Single Center Outcomes of Percutaneous Deep Vein Arterialization in Patients with End-Stage Peripheral Artery Disease.

Background: Peripheral artery disease (PAD) can present as chronic limb threatening ischemia (CLTI) with ischemic pain and tissue loss. Progression of distal disease can lead to a "no option" or end-stage disease without traditional open or endovascular revascularization due to lack of pedal targets. Innovations in endovascular technology allow for the use of percutaneous deep vein arterialization (pDVA) to treat patients with CLTI. Purpose: We describe our experience and technique for treating four patients with end-stage PAD with pDVA. Research Design: Four patients with end-stage PAD were followed during and after pDVA creation. Technical success, complications, wound healing, and freedom from major amputation were analyzed. Data Collection and Analysis: Patient data and outcomes were collected via chart review and at time of follow up appointments in vascular surgery clinic. Results: Technical success was 100%, without post-procedural complications, and patients were continued on antiplatelet and anticoagulation. Three patients (75%) had successful wound healing, with 2 patients healing after transmetatarsal amputation (TMA), and 1 healing a distal foot ulceration that did not require surgery. One patient had worsening ischemic breakdown of a TMA, despite re-intervention on the pDVA, which required a below knee amputation (BKA). Freedom from major amputation was 75% overall, with an average follow-up time of 410 days post-procedure (Range: 113-563 days). Conclusions: Percutaneous deep vein arterialization attempts to provide blood flow to the preserved venous bed in patients with end-stage PAD. Exploration and utilization of this technique continues to expand in the modern vascular era. This case series highlights 4 patients with end-stage PVD who underwent pDVA, with 100% procedural success, and 75% limb salvage rate.

Understanding and addressing varying perceptions of autonomy.

Recently, there has been a major shift in the concept of resident autonomy in the operating room. As a result, surgical residents' independence has decreased during their training years. This change has been secondary to multiple factors, including fragmented attending resident interactions, hospital demands for productivity, operating room efficiency, and the public's perception of resident participation in surgery. Multiple gender, personality, and racial biases have also influenced the autonomy of surgical residents. In this paper, we have analyzed the impact of all these factors on the current state of resident autonomy after reviewing relevant literature. We have proposed a strategy to increase resident autonomy via increased resident and faculty interactions, case planning, and encouraged recruitment of diverse vascular surgery trainees and faculty.

Treatment of a descending thoracic mycotic aneurysm secondary to disseminated aspergillosis infection with thoracic endovascular aortic repair.

Mycotic aortic aneurysms are a rare and potentially fatal aortic pathology. Advancements in vascular technology have allowed endovascular repair to be a durable and less invasive option for the treatment of mycotic aortic aneurysms. We have presented the case of a 51-year-old man with a mycotic aneurysm of the descending thoracic aorta secondary to chronic, disseminated aspergillosis infection after liver transplantation. The aneurysm was successfully treated with thoracic aortic stent graft deployment. No perioperative complications occurred, and follow-up computed tomography angiography showed no signs of an endoleak. The patient will continue with lifelong antifungal therapy and close follow-up with vascular surgery.

The Feasibility and Applicability of Percutaneous Deep Vein Arterialization in Peripheral Artery Disease.

Peripheral artery disease (PAD) can often present with chronic limb threatening ischemia (CLTI), including ischemic rest pain and severe tissue loss. Progression of PAD can lead to "no option" or end-stage disease in which there are no traditional open or endovascular interventions available for revascularization. This cohort of patients have a poor prognosis, with a major amputation rate of 40% and mortality of up to 20% at six months. For this patient population, surgical deep vein arterialization (DVA) is offered as an attempt to provide blood flow to the distal preserved venous bed and reverse the ischemic process. Surgical DVA has traditionally been offered as an option and was pioneered by Herb Dardik. The evolution of endovascular technology has allowed for percutaneous DVA (pDVA). Using ultrasound and fluoroscopic guidance, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts to increase distal limb perfusion with the goals of improving wound healing and amputation-free survival. Lysis of venous valves with a valvulotome also aids with reversal of flow into the distal venous system. Investigations of percutaneous deep vein arterialization are underway with one device, the LimFlow System (LimFlow SA, Paris, France), which is undergoing feasibility trials. Here we present the current clinical indications, feasibility, results, and our institutional experience with the use of percutaneous deep vein arterialization.

Spontaneous compartment syndrome and endovascular repair of tibioperoneal trunk pseudoaneurysm in Ehlers-Danlos syndrome.

Vascular Ehlers-Danlos syndrome is caused by mutations in the COL3A1 (collagen type III alpha-1) gene, resulting in loss of integrity of arteries and hollow organs. Patients are predisposed to dissection, aneurysm, and organ rupture. The median life expectancy is ∼51 years. We have described a unique presentation of spontaneous compartment syndrome, likely secondary to ischemia reperfusion injury, in a 32-year-old man with vascular Ehlers-Danlos syndrome. The compartment syndrome was treated with four-compartment fasciotomy, and subsequent evaluation demonstrated a pseudoaneurysm of the tibioperoneal trunk. Endovascular intervention and stent graft deployment guided by intravascular ultrasound successfully excluded the pseudoaneurysm with three vessel run off preserved.

Thoracic Aortic Endografts: Past, Present, and Future.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) has become first-line therapy for a wide range of thoracic aortic pathologies including traumatic thoracic aortic injury, type B aortic dissection, intramural thoracic aortic hematoma, and penetrating aortic ulcers. This study aims to analyze the progress made of thoracic stent graft devices, review the current Food and Drug Administration (FDA)-approved devices, and discuss the future technological advances. MATERIALS AND METHODS: In this paper, we will review the history of TEVAR and the development of the first iteration of devices. We will discuss the four currently available TEVAR devices, the GORE® TAG® (W. L. Gore and Associates, Flagstaff, Arizona), Medtronic Navion™ (Medtronic plc, Santa Rosa, California), Bolton RELAY® (Terumo Aortic, Sunrise, Florida), and the Zenith® Alpha™ Thoracic and the Zenith® Dissection Stent Graft (Cook Medical, Bloomington, Indiana), and the features and applications of each. Finally, future advancements in TEVAR technology and grafts currently under trial will be reviewed. RESULTS: The first generation of TEVAR grafts had several limitations including large delivery systems, the need for rapid pacing for accurate deployment, wind socking during deployment, and graft migration. The current available TEVAR grafts have novel features to address these prior pitfalls. The GORE® TAG® is initially deployed 50% with subsequent room for adjustment to increase accuracy; the Medtronic Navion™ and Bolton RELAY® are available in low-profile delivery systems; and the Cook Zenith® Alpha™ now has an open cell petticoat specific for use in dissections extending to the visceral abdominal aorta. The current generation of TEVAR devices have broadened the application of TEVAR and reduced the anatomic limitations previously encountered. CONCLUSION: TEVAR has evolved to overcome technical challenges and offer expanded applicability to different types of thoracic aortic pathologies and enhanced accuracy of deployment.

The Current Role of the Percutaneous Arteriovenous Fistula for Hemodialysis Access.

Dialysis is the preferred treatment for patients with end-stage renal disease (ESRD) for the removal of accumulated toxins secondary to compromised renal function. Hemodialysis has traditionally been performed via a surgically created arteriovenous fistula (AVF) or arteriovenous graft (AVG). Novel endovascular techniques have allowed for the creation of percutaneous arteriovenous fistulas for hemodialysis access. Two devices, the Ellipsys® Vascular Access System (Avenu Medical, Inc., San Juan Capistrano, California) and the WavelinQ EndoAVF System (C.R. Bard, Inc., Murray Hill, New Jersey), are currently available for percutaneous AVF creation and investigation of their utility is ongoing. This paper describes the current utilization, differences, and results thus far with these devices and, additionally, investigates the contemporary advantages, disadvantages, and selection criteria for percutaneous AVFs overall.

Preparation of N-(2-alkoxyvinyl)sulfonamides from N-tosyl-1,2,3-triazoles and Subsequent Conversion to Substituted Phthalans and Phenethylamines.

Decomposition of N-tosyl-1,2,3-triazoles with rhodium(II) acetate dimer in the presence of alcohols forms synthetically versatile N-(2-alkoxyvinyl)sulfonamides, which react under a variety of conditions to afford useful N- and O-containing compounds. Acid-catalyzed addition of alcohols or thiols to N-(2-alkoxyvinyl)sulfonamide-containing phthalans provides access to ketals and thioketals, respectively. Selective reduction of the vinyl group in N-(2-alkoxyvinyl)sulfonamide-containing phthalans via hydrogenation yields the corresponding phthalan in good yield, whereas reduction with sodium bis(2-methoxyethoxy)aluminumhydride generates a ring-opened phenethylamine analogue. Because the N-(2-alkoxyvinyl)sulfonamide functional group is synthetically versatile, but often hydrolytically unstable, this protocol emphasizes key techniques in preparing, handling, and reacting these pivotal substrates in several useful transformations.