Rapid progression of carotid artery atherosclerosis and stenosis in a patient with a ventricular assist device.

This case describes the management of cerebrovascular disease in a patient with a left ventricular assist device (LVAD) who was awaiting cardiac transplantation. It demonstrates several unique features in managing vascular disease in patients with cardiac assist devices. First, we detail the difficulties in using duplex ultrasound to assess patients with altered hemodynamic physiology. Second, we report an instance of rapid progression of known carotid stenosis in a patient with a recently placed LVAD. This case suggests that patients with any degree of carotid stenosis before LVAD placement should be monitored closely for progression after the LVAD is placed.

Carotid artery stenting may be performed safely in patients with radiation therapy-associated carotid stenosis without increased restenosis or target lesion revascularization.

OBJECTIVE: Neck radiation therapy (XRT) can induce carotid artery stenosis and may increase the technical difficulty of endarterectomy. It is considered a relative indication for carotid angioplasty and carotid artery stenting (CAS). This study sought to evaluate differences in CAS embolic potential and restenosis performed on XRT and non-XRT patients. METHODS: At three institutions, 366 CAS procedures were performed on 321 patients (XRT, n = 43; non-XRT, n = 323). Mean follow-up was 410 days (median, 282 days; range, 7-1920 days). Patients were observed with duplex ultrasound to assess for restenosis. Additional end points included target lesion revascularization (TLR), myocardial and cerebrovascular events, and perioperative complications. Captured particulate from embolic protection filters was analyzed with photomicroscopy and image analysis software for 27 XRT and 214 non-XRT filters. RESULTS: XRT patients were more likely to be male and had lower rates of hypertension, coronary artery disease, and diabetes mellitus, although the mean age at procedure did not differ. There was no increase in severe internal carotid tortuosity among XRT patients (XRT: 50% vs non-XRT: 34.7%; P = .06). Indication for CAS did not differ between the two groups, including the number of CAS procedures performed for symptomatic carotid stenosis (XRT: 39.7% vs non-XRT: 39.0%; P = NS). Perioperative outcomes, including the composite 30-day stroke, myocardial infarction, and mortality, were not significantly different (XRT: 2.6% vs non-XRT: 3.9%; P = NS.) There were no significant differences in restenosis rate at the 50% (XRT: 9.4% vs non-XRT: 8.6%; P = NS) or 70% (XRT: 3.5% vs non-XRT: 8.6%; P = NS) threshold. Filter particle analysis revealed that filters from XRT patients had more numerous large particles per filter (1.4 vs 0.7; P < .05) and larger mean particle size (464.1 µm vs 320.0 µm; P < .05). TLR did not differ significantly between the groups. CONCLUSIONS: In contrast to earlier studies, this analysis reveals that there are significant differences in XRT and non-XRT patients undergoing CAS in terms of medical comorbidities and embolic material captured in embolic protection filters. The decreased incidence of atherosclerotic risk factors was observed in XRT patients probably because XRT was the primary factor responsible for carotid stenosis. Despite increased embolic particle size, CAS can be performed safely with no increased morbidity, TLR, or restenosis in XRT patients.

Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.

PURPOSE: To examine the outcomes following interventions for type II endoleaks in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR). METHODS: A retrospective review was conducted of all patients who underwent treatment for type II endoleak from July 2001 to September 2010 in a single center. In this time period, 29 (4.7%) patients (22 men; mean age 78.6 years, range 54-87) were identified as having a type II endoleak and enlargement of the aneurysm sac, meeting the criterion for treatment. All patients had at least one attempted percutaneous intervention. Patients were followed both clinically and radiographically, with computed tomographic angiography every 3 to 12 months, over a follow-up period that ranged from 1 to 10 years (mean 3.5). RESULTS: Forty-eight interventions were performed on the 29 patients. Of these, 15 (56%) patients underwent multiple (2-4) procedures. Of the 11 endoleaks with an isolated inferior mesenteric artery identified as the source, initial success for transarterial embolization at 2 years was 72%, with 2 of the failures having successful secondary interventions. For the 18 endoleaks with a lumbar source, the success of the initial intervention was 17% at 2 years; repeated embolization attempts produced a 40% secondary success rate. Seven (24%) patients had continued endoleak despite multiple treatment attempts; 3 ultimately required elective aortic graft explantation. There were no ruptures or deaths during the study period. In a comparison of type II endoleak patients who had stable aneurysm sacs and those who had persistent sac expansion, the only significant differences in preoperative anatomical characteristics were a lower prevalence of mural thrombus (p = 0.036) and longer right iliac arteries (p = 0.012) in the group with sac expansion. Independent predictors of type II endoleak were mural thrombus (p<0.001), patent lumbar arteries (p = 0.004), aneurysm length (p = 0.011), and iliac artery length (p = 0.004). CONCLUSION: This study demonstrates that most patients require multiple reinterventions to treat type II endoleaks; specifically, lumbar artery embolization carries a low midterm success rate.

Endovascular management as first therapy for chronic total occlusion of the lower extremity arteries: comparison of balloon angioplasty, stenting, and directional atherectomy.

PURPOSE: To evaluate the role of endovascular therapy in the management of infrainguinal arterial chronic total occlusions (CTOs). METHODS: Data on all patients with CTOs treated at a single center from 2004 to 2010 were extracted from a prospectively maintained database for retrospective analysis. Patient demographics, angiographic studies, noninvasive vascular test results, and clinical outcomes were evaluated. In this time frame, 481 patients (283 men; mean age 71.7±11.5 years, range 52-85) with claudication (n = 177) or critical limb ischemia (CLI, n = 304) were treated for 688 CTOs. Lesions were segregated according to location [SFA (n = 193), popliteal (n = 67), tibial (n = 217), and multilevel (n = 211)] and analyzed based on treatment mode (angioplasty, angioplasty with stenting, or atherectomy) and clinical indication. Primary patency, assisted primary patency, and secondary patency, as well as limb salvage rates for CLI patients, were calculated. RESULTS: At 2 years in claudicants with CTOs confined to the SFA, primary patency ranged from 44% to 58% and secondary patency to 92% depending on treatment type; there were no significant differences among the treatments. However, in CLI patients with SFA CTOs, atherectomy produced better outcomes at 2 years (p = 0.002 for primary and p = 0.012 for secondary patency) than angioplasty alone. The limb salvage rates ranged from 73% to 91% (no differences among treatment types). In diabetics, CTOs treated with angioplasty and stent had improved secondary patency rates over angioplasty alone. CONCLUSION: The endovascular management of CTO results in reasonable primary patency; moreover, secondary patency at 2 years is excellent. Endovascular therapy should be the first-line option for many patients with peripheral artery disease, including those with CLI, claudicants with poor bypass conduit, or patients at high medical risk for surgery. The presence of CTOs does not appear to change these recommendations. Although multiple reinterventions may be required, endovascular therapies can be considered a primary therapy for many patients with CTO.

Gender differences in outcomes of endovascular treatment of infrainguinal peripheral artery disease.

OBJECTIVE: Our goal was to assess the outcomes of females compared to males treated with endovascular lower extremity interventions in order to determine optimal therapy based on gender. METHODS: We performed a retrospective review evaluating the outcomes of primary transluminal angioplasty (PTA) and PTA + stenting (PTA + S) for peripheral arterial disease (PAD). Patency rates and limb salvage were the primary end points. RESULTS: A total of 1017 lesions were analyzed in 537 patients (229 male and 308 female) between 2004 and 2009. There were no differences between genders in lesion characteristics. Women were more likely to have interventions for critical limb ischemia (CLI). In CLI patients with superficial femoral artery (SFA) and tibial lesions, women had better patency rates (P < .005). CONCLUSIONS: Women have better patency rates compared with men following treatment of some CLI lesions. Interestingly, women are treated more frequently for CLI when compared to men. For some lesion types in women, PTA alone was equivalent to PTA + S. Our results suggest that outcomes may be optimized by tailoring interventions to gender.

Outcomes and timing of aortic surgery in renal transplant patients.

BACKGROUND: Solid organ transplantation in elderly patients has become more common in recent years. An increasing number of patients present with renal failure requiring transplantation and comorbid occlusive or aneurysmal aortic pathology. The optimal strategy for the timing and management of the aortic disease and renal transplantation in these patients is unknown. Before the availability of endovascular therapies, our policy was to provide open repair of aortic disease before cadaveric transplantation, or by simultaneous aortic reconstruction with renal allotransplantation if a living donor was available. Since the wide acceptance of endovascular modalities, our strategy has changed to take advantage of endovascular treatment pre-transplant. This study examines the outcome of both approaches. METHODS: We performed a retrospective review of 12 patients between 1996 and 2009 who underwent both renal transplantation and a major abdominal aortic procedure either simultaneously (n = 6), metachronous, with the procedures occurring within the same month (n = 2), or distant, with the aortic procedures occurring between 5 and 24 months before or after transplantation (n = 4). All patients with occlusive disease underwent an aortobifemoral bypass, one before transplant, one subsequent to transplantation, and four simultaneous with a renal allograft. To assess renal transplant status, patients' serum creatinine levels were followed up every 3 months. Of the 12 patients, eight underwent open aortic procedures, whereas four underwent endovascular aortic aneurysm repair. Patients who underwent endovascular aortic aneurysm repair were followed up with ultrasound examinations at 6-month intervals, and with contrast computed tomography scans every other year. RESULTS: Aortic reconstruction was performed successfully in all the 12 patients irrespective of timing strategy. All the patients who underwent endovascular repair had functional renal allografts for the duration of follow-up. Two patients had simultaneous aortobifemoral bypass and pancreas-kidney transplantation without complication. Among the patients with open aortic repairs, there was one 5-year mortality and one patient had failure of two renal allografts. None of the patients had limb loss, and aortic grafts (one limb required a secondary procedure) remained patent. The 5-year patient survival of 90% and kidney survival of 75% appeared similar to results in the general transplant population without aortic disease. Two significant complications related to the open procedures were observed: two renal transplants developed postoperative hematomas requiring evacuation and one aortobifemoral bypass (ABF) developed a femoral wound infection requiring evacuation and sartorius flap closure. The 30-day mortality rate in all patients was zero. The length of stay for patients receiving simultaneous procedures ranged from 5 to 14 days (median, 10.5) and was significantly lower than the 10-52-day (median, 18) combined length of stay in the metachronous and/or distant groups (p = 0.016). CONCLUSION: The coexistence of aortic disease and renal transplantation is an increasingly common clinical scenario. Exclusion from transplantation of patients with major aortoiliac disease is commonplace in many transplant centers as early registry data suggested a poor outcome. Appropriate planning with a vascular surgical team can lead to outcomes, which are comparable with the general transplant population without significant aortic disease.