Staged Repair of Primary Aortoesophageal Fistula.

Primary aortoenteric fistulas are rare with an incidence reported up to .07% at autopsy. Literature review yields few reported cases, and rarer still is a fistula between a normal thoracic aorta and the esophagus. Rather, 83% of cases are associated with an aneurysmal aorta and 54% involve the duodenum. Patients with aortoesophageal fistula (AEF) usually present with a triad of chest pain, dysphasia, and a herald bleed. Without treatment, AEFs will result in exsanguination and are universally fatal; even with traditional open surgical treatment, mortality is reported over 55%. The complex pathology of AEFs makes repair more challenging, given an infected field, friable tissue, and patients who are often hemodynamically unstable. Staged repair using endografts as initial treatment with the primary goal of controlling bleeding and preventing fatal exsanguination has been reported. We present a case where a descending thoracic aorta to esophageal fistula was repaired, and this strategy was utilized.

Comparative study of clinical outcome of endovascular aortic aneurysms repair in large diameter aortic necks (>31 mm) versus smaller necks.

BACKGROUND: This study compares short-term (30 days) and intermediate term (3 years) clinical outcomes in patients with large (≥31 mm) versus small aortic neck diameters (≤28 and ≤31 mm). METHODS: Prospectively collected data from 741 patients who underwent endovascular aortic aneurysm repair were analyzed. Some surgeons have reported the threshold for a large aortic neck for endovascular aortic aneurysm repair to be 28 mm, whereas for others it is 31 mm. Therefore, we classified aortic neck diameter into less than or equal to 28 versus greater than 28 mm; and less than or equal to 31 versus greater than 31 mm. Logistic regression and Kaplan-Meier analyses were used to compare outcomes. RESULTS: There were 688 patients who had a defined aortic neck diameter: 592 with less than or equal to 28 mm, 96 with greater than 28 mm, 655 with less than or equal to 31 mm, and 33 with greater than 31 mm. The mean follow-up was 25.2 months for less than or equal to 31 mm versus 31.8 months for greater than 31 mm. Clinical characteristics were similar in all groups, except that there were more patients outside the instructions for use in the greater than 31 mm versus less than or equal to 31 mm group (94% vs 44%; P < .0001). There was a significant increase in early type I endoleak for patients with an aortic neck diameter of greater than 31 versus less than or equal to 31 mm (9 [27%] vs 74 [11%]; P = .01); late type I endoleaks (4 [14%] vs 18 [3%]; P = .01); sac expansion (5 [17%] vs 28 [5%]; P = .01); late intervention (5 [17%] vs 23 [4%]; P = .01); and death (9 [31%] vs 48 [8%]; P < .0001). There were no differences in outcomes between the patients with greater than 28 mm aortic neck diameters and the less than or equal to 28 mm diameters. Freedom from late type I endoleak at 1, 2, and 3 years were 96%, 88%, and 88% for patients with a neck diameter of greater than 31 mm versus 97%, 97%, and 97% for a diameter less than or equal to 31 mm (P = .19). The rate of freedom from sac expansion for patients with a diameter greater than 31 mm was 88%, 81%, and 81% at 1, 2, and 3 years versus 99%, 97%, and 92% for a diameter less than or equal to 31 mm (P = .02). Freedom from late intervention for 1, 2, and 3 years for patients with a diameter greater than 31 mm were 91%, 91%, and 91% versus 99%, 97%, and 96% for those with a diameter less than or equal to 31 mm. Survival rates at 1, 2, and 3 years for a diameter greater than 31 mm were 83%, 74%, and 68% versus 96%, 92%, and 90% for a diameter less than or equal to 31 mm (P < .001). Multivariate logistic regression analysis showed that patients with a diameter greater than 31 mm had an odds ratio of 6.1 (95% confidence interval [CI], 2.2-16.8) for mortality, 4.7 (95% CI, 1.4-15.5) for sac expansion, and 4.9 (95% CI, 1.4-17.4) for late type I endoleak. CONCLUSIONS: Patients with large aortic neck diameters (>31 mm) had higher rates of early and late type I endoleak, sac expansion, late intervention, and mortality.

Appropriate Use of Venous Imaging and Analysis of the D-Dimer/Clinical Probability Testing Paradigm in the Diagnosis and Location of Deep Venous Thrombosis.

BACKGROUND: The D-dimer (DD) level combined with the pretest Wells criteria probability (WCP) score can safely exclude deep venous thrombosis (DVT). The objective of this study was to examine the correlation between DD results alongside WCP score with findings on venous duplex ultrasound (VDU). The hypothesis is that VDU remains overutilized in low-risk patients with negative DD and that higher DD levels may correlate with thrombus burden and location. METHODS: Patients who presented to a high-volume tertiary care center with lower limb swelling with or without associated pain were retrospectively examined through June and July for 4 consecutive years (2012 to 2015). After calculating WCP, patients were divided into low-, moderate-, and high-risk categories. Electronic DD results utilizing enzyme linked immunosorbent assay, WCP data, and VDU analysis data were merged and analyzed based on receiver operator characteristic curve to determine the DD cutoff point for each WCP. Abnormal DD with an average value ≥ 0.6 mg/L fibrinogen equivalent units (FEUs) was correlated to positive DVT to differentiate proximal DVT (above popliteal vein) from distal DVT (below popliteal vein). RESULTS: Data of 1,909 patients were analyzed, and 239 (12.5%) patients were excluded secondary to serial repeat visits or follow-ups, surveillance screens, and if they had a previous history of DVT. The average age was 62.1 ± 16.3 years with more women (55.7%) and the majority presented with limb pain and edema (87%). DD studies were ordered and completed in 202 patients and correlated with all positive and negative DVT patients (100% sensitivity and negative predictive value, with specificity and positive predictive value of 14.9% and 15.9%, respectively). Twenty-six of 202 patients had DD that were in the normal range 0.1-0.59 mg/L (FEU), all of which were negative for DVT (100% sensitive). Fifty one of 202 patients had DD values of 0.6-1.2 mg/L FEU, of which only 3 DVTs were recorded, and all of them were distal DVTs. In addition, 685 patients with WCP <1 and negative DD were sent for VDU. Thus, 762 patients had an unnecessary immediate VDU (Wells ≤1 and -DD) study during their initial presentation. Potential charge savings for VDU for all patients are 762 × $1,557 = $1,186,434 and DD for all patients are 762 × $182 = $138,684, with total potential savings of $1,047,750 (USD 2016). CONCLUSIONS: This study suggests that DD is still underutilized, and DD in conjunction with WCP could significantly reduce the number of unnecessary immediate VDUs. Higher value of DD (>1.2 mg/L FEU) may raise concern for proximal DVT. Concern on cost-effectiveness exists and raises the demand for a proposed algorithm to be followed.

Management of Immediate Post-Endovascular Aortic Aneurysm Repair Type Ia Endoleaks and Late Outcomes.

BACKGROUND: Post-endovascular aortic aneurysm repair (EVAR) endoleaks and the need for reintervention are challenging. Additional endovascular treatment is advised for type Ia endoleaks detected on post-EVAR completion angiogram. This study analyzed management and late outcomes of these endoleaks. STUDY DESIGN: This was a retrospective review of prospectively collected data from EVAR patients during a 10-year period. All post-EVAR type Ia endoleaks on completion angiogram were identified (group A) and their early (30-day) and late outcomes were compared with outcomes of patients without endoleaks (group B). Kaplan-Meier analysis was used for survival analysis, sac expansion, late type Ia endoleak, and reintervention. RESULTS: Seventy-one of 565 (12.6%) patients had immediate post-EVAR type Ia endoleak. Early intervention (proximal aortic cuffs and/or stenting) was used in 56 of 71 (79%) in group A vs 31 of 494 (6%) in group B (p < 0.0001). Late type Ia endoleak was noted in 9 patients (13%) in group A at a mean follow-up of 28 months vs 10 patients (2%) in group B at a mean follow-up of 32 months (p < 0.0001). Late sac expansion and reintervention rates were 9% and 10% for group A vs 5% and 3% for group B (p = 0.2698 and p = 0.0198), respectively. Freedom rates from late type Ia endoleaks at 1, 3, and 5 years for group A were 88%, 85%, and 80% vs 98%, 98%, and 96% for group B (p < 0.001); and for late intervention, were 94%, 92%, and 77% for group A, and 99%, 97%, and 95% for group B (p = 0.007), respectively. Survival rates were similar. CONCLUSIONS: Immediate post-EVAR type Ia endoleaks are associated with higher rates of early interventions, late endoleaks and reintervention, which will necessitate strict post-EVAR surveillance.

Aortic Neck Anatomic Features and Predictors of Outcomes in Endovascular Repair of Abdominal Aortic Aneurysms Following vs Not Following Instructions for Use.

BACKGROUND: A significant number of patients undergo endovascular repair of abdominal aortic aneurysms (EVAR) outside the instructions for use (IFU). This study will examine various aortic neck features and their predictors of clinical outcomes. STUDY DESIGN: We performed a retrospective analysis of prospectively collected data on EVAR patients. Neck features outside IFU were analyzed. Kaplan-Meier and multivariate analyses were used to predict their effect as single features, or in combination, on outcomes. RESULTS: Fifty-two percent of 526 patients had 1 or more features outside the IFU. The overall technical success rate was 99%, and perioperative complication rates were 7% and 12% for IFU vs outside IFU use, respectively (p = 0.04). Type I early endoleak and early intervention rates were 7% and 10% for IFU vs 18% and 24% for outside IFU (p = 0.0002 and p < 0.0001). At a mean follow-up of 30 months, freedom from late type I endoleak and late reintervention at 1, 2, and 3 years for IFU were 99.5%, 99.5%, and 98.4%, and 99.4%, 98%, and 96.8%; vs 98.9%, 98.1%, and 98.1%, and 97.5%, 96.2%, and 95.2% for outside IFU (p = 0.049 and 0.799), respectively. Survival rates at 1, 2, and 3 years for IFU were 97%, 93.5%, and 89.8%; vs 93.7%, 88.8%, and 86.3% for outside IFU (p = 0.035). Multivariate analysis showed that a neck angle > 60 degrees had odds ratios for death, sac expansion, and early intervention of 6, 2.6, and 3.3, respectively; neck length < 10 mm had odds ratios of 2.8 for deaths, 3.4 for early intervention, 4.6 for late reintervention, and 4.3 for late type I endoleak. CONCLUSIONS: Patients with neck features outside IFU can be treated with EVAR; however, they have higher rates of early and late type I endoleak, early intervention, and late death.

Current Treatment Strategies for Acute Type B Aortic Dissection.

Acute type B aortic dissection (ATBAD) is a medical emergency that is a common occurrence in patients with atherosclerotic disease. The presentation is usually severe, with tearing pain that radiates to the back, and various levels of end-organ ischemia and malperfusion, even rupture, may occur. Everyone agrees that prompt and aggressive blood pressure control with ß-blockers and nitroprusside is imperative, but when to surgically intervene is still not well characterized. However, the advent of minimally invasive stent graft placement has reshaped our thoughts regarding therapeutic intervention for ATBAD. This review is an attempt to define the current surgical indications for treating ATBAD.

Inadvertent subclavian artery cannulation and options for management.

Central line placement is an integral part of our daily routine and although it is necessary in a select group of patients, serious complications may occur in up to 10% of cases. Inadvertent placement in the subclavian artery is considered to be one of the most challenging complications to the vascular specialist, which is mainly due to its deep anatomical location. Several endovascular options are available and should be tailored to fit each scenario. Herein, we present different approaches for the management of three cases of inadvertent subclavian artery cannulation. The first patient was treated with a covered stent, the second with prolonged balloon inflation, and the third with a closure device.

Impact of chronic renal insufficiency on the early and late clinical outcomes of carotid artery stenting using serum creatinine vs glomerular filtration rate.

BACKGROUND: This study analyzed the impact of chronic renal insufficiency (CRI) on early and late clinical outcomes of carotid artery stenting (CAS) using serum creatinine and glomerular filtration rate (GFR). STUDY DESIGN: There were 313 CAS patients classified into 3 groups: normal (serum creatinine <1.5 mg/dL or GFR ≥ 60 mL/min/1.73 m(2)); moderate CRI, and severe CRI (serum creatinine ≥ 3 or GFR < 30 mL/min/1.73 m(2)). Major adverse events ([MAE] stroke, death, and myocardial infarction) were compared for all groups. RESULTS: Using serum creatinine, perioperative stroke rates for normal, moderate, and severe CRI were: 5%, 0%, and 25%, respectively, (p = 0.05) vs 4.6%, 3.7%, and 11.1%, respectively, (p = 0.44) using GFR. The perioperative MAE rates for symptomatic patients were 9.3% and 0% (p = 0.355) and 2% and 5.9% (p = 0.223) for asymptomatic patients for normal and moderate/severe CRI, respectively, using serum creatinine vs 8.1% and 7.8%, respectively, for symptomatic patients and 2.5% and 3%, respectively, for asymptomatic patients using GFR. At a mean follow-up of 21 months, late MAE rates in normal vs moderate/severe CRI patients were 8.2% and 14%, respectively, (p = 0.247) using serum creatinine vs 6.6% and 13.3%, respectively, (p = 0.05) using GFR. Late MAE rates for symptomatic patients in normal vs moderate/severe CRI were: 8.7% vs 27%, respectively, (p = 0.061) using serum creatinine and 5.7% vs 18.8%, respectively, (p = 0.026) using GFR. Late death rate was 0.55% in normal vs 7.6% (p = 0.002) for moderate/severe CRI. Freedom from MAE at 3 years in symptomatic patients was 81% in normal and 46% in moderate/severe CRI (p = 0.0198). A multivariate Cox regression analysis showed that a GFR of < 60 mL/min/1.73 m(2) had an odds ratio of 1.6 (p = 0.222) of having a MAE after CAS. CONCLUSIONS: The GFR was more sensitive in detecting late MAE after CAS. Carotid artery stenting in moderate CRI patients can be done with a satisfactory perioperative outcome; however, late death was significant.

Amyloidosis and spontaneous hepatic bleeding, transcatheter therapy for hepatic parenchymal bleeding with massive intraperitoneal hemorrhage: a case report and review of the literature.

Hepatic hemorrhage can be devastating, especially in patients with underlying hepatic pathology. This is a case report of a 50-year-old man who presented to the emergency room with Stage 3 shock as evidenced by a systolic blood pressure of 90 mmHg, a heart rate of 125 beats per minute, respiration of 32, with delayed capillary refill and agitation. At this time, he was found to have a massive spontaneous intra-abdominal hemorrhage with an advanced stage of amyloidosis with multiple organ malfunctions. The initial diagnosis was based on an abdominal computed tomography scan and the patient was taken expeditiously to a hybrid angiography suite for a celiac angiogram. An intraoperative diagnosis of extravasation from amyloid related vasculopathy was made based on the angiographic appearance of hepatic circulation. Coil embolization of the feeding branch of the bleeder was achieved using the interlock coil system and a completion angiogram was done showing complete cessation of active bleeding. The postoperative phase was uneventful and the patient was discharged home on postoperative day three. His postoperative visit at five months later was unremarkable.

Current update on the status of totally percutaneous aneurysm repair.

The evolution of minimally invasive procedures to treat aortic aneurysms has expanded to include access interventions as well. Traditionally, groin exposures have been the standard approach for common femoral artery exposure with open cutdown; however, inherent and related complications to that approach have paved the road to the percutaneous approach. Current available evidence from the literature supports the feasibility and the safety of percutaneous endovascular aneurysm repair (PEVAR); however, predictors of success are not well defined. We should examine all available studies (both prospective and retrospective) in order to draw a conclusion and evidence-based outcome for selecting patients who would benefit the most from PEVAR.

Predictors of percutaneous access failure requiring open femoral surgical conversion during endovascular aortic aneurysm repair.

OBJECTIVE: To determine predictors of percutaneous (PEVAR) access failure requiring conversion to an open approach (OEVAR) during endovascular aortic aneurysm repair (EVAR). METHODS: A single-center retrospective review of all EVAR patients from January 2009 through June 2011 with multivariate analysis of clinical and anatomic variables that could impact access outcome was conducted. Target vessel calcification was categorized as mild, moderate, or severe based on circumferential calcium arc (<⅓, ⅓ to ½, and >½ respectively), dyslipidemia (defined as low-density lipoprotein >130 mg/dL or receiving lipid lowering medication), and obesity (defined as body mass index [BMI] >30). RESULTS: We investigated 400 access sites for 200 patients who underwent EVAR. The study cohort's characteristics included an average age of 72.8 ± 9.0 years, vessel size of 9.6 ± 1.8 mm, sheath size of 17.1 ± 3.0 Fr, BMI of 27.6 ± 5.3, and estimated glomular filtration rate of 68.5 ± 24.2 mL/min. Comorbidities included dyslipidemia in 129 patients (64.5%) and diabetes in 54 patients (27%). There were 132 OEVAR (66 patients), two mixed OEVAR with contralateral PEVAR (one patient), and 266 (133 patients) PEVAR approaches. Use of PEVAR increased over time (45.5% [2009], 77.8% [2010], and up to 88.5% [2011]; P = .001) while conversions decreased (24.3% [2009], 8.7% [2010], and 4.3% [2011]; P = .001]. More OEVAR patients (35.8%) stayed longer than 3 days compared with 21.1% for PEVAR (P = .028). For the 266 PEVAR approaches, 32 access sites (12.0%) had to be converted. Severely calcified arteries were most predictive of conversion (odds ratio [OR], 36.4; P < .001). Year of procedure (2010; OR, 0.17; P = .001; 2011, OR, 0.20; P = .049), female gender (OR, 3.1; P = .017), moderately calcified arteries (OR, 2.5; P = .085), and age (OR, 2.3 [per decade]; P = .002) were all also significant. Vessel size, sheath size, and BMI were found to be nonsignificant predictors of conversion. CONCLUSIONS: PEVAR was found to be safe, reliable, and feasible. Several factors, including learning curve, vessel calcification, age, and female gender predicted conversion of PEVAR to OEVAR.

Cystic adventitial disease of the common femoral vein: a case report and review of the literature.

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.

Patency in arteriovenous grafts in hemodialysis patients.

OBJECTIVE: It is difficult to maintain a working access for patients on hemodialysis. Despite current Dialysis Outcome Quality Initiatives recommendations of "Fistula First," not everyone qualifies for a fistula, and those patients undergoing the alternative treatment, a graft, can experience graft failure. This study examines factors associated with arteriovenous graft (AVG) patency. METHODS: A retrospective analysis was completed for all the patients who had an AVG during 2005 to 2010. Data were collected from electronic medical records, including date of first and subsequent interventions, salvage technique (surgical vs percutaneous), medical comorbidities, and use of antiplatelet medications (aspirin and clopidogrel). Continuous variables were compared with 2 sample t tests, and categorical variables with chi-square/Fisher exact test. Logistic regression was used to determine the odds ratio for risk factors associated with patency. A P value of <.05 was considered significant. All analyses were done using SAS 9.2 (SAS Institute Inc, Cary, North Carolina). RESULTS: A total of 193 unique patients had an AVG. Of the 193 patients, 64% were female, 83% were hypertensive, and 64% were diabetic. The locations of the grafts were 80% arm, 15% forearm, and 5% thigh. Configurations, including loop and straight, were 34% and 63%, respectively. Comorbidities were not associated with patency. Primary patency was not found to be different with respect to location and configuration of graft and type of intervention. Primary patency for patients taking only aspirin (n = 43) and only clopidogrel (n = 17) were significantly different from patients on a combination of aspirin and clopidogrel (n = 7), with a P = .0051 and P = .0447, respectively. CONCLUSION: Neither location nor configuration affects the primary patency of AVGs. Aspirin alone is not inferior to aspirin and clopidogrel. Further prospective studies may be warranted to establish a consensus regarding medications and patency with AVGs.

Atypical presentation of priapism in a patient with acute iliocaval deep venous thrombosis secondary to May-Thurner syndrome.

We report on a 42-year-old male who presented with priapism, severe scrotal swelling, and left lower extremity pain and swelling. Initial management of priapism failed, and he was noted to have both cavernosal and glandular venous obstruction. Computed tomography (CT) was performed and identified extensive acute thrombosis involving the distal inferior vena cava and the left iliac veins. Pharmacomechanical thrombolysis (PMT) was started over the course of two days. At completion of thrombolysis, the culprit lesion in the left common iliac vein was treated with angioplasty and stenting. His postoperative course was uneventful, and his priapism as well as the scrotal and leg swelling improved. He was discharged home on full anticoagulation. To our knowledge, this is the first available description of this rare presentation along with a literature review of the underlying vascular etiology for priapism.

Traumatic nonanastomotic pseudoaneurysm of axillofemoral bypass graft: a case report and review of the literature.

Traumatic nonanastomtic disruption of an axillofemoral bypass graft (AFBG) is a relatively rare entity. However, we are reporting on an 82-year-old female who presented with a pulsating mass on her left side, which was noticed about 2 weeks after she fell on her side. The patient had undergone an ABFG about 15 years earlier for limb revascularization, and she had an occluded aortobifemoral bypass graft. A diagnosis of localized rupture with pseudoaneurysm (PSA) was confirmed with arterial duplex ultrasound and computed tomograph (CT) angiogram scans. A 7-cm PSA with partial disruption of the polytetrafluoroethylene (PTFE) graft at the level of the fifth thoracic vertebrae was noted. An initial work-up to eliminate the possibility of sepsis and localized mycotic seeding was negative. The patient was taken to the hybrid angiogram room, and a percutaneous cut down of the AFBG was performed with local dissection below the site of rupture. A limited angiogram showed a focal PSA of the AFBG. An intravascular ultrasound (IVUS) was performed to calibrate the diameter of the AFBG, and a covered stent was deployed across the area of the disrupted graft. A completion angiogram showed complete exclusion of the PSA with good runoff throughout the graft. The authors will review the management of the traumatic PSA with an endovascular approach.

Clopidogrel use before renal artery angioplasty with/without stent placement resulted in tertiary procedure risk reduction.

OBJECTIVE: Contrary to coronary artery literature, the effect of preprocedural clopidogrel on renal artery restenosis (RAR) has not been characterized. This study was designed to evaluate the effect of preprocedural clopidogrel on target vessel revascularization (TVR), reintervention, and restenosis for patients who underwent recurrent renal artery angioplasty. METHODS: A retrospective analysis of patients treated for RAR in a single tertiary center from January 1999 to December 2009 was conducted. Patients were divided into preadmission use of (1) clopidogrel or (2) aspirin only (acetylsalicylic acid [ASA]) for the initial procedure. TVR was defined as occurrence of a tertiary procedure for symptomatic RAR. Rate of freedom from event (ie, tertiary restenosis and TVR) was analyzed using Kaplan-Meier method. RESULTS: Eighty-eight interventions were performed on 77 patients with RAR; 66% were females with average (mean ± SEM) age and body mass index of 68.8 ± 1.1 and 28.6 ± 0.8, respectively. Comorbidities included 96% chronic hypertension, 33% diabetes, 76% hyperlipidemia, 20% renal insufficiency, 39% tobacco use, 58% coronary artery disease, and 51% peripheral vascular disease. Clopidogrel use increased significantly during the index procedure from admission 35.2% to discharge 97.7% (P < .001, McNemar test). There was a trend toward risk reduction of a tertiary intervention (23%) for patients admitted on clopidogrel compared with ASA (P = .052). Likewise, there was a trend (P = .051) toward increased freedom from a tertiary intervention, with cumulative freedom at 8 years 93.5% for clopidogrel vs 61% for ASA. No differences were found for restenosis. CONCLUSIONS: The use of preprocedural clopidogrel was associated with a possible risk reduction of TVR reintervention, but this finding needs to be validated in randomized clinical trial.

Carotid artery stenting outcomes are equivalent to carotid endarterectomy outcomes for patients with post-carotid endarterectomy stenosis.

BACKGROUND: Carotid artery stenting (CAS) has been advocated as an alternative to redo surgery for patients with post-carotid endarterectomy (CEA) stenosis. This study compares early and late clinical outcomes for both groups. METHODS: This study analyzes 192 patients: 72 had reoperation (Group A) and 120 had CAS for post-CEA stenosis (Group B). Patients were followed prospectively and had duplex ultrasounds at 1 month, and every 6 to 12 months thereafter. The perioperative complications (perioperative stroke, myocardial infarction/death, cranial nerve injury) and 4-year end points were analyzed. A Kaplan-Meier lifetable analysis was used to estimate rates of freedom from stroke, stroke-free survival, ≥50% restenosis, and ≥80% restenosis. RESULTS: Demographic/clinical characteristics were comparable for both groups, except for diabetes mellitus and coronary artery disease, which were significantly higher in Group B. The indications for reoperations were transient ischemic attacks/stroke in 72% for Group A versus 57% for Group B (P=.0328). The mean follow-up was 33 months (range, 1-86 months) for Group A and 24 months (range, 1-78 months) for Group B (P=.0026). The proportion of early (<24 months) carotid restenosis prior to intervention was 51% in Group A versus 27% in Group B (P=.0013). The perioperative stroke rates were 3% and 1%, respectively (P=.5573). There were no myocardial infarctions or deaths in either group. The overall incidence of cranial nerve injury was 14% for Group A versus 0% for Group B (P<.0001). However, there was no statistical difference between the groups relating to permanent cranial nerve injury (1% versus 0%). The combined early and late stroke rates for Groups A and B were 3% and 2%, respectively (P=.6347). The stroke-free rates at 1, 2, 3, and 4 years for Groups A and B were 97%, 97%, 97%, and 97% and 98%, 98%, 98%, and 98%, respectively (P=.6490). The stroke-free survival rates were not significantly different. The rates of freedom from ≥50% restenosis at 1, 2, 3, and 4 years were 98%, 95%, 95%, and 95% for Group A versus 95%, 89%, 80%, and 72% for Group B (P=.0175). The freedom from ≥80% restenosis at 1, 2, 3, and 4 years for Groups A and B were 98%, 97%, 97%, and 97% versus 99%, 96%, 92%, and 87%, respectively (P=.2281). Four patients (one symptomatic) in Group B had reintervention for ≥80% restenosis. The rate of freedom from reintervention for Groups A and B were 100%, 100%, 100%, and 100% versus 94%, 89%, 83%, and 79%, respectively (P=.0634). CONCLUSIONS: CAS is as safe as redo CEA. Redo CEA has a higher incidence of transient cranial nerve injury; however, CAS has a higher incidence of ≥50% in-stent restenosis.

Primary carotid artery stenting versus carotid artery stenting for postcarotid endarterectomy stenosis.

BACKGROUND: Carotid artery stenting (CAS) has been advocated as an alternative to carotid endarterectomy (CEA) in high-risk surgical patients, including stenosis after CEA. This study compared early and midterm clinical outcomes for primary CAS vs CAS for post-CEA stenosis. METHODS: This study analyzed 180 high-risk surgical patients: 68 had primary CAS (group A), and 112 had CAS for post-CEA stenosis (group B). Patients were followed-up prospectively and had duplex ultrasound imaging at 1 month and every 6 months thereafter. All patients had cerebral protection devices. Kaplan-Meier life-table analysis was used to estimate rates of freedom from stroke, stroke-free survival, > or =50% in-stent stenosis, > or =80% in-stent stenosis, and target vessel reintervention (TVR). RESULTS: Patients had comparable demographic and clinical characteristics. Carotid stent locations were similar. Indications for CAS were transient ischemic attacks (TIA) or stroke in 50% for group A and 45% for group B. The mean follow-up was comparable, at 21 (range, 1-73) vs 25 (range, 1-78) months, respectively. The technical success rate was 100%. The perioperative stroke rates and combined stroke/death/myocardial infarction (MI) rates were 7.4% for group A vs 0.9% for group B (P = .0294). No perioperative MIs occurred in either group. One death was secondary to stroke. The combined early and late stroke rates were 10.8% for group A and 1.8% for group B (P = .0275). The stroke-free rates at 1, 2, 3, and 4 years for groups A and B were 89%, 89%, 89%, and 89%; and 98%, 98%, 98%, and 98%, respectively (P = .0105). The rates of freedom from > or =50% carotid in-stent stenosis were 94%, 83%, 83%, and 66% for group A vs 96%, 91%, 83%, and 72% for group B (P = .4705). Two patients (3%) in group A and seven patients (6.3%) in group B had > or =80% in-stent stenosis (all were asymptomatic except one). The freedom from > or =80% in-stent stenosis at 1, 2, 3, and 4 years for groups A and B were 100%, 98%, 98%, and 78% vs 99%, 96%, 92%, and 87%, respectively (P = .7005). Freedom from TVR rates at 1, 2, 3, and 4 years for groups A and B were 100%, 100%, 100%, and 100% vs 99%, 97%, 97%, and 92%, respectively (P = .261). CONCLUSIONS: CAS for post-CEA stenosis carried a lower risk of early postprocedural neurologic events than primary CAS, with a trend toward a higher restenosis rate during follow-up.