Factors associated with successful median arcuate ligament release in an international, multi-institutional cohort.

OBJECTIVE: Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure. METHODS: The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up. RESULTS: For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval [CI], 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio [HR], 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure. CONCLUSIONS: No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.

Contemporary management and outcomes of peripheral venous aneurysms: A multi-institutional study.

OBJECTIVE: Extremity venous aneurysms result in the risk of pulmonary embolism (PE) and chronic venous insufficiency. At present, owing to the rarity of these aneurysms, no consensus for their treatment has been established. The purpose of the present study was to review the presentation, natural history, and contemporary management of extremity venous aneurysms. METHODS: We performed a retrospective, multi-institutional review of all patients with extremity venous aneurysms treated from 2008 to 2018. A venous aneurysm was defined as saccular or fusiform with an aneurysm/vein ratio of >1.5. RESULTS: A total of 66 extremity aneurysms from 11 institutions were analyzed, 40 of which were in a popliteal location, 14 iliofemoral, and 12 in an upper extremity or a jugular location. The median follow-up was 27 months (range, 0-120 months). Of the 40 popliteal venous aneurysms, 8 (20%) had presented with deep vein thrombosis (DVT) or PE, 13 (33%) had presented with pain, and 19 had been discovered incidentally. The mean size of the popliteal venous aneurysms presenting with DVT or PE was larger than that of those presenting without thromboembolism (3.8 cm vs 2.5 cm; P = .003). Saccular aneurysm morphology in the lower extremity was associated with thromboembolism (30% vs 9%; P = .046) and fusiform aneurysm morphology with a thrombus burden >25% (45% vs 3%). Patients presenting with thromboembolism were more likely to have had a thrombus burden >25% in their lower extremity venous aneurysm compared with those who had presented without thromboembolism (70% vs 9%). Approximately half of all the patients underwent immediate intervention, and half were managed with observation or antithrombotic regimen. In the non-operative cohort, three patients subsequently developed a DVT. Eight patients in the medically managed cohort went on to require surgical intervention. Of the 12 upper extremity venous aneurysms, none had presented with DVT or PE, and only 2 (17%) had presented with pain. Of the 66 patients in the entire cohort, 41 underwent surgical intervention. The most common indication was the absolute aneurysm size. Nine patients had undergone surgery because of a DVT or PE, and 11 for pain or extremity swelling. The most common surgery was aneurysmorrhaphy in 21 patients (53%), followed by excision and ligation in 14 patients (35%). Five patients (12%) had undergone interposition bypass grafting. A postoperative hematoma requiring reintervention was the most common complication, occurring in three popliteal vein repairs and one iliofemoral vein repair. None of the patients, treated either surgically or medically, had reported post-thrombotic complications during the follow-up period. CONCLUSIONS: Large lower extremity venous aneurysms and saccular aneurysms with thrombus >25% of the lumen are more likely to present with thromboembolic complications. Surgical intervention for lower extremity venous aneurysms is indicated to reduce the risk of venous thromboembolism (VTE) and the need for continued anticoagulation. Popliteal aneurysms >2.5 cm and all iliofemoral aneurysms should be considered for repair. Upper extremity aneurysms do not have a significant risk of VTE and warrant treatment primarily for symptoms other than VTE.

Outcomes for concomitant common iliac artery aneurysms after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: This study evaluated the morbidity of endovascular abdominal aortic aneurysm repair (EVAR) in patients with concomitant common iliac artery aneurysm (CCIAA). METHODS: This was a retrospective review of all patients who underwent elective EVAR from June 2006 through June 2012 at a single institution. Demographics, comorbidities, preoperative presentation, intraoperative details, and postoperative complications were tabulated. Patients with CCIAA were categorized into three groups according to the distal extent of their iliac limb: iliac limb extension into the external iliac artery with internal iliac artery coil embolization (EE); flared iliac limb ≥20 mm in diameter to the iliac bifurcation (FL); and iliac limb ≤20 mm ending proximal to the CCIAA (no-FL). RESULTS: During this period, 627 consecutive patients underwent elective EVAR and preoperative computed tomographic angiograms were available for 523 patients to evaluate the presence of CCIAA. Of these, 211 patients (40.2%) had a CCIAA in at least one common iliac artery, with a total of 307 aneurysmal arteries. Of these 307 aneurysmal arteries, 62 (20.2%) were treated with EE, 132 (43.0%) were treated with FL, and 113 (36.8%) had a sufficient landing zone in the proximal common iliac artery to use an iliac limb ≤20 mm in diameter (no-FL). The overall reintervention rate was 12.4% of patients, with a higher reintervention rate between patients with CCIAA compared with those without (15.2% vs 10.9%; P = .039). There were no significant differences in reintervention rates between the EE, FL, and no-FL techniques (4.5% vs 4.8% vs 6.2%; P = .802) over a mean 59.8 months follow-up. The FL and EE techniques had a lower risk of distal endoleak than the no-FL technique, but the difference was not statistically significant (3.2% vs 2.3% vs 5.3% compared with 4.23% in the entire cohort). CONCLUSIONS: Patients with CCIAA had a higher reintervention rate after EVAR for abdominal aortic aneurysm compared with non-CCIAA patients. Of the techniques studied (EE, FL, and no-FL), there was no significant difference in reintervention rates between the three. All three techniques remain viable options for the endovascular repair of CCIAA.

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

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

The quality and impact of risk factor control in patients with stable claudication presenting for peripheral vascular interventions.

BACKGROUND: Peripheral arterial disease is a manifestation of systemic atherosclerosis and is predictive of future cardiovascular events. Clinical trial data have demonstrated that medical therapy can attenuate cardiovascular morbidity and mortality in patients with peripheral arterial disease. The utilization and impact of recommended medical therapy in a contemporary population of patients who undergo percutaneous interventions for lifestyle-limiting peripheral arterial disease is unknown. METHODS AND RESULTS: Using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention (BMC2 PVI) database, we identified 1357 peripheral vascular intervention encounters between January 2007 and December 2009 for the purpose of treating claudication. Before the intervention, 85% of these patients used aspirin, 76% used statin, 65% abstained from smoking, and 47% did all 3. There was no difference in cardiovascular events among those taking an aspirin and a statin on admission and those who were not. However, in both an unadjusted and a multivariable analysis, the odds of an adverse peripheral vascular outcome (repeat peripheral intervention, amputation, or limb salvage surgery) within 6 months decreased by more than half in patients receiving aspirin and statin therapy before peripheral vascular intervention as compared with those who received neither (odds ratio, 0.45; 95% CI, 0.29-0.71). CONCLUSIONS: The fundamental elements of medical therapy in patients with lifestyle-limiting claudication are often underutilized before referral for revascularization. Appropriate medical therapy before percutaneous revascularization is associated with fewer peripheral vascular events at 6 months.

Safety of contemporary percutaneous peripheral arterial interventions in the elderly insights from the BMC2 PVI (Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention) registry.

OBJECTIVES: This study sought to evaluate the effect of age on procedure type, periprocedural management, and in-hospital outcomes of patients undergoing lower-extremity (LE) peripheral vascular intervention (PVI). BACKGROUND: Surgical therapy of peripheral arterial disease is associated with significant morbidity and mortality in the elderly. There are limited data related to the influence of advanced age on the outcome of patients undergoing percutaneous LE PVI. METHODS: Clinical presentation, comorbidities, and in-hospital outcomes of patients undergoing LE PVI in a multicenter, multidisciplinary registry were compared between 3 age groups: < 70 years, between 70 and 80 years, and ≥ 80 years (elderly group). RESULTS: In our cohort, 7,769 patients underwent LE PVI. The elderly patients were more likely to be female and to have a greater burden of comorbidities. Procedural success was lower in the elderly group (74.2% for age ≥ 80 years vs. 78% for age 70 to < 80 years and 81.4% in patients age < 70 years, respectively; p < 0.0001). Unadjusted rates of procedure-related vascular access complications, post-procedure transfusion, contrast-induced nephropathy, amputation, and major adverse cardiac events were higher in elderly patients. After adjustment for baseline covariates, the elderly patients were more likely to experience vascular access complications; however, advanced age was not found to be associated with major adverse cardiac events, transfusion, contrast-induced nephropathy, or amputation. CONCLUSIONS: Contemporary PVI can be performed in elderly patients with high procedural and technical success with low rates of periprocedural complications including mortality. These findings may support the notion of using PVI as a preferred revascularization strategy in the treatment of severe peripheral arterial disease in the elderly population.

A novel treatment approach to a type II endoleak at endograft implantation using components of an endosensor monitoring device.

PURPOSE: There continues to be debate regarding optimal management of type II endoleaks following endovascular abdominal aortic aneurysm repair. CASE REPORT: We present an intraoperative treatment approach to type II endoleaks using components of the EndoSure Intrasac Pressure Monitor System. Our technique can easily be reproduced with commercially available guidewires and catheters. We also present a literature review that identifies type II endoleak characteristics associated with a high rate of persistence (high-risk endoleaks) and could benefit from early treatment. CONCLUSIONS: If a high-risk type II endoleak is identified intraoperatively, those patients may benefit from our model of an early intervention strategy. Early definitive treatment of the endoleaks could result in lower morbidity and reintervention rates.

Contemporary outcomes for carotid endarterectomy at a large community-based academic health center.

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS) demonstrated the efficacy of carotid endarterectomy (CEA), but these studies were published 15 and 11 years ago, respectively. We hypothesized that present clinical results of CEA have improved compared with those reported by NASCET/ACAS. Every patient having CEA from January 1999 through December 2003 was reviewed as part of a continuous quality-assurance program. Patient demographics and risk factors were recorded; high-risk patients were identified using inclusion criteria for high-risk carotid stent trials. Primary end points recorded were all neurologic events, deaths, and myocardial infarctions (MIs). Outcomes were reported individually or as combined neurologic events and deaths (traditional NASCET/ACAS methodology) and, similar to recent carotid stent trials, individually, combined, and as a composite that included MI. A total of 1,927 CEAs were performed, 1,140 in men (59%) and 787 in women (41%). The average age was 72 +/- 9 years; 21% of patients were age 80 or older. Symptomatic patients accounted for 717 procedures (37%). Perioperative neurologic event, death, and MI occurred in 1.0%, 0.5%, and 1.3% of patients, respectively. The combined neurologic event and death rate was 1.3% (symptomatic = 1.8%, asymptomatic = 1.1%). High-risk patients comprised 54% of the cohort; the neurologic event and death rate for this group was 1.6%. The composite end point including MI was 3.4%. Severe coronary artery disease and prior ipsilateral CEA significantly correlated with a higher incidence of primary end point complications. In contemporary practice, the perioperative neurologic event rate is significantly less than reported in NASCET/ACAS. Perioperative death and MI rates were similar to those seen in NASCET/ACAS. Neurologic events and death rates were not different between high- and low-risk groups. These data may serve as a guide for the modern vascular specialist weighing open and endovascular options for treatment of carotid artery occlusive disease in both high- and low-risk patients.

Intentional coverage of a main renal artery during endovascular juxtarenal aortic aneurysm repair in symptomatic high-risk patients.

PURPOSE: To describe the efficacy and morbidity of intentionally covering a main renal artery during symptomatic juxtarenal endovascular aneurysm repair (EVAR). CASE REPORTS: Two patients with symptomatic juxtarenal abdominal aortic aneurysm (AAA) were felt to be at prohibitive risk for open repair. Each underwent EVAR with intentional coverage of 1 main renal artery to achieve adequate proximal hemostatic seal. One patient died at 24 months; the second is symptom-free at 10 months. Both aneurysms initially decreased in diameter. Both patients had increased serum creatinine and required increased therapy for hypertension, but neither required hemodialysis. Renal volume decreased 48.7% and 68.0%, respectively. CONCLUSION: Intentional coverage of a main renal artery during EVAR for a symptomatic juxtarenal aneurysm resulted in effective short-term AAA repair with no need for dialysis. Despite the increased requirement for antihypertensive medications and the observed decline in renal function, this technique provides an option for treatment of this difficult patient subset.

Diagnosis of total internal carotid occlusions with duplex ultrasound and ultrasound contrast.

It remains a significant technical challenge for duplex ultrasound to accurately differentiate between total and near total internal carotid artery (ICA) occlusions. We have evaluated the efficacy of an ultrasound contrast agent combined with improved imaging techniques in patients with suspected carotid artery occlusions. Patients identified by conventional duplex ultrasound between January and August 2003 as having a possible ICA occlusion were eligible for study. A 1 mL bolus of ultrasound contrast agent was injected into a 50 mL bag of normal saline and given intravenously at a rate of approximately 4-5 mL/minute. Ultrasound imaging and spectral Doppler analysis were done using tissue harmonic imaging for optimum contrast agent to soft tissue discrimination, or with the direct B-mode imaging of blood flow to maximize the brightness of the circulating contrast agent. Ten patients were identified, 6 men and four women with a mean age of 68.3 years. Nine suspected total ICA occlusions were unilateral and 1 was bilateral. Imaging with contrast agent confirmed occlusion of the ICA in 7 of 10 patients; 3 patients had near-total occlusion with flow detected in the distal ICA by spectral and color Doppler. All 3 of these near-total occlusions were ultimately confirmed by either conventional or magnetic resonance carotid angiography. The contrast agent was most beneficial in improving the detection of minimal flow beyond a severe stenosis and in evaluating flow dynamics in the presence of severely calcified plaque. We conclude that the use of an ultrasound contrast agent with newer duplex ultrasound imaging techniques can reliably distinguish total from near-total internal carotid artery occlusions. Future prospective studies should be able to define the efficacy of ultrasound contrast agents in improving the overall diagnostic accuracy of duplex ultrasound in technically difficult cases and in patients with complex peripheral vascular disease.

Gastrointestinal complications following infrarenal endovascular aneurysm repair.

Gastrointestinal complications are known to occur after open elective aortic aneurysm repair. This leads to increased morbidity, mortality, length of stay, and hospital costs. The authors hypothesize a change in the character and/or frequency of early postoperative gastrointestinal complications after endovascular aneurysm repair as compared to open abdominal aortic repair. This is a retrospective cohort study in which the medical records of 153 consecutive patients who underwent endovascular infrarenal aneurysm repair from November 1998 to August 2001 were reviewed for gastrointestinal complications. Of these 153 patients, 9 (5.9%) had postoperative gastrointestinal complications. Three patients (1.9%) underwent exploratory laparotomy for small bowel obstruction. One patient had had a right hemicolectomy for cancer 2 years before stent graft placement. This patient needed a partial small bowel resection. One patient had had a right hemicolectomy 4 months before stent graft placement; he had lysis of adhesions with no bowel resection. A third patient underwent operative repair of an incarcerated inguinal hernia. Six patients (3.9%) had paralytic ileus that was treated by nasogastric tube or observation resulting in an extended hospital length of stay. All cases of ileus resolved without any operative intervention. No patients in this series developed any intestinal ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding. After endovascular aneurysm repair, gastrointestinal complications such as ileus and postoperative small bowel obstruction are seen with a similar frequency as after open aortic repair. This occurs despite the absence of a laparotomy with mesenteric dissection and evisceration. In this series, these complications are associated with longer hospital length of stay but no increased mortality rate. No instances of colonic ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding were seen in this series.

Reliability of extracranial carotid artery duplex ultrasound scanning: value of vascular laboratory accreditation.

OBJECTIVES: The purpose of this study was to evaluate the reliability of carotid duplex ultrasound scanning performed by nonaccredited vascular laboratories and to assess the clinical effect on patient management. METHODS: We retrospectively reviewed concordance of findings of carotid duplex ultrasound scanning between laboratories accredited by the Intersocietal Commission for Accreditation of Vascular Laboratories and nonaccredited laboratories in 174 patients with asymptomatic disease referred to tertiary care community hospitals for surgical evaluation for carotid endarterectomy (CEA) between January 2001 and December 2002, and evaluated changes in clinical management made on the basis of repeat examinations. RESULTS: Concordant findings were noted in 171 of 348 arteries (49%), predominantly those with minimal or mild disease (114 arteries; 67%). Discordant findings of no clinical significance were found in 54 arteries (16%). Clinically significant discordant findings were noted in 123 arteries (35%) in 107 patients (61%). In 104 arteries (88 patients) stenosis was overestimated by the nonaccredited laboratory secondary to technical error (19 arteries), use of B-mode imaging data alone (36 arteries), and use of inappropriate velocity criteria (49 arteries). None of these patients underwent CEA. Stenosis was significantly underestimated in 19 arteries (19 patients); all of these patients underwent uncomplicated CEA. CONCLUSIONS: Incorrect physician interpretation of data is the most common cause of error in carotid duplex ultrasound scanning performed in nonaccredited vascular laboratories. Results of carotid duplex ultrasound scanning from nonaccredited laboratories should be considered with extreme caution, and do not appear reliable in planning treatment of obstructive disease.

Duplex ultrasound imaging with an ultrasound contrast agent: the economic alternative to CT angiography for aortic stent graft surveillance.

The use of endovascular stent graft repair for aortic aneurysmal disease has become increasingly common, with the added requirement for close postoperative surveillance to detect the presence of endoleaks or graft migration. The most commonly used technique for surveillance is computed tomography (CT) angiography, with the need for intravenous contrast posing 1 limitation in those patients with renal dysfunction and the cost of this testing presenting an economic limitation. Early results of duplex imaging in the authors' Vascular Laboratory using an intravenous ultrasound contrast agent have shown sensitivity and specificity equivalent to those of CT angiography, with no evidence of any related morbidity. They have evaluated the cost effectiveness of using duplex ultrasound imaging as the primary surveillance technique for postoperative follow-up in aortic stent graft patients. Surveillance protocols now require that 8 follow-up examinations be performed in the first 3 years after stent graft placement. The charges for CT angiography in their institution average 2,779 dollars per study, for a 3-year total of 22,232 dollars per patient. The charges for aortic duplex ultrasound average 525 dollars per study, with a 3-year total of 4,200 dollars per patient. Adding the cost of routine abdominal radiographs to confirm stent graft position (147 dollars per study) would bring this 3-year total to 5,376 dollars, a savings of 16,856 dollars per patient. For every 100 patients who are followed up after stent graft placement, this represents a 3-year savings of more than 1.6M dollars. Promising early results of duplex ultrasound imaging with an intravenous contrast agent show sensitivity and specificity equivalent to those of CT angiography in detecting aneurysm size and graft endoleaks or other hemodynamic abnormalities. If these results can be demonstrated in larger patient series, this technique should become the method of choice for stent graft surveillance, for it offers very significant economic advantages and avoids the complications of intravenous contrast-induced renal dysfunction.

Transrenal fixation of endovascular stent-grafts for infrarenal aortic aneurysm repair: mid-term results.

PURPOSE: We evaluated mid-term results of a single-center consecutive series of endovascular stent-grafts implanted for aortic aneurysm repair with transrenal fixation, to determine clinical outcome, aneurysm anatomy, renal artery patency, and renal complications. METHODS: Modular stent-grafts were placed with transrenal fixation in 37 patients between November 1998 and July 2000. Follow-up evaluation included clinical examination, laboratory evaluation of serum creatine concentration, computed tomographic angiography, and renal duplex scanning. RESULTS: Thirty-seven patients underwent transrenal fixation of aortic stent-grafts as part of a Phase II US Food and Drug Administration study. Two patients subsequently underwent follow-up at institutions closer to their homes, and thus provided clinical information but no long-term renal or aneurysm morphologic data. There were no perioperative deaths. Five patients died during follow-up, at a mean of 9 months, because of myocardial infarction in 4 patients and respiratory failure in 1 patient. Thirty patients, ages 75 +/- 8 years, have been followed up for 28.5 +/- 7.2 months. Aneurysm diameter at follow-up was 5.0 +/- 0.8 cm, compared with 5.7 +/- 0.8 cm preoperatively. In 5 patients, endoleak developed during follow-up: 1 type I leak was treated with an aortic cuff, with temporary stabilization of the aneurysm and correction of the endoleak; 2 type II endoleaks were treated with translumbar coil embolization, and 1 resolved spontaneously; and 1 type III endoleak was treated with a combination of coil embolization and stent-graft extension to cover a graft defect. Preoperatively, serum creatinine concentration was normal in 23 patients, but increased persistently in 2 patients and was abnormal in 7 patients. Postoperatively, creatine concentration increased in 4 patients to greater than 20% of baseline level. Seventeen patients had no evidence of renal artery stenosis, compared with 13 patients with renal artery stenosis. Of 41 normal renal arteries, 90% remained unchanged, 1 became occluded, 3 demonstrated 60% stenosis. Nephrectomy was necessary in 1 patient because of cancer. Of 19 abnormal renal arteries, progression of disease was noted in 3 arteries. CONCLUSIONS: Transrenal fixation of aortic stent-grafts can be performed with acceptable mid-term outcome with respect to mortality, need for follow-up intervention, and aneurysm exclusion with protection from rupture. Postprocedural stenosis can develop in both normal and abnormal renal arteries. Rate of progression of disease was greater in patients with preprocedural renal dysfunction compared with patients with normal renal arteries. This is merely an observation, and may not be related to transrenal fixation. Long-term follow up is needed.

Efficacy of ultrasound scan contrast agents in the noninvasive follow-up of aortic stent grafts.

OBJECTIVE: Computed tomographic angiography (CTA) is currently the most commonly used technique for postoperative surveillance to detect endoleaks after endovascular stent graft repair of abdominal aortic aneurysms. We have evaluated the efficacy of duplex ultrasound scan with the addition of an ultrasound scan contrast agent in documenting endoleaks and compared these results with CTA. METHODS: Conventional duplex ultrasound scan with color Doppler imaging (CDI) was first done as part of routine postoperative surveillance. After the CDI study, a 1-mL bolus of ultrasound scan contrast was given via an antecubital vein, followed by a 5-mL flush with normal saline solution. The duplex ultrasound scan evaluation of the stent graft was repeated once the contrast agent was circulating throughout the blood pool, with tissue harmonic imaging to optimize visualization of the contrast agent. Status of the stent graft, the presence or absence of any endoleak, and whether these endoleaks were graft related (group I) or arterial branch related (group II) were recorded. Findings were compared with CTA studies done within a 2-week period of the ultrasound scan examination. RESULTS: Twenty patients were evaluated, 18 with modular stent grafts and two with unibody bifurcated stent grafts. Patients had a mean age of 74.5 +/- 7.6 years; 19 were male, with only one female. All stent grafts remained widely patent with normal aortoiliac flow hemodynamics. Duplex ultrasound scan with contrast identified all eight of the endoleaks seen with CTA and was able to determine whether they were group I or group II leaks. In two patients, ultrasound scan with contrast detected small endoleaks at the proximal graft attachment site, with extravasation of contrast into the aneurysm sac during systole. These endoleaks were not seen with CTA but were confirmed with conventional angiography at the time of endovascular closure. Standard duplex ultrasound scan with CDI failed to identify four of the 10 endoleaks in patients with technically difficult conditions. CONCLUSION: Duplex ultrasound scan, when used with an intravenously administered ultrasound scan contrast agent in the noninvasive follow-up of patients with aortic stent grafts, appears to provide good sensitivity to the presence and type of endoleaks, even in patients with technically difficult conditions not amenable to conventional duplex ultrasound scan with CDI.

Simultaneous stent-graft repair of thoracic and infrarenal abdominal aortic aneurysms.

PURPOSE: To describe a technique for concomitant endovascular stent-graft repair of thoracic and infrarenal abdominal aortic aneurysms. CASE REPORT: A 68-year-old man was found to have concomitant thoracic and abdominal aortic aneurysms. Both of the aneurysms were excluded successfully in one procedure using Talent stent-grafts. The patient tolerated the procedure well and was discharged on postoperative day 4. Aside from an infected groin wound, the patient did not have any complications. Computed tomographic scans at 6, 12, and 18 months showed proper position of both stents without evidence of endoleak. CONCLUSIONS: Simultaneous endovascular treatment of thoracic and infrarenal abdominal aortic aneurysms may represent a viable alternative for therapy in some patients.