Significance of preoperative thrombus burden in the prediction of a persistent type II and reintervention after infrarenal endovascular aneurysm repair.

BACKGROUND: Persistent type II endoleak has necessitated prolonged surveillance and is a reason for reintervention after infrarenal endovascular aneurysm repair (EVAR). The aim of this study was to assess the association of thrombus burden (TB) within the aneurysmal sac in the prediction of a persistent type II endoleaks. METHODS: Consecutive patients who underwent infrarenal EVAR from October 2009 to October 2017 in a single vascular network were included. TB was assessed on preoperative computed tomography angiogram and was defined as a percentage of thrombus across the maximal sac diameter in comparison with the luminal diameter measured orthogonally at the same level. Patients were categorized into three groups: low TB (<25%), medium TB (25%-50%), and high TB (>50%). All patients underwent postoperative EVAR surveillance comprising computed tomographic angiography or duplex ultrasound imaging. Type II endoleak observed for more than 1 year was defined as persistent type II endoleak. Odds ratio (OR) and Student's t-test were used to determine significance. RESULTS: Some 275 EVARs were performed in the study period. A total of 45 procedures were excluded because of either iliac-only intervention (n = 9), no preoperative information (n = 7), abandoned (n = 1), or less than 1 year's follow-up data (n = 28). For the 230 procedures included, the median follow-up was 43 (12-102) months. There were no significant differences between the groups for age, gender, and comorbidities nor preoperative sac diameter. There was high interobserver reliability with a kappa value of 0.89 (0.84-0.94) with a total discordance of 7% across the cohorts. Persistent type II endoleak occurred significantly more frequently with reduced TB: 41% of the low TB cohort compared with 4% of the high TB cohort (OR, 15.36 [3.5-67.3]; P = .0003). Reintervention was also significantly more likely to occur in the presence of a persistent type II endoleak compared with its absence; n = 12 of 13 (92%) patients who underwent reintervention had a persistent type II endoleak (OR, 43.4 [5.5-242]; P = .0003). Sac size reduction was significantly greater in medium TB and high TB cohorts when compared with low TB: -25% and -27% vs -15% (P = .0046 and P < .0001). Decreased TB was associated with a significant increase in inferior mesenteric artery (IMA) patency, the mean TB, where the IMA was patent, being 29% compared with 40% where the IMA was occluded P < .0001. When considered together, patients with a low TB and a patent IMA were even more likely to have a persistent type II endoleak when compared with those with a high TB and an occluded IMA (OR, 34.1 [1.99-583]; P = .015). CONCLUSIONS: Low TB is associated with increased rates of persistent type II endoleak, especially in the presence of a patent IMA. High TB is associated with increased sac regression and low reintervention rates. TB can be assessed reliably and could be used for risk stratification in the planning of infrarenal EVAR. Pre-emptive embolization of IMA or lumbar vessels in those with low TB may be beneficial. TB could be a useful tool for designing a post-EVAR surveillance regimen.

Posterior Cerebral Circulation Stroke Secondary to Foetal Origin of Posterior Communicating Artery: An Indication for Carotid Endarterectomy.

INTRODUCTION: Posterior cerebral circulation strokes are most commonly caused by posterior vasculature in situ thrombosis, cardiac emboli, or arterial dissection. However, the foetal origin of the posterior communicating artery is an anatomical variant of the cerebral circulation that results in communication between the internal carotid and posterior cerebral circulation. Therefore, rarely this can result in posterior cerebral territory infarction from internal carotid artery thrombo-embolism. This is the report of a case in which a patient suffered posterior circulation stroke secondary to this anatomical variation of the circle of Willis. REPORT: A 71 year old male patient was admitted to the stroke team with seizures, headache, and confusion. Examination revealed a left sided homonymous hemianopia. Diffusion weighted magnetic resonance imaging (MRI) of the brain 36 hours into his admission revealed an acute right posterior circulation infarct with extensive haemorrhagic transformation. Duplex ultrasound three days later revealed a heavily calcified right internal carotid artery mixed echogenicity plaque with 80%-90% stenosis. Subsequent computed tomography angiography showed a large right foetal variant posterior communicating artery. Following improvement in functional status, the patient underwent uneventful carotid endarterectomy to reduce risk of future stroke. DISCUSSION: In patients presenting with posterior circulation infarction, clinicians should consider embolism from an atheromatous internal carotid artery via the variant foetal origin of posterior communicating artery. If detected, consideration should be given to undertaking carotid endarterectomy to reduce future stroke risk if no other source is detected.

Management of acute and chronic iliofemoral venous outflow obstruction: a multidisciplinary team consensus.

The aim of this manuscript was to establish a consensus for the management of acute and chronic venous obstruction among specialists in the UK. Specialist physicians representing vascular surgery, interventional radiology and hematology were invited to 3 meetings to discuss management of acute and chronic iliofemoral obstruction. The meetings outlined controversial areas, included a topic-by-topic review; and on completion reached a consensus when greater than 80% agreement was reached on each topic. Physicians from 19 UK hospitals agreed on treatment protocols and highlighted areas that need development. Potential standard treatment algorithms were created. It was decided to establish a national registry of venous patients led by representatives from the treating multidisciplinary teams. Technical improvements have facilitated invasive treatment of patients with acute and chronic venous obstruction; however, the evidence guiding treatment is weak. Treatment should be conducted in centers with multi-disciplinary input; robust, coordinated data collection; and regular outcome analysis to ensure safe and effective treatment and a basis for future evolvement.