated a healthy 40-year-old man who experienced a symptomatic SMA dissection with anticoagulation therapy alone. The patient had bilateral internal carotid artery (ICA) dissections in the past that were also managed in a conservative fashion. To their knowledge, this is the first patient reported in the literature with both ICA and SMA dissections, In addition, he is one of only a few patients with an SMA dissection who was successfully treated without surgical intervention. From our experience with this patient and a review of the literature, we believe that a trial of anticoagulation therapy is warranted in all patients with uncomplicated, symptomatic SMA dissections. $$:

BACKGROUND: Selective shunting during carotid endarterectomy is widely performed, but the optimal approach for predicting when a shunt is unnecessary remains uncertain. We evaluated the ability of preoperative cerebral angiography to predict when carotid endarterectomy could be safely performed without a shunt. STUDY DESIGN: Eighty-seven patients undergoing carotid endarterectomy between August 1991 and December 1997 had preoperative cerebral angiograms. The angiograms were evaluated for the presence of collateral flow from the contralateral carotid through the anterior communicating artery and from the posterior circulation through the posterior communicating artery. Patients then underwent endarterectomy and were selectively shunted based on somatosensory evoked potential changes. Internal carotid artery stump pressure was routinely measured in all patients. RESULTS: Nine patients (10%) had a shunt placed based on somatosensory evoked potential changes and none of the 87 patients had a perioperative (30 days) stroke. Angiography revealed that 36 patients (41%) had no cross-filling from the contralateral carotid through the anterior communicating artery. Nine of these patients (25%) required a shunt; none of the 51 patients with adequate cross-filling (p < 0.001) did. Furthermore, 94% of the patients without cross-filling but with a patent ipsilateral posterior communicating artery did not require a shunt using somatosensory evoked potential changes as the standard for shunt insertion. Stump pressure measurements (> or = 25 mmHg) or (> or = 50 mmHg) did not reliably exclude the need for a shunt. Only 2 of 15 patients with contralateral carotid occlusion and 1 of 16 patients with a prior ipsilateral stroke required shunts. CONCLUSIONS: In the presence of cross-filling from the contralateral carotid artery, shunt insertion was uniformly unnecessary. In addition, routine shunting of patients with previous ipsilateral strokes or contralateral carotid occlusion was not always necessary. Stump pressures were less sensitive than angiographic criteria in determining when a shunt was unnecessary. Evaluation of cross-filling from the contralateral carotid artery on preoperative angiography can predict with certainty which patients will not require a shunt

BACKGROUND: The feasibility of endovascular graft (EVG) repair of ruptured aortoiliac aneurysms (AIAs) has yet to be demonstrated. There are inherent limitations in EVG repair, including the need for preoperative measurements of the aneurysmal and adjacent arterial anatomy to determine the appropriate size and type of graft and the inherent delay to obtain proximal occlusion. We developed an EVG system with broad versatility that largely eliminates these problems. STUDY DESIGN: Between 1993 and 1998, within an experience of 134 endovascular AIA repairs, 12 ruptured AIAs were treated using EVGs that facilitated intraoperative customization and eliminated the need for preoperative measurements. The EVGs consisted of either a Palmaz stent and a PTFE graft deployed by a compliant balloon (n = 9) or a self-expanding covered stent graft (n = 3). Both grafts were cut to the appropriate length intraoperatively. The mean age of the patients was 72 years (range 40 to 86 years). The mean size of the aneurysms was 7.6 cm (range 3 to 16 cm). Preoperative symptoms were present in all patients and included abdominal or back pain (n = 9), syncope (n = 4), and external bleeding (n = 2). All patients were high surgical risks because of comorbid disease (n = 10) or previous abdominal operations (n = 6), and nine experienced hypotension. RESULTS: All EVGs were inserted successfully and excluded the aneurysms from the circulation. The mean operating time was 263 minutes, the mean blood loss was 715 mL, and the mean length of hospital stay was 6.5 days. There were two deaths (16%), one from the preexisting acute myocardial infarction and one from multiple organ failure. There were three minor complications (25%). Two patients required evacuation of an intraabdominal hematoma from the initial rupture. All but one of the grafts was functioning at a mean followup of 18 months. CONCLUSIONS: This study demonstrates the feasibility of EVG repair for ruptured AIAs using a graft that can be customized intraoperatively for each patient. Such repairs currently are valuable in patients with ruptured AIAs and serious comorbidities and may be applicable in other circumstances as well