Partial subclavian artery coverage in TEVAR patients for acute type B aortic dissections: an alternative solution.

BACKGROUND: Acute type B aortic dissection with origin of the left subclavian artery (LSA) is generally managed with endovascular therapy for acute coverage of the LSA with: 1) no revascularization; 2) revascularization with open methods; or 3) endovascular revascularization. To identify an alternative solution, we critically evaluated a small cohort of patients who had partial coverage of their LSA. METHODS: Three thoracic endovascular repairs were performed from January-March 2015. Patients were deemed eligible for endovascular repair after they had failed conservative management. Indications included acute type B dissection with lower extremity ischemia, ruptured dissection, and persistent symptoms of dissection after medical therapy. RESULTS: Technical success was achieved in all three patients, and all procedures were performed percutaneously. The mean distance between the ostium of the LSA and the entry point of dissection was 11.1±3.4 mm. Within the 30-day postoperative period, there were no deaths, aortic ruptures, myocardial infarctions, or conversions to open repair. Freedom from re-intervention was noted in all 3 patients. There was no spinal cord ischemia. CONCLUSIONS: There is no strong evidence to support the current optimal approach for treatment of the thoracic aorta. Partial coverage of LSA in patients with <2 cm seal zones may be considered as an alternative. However, due to our small sample size, limited follow-up, and lack of comparison cohort, further investigation is necessary.

A new endovascular technique for the treatment of dialysis-associated steal syndrome.

Background Dialysis access-associated steal syndrome is a major complication of arteriovenous fistula creation whereby the low-resistance venous conduit shunts arterial inflow through the anastomosis, resulting in clinically significant distal artery insufficiency. Herein, we describe a case of severe steal phenomenon with gangrene of a digit following placement of an arteriovenous fistula that was treated with a novel, entirely endovascular technique. To our knowledge, this was the first totally endovascular approach to dialysis access-associated steal syndrome. Methods Catheterization of the right subclavian, axillary, and brachial arteries was performed. A short 5-Fr sheath was exchanged for a long destination 6-Fr sheath and placed in the proximal brachial artery. An arteriogram showed no stenosis of the arterial system, but did show substantial steal phenomenon with inflow to the arteriovenous fistula, instead of the forearm. We placed a stent graft in the brachial artery across the anastomosis such that the graft covered 3/4 of the length of the opening of the anastomosis. Results Immediately after placement of the stent graft the clinical picture improved dramatically. Patient was followed for 15 months after this procedure until her demise for unrelated causes without ever experiencing dialysis access-associated steal syndrome and with a patent and functional arteriovenous fistula. Conclusion We present a patient with severe dialysis access-associated steal syndrome complicated by third fingertip gangrene, which was successfully treated using a completely endovascular technique. This novel endovascular approach enabled a high-risk patient to avoid open surgery, preserve her limb, and maintain the function of her arteriovenous fistula.

Gray-scale median of the atherosclerotic plaque can predict success of lumen re-entry during subintimal femoral-popliteal angioplasty.

OBJECTIVE: This study assessed whether the duplex ultrasound (DUS)-derived gray-scale median (GSM) of the most six distal portion of the occluded femoral-popliteal arterial segment can predict success of lumen re-entry for subintimal angioplasty. METHODS: During the last 3 years, 108 patients (62% men) with a mean age of 73 +/- 10 years underwent 116 primary attempted DUS-guided subintimal angioplasties of the femoral-popliteal segment. Preprocedural B-mode DUS images of the plaque at the most distal occlusion segment were digitalized and normalized using Photoshop (Adobe, San Jose, Calif) software and standard criteria (gray level, 0 to 5 for lumen blood and 185 to 190 for the adventitia on a linear scale of 0 to 255). Overall GSM of the plaque segment about 2 cm long, immediately before the planned re-entry point to the true arterial lumen, was used for retrospective correlation with procedure success and other clinical indicators. RESULTS: Mean plaque GSM for all cases was 22.5 +/- 12.6 (range, 3 to 60). The overall success rate of subintimal angioplasty procedures was 85%. Mean plaque GSM for 99 successful cases (18.4 +/- 7.8) was significantly lower than for 17 cases (46.4 +/- 8.1) where we failed (P < .0001). We failed in 90% of 19 cases with GSM >35, in 71% of 24 cases with GSM >20, and in 50% of 34 cases with GSM >25. There was no statistically significant difference (P = .45) between plaque GSM in 64 patients with diabetes (23.3 +/- 13.5) compared with 52 nondiabetic patients (21.5 +/- 11.4). Similarly, plaque GSM was not statistically different (P = .9) in 52 patients with renal insufficiency (22.7 +/- 13.2) compared with 64 patients with normal creatinine levels (22.4 +/- 12.2). At the 6-month follow-up, no statistically significant difference was found between mean GSM (17.8 +/- 7.8) in 47 stenosis-free cases compared with mean GSM (18 +/- 6.8) in 22 cases where severe restenosis (>70%) or reocclusion was identified by DUS scan (P = .4). CONCLUSIONS: Plaque echogenicity represented by DUS-derived GSM can be used to predict the success of primary subintimal femoral-popliteal angioplasties.

Popliteal artery volume flow measurement: a new and reliable predictor of early patency after infrainguinal balloon angioplasty and subintimal dissection.

OBJECTIVE: We have investigated whether popliteal artery volume flow (PAVF) measured immediately after balloon angioplasties of the superficial femoral artery-popliteal segments (SFA/POP) was predictive of early (30 days) and mid-term (6 months) arterial thrombosis. METHODS: During the last 24 months, 203 patients (56% men) with a mean age of 73 +/- 9 years had 268 duplex-guided balloon angioplasties of the SFA/POP. Critical ischemia was the indication in 36%. Group I included 176 (66%) with stenoses, and group II had 92 (34%) with occlusions. All patients had completion duplex examinations that included three measurements of PAVF of below-the-knee popliteal artery. RESULTS: Early (30 days) thrombosis of the treated femoropopliteal arterial segment developed in 10 patients (3.7%), three in group I (1.7%) and seven in group II (7.6%; P < .04). All 10 cases of early thrombosis were in patients with TransAtlantic Inter-Society Consensus (TASC) class C (6/185, 3.2%) and D (4/26, 15%) lesions. Moreover, the 19% incidence (n = 4) of early thrombosis in patients with PAVF <100 mL/min (mean, 73 +/- 24 mL/min; range, 20 to 99 mL/min) was higher compared with the 2.4% rate for patients with higher flows (mean, 176 +/- 60 mL/min; range, 100 to 450 mL/min; P < .01). At 6 months of follow-up, femoropopliteal occlusions had developed in nine more patients, and it became apparent that low PAVF measurements were still predictive of thrombosis (29%) when compared with higher PAVF cases (6%; P < .002). Log-rank comparison of survival curves for cumulative primary stenosis-free patency in group I and group II demonstrated a statistically significant difference (P < .02). PAVF <100 mL/min and TASC classification were significant predictors of early (30 days) and mid-term (6 months) arterial thrombosis after femoropopliteal angioplasties. PAVF was the most powerful predictor of arterial thrombosis. The respective 6-month and 12-month limb salvage rates were 98% and 94% for patients with claudication and 88% and 85% for those with limb-threatening ischemia (P < .0001). CONCLUSIONS: Our results demonstrate that low PAVF is the most powerful predictor of early (30 days) and mid-term (6 months) arterial thrombosis after femoropopliteal interventions. In the presence of a low postprocedure PAVF (<100 mL/min), one may consider not reversing the heparin or using intermittent calf compression, or both, to augment the arterial flow.

Duplex-guided endovascular treatment for occlusive and stenotic lesions of the femoral-popliteal arterial segment: a comparative study in the first 253 cases.

OBJECTIVE: The standard technique of balloon angioplasty with or without subintimal dissection of infrainguinal arteries requires contrast arteriography and fluoroscopy. We attempted to perform this procedure with duplex guidance to avoid the use of nephrotoxic contrast material and eliminate or minimize radiation exposure. METHODS: From September 2003 to June 2005, 196 patients (57% male) with a mean age of 73 +/- 10 years (range, 42-97 years) had a total of 253 attempted balloon angioplasties of the superficial femoral and/or popliteal artery under duplex guidance in 218 limbs. Critical ischemia was the indication in 38% of cases, and disabling claudication was the indication in 62%. Hypertension, diabetes, chronic renal insufficiency, smoking, and coronary artery disease were present in 78%, 51%, 41%, 39%, and 37% of patients, respectively. The TransAtlantic Inter-Society Consensus (TASC) classification was used for morphologic description of femoral-popliteal lesions. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery, across the diseased segment(s), and parked at the tibioperoneal trunk. The diseased segment(s) were then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Hemodynamically significant defects causing diameter reductions greater than 30% and peak systolic velocity ratios greater than 2 were stented with a variety of self-expandable stents under duplex guidance. Completion duplex examinations and ankle-brachial indices were obtained routinely before hospital discharge. RESULTS: There were 11 (4%) TASC class A lesions, 31 (12%) TASC class B lesions, 177 (70%) TASC class C lesions, and 34 (14%) TASC class D lesions in this series. The overall technical success was 93% (236/253 cases). Eight of the 17 failed subintimal dissections belonged to TASC class C and the remaining 9 to TASC class D. End-stage renal disease was the only significant predictor of subintimal dissection failure in patients with femoral-popliteal occlusions (5/17 cases; P < .04). Intraluminal stents were placed in 153 (65%) of 236 successful cases. Overall pre-procedure and post-procedure ankle-brachial indices changed from a mean of 0.69 +/- 0.16 (range, 0.2-1.1) to 0.95 +/- 0.14 (range, 0.55-1.3), respectively (P < .0001). The mean duration of follow-up was 10 +/- 7 months (range, 1-29 months). The overall 30-day survival rate was 100%. Overall limb salvage rates were 94% and 90% at 6 and 12 months, respectively. Six-month patency rates for TASC class A, B, C, and D lesions were 89%, 73%, 72%, and 63%, respectively. Twelve-month patency rates for TASC class A, B, C, and D lesions were 89%, 58%, 51%, and 45%, respectively. CONCLUSIONS: Duplex-guided balloon angioplasty and stent placement seems to be a safe and effective technique for the treatment of infrainguinal arterial occlusive disease. Technical advantages include direct visualization of the puncture site, accurate selection of the proper size balloon and stent, and confirmation of the adequacy of the technique by hemodynamic and imaging parameters. Additional benefits are avoidance of radiation exposure and contrast material.

Duplex-guided balloon angioplasty and stenting for femoropopliteal arterial occlusive disease: an alternative in patients with renal insufficiency.

BACKGROUND: The technique of balloon angioplasty of infrainguinal arteries requires standard arteriography and fluoroscopic guidance. We attempted to perform this procedure under duplex guidance to avoid the use of nephrotoxic contrast material and radiation exposure in patients with renal insufficiency. METHODS: Over 16 months, 28 patients (17 men) with serum creatinine levels of 1.5 mg/dL or more underwent 37 lower extremity duplex-guided balloon angioplasties at our institution. Ages ranged from 58 to 92 years (mean +/- SD, 74 +/- 9 years). Disabling claudication was the indication in 24 cases (65%), and critical ischemia, in 13 cases. Preoperative duplex arterial mapping showed severe superficial femoral artery and/or popliteal artery stenoses in all cases. No arterial occlusions were treated in this series. Seven procedures (19%) were performed for restenosis. The ipsilateral common femoral artery was cannulated in 32 cases (86%), and the contralateral common femoral artery, in 5 cases (14%), under direct duplex visualization. Contralateral common iliac artery cannulations were performed with the help of fluoroscopy. By using sonographic visualization, a guidewire was directed into the origin of the superficial femoral artery, across the diseased segment, and into the popliteal artery. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Plaque dissections and recoils causing stenosis of 30% or more, a peak systolic velocity ratio of 2 or more, or both were stented under duplex guidance. Arterial duplex examinations and ankle/brachial indexes were obtained before hospital discharge, within 1 month after the procedure, and every 3 months thereafter. RESULTS: Thirty-day survival was 100%. Local complications included one open exploration for expanding hematoma. Technical success was achieved in all cases. Placement of intraluminal stents was deemed appropriate in 23 (62%) of 37 cases. The 1-month patency and limb salvage rates were 100%. Preprocedure and postprocedure ankle/brachial indexes ranged from 0.3 to 0.9 (mean +/- SD, 0.64 +/- 0.16) and 0.64 to 1.2 (mean +/- SD, 0.92 +/- 0.15), respectively (P < .0001). CONCLUSIONS: Duplex-guided balloon angioplasty seems to be a safe and effective technique that allows renal patients to experience continued limb salvage and relief from claudication without the risk of developing dye-induced acute renal failure. Other advantages include direct visualization of the puncture site, accurate selection of the proper size of balloon and stent, confirmation of the adequacy of the technique by hemodynamic and imaging parameters, and avoidance of radiation. Although this technique holds considerable potential, longer follow-up will help to fully evaluate its broader applicability.

Duplex-guided balloon angioplasty and subintimal dissection of infrapopliteal arteries: early results with a new approach to avoid radiation exposure and contrast material.

OBJECTIVE: Balloon angioplasties of stenotic or occluded infrapopliteal arteries may be helpful in selected high-risk patients threatened with limb loss. Thus far, these procedures have demanded fluoroscopy and the injection of potentially nephrotoxic contrast material. Herein, we proposed a new alternative to avoid the harmful effects of radiation exposure and the risk of acute renal failure. METHODS: Over the last 16 months, 30 patients (57% male) aged 74 +/- 9 years (mean +/- SD) had a total of 52 attempted balloon angioplasties of the infrapopliteal arteries in 32 limbs under duplex guidance. Indications for the procedure were critical ischemia in 20 limbs (63%), including rest pain, ischemic ulcers, and gangrene in 4 (13%), 10 (31%), and 6 (19%) limbs, respectively. Severe disabling claudication was an indication in the remaining 12 limbs (37%). All patients had concomitantly performed balloon angioplasties of the superficial femoral and popliteal arteries (28 cases) or the popliteal artery alone (4 cases). Balloon angioplasty of the infrapopliteal arteries was performed as an adjunct to improve runoff. Hypertension, diabetes, renal insufficiency, smoking, and coronary artery disease were present in 77%, 73%, 50%, 47%, and 37% of cases, respectively. There were 42 cases (81%) with infrapopliteal arterial stenoses (25 tibioperoneal trunks, 9 peroneal arteries, 4 anterior tibial arteries, and 4 posterior tibial arteries) in 26 limbs. The remaining 10 cases (19%) had infrapopliteal arterial occlusions (4 tibioperoneal trunks, 5 peroneal arteries, and 1 anterior tibial artery) in 6 limbs. All these cases were combined with more proximal endovascular procedures (21 femoropopliteal stenoses and 11 femoropopliteal occlusions). All patients had preprocedure duplex arterial mapping and ankle/brachial index (ABI) measurement. Local anesthesia with light sedation was used in all cases. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery and distally, beyond the infrapopliteal diseased segment. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to the arterial measurements obtained by duplex guidance. Completion duplex examinations were performed and postprocedure ABIs were obtained in all cases. RESULTS: Although the overall technical success was 94% (49/52 cases), it was 95% for those with stenoses (40/42 cases) and 90% for those with occlusions (9/10 cases; P < .5). Intraoperative thrombosis occurred in three infrapopliteal cases (two tibioperoneal trunks and one peroneal artery) and in one popliteal artery. All four cases were successfully managed with intra-arterial infusion of thrombolytic agents under duplex guidance. Overall, the preprocedure and postprocedure ABIs ranged from 0.4 to 0.8 (mean +/- SD, 0.58 +/- 0.15) and 0.7 to 1.1 (mean +/- SD, 0.9 +/- 0.16), respectively (P < .0001). Twenty-two (88%) of 25 patients experienced a significant (> 0.15) postoperative ABI increase. Overall 30-day survival and limb salvage rates were 100%. CONCLUSIONS: The proposed technique eliminates the need for radiation exposure and the use of contrast material, and it seems to be an effective alternative approach for the treatment of infrapopliteal occlusive disease. Additional advantages include accurate selection of the proper size of balloon and confirmation of the adequacy of the technique by hemodynamic and imaging parameters.

A 10-year experience with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal prosthetic bypasses.

Since up to 20% of patients undergoing lower extremity revascularization do not have an adequate venous conduit, some authors have explored the use of prosthetic grafts with adjunctive techniques for lower extremity revascularization. However, the long-term graft patency of those procedures has not been well documented. The purpose of this study was to examine the long-term patency of polytetrafluoroethylene (PTFE) bypass with adjunctive arteriovenous fistula and venous interposition (AVF/VI) for infrapopliteal revascularization. Over a 10-year period, 246 lower extremity reconstructions were performed in 176 (71.5% men) patients with critical ischemia in whom a totally autogenous vein bypass was not feasible. Seventy-six limbs had undergone 1 or more failed ipsilateral infrainguinal bypasses. Indications for surgery were chronic critical limb-threatening ischemia (86%) (rest pain, ischemic ulcer, or gangrene) or acute ischemia (14%). Ages ranged from 46 to 91 years (mean 74 +/-0.6 [SD] years). Risk factors such as diabetes, hypertension, coronary artery disease, end-stage renal disease, and use of tobacco were present in 49%, 49%, 52%, 8%, and 67% of the patients, respectively. During the follow-up, 112 cases (45%) required reinterventions. Twenty-seven patients (15%) required bypass revision twice. During the follow up, 56 limbs (23%) were amputated (above-the-knee amputation 25 (10%); below-the-knee amputation 31 (13%). To date, 150 (85%) patients of a total of 176 are deceased. The primary graft patency rates were as follows: at 1 year, 51%; at 2 years, 41%; 3 years, 35%; and 5 years, 24%. Limb salvage rates were as follows: 1 year, 79%; 2 years, 76%; 3 years 76%; and 5 years, 74%. Patient survival rates were as follows: 1 year, 69%; 2 years, 60%; 3 years, 54%; and 5 years, 40%. Amputation-free patient survival rates were as follows: 1 year, 66%; 2 years, 57%, 3 years, 51%, and 5 years, 30%. This technique appears to offer reasonable patency and limb salvage rates in patients in whom autogenous bypass grafts are not feasible.

Duplex-assisted internal carotid artery balloon angioplasty and stent placement: a novel approach to minimize or eliminate the use of contrast material.

BACKGROUND: Carotid artery balloon angioplasty and stenting (CBAS) is emerging as an acceptable alternative to carotid endarterectomy in selected high-risk patients. Conversely, patients with pre-existing renal impairment, diabetes, or both may be harmed by the nephrotoxic contrast agents required during CBAS. We attempted to limit or eliminate the use of contrast material during CBAS. METHODS: Eighteen patients with severe carotid stenoses (>70%) underwent CBAS at our institution over the last 12 months with duplex scan-assisted CBAS. Of these, 12 were primary procedures, and 6 were performed for carotid re-stenosis. Fourteen patients (78%) were neurologically asymptomatic. The average age of these patients was 75 +/- 11 years (range, 44-92 years). Hypertension, chronic renal insufficiency (serum creatinine level > or =1.5 mg/dL), coronary artery disease, diabetes, and smoking were present in 89%, 67%, 59%, 33%, and 28% of patients, respectively. Preoperative duplex carotid mapping was performed in all cases. All procedures were performed with patients under local anesthesia and light sedation. RESULTS: An ATL HDI 5000 scanner with the SonoCT feature was used. The common femoral artery was cannulated with a single-entry needle under direct ultrasound visualization. Fluoroscopy was used to assist passage of the guidewire into the aorta and the common carotid artery. In only four cases (22%) was an aortic arch angiogram obtained. Selective catheterization of the internal and external carotid arteries was performed under ultrasound guidance. The distal cerebral protection device (17 cases) was placed under fluoroscopic guidance. Balloon width and length were chosen according to ultrasound measurements. Balloon and stent deployment were successfully achieved with ultrasound guidance alone in all cases. Appropriate stent apposition and resolution of the stenosis was confirmed by duplex scanning in all cases. Five patients (28%) were noted to have low (<100 mL/min) internal carotid artery volume flow after stent deployment (range, 20-88 mL/min; mean +/- SD, 50 +/- 25 mL/min). The internal carotid artery volume flow increased immediately after Filterwire retrieval in all cases and ranged from 136 to 400 mL/min (mean, 245 +/- 107 mL/min). This increase was statistically significant ( P < .02). No ipsilateral strokes or deaths occurred during follow-up from 1 to 12 months (mean follow-up, 5 months). CONCLUSIONS: Duplex scan-assisted CBAS is feasible and may reduce the need for intra-arterial contrast injection in selected patients deemed at high risk for renal failure from nephrotoxic contrast material. Additional advantages include direct visualization of the puncture site, precise position of the balloon and stent, and B-mode and hemodynamic confirmation of the adequacy of the technique.

Carotid endarterectomy in patients with chronic renal insufficiency: a recent series of 184 cases.

BACKGROUND: The published results of carotid endarterectomy (CEA) in chronic renal insufficiency (CRI) patients are contradictory, mostly because of the relatively small number of patients in these studies. To better assess the neurologic complications and mortality, we reviewed a recent and substantially larger series of CRI patients who underwent CEAs. METHODS: From March 2000 to March 2003, 675 consecutive primary CEAs were performed in 609 patients (346 men, 57%) under general anesthesia. Asymptomatic carotid artery stenosis accounted for 71% of cases. CRI (serum creatinine level > or = 1.5 mg/dL) was detected in 166 patients (27%) who underwent 184 CEAs. The remaining 443 patients (73%) had 491 CEAs. RESULTS: Patients with CRI were different in age (76 +/- 8 years vs 72 +/- 9 years, P < .001), male gender (73% vs 51%, P < .001), coronary artery disease (50% vs 28%, P < .001), and diabetes mellitus incidence (38% vs 27%, P < .02). No significant difference in stroke rates was observed between the CRI patients and the control group (1.2% vs 0.5%). The mortality rate for CRI patients was 3%, whereas it was 0% for the control group ( P < .002). The 143 CRI patients with serum creatinine levels from 1.5 to 2.9 mg/dL had a 0.7% mortality rate, whereas it was 17% for 23 patients with serum creatinine levels of 3 mg/dL or more ( P < .001). The stroke rate for the former group was 0.7% and 4.3% for the latter group (NS). Asymptomatic (16) and symptomatic (7) patients with serum creatinine levels of 3 mg/dL or more had mortality rates of 13% and 28%, respectively, with P = .6. CONCLUSION: The high mortality rate observed in patients with serum creatinine levels of 3 mg/dL or more after CEA calls for a nonoperative approach in the management of asymptomatic patients.