Predictors of Groin Access Pseudoaneurysm Complication: A 10-Year Institutional Experience.

OBJECTIVE: In clinical practice, the incidence of femoral pseudoaneurysms requiring repair is small, but at a tertiary care center, the repair rate is higher due to referrals. We sought to specifically study patients who suffered postcatheterization pseudoaneurysms requiring thrombin injection or operative repair and compare them to our routine transfemoral endovascular patients to identify predictors of clinically significant pseudoaneurysms. The underlying goal would be to identify what makes these patients that develop pseudoaneurysms different. METHODS: A search of our billing records for Current Procedural Technology (CPT) codes of these 2 procedures between January 2008 and April 2018 was combined with our institution's Peripheral Vascular Intervention Vascular Quality Initiative database spanning from January 2013 to December 2017. A comparison was then performed between patients who had the outcome of operative intervention for a pseudoaneurysm complication and those who did not, with the goal of elucidating patient demographics and periprocedural factors that would predict pseudoaneurysm formation using univariate and multivariate analyses. RESULTS: There were 77 patients who required thrombin injection or open repair for access-related pseudoaneurysms and 324 patients who did not. Complications occurred more often in patients who were older than 75 (40.2% vs 21.9%; P = .0009), female (57.1% vs 38.6%; P = .003), obese (59.7% vs 33.3%; P < .001), hypertensive (96.1% vs 79.3%; P = .0005), who received a sheath >6F (32.4% vs 13%; P < .0001), intraoperative and postoperative anticoagulation (77.3% vs 32.7% and 52.1% vs 24.2%, respectively; P < .0001), and periprocedural P2Y12 inhibitors (48.7% vs 28%; P = .0005). Less complications were observed in patients who had a closure device used (42.9% vs 8.45%; P < .0001) and protamine reversal (26.5% vs 13.3%; P = .0163). CONCLUSIONS: Our findings validate published reports that incriminate a larger sheath size, perioperative anticoagulation, and female gender as increasing the rate of access site complications, with the use of a closure device being protective.

A prospective study of carbon dioxide digital subtraction versus standard contrast arteriography in the detection of endoleaks in endovascular abdominal aortic aneurysm repairs.

BACKGROUND: The objective of this study is to compare intraoperative endoleak detection by carbon dioxide digital subtraction angiography (CO(2)-DSA) during endovascular aortic aneurysm repair (EVAR) with standard iodinated contrast angiography (ICA). METHODS: Between 2006 and 2010, 76 patients with abdominal aortic aneurysms undergoing EVAR were enrolled in a prospective study. After EVAR, both an ICA and CO(2)-DSA completion study were performed. Two blinded vascular surgeons who were not involved with the EVAR separately interpreted the ICA and CO(2)-DSA results for the presence or absence of an endoleak. Identified endoleaks were classified by types. A third, "tie-breaker" blinded observer was used to resolve differences in interpretations. The sensitivity, specificity, negative predictive value, and positive predictive value were calculated for the ability of CO(2)-DSA to detect endoleaks. Cohen's κ statistic was used to assess interobserver agreement between the 2 initial interpreting surgeons. RESULTS: Of the 76 patients undergoing EVAR, 66 were men with average age of 76 years, a mean aneurysm size of 5.8 cm (range, 4-10 cm), and creatinine of 1 (standard deviation, 0.33). ICA identified 35 type I and 15 type II endoleaks, respectively, while CO(2)-DSA identified 40 type I and 10 type II endoleaks. Overall, CO(2)-DSA had a sensitivity of 0.84, specificity of 0.72, positive predictive value of 0.86, and negative predictive value of 0.69 of intraoperative endoleak detection, with respect to ICA as the criterion standard. The interobserver κ between surgeons for ICA was 0.56, for detection of any endoleak or type I endoleak with CO(2)-DSA was 0.58, and for detection of type II endoleak with CO(2)-DSA was 0.29. CONCLUSIONS: Interobserver agreement for the detection of endoleaks is superior with ICA compared to CO(2)-DSA. However, the sensitivity for detecting any endoleak and both the sensitivity and specificity for detecting type I endoleaks using CO(2)-DSA are acceptable. For detecting type II endoleaks using CO(2)-DSA, the sensitivity and positive predictive value are poor. Compared to ICA, CO(2)-DSA provides adequate images for endoleak detection during EVAR and is an acceptable alternative to ICA in patients at risk for contrast-related nephrotoxicity.

Predictors of wound complications following major amputation for critical limb ischemia.

OBJECTIVES: For patients with end-stage critical limb ischemia (CLI) who have already suffered over an extended period of time, a major amputation that is free of wound complications remains paramount. Utilizing data from the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP), the objective of this report was to determine critical factors leading to wound complications following major amputation. METHODS: ACS-NSQIP was used to identify patients ≥ 50 years, with CLI, and having an ipsilateral below-(BKA) or above-knee amputation (AKA). The primary outcome was wound occurrence (WO) defined by affirmative findings of superficial infection, deep infection, and/or wound disruption. The secondary outcome was 30-day mortality. Following univariate analyses, a multiple logistic regression was performed to identify predictive factors. RESULTS: Between January 1, 2005 and December 31, 2008, 4250 patients fulfilled inclusion criteria (2309 BKAs and 1941 AKAs). WOs were 10.4% for BKAs and 7.2% for AKAs. For BKAs, increasing elevation in international normalized ratio (INR) predicted more WOs (P = .008, odds ratio [OR] 1.5 for every integral increase in INR) as did age 50 to 59 compared with older patients (P = .002, OR 1.9). For AKAs, being a current smoker predicted more WOs (P = .0008, OR 1.8) as did an increasing body mass index (BMI) (P = .02, OR 1.3 for every 10 kg/m(2) increase in BMI). Mortality was 7.6% for BKAs and 12% for AKAs. Complete functional dependence was most predictive of mortality following AKA (P < .0001, OR 2.5). Medical comorbidities such as history of myocardial infarcation (MI) (OR 1.8), congestive heart failure (CHF, OR 1.6), and chronic obstructive pulmonary disease (COPD, OR 1.6) predicted mortality following BKA, while dialysis use (OR 2.4), CHF (OR 2.3), and COPD (OR 2.1) predicted mortality following AKA. CONCLUSIONS: Wound occurrences and mortality rates after major amputation for CLI continue to be a prevalent problem. Normalization of the INR prior to BKA should decrease WOs. Heightened awareness in higher risk patients with improved preventive measures, earlier disease recognition, better treatments, and increased education remain critical to improving outcomes in an already stressed patient cohort.

Safety of carbon dioxide digital subtraction angiography.

OBJECTIVE: Reports of fatality following carbon dioxide digital subtraction angiography (CO2-DSA) have raised concerns regarding its safety. This study reviews the safety of CO2-DSA. DESIGN: Single-institution retrospective review. SETTING: Tertiary care teaching hospital in Los Angeles, California. PATIENTS: A total of 951 patients who underwent 1007 CO2-DSA procedures during a 21-year period. MAIN OUTCOME MEASURES: Preprocedure and postprocedure creatinine values and periprocedural morbidity and mortality. RESULTS: A total of 632 arterial CO2-DSA were performed; 527 were aortograms with or without extremity runoff; 100, extremity alone; and 5, pulmonary. Venous CO2-DSA included 187 inferior vena cavagrams, 182 hepatic or visceral, 5 extremity venograms, and 1 superior vena cavagram. Associated endovascular procedures were performed in 499 cases; 162 were arterial interventions including 62 endovascular aneurysm repairs, 53 visceral or renal percutaneous angioplasty with/without stent, 41 extremity percutaneous angioplasty with or without a stent, and 4 cases of thrombolysis or embolization; 176 caval filters, 98 transjugular intrahepatic portosystemic shunts, 54 transjugular liver biopsies, and 9 other venous interventions. The mean preprocedure creatinine level was 2.1 mg/dL; postprocedure, 2.1 mg/dL (P = .56). There were a total of 61 (6.1%) procedural complications including 4 (0.4%) mortalities. Two were procedure-related complications: 1, suppurative pancreatitis following aortogram; and 2, hepatic bleed following failed transjugular intrahepatic portosystemic shunts. Two were attributable to patient disease; 1, metastatic adenocarcinoma; and 2, refractory, end-stage cardiomyopathy. CONCLUSION: Carbon dioxide digital subtraction angiography is a versatile technique that can be safely used for diagnostic and therapeutic endovascular procedures. Morbidity and mortality are acceptable with preservation of renal function. Thus, CO2-DSA is a safe alternative to iodinated contrast.

Race independently impacts outcome of infrapopliteal bypass for symptomatic arterial insufficiency.

The impact of racial background on the outcome of lower extremity revascularization is unknown because a majority of studies have a preponderance of white patients. The charts of patients between 1988 and 2004 requiring infrapopliteal lower extremity revascularization were reviewed. Life-table analyses, the Cox proportional hazards model, and log-rank test were used to calculate graft patency and limb salvage. Bypasses were performed on 236 limbs in 225 patients. Mean follow-up was 18 +/- 1.5 months. Twenty-eight (12%) bypasses were performed on whites, 43 (18%) on African Americans, 148 (63%) on Hispanics, and 17 (7.2%) on patients of other races. African American race negatively correlated with primary-assisted patency (hazard ratio 2.9, P = .03), secondary patency (hazard ratio 3.64, P = .02), and limb salvage (hazard ratio 8, P = .006) compared with whites. African American race has a negative impact on the long-term outcome of infrapopliteal revascularization, regardless of disease stage or associated risk factors.

Preliminary retrograde visceral artery reconstruction for thoracoabdominal aortic aneurysms.

The recent availability of thoracic endografts has expanded the options for treatment of thoracoabdominal aortic pathology. However, disease that involves the visceral aortic segment presents a special challenge due to the need to preserve mesenteric perfusion. We present three patients in whom preliminary retrograde visceral artery reconstruction was used as an adjunct prior to endovascular repair.

Carbon dioxide digital subtraction angiography-assisted endovascular aortic aneurysm repair in the azotemic patient.

OBJECTIVE: This report analyzes the safety and efficacy of carbon dioxide digital subtraction angiography (CO(2)-DSA) for EVAR in a group of patients with renal insufficiency compared with a concurrent group of patients with normal renal function undergoing EVAR with iodinated contrast angiography (ICA). METHODS: Between 2003 and 2005, 100 consecutive patients who underwent EVAR using ICA, CO(2)-DSA, or both were retrospectively reviewed, and preoperative, intraoperative, postoperative, and follow-up variables were collected. Patients were divided into two groups depending on renal function and contrast used. Group I comprised patients with normal renal function in whom ICA was used exclusively, and group II patients had a serum creatinine >or=1.5 mg/dL, and CO(2)-DSA was used preferentially and supplemented with ICA, when necessary. The two groups were compared for the outcomes of successful graft placement, renal function, endoleak type, and frequency, and the need for graft revision. Comparisons were made using chi(2) analysis, Student t test, and the Fisher exact test. RESULTS: A total of 84 EVARs were performed in group I and 16 in group II. Patient demographics and risk factors were similar between groups with the exception of serum creatinine, which was significantly increased in group II (1.8 mg/dL vs 1.0 mg/dL P < .0005). All 100 endografts were successfully implanted. Patients in group II had longer fluoroscopy times, longer operative times, and increased radiation exposure, and 13 of 16 patients required supplemental ICA. Mean iodinated contrast use was 27 mL for group II vs 148 mL in group I (P < .0005). Mean postoperative serum creatinine was unchanged from baseline, and 30-day morbidity was similar for both groups. No patient required dialysis. No patients died. Perioperatively, and at 1 and 6 months, the endoleak type and incidence and need for endograft revision was no different between groups. CONCLUSIONS: CO(2)-DSA is safe, can be used to guide EVAR, and provides outcomes similar to ICA-guided EVAR. CO2-DSA protects renal function in the azotemic patient by lessening the need for iodinated contrast and associated nephrotoxicity, but with the tradeoff of longer fluoroscopy and operating room times and increased radiation exposure.

Current trends in the management of iatrogenic cervical carotid artery injuries.

This study was undertaken to elicit the opinion of experts regarding the management of iatrogenic injury to the carotid artery. A text questionnaire was transmitted by electronic mail to members of the Western Vascular Society concerning management of iatrogenic injury to the cervical carotid artery. Participants were asked to submit information regarding practice status and their preferred choices for the management of different clinical scenarios. The scenarios were: (1) large bore sheath (> 8.5F) cannulation of the carotid artery in anesthetized patients, (2) large bore sheath cannulation of the carotid artery in an awake patient, (3) delayed recognition of a misplaced sheath by > 4 hours, and (4) arterial puncture was recognized after only the entry needle (16-gauge) was introduced but before sheath insertion. Finally, the members were asked to comment on the management of abnormal findings on duplex scanning, such as intimal flap or pseudoaneurysm. A response rate of 42% was obtained (45/106 active members). Eighty-two percent of respondents had been in practice for longer than 10 years. Eighty-nine percent had seen this complication and 29% had cared for patients in whom subsequent neurologic deficit developed. The institutional incidence of such injury was 1-5 cases per year for 82% of respondents. Sixteen-gauge needle injury was managed by immediate removal and applied pressure by 98% of respondents. When large-bore sheath injury is recognized within 1 hour of insertion, 62% of respondents would remove the sheath and hold pressure, with or without obtaining a duplex ultrasound examination. However, if injury recognition was delayed for > 4 hours, 82% would proceed to surgery. Only 26% operated on asymptomatic carotid flap found on ultrasound, while the remaining 74% would base their decision on size and flow characteristics on ultrasound. The management of pseudoaneurysm differed significantly. Whereas 31% of respondents would manage this finding expectantly, 69% would proceed to surgery regardless of size or symptoms. Despite awareness of iatrogenic injury to the cervical carotid artery, the institutional incidence remains high. Two thirds of respondents would manage a misplaced sheath in the carotid artery nonoperatively if the injury was recognized immediately. However, if injury recognition was delayed for > 4 hours, the majority of respondents would remove the sheath surgically. While the management of intimal flap largely depended on size and flow characteristics, 69% of respondents would operate on a pseudoaneurysm regardless of size or symptoms. The results of this survey may serve as a guideline for the management of this potentially devastating injury.

Current guidelines produce competent endovascular surgeons.

OBJECTIVE: This study was conducted to evaluate the safety of percutaneous endovascular procedures (PEPs) during integration of endovascular skills into an urban academic vascular surgery practice and assess the hypothesis that currently accepted guidelines are a valid benchmark for endovascular competency. METHODS: From 2000 through 2004, an endovascular training paradigm was instituted to integrate endovascular procedures into an academic endovascular practice. The paradigm involved individual mentoring of vascular surgery faculty by a partner with mature endovascular skills. Mentoring continued until each surgeon achieved a procedural experience of 100 diagnostic angiograms and 50 percutaneous endovascular interventions. Once achieved, privileges were granted for independent endovascular practice. To assess the effectiveness of the training process and competency of the newly trained endovascular practitioner, the surgeon-specific 30-day incidence of major complications and deaths for all PEPs performed during and after the mentoring process was determined. Complications and deaths were assigned to the mentor during the training process and to the individual surgeon once endovascular privileges were granted. Complications were classified as local vascular, local nonvascular, or systemic/remote. RESULTS: From 2000 through 2004, 1208 PEPs were performed. During this time, three faculty surgeons achieved sufficient endovascular procedural experience and were granted endovascular privileges. Major complications consisted of 17 local vascular, three local nonvascular, and four systemic/remote. Three deaths occurred. Renal percutaneous transluminal angioplasty/stent procedures had the highest complication and death rate at 9%. The major complication and death rate per year was 1.8% to 4.9% (P = .32) and did not significantly vary. The major complication and death rate for all 1208 PEPs was 2.2%. The surgeon-specific complication and death rate was 1.9% to 3.6% (P = .14) and did not vary between surgeons. CONCLUSION: Endovascular skills can be safely transferred using a vascular surgeon-based training paradigm. When the training paradigm is directed at satisfying currently recommended guidelines for endovascular privileging, competent endovascular surgeons are the result.

Treatment options for traumatic pseudoaneurysms of the paravisceral abdominal aorta.

Penetrating gunshot wounds (GSWs) to the abdominal aorta are frequently lethal. Alternative management options for treatment of traumatic pseudoaneurysms of the abdominal aorta are illustrated by three patient case histories. Patient A sustained two GSWs to the abdomen (midepigastrium, right subcostal region). He was hypotensive in the field. Emergent laparotomy was undertaken with suture ligature of a celiac injury and distal pancreatectomy/splenectomy for a pancreatic injury. Postoperative abdominal CT for an intraabdominal infection with leukocytosis revealed a 4 cm traumatic pseudoaneurysm of the abdominal aorta that extended from the suprarenal aorta to the level of the renal arteries. Six weeks later, he underwent an open repair. Patient B sustained multiple GSWs to his right arm and right upper quadrant. He was hemodynamically stable. He underwent abdominal exploration for a grade 3 liver laceration. Postoperative abdominal CT revealed a supraceliac abdominal aortic pseudoaneurysm. An aortogram demonstrated a 1.5 cm defect in the aortic wall above the celiac trunk communicating with the inferior vena cava (IVC). He underwent endovascular repair with covered aortic stent graft. Patient C sustained multiple thoracoabdominal GSWs. He was hemodynamically stable. Emergent laparotomy revealed multiple left colonic perforations, two duodenal lacerations, and an unsalvageable left kidney laceration. Postoperatively, he developed a duodenal-cutaneous fistula with multiple intraabdominal abscesses. Serial CT scans revealed an enlarging infrarenal aortic pseudoaneurysm. He underwent angiographic coil embolization and intraarterial injection of thrombin into the pseudoaneurysm sac. The average time from injury to surgical treatment was 46 days (range 29-67). Postoperatively, none of the patients developed paraplegia. Advances in endovascular techniques have provided options to deal with traumatic pseudoaneurysms of the abdominal aorta. In a hemodynamically stable patient with a traumatic pseudoaneurysm, careful selection of a specific intervention can be tailored to the clinical scenario electively.

Influence of transmetatarsal amputation in patients requiring lower extremity distal revascularization.

When a transmetatarsal amputation (TMA) is required, successful long-term limb salvage is questioned. We evaluated the influence of TMA on limb salvage in patients undergoing lower extremity revascularization. Patients who had distal bypasses extending to the infrapopliteal arterial tree and adjunctive TMA were retrospectively reviewed. Limb salvage was determined with life-table analysis. Twenty-four patients (29 limbs) were evaluated: 15 male and 9 female. Average age was 64.2 years old. Gangrene was the indication for bypass and TMA in 25 (86.2%) patients. Seven limbs were lost to follow-up. Nine of the remaining 22 limbs required below-knee (8) or above-knee (1) amputations, seven limbs within the first 3 months. In the group of patients who had major amputations within the first 3 months, graft thrombosis was the cause of leg amputation in six (85.7%) cases. No significant predictors of early major amputation were identified. Limb salvage was 62 per cent at 1 year in the TMA group. In comparison, among historical controls requiring distal revascularization and no adjunctive toe or foot amputations, limb salvage was 76.5 per cent (P = NS). Long-term limb salvage is dependent on successful lower extremity revascularization. Requirement for TMA should not influence the decision for limb salvage.

Current endovascular management of atherosclerotic renal artery stenosis.

The recent advances in stent technology and renal endovascular management have provided a technically reproducible method of percutaneously treating atherosclerotic renal artery stenosis (RAS). In many centers, this has resulted in endovascular management being the primary therapy for atherosclerotic RAS. Although still controversial, it appears that endovascular management of RAS by primay stent deployment provides better blood pressure control than that afforded by best medical management. The impact on renal function is less than that found for hypertension, but there is evidence to suggest that the use of protection devices and primary stenting may enhance renal function outcomes. Whether the ultimate benefit of enhanced survival follows remains an important question and should be the subject of future prospective studies.

Endovascular management of iliofemoral venous occlusive disease.

New developments in the management of both acute and chronic iliac vein occlusive disease offer exciting options for the treatment of this often debilitating condition. Percutaneous clot removal using thrombolysis, mechanical thrombectomy, or a combination of the two is fast becoming the treatment of choice for patients presenting with acute iliofemoral deep vein thrombosis. Recanalization of chronic iliac vein occlusions with balloon angioplasty and stenting relieves symptoms of extremity swelling and pain in the majority of treated patients. Existing data provide convincing proof of the efficacy of endovascular recanalization procedures, and upcoming prospective, controlled trials will further clarify the role of these techniques in the therapeutic armamentarium.

Endovascular management of iliac vein occlusive disease.

Iliac vein occlusive disease presents with either acute or chronic symptoms, both of which can be managed with endovascular techniques. This report summarizes our experience in a small cohort of patients undergoing percutaneous treatment of iliac vein occlusive disease. Six women and one man with occlusive lesions in the iliac veins are included in this report. All patients reported leg pain and swelling, involving the right leg in one and the left leg in six. Symptoms were acute in one patient and chronic in six. Two patients presented with a chronic stasis ulcer. All patients with chronic symptoms were treated with self-expanding stents deployed across the occlusive lesion. The patient with acute symptoms was treated successfully with thrombolysis, which uncovered a fixed stenosis that was then stented. Post-procedure follow-up with duplex scanning was used for vein patency. No significant complications occurred. All patients reported symptomatic improvement, with four having complete resolution. Duplex scanning showed all treated venous segments to be patent at a mean of 12 months. Recanalization of obstructed iliac vein segments can be performed successfully and leads to improvement in pain and edema in the affected limb. Midterm patency rates are excellent.

Basilic vein transposition fistula: a good option for maintaining hemodialysis access site options?

PURPOSE: The primary use of autogenous arteriovenous access for chronic hemodialysis is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative practice guidelines. We review the outcomes of basilic vein transposition (BVT) to assess its value as a primary upper arm arteriovenous access option. METHODS: A retrospective review of 56 patients undergoing BVT was performed. Thirty patients were men; average age was 56 years. Etiology of end-stage renal disease, complications, and time to maturation were tabulated. Primary and secondary patency rates were determined by using life table methods. Multivariate regression analysis was performed to assess risk factors for fistula failure. RESULTS: Renal failure was associated with diabetes in 32 (57%) patients, and BVT was the primary access procedure in 22 (39%) patients. Perioperative complications occurred in 5 (9%) patients and included hematoma (n = 3), myocardial infarction (n = 1), and death (n = 1). The average time to maturation was 74 days (range, 12-265 days), and maturation failure occurred in 21 (38%) patients. Logistic regression analysis showed that age older than 60 years was associated with poorer maturation and patency rates. On an intent-to-treat basis, 1-year primary and secondary patencies were 35% and 47%, respectively, but only 18% and 28%, respectively, for age >60 years. Forty-two percent of failed BVT were subsequently replaced with a prosthetic graft by using the same upper arm vessels. CONCLUSION: BVT frequently do not mature in patients older than 60 years, which compromises its utility as a primary access. However, fistulas that mature provide acceptable patency rates, and subsequent conversion to a prosthetic access is frequently possible. Selective use of BVT might improve the utilization of available access sites.

Renal revascularization in Takayasu arteritis-induced renal artery stenosis.

PURPOSE: This study was undertaken to define the long-term effects of renal revascularization on blood pressure, and renal and cardiac function in patients with Takayasu arteritis-induced renal artery stenosis (TARAS). METHODS: Twenty-seven patients (25 women; mean age, 27 years) with TARAS underwent intervention. Primary, primary assisted, and secondary patency rates were determined, and the late effects on blood pressure, renal and cardiac function, and survival were analyzed. RESULTS: All patients had hypertension (mean blood pressure, 167/99 mm Hg; 2.5 antihypertensive medications per patient). Mean estimated glomerular filtration rate in patients not receiving hemodialysis was 76 mL/min, and in five patients serum creatinine concentration was greater than 1.5 mg/dL. Three patients were hemodialysis-dependent, and two had intractable congestive heart failure. Forty interventions were performed, including 32 aortorenal bypass procedures, two repeat implantations, four nephrectomies, and two transluminal angioplasty procedures. Postoperative morbidity was 19%. There were no deaths. During follow-up (mean, 68 months), three graft stenoses, all due to intimal hyperplasia, and three graft occlusions occurred. Two of three graft stenoses were successfully revised. At 1, 3, and 5 years of follow-up, primary patency was 87%, 79%, and 79%, respectively; primary assisted patency was 93%, 89%, 89%, respectively; and secondary patency was 93%, 89%, and 89%, respectively. Intervention resulted in a decrease in blood pressure to a mean of 132/79 mm Hg (P<.0001), and the need for antihypertensive medications was reduced to one per patient (P<.01). Mean glomerular filtration rate increased to 88 mL/min (P<.005), and two patients no longer required hemodialysis. Congestive heart failure resolved in both patients, and did not recur. There were three deaths during follow-up, with 5-year and 10-year actuarial survival of 96% and 80%, respectively. CONCLUSIONS: Renal revascularization to treat TARAS is durable, has a salutary effect on blood pressure, and enhances long-term renal and cardiac function. This response establishes renal revascularization as a successful and durable intervention for TARAS, and a benchmark to which other therapies should be compared.

Rupture of a previously thrombosed thoracoabdominal aneurysm.

Spontaneous thrombosis of abdominal aortic aneurysms is rare. A patient with a 12-cm thoracoabdominal aneurysm developed sudden thrombosis of his aneurysm. He was treated with axillobifemoral bypass. He went on to rupture 7 months later. While spontaneous thromboses of abdominal aortic aneurysms have been previously reported, we did not find any reports of a thrombosed thoracoabdominal aneurysm or a subsequent rupture of this type of aneurysm. The literature on thrombosis of aneurysms is reviewed as well as proposed etiologies for thrombosis and subsequent rupture. We believe that resectional therapy may be warranted even in high-risk patients.

Anticoagulation is an effective treatment for aortic mural thrombi.

BACKGROUND: Aortic mural thrombi (AMT) in the absence of aortic disease are rare. The appropriate indications and the efficacy of surgical thrombectomy, thrombolysis, and systemic anticoagulation remain controversial. METHODS: This study, set in an academic medical center, was a retrospective review of five patients with AMT in the absence of aortic disease who underwent treatment between 1997 and 2001. The main outcome measures were morbidity, mortality, and treatment outcome. RESULTS: Three patients were women, and ages ranged from 40 to 77 years. On admission, all patients had symptoms related to thrombus embolization (extremity pain or abdominal pain). Two patients had a history of venous thromboembolism (pulmonary embolism or deep venous thrombosis). Four patients had biochemical evidence of hypercoaguability, and the fifth had malignant disease. Coagulation disorders included increased homocysteine (n = 2) and factor VIII (n = 1), antithrombin III (n = 1) and protein C deficiency (n = 1), and familial dysfibrinogenemia (n = 1). AMT were located in the infrarenal (n = 1), suprarenal (n = 3), and descending thoracic (n = 1) aorta. One patient needed exploratory laparotomy and one needed lower extremity vascular procedures for visceral and limb-threatening ischemia, respectively. Treatment with systemic anticoagulation therapy resulted in complete resolution on follow-up computed tomographic scan or angiogram of the AMT at a median of 60 days. CONCLUSION: Most patients in whom AMT develops in the absence of underlying aortic disease have underlying coagulation disorders. Anticoagulation therapy alone allows resolution of AMT, with surgical intervention reserved for management of end organ ischemia from thrombus embolization.