Impaired Cerebrovascular Reactivity Predicts Recurrent Symptoms in Patients with Carotid Artery Occlusion: A Hypercapnia BOLD fMRI Study.

BACKGROUND AND PURPOSE: A key factor in predicting recurrent ischemic episodes in patients with carotid artery occlusion is the presence of hemodynamic impairment. There is, however, no consensus on how to best assess this risk in terms of imaging modalities or thresholds used. Here we investigated whether a predefined threshold of hemispheric asymmetry in hypercapnia fMRI predicts recurrent symptoms in patients with carotid artery occlusion. MATERIALS AND METHODS: We studied 23 patients (2 women) with a mean age of 67.5 ± 9 years. Patients were assessed for recurrent ischemic events until lost to follow-up, study end, death, or recurrent ischemic event. Hypercapnia fMRI was used to assess the cerebrovascular reserve and quantify the percentage signal change in GM in the MCA territory and the hemispheric asymmetry index. Kaplan-Meier survival analysis and log-rank tests were performed to assess differences between patients with normal or abnormal hemispheric indices. RESULTS: The median follow-up was 20 months. During this period, 8 patients experienced recurrent events, and 15 did not. The percentage signal change in GM in the MCA territory was significantly decreased in those patients with recurrent events compared with those without (2.39 ± 0.22 versus 2.70 ± 0.42, P = .032). The normal hemispheric index predicted event-free survival during follow-up (median, 20 months) for both the combined outcome (recurrent events and/or death, log-rank, P = .034) and recurrent retinal or ipsilateral ischemic events only (log-rank, P = .012). CONCLUSIONS: The hemispheric asymmetry index derived from hypercapnia fMRI showed hemodynamic impairment in more than half of the studied patients with carotid occlusion, and those patients showed a higher risk of recurrent ischemic symptoms.

MR imaging-detected carotid plaque hemorrhage is stable for 2 years and a marker for stenosis progression.

BACKGROUND AND PURPOSE: MR imaging-detected carotid plaque hemorrhage is associated with an increased risk of recurrent ischemic cerebrovascular events and could be an indicator of disease progression; however, there are limited data regarding the dynamics of the MR imaging-detected carotid plaque hemorrhage signal. We assessed the temporal change of this signal and its impact on carotid disease progression. MATERIALS AND METHODS: Thirty-seven symptomatic patients with 54 carotid stenoses of >30% on sonography underwent serial MR imaging during 24 months. A signal-intensity ratio of >1.5 between the carotid plaque and adjacent muscle was defined as plaque hemorrhage, and a change in signal-intensity ratio of >0.31 between time points was considered significant. Sixteen patients underwent ≥2 carotid sonography scans to determine the peak systolic velocities and degree of stenosis with time. RESULTS: Of the 54 carotids, 28 had the presence of hyperintense signal on an MR imaging sequence (PH+) and 26 had the absence of hyperintense signal on an MR imaging sequence (PH-) at baseline. The signal-intensity ratio was stable in 33/54 carotid plaques, but 39% showed a change. Plaque hemorrhage classification did not change in 87% of carotid plaques, but 4 became PH+, and 3, PH-. As a group, PH+ carotids did not change significantly in signal-intensity ratio (P = .585), whereas PH- showed an increased signal-intensity ratio at 24.5 months (P = .02). In PH+ plaques, peak systolic velocities significantly increased by 22 ± 39.8 cm/s from baseline to last follow-up sonography (Z = 2.427, P = .013). CONCLUSIONS: During 2 years, MR imaging-detected carotid plaque hemorrhage status remained stable in most (87%) cases with 4 (7%) incident plaque hemorrhages. PH+ plaques were associated with increased flow velocity during the follow-up period.

Catheter-directed thrombolysis for iliofemoral deep vein thrombosis.

BACKGROUND: Recent international guidance recommends the use of catheter-directed thrombolysis (CDT) in selected patients with symptomatic iliofemoral deep vein thrombosis (DVT). The aim of this study was to estimate the potential increase in workload as a result of this recommendation. METHODS: Using the radiology database, a review was performed of all DVTs diagnosed between August 2010 and February 2012 at a large tertiary referral hospital. The National Institute for Health and Clinical Excellence and American College of Chest Physicians guidance was applied retrospectively to this cohort, using case-note review by two independent clinicians to determine which patients would have been suitable for CDT. RESULTS: Some 563 patients had DVT confirmed radiologically over the 18-month interval. Fifty-three of the 128 patients with iliofemoral DVT would have been eligible for intervention with CDT, equivalent to 4·4 patients per 100 000 per year. Only eight (15 per cent) of the 53 were actually referred to vascular services for treatment. All eight patients had successful CDT, which involved a stay in critical care for monitoring (median 2 (range 1-3) sessions). CONCLUSION: Vascular units should be prepared for a major increase in the requirement for CDT for iliofemoral DVT. This increase will affect inpatient beds, the interventional radiology suite, critical care and interhospital referrals.

Mid-term results of endovascular aortic aneurysm repair in the young.

OBJECTIVES: To compare the mid-term outcome and secondary intervention rate following elective open and endovascular aortic aneurysm repair (EVAR) in patients aged 65 years and younger. METHODS: A retrospective analysis of patients aged 65 years and younger who had elective abdominal aortic aneurysm repair (AAA) between 1994 and 2012. RESULTS: One hundred and sixty-five patients under the age of 65 years (mean age: 61 years ± 4; 8 women) had elective abdominal aneurysm repair (97 EVAR and 68 open). The overall 30-day mortality rate was 3.7% (2.1% EVAR and 5.9% open). Forty per cent of patients had died at a median follow up of 77 months (interquartile range, 36-140). Most deaths were not related to aneurysm. There was no difference in the long-term mortality between the EVAR and open groups (hazard ratio [HR] = 1.22; 95% confidence interval [CI] 0.75-1.98, p = .43), but there was a trend of better outcomes with the use of commercially made endografts over open repair (HR = 2.9; 95% CI 0.9-10.0, p = .08) and custom-made endografts (HR = 3.1, 95% CI 0.9-10.3; p = .07). Eleven per cent of patients who had EVAR required a further procedure compared with 13% who had open repair. All but one of the re-interventions in the EVAR group was performed on patients who had custom-made endografts. CONCLUSIONS: Young patients with AAA have significant comorbidities and do not necessarily have long lifespans. In the less fit younger patients with AAA, the results with EVAR are comparable with fit patients who had open AAA repair. The management of fitter young patients with AAA remains controversial, but improving results with EVAR over time may increase the role of EVAR in this group.

Endovascular aneurysm repair of tuberculous mycotic abdominal aortic aneurysm on a patient with renal transplant.

The case report describes a gentleman with renal transplant who presented with pulmonary tuberculosis (TB) and mycotic aneurysm of abdominal aorta. The aneurysm was successfully treated with endovascular aneurysm repair. A multidisciplinary approach with renal physicians and infectious diseases unit was necessary to treat TB and maintain immunosuppression. The technique used for deployment of the stent graft in the presence of infection and a transplanted kidney is described. The satisfactory outcome at 5 years follow-up indicates that endovascular option for TB mycotic aneurysm is durable and safe option particularly when major open surgery is associated with significant mortality and morbidity.

The routine intra-operative use of pulse oximetry for monitoring can prevent severe thromboembolic complications in anterior surgery.

INTRODUCTION: Anterior access to the lumbar spine is established for disc replacement surgery and anterior interbody fusion in the lumbar spine. The spine is accessed normally from the left side either by a transperitoneal or retroperitoneal approach through a midline or oblique skin incision. After reaching the retroperitoneum and depending on the level of exposure, the surgeon has to mobilise and retract the aorta or left common iliac artery, as well as the left common iliac vein or internal vena cava to the right lateral border to address the whole disc space. The left common iliac artery is especially stretched during intervertebral disc exposure putting it at a greater risk of adverse events. Not surprisingly, vascular adverse events like direct injuries, thrombosis and embolism are feared complications in anterior surgery. Permanent intra-operative left leg oxygen saturation surveillance via pulse oximetry can help detecting embolic situations thereby allowing immediate treatment minimising the leg ischemia or preventing limb loss. CASE REPORT: In the presented case, a 61-year-old male patient undergoing a two-level anterior interbody fusion lost oxygen saturation in the left leg after vessel retraction for exposure. After cage insertion and release of the retractor blades, the pulse oximetry signal did not return and no pulses were found during instant Doppler investigation below the femoral artery, indicating severe embolism in the left leg. The left common iliac artery was clamped and opened showing a ruptured calcified plaque with adherent fresh thrombotic material. An endovascular embolectomy in the superficial and deep femoral artery revealed several small thrombi. An artherectomy of the common iliac artery followed by patch closure was performed. Immediately after clamp release, pulse oximetry returned and Doppler signals were detectable at the tibialis posterior and dorsalis pedis artery. Post-operative recovery was uneventful and pulses were palpable at all times. CONCLUSION: Arterial adverse events in anterior access surgery are rare complications but none the less, it is of paramount importance to detect and treat these situations immediately. This case highlights the need of routine pulse monitoring during the whole anterior surgery to prevent embolic complications. Even manual pulse control might not be sufficient to rule out any distal embolic events creating severe leg ischemia.

Recognising anaemia and malnutrition in vascular patients with critical limb ischaemia.

INTRODUCTION: Anaemia is a common problem in surgical patients. Patients with critical limb ischaemia (CLI) suffer chronic inflammation, repeated infection, require intervention, and can have a protracted hospital stay. The aims of this study were to assess anaemia and nutritional status in patients presenting with CLI. PATIENTS AND METHODS: Two observational studies were undertaken, initially a retrospective series of 27 patients with CLI. Patient demographics, clinical details, transfusion status and in-patient laboratory haemoglobin values (Hb) were recorded. In a prospective series of 32 patients, laboratory markers to identify the cause for anaemia were assessed. Further nutritional status was assessed by records of height, weight, body mass index and a validated scoring system. RESULTS: In the retrospective series, 15 patients (56%) were anaemic. Ten (37%) were transfused a median of 2 units (range, 2-13), a total of 35 units. Patients who were transfused had lower Hb on admission (P = 0.0019), most were anaemic on admission (90%). At discharge, most patients were anaemic (n = 23; 83%). In the prospective series of 32 patients, 20 (63%) were anaemic. Nutritional assessment was performed on 18, only seven patients were scored undernourished. This was increased to 23 by an independent assessor. Anaemia was associated with malnutrition (n = 17; P = 0.049) and an increased hospital stay (mean 25 days [SD 16] vs mean 12 days [SD 8], P = 0.0125; total 513 vs 144 bed days). CONCLUSIONS: Anaemia and poor nutrition are common and not recognised in vascular patients presenting with critical limb ischaemia. Anaemia is associated with and increased length of hospital stay.

Carotid endarterectomy improves cerebrovascular reserve capacity preferentially in patients with preoperative impairment as indicated by asymmetric BOLD response to hypercapnia.

PURPOSE: In patients with symptomatic carotid artery disease the predominant mechanism causing ischaemic injury is considered to be thromboembolic, however compromise of cerebral haemodynamics is considered to be a significant factor. Removal of the embolic source is accepted as the major benefit from carotid endarterectomy (CEA), however improvement in cerebral haemodynamics may be another beneficial outcome as suggested by transcranial doppler (TCD). Blood oxygen level-dependent (BOLD) hypercapnia functional magnetic resonance imaging (fMRI) can be used to map the cerebrovascular reserve (CVR). The aim of this study was to assess the effects of carotid surgery on cerebral haemodynamics in patients with carotid artery disease using a hypercapnia BOLD fMRI and assessment of hemispheric asymmetry. MATERIALS AND METHODS: Seventeen patients with symptomatic internal carotid artery stenosis were scanned using a clinical 1.5T MR scanner. Scanning was done immediately prior to and between 4 and 8 weeks after CEA. 10% carbon dioxide was administered to achieve transient episodes of hypercapnia. The data was analyzed using FMRIB Software Library (FSL) software to derive percentage signal change (PSC) for the grey matter of the middle cerebral artery (MCA-GM) territory for both hemispheres. MCA-GM PSC was furthermore normalized to the contralateral hemisphere to derive an Hemispheric Asymmetry Index (hAI) for all patients pre- and postoperatively. RESULTS: Ipsilateral GM CVR improved significantly following CEA (2.47% preoperatively vs. 2.73% postoperatively, p=0.038). There was no change in CVR in the contralateral grey and white matter MCA territories (p=0.27, p=0.1). Also, the hAI was significantly more shifted to the ipsilateral hemisphere after CEA (preoperative hAI -0.56, vs. -3.90 postoperatively, p=0.02). Patients with an impaired hAI preoperatively were found to show the greatest improvement in PSC and hAI following CEA (p=0.007). CONCLUSIONS: CEA resulted in improved CVR in patients with carotid artery disease as shown by the absolute and hemispheric asymmetry of BOLD response to hypercapnia.. These findings show that benefits from recanalisation may go beyond removal of the embolic source, by improving the cerebrovascular reserve. Moreover, hypercapnia BOLD fMRI may be a useful clinical tool in predicting this therapeutic potential in patients with severe carotid artery disease.

The importance of anatomical suitability and fitness for the outcome of endovascular repair of ruptured abdominal aortic aneurysm.

INTRODUCTION: Endovascular repair of aortic aneurysm (EVAR) has a lower mortality than open repair. The aim of this study was to assess mortality from EVAR for emergency AAA repair and the impact of fitness for operation and adverse anatomy. METHODS: One-hundred and forty two patients who had EVAR for a ruptured AAA (80, REVAR) or a symptomatic AAA (62, SEVAR) between 1994 and 2007 in a single specialist endovascular centre were reviewed. Fitness for surgery was assessed by Hardman's index (age>76, loss of consciousness, Hb<9.0, Cr>190, ischaemic ECG). CT scans were reviewed, compared with operative images and operation notes for adverse anatomy. Details of perioperative complications, and outcome were recorded. RESULTS: Overall mortality at 24-h, 30-days and one year were, respectively: 17%, 36%, 50% for REVAR and 5%, 8%, 23% for SEVAR. Overall adverse anatomy increased 30-day mortality. Hardman's index of three or more increased mortality HR=2.59 (1.24-5.41), p=0.01. On Cox regression Univariate analysis increasing Hardman's index score and adverse anatomy increased the overall mortality over time. In multivariate Cox regression analysis (controlled for the Hardman's index) adverse anatomy was associated with significant increase in graft related mortality. CONCLUSION: The use of EVAR is feasible in patients who present with a ruptured or acutely symptomatic AAA. Care must be taken not to extend anatomical or clinical guidelines.

Suitability of varicose veins for endovenous treatments.

The aim of the study was to assess the suitability of radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and foam sclerotherapy (FS) for patients with symptomatic varicose veins (VVs). The study comprised 403 consecutive patients with symptomatic VVs. Data on 577 legs from 403 consecutive patients with symptomatic VVs were collected for the year 2006. Median patient age was 55 years (interquartile range 45-66), and 62% patients were women. A set of criteria based on duplex ultrasonography was used to select patients for each procedure. Great saphenous vein (GSV) reflux was present in 77% (446 of 577) of legs. Overall, 328 (73%) of the legs were suitable for at least one of the endovenous options. Of the 114 legs with recurrent GSV reflux disease, 83 (73%) were suitable to receive endovenous therapy. Patients with increasing age were less likely to be suitable for endovenous therapy (P = 0.03). Seventy-three percent of patients with VVs caused by GSV incompetence are suitable for endovenous therapy.

A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm - results of a pilot study and lessons learned for future studies.

INTRODUCTION: EVAR has the potential to improve outcome after ruptured abdominal aortic aneurysm (AAA). Published series have been based upon selected populations. METHODS: An interim analysis of a single centre prospective randomised controlled trial comparing endovascular aneurysm repair (EVAR) with open aneurysm repair (OAR) in patients with ruptured AAA was performed. Patients who had a ruptured AAA and who were considered fit for open repair were randomised to EVAR or OAR after consent had been obtained. Those in the EVAR group had pre-operative spiral computed tomographic angiography (CTA). The primary endpoint was operative (30-day) mortality and secondary endpoints were moderate or severe operative complications, hospital stay and time between diagnosis and operation. A power study calculation required 100 patients to be recruited. RESULTS: Between September 2002 and December 2004, 103 patients were admitted with suspected ruptured AAA. Only 32 patients were recruited to the study. Of these, four patients died before receiving surgical treatment. On an intention to treat basis the 30-day mortality rate was 53% in the EVAR group and 53% in the OAR group. Moderate or severe operative complications occurred in 77% in the EVAR group and in 80% in the OAR group. Median total hospital stay in the EVAR group was 10 days (inter-quartile range 6-28) and 12 days (4-52) in the OAR group. Median time between diagnosis and operation was 75 minutes (64-126) in the EVAR group and 100 minutes (48-138) in the OAR group. CONCLUSIONS: Despite the relative high operative mortality in the EVAR group, these preliminary results show that it is possible to recruit patients to a randomised trial of OAR and EVAR in patients with ruptured AAA. CT scanning does not delay treatment.

Cerebral white matter hyperintense lesions are associated with unstable carotid plaques.

OBJECTIVES: The aim of this study was to determine whether unstable carotid plaques, a known risk factor for cerebral emboli, are associated with cerebral white matter lesions. METHODS: Seventy-one symptomatic patients undergoing magnetic resonance imaging prior to carotid endarterectomy for high grade carotid stenosis were included in this study. The number and volume of white matter hyperintense lesions (WMHL) on fluid attenuated inversion recovery brain scans were compared according to the morphology of carotid plaque based upon the American Heart Association (AHA) histological classification. RESULTS: Of the 57 patients who had good quality brain scans and non-fragmented carotid plaques, 15 plaques were defined as stable (type V) and 42 as unstable (type VI). After adjustment for the major risk factors affecting WMHL, unstable carotid plaques were found to be associated with more WMHL in the ipsilateral cerebral hemisphere than stable plaques (transformed means 2.50+/-1.2 vs. 1.53+/-1.1, p=0.016), however, there was only a trend towards larger WMHL volumes (p=0.079). CONCLUSIONS: The observed association between unstable carotid plaques and the number of white matter lesions suggest that thromboembolic plaque activity may contribute to the development of leukoaraiosis, in particular smaller individual lesions. Larger studies are warranted to confirm this finding and explore the potential clinical impact for selecting candidates for carotid endarterectomy.

A UK multi-centre experience with a second-generation endovascular stent-graft: results from the Zenith Users Group.

BACKGROUND: Endovascular aneurysm repair has been criticised for high rates of technical failure and secondary intervention. Second generation stent-grafts have been developed in an attempt to reduce these problems. The results of a UK multi-centre experience with a second generation device (Zenith) are presented. METHODS: Data were collected retrospectively from five experienced UK vascular centres in patients undergoing endovascular aneurysm repair with the Zenith stent-graft. RESULTS: A total of 269 patients underwent attempted aneurysm repair with the Zenith device. Median aneurysm diameter was 65 (interquartile range 52-78) mm. There were no conversions to open repair. Peri-operative mortality was 4.1% (11/269). On the initial post-operative scan, 94.1% of aneurysms were successfully excluded. During a median follow-up of 363 (interquartile range 154-720) days there were 19 secondary interventions and two aneurysm ruptures. CONCLUSIONS: Second generation endovascular stent-graft designs such as the Zenith are associated with low rates of intra-operative technical complications. Few secondary interventions have been necessary during follow-up; however, surveillance is essential to ensure they continue to perform.

Endovascular repair of a ruptured chronic type B aortic dissection.

Aneurysm formation is a common sequel of chronic type B aortic dissection. Ruptured false lumen aneurysms have traditionally been treated with open repair. These procedures are associated with high morbidity and mortality rates. We report the first successful endovascular repair of a ruptured chronic type B aortic dissection in a patient who had been turned down for elective surgery. The endovascular management of chronic dissection with rupture is difficult and may necessitate stenting of both entry and reentry points to induce false channel thrombosis. The long-term efficacy of this technique is unknown.

Endovascular repair of ruptured abdominal aortic aneurysm--a challenge to open repair? Results of a single centre experience in 20 patients.

INTRODUCTION: The mortality from ruptured abdominal aortic aneurysm (AAA) remains in the region of 50% despite advances in critical care. Endovascular repair of AAA has been shown to be associated with reduced physiological stress in the elective setting. It is hypothesised that the reduced physiological stress associated with EVAR may improve the outcome in patients with ruptured AAA. METHODS: A feasibility study of endovascular repair of ruptured AAA was undertaken at the University Hospital, Nottingham, U.K. between 1994 and 2000. Patients admitted with ruptured AAA were assessed by a team familiar with endovascular techniques for elective repair of AAA. After giving informed consent patients underwent spiral computed tomographic angiography (CTA) in the majority of cases. Patients were then transferred to the operating theatre for EVAR. RESULTS: Twenty patients underwent repair of ruptured AAA. Of these 20 patients, seven were referred from another hospital. Eight patients were considered unfit for open repair. The median duration of procedure was 180 min (range 120-480) and median blood loss was 1200 ml (range 750-2000 ml). The overall peri-operative mortality was 45%. A number of intra-operative and peri-operative procedures (both open and endovascular) were required to ensure aneurysm exclusion and to deal with the complications of endovascular surgery. CONCLUSIONS: Ruptured AAA remains a particularly hazardous condition to treat. There are a number of advantages of EVAR in this condition. A number of the problems early in the experience of EVAR have been addressed, but further experience is required to demonstrate its efficacy when compared with open repair.

Developing a one-stop clinic for leg ulcer patients.

Leg ulceration may be caused by a variety of different factors and specialist assessment is required. Patients with complex leg ulcers in Nottingham are assessed at a one-stop dermatology/vascular clinic. Nurses undertake assessments, provide education and support and liaise with the community nursing services.

The effects of sublingual glyceryl trinitrate on walking distance in patients with intermittent claudication. A randomised, doubled-blind, placebo-controlled, cross-over study.

BACKGROUND: Intermittent claudication (IC) is a common problem in older age. New work shows that the administration of glyceryl trinitrate (GTN) can reduce the fall in ankle brachial pressure index (ABPI) after exercise and can increase maximum walking distance by 19% on treadmill exercise. The aim of this study was to further define the clinical benefits of GTN in patients with PVD. METHODS: The study is of a randomised, double-blind, placebo-controlled cross-over design. We studied 29 patients with intermittent claudication where the median age was 67.5 years (45-84). This included 20 males and nine females, and six of these patients were diabetics. To be selected, the patients had to have a history of IC with a resting ABPI of 1.0 or less, that fell by more than 0.1 on exercise. Patients were walked for 15 min on flat ground following GTN spray or placebo and total distances walked were measured. This was then followed by the crossover component of the trial. RESULTS: Median walking distance with placebo was 825 m (100-1300 m) and with GTN was 900 m (240-1400 m). This is an increase of 9% (p = 0.02, using the Wilcoxon matched pairs signed ranks test). CONCLUSION: This study shows a statistically significant improvement in walking distance with GTN in patients with IC.

Variation of method for measurement of brachial artery pressure significantly affects ankle-brachial pressure index values.

BACKGROUND: Mmeasurement of ankle brachial pressure indices (ABPI) is important in the assessment of patients with peripheral vascular disease. METHODS: Thirty-one hospitals with a vascular surgeon were selected at random. A telephone questionnaire was completed to assess the method used for the measurement of ABPI. Following the survey, 14 patients with peripheral vascular disease had their ABPI measurement done by two observers, a pre-registration house officer and a clinical nurse practitioner. Observers were blinded to their own and each other's results. Brachial systolic pressures were obtained using a DINAMAP(TM)(Critikon, Tampa, U.S.A.) automated blood pressure monitor, the Korotkoff method (12 cm cuff, parallel wrap) and an 8 MHz Doppler probe (Huntleigh) and sphygmomanometer. Ankle systolic pressures were obtained using the Doppler probe. The results were analysed using the Wilcoxon signed rank test. RESULTS: The survey demonstrated that at the majority of centres with vascular laboratories the brachial artery systolic pressures were measured using a Doppler probe. In contrast, at centres where the house officers performed the routine measurements, over 60% used the Korotkoff method to obtain this reading. One in four nurse practitioners used the Korotkoff method. When the ABPI values were calculated, the DINAMAP produced significantly higher median values than the Korotkoff (0.79 vs 0.72, p=0.003) and Doppler methods (0.79 vs 0.70, p<0.0001). The nurse had a higher median ABPI value of 0.76 compared with the doctor (0.71, p=0.01). CONCLUSION: This study shows that measurement of ABPI varies in different vascular units. The technique for ABPI measurement should be standardised.

Incidence and treatment of intraoperative technical problems during endovascular repair of complex abdominal aortic aneurysms.

PURPOSE: The purpose of this study was to assess the incidence and management of intraoperative technical problems during endovascular repair (EVR) of complex abdominal aortic aneurysms (AAA). METHODS: From February 1995 to March 1999, 204 EVRs of nonruptured AAA were performed at our institution. One hundred seventy-six patients had an in-house custom-made graft; 172 were aorto-uni-iliac grafts, and four were aortoaortic grafts. Twenty- eight patients had a bifurcated graft. One hundred fourteen patients (56%) were high risk for conventional open repair. One hundred nine patients (53%) were not suitable for most commercially available devices. RESULTS: Intraoperative technical problems occurred in 81 patients (40%). There were 37 endoleaks (27 proximal, 10 distal), 15 graft stenoses, one failure of graft deployment, two graft thromboses, three aortoiliac ruptures, five renal artery occlusions (one bilateral, four unilateral), and 18 internal iliac occlusions (five bilateral, 13 unilateral). Endovascular management of these problems was successful in 37 of the 81 patients (46%) and included 15 balloon dilatations, 21 additional stent placements, and one graft thrombectomy. Fifteen of the 81 patients (19%) had open procedures (four periaortic ligature placements, six open aneurysm repairs, three common iliac ligations, and two extra-anatomic bypass grafts). In the remaining 29 patients, the on-table problem was managed expectantly. During follow-up, two of 37 patients (5%) who were treated successfully with endovascular procedures experienced recurrence. There were five deaths (33%) among the 15 patients who underwent open procedures. CONCLUSION: Intraoperative problems occur frequently during the endovascular management of complex aneurysms. Many of these problems can be managed with additional endovascular techniques without an increased risk of recurrence or procedure-related complications. Open procedures in high-risk patients carry a high mortality rate. The team performing EVR of AAA should be skillful in advanced endovascular and open surgical procedures.

Mortality rates following endovascular repair of abdominal aortic aneurysms.

PURPOSE: To present the perioperative and late mortality following endovascular repair (EVR) of abdominal aortic aneurysms (AAAs). METHODS: Data were collected prospectively on 221 patients undergoing AAA EVR over a 4-year period (median 5-month follow-up). Patients were classified preoperatively as high risk with at least 1 of these features: serum creatinine > 150 micromol/L, ischemic heart disease or poor left ventricular function, respiratory function < 50% of predicted normal, ruptured or symptomatic AAA, contraindication to or failed open repair, and age > 80 years. RESULTS: One hundred forty (63.3%) patients were classified as high risk, the most common criterion being cardiac disease (n = 96, 68.6%). There were 25 (11.3%) deaths in the 30-day perioperative period, 22 (15.7%) in the high-risk group compared to 3 (3.7%) in the acceptable-risk group (p = 0.02). The most common causes of perioperative death were multisystem organ failure and myocardial infarction. A further 21 (9.5%) late deaths occurred, 16 (11.4%) in the high-risk group and 5 (6.2%) in the acceptable-risk group (p > 0.1). CONCLUSIONS: The mortality of patients at acceptable risk undergoing EVR compares with the best published series for conventional open AAA repair. The perioperative and late mortality in the high-risk patients are substantially higher.