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

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

Outcome of a comprehensive follow-up program to enhance maturation of autogenous arteriovenous hemodialysis access.

OBJECTIVE: To examine the outcome of a comprehensive follow-up program for autogenous arteriovenous hemodialysis access (AVF) when performed by the hemodialysis access surgeon. METHODS: Patients with first time AVFs between 2000 and 2005 underwent history and physical examination between the third and sixth postoperative weeks, followed by repeat examination every 6 to 8 weeks until maturation. Primary outcomes included maturation assessment and interventions required prior to maturation. Maturation was defined as 4 consecutive weeks of sustainable AVF hemodialysis access. RESULTS: One hundred thirteen patients had 113 AVFs. Mean age was 64 years (range: 26-94) and 52% were male. AVFs included 8 (7%) radiocephalic, 90 (80%) brachiocephalic, and 15 (13%) basilic vein transposition. Overall, the maturation rate was 72% (failure rate of 28%). Excluding deaths and transplants prior to maturation, the maturation rate was 82% (failure rate 18%). Eighty-three (73%) patients had no intervention prior to maturation and 30 (27%) required intervention. There was no significant difference in failure rate between AVFs not requiring an intervention (13 of 83, 15%) and those requiring intervention (5 of 30, 16%). For AVFs requiring intervention, 23 (61%) patients had an endovascular intervention and 15 (39%) an operative intervention. One intervention was performed in 64%, two in 24%, and three in 12%. Ninety-three percent of AVFs having an endovascular intervention matured compared with 60% having operative intervention (P = .10). AVFs requiring intervention had a maturation time (mean: 35 weeks, range: 10-54) that was significantly longer (P = .003) than those without (mean 11 weeks, range: 6-35). CONCLUSIONS: With a surgeon directed comprehensive follow-up program to assess AVF maturation, a large proportion (30 of 43, 69%) of AVFs with a problem were detected. Of those identified, most (25 of 30, 83%) could be salvaged to maturation with intervention. The Kidney and Dialysis Outcome Quality Initiative (K/DOQI) should consider incorporating a comprehensive follow-up program into its guidelines.

Establishment of a varicose vein center in a tertiary vascular surgery practice: urban versus rural differences.

We examined changes in practice patterns after the establishment of a varicose vein center (VVC) within two tertiary university vascular surgery practices and compared differences between urban (U) and rural (R) sites. Practice patterns for the treatment of VVs were compared 3 years before (period 1) and 3 years after (period 2) the formation of a U-VVC and an R-VVC in 2001. Both VVCs were part of similar-sized tertiary vascular surgery practices. Evaluation was specific to VVs, reticular veins, and telangiectasias. Prior to U-VVC, there were 338 office visits, six office procedures, and 114 hospital procedures. After U-VVC, there were 624, 120, and 312, respectively. Prior to R-VVC, there were 85 office visits, five office procedures, and 69 hospital procedures. After R-VVC, there were 528, 163, and 303, respectively. In period 1 for U-VVC and R-VVC, VVC relative value unit (RVU) generation as a percent of total practice RVUs was 1.0% and 0.7%, respectively. In period 2 for U-VVC and R-VVC, VVC RVU generation as a percent of total practice RVUs was 2.6% and 2.5%, respectively. In an effort to provide more coordinated treatment for patients with VVs, establishing a VVC within a tertiary academic vascular surgery practice can lead to rapid expansion of clinical volume by increased office visits, office procedures, and hospital procedures. Clinical demand for evaluation and treatment of VVs showed little variation between R-VVC and U-VVC.

Closure of a surgically created arteriovenous fistula with a covered stent-graft in a patient with venous ambulatory hypertension--a case report.

The purpose of this paper is to report the use of a covered stent-graft in the endovascular treatment of a surgically created arteriovenous fistula. A 37-year-old woman with symptomatic venous ambulatory hypertension underwent a left common femoral vein-to-right common iliac vein bypass using 10 mm ringed polytetrafluoroethylene (PTFE) with creation of an arteriovenous (AV) fistula from the superficial femoral artery to the PTFE graft. At 1 year postoperatively, recurrent symptoms thought to be due to the arteriovenous fistula were treated by placement of an 8 mm x 10 cm Viabahn covered stent-graft. Placement was via crossover technique from the right common femoral artery using a 9 French sheath. At 2 months' follow-up symptoms had resolved, the AV fistula was occluded, and venous bypass remained patent. Focal arteriovenous fistulas of the proximal superficial femoral artery can be treated safely with a covered stent-graft via an endovascular approach.

Superior vena cava perforation and cardiac tamponade after filter placement in the superior vena cava--a case report.

The purpose of this paper is to report the complication of perforation of the superior vena cava (SVC) leading to cardiac tamponade after the insertion of a Trapease IVC filter in the SVC position. A 29-year-old man was hit by motor vehicle and sustained numerous injuries including a left skull fracture, intracerebral hemorrhage, and left open tibial shaft fracture. During his hospitalization, he developed an extensive symptomatic right upper extremity deep venous thrombosis involving the brachial, axillary, subclavian, internal jugular, and brachiocephalic veins. Owing to an intracerebral bleed, anticoagulation was contraindicated. Therefore, a Trapease filter (Cordis Inc.) was placed in the SVC via the left subclavian vein. Four hours later, the patient became hypotensive with associated tachycardia and tachypnea. Computed tomography of his chest revealed a hematoma around the SVC, a moderate amount of fluid within the pericardium, and a moderate-sized right pleural effusion. The patient was taken to the operating room and a pericardial window was performed. Approximately 500 cc of blood was evacuated from the pericardium and immediate improvement in vital signs was noted. The patient was discharged from the hospital 2 weeks later and at 6-month follow-up had made full recovery. This is the first case of SVC perforation leading to cardiac tamponade after the insertion of a Trapease filter. Owing to the rigid structure of the filter and associated motion of the SVC and pericardium, the Trapease filter may be contraindicated in the SVC.

The inaccuracy of simple visual interpretation for measurement of carotid stenosis by arteriography.

PURPOSE: To determine intraobserver and interobserver variability of carotid arteriography interpretation as well as the reliability of simple visual interpretation (SVI) or "eyeballing" of arteriography in the measurement of internal carotid artery stenoses. METHODS: Intraobserver and interobserver measurements of 200 carotid arteriograms were performed in a blinded fashion by two vascular surgeons (VS1 and VS2) using a digital caliber computer program similar to software available in catheterization laboratories. The distal normal internal carotid artery was used as a frame of reference. These computer-derived measurements were compared with previous SVI measurements, found by retrospective chart review, that were performed at the initial time of arteriography. RESULTS: Intraobserver agreement (VS1a vs VS1b and VS2a vs VS2b) within +/-5% using the computer program was 94% and 92%. Interobserver agreement within +/-5% using the computer program for the four possible combinations ranged from 43% to 48%. Interobserver agreement using the computer program increased to 83% to 88% for correct stenosis interpretation within +/-20%. In the 16% to 49% category (by computer measurement), SVI would have placed the stenosis in a higher category 40% to 56% of the time. Likewise, in the 50% to 79% category, comparing SVI with the four different computer caliber measurements, SVI overestimated the stenosis to the 80% to 99% category by 30% to 44%. In the 80% to 99% category, SVI overestimated lesions in 27% to 51% of the cases. All occlusions seen on SVI correlated with computer program measurements. The computer readings in many cases downgraded the degree of carotid stenosis into a lower category and in some cases, may have led to a different treatment paradigm. SVI never underestimated carotid stenosis compared with all matched computer program measurements. CONCLUSIONS: Compared with a method of objective measurement similar to that used in a catheterization laboratory, SVI overestimated most carotid artery stenoses. Given the coming era of carotid stenting and a renewed need for arteriography before carotid intervention, knowledge of variability and correct interpretation of carotid stenosis using available technology remains paramount to warranted treatment.

Anesthesia technique and outcomes of endovascular aneurysm repair.

Anesthetic techniques vary widely in the endovascular repair of abdominal aortic aneurysms (EVAR). Previous studies have demonstrated the feasibility of using local anesthesia. However, the ideal anesthetic technique has not been determined. This study examines whether anesthetic technique influences the outcomes of EVAR. Data regarding demographics, risk factors, procedural characteristics, recovery characteristics, treatment complications, acute (<30 day) medical complications, mortality, and anesthetic type were prospectively collected during the AneuRx phase II aortic endograft trial. Patient cohorts receiving general, regional, or local anesthesia were compared. From 1997 to 1998, 424 patients underwent EVAR at 13 sites using the AneuRx Bifurcated endograft. There were 279 patients in the general anesthesia group, 95 patients in the regional group, and 50 patients in the local group. Risk factors were similar. There were no significant differences in age, gender, American Society of Anesthesiologists grade, length of anesthesia, branch artery occlusions, proximal endoleaks, failed implants, or open surgical conversions. Cardiac, renal, and wound-healing complications were all lower in the local group. Mortality was equivalent among the three groups. (p > 0.05, ANOVA). From these results we concluded that EVAR with local anesthesia is a safe and efficacious method that may reduce recovery times and postoperative medical morbidity compared to use of general or spinal/epidural anesthesia.

Predictors of complications after a prospective evaluation of diagnostic and therapeutic endovascular procedures.

OBJECTIVE: To prospectively evaluate complications after diagnostic and therapeutic endovascular procedures (DTEPs) and determine what factors are predictive. METHODS: From December 2002 to December 2003, all patients undergoing DTEPs performed by university vascular surgeons in a catheterization laboratory were prospectively evaluated. Medical demographics, procedure-related details, and type and severity of complications were recorded at the time of the procedure, during the first 24 hours, and at 2 to 4 weeks. Complications were classified as local vascular (LV), local nonvascular (LNV), systemic remote (SR), and major, minor, and nonsignificant. RESULTS: Three hundred-three DTEPs were performed (54.5% DEPs, 45.5% TEPs). At the time of DTEP, 28 complications occurred in 23 patients: 10 LV (3.3%), 15 LNV (5.0%), and 3 SR (1.0%). At 24 hours, 26 complications occurred in 25 patients: 5 LV (1.7%), 7 LNV (2.3%), and 14 SR (4.7%). At 2 to 4 weeks, 26 complications occurred 25 patients: 5 LV (1.7%), 7 LNV (2.3%), and 14 SR (4.7%). The combined major (7.3%) and minor (4.3%) complication rate attributed to DTEPs was 11.6%. Significant predictors (P < .05) by multivariate analysis included thrombolysis, prior stroke, an additional procedure during the study period, and diabetes mellitus (odds ratios: 9.1, 3.2, 2.7, and 2.4, respectively). CONCLUSION: According to newly applied reporting standards, the prospective evaluation of DTEPs reveals that complications are uniformly distributed by type and follow-up period. Just over 1 in 10 patients will suffer either a major or minor complication. Potential predictors have been identified that may assist in patient selection and treatment plans to lower complications resulting from DTEPs.

Characterization and probability of upper extremity deep venous thrombosis.

The objective of this study was to characterize patient demographics, risk factors, and anatomic distribution of upper extremity deep venous thrombosis (UEDVT) to develop a probability model for diagnosis. A retrospective review of all patients who underwent color-flow duplex scanning (CDS) for clinically suspected acute UEDVT over a 5-year period was performed. Patient risk factors and clinical symptoms were evaluated as predictors. Technically adequate complete CDS of 177 upper extremities (UEs) of arms were reviewed. CDS scanning identified acute UE venous thrombosis in 53 (30%) of the arms examined with deep system involvement in 40 (23%). Of the UEs affected, the subclavian was involved in 64%, the axillary in 25%, the internal jugular in 32%, the brachial in 36%, the cephalic in 32%, and the basilic in 47%. Multivariate analysis identified limb tenderness (odds ratio 9.3), history of central venous catheterization (odds ratio 7.0), and malignancy (odds ratio 2.9) as positive predictors for UEDVT. Erythema (odds ratio 0.12) and suspected pulmonary embolism (odds ration 0.06) were identified as negative predictors. A predictive model was designed from these variables. The anatomic distribution of UEDVT obtained from this study is consistent with previous reviews. Potential positive and negative risk factors can be identified from which a predictive model can be designed. Use of this model can help focus clinical suspicion, improve color-flow duplex utilization, and provide timely treatment with anticoagulation.

Pancreatitis caused by rheolytic thrombolysis: an unexpected complication.

Two patients developed acute pancreatitis after mechanical thrombolysis with use of the AngioJet system. Patient 1 had undergone a remote complex revascularization of the lower extremities and presented with acute ischemia after thrombosis of his composite distal bypass. Patient 2 presented with superior vena cava (SVC) syndrome and had thrombosis of the SVC and innominate veins. Despite dissimilar presentations, both patients had renal insufficiency, were treated with mechanical and chemical thrombolysis, and had extensive thrombus burden. The pathophysiology of acute pancreatitis in this setting is believed to be secondary to massive hemolysis in the presence of chronic renal insufficiency. This phenomenon should be considered in patients whom develop abdominal pain after mechanical thrombolysis.

Selective venography versus nonselective venography before vena cava filter placement: evidence for more, not less.

OBJECTIVE: We undertook this study to determine whether additional use of selective venography, compared with nonselective venography alone, reveals more abnormal anatomic venous findings that lead to changes in vena cava filter (VCF) position. METHODS: From January 1998 to June 2002, 94 patients underwent VCF placement by vascular surgeons at a university tertiary care center. Indications, techniques, decision analysis, and complications were reviewed. Nonselective venography and selective venography of the inferior vena cava (IVC) were evaluated for image quality, abnormal findings, aberrant anatomy, and the anatomic relationship of vertebral bodies to major venous tributaries. RESULTS: Absolute and relative indications for VCF placement were 44% and 56%, respectively. Jugular, femoral, and subclavian vein approach was used in 47%, 47%, and 6% of patients, respectively. Seventy-three percent of VCFs were placed in the catheterization laboratory, 21% in the operating room, and 5% at the bedside. Nonselective venography was performed in 80 patients (85%), of whom 44% had undergone selective venography. At nonselective venography plus selective venography 7.5% of patients had an abnormal finding (IVC compression, n = 3; IVC thrombus, n = 2; tortuosity, n = 1). Similarly, 17.5% of patients had aberrant anatomy (accessory renal vein, n = 8; IVC duplication, n = 3; large low right gonadal vein, n = 2; megacava, n = 2). Nonselective venography plus selective venography demonstrated that 16% of VCFs required a major change in position, 10% of which were placed above the renal veins. Compared with nonselective venography alone, selective venography enabled detection of significantly more abnormal and aberrant findings (9% vs 49%; P <.001). Changes in VCF placement were necessary significantly more often in patients undergoing additional selective venography compared with nonselective venography alone (31% vs 4%; P =.003). In one patient in the series, a VCF was malpositioned in the iliac vein with intravascular ultrasound visualization. CONCLUSION: When nonselective venography plus selective venography were performed, 23% of patients had either an abnormal finding or aberrant anatomy, and most of these required a major change in VCF position. Nonselective venography plus selective venography redefines the criterion standard and, because of limitations of other methods of vena cava visualization for VCF deployment, should be performed in most patients.

Retrograde endovascular hypogastric artery preservation (REHAP) and aortouniiliac (AUI) endografting in the management of complex aortoiliac aneurysms.

The preservation of internal iliac artery (IIA) flow during endovascular repair of abdominal aortic aneurysms (er-AAA) remains a controversial area. Ectasia and aneurysmal disease of the iliac arteries represent a formidable challenge to the endovascular surgeon, particularly when aortic neck length and diameter are suitable for er-AAA. We describe a procedure to maintain arterial perfusion to the pelvis during er-AAA called retrograde endovascular hypogastric artery preservation (REHAP). This technique is particularly useful in the presence of common iliac artery (CIA) and internal iliac artery (IIA) aneurysms when pelvic perfusion to one IIA needs to be maintained. A Wallgraft is first placed from the IIA to the ipsilateral EIA followed by er-AAA using an aortouniiliac graft (AUI) and a femorofemoral bypass graft (BPG). This procedure represents one alternative to maintaining pelvic perfusion using standard endovascular and surgical techniques.

Indications and outcomes of AneuRx Phase III trial versus use of commercial AneuRx stent graft.

OBJECTIVE: Approval by the United States Food and Drug Administration of endoluminal repair of abdominal aortic aneurysm (AAA) with the AneuRx stent graft was based on the outcome of a multicenter trial in which patients met strict inclusion and exclusion criteria. Since widespread use of the commercially available graft, little information is available as to whether indications and outcomes have evolved. We examined this important issue at our institution. METHODS: Data concerning indications, repair, and follow-up for all patients undergoing endoluminal repair of AAA was prospectively entered into a patient registry. Group 1 comprised consecutive patients enrolled in the AneuRx Phase III clinical trial between November 1998 and September 2000. Group 2 consisted of consecutive patients who underwent implantation of the commercially available AneuRx graft between May 1999 and June 2001. RESULTS: Group 1 included 42 patients (mean age, 72 years), and group 2 included 54 patients (mean age, 73 years). Patient demographics and risk factors were similar between the two groups. Maximum aortic aneurysm diameter was significantly greater (P =.021) in group 1 (55 mm +/- 10.9 [SD] mm) compared with group 2 (52 +/- 15.6 mm). Maximum infrarenal aortic neck length was significantly longer (P =.022) in group 1 (30 +/- 11.7 mm) than in group 2 (23 +/- 12.0 mm). Maximum left common iliac artery diameter in group 1 (13.0 +/- 3.2 mm) was significantly smaller (P =.032) than that in group 2 (14 +/- 6.5 mm). During follow-up, no differences were observed for number of endoleaks, subsequent interventions, or graft explantation between the two groups. CONCLUSIONS: In group 2 patients AAAs were significantly smaller, infrarenal aortic neck length was shorter, and left common iliac arteries were larger. Common iliac artery ectasia and aneurysmal disease has become another indication for use of the AneuRx commercial graft at our institution, with no significant differences in intermediate outcome. Given the possibility for evolving indications compared with trial inclusion and exclusion criteria, institutions that use the AneuRx commercial graft should prospectively monitor outcomes for quality assurance.

Mechanism of failure in the treatment of type II endoleak with percutaneous coil embolization.

PURPOSE: Type II endoleak after endovascular abdominal aortic aneurysm repair is a failure of aneurysm sac exclusion with unknown long-term consequences. Elevated aneurysm sac pressures documented in these patients have led us to aggressively treat type II endoleaks with percutaneous transluminal coil embolization (PTCE). The purpose of this study was to evaluate the results and the mechanisms of failure of PTCE for type II endoleak. METHODS: One hundred ninety-one patients underwent endograft repair of infrarenal aortic aneurysms. Twenty-three of 28 patients with persistent primary (>3 months) or secondary (new-onset) endoleak underwent angiography; 14 of these patients had type II endoleaks. We reviewed our endovascular registry data, hospital charts, and radiologic studies of patients with type II endoleaks and analyzed the results in those treated with PTCE of the inflow vessel. RESULTS: All 14 patients with type II endoleaks were men, with a mean age of 76.7 years and a mean preoperative maximal aneurysm diameter of 5.7 +/- 1.0 cm. The type II endoleak was primary in 12 patients (86%) and secondary in two patients (14%) and iliolumbar in 11 patients (78%) and mesenteric in three patients (21%). Although a dominant affluent collateral channel (inosculation) was apparent in eight patients (57%), six patients (43%) showed a network of collateral vessels (retiform anastomosis). In six patients (43%), angiography revealed a second or "outflow" vessel indicative of a complex endoleak. In four patients with retiform iliolumbar type II endoleaks, PTCE was not attempted because of the retiform nature of the endoleak. The remaining 10 patients underwent PTCE, with coil deployment in all 10 and apparent initial technical success in nine patients. Follow-up computed tomographic scans revealed persistent endoleaks in six patients (60%). Mechanisms of failure included persistent flow through the coils in the treated vessel in two patients, development of a retiform anastomosis around the coiled vessel in three patients, and development of a new mesenteric endoleak after successful occlusion of an iliolumbar endoleak in one patient. Two patients underwent repeat PTCE with successful aneurysm sac exclusion in one. Internal iliac artery injury complicated one of the 12 PTCEs, and the resulting pseudoaneurysm was successfully treated with PTCE. Angiographic visualization of an outflow vessel (complex endoleak) was associated with PTCE failure (P =.008). CONCLUSION: PTCE of type II endoleaks has a high failure rate because of multiple anatomic mechanisms.

Pitfalls in achieving the Dialysis Outcome Quality Initiative (DOQI) guidelines for hemodialysis access?

The Dialysis Outcome Quality Initiative (DOQI) mandates that 50% of permanent hemodialysis (HD) access be native arteriovenous fistulae (AVFs). Recent reports have shown that when these guidelines are followed, the percentage of new AVFs can exceed DOQI guidelines. From July 1998 to July 2001, 330 HD access procedures were performed in an academic tertiary care center. Patients were categorized into two groups. Group I followed DOQI guidelines and underwent history and physical examination; duplex vein mapping; use of basilic vein transposition; and a postoperative protocol to determine maturation and start needle access in a stepwise progression. Group II had history and physical examination and basilic vein transposition was not used. Patient data were retrospectively reviewed. Overall, 100 (31%) HD shunts were AVFs. Group I (42/183, 23%) had significantly less AVFs (p = 0.005) than group II (58/147, 39%). For first-time placement of HD access, there was no significant difference (p = 0.95) in the percentage of AVFs in group I (26/62, 42%) and group II (29/68, 43%). For patients with prior history of HD access, significantly less AVFs (p <0.001) were placed in group I (16/121, 13%) than in group II (29/79, 37%). Group I had significantly less first-time HDS (P = 0.03) than group II, 34% VS. 46%, respectively. AVF maturation for hemodialysis occurred in 79% of group I and 71% of group II (P = 0.52). There were no significant differences (P > 0.05) when comparing age, gender, and incidence of diabetes between the two groups. AVF formation based largely on duplex vein mapping in group I and lack of basilic vein transposition in group II contributed to the inability to achieve DOQI guidelines. Integration of knowledge and practice among vascular surgeons may help to avoid these pitfalls.

The use of color-flow duplex scan for the detection of endoleaks.

OBJECTIVE: Computed tomographic (CT) scan represents the criterion standard for surveillance of endoleaks after endoluminal repair of abdominal aortic aneurysms (erAAAs). Given need for surveillance, risks, and expense of CT scan, the accuracy of color-flow duplex (CFD) scan after erAAA was determined. METHODS: During a 43-month period, patients enrolled in phase II and III of the AneuRx Multicenter Clinical Trial at our institution underwent CFD scan 1 month after erAAA. Patients with CFD scan results that were positive for endoleak underwent CT scanning at 3 months after erAAA, and those with CFD scan results that were negative for endoleak underwent CT scanning at 6 months after erAAA. RESULTS: Seven of 79 patients (9%) who underwent CFD and CT scanning had the diagnosis of endoleak. All endoleaks that were diagnosed with CT scan were detected with CFD scan. One patient had positive results for endoleak with CFD scan at 1 month and then negative results with CT scan at 3 months. Although this may represent resolution of endoleak, this case was counted as a false-positive result. When compared with CT scan, CFD scan had a sensitivity of 100%, specificity of 99%, positive predictive value of 88%, negative predictive value of 100%, and accuracy of 99%. CONCLUSION: CFD scan is an accurate test for the detection of endoleak after erAAA. In addition, most endoleaks diagnosed with CFD scan at 1 month continued to be present at 6 months. This important finding increases the emphasis on the use of this noninvasive test and may initiate earlier intervention of endoleak.

Endovascular management of iliac limb occlusion of bifurcated aortic endografts.

Although aortic endograft iliac limb occlusion is an uncommon event, its treatment is problematic because standard surgical thrombectomy risks graft dislodgment or component separation. Although femorofemoral bypass grafting can restore perfusion to the affected limb, its longevity may be inferior to reestablishing patency of the endograft itself and represents a failure of the endograft procedure. With aortic endografts now commercially available, implanting surgeons must be aware of this important complication and well versed in all of the endovascular treatment options. We report three cases of endoluminal management of unilateral iliac limb occlusion of bifurcated aortic endografts.