Unselected percutaneous access with large vessel closure for endovascular aortic surgery: experience and predictors of technical success.

INTRODUCTION: The effectiveness of percutaneous access with large vessel closure (pEVR) in non-selective groups of patients undergoing endovascular aneurysm repair (EVR) remains unclear. This study aims to identify factors that predict success in pEVR, performed using percutaneous access and the Prostar XL (Abbott Vascular, Redwood City, Calif) closure device. METHOD: Consecutive patients who underwent pEVR between April 2010 and March 2011 were identified from a prospectively maintained database. Procedural and postoperative outcomes were compared with consecutive patients who underwent endovascular aneurysm repair using standard open femoral access between April 2008 and March 2009. To determine the predictors of technical success of pEVR, the association between clinical, anatomical and procedural variables with technical success, were examined in a multiple logistic regression model. RESULTS: pEVR was attempted in 186 common femoral arteries (CFAs) with a technical success rate of 95.2% (177/186). Conventional open femoral access in the historic control group was performed in 208 CFAs. pEVR was associated with a reduced operation length (131 min [105-152] versus 150 min [124-195], p≤0.001) and length of stay (2 days [2-5] versus 4 days [2-7], p = 0.01) in patients undergoing infrarenal EVR. In secondary analysis of outcomes following percutaneous access in 91 CFAs, pre-operative renal failure, CFA depth (min and max), CFA diameter (min and max) and operator experience predicted success of percutaneous access in univariate analysis. Operator experience was the only independent predictor of technical success (p = 0.05) after adjustment for all confounding variables. CONCLUSION: pEVR using the Prostar XL device is effective in the majority of patients. In this study there were benefits in terms of reduced postoperative complications, shorter procedures and decreased lengths of stay. Operator experience is a predictor of technical success for pEVR, irrespective of clinical and morphological characteristics at baseline.

Imaging vascular trauma.

BACKGROUND: Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions. METHODS: A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000-2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included. RESULTS: Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury. CONCLUSION: Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.

How safe is bilateral internal iliac artery embolization prior to EVAR?

PURPOSE: To assess the outcomes of patients after bilateral internal iliac artery (IIA) embolization prior to endovascular aneurysm repair (EVAR). METHODS: Thirty-nine patients (age range 55-88 years, mean 72.5 years; 2 women) underwent IIA embolization/occlusion before EVAR. There were 28 patients with aorto-biiliac aneurysms and 6 with bilateral common iliac artery (CIA) aneurysms. Five patients with unilateral CIA aneurysms had previous surgical ligation of the contralateral IIA or inadvertent covering by the stent-graft of the contralateral IIA origin. Outcomes were assessed by clinical follow-up. RESULTS: Severe ischemic complications were limited to spinal cord ischemia in 1 patient (3%) who developed paraparesis following EVAR. No other severe ischemic complications such as buttock necrosis, or bowel or bladder ischemia, occurred. Buttock and/or thigh claudication occurred in 12 patients (31%) and persisted beyond 1 year in 3 patients (9%). Sexual dysfunction occurred in 2 patients (5%). Patients who underwent simultaneous embolization had a 25% (3/12) ischemic complication rate versus 41% (11/27) in those with sequential embolization (p = 0.48). Embolization limited to the main trunk of the IIA resulted in a significantly reduced ischemic complication rate of 16% (3/19) versus 55% (11/20) of patients who had a more distal embolization of the IIA (p = 0.019, Fisher's exact test). CONCLUSION: Severe complications after bilateral IIA embolization are uncommon. Although buttock/thigh claudication occurs in around 30% of patients soon after the procedure, this resolves in the majority after 1 year. There is no obvious benefit for sequential versus simultaneous IIA embolization in our series. Occlusion of the proximal IIA trunk is associated with reduced complications compared with occlusion of the distal IIA.

Endovascular stent graft repair of mycotic aneurysms of the thoracic aorta.

Traditional open surgical repair for mycotic aneurysms of the thoracic aorta is associated with significant morbidity and mortality. Endovascular repair has been reported as an alternative treatment in patients with mycotic thoracic aneurysms. This article reports our experience of endovascular stent graft placement in three patients with mycotic aneurysms of the thoracic aorta and compares the results with similar reports on the literature.

Sequential retroperitoneal venous hemorrhage and embolism of an angio-seal puncture closure device complicating iliac artery angioplasty.

PURPOSE: To present a case of iatrogenic puncture closure device embolization complicating surgery for retroperitoneal hemorrhage (RPH) secondary to angioplasty-induced common iliac vein trauma. METHODS AND RESULTS: A 78-year-old woman with rest pain underwent successful kissing balloon dilation of her aortoiliac bifurcation for a calcified ostial stenosis of the left common iliac artery. Hemostatic puncture closure devices (Angio-Seal) were used to secure both femoral punctures. A right-sided retroperitoneal hematoma developed, and during surgical exploration of the right groin, the Angio-Seal device was removed. The only bleeding site found was the external iliac artery puncture and it was repaired. She again became hypovolemic 18 hours later and was returned to surgery, where bilateral groin explorations and laparotomy by the vascular surgical team found a tear in the left common iliac vein. After repair, the patient was stable for 48 hours when the left leg became critically ischemic. Angiography detected a new high-grade stenosis in the left profunda femoris artery; embolectomy retrieved a footplate from the left puncture closure device. The patient died 11 days later from multiorgan failure. CONCLUSIONS: RPH should be considered early as an occult cause of hypovolemic shock developing soon after even technically straightforward iliac angioplasty. Interventionists should be aware that using the Angio-Seal device risks acute limb ischemia if footplate embolization occurs.

Vascular surgical society of great britain and ireland: review of out-of-hours vascular procedures in a tertiary vascular unit

BACKGROUND: The aim of this study was to review out-of-hours vascular procedures in a tertiary vascular unit. METHODS: The vascular emergencies that presented outside normal working hours (17. 00 to 08.00 hours) in a vascular unit between January and June 1998 were reviewed. Only cases considered to be life or limb threatening and requiring urgent surgical or radiological intervention were assessed. RESULTS: The Table shows that a significant number of vascular emergencies was performed out of hours in one unit. This was, in part, due to an increase in the number of tertiary referrals, which represented 57 per cent of all emergency procedures. Reasons for the tertiary referrals were: no consultant vascular surgeon on call (33 per cent), no consultant interventional radiologist on call (26 per cent), lack of intensive care beds (30 per cent) and complex procedure (11 per cent). The overall mortality rate of patients referred in this period was 15 per cent. The unit has three consultant vascular surgeons, two consultant interventional radio- logists and one vascular specialist registrar. CONCLUSION: The significant increase in out-of-hours vascular emergencies, both surgical and radiological, has placed an enormous demand on senior members of the team. In addition, it has had a significant impact on the unit's elective admissions and waiting lists, in particular those for routine general surgery. To support the growth in complex emergency referrals, senior vascular fellows in both vascular surgery and radiology have been appointed and proposals are underway to restructure local vascular services.

Comparison of hemodynamic cerebral ischemia and microembolic signals detected during carotid endarterectomy and carotid angioplasty.

BACKGROUND AND PURPOSE: There has been concern about carotid percutaneous transluminal angioplasty (PTA) carrying a greater risk of cerebral ischemia than carotid endarterectomy. We set out to compare cerebral hemodynamics and microembolization during carotid PTA and CEA. METHODS: We used transcranial Doppler to monitor the middle cerebral artery of 28 patients undergoing carotid PTA (n = 14) or carotid endarterectomy (CEA) with a shunt (n = 14). Each period during which the internal carotid artery was occluded by PTA balloon or by clamp when the shunt was not in place was timed. Individual periods were summated to give a total occlusion time. Ischemic time was defined as the period for which mean middle cerebral artery velocity fell to a third or less of baseline. Microembolic signals were counted during each procedure. RESULTS: CEA resulted in significantly longer individual and total occlusion time than PTA (mean individual occlusion time, seconds), CEA, 168 +/- 51; PTA, 20 +/- 7; P < .001; mean total occlusion time; CEA, 337 +/- 70; PTA, 26 +/- 10; P < .001. Ischemic time was also significantly longer during CEA than during PTA (CEA, 165 +/- 40; PTA, 17 +/- 5; P = .001). There were significantly more microembolic signals during PTA than during CEA (mean number of microembolic signals during CEA, 52 +/- 64; during PTA, 202 +/- 119; P = .001). There was no correlation between any of the parameters measured and periprocedural stroke, which occurred in one patient in each group. CONCLUSION: PTA results in less hemodynamic ischemia but more cerebral microembolism than CEA. In this small series, however, it is not possible to comment on the relations between ischemic time, microembolism, and stroke.

A regional study of thyroidectomy: surgical pathology suggests scope to improve quality and reduce cost.

This study of thyroid histopathological data from hospitals in the South West Thames region was undertaken to assess current practice and the scope for improvement. Over a 6 month period, 186 thyroid operations were performed on 179 patients at eight hospitals serving almost 1.7 million people. The frequency of thyroidectomy in different hospitals varied from 13 to 35 per 100,000 per year and 6.4% of the operations were second thyroidectomies. Benign multinodular goitre was the most common histological finding (34%). A benign solitary nodule was found in 36% and malignancy in 8.4% of the specimens. Correlation of histological analysis and type of operation suggested that a variety of operations were performed for the same pathological condition and that some operations were diagnostic procedures only. Overall, 63 of the 186 operations (34%) might have been avoided by a firm preoperative diagnosis. Only 67 thyroid fine needle aspiration biopsies (FNAC) were performed at the eight hospitals during the study period. Only 15 (8%) of the patients who underwent thyroid operation had been investigated by FNAC. Reduction in thyroid surgery through more widespread use of FNAC could result in savings of 100,000 pounds per million population per year. Regional activity data show that more than 50 surgeons currently undertake a workload of less than 500 thyroidectomies each year. Increased subspecialisation may be required to reduce costs and raise standards.

A meta-analysis of randomized placebo control trials in Fontaine stages III and IV peripheral occlusive arterial disease.

In patients with Fontaine Stage III and IV POAD unsuitable for arterial reconstruction, Iloprost, a prostacyclin analogue, has been shown in six RCTs to have a significant (p < 0.05) beneficial effect with regards to the probability of being alive with both legs at six months follow-up. Iloprost has significant (p < 0.05) beneficial effects over placebo on ulcer healing and pain relief, but these were relatively soft endpoints to study when side effects may have unblinded many observers and patients. Further studies are indicated to investigate the possible benefit of repeated courses of treatment with Iloprost in patients with non-reconstructable Fontaine Stage III and IV POAD as well as studies looking at patients who may be suitable only for relatively high risk reconstructions. Meta-analysis of all other RCTs of pharmacotherapeutic agents in patients with Fontaine Stage III and IV POAD showed no significant benefit over placebo for any of the endpoints reported.

The differences in early haemodynamic response between surgery and angioplasty after successful re-opening of the superficial femoral artery.

In 40 patients with superficial femoral artery disease we prospectively evaluated the effect of angioplasty (n = 20) or femoropopliteal bypass (n = 20) on the ankle-brachial pressure index (ABI) using the Doppler ultrasound probe. The ABI was measured as a baseline 1 day before the procedure, 1 day after the procedure and 30 days later. In the angioplasty group the baseline ABI was 0.57 (0.11), increasing to 0.74 (0.26) 1 day postangioplasty and increasing further to 0.88 (0.26) after 30 days. The increase in ABI over 30 days was significantly greater than the increase over 1 day. In the femoropopliteal bypass group the baseline ABI was lower at 0.46 (0.17). However 1 day postoperatively it had increased to 0.92 (0.2) with almost no further increase at 30 days [0.95 (0.17)]. We concluded that by contrast to a surgical bypass where there was a large improvement in the ABI over the first day, the ABI following angioplasty continued to improve significantly beyond the first day.

Role of ultrasound in the investigation of haematuria after normal intravenous urography and cystoscopy.

The initial investigation of haematuria in the adult includes intravenous urography and cystoscopy. If these investigations reveal no cause for haematuria we propose that renal ultrasound should be considered, and illustrate this with two series of patients from different hospitals (147 from St. Peter's Hospitals, 35 from St. James' Hospital, Balham, London) with primary adenocarcinoma of the kidney.