Common Iliac Artery Aneurysm Repair with Hypogastric Preservation via Balloon-Expandable Covered Stents Using the Eyelet Technique-Iliac Branched Devices Still Inappropriate in Many Patients.

BACKGROUND: Common iliac artery aneurysms (CIAAs) are seen in 20-40% of patients with abdominal aortic aneurysms. Historically treated with sacrifice of the hypogastric artery, which can result in significant morbidity related to pelvic ischemia, new devices have made hypogastric artery preservation more feasible but are only applicable to a small subset of aneurysm anatomy. We sought to assess the safety and efficacy or a novel technique for hypogastric artery preservation applicable to a wider variety of patients with CIAAs. METHODS: We conducted a retrospective review of a prospectively maintained database of all patients with CIAAs treated with a novel endovascular technique at the UC San Diego Sulpizio Cardiovascular Center or the San Diego Veterans Affairs Hospital between March 2016 and December 2017. The endovascular technique involved stent placement in both the internal and external iliac arteries, with balloon expansion to minimize gutters between the endografts. Primary end points included technical success, limb patency, and presence of endoleaks (ELs). RESULTS: A total of 14 limbs (12 patients) were treated for CIAAs with 100% technical success and limb patency at an average of 6.8 months of follow-up. No patients experienced type I or type III ELs or evidence of pelvic ischemia. Two patients required reintervention, and one patient died of causes unrelated to the procedure. CONCLUSIONS: This technique was performed with excellent short- and mid-term safety in patients with varying aneurysm anatomy. The high rates of technical success and low rate pelvic ischemia represent improvement over conventional techniques that sacrifice the hypogastric artery and warrant further testing in a larger patient series with longer term follow-up.

Resurrection of Chronically Occluded Prosthetic Bypass Grafts in a Single Stage with Suction Thrombectomy and Intervention.

BACKGROUND: Peripheral arterial occlusive disease (PAOD) continues to be a vexing problem despite the advent of endovascular techniques augmenting traditional open repair. At our institution, we have found there is a growing number of patients with PAOD who are vein-challenged and have undergone prosthetic bypass previously for infrainguinal arterial reconstruction. When occluded, these grafts have been abandoned for a new bypass strategy or amputation. We present a novel technique of reestablishing flow through chronically occluded prosthetic bypass grafts. METHODS: A retrospective review of a prospectively maintained database compiled at 2 institutions between 2016 and 2019 was performed. Six patients had previous prosthetic bypass grafts with 4 patients having femoral to popliteal grafts, 1 patient with a femoral to femoral graft, and 1 with a femoral to posterior tibial bypass graft. All patients had an attempted single-stage intervention to clear chronically occluded grafts. RESULTS: A total of 6 patients were included in the study. Indications for intervention were chronic, critical limb ischemia with tissue loss (3), severe claudication (2), and acute on chronic limb ischemia (1). Average time from bypass to suction thrombectomy was 29 months (6-60 months). Mean patency duration is 13 months (1-28 months). Adjunctive procedures include overnight lysis to improve outflow in 1 patient (16.6%), drug-coated balloon angioplasty (83.3%), or stents (83.3%). There were no embolic complications during these procedures. All (2) wounds healed and all are maintained on full-dose anticoagulation and/or antiplatelet therapy. CONCLUSIONS: Often, the timing of bypass graft occlusion is unknown, and the risk of embolism with lysis for chronically occluded bypass grafts is concerning with traditional peripheral intervention techniques. We report a new and unique minimally invasive approach to resurrect chronically occluded prosthetic bypass grafts often successful in just one stage. This tool offers an alternative technique for limb salvage in complex patients and as use increases, requires further interrogation.

Follow-up after carotid endarterectomy and stenting: What to look for and why.

Duplex ultrasound testing after open or endovascular extracranial carotid artery interventions is a clinical practice guideline with a strong recommendation from the Society for Vascular Surgery. Neurologic outcomes are improved by the recognition of repair site stenosis or atherosclerotic disease progression in the unoperated carotid artery. The benefit of surveillance outweighs its risk because duplex testing is free of complications and accurate in the detection of internal carotid artery (ICA) stenosis or occlusion. Surveillance for >70% ICA stenosis is recommended within 30 days of the procedure, then every 6 months for 2 years, and annually thereafter. Repair site and contralateral ICA stenosis classification should be based on angle-corrected pulsed Doppler measurements of peak systolic velocity (PSV), end-diastolic velocity (EDV), and the ratio of PSV at the stenosis to a proximal, nondiseased common carotid artery (CCA) segment (ICA/CCA ratio). Interpretation criteria of PSV >300 cm/s, EDV >125 cm/s, and ICA/CCA ratio >4 predicts >70% repair site stenosis. Endovascular intervention is recommended for a carotid repair site stenosis based on the occurrence of an ipsilateral neurologic event and appropriate anatomy for angioplasty. For asymptomatic restenosis, intervention is based on stenosis progression to elevated PSV and EDV >70% stenosis threshold values and the patient is deemed high risk for stroke due to contralateral ICA occlusion or incomplete functional patency of the circle of Willis.

Aortic aneurysm screening using duplex ultrasound: Choosing wisely who to examine.

The noninvasive vascular laboratory plays a critical role in screening patients at risk for development of abdominal aortic aneurysm (AAA). One-time duplex ultrasound screening reduces aneurysm-related mortality due to rupture and is cost-effective. Population screening based on AAA risk factors is recommended, as it allows for proactive, elective repair of aneurysms at risk for rupture, and surveillance of smaller aneurysms for enlargement. Utilization of societal screening guidelines, such as those published by the Society for Vascular Surgery, can be employed by vascular laboratories to justify individual patient screening, aid primary care physicians to refer patients for testing, and encourage integrated medical health care systems to build prompts in patient electronic health records to ensure compliance with a AAA screening program. Risk factors for developing AAA, that is, age older than 65 years, male sex, family history, and a smoking history of >100 cigarettes, should be used to recommend patient screening, including for women and other elderly (older than 75 years) patients who fall outside of professional societal guidelines.

Novel Approach to Treatment of Chronic Iliocaval Occlusion Utilizing Covered Stents.

BACKGROUND: Chronic iliocaval obstruction is a challenging clinical entity to treat. Endovenous iliocaval stenting is becoming the treatment of choice for central vein stenosis and occlusion. However, outcomes in thrombotic disease have not been as robust as nonthrombotic disease. In this article, we describe our experience utilizing covered stents as a novel tool for chronic total occlusions of the iliocaval veins. METHODS: We performed a retrospective review of a prospectively maintained database of all patients undergoing endovenous stenting with a covered stent for chronic occlusive iliocaval disease over a 3-year period at our institution. Patients were followed clinically and with venous duplexes to assess the feasibility, safety, and outcomes of iliocaval endovenous stenting with covered stents. RESULTS: A total of 10 patients (8 men and 2 women) underwent iliocaval stenting with covered stents from July 2015 to May 2018. A total of 20 self-expanding covered stents (SECS) and 13 balloon expandable covered stents (BECS) were deployed in the central veins of the 10 patients. Six SECS and 5 BECS were deployed in the inferior vena cava, 10 SECS and 6 BECS were deployed in the common iliac veins (CIVs) (5 patients had bilateral CIV BECS and 2 patients had bilateral CIV SECS), and 4 SECS and 2 BECS were deployed in the external iliac veins (2 patients had bilateral SECS placed). Median follow-up time was 12.1 (range 0.5-35.0) months. There were no perioperative or postoperative complications. Nine (90%) patients maintained primary stent patency during our follow-up time. One patient (10%) had rethrombosis of his stent due to undertreated common femoral vein disease in the setting of a new myeloproliferative neoplasm and an inappropriate cessation of therapeutic anticoagulation. All patients who were symptomatic preoperatively had improvement in their pain, venous ulceration, and venous claudication. Eight of nine (89%) patients had improvement in their lower extremity edema. CONCLUSIONS: Covered endovenous stenting of chronically occluded central veins is a safe and promising procedure. Their use may improve the short- and long-term outcomes in this challenging patient population. Further studies are required to evaluate the long-term efficacy and cost of their use.

Vascular surgery resident education and hands-on training in vascular laboratory testing.

Diagnostic testing performed in the noninvasive vascular laboratory is a cornerstone of care for patients with suspected or known vascular disease. The Society for Vascular Surgery has mandated that vascular surgery resident training include mentored experience in performing vascular laboratory testing and interpreting its results. The trainee should be experienced with vascular laboratory instrumentation and testing protocols, be knowledgeable in ultrasound imaging of vascular anatomy, and be competent to classify disease severity relevant to the study indication. The scope of test interpretation should include peripheral arterial, peripheral venous, cerebrovascular, and visceral abdominal testing using duplex ultrasound supplemented by indirect physiologic testing for peripheral arterial and venous disease. The emergence of endovascular therapy has expanded duplex ultrasound applications in the areas of screening, procedural imaging, and surveillance following intervention. Pre-procedure testing to assess disease location and severity, and vein mapping for dialysis access or extremity bypass grafting provide important patient-specific information that can reduce the need for more invasive vascular imaging. It is recommended that trainees acquire the hand-on skills to perform duplex testing in vascular clinic and inpatient sites, such as the emergency department and operating room. Training programs should have a structured vascular laboratory curriculum that documents annual educational milestones that encompass both test interpretation aptitude and hands-on duplex scanning skills. Before completion of training, the resident should acquire documented experience in test interpretation sufficient to take the Physician Vascular Interpretation examination, which is required for American Board of Surgery certification as a vascular surgeon.

Impact of Gender on Outcomes Following Abdominal Aortic Aneurysm Repair.

OBJECTIVE: The purpose of this study is to use a large, nationally representative vascular database to assess differences in patient characteristics, aortic neck anatomy, and outcomes between men and women following open (open aneurysm repair [OAR]) and endovascular (endovascular aneurysm repair [EVAR]) abdominal aortic aneurysm (AAA) repair. METHODS: Patients undergoing AAA repair from 2003 to 2018 in Vascular Quality Initiative were identified and stratified by procedure (EVAR vs OAR). Thirty-day mortality and major in-hospital complications were assessed between genders within each operative cohort. An EVAR subset analysis was performed to assess differences in aortic neck anatomy; hostile neck anatomy was defined as length <15 mm (L < 15), angle >60° (A > 60), and/or diameter >28 mm (D > 28). Standard univariate and multivariable analyses were performed. RESULTS: A total of 50 213 patients were identified: 9263 (19%) OAR and 40 950 (82%) EVAR. In both cohorts, majority of patients were men (OAR 73% and EVAR 81%). Women were more likely to have a hostile neck (31.7% vs 24.1%, P < .001), L < 15 (19.8% vs 11.9%, P < .001), and A > 60 (11.5% vs 5.4%, P < .001). Men had larger aneurysm (mean, 57 vs 55 mm, P < .001) and were more likely to have D > 28 (14.0% vs 10.6%, P < .001). Women undergoing EVAR were more likely to undergo aortic extensions (21.9% vs 16.0%) and receive higher contrast volume. After adjusting for potential confounders, female gender was associated with 86% and 50% increased risk of 30-day mortality in OAR and EVAR, respectively. Women were more likely than men to experience renal, cardiac, and pulmonary complications only in the EVAR cohort. Women had a 2-fold increased odds of developing type 1 endoleak. CONCLUSION: Our study demonstrates unfavorable neck anatomy occurs more frequently in women compared to men. Women were also at an increased risk of developing major complications, particularly following EVAR. Careful patient selection is indicated in all patients to reduce complications, with special attention in women with hostile neck.

The diabetic foot: Pathophysiology, evaluation, and treatment.

The pathophysiology of the diabetic foot ulcer and soft-tissue infection is due to neuropathy, trauma, and, in many patients, concomitant peripheral artery occlusive disease. Diabetic neuropathy results in foot deformity, leading to increased skin pressure with walking. Once a foot ulcer develops, the limb is at high risk for invasive infection and, when combined with peripheral artery occlusive disease, the patient should be considered to have critical limb ischemia. A multidisciplinary approach to care for the diabetic foot is recommended, which includes annual (3-month intervals in high-risk patients) assessments by a primary care physician and referral to a podiatrist and vascular surgeon for diabetics with a foot ulcer for evaluation of foot arterial perfusion and off-loading therapy to reduce plantar skin pressure with walking. When invasive foot infection develops and tissue beneath the fascia is involved, inpatient care is recommended for systemic antibiotic therapy, vascular laboratory testing of artery limb perfusion, and surgical debridement of infected tissue. The goals of treatment are to achieve a healed foot and keep the patient ambulatory.

Dialysis Access Hemorrhage: Access Rescue from a Surgical Emergency.

BACKGROUND: Hemorrhage from a dialysis access can be a life-threatening condition. This study details our experience using access rescue strategies, including in situ graft replacement, primary repair, or conversion to an autogenous fistula, coupled with treatment of central vein occlusion to maintain access usage in patients presenting with conduit hemorrhage. METHODS: During a 3-year period (2012-2014), 26 patients (14 women, 12 men) on chronic hemodialysis were treated for access conduit bleeding (n = 18) or life-threatening hemorrhage (n = 8), located in the upper extremity (n = 23) or thigh (n = 3). All patients had developed bleeding from a skin eschar/ulcer over a bovine (n = 9) or polytetrafluoroethylene (n = 9) bridge graft, or aneurysmal autogenous fistula (n = 8). A retrospective review of outcome relative to clinical signs, etiology of conduit bleeding (infection, wall erosion), and the type of rescue procedure(s) was performed. Duplex ultrasound testing was used to guide therapy based on the presence of aneurysmal degeneration, perigraft fluid, or access flow pattern indicative of venous outflow obstruction. RESULTS: One-half of the patients were taken emergently to the operating room for hemorrhage control or impending rupture of an infected false aneurysm, the remaining repaired on an urgent basis. In 18 patients, emergency room personnel attempted control of access site bleeding by suturing (n = 14) or tourniquet (n = 4). Dialysis access salvage was achieved in 22 (85%) of 26 patients by in situ conduit replacement using a rifampin-soaked polytetrafluoroethylene conduit (n = 19) or primary repair (n = 3). Two patients with sepsis and ruptured, infected false aneurysm were treated by ligation, and 2 patients with nonsalvable access had conversion to an autogenous fistula. One-third of rescued accesses (n = 7) had staged endovascular treatment of central vein stenosis. One patient died within 30 days. All dialysis access revisions remained patent and used for immediate dialysis (n = 5), within 4-5 weeks (n = 19), or after vein maturation (n = 2). One replaced graft was revised for infection. Positive blood or bleeding site cultures were obtained from 9 (45%) of 20 patients tested. CONCLUSIONS: Salvage of a functional dialysis access is possible in the majority of patients presenting with conduit hemorrhage. Loss of wall integrity, infection, and venous hypertension were etiologic factors. Application of in situ graft replacement strategies known to be effective in the treatment of graft infection should be considered in the management of this surgical emergency.

Intervention after endovascular aneurysm repair: Endosalvage techniques including perigraft arterial sac embolization and endograft relining.

Endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysm (AAA). However, persistent AAA sac endoleak following EVAR can result in sac diameter increase requiring re-intervention in up to one-third of cases and even result in aneurysm rupture. In this case review, we summarize and detail endovascular re-interventions for each type of endoleak. We also detail specific options including stent-graft relining for indeterminate, Type III, and Type IV endoleaks and perigraft arterial sac embolization to induce thrombosis and resolve acute Type I, II, or III endoleaks. Endograft relining involves placement of a new stent-graft-elevating the bifurcation and extending the repair from renal artery to hypogastric arteries; perigraft arterial sac embolization involves placement of a catheter into the excluded sac from common femoral artery access, characterization of the inflow and outflow of the endoleak, and inducing cessation of the blood flow into the sac by the administration of thrombogenic material. Endoleaks range from low-pressure endoleaks, which can be safely monitored in a surveillance program to high-pressure endoleaks, which mandate intervention when associated with AAA sac diameter increase to protect from rupture. The evaluation of new devices and techniques to treat endoleak after EVAR remains an important issue in patient care after EVAR.

ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome.

Thoracic outlet syndrome is a clinical entity characterized by compression of the neurovascular bundle, and may be associated with additional findings such as venous thrombosis, arterial stenosis, or neurologic symptoms. The goal of imaging is to localize the site of compression, the compressing structure, and the compressed organ or vessel, while excluding common mimics. A literature review is provided of current indications for diagnostic imaging, with discussion of potential limitations and benefits of the respective modalities. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. In this document, we provided guidelines for use of various imaging modalities for assessment of thoracic outlet syndrome.

Congenital agenesis of inferior vena cava: a rare cause of unprovoked deep venous thrombosis.

Congenital anomalies of the inferior vena cava (IVC), although rare, are a risk factor for lower limb deep venous thrombosis (DVT). A 19-year-old male presented with a left flank and groin pain caused by iliofemoral venous thrombosis. Vascular imaging by computed tomography (CT) scanning and venography demonstrated agenesis of the IVC. Catheter-directed thrombolysis via a popliteal vein was attempted but did not alter the patency of the common femoral vein outflow collaterals into the retroperitoneal azygous venous system. The patient was anticoagulated using systemic heparin infusion and clinical symptoms resolved within 5 days. He was transitioned to oral Coumadin anticoagulation, and follow-up venous duplex testing demonstrated no infrainguinal DVT and phasic venous flow with respiration in the femoral vein indicating patent collateral veins. Anomalies of the IVC are present in 0.3-0.5% of otherwise healthy individuals. Agenesis of the IVC has an incidence of 0.0005-1% in the general population but is found in almost 5% of patients <30 years of age with unprovoked lower limb DVT. In adults, IVC agenesis anomaly can cause diagnostic problems in the paravertebral area because of the tumor-like appearance of the azygous venous collaterals on noncontrast CT imaging. In young adults presenting with unprovoked lower limb DVT, the presence of an IVC anomaly should be considered and evaluated for by venous duplex testing and if necessary CT venography.

Estimation of brachial artery volume flow by duplex ultrasound imaging predicts dialysis access maturation.

OBJECTIVE: This study validated duplex ultrasound measurement of brachial artery volume flow (VF) as predictor of dialysis access flow maturation and successful hemodialysis. METHODS: Duplex ultrasound was used to image upper extremity dialysis access anatomy and estimate access VF within 1 to 2 weeks of the procedure. Correlation of brachial artery VF with dialysis access conduit VF was performed using a standardized duplex testing protocol in 75 patients. The hemodynamic data were used to develop brachial artery flow velocity criteria (peak systolic velocity and end-diastolic velocity) predictive of three VF categories: low (<600 mL/min), acceptable (600-800 mL/min), or high (>800 mL/min). Brachial artery VF was then measured in 148 patients after a primary (n = 86) or revised (n = 62) upper extremity dialysis access procedure, and the VF category correlated with access maturation or need for revision before hemodialysis usage. Access maturation was conferred when brachial artery VF was >600 mL/min and conduit imaging indicated successful cannulation based on anatomic criteria of conduit diameter >5 mm and skin depth <6 mm. RESULTS: Measurements of VF from the brachial artery and access conduit demonstrated a high degree of correlation (R(2) = 0.805) for autogenous vein (n = 45; R(2) = 0.87) and bridge graft (n = 30; R(2) = 0.78) dialysis accesses. Access VF of >800 mL/min was predicted when the brachial artery lumen diameter was >4.5 mm, peak systolic velocity was >150 cm/s, and the diastolic-to-systolic velocity ratio was >0.4. Brachial artery velocity spectra indicating VF <800 mL/min was associated (P < .0001) with failure of access maturation. Revision was required in 15 of 21 (71%) accesses with a VF of <600 mL/min, 4 of 40 accesses (10%) with aVF of 600 to 800 mL/min, and 2 of 87 accesses (2.3%) with an initial VF of >800 mL/min. Duplex testing to estimate brachial artery VF and assess the conduit for ease of cannulation can be performed in 5 minutes during the initial postoperative vascular clinic evaluation. CONCLUSIONS: Estimation of brachial artery VF using the duplex ultrasound, termed the "Fast, 5-min Dialysis Duplex Scan," facilitates patient evaluation after new or revised upper extremity dialysis access procedures. Brachial artery VF correlates with access VF measurements and has the advantage of being easier to perform and applicable for forearm and also arm dialysis access. When brachial artery velocity spectra criteria confirm a VF >800 mL/min, flow maturation and successful hemodialysis are predicted if anatomic criteria for conduit cannulation are also present.

Vascular surgical site infection: risk factors and preventive measures.

Surgical site infection (SSI) after arterial intervention is a common nosocomial vascular complication and an important cause of postoperative morbidity. Its prevention requires the vascular surgeon and the health care team to be cognizant of its epidemiology and patient-specific risk factors to apply effective measures to reduce the incidence. The majority of vascular SSIs are caused by Gram-positive bacteria with methicillin-resistant Staphylococcus aureus (MRSA) now a prevalent pathogen that is involved in more than one-third of cases. Nasal carriage of methicillin-sensitive S. aureus or MRSA strains, recent hospitalization, a failed arterial reconstruction, and the presence of a groin incision are major risk factors for developing a vascular SSI. Overall, the SSI rate after arterial intervention is higher than predicted by the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance Risk Category System, and ranges from 1% to 2% after open or endovascular aortic interventions, to as high as 10% to 20% after lower-limb bypass grafting procedures. Application of perioperative measures to reduce S. aureus nasal and skin colonization in conjunction with appropriate, bactericidal antibiotic prophylaxis, meticulous wound closure, and postoperative care to optimize patient host defense regulation mechanisms (eg, temperature, oxygenation, and blood sugar) can minimize SSI occurrence.

Staged Hybrid Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm with Aortocaval Fistula.

There is a growing body of literature expanding the indication of endovascular aneurysm repair, from prophylactic treatment of aneurysms to other indications such as ruptured and complicated ruptured abdominal aneurysms. Concomitant aortocaval fistula is rare, and reports of open and endovascular repair exist. We report a unique hybrid approach to a case of a ruptured abdominal aortic aneurysm with aortocaval fistula, repaired primarily via endovascular approach in a hybrid, two-staged fashion. Representative images are presented in addition to a short review of this pathology.