Infected Groin (Graft/Patch): Managed with Sartorious Muscle Flap.

PURPOSE: The purpose of this study was to review the natural history, clinical outcome and safety in patients undergoing sartorius muscle flap (SMF) for groin infection, including lymphocele. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent SMF in a single center between 2000 and 2009. RESULTS: Thirty patients (17 male, 13 female) underwent SMF for groin infection, which included infections of 22 artificial femoral bypass grafts (including 2 cryoveins) and 5 common femoral patch grafts, and 3 lymphocele infections (2 cardiac catheterizations and 1 penile cancer lymph node dissection). Wound isolates were most commonly Gram-positive organisms (n=22) with Gram-negative isolates and mixed infections accounting for 4 and 3 cases, respectively. In 9 patients there was no growth of organisms. Adjunctive wound vacuum-asssisted wound closure therapy was performed in 18 patients. Follow-up duration ranged from 8 days to 56 months (mean 14.1 months) after SMF. Reoperation was performed in 3 patients due to wound bleeding (n=1) and reinfection (n=1). One patient underwent graft excision with external bypass operation. There was 1 mortality case due to sepsis during the study period. CONCLUSION: We found that muscle flap surgery provides successful single-intervention therapy for groin infections including lymphocele. Graft ligation or aggressive excision with bypass surgery should be reserved for patients requiring rapid control of sepsis for lifesaving.

Institutional differences in endovascular aneurysm repair and aneurysm morphology.

BACKGROUND: Variability exists between institutions in the application of endovascular aneurysm repair (EVAR). This study compares patient-specific variables from a high-volume North American institution with one from the UK. METHODS: One hundred consecutive patients from each institution were studied. All were treated for an intact, infrarenal aortic aneurysm. Patient characteristics and aneurysm-related variables, measured from computed tomography according to Society for Vascular Surgery (USA) reporting standards, were examined. RESULTS: The median (range) age of the American patients was 74 (55-97) years and that of the British patients, 73 (49-89) years. There were 78 men in the American group and 79 men in the British group. All American patients were treated by EVAR compared to 11 % of the British group. Mean (SD) aneurysm diameter for the former was 55 (9) mm and for the latter 64 (11) mm (P < 0.001). While there was no difference in mean diameter of the infrarenal aortic neck (P = 0.918), the aneurysms of British patients (22 %) were more likely to be angulated >60° than those of the American patients (11 %) (P = 0.039). Furthermore, the mean (SD) length of infrarenal aortic neck was shorter in the British patients [21 (11) mm] compared to the American group [25 (12) mm] (P = 0.003). The mean diameter of the common iliac arteries was larger in the British patients than in the American group (P < 0.001). Mean external iliac artery diameter was no different between the groups (P = 0.507). CONCLUSIONS: This group of British patients have a more advanced pattern of aneurysm morphology than American patients of similar age. This difference may, in part, explain variability in the application of EVAR.

Hybrid repair of thoracic aortic lesions for zone 0 and 1 in high-risk patients.

PURPOSE: Some patients with aortic arch or descending thoracic aorta pathologies are not suited for open repair because of comorbidities that may increase their risk of procedural complications or death. Endovascular approaches may also be difficult when there are inadequate proximal landing zones in the aortic arch. We report our experience using rerouting techniques with bypass, stenting of the branches, or a combination of both to create a landing area in zones 0 and 1 of the aortic arch. METHODS: Since November 2002, thoracic aortic endoluminal grafts were placed in 38 patients in whom the endograft was deployed in zone 0 (n = 27) or zone 1 (n = 11). A retrospective review is included. RESULTS: There were 11 women and 27 men with a mean age of 65.4 years (range 38-88). Aortic pathology included 12 Stanford type A dissections, 10 aortic arch aneurysms, 8 Stanford type B dissections, 3 descending thoracic aortic aneurysms, 2 aortobronchial fistulas, 1 innominate artery aneurysm and 2 aortic arch pseudoaneurysms. In zone 0, 21 had thoracic debranching with an ascending bypass, three patients had a remote-inflow and three patients had a chimney-stent with carotid-carotid bypass. In zone 1, five patients had a carotid-carotid bypass, one patient had an aortic to left common carotid artery (LCCA) bypass and five patients had chimney-stent on the LCCA. Fifty-eight percent of the patients were symptomatic and 26% emergent. Three patients required hemodialysis postoperatively (7.9%), 18 patients (47.4%) required prolonged mechanical ventilation for respiratory insufficiency. Paraplegia occurred in one patient (2.7%), and five patients suffered a cerebrovascular accident (13.1%). There were four early type I and two type II endoleaks. Overall 30-day mortality was 23.7%. CONCLUSIONS: The hybrid approach for repair of the aortic arch pathologies is feasible in patients unfit for open repair. We present the results of performing different techniques to treat the aortic arch with hybrid repair with antegrade or retrograde inflow, stenting of the branches or a combination of both. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.

Endovascular management of recurrent adult coarctation of the aorta.

Traditional open surgical repair has proven to be an effective treatment for the management of primary and recurrent coarctation of the thoracic aorta. Potential complications at short-term and long-term follow-up have included recurrent coarctation, hypertension, premature coronary artery disease, cerebrovascular disease, and anastomotic pseudoaneurysm. Endovascular repair of recurrent coarctation of the thoracic aorta offers a less invasive treatment approach in potential high-risk surgical patients.

Contemporary results of endovascular repair of abdominal aortic aneurysms: effect of anatomical fixation on outcomes.

PURPOSE: To report the contemporary controlled trial experience with the fully supported unibody Powerlink stent-graft for endovascular treatment of abdominal aortic aneurysm (AAA). METHODS: Between 2000 and 2008, 3 prospective multicenter trials of the Powerlink system evaluated 157 AAA patients (141 men; mean age 72.0+/-9.1 years) with mean AAA sac diameter of 5.6+/-0.9 cm who received a bifurcated stent-graft featuring anatomical fixation at the aortoiliac bifurcation and proximal sealing with extension stent-grafts as needed. Challenging infrarenal aortic neck anatomy was present in 83% of patients. Postoperative follow-up occurred at defined intervals to 5 years. RESULTS: Technical success was achieved in 99% of patients. Aneurysm exclusion was achieved in all patients over a mean procedure time of 132+/-58 minutes. No aneurysm-related deaths, ruptures, conversions, or migrations have been observed to current follow-up as these aneurysms have continued to remodel, with > or =92% of patients free from sac growth. CONCLUSION: The implant technique of placing a fully-supported unibody stent-graft at the aortoiliac bifurcation with proximal sealing appears to safely and effectively reline the aorta and exclude aneurysms. Results from controlled clinical trial experience suggest this algorithm can provide stable, secure fixation for patients with challenging infrarenal aortic neck anatomy.

Is endovascular repair the new gold standard for primary adult coarctation?

OBJECTIVE: Primary adult aortic coarctation (PAAC) is an unusual cause of hypertension. The standard of care includes surgical repair, which can be associated with considerable morbidity and operative risk. Although balloon angioplasty has been successfully used in paediatric and adolescent patients with coarctation, little information exists regarding the endovascular repair of PAAC. This study examines the procedural safety and efficacy of endovascular repair of PAAC along with midterm outcomes. METHODS: Between January 2000 and July 2008, 16 patients underwent endovascular repair of PAAC. All patients were hypertensive with 13 patients (81.3%) receiving medical therapy. Symptoms included chest pain (n=11, 69%), progressive fatigue (n=5, 31%), exercise intolerance (n=4, 25%) and shortness of breath (n=3, 19%). Associated cardiac concerns included depressed ejection fraction (n=6, 38%), pulmonary hypertension (n=5, 31%), ascending aortic dilatation (n=5, 31%) and bicuspid aortic valve (n=4, 25%). Endovascular repair was achieved using a percutaneous femoral approach. Balloon angioplasty of the coarctation was performed prior to treatment using a balloon-expandable uncovered stent. Aortic diameters were assessed using intravascular ultrasound. Pre- and post-procedure pressure gradients were measured and success was determined as a residual pressure gradient across the treated aorta of less than 20 mmHg. RESULTS: The male:female (M:F) ratio was 9:7 with a mean age of 39.7 years. Procedural success was 100%. Mean pre-procedural aortic diameter was 8.4mm (3-14 mm) and mean post-procedural aortic diameter was 16.3mm (10-20mm) (p=0.04). The mean pre-procedural pressure gradient was 48.3 mmHg (25-100 mmHg) and the mean post-procedural pressure gradient was 0.5 mmHg (0-15 mmHg) (p=0.05). Twelve patients received one stent, two patients received two stents, one patient received three stents and one other patient received a thoracic stent graft. The rate of paraplegia was 0% with no blood transfusions, strokes or deaths. Follow-up ranged from 12 to 72 months (mean=22.8 months). One patient required re-intervention with an additional stent 14 months following the initial procedure and all the patients remain symptom-free. CONCLUSION: Endovascular repair of PAAC is safe and effective and compares favourably with open surgical repair. Midterm follow-up suggests that the treatment is durable and may be an alternative to surgical repair. Although this is the largest endovascular treatment series for PAAC reported to date, additional study and follow-up are needed.

Endovascular repair in the thoracic and abdominal aorta: no increased risk of spinal cord ischemia when both territories are treated.

PURPOSE: To evaluate the morbidity associated with thoracic and abdominal aortic repair using endovascular exclusion alone or combined endovascular and open repair. METHODS: Between January 1998 and February 2007, 49 patients (36 men; mean age 70 years) underwent treatment for thoracic and abdominal aorta disease with descending thoracic aortic (DTA) stent-graft and abdominal aortic repair. Thirty-nine patients with coexisting thoracic and abdominal pathologies were classified with multilevel aortic disease (MLAD), whereas 10 patients presented with thoracoabdominal aneurysm. Patients were separated into 3 groups: 1: thoracic stent-grafts and open abdominal repair (n = 18), group 2: thoracic and abdominal stent-grafts (n = 21), and group 3: thoracic stent-grafts with visceral artery debranching (n = 10). Prior carotid-subclavian bypass was performed in 3 (6%) patients with a dominant left vertebral artery. RESULTS: Stent-graft deployment was technically successful in all cases. Eight (16%) patients underwent emergent thoracic stent-graft placement. In 9 (18%) patients, the left subclavian artery was covered. No incidence of spinal cord ischemia was observed. The 30-day mortality was 4%, and overall mortality was 6% over a mean 33-month follow-up. The endoleak rate was 6% (1 type I, 1 type II, and 1 type III). CONCLUSION: Conventional or endovascular abdominal open repair in combination with DTA stent-grafting is feasible and a safe alternative to traditional open repair. Management of MLAD did not show increased incidence of spinal cord ischemia and was associated with fewer complications and deaths than simultaneous or staged open thoracic and abdominal repairs.

"Cracking and paving": a novel technique to deliver a thoracic endograft despite ilio-femoral occlusive disease.

BACKGROUND: The use of endoluminal grafts to treat thoracic aortic aneurysms has been associated with a decreased morbidity and mortality compared with open thoracic aortic aneurysm repair. High-risk surgical patients with ilio-femoral occlusive disease may not be amenable to general anesthesia and the construction of a retroperitoneal conduit. METHODS AND RESULTS: We report the use of a novel technique consisting of cracking and paving of the ilio-femoral vessels with balloon angioplasty, followed by deployment of an endoconduit to deliver an endoluminal graft under local sedation to treat a high-risk 80-year-old patient with a thoracic aneurysm. CONCLUSION: High-risk surgical patients with iliofemoral disease can undergo endoluminal graft therapy to threat thoracic aortic aneurysms.

Treatment of type II endoleaks associated with left subclavian artery coverage during thoracic aortic stent grafting.

OBJECTIVE: Increasing experience with thoracic aortic stent grafts has led to a more aggressive approach to thoracic aortic pathologies in the distal aortic arch and proximal descending thoracic aorta. To increase the length of the proximal landing zone, it is sometimes necessary to cover the left subclavian artery with the thoracic stent-graft, introducing the risk of retrograde filling of the excluded aorta from the left subclavian artery. It is currently unclear how best to manage these patients to prevent persistent risk of aneurysm expansion or rupture. We report our experience with a minimally invasive endovascular repair of the covered left subclavian artery. METHODS: We reviewed prospectively gathered data on all investigational device exemption-approved patients undergoing thoracic aortic stent grafting at the Arizona Heart Institute from 2000 to 2006 (n = 289 patients). Patients had surveillance with a contrast-enhanced computed tomography scan on the first postoperative day and during follow-up at 1, 6, and 12 months. RESULTS: A total of 289 patients received thoracic stent grafts during the study: Medtronic Talent (Medtronic, Minneapolis, Minn) (n = 25) or Gore TAG (WL Gore & Associates Inc, Flagstaff, Ariz) (n = 261). The left subclavian artery was covered in 23% of patients (n = 66), of whom 17% had preoperative carotid-subclavian bypass (n = 11/66). Among patients with left subclavian artery coverage, the 30-day mortality was 6.1% (n = 4), procedure-related strokes developed in 3 patients (n = 3, 4.6%), and the incidence of left arm claudication was 7.6% (n = 5), necessitating postoperative carotid-subclavian bypass in 2 patients. Twelve patients (18%) had a type I (n = 6) or II (n = 7) endoleak. Coverage of the left subclavian artery accounted for 71% of the type II endoleaks (n = 5), whereas patent intercostals accounted for the rest (n = 2). Type II endoleaks associated with left subclavian artery coverage were successfully treated by retrograde coil embolization from the left brachial artery (n = 3) or left subclavian artery ligation (n = 1). CONCLUSION: Coverage of the left subclavian artery during thoracic aortic stent grafting is associated with a low incidence of arm complications and type II endoleaks. All type II endoleaks were successfully treated by retrograde coil embolization or ligation of the left subclavian artery. Successful treatment of endoleaks may reduce the risk of aneurysm expansion or rupture.

Management of endoleaks associated with endovascular treatment of descending thoracic aortic diseases.

OBJECTIVE: Endoluminal grafting is emerging as a less invasive alternative to the treatment of descending thoracic aorta diseases. Endoleaks (continued pressurization of the treated aorta external to the endoluminal graft) are a potential complication. We reviewed our cumulative endovascular experience for descending thoracic aorta pathologies with respect to the management of endoleaks and associated patient outcomes. METHODS: As part of a single-site investigational device-exemption protocol, 249 patients (146 men, 103 women) with thoracic aortic diseases underwent attempted delivery of a TAG endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) between February 2000 and August 2005. Indications for study enrollment included 111 atherosclerotic aneurysms (44.6%), 67 aortic dissections (26.9%), 27 penetrating aortic ulcers (10.8%), 14 contained ruptures (5.6%), 11 pseudoaneurysms (4.4%), 9 acute aortic transections (3.6%), 7 aortobronchial fistulas (2.8%), 2 endoleaks (0.8%) after prior thoracic endoluminal grafting, and 1 (0.4%) adult coarctation. Endoleak surveillance was performed using serial computed tomography scans. RESULTS: Mean patient age was 68 years (range, 23-91 years). Endoleak developed in 38 patients (15.3%): 15 distal type I (39.5%), 13 proximal type I (34.2%), 8 type II (21.1%) and 2 type III (5.3%). No surgical intervention was performed in 26 patients (68.4%), in which the endoleak spontaneously resolved in 14 (53.8%), 8 (30.8%) are being monitored and are asymptomatic, 3 (11.5%) died of unrelated causes, 2 (7.7%) withdrew from the study, and 1 (3.8%) was lost to follow-up. Twelve patients (31.6%) required reintervention using an additional endoluminal graft: 8 (66.7%) with a proximal type I endoleak, 2 (16.7%) with a distal type I endoleak, 1 (8.3%) with both distal type I and type III endoleaks, and 1 (8.3%) with a type III endoleak. Open conversions were necessary secondary to device deployment difficulties in two patients (0.8%), and due to expansion of a thoracoabdominal aneurysm and rupture of an aneurysm secondary to a type II endoleak in one patient (0.5%) each. CONCLUSION: Endoleaks are an infrequent, yet important, complication after thoracic endografting. Many endoleaks will resolve spontaneously, but some patients may require another endovascular intervention. Close surveillance is recommended for these patients; however, open conversion is rarely indicated. Because more diseases of the thoracic aorta are being treated using an endovascular approach, a standardized treatment algorithm is essential to safely and effectively manage associated endoleaks.

Endoluminal graft therapy for the treatment of an aorto-bronchial fistula: mid-term follow-up.

Open surgical repair of aorto bronchial fistulas is associated with a high morbidity and mortality. Endovascular stent graft as an alternative therapy, though limited, has produced acceptable initial results, but few reports of mid-term follow-up are available. We report the mid-term results with the use of an endograft to treat a patient with both an aorto bronchial fistula and a contained rupture of the thoracic aorta.

Customized endoluminal graft to treat a suspected saccular thoracoabdominal mycotic aneurysm.

Open surgical repair of mycotic aneurysm is associated with a high surgical morbidity and mortality. The role of endovascular graft repair of mycotic aneurysm remains controversial because the graft material remains in contact with possibly infected tissue. We report an endovascular technique of customizing an abdominal endoluminal graft component to treat a suspected saccular thoracoabdominal mycotic aneurysm involving the takeoff of the celiac trunk.

A novel approach for the endovascular repair of the small thoracic aorta: customizing off-the-shelf endoluminal grafts to treat a post-coarctation pseudoaneurysm.

Surgical repair of post-coarctation pseudoaneurysm is associated with high morbidity and mortality. Endovascular stent grafting is a minimally invasive approach to manage this condition. The small thoracic aorta provides a dilemma for endovascular stent grafting using available commercially available thoracic endografts. We describe a hybrid approach including a novel technique to customize various components of the abdominal endoluminal grafts to repair a post-coarctation pseudoaneurysm. The patient is doing well at 1-year follow-up with no endoleaks.

Use of the right brachio-femoral wire approach to manage a thoracic aortic aneurysm in an extremely angulated and tortuous aorta with an endoluminal stent graft.

The presence of a tortuous, elongated thoracic aorta and an angulated arch poses a technical challenge for the delivery of an endoluminal graft to the target site to exclude management of a thoracic aortic aneurysm. Despite the availability of a flexible delivery sheath system, adjunct techniques are necessary to deal with extremely tortuous thoracic aortas. The use of a brachio-femoral wire with tension applied at both ends is a useful technique to deliver an endoluminal graft in an angulated thoracic arch. We describe the use of a right brachio-femoral wire approach to treat a thoracic aortic aneurysm in a 75-year-old man with an elongated, tortuous and angulated arch aorta.

Endovascular repair of an ascending aortic pseudoaneurysm with a septal occluder device: mid-term follow-up.

Ascending pseudoaneurysm is an infrequent complication of ascending aortic surgery. Redo operations are often associated with a high surgical morbidity and mortality. Endovascular management of ascending aortic pathologies with endoluminal graft therapies are challenging due to short landing zones and the fear of flow obstruction to the coronaries and brachiocephalic circulation. We report mid-term follow-up of the management of an ascending aortic pseudoaneurysm using a an Amplatz septal occluder (AGA Medical Corp, Golden Valley, MN) in a 51-year-old man considered at high risk for conventional open surgical repair.

Virtual histology intravascular ultrasound assessment of carotid artery disease: the Carotid Artery Plaque Virtual Histology Evaluation (CAPITAL) study.

PURPOSE: To determine the diagnostic accuracy of virtual histology intravascular ultrasound imaging (VH IVUS) of carotid plaque and to assess the feasibility of VH IVUS to identify plaque with embolic potential in patients undergoing carotid artery stenting (CAS). METHODS: Thirty patients (17 men; mean age 74+/-7 years) were entered nonrandomly into a single-center, prospective, 2-arm study following FDA and Institutional Review Board approval. In one arm, 15 patients underwent VH IVUS examination of carotid plaque with a cerebral protection device immediately followed by carotid endarterectomy (CEA). A comparison of "virtual" with true histology was then performed, classifying plaque type by VH IVUS and histopathology in a blinded study. In the second arm, 15 patients undergoing CAS had a preliminary VH IVUS scan performed with cerebral protection. Debris collected from the filter following stenting was examined histologically and compared with the VH IVUS data. RESULTS: The diagnostic accuracy of VH IVUS to agree with true histology in different carotid plaque types was 99.4% in thin-cap fibroatheroma, 96.1% for calcified thin-cap fibroatheroma, 85.9% in fibroatheroma, 85.5% for fibrocalcific, 83.4% in pathological intimal thickening, and 72.4% for calcified fibroatheroma. Filter debris was captured in 2 patients prior to CEA and in 4 patients undergoing CAS for restenosis; VH IVUS classification of plaque composition was consistent with the histological evaluation of filter fragments. Calcified nodules projecting into the carotid artery lumen were associated with a higher incidence of previous neurological symptoms (66.7% versus 33.3%, p<0.05), while patients on aspirin has significantly less necrotic lipid core plaque detected by VH IVUS than patients not taking aspirin (6.4%+/-4.7% versus 9.7%+/-2.8%, p<0.05). CONCLUSION: This study showed a strong correlation between VH IVUS plaque characterization and the true histological examination of the plaque following endarterectomy, particularly in "vulnerable" plaque types. The feasibility study to examine VH IVUS data and the filter debris histology in CAS patients supports a larger prospective study.

Novel endovascular repair of the small thoracic aorta: customizing off-the-shelf endoluminal grafts.

Treatment of the small thoracic aorta is not currently amenable to standard endovascular repair. New customized endovascular approaches are necessary for these patients who are not candidates, for open repair. We describe a novel endovascular repair of a thoracic aortic pseudoaneurysm associated with a prior coarctation repair.

An extra anatomic, close chest approach to manage an aortic arch aneurysm in an 88-year-old woman.

Repair of thoracic arch aneurysms in the octogenarian is associated with a high morbidity and mortality. In this report we describe a minimally invasive approach to repair and arch aneurysm using an endoluminal graft with an extrathoracic, extra anatomic de-branching of the arch vessels. The advantage of this technique includes avoidance of a median sternotomy, cardiopulmonary bypass, and circulatory arrest with a rapid postoperative recovery.

Have we gone too far? Endovascular stent-graft repair of aortobronchial fistulas.

OBJECTIVE: Although endovascular repair of the descending thoracic aorta has emerged as a viable treatment option, little is known about its potential to treat patients diagnosed with aortobronchial fistulas. We reviewed our comprehensive thoracic endografting experience with regard to the endovascular management and subsequent outcome of patients with aortobronchial fistulas to assess whether endoluminal graft repair is a realistic option. METHODS: Between February 2000 and November 2005, 255 patients were successfully treated with an endoluminal graft to the descending thoracic aorta. Indications for intervention included: atherosclerotic aneurysms (109/255, 42.7%), acute and chronic dissections (75/255, 29.4%), miscellaneous (34/255, 13.3%), penetrating aortic ulcers (30/255, 11.8%), and aortobronchial fistulas (7/255, 2.7%). RESULTS: Average patient age was 73.4 +/- 10.1 years, with 4 male patients (4/7, 57.1%) and 3 female patients (3/7, 42.9%). All patients presented with hemoptysis, with 1 patient (1/7, 14.3%) requiring preoperative blood transfusion. Three patients (3/7, 42.9%) were diagnosed with atherosclerotic aneurysms, 3 patients (3/7, 42.9%) had pseudoaneurysms associated with prior open surgical repair, and 1 patient (1/7, 14.3%) had a prior endoluminal graft placed for a traumatic aortic transection. No standard postoperative antibiotic regimen was followed. There were no endoleaks, no incidences of paraplegia, and no endoluminal graft infections. Survival was 100% (7/7) at both 30 days and 1 year, and all patients are currently alive. Follow-up computed tomography was available for all 7 patients, with an average follow-up of 42.6 +/- 28.5 months. CONCLUSIONS: Endovascular management of aortobronchial fistulas appears to be safe and well tolerated, even in surgically high-risk patients, with minimal risk of prosthesis infection. Long-term surveillance and continued investigation are warranted.