The perceived functional benefit of below-knee amputation (BKA) must be carefully weighed against the need for potential reinterventions. This study sought to examine the contemporary clinical and functional outcomes of patients undergoing BKA in the endovascular era.
All patients who underwent BKA from January 2008 to December 2014 at a single tertiary medical center were retrospectively reviewed. Demographics, comorbidities, ambulation status, and transcutaneous oximetry (TcPO2) values were recorded. Study end points included freedom from conversion to above-knee amputation (AKA), freedom from conversion to AKA or death, BKA healing, and ambulation. Statistical modeling was performed to determine associations with BKA failure.
Over the study interval, 130 limbs underwent BKA in 120 patients. Transcutaneous oximetry studies were obtained in 65% (n = 85). Thirty-eight percent (n = 46) of all BKA patients went on to heal and ambulate. Twenty-five percent (n = 33) required reintervention, 24 with conversion to AKA, and 9 with BKA revision. One-year freedom from conversion to AKA was 76% and was decreased among those with lower TcPO2 levels (60% TcPO2 <40 vs 81% TcPO2 ≥40; P = .04). One-year composite freedom from conversion to AKA/death was 60% and was decreased among those with lower TcPO2 readings (39% TcPO2 <40 vs 69% TcPO2 ≥40; P = .01).
Despite a perceived functional bias toward knee salvage at the time of major amputation, most patients failed to postoperatively ambulate. Those with decreased TcPO2 levels (<40 mm Hg) have a 2-fold higher risk of AKA conversion or death, while nearly one-fourth of all BKA patients will succumb to the same fate irrespective of TcPO2. This suggests that many BKA patients in the endovascular era fail to derive the perceived benefit of knee salvage at the time of their index amputation. These findings highlight the need for careful patient selection and for a shared decision-making model in this frail population.
A significant cohort of patients who have undergone carotid artery stenting (CAS) will have in-stent restenosis (ISR). The optimal management of symptomatic or severe ISR remains poorly defined. The purpose of this study was to describe the indications, treatment, and mid- to long-term outcomes of patients undergoing CAS explantation for ISR.
All patients undergoing internal carotid artery stent explantation with carotid artery reconstruction at Mayo Clinic Rochester, Dartmouth-Hitchcock Medical Center, and Beth-Israel Deaconess Medical Center from 2003 to 2013 were retrospectively reviewed. Isolated common carotid artery stents were excluded. Demographics, comorbidities, indications for explantation, operative details, and perioperative and postoperative outcomes were reviewed.
Over the study interval, a total of 971 patients underwent carotid stenting across the 3 centers. Of these, 8 patients ultimately underwent CAS explantation with carotid artery reconstruction. Mean age was 69 years and 5 patients were male. Index stent placement was for symptomatic stenosis in 4 patients, asymptomatic restenosis after endarterectomy in 2 patients, asymptomatic high lesion in 1 patient, and asymptomatic critical stenosis in 1 patient. Indications for explantation were symptomatic ISR in 4 patients and asymptomatic severe ISR in 4 patients. Method of repair was stent explantation and patch angioplasty in 5 and en bloc carotid resection with bypass in 3 patients. There were no perioperative neurologic events or cranial nerve injuries. At a mean follow-up of 38.7 months, there were 2 late disabling ipsilateral strokes (14.4 months and 19.1 months).
A significant cohort of patients who have undergone CAS will have ISR. Although excellent perioperative results after surgical explantation can be obtained, this patient subgroup remains at risk for late neurologic events. Appropriate patient selection and diligent long-term follow-up are mandated to obtain optimal outcomes.
We describe a novel approach for the endovascular treatment of femoral artery occlusion as a result of Angio-Seal closure device deployment.
Angio-Seal is the most commonly used vascular closure device following percutaneous coronary and peripheral catheterizations worldwide. A rare complication of Angio-Seal deployment is an occlusion of the femoral artery leading to limb ischemia requiring revascularization. Given its unique ability to cut both atherosclerotic plaque and the Angio-Seal anchor with a collagen plug at operator-directed planes, TurboHawk/HawkOne atherectomy device can be a fast and effective approach to treat Angio-Seal-associated femoral artery occlusions.
We studied 13 consecutive patients who developed Angio-Seal-associated femoral artery occlusions that occurred from 3 hours to several weeks after catheterization. These patients were successfully treated with TurboHawk/HawkOne directional atherectomy followed by balloon angioplasty with no complications. During a mean follow-up period of 20.4 ± 17.3 months, 12 patients remained claudication free with no evidence of obstructive arterial disease of the treated segment on imaging studies. One patient developed restenosis that was treated with repeat atherectomy and balloon angioplasty following which he was asymptomatic at follow-up.
The use of directional atherectomy followed by balloon angioplasty is a quick, safe, and effective endovascular approach to treating Angio-Seal-associated femoral artery occlusions. It is associated with an excellent success rate, no complications, and good midterm outcomes.
Inadvertent complications of jugular vein catheterization are not uncommon, however, a persistent symptomatic carotid–jugular fistula has been rarely reported. A 72-year-old male with infected surgical wound after coxofemoral disarticulation for sarcoma presented with symptoms of acute right heart failure. A fistula between the right common carotid artery (CCA) and the internal jugular vein was demonstrated on Doppler ultrasound and confirmed on computed tomography angiogram. Catheterization of the right CCA seemed not possible using a conventional femoral approach due to the tortuosity and elongation of the brachiocephalic artery. A small incision in the right temporal area was used to access the superficial temporal artery and a wire was advanced retrograde into the aorta where it was snared from below, allowing for successful treatment of the fistula with a covered stent. This alternative technique may facilitate safe and stable carotid artery stenting even in patients with a severely tortuous access route due to atherosclerotic disease.
To report the outcome of a series of patients with chronic venous disease due to incompetence of the great saphenous vein (GSV) managed by ultrasound-guided foam sclerotherapy (USGFS).
Controlled clinical trial with maximum 5-year follow-up of results of USGFS of the GSV with new parameters of the procedure.
This research analyzes the results of USGFS of the GSV (395 GSV) and its tributaries in 326 patients with varicose veins of the lower extremities over the period from January 2009 to January 2014 with the following parameters of the procedure: 60° limb elevation, calf bandage, and cooled foam injection.
Ultrasound control of 395 GSV after the first injection of sclerosant from the sixth to the eighth day revealed GSV occlusion in the femoral segment with the absence of reflux in 94.9% of cases (375 GSV). After 5-year follow-up, GSV occlusion was diagnosed in 91.9% of cases.
Our improved technique of foam sclerotherapy allows improving immediate and long-term results. This technique is characterized by the low incidence of side effects and complications.
To consider the clinical outcomes and restenosis rates of drug-eluting balloons (DEBs) and percutaneous transluminal angioplasty (PTA) in diabetic patients with infrapopliteal (IP) arterial disease.
This retrospective, single-center study included 51 patients (37 males; mean age: 63.43 ± 9.81 years) with diabetes mellitus having IP arterial disease, from October 2012 to September 2014. Twenty-two patients were treated with PTA, and 29 patients were treated with DEBs. After intervention, the patients were evaluated in the first week and every 3 months, clinically and radiologically. Univariate and multivariate analyses were used to evaluate the clinical outcomes of diabetic patients with IP arterial disease who were treated with either DEBs or PTA.
There were no statistically significant differences between the groups in terms of age and gender, risk factors, characteristics of lesions, or the diameters or length of the balloons (P > .05). Primary patency was higher in the DEB group than in the PTA group (97.8% vs 81.1%, P = .020) in the first 3 months. However, there was no statistically significant difference at 1-year follow-up (68.2% vs 48.5%, P = .131). At the 12-month follow-up, there was no difference in clinical improvement between the groups (P = .193).
The findings of this study reveal that DEB is a safe alternative treatment method for IP arterial disease in diabetic patients.
Patients with end-stage renal disease (ESRD) who present with critical limb ischemia (CLI) have become an increasingly common and complex treatment problem for vascular surgeons. Dialysis patients have high short-term mortality rates regardless of whether revascularization is pursued. ESRD patients with CLI can be managed with: local wound care, endovascular or surgical revascularization, or amputation. Some patients may heal small foot wounds with local wound care alone, even if distal perfusion is marginal, as long as any infectious process has been controlled. Surgical revascularization has a mortality rate of 5-10% but has a high chance of limb salvage. However, overall 5-year survival may be as low as 28%. Endovascular therapy also carries a high perioperative mortality risk in this population with similar limb salvage rates. Amputation is indicated in patients with advanced stage CLI, as described by the Society for Vascular Surgery’s Wound, Ischemia and foot Infection (WIfI) system. Statistical models predict that endovascular or surgical revascularization strategies are less costly and more functionally beneficial to patients than primary amputation alone. Decisions on how to manage ESRD patients with CLI are complex but revascularization can often result in limb salvage, despite limited overall survival. Dialysis patients with good life expectancy and good quality conduit may benefit most from surgical bypass.
Fracture of the first rib with ensuing callus formation is a rare cause of thoracic outlet syndrome. We report a case of a 17-year-old female volleyball player who presented with months of chronic arm pain. Radiographic imaging demonstrated nonunion fracture of the first rib. Physical therapy had been unsuccessful in relieving the pain, and surgical management was performed with resection of the first rib through a transaxillary approach with complete resolution of symptoms. Inflammation surrounding such fractures may destroy tissue planes, making dissection more technically difficult.
Portal vein (PV) thrombosis (PVT) in the absence of liver disease or thrombophilia is rare. We report a 57-year-old male with a history of stage 3 chronic kidney disease who presented at the emergency department 18 months after abdominal surgery with progressive abdominal pain and distention. Computed tomography revealed PVT with multiple collaterals and moderate ascites. He had undergone partial gastrectomy and gastrojejunal anastomosis at an outside facility for gastrointestinal stromal tumors that caused an iatrogenic stenotic lesion in the PV. The patient underwent balloon angioplasty and endovascular deployment of an 8 mm x 100 mm Viabahn covered stent (W. L. Gore and Associates, Flagstaff, Arizona) in the extrahepatic PV via a transhepatic approach; the device allowed complete restoration of prograde portal flow with clinical improvement. At 6 months from the intervention, he remains symptom-free with normal liver function tests and patent endoprosthesis on antiplatelet therapy.
To evaluate the safety and outcomes of surgical revascularization for patients with symptomatic kinking of the internal carotid artery (ICA).
Twenty-five consecutive patients presented with symptomatic kinking of the ICA and a history of transient ischemic attack (TIA) or stroke were prospectively enrolled in this study. All patients were treated with ICA transection and end-to-side reimplantation at the level of the carotid bulb. Patients were followed up for a median of 32 months.
There were no deaths or strokes within the 30 days of the treatment. No postprocedural thrombosis or narrowing of the ipsilateral ICA was observed. One (4%) patient had temporary recurrent nerve palsy, which was completely recovered at 4-week follow-up. One (4%) patient had a myocardial ischemic event. At the end of the 32-month follow-up, 1 (4%) patient developed ipsilateral minor stroke. No recurrent stenosis was detected by Doppler ultrasound.
Surgical treatment for isolated, symptomatic kinking of the ICA and a history of TIA or stroke is safe, and the outcomes are acceptable.
Thermal ablation techniques have gradually replaced Babcock procedure in varicose vein treatment.
A comparative quantitative–qualitative analysis of complications and failure of endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in a 5-year follow-up.
One hundred ten adult participants with varicose veins clinical grade C2 to C6, treated for isolated great saphenous vein (GSV) or small saphenous vein (SSV) insufficiency in a single lower extremity in 2009 to 2010, were enrolled and subdivided into EVLA (n = 56) and RFA (n = 54) groups. Both groups were compared for demography, disease stage, affected veins, perioperative, and postoperative complications as well as treatment efficacy.
The perioperative and postoperative complications were statistically insignificant. Treatment efficacy, expressed as the number of participants with recurrent varicosity and recanalization, was comparable in both groups. The clinically significant recanalization rate was 3.6% and 5.6% in EVLA and RFA groups, respectively.
Endovenous laser ablation and RFA for the management of lower extremity varicose vein offer comparable efficacy and safety in a 5-year follow-up.
The present study aimed to explore the regulating effect of Toll-like receptor 4 (TLR4) on intimal hyperplasia in rat vein grafts.
Rat models of external jugular vein carotid artery bypass grafting were established. Afterward, TLR4 small interfering RNA (siRNA) recombinant plasmids were constructed, which were transfected into rat vein graft bypass to study the effect of TLR4 silencing on intimal hyperplasia and to explore the underlying mechanisms. Real-time polymerase chain reaction and Western blot were used to detect the expression levels of TLR4 and inflammatory factors in TLR4 siRNA-transfected vein graft bypass. The intimal thickness was evaluated using hematoxylin–eosin staining.
Compared with the scramble siRNA group, the intimal thickness of vein grafting was decreased significantly, while the inflammatory factors including interleukin (IL) 1β, IL-6, and tumor necrosis factor α in grafted vein were dramatically downregulated in the TLR4 siRNA group.
These results showed that local silencing of TLR4 in the vein grafts could inhibit intimal hyperplasia by downregulating the expression of inflammatory factors in the vein grafts, suggesting that TLR4 can be used as a new target for therapy of vascular intimal hyperplasia.
Hypogastric artery (HA) revascularization during endovascular aneurysm repair (EVAR) is still open to debate. Moreover, exclusion-related complication rates reported in literature are not negligible. The aim of this study is to present and analyze the outcomes in patients undergoing EVAR with exclusion of 1 or both HAs at our academic center.
We retrospectively reviewed our results in patients submitted to EVAR and needing HA exclusion, in terms of perioperative (30-day) and follow-up rates of intestinal and spinal cord ischemia, buttock claudication, buttock skin necrosis, and sexual dysfunction.
From January 2008 to December 2014, a total of 527 patients underwent elective standard infrarenal EVAR; among those 104 (19.7%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH), many single HAs were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH), of which 16 (51.6%) had 1 HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both HAs were excluded (group BHE). No 30-day or follow-up aneurysm-related mortality, intestinal, or spinal cord ischemia were recorded. At 30 days, skin necrosis was observed in 2 patients. Buttock claudication and sexual dysfunction rates were significantly greater in group BHE than in group BHR (P < .05). At a mean 18.6 months follow-up (range: 4-47), buttock claudication and sexual dysfunction rates in group BHE were persistently higher than that in groups UH and BHR (P < .05); HA coil embolization was significantly associated with buttock claudication and sexual dysfunction (P < .05).
Whenever anatomically feasible, at least 1 HA should be salvaged in case of bilateral involvement. In case of unilateral HA exclusion, the rate of complications is not negligible. Coil embolization is related to a higher complication rate.
Acute carotid stent thrombosis (ACST) is a rare complication that can lead to dramatic and catastrophic consequences. A rapid diagnosis and prompt recanalization of the internal carotid artery are needed to minimize the ischemic insult and the reperfusion injury. We reviewed the current literature on this devastating complication of CAS with the intention of investigating the potential causative factors and to define the appropriate management. According to our study discontinuation of antiplatelet therapy, resistance to antiplatelet agents and inherent or acquired thrombotic disorders are the main causes of thrombosis. Technical intraprocedural parameters such as dissection, atheroma prolapse, kinking of the distal part of internal carotid artery and embolic protection device occlusion can also result in early carotid stent thrombosis. Rapid reperfusion ensures an improved neurological outcome and a better prognosis in the short and long term. Thrombolysis, mechanical thrombectomy or thromboaspiration in combination with drug or thrombolytic therapy, surgical therapy and re-angioplasty are treatment options that have been used with encouraging results. In conclusion, optimal perioperative antiplatelet treatment as well as technical considerations regarding the carotid artery stenting plays a determinant role.
A 66-year-old man, with an abnormal porta hepatis, consistent with tumor or inflammation, developed massive bleeding from one of numerous hepatic artery aneurysms, and coil embolization achieved control of bleeding. He died of subsequent multisystem organ failure, and the most likely diagnosis was either polyarteritis nodosa or segmental arterial mediolysis. Although the dual hepatic blood supply allows a degree of arterial embolization, this case demonstrates the risks associated with large territory hepatic arterial embolization in the presence of hemodynamic instability. We discuss the management issues related to massive hepatic bleeding when no surgical approach is possible.
Free esophageal perforation following a hybrid visceral debranching and distal endograft extension to repair a ruptured thoracoabdominal aortic aneurysm (TAAA) is a rare complication. The authors report a 56-year-old male who underwent elective thoracic endovascular aortic repair of a thoracic aneurysm. Four and a half years later, he presented with a new aneurysm extending from the distal end of the thoracic stent graft to the aortic bifurcation involving all the visceral arterial branches. The TAAA ruptured while he was awaiting an elective repair, and as a result, he underwent an emergency hybrid procedure. This involved debranching the visceral arterial branches including autotransplantation of the left kidney and distal endograft extension. Postoperatively, he developed free esophageal perforation secondary to ischemic necrosis requiring esophageal resection and gastric pull-up. The patient was well 6 months after the gastrointestinal restorative procedure. Thus, esophageal perforation following an emergency hybrid repair of ruptured TAAA is a rare complication, and a successful outcome depends on early recognition and surgical exclusion of the ruptured viscus.
To report our long-term experience in using the hybrid technique in complex thoracoabdominal aortic aneurysms (TAAAs).
Between March 2005 and September 2013, 10 patients with TAAA underwent hybrid procedures with open renovisceral revascularization and thoracoabdominal aortic endografting. Patients were analyzed retrospectively.
Six men and 4 women with a mean age of 66 years (range 54-81 years) were treated electively during the study period. All 4 visceral vessels were revascularized in 8 patients, whereas 1 patient underwent 3-vessel revascularization and another 2-vessel revascularization. The primary technical success rate was 100%. Eight of the procedures were single staged, and the 2 most recent cases were performed in 2 stages. Perioperative and 30-day mortality was 0%. The mean follow-up was 55 months (4-133 months). None of the patients died due to aortic complications. Major complications included paraplegia (10%, n = 1) and bowel ischemia (n = 1). Postoperative cerebrospinal fluid (CSF) pressure and mean arterial pressure measurements were systematically monitored and corrected. The CSF drainage solved another 4 cases of paraparesis. Three patients required postoperative dialysis, but none of them required permanently. Postoperative spinal cord ischemia and renal complications accumulated in extensive TAAA cases. One renal graft was occluded 45 days after the initial procedure but was successfully treated with thrombolysis. One type I and 1 type III endoleak were noted and successfully treated with an additional stent graft. Two cases of type II endoleak were detected—one with a growing aneurysm sac was treated successfully and another showed no growth and further procedures were abandoned after 2 embolization attempts. In long-term follow-up, 90% of the aneurysms showed shrinkage by a mean of 23 mm (range 7-45 mm).
The results of hybrid repair on high-risk patients with complex TAAAs are encouraging, and this approach is a valuable alternative when branched and fenestrated endovascular techniques are not considered an option.
The purpose of the study is to evaluate the clinical safety and effectiveness of the Denali (Bard, Tempe, Arizona) retrievable inferior vena cava (IVC) filter.
In this retrospective study, authors reviewed the data of Denali IVC filters placed at their institution between 2013 and 2015. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. The frequency of post filter pulmonary embolism (PE) and filter-related complications was assessed.
Denali filters were placed in 87 patients (47 males; mean age: 56 years). Twenty patients presented with PE, 45 with deep vein thrombosis (DVT), and 21 with both PE and DVT, 1 filter was placed prophylactically before surgery. Indications for filter placement included contraindications to anticoagulation (AC; n = 80), failure of AC (n = 4), and complications of AC (n = 3). No patients had PE on follow-up imaging after filter placement. Retrieval was attempted in 31 patients after a mean period of 125 days (range: 34-324 days). The filter was successfully removed in 31 (100%) patients. Follow-up imaging, available in 71 (82%) patients (range: 2-538 days), demonstrated penetration of 15 legs in 5 patients, caval thrombus in 3, 1 resulting in caval occlusion, <15° filter tilt in 5, and no leg fractures or crossed legs.
The Denali filter is safe during deployment and readily retrievable. The overall safety following deployment is similar to those reported in the literature, and the incidence of filter fractures and migration appears to be less than the previous generation of Bard devices.
Disruption of the endothelial lining may be one of the events linking intraluminal thrombus and abdominal aortic aneurysm growth. In the present study, we examined whether von Willebrand factor activity in plasma, contact proteins of blood coagulation, and inflammatory biomarkers may be associated with intraluminal thrombus volume in search of a biochemical marker of endothelial damage and thrombus size.
Prospective study, correlating potential endothelial biomarkers and intraluminal thrombus volume acquired by computed tomography angiography.
Plasma was consecutively obtained from 38 patients with asymptomatic infrarenal abdominal aortic aneurysm. von Willebrand factor activity, thrombin generation time, factor XII, and prekallikrein concentration were measured in plasma on automated and in-house platforms. In total, 8 patients were excluded due to ongoing anticoagulant therapy, renal impairment, or nonappearance, thus leaving 30 patients for further analysis. All patients had computed tomography angiography, and intraluminal volume was quantified off-line by OsiriX 6.5.
Median intraluminal thrombus volume was 42.7 mL. Spearman correlation analysis revealed a positive correlation between thrombus volume, von Willebrand factor activity ( = 0.56, P = .0013), and prekallikrein concentration in plasma ( = 0.54, P = .002).
von Willebrand factor activity and concentration of prekallikrein may both be of importance regarding the evolution of thrombus in abdominal aortic aneurysm and possible biomarkers for aneurysm growth.
We present an 82-year-old man with a history of hairy cell leukemia, having an 11-cm abdominal aortic aneurysm, who also had severe thrombocytopenia (about 20 000 platelets/μL) and splenomegaly at presentation. The patient had unfavorable anatomy for endovascular aneurysm repair, and therefore, an open procedure was planned. To reduce risk for perioperative bleeding and optimize patient preoperative status, a staged approach was employed. Initially, several sessions of embolization of 2 splenic artery branches were performed with the intent to decrease spleen size and to increase platelet count thus decreasing the perioperative bleeding risk. Then, after successfully increasing platelet count (280 000 PLT/μL), open repair of the aneurysm was conducted. This case demonstrates that selective splenic embolization in patients with hypersplenism and subsequent thrombocytopenia who are in need for major surgery may achieve a significant rise in platelet count and optimize patient’s preoperative status in order to avoid bleeding complications.
Patency of femoropopliteal vein bypass above the knee has been estimated between 69% and 77% at 5 years. This article reports a case of a patent femoropopliteal vein bypass 45 years after implantation without any reintervention. The morphologic alterations observed after 45 years at this vein bypass graft are additionally discussed.
Infection of an aortic endograft is a rare complication following endovascular aneurysm repair. These patients have been treated with explantation of the graft to obtain source control followed by an extra-anatomic bypass to restore circulation. The present case study describes an interesting case of Pasteurella infection involving an aortic endograft managed nonoperatively by percutaneous drainage and graft preservation.
Mycotic rupture of the arteries is a rare but deadly disorder. Current management typically involves open surgical repair. However, endovascular repair is a potential treatment that can be used to delay open repair, especially in acutely unstable patients. A case report and review of the literature was conducted to determine whether endovascular therapy could be a destination therapy for patients with arterial rupture secondary to infection.
We present the case of a 72-year-old man with a left common iliac artery aneurysm rupture secondary to Salmonella infection treated with endovascular therapy upon initial presentation. A literature review of PubMed yielded 29 patients with ruptured aortic and iliac infected aneurysms that were initially treated with endovascular repair.
Majority of the patients (76.7%, 23 of 30) were successfully treated with the endovascular treatment and did not require open revision. These patients were often placed on long-term antibiotics.
The literature review supports endovascular repair with a stent graft as a temporizing measure for infected ruptured arteries in an emergent setting and, in select cases, as a destination therapy.
Aortic graft infections are a rare occurrence, most commonly secondary to gram-positive organisms (Staphylococcus and Streptococcus species). We present 2 cases of thoracic aortic graft infections secondary to anaerobic bacteria, Propionibacterium species. The first case, a 40-year-old male, was found to have an anastomotic aneurysm at the distal anastomosis of a previous thoracoabdominal aneurysm repair. During the open repair of his anastomotic aneurysm, the original graft was not incorporated and cultures later speciated Propionibacterium acnes. The second case is a 44-year-old male with a history of abdominal aortic coarctation that was repaired with a thoracic aorta to aortic bifurcation graft as a child who presented with flank pain and was found on imaging to have fluid around his bypass graft. His operating room (OR) cultures also grew out Propionibacterium species. Both patients were treated with graft excision, revascularization, and long-term antibiotics. Anaerobic bacteria are a rare cause of aortic graft infections. Upon review of the literature, these are the first 2 cases of thoracic aortic graft infections secondary to Propionibacterium species. The cultures for both patients took almost a week to speciate, highlighting the importance of following cultures long term. Anaerobic bacteria should be recognized as a cause of latent graft infections.
The treatment of infected iliofemoral pseudoaneurysms is challenging and controversial. We present our experience regarding the efficacy and outcome of endovascular treatment of infected iliofemoral arterial pseudoaneurysms with covered stents. Our experience with 5 cases showed that stent grafting combined with antibiotic therapy and provisional drainage may be a safe and effective option in patients with cancer, patients with history of multiple hip revisions, and drug-addicted users. In our small case series, the reinfection rate was null and no covered stent thrombosis occurred. These results are fairly encouraging, but further studies with longer follow-up in a larger number of patients are needed to confirm the efficacy and durability of the technique.
Atherosclerotic lesions of the supra-aortic trunk vessels, including the innominate artery, subclavian artery, or the common carotid artery, tend to present either as low-flow state distal to the lesion or as embolic events. The risk of embolic cerebrovascular event complicates the management of this condition via a pure endovascular approach. A combined operative–endovascular intervention may be a valuable approach in order to reduce the risk of intraoperative stroke and prevent future embolic events.
An 84-year-old female presented at the emergency department (ED) with a 4-month history of migratory digital cyanotic lesions across various fingers on her right hand. The lesion eventually progressed into dry gangrene on her right middle finger. Selective angiography of the aortic arch vessels demonstrated significant atherosclerotic plaque burden throughout her supra-aortic vessels and a segmental stenosis at the proximal innominate artery. A right carotid cut down was performed to allow clamping of the carotid artery so as to minimize the risk of intraoperative stroke from plaque manipulation. Retrograde balloon angioplasty was performed, and stent was placed across the stenotic segment. The patient tolerated the procedure well and had an uneventful postoperative course. She was discharged on postoperative day 3. At 2-week follow-up, she has had no progression of her digital ischemia nor other focal cranial nerve deficits.
Migratory digital ischemia is a rare presentation of atherosclerotic disease of the supra-aortic vessels. It represents a challenging situation for endovascular intervention due to concern about plaque dislodgment during the procedure. A retrograde balloon-stent angioplasty following distal carotid control with an open approach may be safe and effective in selected patients.
Treatment of juxtarenal abdominal aortic aneurysms (AAAs) remains challenging. A 79-year-old male who had infrarenal endovascular repair of abdominal aortic aneurysm (EVAR) 13 years previously presented with leaking juxtarenal AAA. Emergency fenestrated EVAR (FEVAR) was performed utilizing a stent graft designed and built for a different patient. Despite the need to embolize the celiac artery prior to covering it with the stent graft in order to achieve adequate proximal seal, the patient had uneventful recovery.
The Model of End-Stage Liver Disease (MELD) score has been traditionally utilized to prioritize for liver transplantation; however, recent literature has shown its value in predicting surgical outcomes for patients with hepatic dysfunction. The benefit of carotid endarterectomy in asymptomatic patients is dependent on low perioperative morbidity. Our objective was to use MELD score to predict outcomes in asymptomatic patients undergoing carotid endarterectomy.
Patients undergoing carotid endarterectomy were identified in the National Surgical Quality Improvement Program data sets from 2005 to 2012. The Model of End-Stage Liver Disease score was calculated using serum bilirubin, creatinine, and the international normalized ratio (INR). Patients were grouped into low (<9), moderate (9-14), and high (15+) MELD classifications. The effect of the MELD score on postoperative morbidity and mortality was assessed by multivariable logistic and gamma regressions and propensity matching.
There were 7966 patients with asymptomatic carotid endarterectomy identified. The majority 5556 (70%) had a low MELD score, 1952 (25%) had a moderate MELD score, and 458 (5%) had a high MELD score. High MELD score was independently predictive of postoperative death, increased length of stay, need for transfusion, pulmonary complications, and a statistical trend toward increased cardiac arrest/myocardial infarction. The Model of End-Stage Liver Disease score did not affect postoperative stroke, wound complications, or operative time.
High MELD score places asymptomatic patients undergoing carotid endarterectomy at a higher risk of adverse outcomes in the 30 days following surgery. This provides further empirical evidence for risk stratification when considering treatment for these patients. Outcomes of medical management or carotid stenting should be investigated in high-risk patients.
A 36-year-old young woman with a medical history of recurrent pulmonary embolism and chronic pelvic pain was admitted to our hospital. Contrast-enhanced imaging techniques revealed a large left renal vein aneurysm with a coexisting vascular mass. The patient was operated on electively, and the left kidney was autotransplanted to the right ileac fossa following the ex vivo resection of the vascular mass and the left renal vein aneurysm. Herein, we report an unusual coexistence of a vascular mass and recurrent pulmonary embolism treated successfully with our surgical treatment strategy.
Right-side aortic arch is a rare congenital aortic anomaly occurring in 0.05% to 0.1% of the general population. Approximately, half of these cases may be associated with an aberrant left subclavian artery and occasionally with aneurysmatic change at its origin known as Kommerell diverticulum or aneurysm (KA). Herein we report a challenging case of a right-side aortic arch associated with KA incidentally observed in a 73-year-old male with metastatic lung cancer. After careful multidisciplinary discussion, a conservative strategy of care was successfully adopted.
The residual stump after excision of an infected aortic graft may be subject to acute blowout due to chronic mechanical stress on a weak arterial wall. We present a case of late aortic stump disruption that required revision after 12 months from graft removal. Our strategy consisted of avoiding reexposure of the pararenal aorta by creating a new supraceliac stump with healthy aortic wall after antegrade visceral debranching. This case confirms the need for long-term surveillance of aortic stumps. The use of a supraceliac approach minimizes the risk of intraoperative blowout and postoperative disruption.
Feasibility of single-session mechanical thrombetomy, without thrombolytics, for the treatment of the subacute deep vein thrombosis (DVT) of the lower extremity remains poorly described.
To evaluate the feasibility and efficacy of single-session endovascular treatment of DVT of the lower extremity that is more than 10 days old.
From January 2010 to December 2013, single-session endovascular treatment was performed in 21 limbs of 21 patients (8 men and 13 women) with DVT more than 10 days old at our hospital. The mean age of the thrombosis was 21.5 days (range 11-45 days). Two patients had malignancy-related obstructions. A 14F introducer sheath was inserted through the popliteal vein followed by aspiration thrombectomy with a large bore catheter. Balloon angioplasty and/or maceration of the thrombus were added when needed. Stent insertions were performed for patients with combined iliac vein stenosis. Technical success, clinical success, mean procedure time, and complications were evaluated.
The technical success rate was 90.5% (19 of 21 patients). Among the 19 successful cases, aspiration thrombectomy alone was performed in 16 (84.2%) patients, additional balloon angioplasty of the femoral vein was performed in 2 (10.5%) patients, and both balloon angioplasty of the femoral vein and rotational thrombectomy were performed in 1 (5.3%) patient. Iliac vein stenting was performed due to combined iliac vein narrowing in 13 (68.4%) of the 19 successful cases. The mean procedure time was 86 minutes (26-179 minutes). All of the patients with technical success (19 of 21 patients) showed marked improvement in symptoms at the time of discharge (clinical success). Unexplained gastrointestinal hemorrhage developed in 1 patient.
Single-session endovascular treatment is feasible and effective even for patients with aged deep vein thrombosis of the lower extremity more than 10 days old.
The incidence of concomitant extracranial carotid artery stenosis and ipsilateral intracranial carotid aneurysm has been reported to vary between 2.8% and 5%. These complex lesions may present a challenge for treatment decision-making. This case report describes an asymptomatic male patient with severe carotid bifurcation stenosis, coupled with an unruptured supraclinoid internal carotid aneurysm. Both lesions were treated simultaneously. Patient underwent carotid stenting followed by aneurysm coiling in the same setting without any complication.
Laparoscopic insertion of peritoneal dialysis (PD) catheter has become a preferred method compared to the traditional open technique for PD catheter insertion. We retrospectively report the outcome of 1-port laparoscopic placement PD catheters in our institution.
A total of 263 patients with end-stage renal disease who underwent single-trocar laparoscopic PD catheter insertion during a recent 6-year period were reviewed. Laparoscopic technique involves introducing a PD catheter over a stiff guidewire into the abdominal cavity through a 10-mm laparoscopic port. Pertinent clinical variables, procedural complications, and follow-up outcome were analyzed.
There were 182 men and 81 women. The mean age was 56 years. Technical success was 95.8%. Catheter occlusion was the most common early complications (<6 months) that occurred in 4 (1.5%) patients. Late complications (> 6 months) including catheter occlusion, cuff extrusion, catheter leakage, catheter migration, infection, and hernia occurred in 5 patients (1.9%), 2 patients (0.8%), 3 patients (1.1%), 3 patients (1.1%), 6 patients (2.3%), and 4 patients (1.5), respectively. Mean follow-up time was 39 ± 18 months. Catheter survival rate at 1, 2, 3, 4, and 5 years was 96%, 94%, 90%, 85%, and 82%, respectively.
Laparoscopic PD catheter implantation via a single-trocar utilizing a stiff guidewire technique is feasible and safe. This method can result in low complication and high catheter survival rate.
The present meta-analysis aimed to evaluate the efficacy and safety of compression stockings for postthrombotic syndrome (PTS) prevention in patients with deep venous thrombosis (DVT).
Randomized controlled trials (RCTs) regarding the use of compression stockings for prevention of PTS were identified from the Medline, PubMed, and Embase databases as well as the Cochrane library. The resulting manuscripts were analyzed according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions.
Six RCTs involving 1465 patients with DVT were included. The meta-analysis indicated no statistical differences between the compression stocking and the control groups in PTS incidence, using either the Villalta scale (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.23-1.74) or the Ginsberg scale (OR, 1.13; 95% CI, 0.72-1.77). Based on the Villalta scale categorization, there were no differences in the incidence of mild–moderate PTS (OR, 0.71; 95% CI, 0.36-1.41) or incidence of severe PTS (OR, 0.68; 95% CI, 0.15-3.11). The difference in the recurrence of venous thromboembolism (OR, 0.89; 95% CI, 0.61-1.30) was also not significant. In the 3 RCTs that reported side effects of compression stockings, they were primarily related to discomfort, including itching, erythema, and rash.
The present meta-analysis has indicated that compression stockings may not prevent PTS, as determined by either the Villalta or the Ginsberg scale, in patients with DVT. However, owing to the limited number of trials, the evidence is not strong enough to draw a reliable conclusion. Further larger, randomized, double-blind, placebo-controlled, multicenter trials are needed.
Restenosis due to intimal hyperplasia (IH) is a major clinical issue that affects the success of lower limb endovascular surgery. After 1 year, restenosis occurs in 40% to 60% of the treated vessels. The possibility to reduce IH using local antiproliferative drugs, such as taxols, has been the rationale for the clinical applications of drug-eluting stents and drug-eluting balloons (DEBs). The purpose of this study was to evaluate the clinical and instrumental efficacy of DEBs versus simple percutaneous transluminal angioplasty (PTA) in patients affected by chronic limb ischemia (CLI) with tibial artery "de novo" lesions.
A retrospective analysis was performed and included all consecutive patients who underwent endovascular treatment for CLI in our centers between January 2011 and March 2013. Inclusion criteria were (1) "de novo" tibial artery stenosis and (2) Rutherford class >4. Lesions were further divided by TransAtlantic Inter-Societal Consensus (TASC) classification into groups A, B, C, and D.
Between January 2010 and March 2013, a total of 138 patients underwent simple PTA or DEB for CLI, and the groups were clinically and demographically homogenous. We decided to use DEBs in 70 cases. An improvement in the Rutherford Scale in cumulative and single TASC lesions classification was better in the DEB group (74% vs 51%; P = .024) at 24 months than in the PTA group. In the DEB group, the increase in ankle–brachial index was significantly higher than in the PTA group (P = .039).
Our experience in addition to the existing literature supports the use of DEB in patients with CLI Rutherford class >3.
The initial survival advantage seen with endovascular aneurysm repair (EVAR) over open repair does not persist in the long term. Pulse wave velocity (PWV) is a measure of arterial stiffness, and increased PWV is an independent risk factor for increased cardiovascular morbidity and mortality. This prospective comparative pilot study examined the effect of implantation of an aortic graft on PWV in patients undergoing open or endovascular aortic aneurysm repair.
Thirty-four patients (15 open and 19 EVAR) were recruited. Patient demographics were similar in both the groups. Pulse wave velocity was calculated for all patients preoperatively and postoperatively using a standardized technique on a Philips IU22 Vascular Ultrasound machine and the results compared.
An increase in mean PWV following EVAR was demonstrated. The mean postprocedure PWV of 9.7 (± 4.5) cm/sec detected in the open group was significantly lower than the elevated 12.2 (± 4.5) cm/sec detected in the EVAR group. The surgical group also demonstrated a mean decrease of 0.2 (± 4.9) cm/sec in PWV following open repair compared to a mean increase of 3.3 (± 3.7) cm/sec in the EVAR group.
EVAR patients have a significantly higher postoperative PWV measurement than those undergoing open abdominal aortic aneurysm repair. Patients who have undergone EVAR may be at a higher risk of cardiovascular morbidity in the long term. A larger scale study with a longer prospective follow-up is required.
Systemic multiple aneurysms are rare and usually associated with collagen tissue disease, such as Ehlers-Danlos syndrome (EDS) or Marfan syndrome. In the present case, we describe a 39-year-old male patient with systemic multiple aneurysms and acute intraperitoneal hemorrhage who was clinically diagnosed with vascular EDS. Coil embolization of the distal segment of the common hepatic artery was performed, which resolved the patient’s symptoms. With this case presentation, we aim to increase the awareness of vascular EDS among clinicians and emphasize the extreme fragility of the arteries in patients with vascular EDS.
Duplex ultrasound scanning with B-mode imaging and both color Doppler and Doppler spectral waveforms is relied upon for diagnosis of vascular pathology and selection of patients for further evaluation and treatment. In most duplex ultrasound applications, classification of disease severity is based primarily on alterations in blood flow velocities, particularly the peak systolic velocity (PSV) obtained from Doppler spectral waveforms. We developed a duplex ultrasound simulator for training and assessment of scanning skills.
Duplex ultrasound cases were prepared from 2-dimensional (2D) images of normal and stenotic carotid arteries by reconstructing the common carotid, internal carotid, and external carotid arteries in 3 dimensions and computationally simulating blood flow velocity fields within the lumen. The simulator displays a 2D B-mode image corresponding to transducer position on a mannequin, overlaid by color coding of velocity data. A spectral waveform is generated according to examiner-defined settings (depth and size of the Doppler sample volume, beam steering, Doppler beam angle, and pulse repetition frequency or scale). The accuracy of the simulator was assessed by comparing the PSV measured from the spectral waveforms with the true PSV which was derived from the computational flow model based on the size and location of the sample volume within the artery.
Three expert examiners made a total of 36 carotid artery PSV measurements based on the simulated cases. The PSV measured by the examiners deviated from true PSV by 8% ± 5% (N = 36). The deviation in PSV did not differ significantly between artery segments, normal and stenotic arteries, or examiners.
To our knowledge, this is the first simulation of duplex ultrasound that can create and display real-time color Doppler images and Doppler spectral waveforms. The results demonstrate that an examiner can measure PSV from the spectral waveforms using the settings on the simulator with a mean absolute error in the velocity measurement of less than 10%. With the addition of cases with a range of pathologies, this duplex ultrasound simulator will be a useful tool for training health-care providers in vascular ultrasound applications and for assessing their skills in an objective and quantitative manner.
Spontaneous intrahepatic portal venous shunts are rare with only few case reports published. Treatments using various endovascular techniques have been described, although no single technique has been shown to be preferred. We present a patient who was referred for treatment of a spontaneous portal venous shunt and describe our treatment approach and present a review on previously reported cases.
We aim to review an 8-year experience of median arcuate ligament syndrome (MALS) with chronic gastrointestinal ischemia (CGI) and evaluate clinical outcomes of arcuate ligament decompression, celiac sympathectomy, and selective revascularization. Between December 2002 and March 2012, of 25 patients referred with symptoms of CGI, 11 patients (10 women and 1 man) had clinical signs of abdominal angina and radiological evidence of MALS. Mean age was 50 ± 20.4 years. Median symptom duration was 34 months. All patients had median arcuate decompression and celiac sympathectomy. In all, 8 did not require revascularization, 2 had retrograde celiac and/or superior mesenteric artery (SMA) stenting, and 1 had SMA bypass. There was no mortality. The 30-day morbidity was 9%. Mean follow-up was 60 months. Eight patients noted complete relief of abdominal pain, and 1 reported some improvement. The MALS is not solely a vascular compression syndrome. The neurological component requires careful celiac plexus sympathectomy in addition to arcuate ligament decompression.
Vein graft stenosis is a well-recognized complication of infrainguinal bypass surgery. Balloon angioplasty is an accepted method for managing vein graft stenosis in selected patients. This intervention is not without complication. We present 2 cases of delayed pseudoaneurysm formation after balloon angioplasty of vein graft stenoses. Both cases showed a persistent contrast stain or blush as an indication of vein wall damage and propose that this is a radiological harbinger of delayed rupture and pseudoaneurysm formation.
Spontaneous compartment syndrome is a rare condition and requires urgent surgical treatment to achieve favorable outcome. Several cases have been reported in the literature, and it has been associated with patients with diabetes. We present a case of acute spontaneous sequential compartment syndrome of the lower limbs in a patient with poorly controlled type 1 diabetes.
An interesting case report detailing the management of an aorta that was inadvertently screwed during spinal fixation. The management and imaging encompass the use of computer tomography and intravascular ultrasound to determine the trajectory of the screw and the successful management of the patient.
Purpose: To report the use of multilayer uncovered stent to treat primary infected juxtarenal aortic aneurysm. Case Report: A 50-year-old man was admitted to hospital for rapid onset of intractable abdominal pain and high fever. Computed tomographic scan showed 2 juxtarenal saccular aneurysms of abdominal aorta with morphologic and clinical changes compatible with infectious etiology. Patient was treated with multilayer flow-modulating stent. Follow-up imaging showed persistent aneurysm exclusion and continuous aneurysm shrinkage of the sac until complete regression to a normal aortic configuration was seen at 1 year. During follow-up (24 months), patient continued to do well, and there was no recurrence of infection.Conclusion: Multilayer stent appeared to be an acceptable treatment option for primary infected juxtarenal aortic aneurysms. Aneurysmal sac completely disappeared and visceral branches remained patent at 2-year follow-up. However, longer follow-up is necessary to evaluate the long-term patency of involved visceral arteries.
Purpose: Monitoring of fibrinogen level is used to predict bleeding during lower extremity tissue plasminogen activator (tPA) infusions for peripheral arterial or venous thrombolysis. This practice is not fully addressed in the literature.Materials and Methods: We retrospectively reviewed fibrinogen levels and studied bleeding rate from charts of patients who underwent lower extremity tPA infusions at a single hospital from January 2010 to May 2012. Results: The rate of thrombolytic success did not correlate with fibrinogen level (P = .53). The rate of major bleeding was significantly higher for patients with a fibrinogen level at or below 150 mg/dL (P = .01). Patients whose tPA infusion was terminated within 46 hours had significantly lower rates of major bleeding (P = .01) and thrombolytic failure (P < .01). Periprocedural systolic blood pressure above 160 mm Hg was a risk factor for major bleeding (P = .02). There was no association between concomitant aspirin use (P = .90, .51) or hourly tPA dose (P = .71, .62) and thrombolytic success or major bleeding, respectively. Conclusion: Fibrinogen level ≤150 mg/dL is associated with increased risk of major bleeding during tPA infusions. We suggest serial fibrinogen measurement as a viable method to monitor bleeding risk during lower extremity tPA infusions.
Disruption of arterial wall integrity as a result of trauma, iatrogeny, inflammation, or infection may result in pseudoaneurysm formation. Gluteal artery aneurysms are rare and represent less than 1% of all arterial aneurysms. Pseudoaneurysms of the inferior gluteal artery (IGA) following blunt trauma are exceptionally rare with only 6 reported cases in the English literature. We describe an 82-year-old female with a remote history of a fall presenting with an enlarging buttock mass. Imaging confirmed an IGA pseudoaneurysm with associated arteriovenous fistula that was successfully treated with endovascular embolization.
Objective: To examine the influence of local meteorological conditions on the onset of ruptured abdominal aortic aneurysms (AAA). Methods: A review of 6551 consecutive days with a total of 191 ruptured AAA was performed between January, 1994 and December, 2011. Days with and without ruptured AAA were compared considering local meteorological data. A systematic review of the literature was performed. Results: Atmospheric pressure, cloudiness, relative humidity, precipitation, and water vapor pressure were comparable at event and nonevent days. The 4-day variance of atmospheric pressure prior to event days was significantly higher compared to nonevent days. Maximal and average temperature and water vapor pressure were significant lower at event days. Binary regression analysis identified a higher 4-day variance in atmospheric pressure as an independent factor for ruptures. Conclusions: Further studies—collected at different geographic and climate areas—are necessary to prove that meteorological conditions may trigger the incidence of ruptured AAA.
The objective of this study was to explore the protective effect and the possible mechanism of Ginkgo biloba extract (Ginaton) on human vascular endothelial cells (VECs) injured by angiotensin II (Ang-II) and hypoxia. The human aortic VECs were divided into different groups to observe the changes in endothelin (ET), calcium concentration ([Ca2+]i), and mitochondrial membrane potential (MMP). The results showed that Ginaton had inhibited ET secretion induced by hypoxia and Ang-II (P < .01). the protection offered by Ginaton at mid (10 mg/mL) and low (5 mg/mL) concentrations was obviously better than that offered at high concentration (25 mg/mL). The [Ca2+]i increased and MMP decreased significantly in both hypoxia group and Ang-II group (P < .01); however, the changes in [Ca2+]i and MMP could be meliorated by Ginaton. This study suggested that Ginaton could effectively protect VECs against injury, and the dose used clinically would rather be low than too high for getting better results.
We report on a 52-year-old female patient who presented with a 6-month history of right lower extremity swelling and tenderness. The patient was treated as an outpatient with full anticoagulation, without any improvement. Her medical history was significant for hypertension and high cholesterol, and she had a full coagulopathy profile that was negative for any hypercoagulable syndrome. On examination, the patient was moderately obese, with significant tenderness over the medial aspect of the right groin. A venous duplex examination revealed hypoechoic structure ± acute deep vein thrombosis of right common femoral vein (CFV). A computed tomography of the venous phase revealed an eccentric compression over the medial wall of the right CFV. During surgical exploration, adventitial cystic mucinous disease was enucleated from the medial wall of the right CFV, and the pathological examination confirmed the diagnosis. The postoperative course was uneventful, and all swelling and tenderness were completely resolved. The patient continued to do well, and she had an unremarkable venous duplex evaluation at her 6-month follow-up.
Ischemia–reperfusion (I/R) injury negatively affects the outcome of surgical interventions for amputated or severely traumatized extremities. This study aimed to evaluate the protective role of <sc>l</sc>-carnitine on the contractile properties of fast-twitch (extensor digitorum longus [EDL]) and slow-twitch (soleus [SOL]) skeletal muscles following I/R-induced injury in a rat model. Rats were divided into 4 groups (1) saline pretreatment, (2) <sc>l</sc>-carnitine pretreatment, (3) saline pretreatment and I/R, and (4) <sc>l</sc>-carnitine pretreatment and I/R. Twitch and tetanic contractions in the EDL and SOL muscles in each group were recorded. Additionally, a fatigue protocol was performed in these muscles. Twitch and tetanic contraction amplitudes were lower in the EDL and SOL muscles in which I/R was induced (P < .01). <sc>l</sc>-Carnitine pretreatment significantly increased tetanic contraction amplitude in the SOL muscles following I/R (P < .01) but not in the EDL muscles. <sc>l</sc>-Carnitine pretreatment did not alter the fatigue response in any of the muscles.
Objective We conducted a retrospective study to compare short- and mid-term patencies of Viabahn with surgical above-knee prosthetic bypass (pAKB).
Methods The records of 52 patients with either pAKB (n = 25) or Viabahn (n = 27) were reviewed. The majority had Rutherford clinical grade 3. Patients were followed after 3, 6, and 12 months and yearly thereafter.
Results For Viabahn, the short-term (1-16 months) primary patency rate was 60% with a secondary patency rate of 90%, and mid-term (1-68 months) patencies of 47% and 83.3%, respectively. In pAKB, the short-term results revealed a primary patency rate of 78% with a secondary patency of 91% and mid-term results of 65% and 90%, respectively. No statistical difference was found concerning short-term patencies. Mid-term primary patency was lower for Viabahn (P < .05) and secondary patency proved no significant difference.
Conclusion Viabahn revealed similar short-term primary and secondary patencies but lower mid-term primary patency. It provides a good alternative therapy to pAKB.
Objectives: The purpose of this study was to report our experience with popliteal artery entrapment syndrome (PAES) with special emphasis on the applicability of duplex ultrasound scanning (DUS) when diagnosing PAES. In addition to examining the correlation between DUS and intraoperative findings in symptomatic limbs, the ultrasonic effect of plantar flexion in healthy volunteers were also evaluated.Methods: During a 12-month period, 11 symptomatic limbs in 8 patients with a mean age of 29 years were referred with suspected PAES and enrolled consecutively. The popliteal artery was studied preoperatively with DUS in rest and during active plantar flexion. The popliteal artery was explored in all symptomatic limbs, and the intraoperative findings served as gold standard. Additionally, the popliteal arteries in 11 healthy volunteers (22 limbs) were evaluated with DUS during rest and plantar flexion.Results: Intraoperative findings confirmed PAES in all 11 symptomatic limbs in accordance with the preoperative DUS examination. Surgical release of the popliteal artery was performed in 11 limbs. At a median follow-up of 15 months, all 11 limbs were free of ischemic symptoms and regained normalized popliteal flow on DUS. In the 22 symptom-free limbs, DUS showed normal popliteal flow during both rest and plantar flexion.Conclusion: In this series of patients with surgically confirmed PAES, we found preoperative DUS to have perfect agreement with the intraoperative findings in diagnosing PAES. The applicability of the method seems to be emphasized by the restoration of popliteal flow and relief of arterial insufficiency after surgical release in all patients, and by the fact, that none of the healthy volunteers were able to compress the popliteal artery during plantar flexion.
Background: Uncomplicated type B dissections have been traditionally managed with antihypertensive therapy. In the endovascular era, this dictum has been revisited. This review pooled the available studies to compare the outcomes of best medical therapy (BMT) to thoracic endovascular aortic repair (TEVAR) for uncomplicated type B dissections.Methods: A literature search was performed to identify studies on uncomplicated type B dissections managed with BMT with and without TEVAR. The primary outcome measures were mortality rates at 30 days and at 2 years following intervention. Results: A total of 6 studies included 123 patients who underwent TEVAR/BMT, and 566 patients who had BMT alone. The mortality rates at 30 days (6.5% TEVAR/BMT vs 4.8% BMT, P = .21) and at 2 years (9.7% vs 11.9%, P = .32) were similar. Renal failure was greater in TEVAR/BMT (15.4% vs 2.1%, P < .01). Rates of surgical reintervention/intervention were similar (17.6% vs 20.1%, P = .31).Conclusion: The TEVAR with BMT does not provide survival benefit compared to BMT alone, 2 years following uncomplicated type B aortic dissection.
Objectives: There are limited data available evaluating longitudinal outcomes after tibioperoneal angioplasty (TA) alone compared to adjunctive tibial procedures including stenting and atherectomy.Methods: Using the Centers for Medicare & Medicaid Services inpatient claims (2005-2007), patients evaluated TA only, TA plus stent placement (TA + S), and TA plus atherectomy (TA + A).Results: A total of 2080 patients with critical limb ischemia underwent percutaneous tibioperoneal intervention for the indication of ulceration. Procedures included TA (56.3%), TA + S (16.2%), and TA + A (27.5%). Rates of amputation were not statistically different between the groups at 30, 90, and 365 days after the intervention. Mean total hospital charges were TA ($35 867), TA + A ($41 698; P = .0004), and TA + S ($51 040; P < .0001).Conclusion: Patients undergoing TA alone compared to concomitant stenting or atherectomy for ulceration demonstrated no improvement in limb salvage. Future analysis of adjunctive tibioperoneal interventions is essential to temper cost, as they fail to improve long-term limb salvage.
Vascular abnormalities in neurofibromatosis type 1 (NF-1) are rare but sometimes fatal. We report a case of spontaneous rupture of a left renal artery aneurysm in a patient with NF-1. A 41-year-old nonpregnant normotensive woman known to have NF-1 presented to our emergency department with left flank pain. Computed tomography showed a large retroperitoneal hematoma due to left renal artery aneurysm rupture. She was treated with selective transcatheter coil embolization and fully recovered.