Ex vivo repair of renal artery aneurysms.

OBJECTIVE: Renal artery aneurysms (RAAs) are rare but remain challenging lesions when treatment is required. Endovascular techniques may be useful in selected, more proximal lesions with amenable morphology, but open surgical repair is often required for more distal, anatomically complex hilar RAAs that often have several branches and unfavorable anatomy. This study reviewed a single-center experience with ex vivo repair of 14 of these more complex, distal RAAs. METHODS: The records of 14 consecutive patients having ex vivo RAA repair between 1997 and 2013 were retrospectively reviewed. Demographic data, operative details, and blood pressure and renal function status were recorded. Graft patency was observed with renal duplex sonography. RESULTS: Fourteen hilar RAAs were repaired in 10 women and 4 men with a mean age of 54 years. Hypertension was present in 12 (86%). Preoperative renal dysfunction was present in two (14%). Aneurysm size averaged 2.9 cm. Six RAAs (43%) were symptomatic with flank or abdominal pain. Ex vivo repair was performed in all cases with use of saphenous vein for renal-renal bypass. No patient had pelvic autotransplantation or concomitant aortic reconstruction. Ex vivo RAA repair was technically successful in 12 cases; two patients required nephrectomy. Two patients with pre-existing renal insufficiency had improvement postoperatively, but hypertension was clinically unchanged in all patients. No patient required postoperative dialysis. Duplex sonography documented continued graft patency in the 12 technically successful cases during a mean follow-up of 19 months. CONCLUSIONS: Open ex vivo surgical repair with renal-renal bypass is a successful and durable treatment for complex distal RAAs that require repair. These procedures had low morbidity and mortality and an acceptable rate of renal function preservation. Blood pressure control in these patients did not change significantly after RAA repair.

Traumatic arteriovenous fistula 52 years after injury.

Untreated traumatic arteriovenous fistulae (AVF) have been associated with aneurysmal dilatation of the involved artery and vein, congestive heart failure, and limb ischemia. Open surgical repair of these lesions can be challenging due to the elevated venous pressure and surrounding inflammation. This case report describes a hybrid open and endovascular approach to treatment of a traumatic AVF in the right groin, presenting with aneurysmal ileo-femoral arteries and veins and pulmonary hypertension. It provides a rare look at the natural history of a traumatic AVF over 50 years following the initial injury.

Endograft repair of traumatic aortic injury-a technique in evolution: a single institution's experience.

OBJECTIVE: We evaluated a large single center experience of endograft repair of blunt traumatic injury of the thoracic aorta. SUMMARY BACKGROUND DATA: Traumatic aortic transection is a devastating injury with high morbidity and mortality. Endograft repair of these injuries has reduced the rates of death and paraplegia seen with open surgical treatment in the past. However, endograft repair has been associated with a higher incidence of device related failure. METHODS: The records of 43 consecutive cases of endograft treatment of traumatic aortic injury from December 2004 to November 2008 were reviewed. Patient demographics, procedure details, and outcomes were recorded. Aortic morphology was analyzed for predictors of device failure. RESULTS: Forty-three patients (32 men) with a mean age of 44 years (range: 17-88) were treated. Primary technical success was 86%. Six proximal endoleaks (14.3%) occurred. Two were repaired with a more proximal cuff, but 3 required explantation and open repair (7%). Mortality in this series was 11.6%, but no death was aorta related. No patient having endograft treatment suffered postoperative paraplegia. Early device failure is associated with sharp angulation of the aorta and shortened distance between the left subclavian artery and the site of injury. Follow-up ranged from 1 to 38 months (mean: 7.4 months). There were no late device failures or complications. CONCLUSIONS: Endovascular repair of blunt traumatic aortic injury can be performed with a low morbidity and mortality. Anatomic patterns in the aortic arch appear to be predictive of early device failure. Midterm durability is excellent, but reliable follow-up remains challenging in this group of patients.

Endovascular embolization of a giant renal artery aneurysm with preservation of renal parenchyma.

Renal artery aneurysm is a rare condition that has an unclear etiology. Although some patients present with symptoms of hypertension, pain, hematuria, or rupture, the majority are asymptomatic. Traditional surgical repair of renal artery aneurysms is often complex and may require ex vivo repair and reimplantation of the kidney if branch vessels are involved. Very large aneurysms made require nephrectomy. More recently, reports have described endovascular approaches to renal artery aneurysms, including coil embolization and stent graft coverage. This report describes successful endovascular treatment of a 10-cm renal artery aneurysm with preservation of renal mass.

Intraoperative coil embolization reduces transplant nephrectomy transfusion requirement.

Transplant nephrectomy for failed renal transplants can be challenging. Patients often have numerous comorbidities, and the procedure may be associated with considerable blood loss. This study was performed to determine if intraoperative coil embolization of the transplant renal artery reduces blood loss associated with transplant nephrectomy. Data were collected retrospectively on 13 consecutive transplant nephrectomies performed immediately following coil embolization and compared with the 13 most recently performed consecutive transplant nephrectomies without coil embolization. The groups were compared for operative time, estimated blood loss, and transfusion requirements. Mean age was 45 in both groups. There were no major complications in either group. Operative times were not significantly different, although open operative time was reduced in the embolization group (113 vs 96 minutes). Estimated blood loss was 465 mL versus 198 mL (P = .035); packed red blood cell requirements during the operation and subsequent 48 hours were 1.85 units versus 0.31 units (P = .008) and during the operation and subsequent hospital stay were 2.3 units versus 0.69 units (P = .027) in the nonembolized group and embolized group, respectively. Intraoperative embolization of the transplant renal artery immediately prior to surgery facilitates transplant nephrectomy by significantly reducing intraoperative blood loss and transfusion requirements while slightly reducing open operative time.

The bedside insertion of inferior vena cava filters using ultrasound guidance.

Since the introduction of inferior vena cava (IVC) filters more than 30 years ago, there has been a steady improvement in the design, ease, and safety of the delivery systems. Today, all of the commonly used filters can be placed via a peripheral vein by using standard percutaneous Seldinger technique. However, this typically requires fluoroscopy, intravenous contrast agents, radiation exposure, and transport of the patient to the interventional or operating suite. In the multiply injured trauma or critically-ill intensive care unit patient, often requiring inotropic and ventilator support, transport to these facilities can be hazardous. In addition, these patients frequently have a combination of neurospinal and long bone injuries, which require skeletal immobilization, thus further complicating transportation. Advancing technology with portable duplex ultrasound and improved deep abdominal duplex imaging has allowed for routine diagnostic evaluation of the IVC, renal veins, and surrounding visceral structures. This degree of accuracy has allowed numerous centers to gain experience with ultrasonic imaging of the IVC and insertion site after a filter has been placed. A logical progression has evolved to the point in which, today, duplex ultrasound can be used to guide the insertion of IVC filters. The following describes, in detail, a technique for the percutaneous placement of an IVC filter at the bedside using only duplex ultrasound guidance. The article also briefly compares and contrasts this technique with an alternate technique using intravascular ultrasound. Vena caval interruption can be safely performed under ultrasound guidance in a monitored, intensive care unit environment. In selected intensive care unit or multiply injured trauma patients, this will reduce the risk, complexity and cost of transport for these critically ill patients. Duplex-guided IVC filter placement also reduces procedural costs compared to an operating room or interventional suite, and eliminates intravenous contrast material exposure.

Results of the national pilot screening program for venous disease by the American Venous Forum.

OBJECTIVE: This report describes the pilot of a free comprehensive national screening program for venous disease. METHODS: The screening process consisted of a venous thromboembolism (VTE) risk assessment, abbreviated duplex examination for venous obstruction and reflux, inspection for signs of chronic venous insufficiency (CVI), and an exit interview. Physicians coordinating the screenings were members of the American Venous Forum. RESULTS: Seventeen institutions screened 476 people (mean, 28 per site; range, 6 to 71). Mean age was 60 years (range, 40 to 91 years), with 78% women and 68% with a body mass index of > or =25. If placed in a situation conducive for VTE, 22 participants (5%) were low risk, 87 (18%) were moderate risk, 186 (39%) were high risk, and 179 (38%) were at very high risk. In 26 people (6%), one or more segments had venous obstruction, and 190 (40%) had one or more segments of venous reflux in the lower extremities. Varicose veins were present in 32%, edema without skin changes in 11%, skin changes attributable to venous disease in 8%, and healed or active venous stasis ulcer in 1.3% (CEAP classification 2, 3, 4, 5, and 6, respectively). Increasing age and increasing deep venous thrombosis risk score significantly correlated with increasing clinical classification, r = 0.09, P = .04, and r = 0.16, P = .0004, respectively. Those participants with reflux in one or more segments were significantly more likely to have a higher clinical classification compared with those with no reflux (P = .0001). CONCLUSION: The first comprehensive national screening for venous disease was performed. Participants were informed of their risk for VTE if placed in a situation conducive to VTE, screened for evidence of obstruction, reflux, and CVI, and empowered to share their results with their primary care provider.

Twenty consecutive cases of endograft repair of traumatic aortic disruption: lessons learned.

OBJECTIVES: Endograft repair holds considerable promise in the treatment of traumatic disruption of the thoracic aorta because patients often have multiple coexisting injuries further complicating traditional open repair. In addition, patients are often young, with an aortic anatomy dissimilar to those with atherosclerotic aneurysms. As a result, techniques for endograft repair have to be refined accordingly. METHODS: The records of 20 consecutive cases of traumatic aortic disruption treated by endograft repair at a single institution were reviewed. RESULTS: Mean patient age was 40 years (range, 17 to 88 years), and 17 (85%) of 20 patients were men. All cases were completed. There were no procedure related deaths, but four (20%) patients died of their co-injuries. Only two (10%) of 20 required a graft >28 mm in diameter, and nine (45%) aortas were small enough to require use of 23-mm abdominal cuffs. Six (30%) of 20 cases required complete or partial coverage of the left subclavian artery. Placement of a proximal extension was required in one patient for a type I endoleak. A graft collapse occurred in one patient that required surgical removal and aortic repair. CONCLUSIONS: Endovascular repair of traumatic aortic disruption can be accomplished in most cases. Compared with atherosclerotic aneurysms, the proximal thoracic aorta tends to be smaller and the arch angle tighter in an aorta 19mm in diameter. This frequently necessitates the use of smaller devices and less stiff wires. Surgeons should be prepared to cover the left subclavian artery if needed, have a wide range of device sizes in stock to avoid over-sizing, and show restraint if the anatomy appears unsuitable.

Lemierre's syndrome: a potentially fatal complication that may require vascular surgical intervention.

Septic phlebitis of the internal jugular vein, Lemierre's syndrome, is extremely rare. However, Lemierre's syndrome may cause septic pulmonary emboli or result in fatal systemic sepsis, or both, if a timely diagnosis and appropriate treatment are not provided. We present a case of Lemierre's syndrome that occurred in an otherwise healthy young man. In this case, progression to a moribund state was rapid, and surgical intervention proved lifesaving.

The effect of exercise intensity on the response to exercise rehabilitation in patients with intermittent claudication.

PURPOSE: The purpose of this randomized trial was to compare the efficacy of a low-intensity exercise rehabilitation program vs a high-intensity program in changing physical function, peripheral circulation, and health-related quality of life in peripheral arterial disease (PAD) patients limited by intermittent claudication. METHODS: Thirty-one patients randomized to low-intensity exercise rehabilitation and 33 patients randomized to high-intensity exercise rehabilitation completed the study. The 6-month exercise rehabilitation programs consisted of intermittent treadmill walking to near maximal claudication pain 3 days per week at either 40% (low-intensity group) or 80% (high-intensity group) of maximal exercise capacity. Total work performed in the two training regimens was similar by having the patients in the low-intensity group exercise for a longer duration than patients in the high-intensity group. Measurements of physical function, peripheral circulation, and health-related quality of life were obtained on each patient before and after the rehabilitation programs. RESULTS: After the exercise rehabilitation programs, patients in the two groups had similar improvements in these measures. Initial claudication distance increased by 109% in the low-intensity group (P < .01) and by 109% in the high-intensity group (P < .01), and absolute claudication distance increased by 61% (P < 0.01) and 63% (P < .01) in the low-intensity and high-intensity groups, respectively. Furthermore, both exercise programs elicited improvements (P < .05) in peak oxygen uptake, ischemic window, and health-related quality of life. CONCLUSION: The efficacy of low-intensity exercise rehabilitation is similar to high-intensity rehabilitation in improving markers of functional independence in PAD patients limited by intermittent claudication, provided that a few additional minutes of walking is accomplished to elicit a similar volume of exercise.

Exteriorization and control of a retained embolization coil in the carotid artery--a case report.

Advances in endovascular technology have enabled the development of complex techniques for the treatment of vascular conditions. Not surprisingly, the modern vascular surgeon will likely encounter unusual complications and will need to formulate plans for their management. In the current case report, the vascular surgery service was consulted to assist in the management of a retained embolization coil in the carotid artery. Relevant aspects of detachable coils are discussed and the successful management of this potentially hazardous complication is described.

Combined endovascular and surgical repair of a large traumatic pseudoaneurysm of the thigh-a case report.

Thigh pseudoaneurysms are rare compared to pseudoaneurysms of the groin, and usually result from direct injury to an arterial branch. Direct open repair can be associated with a large volume blood loss. The authors describe a combined endovascular and surgical approach to a large, traumatic, pseudoaneurysm of the thigh. The patient was a 49-year-old man with a history of left femur fracture treated by open reduction and internal fixation, who presented with a painfully swollen left thigh. Duplex ultrasound and computed tomography (CT) scan suggested a large (7.7 x 5.0 x 6.3 cm) pseudoaneurysm that appeared to be associated with a branch of the deep femoral artery. In the operating room, angiography was used to identify and selectively access the feeding artery. This artery was then successfully coil embolized, allowing surgical decompression of the thigh with minimal effort and blood loss. Endovascular and surgical therapy were complementary in successfully treating a large traumatic pseudoaneurysm of the thigh.

Surgical thrombectomy and transluminal balloon angioplasty for failed above-knee femoropopliteal polytetrafluoroethylene bypass grafts.

Endovascular therapy offers an alternative to redo bypass or surgical graft revision for failed above-knee femoropopliteal PTFE bypass grafts. We evaluated the outcome of surgical thrombectomy and balloon angioplasty for the treatment of thrombosed bypass grafts. Thirty selected patients with thrombosed above-knee femoropopliteal PTFE bypass grafts were treated. Under local anesthesia, a surgical thrombectomy followed by bypass graft angiography and balloon angioplasty of perianastomotic stenoses was performed. Stents were used selectively for suboptimal angioplasty results. Patients underwent duplex scanning of the bypass graft postoperatively and at 6-month intervals. Life-table analysis and log-rank (Mantel-Cox) comparisons were performed. Patients were categorized into two groups on the basis of time elapsed from initial bypass graft construction to graft failure. Group 1 included 21 patients with a mean time to graft failure of 10 months (range, 0-20). Surgical thrombectomy was successful in 20 grafts (95%) and 17 patients had a stent placed after angioplasty. Rethrombosis occurred within 30 days in seven grafts (33%) in group 1 and major amputations were performed in six patients (28%). Group 2 included nine patients with a mean time to initial bypass graft failure of 48 months (range, 29-96). All patients in group 2 had a successful surgical thrombectomy and all received a stent. None of the grafts treated in group 2 reoccluded within 30 days of intervention and one patient (11%) went on to require a major amputation. By life-table analysis, the 6- and 12-month patency for group 1 was 15.3% and 5.1%, compared to 58.3% and 38.9% for group 2 (p = 0.027). Surgical thrombectomy along with balloon angioplasty has an unacceptably high rate of failure and limb loss in patients treated for early (<2 years) femoropopliteal PTFE bypass graft thrombosis. Surgical graft revision or redo bypass is recommended to achieve successful revascularization in these patients. Treatment with surgical thrombectomy and balloon angioplasty achieves significantly greater short-term patency results in patients with late (>2 years) bypass graft failure and may be a reasonable alternative for patients who cannot tolerate reoperation or lack autogenous conduit.

The role of arteriography in assessing popliteal artery injury in knee dislocations.

BACKGROUND: This study aimed to review the need for angiography among patients with traumatic knee dislocations, and to evaluate any adverse consequences associated with the clinical decision to pursue or defer angiography. METHODS: A retrospective analysis was performed for 55 patients (57 knees) with traumatic knee dislocation during a 7-year period. The presence or absence of arterial injury was assessed via physical examination (to determine presence of foot pulses and ankle-brachial index > or = 0.80) and, in selected cases, via angiography. RESULTS: At the vascular examination, 32 knees (56%) were found to be normal and 25 (44%) to be abnormal. None of the 32 knees with normal examination results had substantial vascular injuries, as determined by angiography in 13 cases (41%) or by clinical follow-up assessment in 19 cases (59%). All 25 patients with abnormal vascular examination results underwent angiography, with 12 patients (48%) demonstrating vascular injury (7 major and 5 minor injury). Seven patients (6 with major and 1 with minor injury) underwent surgical repair with reverse saphenous vein grafting. CONCLUSIONS: No limb with initial normal vascular examination results was found to have a vascular injury that required treatment. Routine screening angiography may not be necessary for all patients with traumatic knee dislocations.

Endovascular repair of a penetrating thoracic aortic ulcer by way of the carotid artery.

INTRODUCTION: Endovascular repair of thoracic aortic lesions offers an attractive alternative to traditional open repair. Access to the thoracic aorta can occasionally be challenging because of large device size and vessel tortuosity. Traditional access by way of the femoroiliac vessels might not be possible in the setting of synchronous iliac occlusive disease. MATERIALS AND METHODS: A 63-year-old woman presented with a 7.1-cm symptomatic, penetrating ulcer of the descending thoracic aorta. The patient's severe pulmonary disease prohibited an open repair. A Talent endoprosthesis was placed under compassionate use with approval of the institutional review board. The graft was placed by way of the left common carotid artery because of severe iliac occlusive disease. RESULTS: The thoracic endograft was successfully placed with exclusion of the pseudoaneurysm. The patient's chest pain resolved immediately. She developed mild left-sided weakness from a postoperative right anterior cerebral artery stroke that quickly resolved. The patient was discharged on postoperative day 5. No aortic endoleak was noted on follow-up computerized tomography scan at 1 month. CONCLUSIONS: Endovascular repair should be considered in patients with thoracic aortic aneurysms, particularly those with severe medical comorbidities. Placement by way of the common carotid artery is technically feasible in the setting of synchronous aortoiliac disease.

Coagulopathy as a result of factor V inhibitor after exposure to bovine topical thrombin.

We describe a case of severe coagulopathy after mesenteric revascularization. Laboratory investigation results revealed the presence of plasma inhibitors of factor V believed to result from exposure to bovine thrombin used for intraoperative hemostasis. Vascular and cardiothoracic surgeons commonly use topical thrombin for surgical hemostasis, and many patients undergo multiple exposure. More patients likely have factor V inhibitors develop than has previously been realized, and this may account for some otherwise unexplained postoperative coagulation disorders. This report may alert surgeons to coagulation disturbances that can result from exposure to bovine thrombin and provide guidelines for diagnosis and management.