Retrograde superficial femoral artery recanalization through a deep femoral collateral: A transradial approach.

A novel endovascular approach using retrograde access to an occluded superficial femoral artery via collaterals of the deep femoral artery is described. Owing to a prior aortobifemoral bypass, transradial access was used.

Acute upper extremity ischemia and symptomatic popliteal artery aneurysm secondary to coronavirus disease 2019.

We report the cases of two patients with coronavirus disease 2019 (COVID-19). One patient had presented with acute right upper extremity ischemia (axillary artery thrombosis) and one patient with a symptomatic popliteal artery aneurysm (7.5 × 7.2 cm). Both patients had tested positive for COVID-19 but had no systemic symptoms. The patients were successfully treated using percutaneous techniques and subsequently discharged with oral anticoagulation therapy. A review of the pathogenesis of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2)-related arterial thrombosis and aneurysmal disease was performed and discussed.

Angiotensin-converting enzyme 2, coronavirus disease 2019, and abdominal aortic aneurysms.

OBJECTIVE: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the etiologic agent of the current, world-wide coronavirus disease 2019 (COVID-19) pandemic. Angiotensin-converting enzyme 2 (ACE2) is the SARS-CoV-2 host entry receptor for cellular inoculation and target organ injury. We reviewed ACE2 expression and the role of ACE2-angiotensin 1-7-Mas receptor axis activity in abdominal aortic aneurysm (AAA) pathogenesis to identify potential COVID-19 influences on AAA disease pathogenesis. METHODS: A comprehensive literature search was performed on PubMed, National Library of Medicine. Key words included COVID-19, SARS-CoV-2, AAA, ACE2, ACE or angiotensin II type 1 (AT1) receptor inhibitor, angiotensin 1-7, Mas receptor, age, gender, respiratory diseases, diabetes, and autoimmune diseases. Key publications on the epidemiology and pathogenesis of COVID-19 and AAAs were identified and reviewed. RESULTS: All vascular structural cells, including endothelial and smooth muscle cells, fibroblasts, and pericytes express ACE2. Cigarette smoking, diabetes, chronic obstructive pulmonary disease, lupus, certain types of malignancies, and viral infection promote ACE2 expression and activity, with the magnitude of response varying by sex and age. Genetic deficiency of AT1 receptor, or pharmacologic ACE or AT1 inhibition also increases ACE2 and its catalytic product angiotensin 1-7. Genetic ablation or pharmacologic inhibition of ACE2 or Mas receptor augments, whereas ACE2 activation or angiotensin 1-7 treatment attenuates, progression of experimental AAAs. The potential influences of SARS-CoV-2 on AAA pathogenesis include augmented ACE-angiotensin II-AT1 receptor activity resulting from decreased reciprocal ACE2-angiotensin 1-7-Mas activation; increased production of proaneurysmal mediators stimulated by viral spike proteins in ACE2-negative myeloid cells or by ACE2-expressing vascular structural cells; augmented local or systemic cross-talk between viral targeted nonvascular, nonleukocytic ACE2-expressing cells via ligand recognition of their cognate leukocyte receptors; and hypoxemia and increased systemic inflammatory tone experienced during severe COVID-19 illness. CONCLUSIONS: COVID-19 may theoretically influence AAA disease through multiple SARS-CoV-2-induced mechanisms. Further investigation and clinical follow-up will be necessary to determine whether and to what extent the COVID-19 pandemic will influence the prevalence, progression, and lethality of AAA disease in the coming decade.

Coil Embolization of Tributaries of Brachiocephalic Fistula is Effective in the Management of Vascular Steal.

BACKGROUND: To determine if an aggressive approach to occlude all or majority of the tributaries of the cephalic vein is effective in eliminating signs and symptoms of vascular steal in patients with brachiocephalic fistula. METHODS: Retrospective chart review over a 15-month period of all patients managed with coil embolization of tributaries of brachiocephalic fistulae. RESULTS: A total of 19 patients (11 females, age 65 ± 9.7 years), presented with signs and symptoms of vascular steal. All patients had a brachiocephalic fistula with a 6.3 month average fistula age. Overall, a total of 111 coils were used to occlude 42 tributaries. Two patients had concomitant surgical ligation of 3 tributaries. Postoperative pain at the site of coiled tributaries was reported by two patients. A single patient suffered a major postprocedure complication (delayed hypotension), requiring hospital admission. All but one patient had significant improvement in symptoms of vascular steal postintervention. CONCLUSIONS: An aggressive approach to coil embolization of all major tributaries of a brachiocephalic fistula is effective in eliminating signs and symptoms of vascular steal.

Use of a novel embolic filter in carotid artery stenting: 30-Day results from the EMBOLDEN Clinical Study.

OBJECTIVES: The EMBOLDEN study was conducted to test the safety and efficacy of a novel emboli protection filter design for use in carotid artery stenting (CAS) in patients with severe carotid stenosis who were at high risk of operative complications from carotid endarterectomy (CEA). BACKGROUND: General considerations for filter design usually involve trade-offs between trackability/profile and wall apposition/capture efficiency. The GORE® Embolic Filter (GEF) is intended to address these design goals via a hybrid construction. METHODS: Patients at high risk for CEA (N = 250) were treated with CAS using the GEF study device paired with an FDA-approved carotid stent. The primary outcome was death, stroke, and myocardial infarction (MI) at 30 days, compared to a pre-determined performance goal. Neurologic outcomes were judged by an independent assessor and angiographic results evaluated by an independent central core lab. RESULTS: The GEF study device was successfully deployed in 96.4% of procedures. The primary endpoint of 30-day death, stroke, and MI occurred in 4.0% of subjects and was significantly lower than the pre-defined performance goal (P < 0.001). The 30-day rate for death and major stroke was 1.2% and for death and any stroke was 3.6%. The rate of major adverse events was 5.4% among octogenarians and 3.2% among non-octogenarians. CONCLUSION: In patients at high risk for CEA undergoing CAS, the GEF not only showed high rates of successful deployment but also met the primary endpoint of low death, stroke, and MI rates, thus demonstrating safety and effectiveness.

Computed tomography angiography-based evaluation of great saphenous vein conduit for lower extremity bypass.

OBJECTIVE: Lower extremity computed tomography angiography (CTA) is frequently used for anatomic assessment of lower extremity peripheral arterial disease. When lower extremity bypass is planned, duplex ultrasound (DUS) is routinely obtained to evaluate the great saphenous vein (GSV) for use as conduit. Although GSV can be visualized on CTA images, diameter assessment is not routinely included in formal study interpretation. We hypothesized that CTA images could be used to measure GSV diameters and that CTA-based diameters would correlate with measurements obtained using DUS. METHODS: Consecutive patients undergoing lower extremity arterial bypass who were evaluated preoperatively with both CTA and DUS vein mapping were identified at a single hospital. Minimum above- and below-knee GSV diameters were measured from electronically archived CTA images by two independent observers. CTAs were performed using standard arterial phase protocol without additional venous phase imaging. Between-observer reproducibility of CTA-based diameter measurements was evaluated using intraclass correlation coefficients. Correlation between CTA and DUS-based GSV diameters was evaluated with Spearman correlation coefficients. CTA diameter cut-points for identification of adequate GSV bypass conduit, defined as DUS-based minimum GSV diameter≥3 mm, were determined using receiver-operating characteristic curves. RESULTS: Sixty-three lower extremities were evaluated in 36 patients. In the absence of previous surgical removal, GSV was visible on all CTAs reviewed. No instances of GSV thrombosis were identified on DUS. Minimum DUS-based above-knee GSV diameter was 2.9±0.1 mm (range, 1.4-4.6 mm), and mean below-knee diameter was 2.6±0.1 mm (range, 1.3-4.0 mm). When GSV was visible and exceeded the minimum diameter threshold for CTA measurement, correlation between CTA- and DUS-based diameters was both positive and highly significant (ρ=0.595; P<.0001). CTA-based diameters also had excellent reliability between observers (r [95% CI]: 0.88 [0.85-0.91]). For identification of adequate bypass conduit using CTA, above-knee GSV diameter≥3.9 mm was 67% sensitive and 73% specific; below-knee GSV diameter≥3.0 mm was 75% sensitive and 84% specific. CONCLUSIONS: CTA-based GSV diameter measurements have good reproducibility and highly significant correlation with DUS-based diameters. CTA-based GSV diameter is a specific but relatively insensitive indicator of adequate bypass conduit. When CTA-based diameters indicate inadequate GSV bypass conduit, confirmatory DUS vein mapping is warranted. Confirmatory DUS vein mapping may be unnecessary when adequate vein diameter is identified on CTA.

Technical tips for successful outcomes using adjunctive procedures during endovascular aortic aneurysm repair.

The inability to obtain proximal or distal seal continues to remain one of the main challenges of endovascular aneurysm repair. This is particularly relevant when endografts are used in patients with unsuitable proximal or distal landing zones. A variety of techniques can be used to achieve a seal in these difficult situations. Two specific techniques that can help intraoperatively to resolve the lack of adequate graft to aortic wall opposition are discussed in this article. These include the use of Palmaz stents for proximal seal and hypogastric snorkel for distal seal with internal iliac flow preservation.

Pivotal results for the Medtronic Valiant Thoracic Stent Graft System in the VALOR II trial.

OBJECTIVE: We report 30-day and 12-month results of endovascular treatment with the Valiant Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, Calif) in patients with descending thoracic aortic aneurysms of degenerative etiology. The Valiant stent graft is an evolution of the Talent thoracic stent graft (Medtronic Vascular). METHODS: The VALOR II (Evaluation of the Clinical Performance of the Valiant Thoracic Stent Graft System in the Treatment of Descending Thoracic Aneurysms of Degenerative Etiology in Subjects Who Are Candidates for Endovascular Repair) was a prospective, nonrandomized, pivotal trial conducted at 24 U.S. sites with enrollment between December 2006 and September 2009. Standard follow-up examinations, including physical examination, computed tomography, and chest radiography, were at 1, 6, and 12 months, and annually through 5 years. VALOR II outcomes were compared with those from the pivotal VALOR (Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms) trial of the Talent stent graft, which enrolled 195 patients with similar enrollment criteria. RESULTS: VALOR II enrolled 160 patients. Compared with VALOR patients, VALOR II patients had similar age and sex distribution but higher rates of cardiovascular risk factors and significantly more severe modified Society for Vascular Surgery/American Association for Vascular Surgery risk scores. Stent graft delivery and deployment were successful in 154 patients (96.3%). Outcomes at 30 days in VALOR II were perioperative mortality, 3.1%; major adverse events, 38.1%; paraplegia, 0.6%; paraparesis, 1.9%; and stroke, 2.5%. At 12 months, after the minimum sample size was reached, 151 patients were evaluated: aneurysm-related mortality was 4.0%, stent graft migration was 2.9%, and endoleak was 13.0%. Through 12 months, there were no ruptures, conversions to open surgery, secondary procedures due to endoleak >30 days, or loss of stent graft patency. The Valiant stent graft was statistically noninferior to the Talent stent graft in 12-month all-cause mortality (12.6% vs 16.1%) and exceeded the primary effectiveness goal of 12-month successful aneurysm treatment, defined as absence of aneurysm growth >5 mm and of secondary procedures for type I/III endoleak (97.4% vs 80.0%). CONCLUSIONS: The VALOR II 12-month results demonstrate that the Medtronic Valiant thoracic stent graft is a safe and effective treatment for patients with descending thoracic aortic aneurysms of degenerative etiology.

Outcomes after heparin-induced thrombocytopenia in patients with Propaten vascular grafts.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) can result in a life- or limb-threatening condition that can be reversed with early detection and prompt discontinuation of systemic heparin. The advent of heparin-bonded grafts may introduce a new level of complexity in some patients with a suspected diagnosis of HIT. This review evaluates the outcomes of patients who received the Gore Propaten vascular graft with a subsequent suspicion of HIT. METHODS: This is a retrospective analysis of cases with suspected type II HIT after implant of the Propaten vascular graft that were reported to W.L. Gore & Associates. Data reviewed included clinical studies, including physician-sponsored studies, both inside and outside the United States; published literature; and Gore's product surveillance records. RESULTS: Overall, as of June 2011, there have been 27 cases (27 patients and 30 vascular grafts) of suspected HIT after graft implant. Of these 27 patients, 18 were tested for HIT antibodies (enzyme-linked immunosorbent assay, heparin-induced platelet activation test, serotonin release assay, drug-induced platelet activation test, platelet aggregation test, an HIT panel, or an unknown HIT test), with a positive test result in 17 of the 18 cases. In 5 of the 18 cases, patients were tested with two distinct HIT assays, resulting in one positive and one negative test. Among patients with available data, the mean preoperative heparin dose was 4850 ± 1634 U, and four patients had a postoperative heparin drip. The mean preoperative platelet count was 227,000 ± 71,616. Mean platelet count at time of diagnosis of HIT was 53,429 ± 36,832. For the majority of those patients known to have had heparin discontinued once HIT was suspected, Argatroban was the anticoagulant of choice. Sixteen patients had grafts that remained implanted and in circulation, eight patients had grafts that were explanted, two patients had grafts that were ligated in situ, and the outcome was unknown for one patient. Among the 16 patients with grafts remaining in circulation, four grafts required thrombectomy for occlusion. Two patients died, one other patient had a remote thrombotic event, and the remaining patients had no reported adverse events. Among the 10 patients with graft removal or ligation, six had a graft occlusion, four required an amputation, and two died. Among the cases in which the recovery of platelet count was reported after systemic heparin was discontinued, the majority were cases in which the grafts were left in circulation. CONCLUSION: Analysis of the cases of suspected HIT in patients with implanted Propaten vascular grafts reveals that the HIT observed appears to be related to the systemic administration of heparin. After discontinuation of systemic heparin, platelet counts normalized in the presence of patent Propaten vascular grafts. Hence, based on current data, our recommendation would be to tailor treatment to individual patients. Functioning grafts in patients with or without thrombotic events and return of platelet count to normal values may not require grafts to be explanted in the presence of HIT.

Endovascular management of aortic arch vessel occlusion: successful revascularization of innominate and left subclavian arteries.

A 56-year-old female presented with pain in her bilateral upper extremities. Angiogram demonstrated occlusion of her left subclavian and innominate arteries (IAs). The patient's left subclavian occlusion was successfully treated with percutaneous mechanical thrombectomy, angioplasty, and stenting. One month later, endovascular revascularization of the IA was performed. Initially the lesion could not be directly transversed from neither an antegrade nor a retrograde approach. Wires were passed from the brachial and femoral arteries into the right common carotid artery where the femoral wire was snared and brought out through the right brachial access. Over this through-and-through wire access, angioplasty and stenting of the IA was performed with an excellent angiographic result. In follow-up, the patient remained free of upper extremity symptoms. Occlusive lesions of the aortic arch vessels can be successfully managed with antegrade and retrograde endovascular techniques.

Incidental findings in patients evaluated for thoracic aortic pathology using computed tomography angiography.

BACKGROUND: Computed tomography angiography (CTA) is routinely used to diagnose thoracic aortic pathology and for surveillance after thoracic endovascular aortic repair. The purpose of our study was to assess the prevalence of unsuspected disease identified on CTA examination for thoracic aortic pathology and to determine potential clinical significance of these findings. METHODS: A retrospective review of 242 patients (136 men and 106 women; mean age, 65.7 ± 13.9 years) referred for clinical evaluation of thoracic aortic pathology during a 12-year period was performed. CTA was acquired after obtaining full written informed consent and injecting nonionic contrast Omnipaque 350 intravenously. Subsequently, axial images were obtained from the thoracic inlet through the pubic symphysis. The prevalence of incidental findings was recorded. A finding was judged potentially significant if a therapeutic intervention or radiologic follow-up was deemed advisable on the basis of the CTA findings. RESULTS: Prevalence of incidental findings were noncalcified pulmonary lesions (subcentimeter nodule [28, 11.57%], nodule >1 cm [16, 6.61%], and pulmonary mass >3 cm [4, 1.65%]), calcified pulmonary nodules (35, 14.46%), simple liver cysts (32, 13.22%), contrast-enhancing liver lesion (7, 2.89%), renal mass (7, 2.89%), and pancreatic mass (5, 2.06%). Subsequent diagnostic tests were recommended for 63 findings in 55 (22.72%) patients, which revealed 11 (4.5%) patients had metastatic disease-six primary lung cancer, one metastatic lesion (mets) to the lung, one renal cell carcinoma with mets in the lung, one primary pancreatic adenocarcinoma with mets in the liver, one unknown primary with mets in the liver, and one other poorly differential metastatic carcinoma with lesions in the pancreas, adrenal glands, kidneys, and small bowel with unknown primary. CONCLUSION: CTA evaluation in patient with aortic pathology may reveal a high rate of malignant lesions. Attention to the incidental finding of suspicious lesion on computed tomographic scans in the chest and abdomen and appropriate follow-up by the requesting surgeon is important in patients undergoing surveillance for aortic pathologies.

Incidence and outcomes after infolding or collapse of thoracic stent grafts.

OBJECTIVE: Device-related complications in the thoracic aorta are partly due to the unavoidable proximal angulation and increased flow-related forces. The present study evaluated the incidence, predictors, and outcome of the complication of infolding with the GORE TAG thoracic endoprosthesis (TAG device) to better understand the factors that might help predict these events. METHODS: We reviewed all complaints reported to W. L. Gore and Associates (Flagstaff, Ariz) related to device infolding after the use of the GORE TAG device on or before December 2008. Events related to device infolding were evaluated. Reporting physicians and local company representatives were contacted, when necessary, to assemble all available imaging, data, and outcomes related to these case reports. When available, computed tomography images were reviewed to confirm aortic landing zone diameters, which were subsequently compared with the implanted device size. RESULTS: From 1998 through December 2008, device infolding was reported in 139 patients (mean age, 40 ± 17 years; 73.4% men) from 33,289 device implants (reported incidence, 0.4%). Events were noted in implants for trauma (60%), dissection (19%), aneurysm (10%), and other (9%) and unknown (2%) etiologies. In 77 patients with available imaging, the average minimum aortic diameter was 21.4 ± 4.4 mm. The mean device diameter was 28.5 ± 3.5 mm, with an average oversizing of nearly 33%. Of reported patients, 51% were asymptomatic, with the diagnosis being made on routine chest imaging. Time to diagnosis was 76 ± 222 days (median, 9.5 days). Only 16 patients received no intervention after the diagnosis of device infolding, all of whom were asymptomatic. The other 123 patients underwent 135 interventions. Of these, 30 patients (24%) underwent open surgical conversion and complete or partial endograft removal. The other interventions included a variety of endovascular techniques, such as large balloon-expandable stent(s) in 40%, relining with additional endograft(s) in 31%, and repeat ballooning in seven patients. Ten patients died after device infolding, all after one or more attempts to repair the infolded device: five died of symptoms related to the infolding and five secondary to the intervention undertaken to correct the device infolding. CONCLUSIONS: TAG device infolding appears to be an infrequent event, primarily occurring in young trauma patients secondary to excessive oversizing and severe proximal aortic angulation. However, there clearly exists a need for devices that treat such patients. As a result, future device designs should consider the compression failure mode when being designed in order to help prevent such events.

Characterization of resident surgeon participation during carotid endarterectomy and impact on perioperative outcomes.

INTRODUCTION: The impact of resident surgeon participation during vascular procedures on postoperative outcomes is incompletely understood. We characterized resident physician participation during carotid endarterectomy (CEA) procedures within the 2005-2009 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and evaluated associations with procedural characteristics and perioperative adverse events. METHODS: CEAs were identified using primary current procedural terminology codes; those performed simultaneously with other major procedures or unknown resident participation status were excluded. Group-wise comparisons based on resident participation status were performed using χ(2) or Fisher's exact test for categorical variables and t tests or nonparametric methods for continuous variables. Associations with perioperative adverse events (major = stroke, death, myocardial infarction, or cardiac arrest; minor = peripheral nerve injury, bleeding requiring transfusion, surgical site infection, or wound disruption) were assessed using multivariable logistic regression models adjusting for other known risk factors. RESULTS: A total of 25,280 CEA procedures were analyzed, of which residents participated in 13,705 (54.2%), while residents were absent in 11,575 (45.8%). Among CEAs with resident physician participation, resident level was categorized as junior (postgraduate year [PGY] 1-2) in 21.9%, senior (PGY 3-5) in 52.7%, and fellow (PGY ≥6) in 25.3%. Major adverse event rates with and without resident participation were 1.9% versus 2.1%, and minor adverse event rates with and without resident participation were 0.9% versus 1.0%, respectively. In multivariable models, resident physician participation was not associated with perioperative risk for major adverse events (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.75-1.08) or minor adverse events (OR, 0.93; 95% CI, 0.72-1.21). CONCLUSIONS: Resident surgeon participation during CEA is not associated with risk of adverse perioperative events.

Preoperative inpatient hospitalization and risk of perioperative infection following elective vascular procedures.

BACKGROUND: Health care-associated infections are not uncommon after elective vascular surgery and can negatively impact mortality rates and hospital resource utilization. Identification of modifiable risk factors for perioperative infection is critical for efforts aimed toward reducing their incidence. We evaluated the associations between preoperative inpatient hospitalization and perioperative surgical site infection (SSI), pneumonia, and urinary tract infection (UTI) following elective vascular surgery procedures. METHODS: Vascular procedures were identified from the 2005 to 2008 American College of Surgeons National Safety Quality Improvement Participant User Data File by using primary Current Procedural Terminology (CPT) codes. Perioperative infections were evaluated as outcomes based on three categories: SSI, pneumonia, and UTI. Patients admitted ≥1 day before operation were considered inpatients before surgery. Associations between preoperative inpatient hospitalization and perioperative SSI, pneumonia, and UTI were evaluated using the Cochran-Armitage trend test and multivariable logistic regression. RESULTS: In total 40,669 elective vascular procedures were identified, of which 7,514 (18.5%) were preoperative inpatients. Patients with preoperative inpatient hospitalization had a greater frequency of age >80 years and dependent functional status and also had higher rates of several comorbid conditions, including congestive heart failure, severe chronic obstructive pulmonary disease, >10% weight loss over the past 6 months, history of bleeding disorder, and current smoker within 1 year, than patients admitted on the same day of their procedure. The overall rates of SSI, pneumonia, and UTI were 3.2%, 1.9%, and 1.4%, respectively. Patients with preoperative inpatient hospitalization had higher 30-day incidence of SSI (4.5 vs. 2.9%), pneumonia (3.1 vs. 1.6%), and UTI (2.3 vs. 1.2%). In multivariable models including preoperative risk factors, preoperative inpatient hospitalization was associated with increased 30-day risk of SSI (odds ratio [OR], 1.21; 95% confidence interval [CI]: 1.06-1.39; p = 0.0066), pneumonia (OR, 1.64; 95% CI: 1.39-1.94; p < 0.0001), and UTI (OR, 1.46; 95% CI: 1.20-1.77; p < 0.0001). CONCLUSION: Preoperative inpatient hospitalization is associated with higher rates of perioperative SSI, pneumonia, and UTI in patients undergoing elective vascular surgery procedures. Avoidance of unnecessary preoperative hospitalization has potential to reduce rates of perioperative infection, but additional research is needed to develop evidence-based management strategies when hospitalization before elective procedures is necessary.

Noninterruption of warfarin therapy is safe and does not compromise outcome in patients undergoing endovenous laser therapy (EVLT).

OBJECTIVE: To assess the need for cessation of oral anticoagulation with warfarin for patients undergoing endovenous laser therapy (EVLT). METHODS: Between September 2004 and July 2010, 518 patients underwent 770 EVLT procedures on the lower extremity, at our institution. Of these patients, 5 underwent a total of 12 separate lower extremity EVLT procedures for the treatment of symptomatic reflux without interruption of warfarin therapy. RESULTS: No bleeding complications were observed during the procedure or in early follow-up. None of the patients developed a deep venous thrombosis. Complete ablation of the target vessel was observed in all patients on follow-up Duplex ultrasounds at 1 and 8 weeks postintervention. CONCLUSION: Endovenous laser therapy can be safely performed and does not compromise target vessel ablation in patients receiving oral anticoagulation warfarin therapy. Warfarin therapy should not be routinely interrupted in patients undergoing this procedure.

Sex-based outcomes after endovascular repair of thoracic aortic aneurysms.

INTRODUCTION: Unlike with abdominal aortic aneurysms (AAA), women appear to have an almost comparable incidence as men for thoracic aortic aneurysms (TAA). However, the extent to which a patient's sex influences endograft treatment of TAA has not been reported. The current study analyzes the influence of sex on the endovascular management of TAAs. METHODS: A total of 421 patients (265 men and 156 women) were identified as part of the TAG (W. L. Gore and Associates, Flagstaff, Ariz) thoracic stent graft trials. Preoperative risk factors, intraoperative events, and 365-day follow-up data were analyzed. RESULTS: Among 18 different preoperative risk factors evaluated, women were less likely to have prior vascular procedures (38.9% vs 55.3%; P = .004). A trend was noted toward lower rates of coronary artery disease (41.3% vs 51.2%; P = .09) and smoking (77.8% vs 85.6%; P = .08). Women were also more likely to be nonwhite (81.4% vs 87.9%; P = .007). Women had a smaller mean external iliac vessel diameter (7.1 vs 9.0 mm; P < .001), resulting in 24.4% vs 6.0% conduit use (P < .001) for device delivery. Local access site complications were significantly higher in women (14.1% vs 4.5%; P < .001). No difference was noted between sexes in the technical success rate (device delivery and successful aneurysm exclusion) or the major adverse event rate at 30 days (26.3% vs 20.4%; P = .18). The overall length of stay was 5.5 ± 6.2 days for female patients vs 4.8 ± 13.0 days (P < .001). No sex-related difference was noted in endoleak rate, aneurysm rupture, prosthetic migration, or aneurysm diameter change at 365 days. CONCLUSIONS: No significant differences in major outcomes were noted between men and women treated with endovascular repair of TAA at 1 month and 1 year. Women have more vascular complications, which are associated with smaller access vessels. A lower threshold for using conduits in women may be a more prudent approach.

Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death.

INTRODUCTION: Left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) is often necessary due to anatomic factors and is performed in to up to 40% of procedures. Despite the frequency of LSA coverage during TEVAR, reported associations with risk of periprocedural stroke or death are inconsistent in reported literature. We examined the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data file to determine associations between LSA coverage during TEVAR and risk of perioperative stroke or death. METHODS: Current procedural terminology (CPT) codes were used to identify patients undergoing TEVAR, LSA coverage, and subclavian revascularization. Patients undergoing coronary bypass, ascending aortic repair, abdominal aortic aneurysm repair, or nonvascular intra-abdominal procedures during the same operation were excluded. Perioperative stroke and mortality associations with LSA coverage were examined using logistic regression models for each outcome. Significance was assessed at α = 0.05, with univariable P < .05 required for multivariable model entry. RESULTS: Eight hundred forty-five TEVAR procedures were identified, of which 52 patients were excluded due to additional major procedures performed with TEVAR. Seven hundred thirty-three of the remaining 793 procedures included CPT codes indicating primary placement of an initial thoracic endograft and form the basis of this analysis. LSA coverage occurred in 279 procedures (38%). Thirty-day stroke and mortality rates were 5.7% and 7.0%, respectively. LSA coverage was associated with increased 30-day risk of stroke in multivariable modeling (odds ratio [OR], 2.17 95% confidence interval [CI], 1.13-4.14; P = .019). Other significant multivariable risk factors for stroke included proximal aortic cuff placement during TEVAR (OR, 2.58; 95% CI, 1.30-5.16; P = .007) and emergency procedure status (OR, 3.60; 95% CI, 1.87-6.94; P < .001). No significant association between LSA coverage and perioperative mortality was identified (univariable OR, 1.70; 95% CI, 0.98-2.93; P = .0578). CONCLUSION: LSA coverage during thoracic endovascular repair is associated with increased risk of perioperative stroke following TEVAR. Further evidence is needed to determine whether procedural modifications, including LSA revascularization, reduce the incidence of stroke associated with TEVAR.

Endovascular management of a ruptured thoracoabdominal aneurysm-damage control with superior mesenteric artery snorkel and thoracic stent-graft exclusion.

We report a case of a large ruptured thoracoabdominal aortic aneurysm, which was stabilized with endovascular aortic exclusion and snorkel bypass of the superior mesenteric artery (SMA). An 80-year-old African American woman with multiple medical comorbidities and previous open infrarenal abdominal aortic aneurysm repair presented with a ruptured 10.7 × 7.3 cm thoracoabdominal aortic aneurysm involving the origins of the renal and mesenteric vessels. The patient underwent emergent endovascular aortic repair with placement of a covered stent into the SMA coursing parallel to the aortic endograft. This technique was initially successful in clinically stabilizing the patient; however; 3 weeks after the initial procedure, she presented with recurrent rupture necessitating proximal extension of her snorkeled SMA bypass and aortic endograft into the mid-descending thoracic aorta. The patient stabilized and was successfully discharged home.

Thoracic endovascular repair as a safe management strategy for aortobronchial fistulas.

OBJECTIVES: This study assessed the safety and efficacy of thoracic endovascular aortic repair (TEVAR) in the management of aortobronchial fistulas. METHODS: A retrospective review was performed at Emory University Hospital to identify all patients who presented with an aortobronchial fistula. The diagnosis was based on clinical, radiologic, and bronchoscopic findings. Patients who underwent TEVAR as definitive management of these fistulas were identified. Demographics, history of thoracic aorta pathology or intervention, type and number of endografts used, need for reoperation, and clinical and radiologic follow-up data were collected for each individual. RESULTS: Between 2000 and 2009, 11 patients received TEVAR as definitive management of aortobronchial fistulas. Technical success was achieved in 10 patients (91%). Six patients (55%) had previously undergone thoracic aortic surgery. A proximal type 1 endoleak developed in one patient after graft deployment and required reintervention for additional graft placement. No intraoperative or 30-day deaths occurred. Postoperative clinical and radiographic assessment was a mean of 8.8 months (range, 1-40 months). For all 10 patients in whom technical success was achieved at the initial operation, no endoleaks were noted at the follow-up CT scan. In addition, no patient required a further intervention. CONCLUSIONS: This study represents the largest reported series on the use of TEVAR in the management of aortobronchial fistulas. Supported by postoperative surveillance imaging and clinical evaluation, TEVAR has proven to be a safe and effective management strategy for an otherwise lethal condition. Long-term follow-up data are needed to ascertain the durability of this approach.