Treatment of Aortoiliac Occlusive Disease with the Endologix AFX Unibody Endograft.

OBJECTIVE/BACKGROUND: Aorto-bifemoral bypass remains the gold standard for treatment of aortoiliac occlusive disease (AIOD) in patients with advanced (TASC D) lesions, but has significant associated morbidity and mortality. Treatment with a unibody stent-graft positioned at the aortic bifurcation is a potential endovascular option for the treatment of AIOD. The current study examines the safety, efficacy, and early patency rates of the Endologix AFX unibody stent-graft for treatment of AIOD. METHODS: A multicenter retrospective review was conducted of patients treated exclusively for AIOD with the AFX device. Primary, assisted primary, and secondary patency rates were noted. Clinical improvement was assessed using Rutherford classification and ankle brachial index. Mean duration of follow-up was 22.2 ± 11.2 months. Ninety-one patients (56 males [62%]) were studied. RESULTS: Sixty-seven patients (74%) presented with lifestyle-limiting intermittent claudication and the remaining 24 (26%) had critical limb ischemia. Technical success was 100%. Complications included groin infection (n = 4 [4%]), groin hematoma (n = 4 [4%]), common iliac rupture (n = 4 [4%]), iliac dissection (n = 4 [4%]), and thromboembolic event (n = 3 [3%]; one femoral, one internal iliac artery, and one internal iliac with bilateral popliteal/tibial thromboemboli). Thirty-day mortality was 1% (1/91) resulting from a case of extensive pelvic thromboembolism. At 1 year, 73% of patients experienced improvement in Rutherford stage of -3 or greater compared with baseline. Nine patients (10%) required 16 secondary interventions. At all time points, primary patency rates were > 90%, assisted patency rates were > 98%, and secondary patency rates were 100%. CONCLUSION: This is the largest study to examine the use of the Endologix AFX unibody stent-graft for the treatment of AIOD. Use of the AFX stent-graft appears to be a safe and effective endovascular treatment for complex AIOD.

A combined genome-wide linkage and association approach to find susceptibility loci for platelet function phenotypes in European American and African American families with coronary artery disease.

BACKGROUND: The inability of aspirin (ASA) to adequately suppress platelet aggregation is associated with future risk of coronary artery disease (CAD). Heritability studies of agonist-induced platelet function phenotypes suggest that genetic variation may be responsible for ASA responsiveness. In this study, we leverage independent information from genome-wide linkage and association data to determine loci controlling platelet phenotypes before and after treatment with ASA. METHODS: Clinical data on 37 agonist-induced platelet function phenotypes were evaluated before and after a 2-week trial of ASA (81 mg/day) in 1231 European American and 846 African American healthy subjects with a family history of premature CAD. Principal component analysis was performed to minimize the number of independent factors underlying the covariance of these various phenotypes. Multi-point sib-pair based linkage analysis was performed using a microsatellite marker set, and single-SNP association tests were performed using markers from the Illumina 1 M genotyping chip from deCODE Genetics, Inc. All analyses were performed separately within each ethnic group. RESULTS: Several genomic regions appear to be linked to ASA response factors: a 10 cM region in African Americans on chromosome 5q11.2 had several STRs with suggestive (p-value < 7 x 10-4) and significant (p-value < 2 x 10-5) linkage to post aspirin platelet response to ADP, and ten additional factors had suggestive evidence for linkage (p-value < 7 x 10-4) to thirteen genomic regions. All but one of these factors were aspirin response variables. While the strength of genome-wide SNP association signals for factors showing evidence for linkage is limited, especially at the strict thresholds of genome-wide criteria (N = 9 SNPs for 11 factors), more signals were considered significant when the association signal was weighted by evidence for linkage (N = 30 SNPs). CONCLUSIONS: Our study supports the hypothesis that platelet phenotypes in response to ASA likely have genetic control and the combined approach of linkage and association offers an alternative approach to prioritizing regions of interest for subsequent follow-up.

A simple means of access for harvesting the lesser saphenous vein.

Enhanced patient expectations combined with improvements in vascular technique have increased the number of lower limb arterial bypass operations performed. The natural consequence is a parallel increase in the number of re-operations for failed or failing bypasses where the optimal conduit--the ipsilateral long saphenous vein has already been used. Indeed, there are many occasions where the long saphenous vein cannot be utilised at the primary operation, either because of the demands of coronary artery bypass surgery, or because of the presence of phlebitic vein segments. As autologous vein is generally preferred to prosthetic material for distal (tibial) bypasses, the vein must be harvested from other sites. Frequently there is insufficient or inadequate arm vein from a single source. Also, there is a natural reluctance to use the contralateral long saphenous vein, even if it is still available, because of the potential need for an arterial bypass on that side. The short saphenous vein is a valuable alternative. We describe a simplified approach (compared to the more conventional posterior approach) to harvest this vein which can then be used either in isolation or in combination with a superficial femoral endarterectomy or as part of a composite vein graft.

Concomitant renal artery revascularization and aortic reconstruction in the adult patient.

Concomitant renal artery revascularization and aortic reconstruction in the adult patient are thought to be associated with a high degree of morbidity and mortality. This has been attributed to the diffuse nature of atherosclerosis generally present in these patients and, as a consequence, a poor overall medical condition. Although this series confirms the fragile pre-operative nature of these patients it demonstrates that, with careful surgical management, they can be treated effectively.

Microcomputer database and system of audit for the vascular surgeon.

We have set up a vascular database based upon an IBM personal computer in the vascular unit at Repatriation General Hospital, Concord, using 'Dataease'. This is commercially available software that allows the development of a database by users with little or no programming knowledge. The database is menu driven and designed to record details of admissions, indications for surgery, operations, complications and follow-up and has been set up as a prospective project from 1 January 1989 after a pilot study in 1988. Currently, interns, residents and registrars enter data directly onto the computer, providing an excellent teaching and review medium. Unit audit is easy as the program is completely menu driven and there are more than 100 customized reports written, ranging from providing simple complication details to complex reports deriving graft cumulative patency rates. This system also provides for 'instant' discharge letters which have markedly improved communication with the general practitioner.

Upper extremity limb salvage accomplished by in situ vein bypass graft.

The need for revascularization procedures in individuals with hand ischemia is uncommon. Previous reports describe the successful utilization of reversed saphenous vein to reconstruct the distal vasculature of the arm. This case report details the use of in situ arm vein to restore perfusion to a threatened hand.

Management of an unusual case of congenital lobar emphysema.

A 10-week-old infant, who presented with respiratory embarrassment, was found to have an azygos lobe complicated by congenital lobar emphysema. The pediatric work-up, operative management, and postoperative course are described. The cases presenting at Duke University Medical Center are reviewed.

Colonization and sepsis from triple-lumen catheters in critically ill patients.

Sepsis from central triple-lumen catheters remains a serious and life-threatening problem. Patients requiring triple-lumen catheter placement frequently have multiorgan failure or very serious illness. Every effort should be made to reduce the incidence of catheter-related sepsis. Earlier recognition of catheter sepsis may allow removal of the offending line before sepsis becomes clinically apparent. These data indicate that line colonization occurs early and frequently after triple-lumen catheter placement, and suggests that early, frequent line changes may reduce the incidence of clinical sepsis.