Percutaneous Axillary Artery Access in Complex Endovascular Aortic Repair.

PURPOSE: This study was designed to assess the feasibility and safety of percutaneous axillary access in complex endovascular aortic repair (EVAR) with use of a percutaneous closure device. MATERIALS AND METHODS: All patients undergoing percutaneous axillary artery access between 2012 and 2017 were included. Left percutaneous axillary access was the sole antegrade aortic approach used. Patient and intervention characteristics were documented. Mortality, procedural success, technical success, peri- and postoperative complications, and repeat interventions were examined. A total of 25 percutaneous axillary access procedures were performed in 23 patients. The mean age of the treated patients was 72.2 years, and 71% were male. Percutaneous axillary access was obtained for a variety of indications (chimney EVAR, thoracoabdominal aortic aneurysm repair, thoracic EVAR, and type B dissections). Vascular access sheath sizes ranged from 6 F to 12 F. RESULTS: The procedural success rate was 96%. Technical success of vascular closure was 100%. The perioperative access complication rate was 8%: 1 dissection of the axillary artery and 1 stenosis occurred. No hematoma, hemorrhage, or neuropathies were seen. One access-related repeat intervention had to be performed. The 30-d mortality rate was 4%. CONCLUSIONS: Direct puncture and percutaneous closure of the axillary artery for complex aortic procedures is safe and feasible.

Short-term morbidity associated with sentinel lymph node biopsy in cutaneous malignant melanoma.

Guidelines for the surgical treatment of cutaneous primary malignant melanoma are well established; however, the approach to the treatment of the regional lymph nodes remains more controversial. In many centres, sentinel lymph node biopsy has been adopted as routine in the treatment of malignant melanoma for prognostic purposes, as it is not of proven therapeutic benefit. The Multicentre Selective Lymphadenectomy Trial II aims to determine the comparative benefits of subsequent completion lymphadenectomy versus observation in those found to have a positive sentinel node biopsy. Until results are available, the risks of the procedure must be weighed against the value of prognostic information gained from performing a sentinel node biopsy. In this retrospective analysis of sentinel lymph node biopsies at our institution, we show that in general, short-term morbidity associated with this procedure is low, but that morbidity is higher in a subgroup of people with higher weight or body mass index, and in those whose biopsy is located in the groin.

Stenting for carotid artery stenosis: fractures, proposed etiology and the need for surveillance.

PURPOSE: Carotid artery stenting is a relatively new intervention for the treatment of carotid artery stenosis, and the long-term outcomes and complications are therefore yet to be determined. In one surgeon's practice, it was found that a stent fracture was the etiological factor for recurrent stenosis. A retrospective study was therefore performed with the hypothesis that carotid stent fractures are common. The aims were to determine prevalence of fractures in this surgeon's series, risk factors, and most importantly, clinical relevance. METHODS: Patients from one surgeon's private practice who had carotid stenosis deemed suitable for intervention (>80% asymptomatic, >70% symptomatic, 50% to 70% if an ulcerated lesion) and had suitable aortic and carotid morphology for carotid stenting between March 2004 and December 2006 were included. To enhance the quality of the measurement, two vascular surgeons and one radiologist examined the films independently to determine if there was a fracture present. Given that this was a retrospective study, there was no preconceived sample size determined. RESULTS: Fracture prevalence was found to be 29.2% or 14 out of 48 stents. Restenosis occurred in 21% of those stents with a detected fracture, after an average follow-up of 15 months. Several anetiological factors are proposed, with a finding in this series, of a strong and significant association between the presence of calcified vessels and the presence of fractures (odds ratio 7.7; standard error 5.6; 95% confidence interval 1.9-32.0, P =.003). CONCLUSIONS: Although this is a small study, it demonstrates that carotid stent fractures do exist, and importantly, not all of them are benign. Therefore, the authors recommend regular surveillance with plain radiography in addition to duplex ultrasonography to enable early detection of fracturing. Following detection, institution of increased surveillance frequency and/or any appropriate intervention can be implemented, to aid in the prevention of complications resulting from restenosis should it become apparent.

Treatment of a large type II endoleak via extraperitoneal dissection and embolization of a collateral vessel using ethylene vinyl alcohol copolymer (Onyx).

Type II endoleak is defined as persistent blood flow and pressure within an aneurysmal sac after endovascular deployment of a stent graft from patent aortic branches. This paper describes the simultaneous deployment of an endoluminal graft, with limited extraperitoneal dissection of a collateral vessel and use of an ethylene vinyl alcohol copolymer, Onyx, to obliterate a large type II endoleak.

Simultaneous microsurgical and endovascular management of multiple cerebral aneurysms in acute subarachnoid haemorrhage.

Most aneurysms can be effectively managed using endovascular coiling or microsurgical clipping, but in an acute subarachnoid haemorrhage where there are multiple aneurysms identified, a sequential multimodal approach may prove more beneficial. This report involves a 31-year-old man who presented with sudden onset of severe headache and photophobia. A computed tomography brain scan revealed a diffuse grade II subarachnoid haemorrhagic pattern, and four-vessel angiography revealed two aneurysms: a right middle cerebral artery bifurcation aneurysm measuring 12 x 8 mm and a 4-mm basilar artery aneurysm associated with a fenestration at the confluence of the vertebral arteries. It was not possible to determine which aneurysm or aneurysms were responsible for the haemorrhage using the customary criteria. The patient underwent sequential endovascular coiling of the vertebrobasilar aneurysm without delay, followed immediately by microsurgical clipping of the right middle cerebral artery aneurysm, under a single anaesthetic. The postoperative course was uneventful. This method is a treatment option for acute subarachnoid haemorrhage where there are multiple aneurysms. It is a logical progression of management that could be employed at any experienced neurovascular centre; the employment of a sequential multimodal approach from the integration of these techniques is beneficial to the patient because it decreases morbidity and mortality.