Midterm outcome after the distal revascularization and interval ligation (DRIL) procedure.

BACKGROUND: The distal revascularization and interval ligation (DRIL) procedure has evolved as the optimal treatment for access-related hand ischemia despite concerns about its durability. This study was designed to review our institutional experience and objectively define its mid-term outcome. METHODS: A retrospective review of all patients undergoing the DRIL procedure was performed. The diagnosis of severe hand ischemia was made based primarily upon clinical presentation, but confirmed with noninvasive imaging in select cases. The DRIL conduit was selected based upon noninvasive imaging (vein conduit criteria: saphenous > arm; diameter >/=3 mm) and the proximal anastomosis was positioned >/=7 cm from the access anastomosis. The DRIL bypasses were followed in a graft surveillance protocol and remedial procedures performed as dictated by clinical or ultrasound scan findings. RESULTS: Sixty-four DRIL procedures were performed in 61 patients (age - 58 +/- 13 standard deviation [SD], female - 62%, diabetic - 72%). The index access procedures included: autogenous brachiocephalic - 46%, autogenous brachiobasilic - 31%, autogenous brachioaxillary translocated femoral vein - 20%, other -3%. The precipitating symptoms were pain (25%), paresthesia (34%), motor dysfunction (24%), and tissue loss (17%); a pre-emptive DRIL was performed in 5 patients. The timing of the DRIL relative to the index access was dictated by the symptoms: <24 hrs - 19%; 1 day 30 days - 44%. Perioperative mortality rate was 3% and the complication rate was 22% (wound - 14%). The DRIL procedure relieved the ischemic symptoms in 78% of the cases (residual symptoms: paresthesia - 13%; pain - 5%; tissue loss - 4%; motor - 2%). The DRIL also resulted in significant (P < .05) increases in both the wrist/brachial index (WBI) and digital/brachial index (DBI) with the mean increases of 0.34 +/- 0.26 and 0.41 +/- 0.21, respectively. The primary DRIL patency rates (+/- standard error of the mean [SEM]) were 77 +/- 8%, 74 +/- 9%, and 71 +/- 9% at 1 year, 3 years, and 5 years, respectively, while the corresponding secondary patency rates were 81 +/- 7%, 76 +/- 9%, and 76 +/- 9%, and the survival rates were 71 +/- 6%, 59 +/- 7%, and 33 +/- 9%. The index access procedure went on to mature sufficiently for cannulation in 68% of the cases when the DRIL was performed early (ie, <3 months from index access); all accesses functional at the time of the DRIL were used for dialysis throughout the perioperative period. CONCLUSION: The DRIL procedure safely and effectively relieves the symptoms of severe access-related hand ischemia while preserving the access. The midterm results suggest that the DRIL bypasses are durable, although long-term graft surveillance may be justified given the observed failures.

Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using the Preclose technique.

OBJECTIVE: Percutaneous access during endovascular aortic repair has been shown to be feasible and safe using a suture-mediated closure device ("Preclose" technique) for closure of up to 24F introducer sheaths. The purpose of this study is to examine the late outcomes of those femoral arteries repaired in this manner. METHODS: The Preclose technique has been previously described. Briefly, the technique involves two Perclose Proglide devices deployed in the femoral artery prior to insertion of the large diameter introducer sheath and then closure of the arteriotomy by tying down knots of the Proglide following removal of the sheath. The medical records of all patients who underwent endovascular aortic repairs using the Preclose technique between December 2004 and August 2007 were reviewed. Follow-up protocol consisted of computed tomography (CT) angiograms performed at 1, 6, and 12 months, and annually thereafter. All Preclose patients who had at least a 6-month postoperative scan were included in the study. For each patient, the most recent postoperative scan was compared with the preoperative scan for evidence of any new anatomic abnormalities of the femoral artery such as dissection, stenosis, or pseudoaneurysm. Three-dimensional post processing with multiplanar reconstructions was also performed as necessary to confirm axial scan findings. RESULTS: A total of 292 patients underwent percutaneous endovascular aortic repairs (TEVAR-125, EVAR-167). Four hundred thirty-two femoral arteries were closed with 870 devices. Four hundred eighteen vessels were approximated with two devices, while 30 arteries required three devices for hemostasis and an additional four vessels only required a single device. Two hundred seventy-eight (64.3%) vessels were accessed with sheaths 18 to 24F. Four hundred eight femoral arteries (94.4%) were closed successfully with the Preclose technique. There were 100 patients (TEVAR-35, EVAR-65) who had adequate postoperative CT scan at 6-months or later. The mean follow up was 11.6 +/- 5.0 months. Of the 156 femoral arteries in these 100 patients repaired using the Preclose technique, there were 3 late complications in 3 patients, 1 asymptomatic femoral artery dissection, and 2 femoral artery pseudoaneurysms requiring surgical repair, resulting in a late complication rate of 1.92% (3/156). CONCLUSION: Percutaneous closure of femoral arteries after large diameter introducer sheaths using the Preclose technique has a low incidence of early and late complications related to the closure site.

Impact of endograft design and product line on the device cost of endovascular aneurysm repair.

OBJECTIVE: Device cost is a substantial component of the overall cost of endovascular abdominal aneurysm repair (EVAR), and the four commercially available devices differ significantly in the cost of their basic configuration. This study examined the impact of three different endografts and their product lines on the overall cost of repair. METHODS: Implant records of 467 EVAR procedures performed during 2000 through 2006 were reviewed. The three devices used were the AneuRx in 178 (38.1%; Medtronic, Santa Rosa, Ca), the Excluder in 123 (26.3%; W. L. Gore & Associates, Flagstaff, Ariz), and the Zenith in 166 (35.5%; the Cook Zenith (Bloomington, Ind). The Powerlink device (Endologix, Irvine, Calif) was not studied. The specific device implanted was determined by its commercial availability at the time of repair, patient anatomy, and surgeon preference. Retail list prices were used for all calculations, and only devices used during the original repair were used for analysis. RESULTS: The device cost of the most basic configuration for repair (ie, 2 pieces for AneuRx and Excluder, 3 pieces for Zenith) differed by $3022 between the most expensive (Zenith) to the least expensive (AneuRx). However, the AneuRx system required the most number of extensions (1.90 +/- 1.25 per case; range, 0-7), whereas the Zenith required the fewest (0.21 +/- 0.51 per case; range, 0-3). When the costs of the extensions were added, the overall mean device costs per case were similar. CONCLUSION: The initial cost advantage of the AneuRx and Excluder endograft systems were offset by the more frequent need for proximal and distal extensions. The minimum device cost of a basic repair should not factor into the decision to select one specific device over another because additional devices may be required depending on the design and construction of the endograft system and the accuracy and reliability of their deployment mechanisms.

Early results after staged hybrid repair of thoracoabdominal aortic aneurysms.

BACKGROUND: The morbidity and mortality rates associated with open thoracoabdominal aortic aneurysm (TAAA) repair are substantial. This study was designed to review our early experience with the hybrid endovascular and, or open approach for TAAA repair. STUDY DESIGN: Patients undergoing elective hybrid repair of their TAAAs were retrospectively reviewed. RESULTS: Seventeen patients (mean age 69+/-15 years, male, 76%) underwent visceral and renal revascularization as the first stage of their hybrid repair. The Crawford extent included: II, 2; III, 8; and IV, 7. Perioperative mortality and complication rates after the first stage were 24% and 25%, respectively; the mean intensive care unit stay and total length of stay were 7+/-12 days (range 1 to 45 days) and 22+/-33 days (range 3 to 100 days), respectively. The endovascular aneurysm repair or second stage procedure was performed in 12 of 13 (92%) of the surviving patients, with a mean of 27+/-27 days (range 6 to 99 days) between the procedures. Two patients experienced intraoperative complications during the second stage, but there were no deaths or additional postoperative complications. Patients did not require the intensive care unit, and the overall mean length of stay after the second stage was 2+/-2 days (range 1 to 5 days). The mean postoperative followup among the 11 patients completing both stages was 8+/-12 months (range 1 to 15 months). The primary patency rate for the visceral and renal bypasses was 96% (54 of 56). CONCLUSIONS: The hybrid approach for patients with TAAAs may reduce complications in the average, low-risk patient and may extend the indications for repair to patients considered higher risk based on age, comorbidities, or anatomic considerations.

Genomic and proteomic determinants of lower extremity revascularization failure: rationale and study design.

This translational research program applies a working model of advanced functional genomics/proteomics and bioinformatics to human peripheral arterial occlusive disease (PAOD). It is a multidisciplinary collaborative effort of clinicians, scientists, and statisticians with an advisory panel consisting of experts in inflammation biology, vascular biology, molecular genetics, bioinformatics, clinical trial design, and epidemiology. The proposed human initiative is designed to study 300 symptomatic patients with PAOD undergoing medical management with or without vascular intervention by lower extremity angioplasty/stenting or vein graft bypass. The study aims to test the hypothesis that the systemic inflammatory response after vascular intervention influences the local milieu responsible for vascular repair and adaptation. The expectation is that this response is not uniform in all patients but, rather, is modulated by either preoperative genetic predisposition or postprocedure differential regulation of the innate immune response to injury that promotes a maladaptive phenotype leading to intervention failure. Therefore, some of these differences may be present and detectable before intervention and amenable to class prediction and prospective treatment strategies, whereas others may be detectable in the early postprocedural period, before the onset of clinical failure, permitting interventions to prevent an adverse outcome. The combination of genomic/proteomic data together with functional and quality-of-life outcome measures to define a critical model for class prediction and analysis should lead to new knowledge about failure mechanisms of vascular intervention and new strategies to improve existing approaches to lower extremity revascularization.

Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR).

PURPOSE: To determine the clinical and anatomical risk factors for cerebrovascular accidents (CVA) in patients undergoing thoracic endovascular aortic repair (TEVAR). METHODS: Between September 2000 and December 2006, 196 patients (135 men; mean age 68.6+/-13.5 years, range 17-92) underwent TEVAR for a variety of aortic pathologies. The majority (156, 79.6%) were treated with the TAG stent-graft. Demographics, pathologies, intraoperative procedure-related measures, device usage, and postoperative outcomes were assessed. CVA was defined as a new focal or global neurological (motor or sensory) deficit lasting >48 hours associated with acute intracranial abnormalities on computed tomography or magnetic resonance brain imaging. Spinal cord ischemia was excluded. In a subset of patients with planned left subclavian artery (LSA) coverage and an incomplete circle of Willis or a dominant left vertebral artery, prophylactic carotid-subclavian bypasses were performed. RESULTS: Nine (4.6%) patients suffered a CVA. Factors not predictive of a CVA on univariate analysis included aortic pathology, urgency of repair, ASA classification, type of anesthesia, blood loss, procedure time, and device used. Proximal extent of repair (with or without extra-anatomical revascularization) was significantly associated with a higher incidence of strokes (zones 0-2 versus 3-4, p=0.025). Five (55.6%) patients with a CVA had documented intraoperative hypotension (systolic blood pressure<80 mmHg). Additionally, while 2 patients had hemispheric infarcts, 5 had acute posterior circulation infarcts involving the cerebellum and brainstem; a single patient had both anterior and posterior circulation infarcts. Seven of the CVA patients had proximal coverage of the thoracic aorta in zones 0-2; of these, 6 had posterior circulation infarcts. Selective LSA revascularization based on preoperative cerebrovascular imaging resulted in lower rates of CVA (6.4% to 2.3%, p=0.30) and posterior circulation infarcts (5.5% to 1.2%, p=0.13). CONCLUSION: Proximal extent of repair may serve as a surrogate marker for greater severity of degenerative disease of the aortic arch. Avoidance of intraoperative hypotension and preservation of antegrade vertebral perfusion may be important in prevention of posterior circulation strokes.

Perioperative differences between endovascular repair of thoracic and abdominal aortic diseases.

BACKGROUND: With the US Food and Drug Administration approval of the TAG thoracic device, more thoracic pathologies are being treated using endovascular techniques. Although endovascular abdominal and thoracic aortic repairs have some apparent similarities, there are substantive anatomic, pathologic, and technical differences that could impact perioperative outcomes. The purpose of this study is to identify these differences. METHODS: During a 5-year period, 121 endovascular thoracic aortic repairs (TEVAR) and 450 abdominal aortic repairs (EVAR) were performed at a single institution. Preoperative, intraoperative, and early postoperative data were prospectively collected and retrospectively reviewed. Aggregate outcome measures were compared between the two cohorts, with statistical significance achieved at P < .05. RESULTS: The mean age of patients undergoing EVAR was 72.8 +/- 8.3 compared with 68.3 +/- 13.9 for TEVAR (P = .02). More women underwent TEVAR (30.6% vs 11.1%, P < .001). Aneurysms undergoing TEVAR were larger than those for EVAR (62.0 mm vs 58.3 mm, P = .01). Intraoperatively, EVAR required 26.2 minutes of fluoroscopy compared with 22.1 minutes for TEVAR (P < .001). The amount of contrast used was higher in TEVAR (133.6 mL vs 93.6 mL, P < .001). The mean procedure times were 164 minutes for EVAR and 115 minutes for TEVAR (P < .001). Iliac conduits were required in 46 patients (10.2%) undergoing EVAR, and in 24 (19.8%) undergoing TEVAR (P = .007). The 30-day or in-hospital mortality was 2.0% for EVAR and 5.0% for TEVAR (P = NS). The median length of stay was longer for TEVAR (3 days vs 2 days, P =.034). There were 54 postoperative complications in 36 TEVAR patients (29.8%), including 13 neurologic (10.7%), 8 renal (6.6%), 7 pulmonary (5.8%), 6 ischemic (5.0), and 5 (4.1%) hemorrhagic events. Among the EVAR group, 136 (30.2%) patients had postoperative complications, which included 45 ischemic (10.0%), 34 wound (7.6%), 22 renal (4.9%), 12 cardiac (2.7%), 8 pulmonary (1.8%), 5 gastrointestinal (1.1%), and 4 neurologic (0.9%) events. CONCLUSIONS: A relatively higher proportion of women underwent TEVAR than EVAR, and this was reflected in the greater need for iliac conduits to accommodate the larger delivery catheters of the thoracic devices. Intraoperative imaging techniques were also different, and TEVAR required higher contrast volumes despite shorter overall procedure times. The incidence of strokes and spinal cord ischemia was also higher during TEVAR. Despite apparent similarities of devices and techniques, EVAR and TEVAR are fundamentally different procedures with different perioperative outcomes.

Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair.

BACKGROUND: Multiple strategies have been devised to extend the applicability of endovascular aneurysm repair (EVAR) in patients with common iliac artery (CIA) aneurysms. This study was designed to examine outcome in patients undergoing EVAR with either hypogastric artery embolization or common iliac artery bifurcation advancement by hypogastric bypass. METHODS: A retrospective review of all patients undergoing EVAR since the inception of our program (1997-2006) was performed. Data were prospectively collected in an EVAR registry. Patients with large common iliac artery aneurysms (> or = 20 mm) and patent hypogastric arteries not amenable to a cuff or "bell bottom" technique were treated with coil embolization (EMBO) and/or hypogastric revascularization (BYPASS). The perioperative and mid-term outcomes were compared with the larger group of patients undergoing EVAR that did not require either treatment (CTRL). Bilateral common iliac artery aneurysms were treated with unilateral coil embolization and contralateral bypass. RESULTS: Common iliac artery aneurysms were present in 137 (31%) of the 444 patients undergoing EVAR, but only 57 (42%) of 137 required direct management. This included hypogastric artery embolization alone (EMBO) in 31 or hypogastric artery revascularization (BYPASS) in 26, with and without contralateral embolization (both revascularization/embolization in 46%). The procedure length (CTRL, 159 +/- 72 minutes; EMBO, 153 +/- 39 minutes; BYPASS, 283 +/- 75 minutes) and estimated blood loss (CTRL, 251 +/- 313 mL; EMBO, 233 +/- 158 mL; BYPASS, 400 +/- 287 mL) were significantly greater (P < .05) in the BYPASS group. The incidence of any postoperative complication (CTRL, 26%; EMBO, 68%; BYPASS, 54%), any ischemic complication (CTRL, 6%; EMBO, 55%; BYPASS, 27%), and new-onset buttock claudication (CTRL, 3%; EMBO, 39%; BYPASS, 27%) were all significantly greater in the BYPASS and EMBO group relative to the control (CTRL) group (n = 387). The incidence of new-onset buttock claudication ipsilateral to the hypogastric bypass was 4%; the balance of the new onset claudication in the BYPASS group was due to the contralateral embolization. The primary hypogastric artery bypass patency was 91 +/- 11% (SE) at 36 months by life-table analysis. CONCLUSIONS: Despite its increased complexity, hypogastric artery bypass is an excellent alternative to embolization in terms of patency and freedom from ischemic symptoms for patients with large common iliac artery aneurysms undergoing EVAR.

Late type III endoleak from graft erosion of an Excluder stent graft: a case report.

We report a case of a late type III endoleak from a hole in the expanded polytetrafluoroethylene graft material of an Excluder bifurcated stent-graft approximately 12 months after implantation. The endoleak was successfully repaired by relining the defect site with an Excluder iliac limb. To our knowledge, this is the first reported case of late graft-material related Type III endoleak involving the Excluder device.

Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms.

OBJECTIVE: Our purpose was to examine the impact of the introduction of endovascular treatment on the early outcomes of ruptured abdominal aortic aneurysms (AAAs) during 2 consecutive time periods at a single institution. METHODS: The hospital records of a single tertiary care center from 1997 to 2004 were retrospectively reviewed, and 36 consecutive patients who underwent treatment for acute ruptured AAA were identified. They were divided into 19 (53%) patients who were all treated with conventional open surgery from 1997 to 2001 (early) and 17 (47%) patients who were treated either with open (n = 4, 24%) or endovascular (n = 13, 76%) methods from 2002 to 2004 (late). All endovascular repairs were performed with commercially available bifurcated devices. Outcome measures included death, major complications, disposition at discharge (home or extended care facility), procedure time, blood loss, and hospital length of stay. RESULTS: Age, sex, and AAA size were similar between the 2 groups. Perioperative mortality in the early and late periods were 37% versus 12%, respectively (P =.13); rates of major complications were 84% versus 65%, respectively (P =.26); and discharge to home rather than extended care facility was 32% versus 59%, respectively (P =.18). Median procedure times (275 vs 149 minutes, P <.01), blood loss (3800 vs 138 mL, P <.0001), and length of stay (18 vs 6 days, P <.05) were all higher during the early period than in the late period. CONCLUSIONS: This preliminary study suggests that introduction of endovascular therapies may be potentially beneficial in the overall treatment scheme of patients with ruptured AAAs. However, longer follow-up and larger cohorts are needed to better establish its feasibility and efficacy compared with conventional open surgical repair.

Outcome after autogenous brachial-axillary translocated superficial femoropopliteal vein hemodialysis access.

OBJECTIVE: The optimal configuration for patients with "complex" or "tertiary" hemodialysis access needs remains undefined. This study was designed to examine the utility of the autogenous brachial-axillary translocated superficial femoropopliteal vein access (SFV ACCESS) in this subset of patients. METHODS: Patients presenting for permanent hemodialysis access without a suitable upper extremity vein for autogenous access identified by duplex ultrasound mapping and those with repeated prosthetic access failures were considered candidates for SFV ACCESS. Ankle-brachial indices were obtained, and duplex scanning of the superficial femoropopliteal and saphenous veins was performed. Patients deemed candidates for SFV ACCESS also underwent preoperative upper extremity arteriography and venography. A retrospective review of the complete medical record was performed, and a follow-up telephone or personal interview was conducted. RESULTS: Thirty patients (mean age +/- SD, 54 +/- 15 years; male, 33%; white, 37%; with diabetes, 50%; obese, 21%) underwent SFV ACCESS among approximately 650 access-related open surgical procedures during the study period. The patients had been receiving dialysis for 4 +/- 5 years (range, 0-24 years), and had 3 +/- 3 (range, 0-17) prior permanent accesses, whereas 90% were actively dialyzed through tunneled catheters. In-hospital 30-day mortality was 3%, and the hospital length of stay was 7 +/- 7 days. Fifty-seven percent of the patients experienced some type of perioperative complication, and 38% required a remedial surgical procedure. Hand ischemia developed in 43% of the patients (severity grade: 1, 10%; 2, 7%; 3, 27%), and a distal revascularization, interval ligation was performed in all those with grade 3 ischemia. Thigh wound complications or hematomas developed in 23% of the patients, and arm wound complications or hematomas developed in 17%. The incidence of thigh wound complications was significantly greater (57% vs 9%; P =.03) in obese patients, but the other perioperative complications analyzed could not be predicted on the basis of age, gender, or comorbid conditions. The SFV ACCESS was cannulated 7 +/- 1 weeks postoperatively. The primary, primary assisted, and secondary patency rates were 96% +/- 4%, 100% +/- 0%, and 100% +/- 0%, respectively, at 6 months; 79% +/- 8%, 91% +/- 6%, and 100% +/- 0%, respectively, at 12 months; and 67% +/- 13%, 86% +/- 9%, and 100% +/- 0%, respectively, at 18 months (life table analysis; % +/- SE). CONCLUSIONS: The intermediate term functional patency rate after SFV ACCESS is excellent, although the magnitude of the procedure and the complication rate are significant. SFV ACCESS should only be considered in patients with limited access options.

Twenty-one cases of aortoenteric fistula: lessons for the general surgeon.

We retrospectively reviewed our experience from 1984 to 2001 with 21 cases of aortoenteric fistula (AEF) in 19 patients. The majority of cases were in men (13 of 19, 68%). One AEF was spontaneous, the other 20 developed after prior vascular reconstruction (95%). The majority of AEF were duodenal (48%) followed by small bowel (38%), colon (10%), and esophageal AEF (5%). The proximal anastomosis of the prior vascular repair was the site of AEF origin in 62 per cent of cases, the distal anastomosis accounted for 19 per cent, and the body of the graft for 14 per cent. The intestinal repair was chosen on a case-by-case basis by the general surgeon and consisted of a simple primary repair in 48 per cent, resection with primary anastomosis in 38 per cent, and patching with pleura or omentum in individual cases. Colostomies were created in the two cases with colonic AEF. The duodenum was excluded in one of 10 duodenal AEF. Six patients (32%) died in the 90 days following surgery. The biggest risk of postoperative death was presentation with sepsis (P = 0.069); interestingly, women were more likely to present with sepsis (P = 0.019) and experienced a disproportionate rate of postoperative death (male 23%, female 50%, P = 0.24). The method used to repair the bowel was linked to a higher rate of postoperative death, and patients that required bowel resection died more frequently (66%) than those who had a simple repair (10%, P = 0.07). Overall mortality with AEF remains high despite routine SICU care. The biggest risk for death is preoperative sepsis. Women presented with sepsis more frequently than men. The method of bowel repair appears to be related to overall survival and along with sepsis is, perhaps, a surrogate for the degree of erosion present at the site of the AEF. Simple bowel repairs were sufficient when technically possible. Duodenal exclusion is not an obligatory adjunct to duodenal repairs.

Evidence-based data for the hemodialysis access surgeon.

The National Kidney Foundation Dialysis Outcomes Quality Initiative Clinical Practice Guidelines for Vascular Access (DOQI) have defined the access-related care for patients with end-stage renal disease (ESRD). However, the standard of care across the country has fallen short of the DOQI targets. One potential explanation for these shortcomings is the lack of compelling evidence in the literature to support the recommendations. This study was designed to compare the DOQI with the best available evidence in the literature for four clinical questions relevant to the hemodialysis access surgeon: the choice of access type (autogenous versus prosthetic), the type of prosthetic graft, management of the "failing" (nonthrombosed) access, and management of the thrombosed access. The electronic literature databases MEDLINE and Evidence-Based Medicine Reviews were searched and relevant randomized controlled trials or meta-analyses were identified for review. No randomized controlled trials comparing autogenous to prosthetic accesses were identified. However, a recent systematic review reported that the patency rates for upper extremity autogenous accesses were superior to their polytetrafluoroethylene (PTFE) counterparts. The identified randomized trials suggested that the patency rates for the different types of commercially available prosthetic grafts used for access appear comparable. They suggested that standard wall PTFE thickness and prosthetic anastomotic cuffs may be associated with better graft patency, while venous cuffs may be associated with worse patency. Furthermore, the trials suggested percutaneous angioplasty of "failing" prosthetic accesses with greater than 50% stenoses did not appear to improve patency and that routine use of intraluminal stents, as an adjunct to angioplasty, was not beneficial. They did suggest that patency after open surgical revision of "failing" prosthetic accesses was superior to that after percutaneous angioplasty. Lastly, the identified trials suggested that the patency rates after open surgical revision of thrombosed prosthetic accesses was better than after endovascular treatment. Despite the magnitude of hemodialysis-related access problems, the quality of the evidence supporting the clinical decisions relevant to the access surgeon is limited and further clinical trials are justified.

Genomic and proteomic determinants of outcome in patients undergoing thoracoabdominal aortic aneurysm repair.

Thoracoabdominal aortic aneurysm repair, with its requisite intraoperative mesenteric ischemia-reperfusion, often results in the development of systemic inflammatory response syndrome, multiorgan dysfunction syndrome (MODS), and death. In the present study, an adverse clinical outcome following thoracoabdominal aortic aneurysm repair was identified by blood leukocyte genomic and plasma proteomic responses. Time-dependent changes in the expression of 146 genes from blood leukocytes were observed (p < 0.001). Expression of 138 genes (p < 0.001) and the concentration of seven plasma proteins discriminated between patients who developed MODS and those who did not, and many of these differences were evident even before surgery. These findings suggest that changes in blood leukocyte gene expression and plasma protein concentrations can illuminate pathophysiological processes that are subsequently associated with the clinical sequelae of systemic inflammatory response syndrome and MODS. These changes in gene expression and plasma protein concentrations are often observed before surgery, consistent with either a genetic predisposition or pre-existing inflammatory state.

Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001.

OBJECTIVE: Small patient numbers, mixed data from clinical trials, and longitudinal series representing institutional learning curves have characterized previous studies of early outcomes after endovascular abdominal aortic aneurysm (AAA) repair. We compared the perioperative outcomes of endovascular and open surgical AAA repair in an unselected sample of patients in a single calendar year using a national administrative database. METHODS: The 2001 National Inpatient Sample database was retrospectively reviewed. This database represents 20% of all-payer stratified sample of non-federal US hospitals. Patients older than 49 years were identified by primary diagnostic codes (International Classification of Disease, ninth revision [ICD-9], 441.4, intact, nonruptured AAA) and procedure codes (ICD-9 38.44 for open, 39.71 for endovascular repair). Patient demographic data (age, sex), comorbid conditions (ICD-9 coded), inpatient complications (ICD-9 coded), length of stay, final discharge disposition (home vs institution vs death), and hospital charges were examined with univariate and multivariate analyses. RESULTS: In calendar year 2001, 7172 patients underwent either open (64%) or endovascular (36%) repair of intact, nonruptured AAAs. Despite comparable rates of preoperative comorbid conditions and a greater proportion of octogenarians (23% vs 16%%; P =.0001), morbidity (18% vs 29%; P =.0001) and mortality (1.3% vs 3.8%; P =.0001) were significantly lower for endovascular repair than for open repair. The median length of stay (2 vs 7 days; P =.0001) and the rate of discharge to an institutional facility versus home (6% vs 14%; P =.0001) were also much lower in the endovascular group than in the open repair group. At multivariate analysis, open AAA repair and age older than 80 years were strong independent predictors (P =.0001 for all) for death (open repair: odds ratio [OR], 3.3; 95% confidence interval [CI], 2.3-4.9; age: OR, 14.2; 95% CI, 3.5-58.1), complications (open repair: OR, 1.9; 95% CI, 1.7-2.1; age: OR, 1.9; 95% CI, 1.5-2.5), and not being discharged to home (open repair: OR, 3.4; 95% CI, 2.9-4.1; age: OR, 12.0; 95% CI, 7.0-20.4). Mean hospital charges were significantly greater (difference, $3337; P =.0009) for endovascular repair than for open repair. Extrapolated to the total number of endovascular AAA repairs performed during the single 2001 calendar year, this resulted in a staggering $50.3 million in additional hospital charges. CONCLUSIONS: Endovascular repair of intact AAAs results in a significantly lower number of complications and deaths, shorter hospital stay, and improved likelihood of discharge to home, even in older patients, when compared with open surgical repair. These impressive gains in clinical outcome, however, are achieved at similarly impressive increases in health care costs.

Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review.

OBJECTIVE: Patency rates for autogenous accesses are presumed to be better than for polytetrafluoroethylene (PTFE) accesses, although the strength of the supporting evidence is limited. We undertook this study to test the hypothesis that patency rates for upper extremity autogenous hemodialysis arteriovenous accesses in adults are superior to those for PTFE counterparts. METHODS: A systematic review of relevant literature and meta-analysis of the patency data were performed. Studies were considered acceptable if patency data were reported by either life table or Kaplan-Meier method, including number of patients at risk. RESULTS: The thirty-four studies that satisfied the inclusion criteria were composed predominantly of case series or nonrandomized controlled studies; no randomized, controlled studies comparing autogenous and PTFE accesses were included. The primary patency rate for autogenous accesses was 72% (95% confidence interval [CI], 70%-74%) at 6 months and 51% (95% CI, 48%-53%) at 18 months, and the corresponding primary patency rate for PTFE accesses was 58% (95% CI, 56%-61%) and 33% (95% CI, 31%-36%), respectively. The secondary patency rate for autogenous accesses was 86% (95% CI, 84%-88%) at 6 months and 77% (95% CI, 74%-79%) at 18 months, and the corresponding secondary patency rate for PTFE accesses was 76% (95% CI, 73%-79%) and 55% (95% CI, 51%-59%), respectively. CONCLUSIONS: The patency rate for autogenous upper extremity arteriovenous hemodialysis accesses in adults is superior to that for PTFE counterparts, although the overall quality of the studies in the meta-analysis was less than ideal. Randomized, controlled studies to further examine the differences in outcome between these two access types are necessary.

Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair.

PURPOSE: Retroperitoneal iliac procedures can enable successful endovascular repair of abdominal aortic aneurysm (AAA) in patients who otherwise would not be anatomically eligible. The purpose of this study was to determine perioperative outcome with adjunctive retroperitoneal procedures compared with standard bilateral femoral exposure. METHODS: Between August 1997 and November 2002, 164 patients underwent elective endovascular AAA repair at a single university medical center. Anatomic, demographic, and early postoperative outcome data gathered prospectively were analyzed. Thirty-two patients (20%) underwent 38 separate adjunctive retroperitoneal procedures. Indications included small external iliac arteries (16 of 32 patients; 50%) and concomitant iliac aneurysm that precluded fixation of the endograft limbs in the common iliac arteries (16 of 32 patients; 50%). The 38 procedures consisted of 8 iliac conduits only, 14 iliac conduits with iliofemoral bypass grafts, and 16 hypogastric revascularization procedures. Data for the study patients were compared with data for 132 patients who underwent endovascular AAA repair through femoral incisions. Primary end points were hospital length of stay, and early morbidity and mortality. RESULTS: Retroperitoneal procedures enabled an additional 14% of patients with AAA to undergo endovascular techniques. However, there was a significantly higher proportion of women and patients at high risk for anesthesia (American Society of Anesthesiologists class IV or higher) in the group who underwent retroperitoneal procedures. On average, retroperitoneal procedures were associated with 2.6-fold greater blood loss, 82% longer procedure time, 1.5 days additional hospital stay, and 1.8-fold higher rate of perioperative complications, compared with endovascular AAA repair with femoral exposure alone. In contrast, early mortality was similar in the two groups. CONCLUSION: Adjunctive retroperitoneal procedures during endovascular AAA repair are associated with increased risk for complications and longer hospital length of stay, compared with AAA repair with standard femoral exposure only. They do not, however, increase early mortality, even in patients at high risk, and enable a larger subset of patients with AAA to undergo endovascular repair.