The Effects of Clopidogrel Duration on Carotid Artery In-Stent Restenosis.

BACKGROUND: There are limited data supporting a specific duration for dual antiplatelet therapy in carotid artery stenting (CAS), and most clinical evidence is derived from studies involving coronary interventions. As a result, the appropriate duration of dual antiplatelet therapy after CAS is yet to be determined. We aimed to elucidate whether the duration of dual antiplatelet therapy played a role in the rate of carotid in-stent restenosis. METHODS: A retrospective analysis of all patients who underwent CAS at our institution over a 20-year period (1996-2016) was performed (n = 279). Patients who did not complete their follow-up duplex studies or were not discharged on clopidogrel were excluded from the study. Patients were separated into short-term (<6 weeks, n = 159) and long-term (>6 weeks, n = 112) clopidogrel users based on duration of therapy. We defined clinically significant in-stent restenosis as >50% restenosis (peak systolic velocity = 224 cm/s) in symptomatic patients and >80% restenosis (peak systolic velocity = 325 cm/s) in asymptomatic patients status-post prior CAS based on published velocity criteria. Rates of in-stent restenosis at 1-year, 2-year, and 5-year intervals were analyzed between the 2 groups using chi-squared analysis. RESULTS: Demographic information was largely similar between the 2 groups; however, short-term clopidogrel users were more likely to have a history of atrial fibrillation (9.43% vs. 1.68%, P = 0.008) and were less likely to have a history of coronary artery bypass graft (16.35% vs. 29.41%, P = 0.009), diabetes (33.34% vs. 49.58%, P = 0.006), and coronary artery disease (50.31% vs. 63.03%, P = 0.035). All patients were on long-term aspirin therapy. There was no significant difference between overall rates of in-stent restenosis between the short-term and long-term clopidogrel users (5.03% vs. 9.24%, P = 0.168) within 5 years of the index procedure. Similar results were observed when these groups were evaluated at 1-year (5.61% vs. 3%, P = 0.321), 2-year (2.02% vs. 6.59%, P = 0.072), and 5-year (2.24% vs. 3.57%, P = 0.635) follow-up. CONCLUSIONS: No statistically significant difference was observed in the rate of in-stent restenosis after CAS between short-term and long-term clopidogrel therapy. Patients in whom there is no other indication for longer duration clopidogrel therapy may be considered for shorter duration course of dual antiplatelet therapy following CAS.

Single Center Outcomes of Carotid Artery Stenting in Veterans with Prior Head and Neck Cancer.

BACKGROUND: Patients meeting criteria for intervention of carotid stenosis with a history of prior cervical radiation or neck dissection are considered "high risk" for carotid endarterectomy. This is a well-established indication for carotid artery stenting (CAS). The long-term outcomes of CAS in this population are less frequently published in the literature but are poor. The purpose of this study was to review long-term results of CAS in veteran patients with a prior history of treatment for head and/or neck cancer. METHODS: This is a retrospective review of a veteran patient population from 1998 to 2016. All patients at our institution with a prior history of treatment for head and/or neck cancer who underwent CAS were included in the analysis. During this time period, 44 patients met inclusion criteria and were treated with 57 carotid stenting interventions. The Kaplan-Meier analysis was used to determine survival and primary patency. The secondary aims were to analyze early outcomes and to identify predictive risk factors for mortality and reintervention. RESULTS: The mean follow-up was 42.9 ± 36.6 months. The cumulative survival at 1, 5, and 10 years was 91%, 67%, and 48%, respectively. The primary patency at 1, 5, and 10 years was 95%, 86%, and 86%, respectively. The reintervention rate was 11% (n = 6) with an assisted primary patency rate of 100%. No neurologic events occurred within 30 days. There were 3 strokes in late follow-up and no stroke-related deaths. Eighteen patients (41%) died during the follow-up period, 15 of whom died during the first 5 years of follow-up. Ten (66%) of those patients died of recurrent or active index cancer. On univariate analysis, tumor, node, metastasis stage IV was significantly associated with death (P = 0.02). Multivariate models were not statistically significant for predicting mortality or reintervention CONCLUSIONS: On the basis of the results in this series, CAS can be performed in these patients with low long-term rates of neurologic events and need for reintervention. However, the survival of patients with head and neck cancer undergoing CAS in this cohort is poor, which is consistent with other published series of patients undergoing CAS for head/neck cancer with at least 5-year follow-up. In this specific patient population, a more critical analysis of the patient's overall prognosis, especially as related to cancer, should be undertaken before offering CAS.

Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation.

OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. METHODS: We conducted a retrospective institutional review board-approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010-January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near-infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. RESULTS: A total of 91 patients were placed on ECMO via femoral arterial cannula (16-F to 24-F) for a mean duration of 9 days (range, 1-40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20-Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. CONCLUSIONS: Limb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.

Arteriovenous access does not perform as well for plasmapheresis.

PURPOSE: Access surgeons are occasionally asked to create arteriovenous access for non-dialysis functions. Subjectively noting overall poor results, we seek to present our experience with arteriovenous access creation for apheresis. METHODS: Billing records were reviewed using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) codes to identify patients undergoing arteriovenous access creation for diseases other than renal failure from January 2007 to August 2014. Inpatient and outpatient records were reviewed to identify patient demographics, disease-specific medications/treatments, access-specific characteristics, patency data, and reinterventions required. RESULTS: A total of 16 access creation procedures were performed for 8 patients, accounting for just 1.6% of total access creations during the period. Treatment was for myasthenia gravis (n = 6), chronic inflammatory degenerative polyneuropathy (n = 9), and stiff man syndrome (n = 1). Access failure was by thrombosis (n = 7), non-maturation (n = 4), and infection/steal syndrome (n = 1), with four accesses still functional at conclusion of review. There was 50% autogenous access creation and overall maturation rate of 37.5%. Mean primary patency was 236 days (range 10-878), with secondary patency achieved in three patients adding a mean of 174 days (range 2-517). Cumulative 3-month and 1-year patency rates were 36.5% and 25%, respectively. CONCLUSIONS: Arteriovenous access creation for plasmapheresis represents a minority of access procedures. Though it remains unclear why, patency and maturation rates are significantly lower than expected when compared to access for hemodialysis access. These high failure rates must be taken into account when considering replacement of temporary catheters with surgical access for non-hemodialysis needs.

Concomitant Parallel Endografting and Fenestrated Experience in a Regional Aortic Center.

BACKGROUND: Off-label parallel endografting (PE) has been increasingly criticized in favor of on-label custom fenestrated endografts. There remain limited direct comparisons, however, between concurrent patient populations treated by similarly experienced operators. Hence, we seek to evaluate the relative efficacy of the two techniques in treating complex aortic pathology. METHODS: All patients treated by PE or with Cook Zenith Fenestrated (Zfen) devices from January 2010 to June 2015 were reviewed, excluding those treated for rupture. Patients were all evaluated for open repair as well as for fenestrated devices since its availability at our center in July 2013. Patients predating fenestrated access or not meeting anatomic indications for use criteria and preferring endovascular therapy were treated with PE. RESULTS: A total of 93 patients were treated during the period reviewed, 54 (58.1%) by PE and 39 (41.9%) with Zfen. The two procedures required similar length of surgery (234 min PE vs. 239 min Zfen), blood loss (634 cc vs. 409 cc), and length of stay (median 6 days). PE, however, was associated with less fluoroscopy time (52.8 vs. 64.6 min) and contrast volume (103.5 cc PE vs. 133 cc Zfen). At mean 202 days follow-up, Zfen has required three reinterventions (two type III endoleaks and one superior mesenteric artery stenosis causing mesenteric ischemia) and there have been zero branch vessels lost. At mean 427 days follow-up, PE patients experienced three stent occlusions (one repaired endovascularly) and required eight additional interventions (two type I endoleaks, two type II endoleaks with sac growth, two type III endoleaks, one graft infection, and one aneurysm rupture). Reintervention rates for PE and Zfen were 17.6% and 7.7%, respectively, with branch patency rates of 98% and 100%. CONCLUSIONS: PE and fenestrated repair offer similarly high branch patency and technical success. PE performed for juxtarenal aneurysms has similar reintervention rate to fenestrated repair. The two techniques have similar length of stay, operative time, and blood loss, but fenestrated repair is associated with greater fluoroscopy time and contrast usage.

Median Arcuate Ligament Syndrome-Review of This Rare Disease.

IMPORTANCE: Median arcuate ligament (MAL) syndrome is a rare disease resulting from compression of the celiac axis by fibrous attachments of the diaphragmatic crura, the median arcuate ligament. Diagnostic workup and therapeutic intervention can be challenging. OBJECTIVE: To review the literature to define an algorithm for accurate diagnosis and successful treatment for patients with MAL syndrome. EVIDENCE REVIEW: A search of PubMed (1995-September 28, 2015) was conducted, using the key terms median arcuate ligament syndrome and celiac artery compression syndrome. FINDINGS: Typically a diagnosis of exclusion, MAL syndrome involves a vague constellation of symptoms including epigastric pain, postprandial pain, nausea, vomiting, and weight loss. Extrinsic compression of the vasculature and surrounding neural ganglion has been implicated as the cause of these symptoms. Multiple imaging techniques can be used to demonstrate celiac artery compression by the MAL including mesenteric duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry, and mesenteric arteriography. Surgical intervention involves open, laparoscopic, or robotic ligament release; celiac ganglionectomy; and celiac artery revascularization. There remains a limited role for angioplasty because this intervention does not address the underlying extrinsic compression resulting in symptoms, although angioplasty with stenting may be used in recalcitrant cases. CONCLUSIONS AND RELEVANCE: Median arcuate ligament syndrome is rare, and as a diagnosis of exclusion, diagnosis and treatment paradigms can be unclear. Based on previously published studies, symptom relief can be achieved with a variety of interventions including celiac ganglionectomy as well as open, laparoscopic, or robotic intervention.

Acute Paget-Schroetter syndrome: does the first rib routinely need to be removed after thrombolysis?

BACKGROUND: Most clinicians feel that treatment for patients with acute primary axillosubclavian vein thrombosis ("effort thrombosis") is catheter-directed thrombolysis followed by thoracic outlet decompression. Several investigators feel that first rib resection (FRR) is not indicated in every case. No randomized data exist to answer this question. METHODS: A MEDLINE search was done using the terms "Paget-Schroetter syndrome," "upper extremity DVT," "first rib resection," "effort thrombosis," and "primary upper extremity thrombosis," with thrombolysis used as an "AND" term. We also specifically explored references cited to support either side of this argument in the past. Analysis was limited to patients aged 18 years or older with symptoms of 14-day duration or less undergoing thrombolysis for primary axillosubclavian vein thrombosis. Those studies that did not report follow-up, duplicate series from the same institution, and those in which patients were stented were excluded. Results were analyzed on an intent-to-treat basis, with groups assigned according to each authors' prospectively described algorithm. RESULTS: Twelve series were included. Patients were divided into 3 groups according to treatment after thrombolysis: FRR (448 patients), FRR plus endovenous balloon venoplasty (FRR + PLASTY; 68 patients), and those with no further intervention after thrombolysis (rib not removed; 168 patients). Symptom relief at last follow-up was significantly more likely in the FRR (95%) and FRR + PLASTY (93%) groups than in the rib not removed (54%) group (both <0.0001) as was patency (98%, 86%, and 48%, respectively; both <0.0001 vs. rib not removed). More than 40% of patients in the rib not removed group eventually required rib resection for recurrent symptoms. No differences in symptom-free rates were seen when comparing FRR with FRR + PLASTY. CONCLUSIONS: In patients with acute effort thrombosis who undergo thrombolysis, permanent symptom relief and long-term patency are more likely to be achieved in patients who undergo FRR with or without endovenous balloon venoplasty than those whose rib is left intact.

An interesting anatomic variant of inferior vena cava duplication: case report and review of the literature.

Congenital anomalies of the inferior vena cava (IVC) occur in roughly 4% of the population. We report an interesting case of an atypical variant of duplicated IVC. A 20-year-old man presented with orthopedic injuries and intracranial hemorrhage following a motorcycle accident. He was taken to the fluoroscopy suite for IVC filter placement; duplication of the IVC was noted. The right and left iliac veins shared a normal confluence but two IVCs drained independently into renal veins before reuniting into a single structure. Both IVC filters were placed via a single puncture in the groin. We performed a search of the PubMed database using' inferior vena cava duplication' and reviewed common anomalies of the IVC. Several variants of duplicated IVC exist; the most common of which is two distinct IVCs that arise from each iliac vein without a normal confluence. Our patient had a unique anomaly which allowed filter placements from a single puncture.

Coral reef aorta: case report and review of the literature.

Coral reef aorta (CRA) is a rare form of atherosclerosis that affects the paravisceral and pararenal aorta and its branches. Patients typically present with arterial insufficiency of the bowels, kidneys and lower extremities. The current mainstay of treatment is operative, typically involving transaortic endarterectomy. Herein, we describe a 54-year-old woman with incapacitating lower extremity claudication secondary to a paravisceral coral reef atheroma treated successfully with transaortic endarterectomy via a left retroperitoneal approach. In addition, we present a complete review of modern English literature on CRA.

Results of polytetrafluoroethylene-covered nitinol stents crossing the inguinal ligament.

OBJECTIVE: Placement of arterial endoprostheses across the inguinal ligament is generally thought to be contraindicated for fear of device kinking, fracture, or occlusion and possible obliteration of the deep femoral artery (DFA). We present a series of selected patients who underwent insertion of polytetrafluoroethylene-covered nitinol stents (Viabahn stent grafts. W. L. Gore and Associates Inc, Flagstaff, Ariz) crossing the middle common femoral artery (CFA) on an emergency basis or who were considered high risk for open surgery. METHODS: We treated 16 patients with 17 lesions adjacent to or within the CFA with stent grafts that originated in the common iliac (two) or external iliac (15) artery and terminated in the distal CFA (12), DFA (three), or superficial femoral (two) artery. Stent grafts were placed on an elective (10) or emergency (seven) basis for arterial occlusive disease (10), bleeding (six), and aneurysmal disease (one). Comorbidities favoring endovascular treatment were high medical risk (10) previous scarring (four), morbid obesity (two), and dense arterial calcification precluding open surgical repair (one). RESULTS: The DFA was deliberately sacrificed in one of the 17 cases. No patient suffered major complications after the procedure. All grafts remained patent based on duplex ultrasound imaging during follow-up (mean, 12.3 months; range, 1-58 months). Two patients required an additional endovascular intervention to treat inflow or outflow stenoses during follow-up, yielding a 2-year primary patency rate of 93.8% and assisted primary patency rate of 100%. CONCLUSIONS: These results suggest that selective placement of Viabahn stent grafts across the inguinal ligament to treat arterial occlusive disease or bleeding may prove to be safe, effective, and associated with acceptable patency rates. This strategy helps avoid complicated open arterial surgery in high-risk patients with associated multiple medical risk factors or hostile scarred groins.

Robotic-assisted median arcuate ligament release.

Median arcuate ligament syndrome results from external compression of the celiac axis by attachments of the diaphragmatic crura. It has been treated with open or laparoscopic surgical decompression of the celiac axis with neurolysis. We describe our initial experience treating three patients using a robotic-assisted technique with median arcuate ligament release and celiac neurolysis. Average operative time was 2.2 hours. No intraoperative complications occurred. At an average of 11 months postoperative (14, 11, and 8 months), two patients continue with resolution of preoperative symptoms. Our experience affirms that further study using the robotic approach appears warranted.

An unusual cause of venous hypertension after dialysis access creation.

Venous hypertension after creation of arteriovenous fistula or arteriovenous shunt occurs in approximately 10-15% of patients (Kojecky et al., Biomed Papers, 2002;146:77-79; Criado et al., Ann Vasc Surg 1994;8:530-535). Its etiology is commonly stenosis and/or thrombosis of the central venous system secondary to previous catheterization with subsequent development of venous hypertension after the arteriovenous connection is made. Treatment strategies often involve venography to determine the site of venous stenosis and/or occlusion centrally and subsequent endovascular recanalization of the stenotic or occluded veins. In this article, we report a case of venous hypertension in a 76-year-old man who presented with a swollen arm after placement of an arteriovenous fistula. In this circumstance, venography revealed extrinsic compression of the subclavian vein at the level of the first rib, the anatomic abnormality seen in venous thoracic outlet syndrome. In this report, we describe surgical and endovascular management of this patient, and review the literature on the causes of central vein stenosis discovered after creation of dialysis access.

Is gastrectomy safe in the elderly? A single institution review.

The population of the United States is aging. Studies within the last several years have demonstrated that major abdominal operations in elderly patients can be done safely, but with increased rates of complications. We set out to determine the rates of morbidity and mortality in elderly patients undergoing gastric resection at a tertiary care university hospital. A retrospective analysis was performed of 157 consecutive gastric resections between January 1998 and July 2007. Group A (n = 99) consisted of patients < 75-years-old at surgery, whereas group B (n = 58) included patients who were ≥ 75 years of age at time of surgery. These two groups had their clinical and demographic data analyzed. Postoperative length of hospital stay, perioperative major morbidity, and in-hospital mortality were analyzed using analysis of variance, χ(2), and multivariate analyses. The average age of patients in group A was 57 years, compared with 81 years in group B. We found no significant difference in the percentage of gastric resections for malignancy (group A, 49% vs group B, 62%) or emergency surgery (group A, 10% vs group B, 10%) between age groups. There was a significant increase in length of stay in the older patients (11.7 days vs 17.6 days; P = 0.032), as well as major complications (11.1% in group A vs 27.6% in group B; P = 0.008). The in-hospital mortality rates approached significance (group A, 4% vs group B, 12%; P = 0.057). Gastric resection in elderly patients carries with it longer hospital stays, higher risk of complications, and in-hospital mortality rates despite similarity in patient disease. This information is imperative to convey to the elderly patients in the preoperative period before gastric resection.

Endothelial differentiation of adipose-derived stem cells from elderly patients with cardiovascular disease.

Adipose-derived stem cells (ASCs) possess significant therapeutic potential for tissue engineering and regeneration. This study investigates the endothelial differentiation and functional capacity of ASCs isolated from elderly patients. Isolation of ASCs from 53 patients (50-89 years) revealed that advanced age or comorbidity did not negatively impact stem cell harvest; rather, higher numbers were observed in older donors (>70 years) than in younger. ASCs cultured in endothelial growth medium-2 for up to 3 weeks formed cords upon Matrigel and demonstrated acetylated-low-density lipoprotein and lectin uptake. Further stimulation with vascular endothelial growth factor and shear stress upregulated endothelial cell-specific markers (CD31, von Willebrand factor, endothelial nitric oxide synthase, and VE-cadherin). Inhibition of the PI(3)K but not mitogen-activated protein kinase pathway blocked the observed endothelial differentiation. Shear stress promoted an anti-thrombogenic phenotype as demonstrated by production of tissue-plasminogen activator and nitric oxide, and inhibition of plasminogen activator inhibitor-1. Shear stress augmented integrin α(5)ß(1) expression and subsequently increased attachment of differentiated ASCs to basement membrane components. Finally, ASCs seeded onto a decellularized vein graft resisted detachment despite application of shear force up to 9 dynes. These results suggest that (1) advanced age and comorbidity do not negatively impact isolation of ASCs, and (2) these stem cells retain significant capacity to acquire key endothelial cell traits throughout life. As such, adipose tissue is a practical source of autologous stem cells for vascular tissue engineering.

May-Thurner syndrome: case report and review of the literature involving modern endovascular therapy.

May-Thurner syndrome is a rare clinical entity involving venous obstruction of the left lower extremity. Obstruction occurs secondary to compression of the left common iliac vein between the right common iliac artery and the underlying vertebral body. Current management largely involves endovascular therapy. A review was conducted of six studies containing at least five patients with May-Thurner syndrome treated by endovascular therapy. We compiled data on 113 patients, analyzing patient demographics, treatment details, and outcome. An 18-year-old female presented 1 week after the onset of left lower extremity pain and swelling. Duplex ultrasonography revealed extensive left-sided deep venous thrombosis (DVT). Thrombolysis followed by iliac vein stent placement restored patency to the venous system, with subsequent resolution of symptoms. Review of 113 patients revealed that the majority were females (72%) presenting with DVT (77%), most of which was acute in onset (73%). Therapy consisted of catheter-directed thrombolysis and subsequent stent placement in the majority of patients, resulting in a mean technical success of 95% and a mean 1-year patency of 96%. Endovascular therapy is the current mainstay of treatment for May-Thurner syndrome. Review of the current literature supports treatment via catheter-directed thrombolysis followed by stent placement with good early results.

Incidence of anastomotic leak in patients undergoing elective colon resection without mechanical bowel preparation: our updated experience and two-year review.

Mechanical bowel preparation before elective colon resection has recently been questioned in the literature. We report a prospective study evaluating the anastomotic leak rate in patients undergoing elective colorectal surgery without preoperative mechanical bowel preparation. One hundred fifty-three patients undergoing elective colon resection from July 2006 to June 2008 were enrolled into this Institutional Review Board-approved study. All patients were operated on by a single surgeon at a single institution. No patients received mechanical bowel preparation. Of the 153 patients enrolled, 51.6 per cent had a colorectostomy, 32 per cent had an ileocolostomy, 10.4 per cent had a colocolostomy, 5.2 per cent had an ileoanal anastomosis, and 0.6 per cent had an ileorectostomy performed. A total of eight patients (5.2%) developed an anastomotic leak. Of these patients, four required reoperation, three were managed with percutaneous drainage, and one was managed with antibiotics alone. Five of the eight patients who developed an anastomotic leak had significant preoperative comorbidities, including neoadjuvant radiation therapy, diabetes mellitus, end-stage renal disease, prior anastomotic leak, and tobacco use. Elective colon resection can be performed safely without preoperative mechanical bowel preparation. Vigilance for anastomotic leak must be maintained at all times, especially in patients with comorbidities that predispose to anastomotic leak.

Coil-assisted false lumen thrombosis in complicated chronic type B dissection.

Type B dissections complicated by pain, malperfusion, or aneurysm expansion mandate surgical intervention. Success of this therapy is predicated on exclusion and thrombosis of the false lumen of the aneurysm. We report a case where cessation of flow was achieved using covered stent grafts in conjunction with coil embolization of the false lumen. The introduction of coils into the false lumen is a novel approach and may provide a helpful adjunct in endovascular treatment of complicated type B aortic dissections.

A new anatomic variant of the aorta: a case report.

Anatomic anomalies of the infrarenal aorta and iliac arteries are rare. We report a 39-year-old man who presented with an ileo-cecal fistula secondary to Crohn disease. A computed tomography scan and subsequent arteriography noted his aorta bifurcated immediately inferior to the main renal arteries, at the level of the second lumbar vertebrae. Associated vascular anomalies included a common superior mesenteric artery/celiac axis plus multiple renal arteries. To our knowledge, this is the first report of this aortic anomaly in the literature.