Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms.

OBJECTIVE: Our purpose was to examine the impact of the introduction of endovascular treatment on the early outcomes of ruptured abdominal aortic aneurysms (AAAs) during 2 consecutive time periods at a single institution. METHODS: The hospital records of a single tertiary care center from 1997 to 2004 were retrospectively reviewed, and 36 consecutive patients who underwent treatment for acute ruptured AAA were identified. They were divided into 19 (53%) patients who were all treated with conventional open surgery from 1997 to 2001 (early) and 17 (47%) patients who were treated either with open (n = 4, 24%) or endovascular (n = 13, 76%) methods from 2002 to 2004 (late). All endovascular repairs were performed with commercially available bifurcated devices. Outcome measures included death, major complications, disposition at discharge (home or extended care facility), procedure time, blood loss, and hospital length of stay. RESULTS: Age, sex, and AAA size were similar between the 2 groups. Perioperative mortality in the early and late periods were 37% versus 12%, respectively (P =.13); rates of major complications were 84% versus 65%, respectively (P =.26); and discharge to home rather than extended care facility was 32% versus 59%, respectively (P =.18). Median procedure times (275 vs 149 minutes, P <.01), blood loss (3800 vs 138 mL, P <.0001), and length of stay (18 vs 6 days, P <.05) were all higher during the early period than in the late period. CONCLUSIONS: This preliminary study suggests that introduction of endovascular therapies may be potentially beneficial in the overall treatment scheme of patients with ruptured AAAs. However, longer follow-up and larger cohorts are needed to better establish its feasibility and efficacy compared with conventional open surgical repair.

Outcome after autogenous brachial-axillary translocated superficial femoropopliteal vein hemodialysis access.

OBJECTIVE: The optimal configuration for patients with "complex" or "tertiary" hemodialysis access needs remains undefined. This study was designed to examine the utility of the autogenous brachial-axillary translocated superficial femoropopliteal vein access (SFV ACCESS) in this subset of patients. METHODS: Patients presenting for permanent hemodialysis access without a suitable upper extremity vein for autogenous access identified by duplex ultrasound mapping and those with repeated prosthetic access failures were considered candidates for SFV ACCESS. Ankle-brachial indices were obtained, and duplex scanning of the superficial femoropopliteal and saphenous veins was performed. Patients deemed candidates for SFV ACCESS also underwent preoperative upper extremity arteriography and venography. A retrospective review of the complete medical record was performed, and a follow-up telephone or personal interview was conducted. RESULTS: Thirty patients (mean age +/- SD, 54 +/- 15 years; male, 33%; white, 37%; with diabetes, 50%; obese, 21%) underwent SFV ACCESS among approximately 650 access-related open surgical procedures during the study period. The patients had been receiving dialysis for 4 +/- 5 years (range, 0-24 years), and had 3 +/- 3 (range, 0-17) prior permanent accesses, whereas 90% were actively dialyzed through tunneled catheters. In-hospital 30-day mortality was 3%, and the hospital length of stay was 7 +/- 7 days. Fifty-seven percent of the patients experienced some type of perioperative complication, and 38% required a remedial surgical procedure. Hand ischemia developed in 43% of the patients (severity grade: 1, 10%; 2, 7%; 3, 27%), and a distal revascularization, interval ligation was performed in all those with grade 3 ischemia. Thigh wound complications or hematomas developed in 23% of the patients, and arm wound complications or hematomas developed in 17%. The incidence of thigh wound complications was significantly greater (57% vs 9%; P =.03) in obese patients, but the other perioperative complications analyzed could not be predicted on the basis of age, gender, or comorbid conditions. The SFV ACCESS was cannulated 7 +/- 1 weeks postoperatively. The primary, primary assisted, and secondary patency rates were 96% +/- 4%, 100% +/- 0%, and 100% +/- 0%, respectively, at 6 months; 79% +/- 8%, 91% +/- 6%, and 100% +/- 0%, respectively, at 12 months; and 67% +/- 13%, 86% +/- 9%, and 100% +/- 0%, respectively, at 18 months (life table analysis; % +/- SE). CONCLUSIONS: The intermediate term functional patency rate after SFV ACCESS is excellent, although the magnitude of the procedure and the complication rate are significant. SFV ACCESS should only be considered in patients with limited access options.

Prospective validation of an algorithm to maximize native arteriovenous fistulae for chronic hemodialysis access.

OBJECTIVE: The purpose of this study was to evaluate an algorithm to maximize native arteriovenous fistulae (AVF) for hemodialysis access. METHODS: The prospective study design was set in an academic, tertiary care medical center. The study subjects were adults referred for permanent, upper extremity hemodialysis access between April 1999 and May 2001. Intervention included Doppler arterial pressures/waveforms and duplex imaging of the basilic, cephalic, and central veins. The optimal configuration for an AVF was determined (criteria: vein >3 mm, no arterial inflow stenosis, no venous outflow stenosis) on the basis of the noninvasive studies, and unilateral arteriography/venography was performed to confirm the choice. Permanent hemodialysis access was created on the basis of the imaging studies, and remedial imaging/intervention was performed if the AVF failed to mature. Outcome measures included impact of the noninvasive/invasive imaging, perioperative morbidity/mortality, incidence of successful AVF, time to cannulation, and predictors of AVF failure with multivariate analysis. RESULTS: A total of 139 new access procedures was performed in 131 patients (age, 53 +/- 16 years; male, 51%; white, 60%; diabetic, 49%; actively undergoing dialysis, 50%; prior permanent access, 26%). The noninvasive imaging showed that 83% of the patients were candidates for AVF, with a mean of 2.7 +/- 2.1 possible configurations. Invasive imaging was abnormal in 38% (forearm arterial disease > central vein stenosis > inflow stenosis) and impacted the operative plan in 19%. AVF were performed in 90% of the cases (brachiobasilic > brachiocephalic > radiocephalic > radiobasilic), with prosthetic AVF performed primarily because of inadequate veins. Among the patients who underwent AVF, the 30-day mortality rate was 1%, the complication rate was 20% (wound, 10%; hand ischemia, 8%), and 24% needed a remedial procedure. The AVF matured sufficiently for cannulation in 84% of those with sufficient follow-up and was suitable for cannulation by 3.4 +/- 1.8 months. On the basis of an intention to treat approach, an AVF sufficient for cannulation developed in 71% of the 139 cases referred for access. The multivariate analysis predicted that female gender (odds ratio, 9.7; 95% CI, 2.2 to 43.5) and the radiocephalic configuration (odds ratio, 4.6; 95% CI, 1.1 to 18.6) were both independent predictors of failure of the fistula to mature. CONCLUSION: With the aggressive algorithm, the construction of native AVF is possible in the overwhelming majority of patients presenting for new hemodialysis access.

Eligibility rates of ruptured and symptomatic AAA for endovascular repair.

PURPOSE: To determine the anatomical eligibility rate for endovascular repair of ruptured and symptomatic abdominal aortic aneurysms (AAA) using commercially available endografts. METHODS: In a retrospective review, 28 preoperative computed tomographic (CT) scans were examined from among 83 patients who underwent surgical repair of a ruptured or acutely symptomatic AAA at a university-based tertiary care center during the past 10 years. The proximal aortic neck, aneurysm, and iliac dimensions were compared to corresponding measurements from 100 preoperative CT scans from patients who underwent elective repair of asymptomatic AAA. Based on expanded selection criteria for the 2 FDA-approved endografts (AneuRx and Ancure), eligibility rates for endovascular repair were compared between patients with ruptured/symptomatic and asymptomatic AAAs. RESULTS: The proximal neck of the ruptured/symptomatic AAAs was on the average 2 mm larger in diameter (25 +/- 4 versus 23 +/- 3 mm, p=0.04) and 7 mm shorter (16 +/- 10 versus 23 +/- 14, p=0.017) than asymptomatic AAAs. The maximum AAA diameter was significantly larger in the ruptured/symptomatic group (64 +/- 16 mm) than in the asymptomatic group (58 +/- 11 mm, p=0.033). Of the 28 ruptured/symptomatic AAAs assessed morphologically, 13 (46%) were anatomically eligible for endovascular repair compared to 74 of the 100 asymptomatic AAAs (p=0.006). The main cause for exclusion was an unfavorable proximal neck, which was present in 15 (54%) of the 28 ruptured/symptomatic AAAs and in 24 (24%) of the 100 asymptomatic AAAs (p=0.003). CONCLUSIONS: A significantly smaller proportion of patients presenting with ruptured/symptomatic AAA are anatomically eligible for endovascular AAA repair compared to patients with asymptomatic AAA due to unfavorable proximal neck anatomy.