Faculty Bibliography

BACKGROUND: To determine the need for routine versus selective intraoperative IVUS during endovascular aortoiliac aneurysm (AIA) repair. METHODS: One-hundred and eighty-eight endovascular AIA repairs performed over a 5-year period were reviewed and included in the study. Surgeon-made aorto-uni-femoral grafts (n=78) and industry-made bifurcated or tube grafts (n=110) were used. In the initial 51 cases IVUS was routinely performed. In the latter 137 cases IVUS was used selectively. In this group graft deformities suspected on completion angiography or pullback pressure measurements were treated with balloon dilatation and stenting. IVUS was then performed only in the presence of a persistent pressure gradient or inconclusive angiographic findings. RESULTS: In the initial 51 cases IVUS revealed 20 lesions of which 8 were not initially detected angiographically and which required further treatment. In the latter 137 cases IVUS was necessary in only 1 case, and guided the treatment of an angiographically undetectable lesion. There have been no late episodes of graft compression, kinking, or thrombosis in the selective IVUS group. CONCLUSIONS: The use of pullback pressure measurements with a low threshold for angioplasty and stenting, especially in unsupported grafts, followed by the selective use of IVUS decreases the overall requirement for IVUS and its associated costs

OBJECTIVE: The purpose of this study was to analyze the incidence, severity, and etiologic factors of the development of colon ischemia after endovascular aortoiliac aneurysm repair (EVAR). METHODS: During the last 9 years we performed 278 elective EVARs using a variety of grafts. To facilitate these repairs, one hypogastric artery (HA) was coil embolized in 109 patients and both HAs were coil embolized in 13 patients. The preprocedural status of the inferior mesenteric, hypogastric, and iliac arteries as well as anatomical characteristics of the abdominal aortic aneurysm were determined arteriographically and by computerized tomographic scans. Postoperative colon ischemia was documented by colonoscopy or operative findings. RESULTS: Colon ischemia occurred in eight patients (2.9%). Three patients with colon ischemia died and had evidence of widespread (cutaneous, renal, small bowel, and/or lower extremity) microembolization. One of these three had a colectomy and microscopic emboli were present. One other patient who required a colectomy also had pathologic evidence of colonic microembolization but survived. Four other patients with colon ischemia were treated conservatively and survived. In one patient, previous colectomy with interruption of mesenteric collaterals may have been a contributory cause of colon ischemia. Of the eight patients with colon ischemia, only one had unilateral HA occlusion, and none had bilateral HA occlusion. The other 121 patients with unilateral and bilateral HA occlusion had no evidence of colon ischemia. CONCLUSIONS: Colon ischemia occurs after EVAR with an incidence approximating that of open repair. Colon ischemia was unrelated to HA interruption. Embolization appears to be a major cause of colon ischemia, although inadequate mesenteric collateral circulation may also play an etiologic role. Mortality with colon ischemia accompanied by widespread embolization was high, whereas colon ischemia without it was often mild and amenable to nonoperative management

OBJECTIVE: To analyze the late complications after endovascular graft repair of elective abdominal aortic aneurysms (AAAs) at the authors' institution since November 1992. SUMMARY BACKGROUND DATA: Recently, the use of endovascular grafts for the treatment of AAAs has increased dramatically. However, there is little midterm or long-term proof of their efficacy. METHODS: During the past 9 years, 239 endovascular graft repairs were performed for nonruptured AAAs, many (86%) in high-risk patients or in those with complex anatomy. The grafts used were Montefiore (n = 97), Ancure/EVT (n = 14), Vanguard (n = 16), Talent (n = 47), Excluder (n = 20), AneuRx (n = 29), and Zenith (n = 16). All but the AneuRx and Ancure repairs were performed as part of a U.S. phase 1 or phase 2 clinical trial under a Food and Drug Administration investigational device exemption. Procedural outcomes and follow-up results were prospectively recorded. RESULTS: The major complication and death rates within 30 days of endovascular graft repair were 17.6% and 8.5%, respectively. The technical success rate with complete AAA exclusion was 88.7%. During follow-up to 75 months (mean +/- standard deviation, 15.7 +/- 6.3 months), 53 patients (22%) died of unrelated causes. Two AAAs treated with endovascular grafts ruptured and were surgically repaired, with one death. Other late complications included type 1 endoleak (n = 7), aortoduodenal fistula (n = 2), graft thrombosis/stenosis (n = 7), limb separation or fabric tear with a subsequent type 3 endoleak (n = 1), and a persistent type 2 endoleak (n = 13). Secondary intervention or surgery was required in 23 patients (10%). These included deployment of a second graft (n = 4), open AAA repair (n = 5), coil embolization (n = 6), extraanatomic bypass (n = 4), and stent placement (n = 3). CONCLUSION: With longer follow-up, complications occurred with increasing frequency. Although most could be managed with some form of endovascular reintervention, some complications resulted in a high death rate. Although endovascular graft repair is less invasive and sometimes effective in the long term, it is often not a definitive procedure. These findings mandate long-term surveillance and prospective studies to prove the effectiveness of endovascular graft repair

OBJECTIVE: Precise diameter changes in iliac artery aneurysms (IAAs) after endovascular graft (EVG) repair are yet to be determined. This report describes the midterm size changes in isolated IAAs 13 to 72 months after treatment with an EVG. METHODS: From January 1993 to April 1999, 31 patients with 35 true isolated IAAs (32 common iliac and 3 hypogastric) had these lesions treated with EVGs and coil embolization of the hypogastric artery or its branches. The EVG used in this study consisted of a balloon-expandable stent attached to a polytetrafluoroethylene graft. Contrast-enhanced spiral computed tomographic scans were performed at 3- to 6-month intervals to follow the aneurysms for change in diameter and endoleaks. RESULTS: Thirty patients had a decrease in the size of their iliac aneurysms with EVG repair. All EVGs remained patent. All patients, except for one, were followed up for 13 to 72 months (mean, 31 months). The pretreatment aneurysm size ranged from 2.5 to 11.0 cm in diameter (mean, 4.6 +/- 1.62 cm). After EVG treatment, the aneurysms ranged from 2.0 to 8.0 cm in diameter (mean, 3.8 +/- 1.36 cm). The change in aneurysm diameter ranged from 0.5 to 3.1 cm (mean, 1.1 +/- 0.62 cm) with an average change of -0.516 +/- 0.01 cm/y for the first year. Five patients died of their intercurrent medical conditions during the follow-up period. One of the patients had a new endoleak and an increase in common iliac aneurysm size 18 months after EVG treatment, despite an early contrast-enhanced computed tomographic scan that showed no endoleak. This patient's aneurysm ruptured, and a standard open surgical repair was successfully performed. Another patient had a decrease in hypogastric aneurysm size after EVG treatment and no radiographic evidence of an endoleak, but eventually the aneurysm ruptured. He was successfully treated with a standard open surgical repair. CONCLUSIONS: EVGs can be an effective treatment for isolated IAAs. Properly treated with EVGs, IAAs decrease in size. The enlargement of an IAA, even if no endoleak can be detected, appears to be an ominous sign suggestive of an impending rupture. IAAs that enlarge should be closely evaluated for an endoleak. If an endoleak is detected, it should be eliminated if possible. If an endoleak cannot be found, open surgical repair should be considered

OBJECTIVE: Hypogastric artery (HA) occlusion during aortic aneurysm repair has been associated with considerable morbidity. We analyzed the consequences of interrupting one or both HAs in the standard surgical or endovascular treatment of aortoiliac aneurysms (AIAs). METHODS: From 1992 to 2000, 154 patients with abdominal aortic aneurysms (n = 66), iliac aneurysms (n = 28), or AIAs (n = 60) required interruption of one (n = 134) or both (n = 20) HAs as part of their endovascular (n = 107) or open repair (n = 47). Endovascular treatment was performed with a variety of industry- or surgeon-made grafts in combination with coil embolization of the HAs. The standard surgical techniques included oversewing or excluding the origins of the HAs and extending the prosthetic graft to the external iliac or femoral artery. RESULTS: There were no cases of buttock necrosis, ischemic colitis requiring laparotomy, or death when one or both HAs were interrupted. Persistent buttock claudication occurred after 16 (12%) of the unilateral and 2 (11%) of the bilateral HA interruptions. Impotence occurred in 7 (9%) of the unilateral and 2 (13%) of the bilateral HA interruptions. Minor neurologic deficits of the lower extremity were observed in 2 (1.5%) of the patients with unilateral HA interruption. CONCLUSIONS: Although HA flow should be preserved if possible, selective interruption of one or both HAs can usually be accomplished safely during endovascular and open repair of anatomically challenging AIAs. We believe other comorbid factors such as shock, distal embolization, or the failure to preserve collateral branches from the external iliac and femoral arteries may have contributed to the morbidity in other reports of HA interruption

OBJECTIVES: Endovascular aortoiliac aneurysm (EAIA) repair uses substantial fluoroscopic guidance that requires considerable radiation exposure. Doses were determined for a team of three vascular surgeons performing 47 consecutive EAIA repairs over a 1-year period to determine whether this exposure constitutes a radiation hazard. METHODS: Twenty-nine surgeon-made aortounifemoral devices and 18 bifurcated devices were used. Three surgeons wore dosimeters (1) on the waist, under a lead apron; (2) on the waist, outside a lead apron; (3) on the collar; and (4) on the left ring finger. Dosimeters were also placed around the operating table and room to evaluate the patient, other personnel, and ambient doses. Exposures were compared with standards of the International Commission on Radiological Protection (ICRP). RESULTS: Total fluoroscopy time was 30.9 hours (1852 minutes; mean, 39.4 minutes per case). Yearly total effective body doses for all surgeons (under lead) were below the 20 mSv/y occupational exposure limit of the ICRP. Outside lead doses for two surgeons approximated recommended limits. Lead aprons attenuated 85% to 91% of the dose. Ring doses and calculated eye doses were within the ICRP exposure limits. Patient skin doses averaged 360 mSv per case (range, 120-860 mSv). The ambient (> 3 m from the source) operating room dose was 1.06 mSv/y. CONCLUSIONS: Although the total effective body doses under lead fell within established ICRP occupational exposure limits, they are not negligible. Because radiation exposure is cumulative and endovascular procedures are becoming more common, individuals performing these procedures must carefully monitor their exposure. Our results indicate that a team of surgeons can perform 386 hours of fluoroscopy per year or 587 EAIA repairs per year and remain within occupational exposure limits. Individuals who perform these procedures should actively monitor their effective doses and educate personnel in methods for reducing exposure

PURPOSE: Techniques for managing the distal anastomoses of aortofemoral and iliofemoral endovascular grafts are described. METHODS: Over a 2(1/2)-year period 46 endovascular grafts were successfully placed to treat severe iliac artery occlusive disease. Endovascular grafts were anchored proximally in the distal aorta or iliac arteries with Palmaz balloon-expandable stents. The distal anastomoses were performed with the use of open, sutured anastomotic techniques. In contrast to stented distal anastomoses, these techniques allowed us to (1) treat occlusive lesions extending from the distal aorta to below the inguinal ligament, (2) terminate endovascular grafts in the groin where stents are contraindicated, (3) vary the distal anastomotic site depending on the local pattern of disease, and (4) standardize the preinsertion length of the endovascular graft. RESULTS: Two distal perianastomotic stenoses and one graft occlusion were detected postoperatively in 11 bypass grafts that had distal anastomoses sewn endoluminally without an overlying patch angioplasty. Only one perianastomotic stenosis was found among 35 anastomoses performed with other techniques. There were no significant differences in primary and secondary patency between grafts originating in the distal aorta or iliac arteries. CONCLUSIONS: Hand-sewn distal anastomoses can simplify the insertion of endovascular grafts used for the treatment of aortoiliac occlusive disease. These anastomoses permit tailoring of the graft according to the patients' pattern of disease and eliminate the need to precisely measure the length of the graft preoperatively. In addition, because a distal stent is not required, endovascular grafts can be safely terminated in the groin instead of the external iliac artery where disease progression can lead to graft failure. Finally, endovascular distal anastomoses should be closed with a patch or the hood of a more distal bypass graft to prevent perianastomotic stenoses or occlusions in the postoperative period

A bilayered tissue-engineered skin graft composed of human neonatal foreskin fibroblasts and keratinocytes in a type I bovine collagen matrix has been developed. We sought to determine if this graft improves wound healing after lower extremity revascularization. Thirty-one previously ischemic foot wounds were randomly assigned to moist dressing changes or tissue-engineered skin graft within 60 days of revascularization. In the grafted group, 10 received meshed and 11 received unmeshed graft. Wound healing was followed by wound area measurements and photography. There were no statistically significant differences between groups in patient age, sex, diabetes or renal failure risk factors, revascularization procedure, or wound location or size. Treatment with tissue-engineered skin graft was significantly more effective than moist dressing in the percentage of wounds healed (62 vs. 0% at 8 weeks, 86 vs. 40% at 12 weeks, p < 0.01) and the median time to complete wound closure (7 vs. 15 weeks, p = 0.0021, rank-sum test). There was no difference in the wound closure rate of meshed and unmeshed graft at 4, 8, 12, or 24 weeks (p > 0.05). Three indolent localized wound infections in the tissue-engineered skin graft group were the only complication. Tissue-engineered skin grafting can be used safely in previously ischemic wounds after lower extremity revascularization. Treatment with this graft promotes healing more rapidly and in more patients than standard moist dressings. It obviates the risk, inconvenience, and expense of donor skin harvesting, anesthesia, and hospitalization associated with autologous skin grafting. This graft may represent an advance in the treatment of previously ischemic lower extremity foot wounds

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. $$:

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