New predictors of complications in carotid body tumor resection.

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques.

BACKGROUND: Practice guidelines for management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) are based on low-quality evidence, and there is limited literature that addresses optimal revascularization techniques. The purpose of this study was to compare outcomes of LSA coverage during TEVAR and revascularization techniques. STUDY DESIGN: We performed a single-center retrospective cohort study from 2001 to 2013. Patients were categorized by LSA revascularization and by revascularization technique, carotid-subclavian bypass (CSB), or subclavian-carotid transposition (SCT). Thirty-day and mid-term stroke, spinal cord ischemia, vocal cord paralysis, upper extremity ischemia, primary patency of revascularization, and mortality were compared. RESULTS: Eighty patients underwent TEVAR with LSA coverage, 25% (n = 20) were unrevascularized and the remaining patients underwent CSB (n = 22 [27.5%]) or SCT (n = 38 [47.5%]). Mean follow-up time was 24.9 months. Comparisons between unrevascularized and revascularized patients were significant for a higher rate of 30-day stroke (25% vs 2%; p = 0.003) and upper extremity ischemia (15% vs 0%; p = 0.014). However, there was no difference in 30-day or mid-term rates of spinal cord ischemia, vocal cord paralysis, or mortality. There were no statistically significant differences in 30-day or midterm outcomes for CSB vs SCT. Primary patency of revascularizations was 100%. Survival analysis comparing unrevascularized vs revascularized LSA was statistically significant for freedom from stroke and upper extremity ischemia (p = 0.02 and p = 0.003, respectively). After adjustment for advanced age, urgency, and coronary artery disease, LSA revascularization was associated with lower rates of perioperative adverse events (odds ratio = 0.23; p = 0.034). CONCLUSIONS: During TEVAR, LSA coverage without revascularization is associated with an increased risk of stroke and upper extremity ischemia. When LSA coverage is required during TEVAR, CSB and SCT are equally acceptable options.

High-risk anatomic variables and plaque characteristics in carotid artery stenting.

OBJECTIVES: To determine anatomic and plaque-related risk factors for patients undergoing carotid artery stenting. METHODS: A retrospective review of patients from a prospectively maintained database undergoing carotid artery stenting at our institution between 2001 and 2010 was performed. Preoperative imaging studies (ie, ultrasound, computed tomography angiography, magnetic resonance angiography, and angiograms) were reviewed for specific anatomic criteria and plaque characteristics. Primary outcomes included 30-day stroke or transient ischemic attack (TIA). Secondary outcomes included 30-day death and myocardial infarction (MI). Statistical significance was assumed for P = .05. RESULTS: Imaging was reviewed for 381 carotid arteries in 375 patients. There were 14 (3.7%) perioperative neurologic events, which included 8 TIA and 6 strokes. Thirty-day mortality and MI were 0.5% and 0.75%, respectively. Degree of internal carotid artery stenosis was associated with primary outcomes (P = .03), and the presence of arch calcification trended toward an increase in primary outcomes (P = .07). However, arch type, ostial involvement, tandem lesions, and plaque calcification did not correlate with primary outcomes. Differences were noted between the sexes, with females having more common carotid artery tortuosity than males (34% vs 27%, P = .04). Females also had a trend toward more plaque calcification and more severe arch calcification than males. These differences did not translate to differences in perioperative neurologic events. CONCLUSION: Our data suggest that degree of internal carotid artery stenosis and aortic arch calcification may be associated with increased perioperative neurologic risk during carotid stenting, but arch type is not.

Conformable GORE TAG thoracic endoprosthesis.

US FDA approval of the conformable Gore TAG thoracic endoprosthesis for multiple indications including aneurysm, traumatic transection and Type B dissection marks significant progress in minimally invasive therapies for the treatment of complex, life-threatening thoracic aortic pathology. This second generation device, with its enhanced flexibility and conformability, is providing improvements in both short- and long-term outcomes for many patients who may otherwise be denied life-saving treatment for thoracic aortic pathology.

Surgical management of aortitis with early aneurysmal dilation.

BACKGROUND: Aortitis is a rare and serious condition that requires expedient surgical evaluation. Diagnosis is generally made by computed tomography (CT). Surgery is most often performed when significant aneurysmal changes have already occurred. Outcomes of early surgical management of aortitis with early aneurysmal dilation have not been reported previously. METHODS: A retrospective review of open abdominal aortic repairs performed from 1999 to 2009 at a single center was done from a prospectively collected database. Patients with a confirmed radiographic appearance of aortitis and treated surgically were selected. Demographic, clinical, and surgical data of patients with aortitis showing early aneurysmal changes (aortic diameter <4 cm) were then analyzed. All aortitis cases with >4-cm aortic diameters and with prosthetic aortic grafts were excluded. RESULTS: During the observation period, 421 open abdominal aortic repairs were performed. Of these, 10 (2.4%) were identified as having primary aortitis without significant aneurysmal changes. The mean age of the patients was 62 (range 48-77) years. There were 6 (60%) men and 4 (40%) women in the cohort. Four patients (40%) had culture-negative aortitis, whereas 6 (60%) had positive microbial cultures at the time of diagnosis. Paravisceral involvement was seen in 8 (80%) cases. All patients underwent in situ repair with aortic homografts. Mean operative time was 348 minutes and mean estimated blood loss was 2475 mL. Median follow-up time was 23.1 months with a range of 1.7-51.4 months. Operative mortality was 0%, and 1 late death occurred at 23 months postoperatively. There were 9 significant in-hospital (30-day) events occurring in 5 patients, including 3 cardiovascular events, 2 pulmonary events, 3 acute renal failures, and 1 deep surgical site infection. CONCLUSIONS: Aortitis is an uncommon indication for aortic repair. Infectious aortitis is most commonly confirmed by microbiologic studies, but a significant number of cases have no demonstrable microbial source. Outcomes after early surgical management for aortitis with small aneurysms demonstrated improved mortality when compared with series reviewing outcomes in aortitis patients with large mycotic aneurysms.

The use of cryopreserved aortoiliac allograft for aortic reconstruction in the United States.

BACKGROUND: Aortic infections, even with treatment, have a high mortality and risk of recurrent infection and limb loss. Cryopreserved aortoiliac allograft (CAA) has been proposed for aortic reconstruction to improve outcomes in this high-risk population. METHODS: A multicenter study using a standardized database was performed at 14 of the 20 highest volume institutions that used CAA for aortic reconstruction in the setting of infection or those at high risk for prosthetic graft infection. RESULTS: Two hundred twenty patients (mean age, 65; male:female, 1.6/1) were treated since 2002 for culture positive aortic graft infection (60%), culture negative aortic graft infection (16%), enteric fistula/erosion (15%), infected pseudoaneurysm adjacent to the aortic graft (4%), and other (4%). Intraop cultures indicated infection in 66%. Distal anastomosis was to the femoral artery and iliac. Mean hospital length of stay was 24 days, and 30-day mortality was 9%. Complications occurred in 24% and included persistent sepsis (n = 17), CAA thrombosis (n = 9), CAA rupture (n = 8), recurrent CAA/aortic infection (n = 8), CAA pseudoaneurysm (n = 6), recurrence of aortoenteric fistula (n = 4), and compartment syndrome (n = 1). Patients with full graft excision had significantly better outcomes. Ten (5%) patients required allograft explant. Mean follow-up was 30 ± 3 months. Freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. Primary graft patency was 97% at 5 years, and patient survival was 75% at 1 year and 51% at 5 years. CONCLUSIONS: This largest study of CAA indicates that CAA allows aortic reconstruction in the setting of infection or those at high risk for infection with lower early and long-term morbidity and mortality than other previously reported treatment options. Repair with CAA is associated with low rates of aneurysm formation, recurrent infection, aortic blowout, and limb loss. We believe that CAA should be considered a first line treatment of aortic infections.

Influence of oversizing on outcome in thoracic endovascular aortic repair.

PURPOSE: To investigate the influence of stent-graft oversizing on device-related complications after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA). METHODS: The study cohort was composed of patients enrolled in 4 clinical trials of the TAG thoracic stent-graft. A total of 337 TAA patients (222 men; mean age 72 years) treated in these trials had sufficient data for analysis of oversizing and post-procedure mortality and complications, such as endoleak, migration, rupture, and reinterventions. Mean oversizing at the proximal landing zone was 14.6% (range -3.4% to 39.7%). Patients were stratified based on the percentage of oversizing: <10% (n=85, group 1), 10%-20% (n=188, group 2), and >20% (n=64, group 3). RESULTS: Patients in group 1 had significantly larger preoperative proximal aortic diameters (32.6 vs. 31.3 vs. 28.2 mm, respectively; p<0.001) and neck lengths (6.9 vs. 5.8 vs. 5.2 cm (p=0.035). Overall, type I endoleak was the most frequent complication during the first 30 days of follow-up (35, 10.4%), but the incidences did not differ among the 3 groups (10.6% vs. 11.2% vs. 7.8%, respectively; p=0.809). Over a mean follow-up of 41.8±20.7 months, there were no significant differences in the occurrence of device-related complications among the groups, though the incidence of type I endoleaks was lower in group 2 (9.4% vs. 3.2% vs. 7.8%, respectively; p=0.073). Cox proportional hazards modeling showed no difference in the time to type I endoleak among oversizing groups [group 1 vs. 2: HR 1.24, 95% CI 0.65 to 2.36 (p=0.509) and group 3 vs. 2: HR 1.24, 95% CI 0.60 to 2.60 (p=0.562)]. CONCLUSION: The percentage of oversizing did not significantly affect the incidence of device-related complications after TEVAR for TAA. Although oversizing may enhance the radial force and help maintain a good proximal seal, additional oversizing seemed not to improve the overall outcome in this analysis. The current guidelines regarding stent-graft oversizing for TAA seem appropriate, though the correct percentage remains to be determined.

Use of dairies by postreproductive flocks of European starlings.

Knowledge of the behavior and movement patterns of European starlings (Sturnus vulgaris L.) is important to wildlife managers that seek to resolve conflicts at livestock facilities. We captured and radio tagged 10 starlings at each of 5 dairies in northeastern Ohio. From September 19 to October 31, 2007, we obtained sufficient data from 40 birds to study their behavior and movements. The birds visited the dairies where they were initially captured (home sites) on 85% of the days, spending 58% of each day at the dairies. Onsite arrival and departure times were 2.5h after sunrise and 3.1h before sunset. Daily visits by radio-tagged cohorts from the other dairies were greatest for the 2 most proximate dairies (1.3 km apart), with number of visits between this pairing >7× that of the 9 other pairings combined (4.1-6.5 km apart). Two birds used their home sites intermittently as roosts, arriving 3.8h before sunset and departing 0.2h after sunrise. In addition to using home-site roosts, these birds also used a distant roost (22km) that was used by 36 of the 40 birds. The efficacy of starling management programs, especially lethal management, depends on degree of site fidelity, use of other facilities, and roosting behavior. For example, starlings that use dairies as roosting sites may require a different management strategy than required at dairies used as daytime sites because of differences in arrival and departure behavior. Our research will help resource managers evaluate current management strategies already in place and change them, if needed, to fit the behavior profile of starlings using dairies and other types of livestock facilities.

Primary extracranial vertebral artery aneurysms.

BACKGROUND: Extracranial vertebral artery aneurysms are uncommon and are usually associated with trauma or dissection. Primary cervical vertebral aneurysms are even rarer and are not well described. The presentation and natural history are unknown and operative management can be difficult. Accessing aneurysms at the skull base can be difficult and, because the frail arteries are often afflicted with connective tissue abnormalities, direct repair can be particularly challenging. We describe the presentation and surgical management of patients with primary extracranial vertebral artery aneurysms. METHODS: In this study we performed a retrospective, multi-institutional review of patients with primary aneurysms within the extracranial vertebral artery. RESULTS: Between January 2000 and January 2011, 7 patients, aged 12-56 years, were noted to have 9 primary extracranial vertebral artery aneurysms. All had underlying connective tissue or another hereditary disorder, including Ehler-Danlos syndrome (n=3), Marfan's disease (n=2), neurofibromatosis (n=1), and an unspecified connective tissue abnormality (n=1). Eight of 9 aneurysms were managed operatively, including an attempted bypass that ultimately required vertebral ligation; the contralateral aneurysm on this patient has not been treated. Open interventions included vertebral bypass with vein, external carotid autograft, and vertebral transposition to the internal carotid artery. Special techniques were used for handling the anastomoses in patients with Ehler-Danlos syndrome. Although endovascular exclusion was not performed in isolation, 2 hybrid procedures were performed. There were no instances of perioperative stroke or death. CONCLUSIONS: Primary extracranial vertebral artery aneurysms are rare and occur in patients with hereditary disorders. Operative intervention is warranted in symptomatic patients. Exclusion and reconstruction may be performed with open and hybrid techniques with low morbidity and mortality.

Early versus delayed carotid endarterectomy in symptomatic patients.

BACKGROUND: Delayed carotid endarterectomy (CEA) after a stroke or transient ischemic attack (TIA) is associated with risks of recurrent neurologic symptoms. In an effort to preserve cerebral function, urgent early CEA has been recommended in many circumstances. We analyzed outcomes of different time intervals in early CEA in comparison with delayed treatment. STUDY DESIGN: Retrospective chart review from a single university hospital tertiary care center between April 1999 and November 2010 revealed 312 patients who underwent CEA following stroke or TIA. Of these 312 patients, 69 received their CEA within 30 days of symptom onset and 243 received their CEA after 30 days from symptom onset. The early CEA cohort was further stratified according to the timing of surgery: group A (27 patients), within 7 days; group B (17), between 8 and 14 days; group C (12), between 15 and 21 days; and group D (12), between 22 and 30 days. Demographic data as well as 30-day (mortality, stroke, TIA, and myocardial infarction) and long-term (all-cause mortality and stroke) adverse outcome rates were analyzed for each group. These were also analyzed for the entire early CEA cohort and compared against the delayed CEA group. RESULTS: Demographics and comorbid conditions were similar between groups. For 30-day outcomes, there were no deaths, 1 stroke (1.4%), 0 TIAs, and 0 myocardial infarctions in the early CEA cohort; in the delayed CEA cohort, there were 4 (1.6%), 4 (1.6%), 2 (0.8%), and 2 (0.8%) patients with these outcomes, respectively (P > .05 for all comparisons). Over the long term, the early group had one ipsilateral stroke at 17 months and the delayed group had two ipsilateral strokes at 3 and 12 months. For long-term outcomes, there were 16 deaths in the early CEA cohort (21%) and 74 deaths in the delayed CEA cohort (30%, P > .05). Mean follow-up times were 4.5 years in the early CEA cohort and 5.8 years in the delayed CEA cohort. CONCLUSIONS: There were no differences in 30-day and long-term adverse outcome rates between the early and delayed CEA cohorts. In symptomatic carotid stenosis patients without evidence of intracerebral hemorrhage, carotid occlusion, or permanent neurologic deficits early carotid endarterectomy can be safely performed and is preferred over delaying operative treatment.

Emergent repair of acute thoracic aortic catastrophes: a comparative analysis.

OBJECTIVE: To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR). DESIGN: Single-center retrospective review (April 2001-January 2010). SETTING: Academic medical center. PATIENTS: One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2). MAIN OUTCOME MEASURES: Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months. RESULTS: Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P < .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001). CONCLUSION: Patients presenting with ACDTA are best treated with TEVAR whenever feasible.

A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation.

INTRODUCTION: A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability. METHODS: Patients with CIAA who underwent EVAR were identified in two teaching hospitals. Bell-bottom technique (BBT; iliac limb ≥20 mm) or internal iliac artery embolization and limb extension to the external iliac artery (IIE + EE) were used. Outcome between these two approaches was compared. RESULTS: We identified 185 patients. Indication for EVAR included asymptomatic abdominal aortic aneurysm (AAA) in 157, symptomatic or ruptured aneurysm in 19, and CIAA in nine. Mean AAA diameter was 59 mm. Among 260 large CIAAs that were treated, BBT was used to treat 166 CIAA limbs, and 94 limbs underwent IIE + EE. Total reintervention rates were 11% for BBT (n = 19) and 19.1% for IIE + EE (n = 18; P = .149). Rates of reintervention for type Ib or III endoleak were 4% for BBT (n = 7) and 4% for IIE + EE (n = 4; P > .99). The difference in limb patency rates was not significant. The 30-day mortality rate was 1%. Median follow-up was 22 months. Complications did not differ significantly between the two groups; however, the combined incidence of perioperative complications and reinterventions was higher in the IIE + EE group (49% vs 22%; P = .002). CONCLUSIONS: The combined incidence of perioperative complications and reinterventions is significantly higher with IIE + EE than with BBT; therefore, when feasible, BBT is desirable.

Comprehensive assessment of prophylactic preoperative inferior vena cava filters for major spinal reconstruction in adults.

STUDY DESIGN: A retrospective data analysis. OBJECTIVE: To report a comprehensive assessment of preoperative prophylactic inferior vena cava (IVC) filter placement in spine surgery. SUMMARY OF BACKGROUND DATA: Venous thromboembolism (VTE) is a serious complication after major spinal reconstructive surgery in adults. Specifically, pulmonary embolism (PE) can result in significant morbidity and mortality, and it has been reported in up to 13% of patients. Prophylactic IVC filter placement was initiated for all "high-risk" spinal surgery patients after a pilot study demonstrated decreased VTE-related morbidity and mortality. METHODS: After institutional review board approval, the medical records of all patients receiving an IVC filter at a single institution from 2000 to 2007 were reviewed. Age, sex, surgical approach, postoperative deep vein thrombosis (DVT), postoperative superficial thrombus, presence of pulmonary or paradoxical embolus, mortality, and IVC filter complications were all evaluated. Indications for IVC filter placement included history of DVT or PE, malignancy, hypercoagulability, prolonged immobilization, staged procedures of longer than 5 segment levels, combined anterior-posterior approaches, iliocaval manipulation during exposure, and anesthetic time of more than 8 hours. Descriptive statistics were used for the analysis of patient characteristics. Nonparametric frequency statistics (odds ratios [OR], χ) were used for analysis of main outcomes. RESULTS: A total of 219 patients (150 women, 69 men) with a mean age of 58.8 (range, 17-86) years, were analyzed. There were 2 complications from IVC filter placement (66 Greenfield filters; 157 retrievable filters). The incidence of lower extremity DVT was 18.7% (41/219) in 36 patients. PE incidence was 3.7% (8/219 patients), and the paradoxical embolus rate was 0.5% (1 patient). Prophylactic IVC filter use reduced the odds of developing a pulmonary embolus (OR = 3.7, P < 0.05) compared with population controls. Patients receiving Greenfield filters had significantly higher VTE incidence than those receiving retrievable filters (OR = 2.8, P = 0.008). Anesthesia duration of more than 8 hours significantly increases VTE incidence (P = 0.029). No statistical significance (P < 0.05) was noted with combined anterior-posterior approach (118 patients) versus posterior-only approach (101 patients) and the incidence of DVT (24/118, 20.3% for former; 17/101, 16.8% for latter). There were a total of 14 deaths; none related to PE or paradoxical embolism during an 8-year period. Mean and median follow-up was 2.8 and 2.4 years, respectively, with 126 achieving 2 or more years of follow-up. CONCLUSION: VTE-related morbidity and mortality have heightened the awareness within the spine community to the perioperative management of patients undergoing major spinal reconstruction. Prophylactic IVC filter placement significantly lowers VTE-related events, including PE development, than population controls.

Are carotid stent fractures clinically significant?

PURPOSE: Late stent fatigue is a known complication after carotid artery stenting (CAS) for cervical carotid occlusive disease. The purpose of this study was to determine the prevalence and clinical significance of carotid stent fractures. MATERIALS AND METHODS: A single-center retrospective review of 253 carotid bifurcation lesions treated with CAS and mechanical embolic protection from April 2001 to December 2009 was performed. Stent integrity was analyzed by two independent observers using multiplanar cervical plain radiographs with fractures classified into the following types: type I = single strut fracture; type II = multiple strut fractures; type III = transverse fracture; and type IV = transverse fracture with dislocation. Mean follow-up was 32 months. RESULTS: Follow-up imaging was completed on 106 self-expanding nitinol stents (26 closed-cell and 80 open-cell stents). Eight fractures (7.5%) were detected (type I n = 1, type II n = 6, and type III n = 1). Seven fractures were found in open-cell stents (Precise n = 3, ViVEXX n = 2, and Acculink n = 2), and 1 fracture was found in a closed-cell stent (Xact n = 1) (p = 0.67). Only a previous history of external beam neck irradiation was associated with fractures (p = 0.048). No associated clinical sequelae were observed among the patients with fractures, and only 1 patient had an associated significant restenosis (≥ 80%) requiring reintervention. CONCLUSIONS: Late stent fatigue after CAS is an uncommon event and rarely clinically relevant. Although cell design does not appear to influence the occurrence of fractures, lesion characteristics may be associated risk factors.

Does a contralateral carotid occlusion adversely impact carotid artery stenting outcomes?

BACKGROUND: Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood. METHODS: A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years). RESULTS: Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant). CONCLUSION: A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.

Plaque Characteristics in the Superficial Femoral Artery Correlate with Walking Impairment Questionnaire Scores in Peripheral Arterial Disease: The Walking and Leg Circulation Study (WALCS) III.

PURPOSE: We studied associations of magnetic resonance imaging (MRI)-measured plaque area and relative percent lumen reduction in the proximal superficial femoral artery with Walking Impairment Questionnaire (WIQ) scores and quality of life in people with lower extremity peripheral arterial disease (PAD). METHODS: Four-hundred forty-two participants with PAD underwent cross-sectional imaging of the proximal superficial femoral artery with MRI, and completed the WIQ and the Short-Form-12 mental and physical functioning questionnaires. Questionnaires were scored on a 0-100 scale (100=best). Results adjust for age, sex, race, the ankle brachial index (ABI), comorbidities, and other covariates. RESULTS: Adjusting for age, sex, race, ABI, comorbidities, and other covariates, higher mean plaque area was associated with poorer WIQ distance scores (1st quintile (least plaque)-44.8, 2nd quintile-43.3, 3rd quintile-38.9, 4th quintile-34.6, 5th quintile (greatest plaque)-30.6, p trend <0.001) and poorer WIQ speed scores (1st quintile-40.6, 2nd quintile-39.6, 3rd quintile-39.5, 4th quintile-32.8, 5th quintile-33.0, p trend =0.019). Similar associations of higher maximum plaque area, mean lumen reduction, and maximum lumen reduction with poorer WIQ distance and speed scores were observed. Plaque measures were not associated with WIQ stair climbing scores or SF-12 scores. CONCLUSION: Among participants with PAD, greater plaque burden and smaller lumen area in the proximal superficial femoral artery are associated with poorer walking endurance and slower walking speed as measured by the WIQ, even after adjusting for the ABI.

Stepwise age-related outcomes of elective endovascular abdominal aortic aneurysm repair: 11-year institutional review.

OBJECTIVE: Endovascular repair of abdominal aortic aneurysms (EVAR) has largely supplanted open surgery over the past 2 decades. Faced with an aging population, the outcomes of EVAR among various age groups were examined. METHOD: Retrospective review of elective EVAR cases was performed at a single institution from 1998 to 2009. Patients were separated into 4 age groups for easy comparison. Perioperative data were analyzed using Fisher's exact test. RESULTS: Demographics were similar among the groups except for sex, BMI, and smoking status. The 30-day morbidity and mortality data were not statistically different among groups. From EVAR to end of the study, there was a 10.9% all-cause mortality rate (with no difference among groups) and an 8.0% reintervention rate (with the oldest age group having a lower reintervention rate; P < .03). CONCLUSIONS: EVAR remains a good treatment option for elective aneurysm repair despite advanced age, which alone does not appear to be an independent predictor of outcome.

Late abdominal aortic endograft explants: indications and outcomes.

BACKGROUND: Despite advances in endoluminal salvage for failed endografts, certain circumstances necessitate open endovascular abdominal aneurysm repair (EVAR) conversion. We review the indications for and outcomes after late EVAR explants. METHODS: Retrospective review of EVAR patients requiring delayed (>30 days) conversion from 1999 to 2009. Demographics, index endovascular procedure, conversion indication/technique, and outcomes were analyzed. RESULTS: Among 16 patients who required late conversion, the mean age was 73 years (range, 41-84 years) and 94% were men. Indications included 9 device failures, 6 endograft infections, and a single type II endoleak with sac enlargement. Explanted prostheses included the following: 7 Cook Zenith(®) endoprosthesis, 3 Gore Excluder(®) grafts, 3 Medtronic AneuRx(®) endograft devices, 2 Endologix Powerlink(®) endografts, and 1 Guidant Ancure(®) graft. Before conversion, 7 patients underwent unsuccessful secondary salvage procedures. Transperitoneal (81%) and left retroperitoneal approaches (19%) were used, with 75% requiring supraceliac control. Reconstructions depended on clinical manifestations and included 10 in situ prosthetic repairs, 4 extra-anatomic bypasses, and 2 in situ cryopreserved human allograft repairs. Two patients died during their hospitalization, resulting in a 13% mortality rate. Mean hospitalization for survivors was 18 days (range, 6-78 days), and 7 (50%) of the patients were discharged directly home. CONCLUSION: Most delayed EVAR conversions are because of device failure or infection and can be successfully converted to open surgical reconstruction. Supraceliac control is often required, and the perioperative complications are greater than primary elective open or endovascular repair. This study addresses how best to manage failed abdominal aortic endografts and what can be done to improve patient outcomes with this difficult clinical problem.

Normal preoperative white blood cell count is predictive of outcomes for endovascular procedures.

BACKGROUND: An abnormally elevated preoperative white blood cell count (WBC) has been associated with postoperative morbidity and mortality. However, it is unknown if a normal WBC is predictive of postoperative outcomes following vascular interventions. Thus, the objective of this study is to determine if a WBC within the normal range is predictive of outcomes following vascular interventions. METHODS: The medical records of patients undergoing endovascular and open repair of carotid stenosis, aortic aneurysm, and peripheral arterial disease from 1999 to 2009 were retrospectively reviewed. Major adverse events (MAE) were defined as death, stroke, and myocardial infarction. RESULTS: Of 1773 cases with normal preoperative WBC (3.5-10.5 K/µL), there were 804 [45.3%] endovascular and 969 [54.7%] open vascular surgeries. Patients with complications (55) or MAE (19) after endovascular intervention had higher preoperative WBC compared with patients without complications (WBC 7.7 ± 1.47 vs 7.1 ± 1.57, respectively, P = .002) or MAE (WBC 8.3 ± 1.26 vs 7.1 ± 0.06, respectively, P = .001). No difference was observed for patients who received open surgery. Patients undergoing endovascular intervention were 2.3, 4.8, and 22 times more likely to experience complications (P = .004), MAE (P = .003), or death (P = .036) when WBC exceeded 7.5 K/µL. Multivariate analysis showed that preoperative normal WBC was an independent predictor of complications, MAE, and death in patients after endovascular procedures but only for death in patients after open vascular procedures. CONCLUSIONS: This study demonstrates a strong linear correlation between an increasing preoperative WBC within the normal range and an increased risk for postoperative complications and death following endovascular interventions. The study also found a significant curvilinear U-shaped relation between a normal preoperative WBC and death in the open surgical cohort, with patients in the very low and very high normal WBC range at an increased risk of death.

Treatment of vertebral disease: appropriate use of open and endovascular techniques.

Vertebral artery disease is an often underdiagnosed and undertreated cause of posterior circulation ischemia. Revascularization of the vertebral circulation should be considered in patients refractory to medical therapy. Surgical and endovascular techniques are discussed and reviewed in the context of the location and type of vertebral artery disease.