Splenic hematoma and hemoperitoneum in a Thoroughbred racehorse after racing.

OBJECTIVE: To describe the clinical presentation of a Thoroughbred filly with acute hemoperitoneum from a splenic source immediately after racing. ANIMAL: A 3-year-old Thoroughbred filly used for racing and that had raced shortly before presentation to the hospital. CLINICAL PRESENTATION, PROGRESSION, AND PROCEDURES: On presentation, the filly was quiet, alert, and responsive with a heart rate of 76 beats/min, pale mucous membranes, and absent borborygmi. All other physical examination parameters were within normal limits. Abdominal ultrasound was performed and revealed echogenic free abdominal fluid and a splenic hematoma. Abdominocentesis yielded sanguinous fluid with a PCV of 35%. The next day, repeat ultrasound revealed the splenic hematoma with capsular separation. TREATMENT AND OUTCOME: The filly was treated overnight with isotonic crystalloid fluids and aminocaproic acid (40 mg/kg, IV, slow bolus over 30 minutes followed by 20 mg/kg, IV, q 6 h), potassium penicillin (22,000 IU/kg, IV, q 6 h), gentamicin (6.6 mg/kg, IV, q 24 h), and omeprazole (4 mg/kg, PO, q 24 h). The lowest PCV obtained from the filly was 36 hours after presentation. The filly stabilized with medical treatment and was discharged to a farm for further recuperation. CLINICAL RELEVANCE: There are no published reports detailing hemoperitoneum of splenic origin in Thoroughbreds immediately after racing. Hemoperitoneum of splenic origin is not common in horses, with most cases of hemoperitoneum being secondary to acute trauma, neoplasia, parturition, or postoperative complications. While uncommon, this case raises awareness to another differential for a colicky horse immediately after racing.

Equine synovial sepsis laboratory submissions yield a low rate of positive bacterial culture and a high prevalence of antimicrobial resistance.

OBJECTIVE: To investigate (1) variables associated with the likelihood of obtaining a positive culture, (2) commonly isolated microorganisms, and (3) antimicrobial resistance patterns of isolates from horses with presumptive synovial sepsis. SAMPLES: Synovial fluid, synovium, and bone samples from equine cases with presumptive synovial sepsis submitted to the Cornell University Animal Health Diagnostic Center from 2000 to 2020 for microbial culture and antimicrobial sensitivity testing. PROCEDURES: Univariable and multivariable analyses were performed to determine the effect of variables on the likelihood of positive culture. Frequency distributions for isolated organisms and antimicrobial resistance were generated. Multidrug resistance patterns and associations were assessed with association rule mining. RESULTS: The positive culture rate for all samples was 37.4%, while the positive culture rate among samples confirmed to be septic by a combination of clinical pathological variables and case details was 43%. Blood culture vial submissions were 1.7 times more likely to yield a positive culture compared to samples submitted in a serum tube. Structure sampled, tissue submitted, and horse age were associated with a positive culture. Staphylococcus spp (23.7%), Streptococcus spp (22.4%), and Enterococcus spp (9.67%) were commonly isolated. Multidrug resistance prevalence decreased from 92% (2000 to 2009) to 76% (2010 to 2020) of gram-negative isolates and 60% (2000 to 2009) to 52% (2010 to 2020) of gram-positive isolates. CLINICAL RELEVANCE: The positive culture rate from synovial fluid submissions with traditional sampling and culture methods remains low and may be optimized by submitting samples in blood culture vials. Overall, antimicrobial resistance was frequently observed but did not increase from the first to second decade for most genera.

Equine Sinus Surgery.

The anatomy of the equine paranasal sinuses is critical to understand to assess the extent of the disease process, the optimal surgical approach, and the ability to drain through the normal nasomaxillary pathway. By following established anatomic landmarks, direct sinus access can be used to further explore the sinus compartments, remove compromised cheek teeth, remove any purulent debris or feed contamination, and establish drainage. Many complications can be avoided or minimized by thoroughly evaluating all sinus compartments and critically assessing the ability of the sinus to drain.

Subchondral lucencies of the proximal tibia in 17 horses.

OBJECTIVE: To describe subchondral lucencies (SCL) in the equine proximal tibia, several treatment options, and clinical outcomes. STUDY DESIGN: Retrospective study. ANIMALS: Seventeen horses with proximal tibial SCL. METHODS: Medical record and radiograph review. Follow-up was obtained via examination and radiography when possible and by telephone and race records when required. The median duration of follow-up was 20 months (range, 0-48). RESULTS: Proximal tibial SCL were associated with lameness in 14 of 17 horses. Subchondral lucencies were primary in 11 horses and secondary to an ipsilateral medial femoral condyle SCL in six horses. One foal with a primary SCL was euthanized because of osteomyelitis. Six horses ≤1 year old with primary SCL were managed with exercise restrictions only; SCL in three horses without lameness decreased in size, whereas three horses with lameness did not improve. One young horse treated with surgical debridement failed to improve and was euthanized. Lameness resolved in three horses with primary tibial SCL treated with screw fixation. Screw fixation of secondary SCL in five horses led to a reduction in SCL size and degree of lameness. CONCLUSION: Primary tibial SCL healed with rest in 3 non-lame young horses with small SCL, but was not successful in lame horses with larger SC. Radiographic size and associated lameness improved or resolved with screw fixation in primary and secondary proximal tibial SCL. CLINICAL SIGNIFICANCE: Primary tibial SCL that did not cause lameness healed with conservative management, but persistent primary and secondary tibial SCL required screw fixation to reduce lameness.

Acute Outcomes With a Novel Plaque Modification System in Real-World Femoropopliteal Lesions.

PURPOSE: To report outcomes of a multicenter feasibility study using the FLEX Vessel Prep (VP) System, a novel technology that facilitates plaque incision and lumen gain in stenosed or occluded femoropopliteal arteries prior to balloon angioplasty. MATERIALS AND METHODS: Two hundred fifty-five patients (mean age 71.8±9.1 years) were treated with the FLEX VP System at 38 centers between December 2015 and November 2017. Average lesion length was 133±88 mm. Average baseline stenosis was 92%±11%; 112 (44.3%) of 253 patients presented with a chronic total occlusion. Conventional or drug-coated balloon (DCB) angioplasty was performed in all patients after vessel preparation. Vessel measurements were derived from angiograms acquired at baseline, after FLEX passage, and after subsequent ancillary procedures. Logistic regression analyses were performed to identify baseline or procedure variables that predicted the need for provisional stenting. RESULTS: Average percent reduction in vessel stenosis following treatment with the FLEX VP System was 27%±17%. No flow-limiting dissection, vessel perforation, or embolization was observed; 15 (5.9%) patients had minor (type A or B) dissections. Provisional stenting was performed in 49 (19.2%) patients. Average stenosis following angioplasty ± stenting was 9.1%±7.4%; 9 (3.6%) patients had significant residual stenosis ≥30%. Logistic regression analyses found that patients with dissections, longer lesions, and those receiving conventional balloon dilation alone were most likely to undergo stenting. CONCLUSION: In a real-world patient population with long, complex femoropopliteal lesions, use of the FLEX VP System as vessel preparation for angioplasty improved acute outcomes compared to historical controls. The rate of provisional stenting was low, and no serious vessel complications were observed.

Lower Extremity Revascularization Using Optical Coherence Tomography-Guided Directional Atherectomy: Final Results of the EValuatIon of the PantheriS OptIcal COherence Tomography ImagiNg Atherectomy System for Use in the Peripheral Vasculature (VISION) Study.

PURPOSE: To evaluate the safety and efficacy of a novel optical coherence tomography (OCT)-guided atherectomy catheter in treating patients with symptomatic femoropopliteal disease. METHODS: The VISION trial ( ClinicalTrials.gov identifier NCT01937351) was a single-arm, multicenter, global investigational device exemption study enrolling 158 subjects (mean age 67.2±10.5 years; 87 men) across 20 participating sites. In this cohort, 198 lesions were treated with an average length of 53±40 mm using the Pantheris catheter alone or Pantheris + adjunctive therapy. The primary safety endpoint was the composite of major adverse events (MAEs) through 6 months (objective performance goal 43.2%). Technical success (primary efficacy outcome) was defined as the percent of target lesions with a residual diameter stenosis ≤50% after treatment with the Pantheris device alone (objective performance goal 87.0%). Procedural success was defined as reduction in stenosis to ≤30% after Pantheris ± adjunctive therapy. Tissue specimens retrieved from each treated lesion were histologically analyzed to evaluate the accuracy and precision of OCT image guidance. RESULTS: The primary efficacy outcome was achieved in 192 (97.0%) of the 198 lesions treated with the Pantheris catheter. Across all lesions, mean diameter stenosis was reduced from 78.7%±15.1% at baseline to 30.3%±11.8% after Pantheris alone (p<0.001) and to 22.4%±9.9% after Pantheris ± adjunctive therapy (p<0.001). Of the 198 target lesions, 104 (52.5%) were treated with the Pantheris alone, 84 (42.4%) were treated with Pantheris + adjunctive angioplasty, and 10 (5.1%) with Pantheris + angioplasty + stenting. The composite MAE outcome through 6 months occurred in 25 (16.6%) of 151 subjects. There were no clinically significant perforations, 1 (0.5%) catheter-related dissection, 4 (2%) embolic events, and a 6.4% clinically driven target lesion revascularization rate at 6 months. The 40-lesion chronic total occlusion (CTO) subset (mean lesion length 82±38 mm) achieved a similar significant reduction in stenosis to 35.5%±13.6% after Pantheris alone (p<0.001). Histological analysis of atherectomy specimens confirmed <1% adventitia in 82.1% of the samples, highlighting the precision of OCT guidance. Characterization of the OCT-guided lesions revealed evidence of an underestimation of disease burden when using fluoroscopy. CONCLUSION: OCT-guided atherectomy for femoropopliteal disease is safe and effective. Additionally, the precision afforded by OCT guidance leads to greater removal of plaque during atherectomy while sparing the adventitia.

Final results of the Chronic Total Occlusion Crossing With the Ocelot System II (CONNECT II) study.

PURPOSE: To evaluate the safety and effectiveness of the optical coherence tomography-guided Ocelot catheter to cross femoropopliteal chronic total occlusions (CTOs). METHODS: The CONNECT II study was a prospective, multicenter, non-randomized single-arm study of the safety and effectiveness of the Ocelot catheter in CTO crossing. Key inclusion criteria were a 99% to 100% stenosed femoropopliteal segment, lesion length between 1 and 30 cm, and resistance to guidewire crossing. The main exclusion criterion was a severely calcified target vessel. The primary safety endpoint was 30-day major adverse events (MAE), while the primary effectiveness endpoint was successful CTO crossing (i.e., guidewire placement in the distal true lumen) with the Ocelot catheter. Endpoint analysis was based on pre-specified objective performance criteria. Between February and June 2012, 100 patients (55 men; mean age 69 years) were enrolled. Most of the CTOs (94%) were in the superficial femoral artery (SFA); mean lesion length was 16.6±9.3 cm. RESULTS: Through 30 days, 2 patients experienced MAE (significant perforations) related to the Ocelot catheter. The Ocelot catheter successfully crossed 97% of target CTOs either alone (72%), in conjunction with an assist device (18%), or in conjunction with a re-entry device (7%). Both primary safety and effectiveness endpoints were met. CONCLUSION: The Ocelot catheter with optical coherence tomography guidance offers physicians a reliable option for crossing femoral and popliteal chronic total occlusions with low MAE rates.

Investigation of the immune response to autologous, allogeneic, and xenogeneic mesenchymal stem cells after intra-articular injection in horses.

Mesenchymal stem cells have demonstrated immunomodulatory capabilities as well as modest efficacy in animal models of joint injury, warranting further study as a potential treatment of joint disease. The goal of the study was to investigate the blood and synovial immune and histologic response to intra-articular injection of autologous, allogeneic, and xenogeneic bone marrow-derived mesenchymal stem cells (MSC) in horses. The study group consisted of 6 five-year-old Thoroughbred mares that had been injected previously with 15 million, genetically modified autologous, allogeneic, or xenogeneic MSC into the fetlock joints. One group of autologous cells was genetically modified to permit MSC biolocalization in the synovium. To assess response to the injection, synovial biopsies were obtained via arthroscopy 60 days after MSC injection for gross, histologic and molecular analyses. Peripheral blood mononuclear cells were isolated from each horse 120 days after MSC injection and co-cultured with a monolayer of each MSC group to permit quantification of activated CD4+ lymphocytes and cytokine release (ELISA) upon re-exposure to MSC. Arthroscopic examination revealed normal synovium with no grossly detrimental effect to the synovium or cartilage. Intra-articular MSC produced a persistent mononuclear infiltrate for at least 60 days, mostly perivascular, identified as CD3+ lymphocytes. An immune response (significant increase in CD4+ lymphocytes) was detected upon re-exposure to xenogeneic but not to allogeneic or autologous MSC. An inflammatory cytokine release from peripheral blood mononuclear cell/MSC co-cultures was present in all MSC groups but was significantly greater in the xenogeneic group. In conclusion, intra-articular injection of MSC, regardless of cell origin, incited a persistent mononuclear synovitis demonstrating a sustained biologic influence of these cells. Allogeneic cells did not elicit a detectable immune response upon re-exposure using our methods.

Reintervention after EVAR and open surgical repair of AAA: a 15-year experience.

OBJECTIVE: This study examined the frequency and reason for reinterventions and their impact on survival in contemporaneously treated cohorts of EVAR and open surgical repair (OSR) patients. BACKGROUND: EVAR has largely replaced OSR for anatomically appropriate AAA because of improved short-term outcomes. However, EVAR is associated with a notable reintervention rate. METHODS: Data for patients undergoing elective AAA repair between 1996 and 2011 were collected and analyzed to assess time from initial procedure to reintervention and rate of reintervention. Patient demographics, comorbidities, number and type of reinterventions, graft type, and timing of reintervention were analyzed. RESULTS: A total of 1144 patients underwent AAA repair; 558 had EVAR and 586 had OSR. In 76 EVAR patients, 123 reinterventions were performed; 46 reinterventions were performed in 30 OSR patients (P < 0.0001). Endoleak was responsible for 66% of EVAR reinterventions; colonic ischemia, bleeding, and incisional hernias caused 30%, 22%, and 22% of OSR reinterventions, respectively. Time to first reintervention was shorter in OSR patients (P < 0.001) and was related to AAA size (P < 0.001). Early reintervention at the index procedure in OSR patients had a 23% mortality rate. If reinterventions were not required, survival curves were similar. Current endografts require fewer reinterventions than earlier generation endografts. CONCLUSIONS: Reintervention was more common with EVAR and occurred later. Early reintervention after OSR is associated with significant mortality. If early reintervention in OSR patients can be avoided, there is no early survival advantage to EVAR. Current endografts require fewer reinterventions than earlier devices.

Crossing chronic total occlusions with the Ocelot system: the initial European experience.

AIMS: The aim of the study was to determine the safety, efficacy and feasibility of a new chronic total occlusion (CTO) device using optical coherence tomography (OCT) technology, the Ocelot catheter (Avinger, Inc., Redwood City, CA, USA), for crossing of SFA CTOs following guidewire failure. METHODS AND RESULTS: Prospective, multicentre, market preference testing. Thirty-three patients with confirmed CTO (99-100% stenosis by visual estimate) of their superficial femoral artery (SFA) were treated between September 28, 2011, and December 9, 2011, at three European centres. Ocelot crossed 94% (31/33) of CTOs, allowing guidewire placement in the distal true lumen. All (100%) lesions were treated without any major adverse safety events. Procedural time and contrast dose were significantly reduced (p<0.0001) when compared with a similar, non-OCT-guided CTO crossing device (Wildcat catheter; Avinger, Inc.). Overall physician feedback on the catheter performance was positive with an 87% average rating of excellent or good across seven categories. Performance ratings of Ocelot's OCT imaging guidance were consistently positive with an 86% average rating of excellent or good across five OCT categories. CONCLUSIONS: The Ocelot catheter combines advanced CTO crossing technology with real-time OCT guidance. When compared with a similar non-OCT-guided catheter, crossing efficacy and safety profile improved. Total procedure time and contrast volumes were significantly reduced. The Ocelot is a safe, efficient and effective tool for crossing CTOs.

A multicenter experience evaluating chronic total occlusion crossing with the Wildcat catheter (the CONNECT study).

OBJECTIVE: Percutaneous techniques for crossing femoropopliteal chronic total occlusions (CTOs) offer an alternative to bypass surgery in patients deemed to be at increased risk due to advanced age or comorbidities. Recent reports document good success rates in catheters designed to reconstitute peripherally occluded arteries following failed guidewire passage. The Wildcat catheter (Avinger, Redwood City, Calif) is a novel device with a rotating distal tip and deployable wedges fashioned for channeling a passage through arterial occlusions. This report describes the results of a prospective, multicenter, nonrandomized trial evaluating the safety and efficacy of the Wildcat device when crossing de novo or restenotic femoropopliteal CTOs. METHODS: Between August 2010 and April 2011, patients with peripheral arterial disease due to a femoropopliteal CTO>1 cm and ≤35 cm were evaluated for study enrollment at 15 U.S. sites. During treatment, the physician initially attempted to cross the CTO using conventional guidewires per protocol; if the guidewire successfully crossed, the patient was considered a screen failure and the Wildcat was not deployed. At 30 days, patients were reevaluated. The primary efficacy end point was successful crossing of the Wildcat into the distal true lumen as confirmed by angiography. Primary safety end points included no in-hospital or 30-day major adverse events, no clinically significant perforation or embolization, and no grade C or greater dissection. Additional data collected included lesion length, degree of calcification, and location. RESULTS: Eighty-eight patients were enrolled in the trial. Of these, the Wildcat device was used in 84 patients (95%) per protocol. Successful CTO crossing was reported and confirmed by independent review in 89% (75/84) of cases with 5% (4/84) major adverse events as defined in the protocol (predominantly perforations sealed with balloon inflation). There were no clinically relevant events associated with any of the perforations. The mean CTO length was 174±96 mm (range, 15-350 mm). Approximately 57% (n=48) of all lesions were categorized as containing at least moderate calcification. Eighty-nine percent (n=75) of vessels recanalized were superficial femoral arteries. CONCLUSIONS: In this multicenter study, the Wildcat catheter demonstrated an 89% crossing success rate with little associated morbidity. The Wildcat catheter is a viable device for crossing moderately calcified femoropopliteal CTOs.

Subintimal angioplasty for advanced lower extremity ischemia due to TASC II C and D lesions of the superficial femoral artery.

OBJECTIVE: Subintimal angioplasty (SA) has evolved into a viable revascularization procedure for complex lower extremity lesions. Although patency rates are lower than those for autogenous bypass, limb salvage rates are comparable. This study reviewed the 8-year experience of SA in a single center. METHODS: Records of patients undergoing SA were reviewed. Clinical presentation and noninvasive exams were used to classify patients. Lesions were categorized by TransAtlantic InterSociety Consensus (TASC) II guidelines. Outcomes included technical success, patency, amputation-free survival, and limb salvage. RESULTS: 120 patients with TASC II C/D lesions underwent SA. Technical success was 91%. Primary patency at 6 and 12 months was 90% and 73%. Secondary patency at 6 and 12 months was 94% and 85%. One-year amputation-free survival was 90%. One-year limb salvage was 98%. CONCLUSIONS: SA for TASC C/D lesions is a safe procedure and may be considered an alternative to bypass, especially in high-risk patients.

Role of the hypoglossal nerve in equine nasopharyngeal stability.

The equine upper airway is highly adapted to provide the extremely high oxygen demand associated with strenuous aerobic exercise in this species. The tongue musculature, innervated by the hypoglossal nerve, plays an important role in airway stability in humans who also have a highly adapted upper airway to allow speech. The role of the hypoglossal nerve in stabilizing the equine upper airway has not been established. Isolated tongues from eight mature horses were dissected to determine the distal anatomy and branching of the equine hypoglossal nerve. Using this information, a peripheral nerve location technique was used to perform bilateral block of the common trunk of the hypoglossal nerve in 10 horses. Each horse was subjected to two trials with bilateral hypoglossal nerve block and two control trials (unblocked). Upper airway stability at exercise was determined using videoendoscopy and measurement of tracheal and pharyngeal pressure. Three main nerve branches were identified, medial and lateral branches and a discrete branch that innervated the geniohyoid muscle alone. Bilateral hypoglossal block induced nasopharyngeal instability in 10/19 trials, and none of the control trials (0/18) resulted in instability (P<0.001). Mean treadmill speed (+/-SD) at the onset of instability was 10.8+/-2.5 m/s. Following its onset, nasopharyngeal instability persisted until the end of the treadmill test. This instability, induced by hypoglossal nerve block, produced an expiratory obstruction similar to that seen in a naturally occurring equine disease (dorsal displacement of the soft palate, DDSP) with reduced inspiratory and expiratory pharyngeal pressure and increased expiratory tracheal pressure. These data suggest that stability of the equine upper airway at exercise may be mediated through the hypoglossal nerve. Naturally occurring DDSP in the horse shares a number of anatomic similarities with obstructive sleep apnea. Study of species with extreme respiratory adaptation, such as the horse, may provide insight into respiratory functioning in humans.

Heparin-induced thrombocytopenia after implantation of a heparin-bonded polytetrafluoroethylene lower extremity bypass graft: A case report and plan for management.

The proprietary heparin-bonded expanded polytetrafluoroethylene graft appears to be an attractive option for lower extremity revascularization in patients with compromised runoff and no autogenous vein. There is no detectable elution of heparin from the graft surface, but antithrombotic activity has been detected in devices implanted for >2 years. Although 15,000 Propaten (W. L. Gore and Associates, Flagstaff, Ariz) grafts have been implanted, to our knowledge, this is the first report of heparin-induced thrombocytopenia developing from this heparin-bonded graft. The heparin-induced thrombocytopenia responded promptly to graft explantation. A management plan is suggested for patients being considered for this graft.

Use of the abdominal aorta as an alternative access site for thoracic aortic stent graft placement.

The treatment of thoracic aortic pathology has undergone a paradigm shift in recent years, with a trend toward less invasive endovascular techniques and away from open surgical repair. Reports on the successful use of endografts in the thoracic aorta have demonstrated decreased morbidity and mortality of these procedures compared with traditional open repair. However, some patients are not candidates for an endovascular approach because of a short proximal landing zone, arch angulation, luminal irregularities, or a large diameter of the transverse arch and the proximal descending aorta. Other patients are excluded because of distal pathology or anatomic irregularities. This article presents 2 patients with thoracic aortic pathology, and both had inadequate proximal landing zones and small, calcified iliac arteries prohibiting femoral or iliac access. Successful repair of these patients was achieved by a staged procedure using a brachiocephalic debranching technique, followed by direct infrarenal aortic cannulation through a limited celiotomy.

Elective endovascular and open repair of abdominal aortic aneurysms in octogenarians.

OBJECTIVES: Endovascular aortic aneurysm repair (EVAR) is an increasingly popular treatment option for patients with abdominal aortic aneurysms (AAA), although open repair is considered the standard by virtue of its durability. Octogenarians, as a subgroup, may stand to benefit the most by EVAR. The purpose of this study is to review operative results and durability of open AAA repair and EVAR in octogenarians. METHODS: From May 1996 to August 2006, 150 patients aged >or=80 years underwent elective repair of their infrarenal AAA. Eighty-one underwent EVAR and 69 had open repair. Demographic data, aneurysm specifics, comorbidities, operative morbidity and mortality, intensive care unit and hospital length of stay, and late outcomes were analyzed. RESULTS: In the EVAR group, 27 of 81 (33%) patients died during a mean follow-up of 25 months. In the open repair group, 34 of 69 (49%) patients died during a mean follow-up of 43 months. The median survival time for EVAR was 350 weeks (range, 145-404 weeks) compared with 317 weeks (range, 233-342 weeks) for the open repair group. A Kaplan-Meier log-rank analysis showed no difference in early or long-term survival between EVAR and open repair (P = .13). EVAR was associated with decreased blood loss, decreased length of intensive care unit and hospital stays, and a greater number of patients discharged to home. CONCLUSIONS: EVAR and open repair are comparable in safety and efficacy in octogenarians. Operative repair outcomes remain acceptable. Mid- and long-term survival are similar, indicating no survival advantage of one procedure compared with the other.

Elective treatment of abdominal aortic aneurysm with endovascular or open repair: the first decade.

OBJECTIVES: The development of endovascular aneurysm repair (EVAR) as an alternative to open repair of abdominal aortic aneurysms (AAA) has led to an increasing number of patients being treated by this less-invasive technique. It was anticipated that EVAR would reduce the operative mortality and morbidity compared with open repair. This study examined the initial 10-year experience in one center when both techniques were available to determine if there were advantages to one technique or the other, putting the results into the perspective of routine clinical care of patients with infrarenal AAA. METHODS: From June 1996 to May 2005, 677 patients underwent elective repair of their infrarenal AAA, of which 417 were treated with open repair and 260 by EVAR. Demographic and aneurysm-specific data, comorbidities, operative morbidity, mortality, and late outcome were analyzed. RESULTS: Open repair patients were 2 years younger (71 vs 74 years, P < .001), had larger aneurysms (6.01 +/- 1.38 cm vs 5.45 +/- 0.99 cm, P < .001), greater familial predisposition, a higher incidence of current smokers, and a higher incidence of chronic obstructive pulmonary disease than the EVAR group. There were no differences in renal function, hypertension, coronary artery disease, or heart failure between the two groups. Overall operative mortality was 3.1%; operative mortality per group was 3.5% for open and 2.7% for EVAR (P = .627). Procedure-related outcomes showed significant differences in operative blood loss and length of hospital stay in favor of EVAR, and 95% of the EVAR patients were discharged home vs 83% in the open repair group (P < .001). A Kaplan-Meier log-rank analysis showed no difference in early or long-term survival between open repair and EVAR (P = .20), but did show a difference in mid-term (3-year) survival favoring open repair (P < .002). Survival analysis by age (<70 and > or =70 years) showed no difference between treatment groups. CONCLUSIONS: Open repair and EVAR are both performed safely in patients treated for elective infrarenal AAA. EVAR has the perioperative advantages of reduced blood loss, reduced length of intensive care unit and hospital stay, and increased number of patients discharged to home. The mid-term survival advantage of open repair has been observed in other reports and deserves further study.

Endoluminal embolization and revascularization for complicated mesenteric pseudoaneurysms: a report of two cases and a literature review.

Mesenteric artery pseudoaneurysms are a rare and complex complication after abdominal trauma, surgery, or inflammatory disease. These lesions can be associated with compression or erosion into adjacent structures and may result in life-threatening hemorrhage. Traditional management has been open surgical ligation, aneurysm resection with interposition grafts, or resection or partial resection of the end organ involved. We present two cases of endovascular repair of complex mesenteric pseudoaneurysms. One patient presented with a recurrent pseudoaneurysm of the superior mesenteric artery and the second presented as recurrent gastrointestinal bleeding secondary to a traumatic celiac artery pseudoaneurysm-to-pancreatic duct fistula. A systematic review of the literature on endovascular management of mesenteric vascular disease and mesenteric pseudoaneurysms is included in this report to allow these cases to be put into proper perspective.

Carotid artery velocity characteristics after carotid artery angioplasty and stenting.

OBJECTIVE: Correlation of carotid duplex ultrasound (DUS) flow velocities with carotid artery stenosis before and after carotid endarterectomy is well established. With the evolution of catheter-based techniques, carotid stenosis increasingly is being treated with angioplasty and stenting (CAS). CAS changes the physical properties of the arterial wall, which may alter blood flow velocities compared with the nonstented carotid. Opinions differ about whether DUS is a reliable tool to assess technical outcome and recurrent stenosis after CAS. This study correlated carotid DUS flow velocity findings with carotid arteriography after CAS. METHODS: Data from 77 pairs of carotid arteriograms with corresponding DUS after CAS in 68 patients were reviewed. Preintervention and postintervention DUS and carotid arteriogram data were evaluated for each patient. Peak systolic velocities (PSV), end-diastolic velocities (EDV), and internal carotid artery/common carotid artery ratios (ICA/CCA) were correlated with the post-CAS arteriogram. RESULTS: The mean preintervention PSV was 390 +/- 110 cm/s (range, 216 to 691 cm/s), and the average EDV was 134 +/- 51 cm/s (range, 35 to 314 cm/s). Postintervention DUS was obtained a mean of 5 days after CAS (range, 1 to 30 days). Sixty (81%) post-CAS arteriograms were normal, and each corresponded to a normal postintervention DUS (PSV range, 30 to 118 cm/s; EDV range, 18 to 60 cm/s). In 14 arteries (19%), completion arteriograms revealed residual stenoses of 20% to 40% in 13, and 50% in one. The mean PSV was 175 cm/s (range, 137 to 195 cm/s), and the mean EDV was 44 cm/s (range, 20 to 62 cm/s). All velocities exceeded the threshold of a 50% stenosis by DUS criteria for a nonstented carotid artery. In three arteries (2 patients), high-grade recurrent stenoses detected by DUS developed that required reintervention during follow-up. This high-grade restenosis was confirmed by arteriography in each patient, providing an additional three correlations. CONCLUSIONS: Normal DUS imaging reliably identifies arteriographically normal carotid arteries after CAS. Carotid velocities are disproportionately elevated with mild and moderate degrees of stenoses, and velocity criteria for quantitating stenoses in these patients require modification. However, DUS appropriately identifies severe recurrent stenoses after CAS.