Pseudoaneurysms of the Peripheral Arteries.

Peripheral arterial pseudoaneurysm, while relatively rare, are encountered by most vascular specialists. This review evaluates the epidemiology, diagnosis, natural history, and treatment of pseudoaneurysm in the peripheral arteries. Most of this review concentrates on iatrogenic peripheral pseudoaneurysms, but pseudoaneurysms of other etiologies will also be discussed.

Endovascular Repair of Incidentally Found Subclavian Artery Aneurysm: A Case Report From an Urban Level 1 Trauma Center.

Subclavian artery aneurysms (SAAs) are historically rare peripheral aneurysm. However, it can be associated with serious life-threatening complications including rupture, thrombosis, and embolism. The majority of such aneurysms are found incidentally. Historically, SAA have been repaired via an open approach. Increasing case reports demonstrate successful management of SAAs with endovascular repair. The present report describes a case of incidentally discovered large proximal saccular subclavian aneurysm with suspected remote traumatic etiology with a successful endovascular repair.

Endovascular Treatment of Abdominal Aortic Aneurysm with Complete Iliac Occlusion: Case Series and Literature Review.

In patients with abdominal aortic aneurysms (AAA) and complete iliac occlusion, endovascular aortic aneurysm repair (EVAR) using a bifurcated stent graft has clear advantages over aortouniiliac stent grafts. Bifurcated stent grafts had improved hemodynamic flow and increased primary and secondary patency rates compared with aortouniiliac stent grafts. The use of aortouniiliac stent grafts with femorofemoral crossover bypass is associated with complications including infection of the prosthesis, steal phenomenon, and the associated difficulties for further endovascular access at the site of the femoral anastomosis. Recanalization of occluded iliac arteries at the time of EVAR avoids the complications mentioned above. We report three cases of patients with AAA and iliac occlusion who were successfully treated with iliac recanalization at the time of EVAR.

Treatment of peripheral arterial disease via percutaneous brachial artery access.

OBJECTIVE: This review was conducted to evaluate the types of endovascular procedures that can be performed via brachial artery access, evaluate the access success rate, and determine the incidence of technical complications. METHODS: A retrospective 10-year record review at a tertiary facility from January 1, 2005, through June 30, 2015, was completed. Patients who underwent attempted brachial artery access were eligible for review. Outcomes intended to be evaluated included ability to access the vessel, reach an identified lesion, and perform an indicated procedure, while describing the incidence and type of complications that occurred to clarify the utility and safety of brachial artery access. RESULTS: The review included 265 access cases in 179 patients. The access success rate was 98.9%. Intervention was performed in 223 cases (84.2%). Angioplasty was the most common intervention (59%, [154 cases]), with stents, atherectomy, coiling, and percutaneous thrombectomy having also been performed. Complications included hematoma (2.3%) and pseudoaneurysm (1.5%). Complications requiring intervention occurred in 1.9% of procedures. Interventions were performed on all major vessels as distal as the dorsalis pedis. Sheath sizes ranged from 4F to 7F. Intervention was performed on bilateral lower extremities in 38 cases (14.5%). A femoral bypass graft was present in 141 patients (53%) as the main indication for brachial artery access. CONCLUSIONS: Brachial access is a reliable and effective option for treatment of peripheral vascular disease and should be considered when femoral access is difficult or contraindicated and when a bypass graft is present in the femoral region. In addition, bilateral lesions may be approached easily through one brachial artery access site, making this approach advantageous when bilateral lesions are expected. The complication rate is similar to femoral access and can be minimized with ultrasound-guided access distally over the humerus, micropuncture access, and a dedicated postprocedure "hold team."

Endovascular Treatment of Massive Axillary Artery Aneurysm for Palliation.

Atherosclerotic axillary artery aneurysms are rare. We report a case of a ninety six year old female who presented with a pulsatile left breast mass causing her intractable pain. She was diagnosed with a massive axillary artery aneurysm which was treated with and endovascular aneurysm repair for palliation of her symptoms.

Autologous bone marrow mononuclear cell implantation therapy is an effective limb salvage strategy for patients with severe peripheral arterial disease.

OBJECTIVE: This study was conducted to determine if intramuscular and intra-arterial stem cell injections delay or prevent major limb amputations, improve ankle-brachial index measurements, relieve rest pain, and improve ulcer healing. METHODS: A prospective case series with interventions occurring between December 2007 and September 2012 and a 3-month minimum follow-up was conducted at an urban tertiary care referral hospital. Patients with severe limb-threatening peripheral arterial disease, without other options for revascularization, were eligible for enrollment. Dual intramuscular and intra-arterial injection of bone marrow mononuclear cells harvested from the iliac crest was performed. Major limb amputation at 3 months was the primary outcome measure. Secondary outcome measures included ankle-brachial index measurements, rest pain, and ulceration healing. Kaplan-Meier survivorship was performed to ascertain overall survivorship of the procedure. RESULTS: No complications related to the procedure were reported. Of 49 patients (56 limbs) enrolled, two patients (two limbs) died, but had not undergone major amputation, and five limbs (8.9%) underwent major amputation within the first 3 months. Three-month follow-up evaluations were conducted on the remaining 49 limbs (42 patients). Median postprocedure revised Rutherford and Fontaine classifications were significantly lower compared with median baseline classifications. After 3 months, seven patients (nine limbs) died but had not undergone major amputation, and seven limbs (14.3%) underwent major amputation. At a mean follow-up of 18.2 months, the remaining 33 limbs (29 patients) had not undergone a major amputation. Freedom from major adverse limb events (MALE) was 91.1% (95% confidence interval, 79.9-96.2) at 3 months and 75.6% (95% confidence interval, 59.4-86.1) at 12 months. CONCLUSIONS: This procedure was designed to improve limb perfusion in an effort to salvage limbs in patients for whom amputation was the only viable treatment option. The results of this analysis indicate that it is an effective strategy for limb salvage for patients with severe peripheral arterial disease.

Delayed Endovascular Aneurysm Repair for Aorto-caval Fistula with Correction of Physiologic and Metabolic Abnormalities: A Disease Process Review.

Reports regarding the management of ruptured abdominal aortic aneurysm with aorto-caval fistula (ACF) outline various treatment options and high mortality rates associated with this condition. This case illustrates a patient with a large ACF secondary to a prior rupture into the inferior vena cava with a delayed presentation. Because of preexisting conditions and severe metabolic sequelae of the ACF, palliative care was considered by the medical team. Minimally invasive endovascular techniques and prompt treatment resulted in a successful outcome with complete resolution of physiologic and metabolic abnormalities.

Endovascular repair of concomitant vertebral artery and subclavian artery iatrogenic perforations.

Inadvertent arterial puncture is a well-established complication of central venous catheter insertion. The carotid artery is the most frequently injured artery involved with injury to the subclavian artery and vertebral artery being much less common. When these injuries do occur, they are often treated with open surgical repair or endovascular, with stent-graft placement or embolization. Repair of acute vertebral artery injury with endovascular stent-graft repair has not been well represented in the literature to date. The present report discusses the successful treatment of concomitant injuries to the left subclavian and left vertebral arteries from acute iatrogenic puncture with endovascular stent-graft placement.

Accuracy of duplex ultrasonography in estimation of severity of peripheral vascular disease.

Duplex ultrasonography (DUS) is a safe, noninvasive method for imaging vasculature when compared with conventional angiography. Our goal is to assess the accuracy of DUS compared with angiography of the lower extremities. We reviewed a total of 373 lesions in 278 patients from July 2005 through June 2010. Patients underwent DUS followed by angiography within 30 days. Peak systolic velocities (PSV) were stratified into one of four categories and compared with the angiographic findings. Seventy-five chronic total occlusions were found. Of the remaining 298 lesions, a significant relationship was found between PSV and degree of angiographic stenosis (p < 0.001). DUS was found to demonstrate a sensitivity of 79.7%, specificity of 79.2%, positive predictive value of 88.2%, and negative predictive value of 66.7% for lesions ≥ 70%. The 66.7% of the false-negative lesions with the lowest velocities were below the knee joint. DUS of the lower extremities is accurate in determining the degree of stenosis ranging from mild-to-severe disease. Some limitation may exist in estimating the degree of stenosis below the knee.

A five-year review of management of upper-extremity arterial injuries at an urban level I trauma center.

BACKGROUND: Upper-extremity arterial injuries are relatively uncommon, but they may significantly impact patient outcome. Management of these injuries was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome. METHODS: Upper-extremity trauma patients presenting with arterial injury between January 2005 and July 2010 were included in this retrospective review. Descriptive statistics were used to describe demographic, injury, treatment, and outcome data. These variables also were compared between blunt and penetrating arterial injuries and between proximal and distal arterial injuries. RESULTS: During a 5.6-year period, 135 patients with 159 upper-extremity arterial injuries were admitted, yielding an incidence of 0.74% among trauma admissions. The majority of patients (78.5%) suffered concomitant upper-extremity injuries. The most common injury mechanism was laceration by glass (26.4%). Arterial injuries were categorized into 116 penetrating (73.0%) and 43 blunt (27.0%) mechanisms. Arterial distribution involved was as follows: 13 axillary (8.2%), 40 brachial (25.2%), 52 radial (32.7%), 51 ulnar (32.1%), and 3 other (1.9%). The types of arterial injuries were as follows: 69 transection (43.4%), 68 laceration (42.8%), 16 occlusion (10.1%), 3 avulsion (1.9%), and 3 entrapment (1.9%). One patient (0.7%) required a primary above-elbow amputation. The majority of injuries (96.8%) receiving vascular management underwent surgical intervention--76 primary repair (49.7%), 41 ligation (26.8%), 31 bypass (20.3%), and 5 endovascular (3.3%). Conservative treatment was the primary strategy for five arterial injuries (3.3%). Of the patients receiving vascular intervention, three (2.2%) required major and three (2.2%) required minor amputations during hospitalization and no patients expired. CONCLUSION: The current multidisciplinary team management approach with prompt surgical management resulted in successful outcomes after upper-extremity arterial injuries. No outcome differences between penetrating and blunt or between proximal and distal arterial injuries were calculated. This management approach will continue to be used.

A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries.

BACKGROUND: Despite progress in diagnosing and managing blunt cerebrovascular injury (BCVI), controversy remains regarding the appropriate population to screen. A systematic review of published literature was conducted to summarize the overall incidence of BCVI and the various screening criteria used to detect BCVI. A meta-analysis was performed to evaluate which screening criteria may be associated with BCVI. Goals were to confirm inclusion of certain criteria in current screening protocols and possibly eliminate criteria not associated with BCVI. STUDY DESIGN: Studies published between January 1995 and April 2011 using digital subtraction angiography or CT angiography as a diagnostic modality and reporting overall BCVI incidence or prevalence of BCVI for specific screening criteria were examined. Screening criteria were analyzed using a random effects model to determine if an association with BCVI was present. RESULTS: The incidence range of BCVI was between 0.18% and 2.70% among approximately 122,176 blunt trauma admissions. The meta-analysis encompassed 418 BCVI and 22,568 non-BCVI patients. Of the 9 screening criteria analyzed, cervical spine (odds ratio [OR] 5.45; 95% CI 2.24 to 13.27; p < 0.0001) and thoracic (OR 1.98; 95% CI 1.35 to 2.92; p = 0.001) injuries demonstrated a significant association with BCVI. CONCLUSIONS: Patients with cervical spine and thoracic injuries had significantly greater likelihoods of BCVI compared with patients without these injuries. All patients with either injury should be screened for BCVI. Multivariate logistic regression analysis is needed to elucidate the possible impact of the combined presence of screening criteria, but it was not possible in our study due to limitations in data presentation. Standardized reporting of BCVI data is not established and is recommended to permit future collaboration.

Spirituality and quality of life in limb amputees.

Limb amputation is a life-changing event that signifies long-term physical, social, psychological, and environmental change. Spiritual well-being in patients plays a significant role in coping and may affect outcomes of patients with limb loss. The objective of this study was to describe the role of spirituality in individuals with limb amputation and to determine whether spirituality is related to the quality of life (QOL) in this sample. Study participants were recruited through prosthetists, physicians, amputee support groups, the Amputee Coalition of America, and amputee listserv discussion groups in the United States and Canada. Participants completed questionnaires containing measures of satisfaction with life, general health, mobility, and social integration. A quantitative descriptive research design was used to examine the relationships between existential spirituality (belief that one's life is meaningful or has purpose) and religious spirituality and QOL among individuals with limb amputation. A prospective study of 108 patients with a history of limb amputation was performed. The study population consisted of 66.3% males and 33.7% females. Most patients were Caucasian (96.2%). Of the 108 participants, 86 (79.6%) were 41 years of age or older with a mean of 18 years since amputation. The most frequent cause of amputation was trauma (55.6%) and the most common location of amputation was below-the-knee (49.1%). Existential spirituality, female gender, and age above 50 years related to higher QOL in patients with a history of limb amputation. The findings of this research confirmed that amputees use spirituality to cope with limb amputation. Existential spirituality was a significant predictor of satisfaction with life, general health, and social integration.

Treatment of varicose veins by transilluminated powered phlebectomy surgery: a 9-year experience.

Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique for varicose vein removal that addresses some limitations of traditional procedures. The study objective was to analyze perioperative and follow-up outcomes after TIPP and present modifications gleaned over 9 years of performing the technique. Four hundred and thirty-one patients who underwent TIPP performed between June 2002 and April 2011 were included in this retrospective review. Descriptive statistics were used to describe demographic, treatment, and outcome data. The mean procedure time was 20.2 minutes. The majority (50.5%) of cases involved 10 to 20 incisions. No significant varicosities were reported at a follow-up of 12 weeks. Postoperative complications included 2 (0.5%) deep vein thromboses, 8 (1.9%) cellulitis episodes, 16 (3.7%) hemosiderin staining cases, 2 (0.5%) abscesses, and 2 (0.5%) cases of excessive or hypertrophic scarring. All but one patient reported good outcomes and were satisfied with the procedure. With proper training and experience, TIPP with a lower oscillation frequency and secondary tumescence results in good outcome and high patient satisfaction.

A unique case of a type II endoleak after EVAR caused by patent inferior mesenteric and accessory renal arteries.

Type II endoleaks have been viewed as the Achilles' heel of endovascular repair of abdominal aortic aneurysms. This report describes a unique etiology to this common challenge and our approach to endovascular repair.

Treatment of pulmonary embolism using ultrasound-accelerated thrombolysis directly into pulmonary arteries.

Traditional therapy for pulmonary embolism includes systemic anticoagulation, systemic thrombolysis, catheter-directed thrombolysis / suction catheter thrombectomy, and surgical thromboembolectomy. Currently, the standard treatment for submassive and massive pulmonary embolism involves the use of systemic anticoagulation. However, unlike systemic anticoagulation there is no standard treatment algorithm for the use of thrombolytics to aggressively treat pulmonary embolism and its sequelae. This case report discusses the successful use of thrombolytics using the EKOS EkoSonic Ultrasound-Accelerated Thrombolysis System in the treatment of bilateral submassive pulmonary emboli along with a saddle pulmonary embolus. The EKOS ultrasound-accelerated thrombolysis procedure resulted in rapid substantial clinical improvement, resolution of bilateral pulmonary emboli along with resolution of the saddle pulmonary embolus, restoration of pulmonary blood flow with resolution of pulmonary hypertension, and normalization of pulmonary embolism-related cardiac dysfunction. This novel application of ultrasound-accelerated thrombolytic infusion directly into the pulmonary arteries for pulmonary embolism provides a potential new treatment option and a valuable addition to the treatment algorithm for the management of both submassive and massive pulmonary embolism.

Short- to mid-term results using autologous bone-marrow mononuclear cell implantation therapy as a limb salvage procedure in patients with severe peripheral arterial disease.

Short- to mid-term results of a prospective study evaluating dual intramuscular and intra-arterial autologous bone-marrow mononuclear cell (BM-MNC) implantation for the treatment of patients with severe peripheral arterial occlusive disease (PAD) in whom amputation was considered the only viable treatment option are presented. Ankle-brachial indices (ABIs), rest pain, and ulcer healing were assessed at 3 months. Success was defined as improvement in ABI measurements; absence of rest pain; absence of ulcers; and absence of major limb amputations. Twenty patients (21 limbs) have been enrolled. Three-month follow-up evaluation accounting included 18 patients (19 limbs). Four (22.2%) major and 2 (11.1%) minor amputations were performed within 3 months postoperatively. With 17 (94.4%) of 18 limbs demonstrating at least one criterion for success and major amputation avoided in 14 (77.8%) of 18 limbs at the 3-month evaluation, this specific BM-MNC implantation technique is an effective limb salvage strategy for patients with severe PAD.

A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center.

BACKGROUND: The purpose of this study was to review the management of lower extremity arterial injuries to determine incidence, assess the current management strategy, and evaluate hospital outcome. METHODS: This was a retrospective review, including trauma database query, and medical records review set in an urban level I trauma center. Sixty-five patients with 75 lower extremity arterial injuries were admitted between April 2005 and April 2010. The interventions were primary amputation, medical management, vascular surgical intervention, and subsequent amputation. The main outcome measures were age, gender, race, mechanism of injury, type of injury, associated lower extremity injuries, concomitant injuries, Injury Severity Score, Abbreviated Injury Scale, surgical procedures and interventions, limb salvage rate, mortality, length of stay, and discharge disposition. RESULTS: During a 5-year period, 65 patients with 75 lower extremity arterial injuries were admitted to the hospital, yielding an incidence of 0.39% among trauma admissions. The study population was comprised primarily of young men, with a mean Injury Severity Score of 15.2 and a mean Abbreviated Injury Scale of 2.7 (moderate to severe injuries). The majority of patients (78.4%) suffered concomitant lower extremity injuries, most frequently bony or venous injuries, whereas 35.4% experienced associated injuries to other body regions. The most common injury mechanism was a gunshot wound (46.7%). Arterial injuries were categorized into 42 penetrating (56.0%) and 33 blunt mechanisms (44.0%). Involved arterial distribution was as follows: 4 common femoral (5.3%), 4 profunda femoris (5.3%), 24 superficial femoral (32.0%), 16 popliteal (21.3%), and 27 tibial (36.0%) arteries. The types of arterial injuries were as follows: 28 occlusion (37.3%), 23 transection (30.7%), 16 laceration (21.3%), and 8 dissection (10.7%). Orthopedic surgeons performed amputations as primary procedures in 3 patients (4.6%). The majority (76.8%) of injuries receiving vascular management underwent surgical intervention, with procedure distribution as follows: 26 bypass (49.1%); 13 primary repair (24.5%); 7 ligation (13.2%); 4 endovascular (7.5%); and 3 isolated thrombectomy (5.7%) procedures. Concomitant venous repair and fasciotomy were performed in 22.4% and 38.2% of cases, respectively. Medication was the primary strategy for 16 arterial injuries (23.2%). Subsequent major amputation was required for 3 patients (4.8%) who initially received vascular management. Three patients (4.6%) died during hospitalization. CONCLUSION: The current multidisciplinary team management approach, including use of computed tomographic or conventional angiography and prompt surgical management, resulted in successful outcomes after lower extremity arterial injuries and will continue to be utilized.

Oral prostaglandin e1 in combination with sodium bicarbonate and normal saline in the prevention of contrast-induced nephropathy: a pilot study.

The purpose of this study was to evaluate the use of prostaglandin E1 (PGE1) as a renal protective medication for patients exposed to contrast agents, as well as to demonstrate the safety, efficacy, and low side-effect profile of PGE1. A prospective, randomized, double-blind study was designed to compare combination of intravenous sodium bicarbonate, normal saline, and oral PGE1 200 µg versus the combination and placebo for renal protection from contrast agents. All patients receiving nonionic contrast during their interventional procedure were eligible for enrollment. Creatinine levels were recorded before and after the administration of contrast and renal protective medications. Contrast-induced nephrotoxicity (CIN) was defined as an increase of 0.5 mg/dL or greater in creatinine level, or an increase of 25% or more above baseline. Age, gender, total amount of contrast used, and incidence of renal failure requiring dialysis were recorded. We conducted the study on 41 patients. Of these, 20 patients received PGE1 and 21 received the placebo. The study group comprised 29 males and 12 females. Diabetes mellitus occurred in 41.5% of the cases (including 40% of PGE1 and 43% of placebo patients). Average contrast use was 77.2 mL (range, 15 to 200 mL). Mean age of the groups was 67.2 years. Average baseline creatinine level was 1.17. The differences between the groups were not statistically significant. CIN by definition occurred in one patient, who received the placebo. Incidence of new onset renal failure requiring dialysis was zero. Postcontrast change in creatinine level for the study was 0.11. There was a change in the creatinine level of 0.161 in the PGE1 group and 0.061 in the placebo group; an improvement of 0.10. PGE1 was not effective in significantly altering postcreatinine levels (p = 0.176). None of the patients enrolled in the study suffered any side effects from taking the PGE1 tablet. Although preliminary, this study shows that the addition of PGE1 for the prevention of CIN is well-tolerated by patients and is a safe modality. Additional studies are required to evaluate efficacy.

Treatment of Iatrogenic Pseudoaneurysms Using Ultrasound-Guided Thrombin Injection over a 5-Year Period.

In this study we demonstrate that ultrasound (US)-guided injection of thrombin is a safe and effective way to treat iatrogenic pseudoaneurysms as a new treatment modality at a 650-bed urban community hospital. We included retrospective chart review of patients who were treated for iatrogenic pseudoaneurysms from January 2004 to June 2010 at a single institution. All patients' pseudoaneurysms were treated using US-guided thrombin injection. This study demonstrated an overall success rate of 97.1% in treating iatrogenic pseudoaneurysms in 33 of 34 patients. One patient underwent open surgical repair. No mortality or complications were noted. The study was successful in demonstrating that the US-guided injection of thrombin is an efficacious way to treat iatrogenic pseudoaneurysms and can be safely implemented as a new treatment modality by appropriately trained vascular surgeons. A review of different techniques is included. An algorithm for the treatment of iatrogenic pseudoaneurysms is proposed from this study.

Initial results of a 12-week, institution-based, supervised exercise rehabilitation program for the management of peripheral arterial disease.

This study assessed the effectiveness of a 12-week, institution-based, supervised exercise rehabilitation program with atherogenic risk factor modification in improving cardiovascular profile, ambulatory function, and quality of life of patients with peripheral arterial disease (PAD) by comparing pre- and postprogram measurements. Participants were prospectively enrolled. Cardiovascular profile variables, ambulatory function tests, and quality of life questionnaires were evaluated. Of 101 institution-based program participants, 69 completed the 12-session minimum and 47 completed a postprogram evaluation. Mean postprogram results were significantly different from preprogram results, corresponding to improvement, for the following variables: triglyceride levels (p  =  .036), both function tests (p < .001 for both), four of five Walking Impairment Questionnaire measurements, and Intermittent Claudication Questionnaire score (p  = .001). This supervised exercise program improved the cardiovascular profiles, ambulatory function, and quality of life of PAD patients completing the program and is a viable adjunct to drug therapy and surgical intervention.