Fenestrated endografts: are they the solution for visceral and aortic neck issues?

Many patients with short neck or no neck juxtarenal abdominal aortic aneurysms are not candidates for open surgical repair. Current treatment options for such patients include fenestrated endograft repair, placement of chimneys and snorkels (parallel grafts) or use of physician modified endografts. The purpose of this review is to examine the reported literature on the use of fenestrated aortic endografts for juxtarenal aortic aneurysms. A systematic review of the literature, to include clinical trials, case series, and meta-analyses was performed to report the outcomes of the use of fenestrated endovascular repair. The early and midterm results of fenestrated endografting is quite promising. As expected with real world use of the device, many patients do not meet the inclusion criteria of the initial pivotal clinical trials. As such, the results are not as good with respect to morbidity, re-intervention, and device related problems. However, despite such issues, in this difficult to treat population the initial and mid-term results as outlined below are quite acceptable. Fenestrated endografts will continue to gain acceptance and will become the treatment of choice for juxtarenal abdominal aortic aneurysms in the future.

Factors associated with saphenous vein recanalization after endothermal ablation.

BACKGROUND: Endovenous thermal ablation has emerged as an alternative therapy for the treatment of chronic superficial venous insufficiency (CVI) of the lower extremities. Recanalization, or anatomic failure, of a vein after endovenous radiofrequency ablation (RFA) has been described, albeit an infrequent occurrence. This study was performed to demonstrate risk factors associated with the efficacy of RFA and recanalization in the treatment of CVI. METHODS: Data were collected in an ongoing multicenter registry, which was retrospectively reviewed. This study reviewed 249 limbs that underwent RFA of either the great saphenous vein (GSV) or the small saphenous vein (SSV) over a three-year period, including only patients for whom an intermediate (6 month) follow-up venous duplex ultrasound was available. Patients in whom recanalization was demonstrated via duplex (n = 17, 6.8%) were analyzed for patient-level characteristics. Logistic regression analysis was performed to determine the existence of any significant clinical risk factors associated with anatomic failure. The need for secondary interventions because of clinical symptoms associated with recanalization was analyzed as well. RESULTS: In this cohort, the initial vein occlusion rate was 93.1%. Segmental (n = 9, 53%) or complete (n = 8, 47%) recanalization was seen in 17 limbs (6.8%) after initial successful GSV ablation. All SSV remained persistently ablated. Anatomic failure was associated with higher rate of clinical symptom recurrence (41% vs. 21%; relative risk (RR), 2.75; 95% confidence interval [CI], 0.99-7.6; P < 0.05) and an increased need for secondary vein procedures in the affected limbs (35% vs. 12%; RR, 3.96; 95% CI, 1.3-11.7; P < 0.05). Two recanalized GSVs required repeated endothermal ablation, in efforts to aid in the healing of ulcerations. Patient factors including diabetes, hypertension, hyperlipidemia, anticoagulation or antiplatelet agent usage, presence of deep venous reflux, or tobacco use did not increase the risk of RFA failure. Comparatively, patients with GSV recanalization had a longer mean follow-up time (63.3 vs. 41.6 weeks) but no difference in disease severity (C4, 35% vs. 17%; C5, 18% vs. 15%; C6, 6% vs. 8%; not significant). CONCLUSIONS: Endothermal ablation is an efficacious treatment for CVI with most patients remaining reflux free. Recanalization of an isolated vein segment after RFA, although shown in recent literature to be effected by anatomic risk factors, appears to be a sporadic phenomenon with respect to clinical risk factors. Nevertheless, in our cohort, anatomic failure was associated with a 2-fold increase in symptom recurrence and the need for interval secondary vein procedures. Ultrasound interrogation is recommended especially in patients with persistent or recurrent symptoms or nonhealing ulcerations.

Effect of increasing heart rate and tidal volume on stroke volume variability in vascular surgery patients.

OBJECTIVE: Because heart rate affects ventricular filling, the aim of the present study was to assess the effects of increasing heart rate and tidal volume on stroke volume variability to determine whether this dynamic index is heart-rate dependent. DESIGN: Prospective, randomized study. SETTING: Single university hospital. PARTICIPANTS: Eighteen vascular surgery patients having general anesthesia and endotracheal intubation with an arterial catheter connected to the Vigileo FloTrac system (Edwards Lifesciences, Irvine, CA) and a transesophageal atrial pacemaker (CardioComman Inc, Tampa, FL). INTERVENTION: A 2 × 2 factorial study of changes in heart rate (80 bpm and 110 bpm) and tidal volume (6 mL/kg and 10 mL/kg). MEASUREMENTS AND MAIN RESULTS: With tidal volume at 6 mL/kg, increasing heart rate from 80 mL/kg to 110 bpm caused stroke volume variability to increase from 12.2% ± 5.7% to 13.2% ± 5.3% (p<0.05), and with tidal volume at 10 mL/kg, increasing heart rate from 80 mL/kg to 110 bpm caused stroke volume variability to increase from 19.7% ± 7.9% to 22.0% ± 8.6% (p<0.05). In comparison, increasing tidal volume from 6 mL/kg to 10 mL/kg produced a significantly greater effect on stroke volume variability than increasing heart rate. CONCLUSIONS: Stroke volume variability is sensitive to increases in heart rate in addition to tidal volume. Increasing heart rate caused stroke volume variability to increase significantly, although not to the same magnitude as increasing tidal volume. When using dynamic volume indices, clinicians should be aware of increases in heart rate, although its clinical impact may be relatively minor compared with changes in tidal volume.

Portal vein aneurysm: a rare occurrence.

Portal vein aneurysms (PVA) are a rare vascular anomaly of the portal system, representing fewer than 3% of all venous aneurysms, with only 150 known cases since first reported in l956 by Barzilai and Kleckner. PVA can be divided into 2 categories: extrahepatic and intrahepatic with acquired and congenital etiologies. Bimodal treatment includes medical and surgical approaches. With increased use of noninvasive radiological imaging, PVA will be increasingly recognized in the practice of vascular surgery.

Validation of Venous Clinical Severity Score (VCSS) with other venous severity assessment tools from the American Venous Forum, National Venous Screening Program.

BACKGROUND: Several standard venous assessment tools have been used as independent determinants of venous disease severity, but correlation between these instruments as a global venous screening tool has not been tested. The scope of this study is to assess the validity of Venous Clinical Severity Scoring (VCSS) and its integration with other venous assessment tools as a global venous screening instrument. METHODS: The American Venous Forum (AVF), National Venous Screening Program (NVSP) data registry from 2007 to 2009 was queried for participants with complete datasets, including CEAP clinical staging, VCSS, modified Chronic Venous Insufficiency Quality of Life (CIVIQ) assessment, and venous ultrasound results. Statistical correlation trends were analyzed using Spearman's rank coefficient as related to VCSS. RESULTS: Five thousand eight hundred fourteen limbs in 2,907 participants were screened and included CEAP clinical stage C0: 26%; C1: 33%; C2: 24%; C3: 9%; C4: 7%; C5: 0.5%; C6: 0.2% (mean, 1.41 ± 1.22). VCSS mean score distribution (range, 0-3) for the entire cohort included: pain 1.01 ± 0.80, varicose veins 0.61 ± 0.84, edema 0.61 ± 0.81, pigmentation 0.15 ± 0.47, inflammation 0.07 ± 0.33, induration 0.04 ± 0.27, ulcer number 0.004 ± 0.081, ulcer size 0.007 ± 0.112, ulcer duration 0.007 ± 0.134, and compression 0.30 ± 0.81. Overall correlation between CEAP and VCSS was moderately strong (r(s) = 0.49; P < .0001), with highest correlation for attributes reflecting more advanced disease, including varicose vein (r(s) = 0.51; P < .0001), pigmentation (r(s) = 0.39; P < .0001), inflammation (r(s) = 0.28; P < .0001), induration (r(s) = 0.22; P < .0001), and edema (r(s) = 0.21; P < .0001). Based on the modified CIVIQ assessment, overall mean score for each general category included: Quality of Life (QoL)-Pain 6.04 ± 3.12 (range, 3-15), QoL-Functional 9.90 ± 5.32 (range, 5-25), and QoL-Social 5.41 ± 3.09 (range, 3-15). Overall correlation between CIVIQ and VCSS was moderately strong (r(s) = 0.43; P < .0001), with the highest correlation noted for pain (r(s) = 0.55; P < .0001) and edema (r(s) = 0.30; P < .0001). Based on screening venous ultrasound results, 38.1% of limbs had reflux and 1.5% obstruction in the femoral, saphenous, or popliteal vein segments. Correlation between overall venous ultrasound findings (reflux + obstruction) and VCSS was slightly positive (r(s) = 0.23; P < .0001) but was highest for varicose vein (r(s) = 0.32; P < .0001) and showed no correlation to swelling (r(s) = 0.06; P < .0001) and pain (r(s) = 0.003; P = .7947). CONCLUSIONS: While there is correlation between VCSS, CEAP, modified CIVIQ, and venous ultrasound findings, subgroup analysis indicates that this correlation is driven by different components of VCSS compared with the other venous assessment tools. This observation may reflect that VCSS has more global application in determining overall severity of venous disease, while at the same time highlighting the strengths of the other venous assessment tools.

Economic and outcomes-based analysis of the care of symptomatic varicose veins.

OBJECTIVE: Endoluminal treatment of symptomatic varicose veins (VV) reduces or eliminates inpatient hospital stays, lowers complication rates, and increases revenue for vein care centers adopting the technique. This study compares the outcomes and economics of two treatments for VV. METHODS: Since May 2007, endovenous radiofrequency ablation (RFA) of symptomatic VV has been performed at our institution. For outcome measurements, a cohort of 100 RFA procedures (26% CEAP class C5 and C6) was compared with 100 open greater or lesser saphenous stripping and ligation procedures (SL, 18% C5 and C6). Procedures were performed between August 2002 and October 2007. The time frame was chosen to allow for a 6-mo follow-up. Patients who had adjunctive removal of secondary varicosities were included in both cohorts. Cost estimates are based on the actual total direct costs derived from the hospital's charge sheets for 20 of the 100 patients in each of the cohorts (n = 40). The actual direct costs are based on 2009-dollar values and do not include the surgeons' professional fees. RESULTS: Seventy-nine percent of the RFA therapies were performed in an outpatient clinic treatment room with the remaining 21% performed in an operating room (OR). For the SL group, all procedures were performed in the OR with 68% of patients requiring at least one night of hospital stay (average length of stay 1.2 d). The estimated direct cost of performing RFA in the treatment room was $906. This was considerably less than the estimated $4241 total direct cost for open SL followed by in-hospital observation. Outpatient open SL cost $2622, which is only slightly more than the $2533 cost for outpatient RFA performed in the OR. The use of RFA was associated with an earlier return to normal leisure activities (3.3 d versus 26 d, P < 0.05), fewer total hospital nights (3 d versus 82 d, P < 0.05), and less use of general anesthesia (16% versus 95%, P < 0.05). There were no major complications in the RFA group compared with three major complications in the SL group. CONCLUSIONS: With the introduction of endovenous techniques at our institution, there has been a significant increase in the volume of patients seeking this less invasive treatment modality. This is due largely to the ease and comfort with which patients can now be treated as well as the reduced length of stay, reduction of general anesthetic use, and the speed at which they can return to normal activities. We recommend endovenous ablation techniques as both cost-saving and patient-preferred.

Percutaneous mechanical thrombectomy and pharmacologic thrombolysis for renal artery embolism: case report and review of endovascular treatment.

Renal artery embolism (RAE) is an uncommon event that is associated with a high rate of renal loss. We present a case of RAE to a solitary kidney that was treated with combined percutaneous rheolytic thrombectomy, intra-arterial thrombolysis, and supplemental renal artery stent placement.

Endovenous ablation for the treatment of chronic venous insufficiency and venous ulcerations.

OBJECTIVE: Conventional treatment of chronic venous disease with ulceration is layered compression dressings. Saphenous vein stripping is reserved for recurrent or nonhealing ulcers. This study examines outcomes of aggressive endovenous therapy in promoting ulcer healing and/or preventing ulcer recurrence. The role of additional perforator vein ablation also is analyzed. METHODS: This retrospective chart review occurred during a 2.5-year time frame during which 356 patients with venous insufficiency were seen in our vein center and underwent 412 venous operations (56 with bilateral disease treated on separate dates). A cohort of 75 (21.1%) patients with severe chronic venous disease underwent 83 (20.1%) procedures (C5: n = 52, 63%; C6: n = 31, 37%); 8 patients had bilateral procedures. Data analysis included body-mass index (BMI), history of deep vein thrombosis (DVT) or previous vein surgery, and type of procedure (radiofrequency ablation (RFA) of greater saphenous vein (GSV) alone or GSV and perforator ablation (GSVP)). Complications, ulcer healing rates, and recurrent ulcerations were examined. Descriptive statistics are reported and contingency tables used when appropriate. RESULTS: Overall, the patients were 63.5 +/- 13.4 years of age (men: n = 36, women: n = 39) with a BMI of 32.4 (range, 20.8-53.4). All of the patients had GSV insufficiency and 30 (44%) patients had deep vein incompetence. Only 19 (28%) patients had a history of a DVT and 13 (19%) had previous vein procedures. The 31 extremities with C6 disease had been treated conservatively with compression for an average of 7.6 +/- 4.2 (range, 1-156) months before undergoing ablation. Ablation site was GSV in 49 (72%) and GSVP in 19 (28%). Only two (2.9%) complications occurred: excessive hemosiderin staining and paresthesias each occurred in one patient. Of the C5 patients treated, two (4.7%) developed recurrent ulcerations and five (20%) C6 patients did not heal completely or developed a recurrent ulcer. There was no statistically significant difference in ulcer healing or recurrence rates between C5 and C6 patients treated with and without the addition of perforator interruption. CONCLUSIONS: Chronic venous insufficiency with active or healed ulceration is commonly seen in our academic vein center. In this series, endovenous ablation allowed for excellent healing rates and acceptable recurrent ulcer rates. It is unclear from this small cohort whether the addition of perforator ablation was of benefit in improving venous hemodynamics.

Stent-graft repair for blunt traumatic aortic injury as the new standard of care: is there evidence?

Designed to treat degenerative aneurysms of the thoracic and abdominal aorta, endovascular stent-grafts have been increasingly employed as an off-label emergency treatment for blunt traumatic aortic injury (BTAI). In this review we explore the controversies associated with thoracic endovascular aortic repair (TEVAR) for BTAI. Early versus delayed treatment of aortic injuries is controversial, and stent-graft repair has further confused the issue of timing the repair. The diagnosis and management of minimal aortic injuries remains elusive. We analyze the available literature pertaining to BTAI, including the recent multicenter prospective trial from the American Association for the Surgery of Trauma. The strengths and weaknesses of the stent-grafts currently available for use in the US are examined to provide insight into which graft may be best suited for BTAI at the present time. Also of importance, we offer recommendations regarding clinical situations in which TEVAR should not be the first line therapy for BTAI. We conclude with a discussion of upcoming trials and new devices that will shape the future of endovascular treatment of BTAI.

Technical tips for carotid angioplasty and stenting.

Angioplasty and stenting of the carotid artery has become an accepted procedure in properly selected patients with carotid artery stenosis. The potential for devastating neurologic complications and significant hemodynamic changes separates endovascular treatment of the carotid artery from other percutaneous peripheral vascular procedures. In this article, the technique for carotid artery angioplasty and stenting is described and the strategies for management of the hemodynamic changes occuring with carotid stenting are reviewed.

How I do it: cervical access for carotid artery stenting.

Atypical aortic arch anatomy, vessel tortuosity, and extensive atherosclerotic disease in the aortic arch and great vessels represent significant risks for embolization during angioplasty and stenting of carotid occlusive lesions. The technique of cervical access to the proximal common carotid artery is demonstrated as a safer means for dealing with these problems. Combining endovascular and open surgical techniques can simplify and help ensure the safety of carotid stent procedures.

Safety and efficacy of carotid arteriography in vascular surgery practice.

OBJECTIVE: Carotid arteriography (CA) is an important method of assessing carotid artery occlusive disease and is the best method of planning for carotid angioplasty and stent placement (CAS). This study compared the results of CA performed by vascular surgeons in a contemporary series against widely recognized interdisciplinary quality standards for this procedure. Although many vascular surgeons perform CA, there is a paucity of data about its safety, efficacy, and compliance with quality standards in vascular practice. The importance of quality CA will likely increase as CAS emerges to assume a broader clinical role. METHOD: Carotid arteriograms performed by seven vascular surgeons at three institutions from September 2000 to May 2004 were reviewed. These results were compared with quality standards for the performance of CA. RESULTS: Five hundred three carotid arteriograms were performed over 45 months. Indications for the procedure were extracranial cerebrovascular disease (86%), trauma (5%), and other conditions (9%). Indications for the procedure were appropriate in 100% of patients (as determined by guidelines document) and exceeded the recommended standard of appropriate indications in 99%. All procedures successfully provided the information required, exceeding the threshold of 98% for procedural success. Reversible neurologic deficits occurred in 0.6% (two transient ischemic attacks and one stroke) compared with the threshold of 2.5%. A permanent neurologic deficit occurred in 0.2% (1 patient) compared with the published guideline of 1% after carotid arteriography. Major non-neurologic complications occurred in 1.2% (6 patients), less than the standard of 2.0%. CONCLUSIONS: The safety and efficacy of a contemporary series of CA performed in vascular surgery practice compared favorably with recognized interdisciplinary quality standards for this procedure. Ensuring safe and effective CA is likely to support the successful growth of CAS as a treatment option.

Endoluminal retrieval of a dislodged umbilical vein catheter--a case report.

Endoluminal retrieval of foreign bodies in the pediatric and infant population is an uncommon and challenging procedure for the endovascular specialist. The alternative is an open exploration of these often-fragile patients. The availability of smaller catheter systems allows retrieval with minimally invasive techniques. We report retrieval of a catheter fragment using an Amplatz loop snare through the umbilical vein and review the literature.

Characterization and probability of upper extremity deep venous thrombosis.

The objective of this study was to characterize patient demographics, risk factors, and anatomic distribution of upper extremity deep venous thrombosis (UEDVT) to develop a probability model for diagnosis. A retrospective review of all patients who underwent color-flow duplex scanning (CDS) for clinically suspected acute UEDVT over a 5-year period was performed. Patient risk factors and clinical symptoms were evaluated as predictors. Technically adequate complete CDS of 177 upper extremities (UEs) of arms were reviewed. CDS scanning identified acute UE venous thrombosis in 53 (30%) of the arms examined with deep system involvement in 40 (23%). Of the UEs affected, the subclavian was involved in 64%, the axillary in 25%, the internal jugular in 32%, the brachial in 36%, the cephalic in 32%, and the basilic in 47%. Multivariate analysis identified limb tenderness (odds ratio 9.3), history of central venous catheterization (odds ratio 7.0), and malignancy (odds ratio 2.9) as positive predictors for UEDVT. Erythema (odds ratio 0.12) and suspected pulmonary embolism (odds ration 0.06) were identified as negative predictors. A predictive model was designed from these variables. The anatomic distribution of UEDVT obtained from this study is consistent with previous reviews. Potential positive and negative risk factors can be identified from which a predictive model can be designed. Use of this model can help focus clinical suspicion, improve color-flow duplex utilization, and provide timely treatment with anticoagulation.

Technical note on renal angioplasty and stenting: new developments that facilitate its performance.

Technologic advances in percutaneous catheter-based therapy for renovascular occlusive disease have resulted in progressively miniaturized wires, balloon catheters, stents, and delivery systems. The technique of angioplasty and stenting of renal artery stenoses has been shown to be a safe and effective option for severe hypertension and ischemic nephropathy. Renal artery stenting, especially when performed with the newer lower-profile systems, can be performed with minimal morbidity and a reliably high degree of initial technical success. In this article, we describe our technique using a lower-profile platform of balloons and stents and review data supporting renal artery stenting.

Value, limitations, and techniques of renal artery stenting.

Percutaneous therapy for renovascular occlusive disease has become the preferred alternative to open renal artery revascularization. Angioplasty and stenting of renal artery stenoses has been shown to be a safe and effective option for severe hypertension and ischemic nephropathy. Catheter-based treatment, especially when performed with lower-profile systems can be performed with minimal morbidity and a reliably high degree of initial technical success. The long-term beneficial effects on blood pressure control and renal function, while debated, appear to be valid. In this article, data supporting the value and limitations of renal artery stenting are reviewed, and our technique for renal artery stenting using a lower-profile platform of balloons and stents is described.

Treatment of portal venous thrombosis with selective superior mesenteric artery infusion of recombinant tissue plasminogen activator.

Portal and mesenteric venous thrombosis is an uncommon condition that is usually treated with systemic anticoagulation. Catheter-directed thrombolysis via the superior mesenteric artery may be a viable adjunct to treatment of this potentially morbid condition. We present a case of portal and mesenteric venous thrombosis treated with systemic anticoagulation and catheter-directed infusion of tissue plasminogen activator via the superior mesenteric artery.

Abdominal aortic aneurysm demonstrated on renal scintigraphy.

A 74-year-old hypertensive woman presented with abdominal discomfort and a pulsatile abdominal mass. Anterior abdominal angiography during cardiac blood pool, and renal scintigraphic imaging demonstrated a large abdominal aortic aneurysm. 1, 2 Before endovascular repair with an aortoiliac endograft, the abdominal aneurysm measured 7.5 x 7.0 cm on abdominal computed tomography. This study demonstrates that a suspected abdominal aortic aneurysm can be confirmed using the addition of anterior abdominal imaging with normal posterior imaging at the time of renal scintigraphy.

Fluoroscopy-assisted dual-catheter thromboembolectomy: a new technique useful in patients with embolization to arteries of disproportionate diameters.

Distal embolization is a complication of aortoiliac aneurysm repair. Fluoroscopy-assisted catheter thromboembolectomy is useful in removing popliteal and tibial emboli from the femoral approach. Concomitant presence of aortoiliac and popliteal aneurysms, a known association, may present a difficult challenge to embolus extraction. Currently available embolectomy catheters large enough for thrombus extraction from a popliteal aneurysm are too large for safe tibial artery cannulation, and tibial balloon catheters cannot be enlarged sufficiently to transfer the thrombus through the aneurysmal popliteal segment. We treated a patient who embolized to his popliteal aneurysm and distal tibial circulation following aortoiliac aneurysm repair. A fluoroscopy-assisted dual-catheter technique was used to extract the thrombus through the femoral approach, eliminating the need for direct popliteal or tibial exploration. This technique uses two balloon catheters of graduated size, maneuvered concurrently under fluoroscopic guidance into the tibial and popliteal circulation. The smaller tibial catheter is inflated, and thrombus is withdrawn into the popliteal segment. The larger popliteal balloon catheter is then inflated distal to the smaller catheter, and both catheters are withdrawn simultaneously to deliver the clot through the femoral arteriotomy. This technique can be useful for successful balloon catheter extraction of thrombus via remote access, in an arterial system with variable diameter, eliminating the need for direct popliteal or tibial exploration.