Association between heart failure and arteriovenous access patency in patients with end-stage renal disease on hemodialysis.

BACKGROUND: Heart disease and chronic kidney disease are often comorbid conditions owing to shared risk factors, including diabetes and hypertension. However, the effect of congestive heart failure (CHF) on arteriovenous fistula (AVF) and AV graft (AVG) patency rates is poorly understood. We hypothesize preexisting HF may diminish blood flow to the developing AVF and worsen patency. METHODS: We conducted a single-institution retrospective review of 412 patients with end-stage renal disease who underwent hemodialysis access creation from 2015 to 2021. Patients were stratified based on presence of preexisting CHF, defined as clinical symptoms plus evidence of reduced left ventricular ejection fraction (EF) (<50%) or diastolic dysfunction on preoperative echocardiography. Baseline demographics, preoperative measures of cardiac function, and dialysis access-related surgical history were collected. Kaplan-Meier time-to-event analyses were performed for primary patency, primary-assisted patency, and secondary patency using standard definitions for patency from the literature. We assessed differences in patency for patients with CHF vs patients without CHF, patients with a reduced vs a normal EF, and AVG vs AVF in patients with CHF. RESULTS: We included 204 patients (50%) with preexisting CHF with confirmatory echocardiography. Patients with CHF were more likely to be male and have comorbidities including, diabetes, chronic obstructive pulmonary disease, hypertension, and a history of cerebrovascular accident. The groups were not significantly different in terms of prior fistula history (P = .99), body mass index (P = .74), or type of hemodialysis access created (P = .54). There was no statistically significant difference in primary patency, primary-assisted patency, or secondary patency over time in the CHF vs non-CHF group (log-rank P > .05 for all three patency measures). When stratified by preoperative left ventricular EF, patients with an EF of <50% had lower primary (38% vs 51% at 1 year), primary-assisted (76% vs 82% at 1 year), and secondary patency (86% vs 93% at 1 year) rates than those with a normal EF. Difference reached significance for secondary patency only (log-rank P = .029). AVG patency was compared against AVF patency within the CHF subgroup, with significantly lower primary-assisted (39% vs 87% at 1 year) and secondary (62% vs 95%) patency rates for AVG (P < .0001 for both). CONCLUSIONS: In this 7-year experience of hemodialysis access creation, reduced EF is associated with lower secondary patency. Preoperative CHF (including HF with reduced EF and HF with preserved EF together) is not associated with significant differences in overall hemodialysis access patency rates over time, but patients with CHF who receive AVG have markedly worse patency than those who receive AVF. For patients with end-stage renal disease and CHF, the risks and benefits must be carefully weighed, particularly for those with low EF or lack of a suitable vein for fistula creation.

Efficacy and safety associated with the use of the Surfacer® Inside-Out® Access Catheter System: Results from a prospective, multicenter Food and Drug Administration-approved Investigational Device Exemption study.

PURPOSE: Thoracic central venous obstruction is commonly associated with the use of central venous catheters. The Surfacer System to Facilitate Access in Venous Occlusions Study was an Food and Drug Administration-approved US Investigational Device Exemption study designed to evaluate the performance and safety of the Surfacer System when used to facilitate central venous access in patients with thoracic central venous obstruction. METHODS: Thirty patients were enrolled in this prospective, multicenter, single-arm study between December 2017 and May 2019. Device performance and adverse events were collected peri-procedurally and at discharge. Enrollment included 15 female and 15 male subjects with a mean age of 55.5 ± 12.9 (range: 30-79) years. Twenty-eight patients (93.3%) required central venous access for hemodialysis access. Locations of thoracic central venous obstruction were graded from 1 to 4 based on severity and extension of venous occlusions. Seven patients (23.3%) had type 1, 6 (20.0%) type 2, 16 (53.3%) type 3, and 1 (3.3%) type 4 obstruction. RESULTS: Successful central venous catheter placement was achieved in 27 of 30 patients (90.0%). The procedure was discontinued in three (10.0%) due to tortuous anatomy discovered intraprocedurally. All 27 patients with successful CVC placement achieved adequate catheter patency and tip positioning with a mean overall procedural time and time to achieve central venous access with the Surfacer System being 44.1 ± 30.6 and 19.1 ± 25.1 min, respectively. There were no device-related adverse events or catheter malposition. CONCLUSION: The results of the SAVEUS Study confirm the safety and efficacy of the Surfacer System and the Inside-Out procedure when used for the placement of right-sided central venous access in patients with thoracic central venous obstruction.

Long-term durability of Oakes salvage procedure to preserve Brescia-Cimino arteriovenous fistula.

BACKGROUND: In 2002, Oakes et al described a novel procedure designed to salvage the distal cephalic venous outflow of a Brescia-Cimino fistula by placing a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist. In this fashion, the more proximal veins were saved for future procedures. Their approach was reported and found to be successful in the short term, but the long-term durability of the Oakes procedure has not been described. This study aimed to determine the long-term primary, primary-assisted, and secondary patency rates of the brachial to distal cephalic vein Oakes procedure. METHODS: This is a retrospective review of a prospective database in a large, single institution. All patients who underwent the Oakes procedure from 1998 to 2012 were followed up to 2018. We reviewed the time to intervention, type of intervention, patency rates, and mortality of this patient population. RESULTS: Over the 5-year study period, 14 patients were identified who underwent the Oakes procedure, of whom seven (50%) were female. The average age was 55.7 years (range, 38-73 years). All patients had a previously placed Brescia-Cimino that was not suitable for dialysis but was patent. The average number of days to placement of an Oakes brachial to distal cephalic graft was 396 (range, 119-1167) days. A total of 71% (10) of patients underwent an intervention to maintain the graft, of whom 50% (5) underwent an angioplasty and 50% (5) had a thrombectomy/revision procedure. The average number of days to first intervention was 367.3 (range, 21-1048) days from Oakes placement. Of this cohort, 30% (3) of patients had a second intervention, of whom one (33%) underwent an angioplasty and two (66%) had revisions. One patient had a third and a fourth intervention at 39 days and 74 days, respectively, that were both angioplasties. The overall number of days the Oakes procedure remained usable from placement was 843.6 (range, 21-3790) days or 2.3 years. CONCLUSIONS: This study concluded that the Oakes procedure may extend the use of the distal dialysis access site by 2.3 years without increasing infection and is hence a durable solution that should be considered in patients requiring dialysis access.

Secondary interventions in patients with implantable cardiac devices and ipsilateral arteriovenous access.

OBJECTIVE: The number of patients with end-stage renal disease who require implantable cardiac devices is increasing. Rates of secondary interventions or fistula failure are not well studied in patients who have arteriovenous fistula (AVF) access placed on the ipsilateral side as a pacemaker. This study aimed to compare central vein-related interventions and failure rates of arteriovenous access in patients with pacemakers placed on the ipsilateral vs contralateral side. METHODS: A retrospective review of a prospectively collected database at a single high-volume dialysis institution was performed; all patients 18 years or older who had both arteriovenous access and a pacemaker were included. Data points included the number of interventions such as thrombectomy, percutaneous transluminal angioplasty, and stent placement, as well as time to first intervention and failure of the fistula or graft. Patients with an implantable cardiac device who had contralateral AVF access were compared with AVF ipsilateral access using a t-test and Kaplan-Meier curves for primary patency. Outcomes evaluated included number of interventions and time to intervention from access creation. RESULTS: A total of 32 patients were identified; 20 had arteriovenous access on the contralateral side from the pacemaker and 12 had access on the ipsilateral side. In the contralateral group, there were a mean of 3.6 percutaneous transluminal angioplasties per patient (range, 1-12). In the ipsilateral group, there were an average of 2.8 percutaneous transluminal angioplasties per patient (range, 1-6). There was no difference in intervention rates between these cohorts; however, the time to intervention was increased in patients who had arteriovenous access on the contralateral side to their pacemaker (9.5 vs 19.5 months; P < .05). Patency rates did not differ (P = .068). CONCLUSIONS: There was no difference in intervention rates between ipsilateral and contralateral patients; however, the time to intervention was increased in patients who had arteriovenous access on the contralateral side to their pacemaker (9.5 months vs 19.5 months). This study was limited by its lack of power. Patency rates did not differ (P = .068). Ipsilateral access placement should be considered rather than abandoning access in that extremity.

Arteriovenous Fistula and Graft Construction in Patients with Implantable Cardiac Devices: Does Side Matter?

BACKGROUND: Limited reports have documented the effect cardiac implantable electronic devices (CIEDs) have on arteriovenous (AV) access patency. Current recommendations suggest placing the access on the contralateral side of the CIEDs, as there is concern for increased central venous stenosis and access failure. The goal of this study is to review our single-center AV access patency rates for dialysis patients with an ipsilateral or contralateral side CIED. METHODS: A retrospective review was performed from 2008 to 2016 at a single institution identifying all patients who have received a CIED and the diagnosis of end-stage renal disease (ESRD). Medical records were queried to identify each patient's dialysis access and whether it was ipsilateral or contralateral to the CIED. Primary outcomes of study were primary and secondary patency rates. RESULTS: A total of 44 patients were identified to have ESRD and CIED. Of these patients, 28 patients with fistulas or grafts (13 ipsilateral and 15 contralateral) had follow-up with regards to their AV access. There were 3 primary failures in both groups. For patients who had the CIED placed after already starting the dialysis, patency was based on when the cardiac device was implanted. Primary patency for ipsilateral and contralateral access was 20.2 and 22.2 months, respectively. With secondary interventions, ipsilateral and contralateral mean patency was 39 and 48.8 months, respectively. Six-month and 1-year primary patency for arteriovenous fistula or arteriovenous graft on patients with ipsilateral access was 69.2% and 53.8%, respectively. Ipsilateral 1-year cumulative patency was 39 months. CONCLUSIONS: CIED may lead to stenosis or occlusion to one's AV access; however, primary assisted and secondary patency rates are still acceptable at 6 months and 1 year compared to Kidney Disease Outcomes Quality Initiative guidelines. Despite a CIED, a surgeon's algorithm should not lead to the abandonment of an ipsilateral access if the central venous system is patent.

Mycotic Renal Artery Aneurysm Presenting as Critical Limb Ischemia in Culture-Negative Endocarditis.

Mycotic renal artery aneurysms are rare and can be difficult to diagnose. Classic symptoms such as hematuria, hypertension, or abdominal pain can be vague or nonexistent. We report a case of a 53-year-old woman with a history of intravenous drug abuse presenting with critical limb ischemia, in which CT angiography identified a mycotic renal aneurysm. This aneurysm tripled in size from 0.46 cm to 1.65 cm in a 3-week interval. Echocardiography demonstrated aortic valve vegetations leading to a diagnosis of culture-negative endocarditis. The patient underwent primary resection and repair of the aneurysm, aortic valve replacement, and left below-knee amputation after bilateral common iliac and left superficial femoral artery stenting. At 1-year follow-up, her serum creatinine is stable and repaired artery remains patent.

Iliac artery recanalization of chronic occlusions to facilitate endovascular aneurysm repair.

INTRODUCTION: Concurrent iliac occlusion and abdominal aortic aneurysm is rare. Traditionally, the endovascular approach to these patients has consisted of aortouniiliac devices combined with femoral-femoral bypass. With improved facility of endovascular techniques, standard bifurcated endografts represent an alternative option in these patients. This study examined outcomes of patients undergoing iliac recanalization and traditional bifurcated endovascular aneurysm repair in the face of access vessel occlusion. METHODS: Outcomes of patients at three academic tertiary referral centers who underwent attempted iliac recanalization of chronic iliac occlusions and concurrent endovascular aneurysm repair of an infrarenal aortic aneurysm were retrospectively reviewed. Patients with acute iliac thrombosis and those with severely stenotic (but patent) iliac vessels were excluded. RESULTS: During a 6-year period, 15 occluded iliac arteries were treated in 14 patients (13 men). Mean age was 67.8 years (range, 52-80 years). Primary indication for intervention was disabling claudication in four patients, size of abdominal aortic aneurysm in nine, and symptomatic aneurysm in one. Seven patients presented with a unilateral common iliac artery (CIA) occlusion, four with a unilateral external iliac artery (EIA) occlusion, three with a unilateral combined CIA and EIA occlusion, and one with bilateral CIA occlusions. Stents had been placed previously in two of the occluded CIAs and in one of the occluded EIAs. Average length of the occluded segment was 7.5 cm (range, 2-17 cm). The occluded CIAs and EIAs had mean diameters of 8.6 and 5.7 mm, respectively. Successful recanalization was achieved in 14 of the 15 vessels (93.3%). One EIA ruptured during recanalization but was easily controlled with a covered stent. A re-entry device was used in two cases. Overall, 13 bifurcated devices were successfully implanted. Bilateral iliac occlusions in one patient were recanalized. One Talent (Medtronic, Santa Rosa, Calif), eight Excluder (W. L. Gore and Associates, Flagstaff, Ariz), and four Zenith (Cook Medical, Bloomington, Ind) devices were used. Mean length of stay was 2.3 days (range, 1-6 days). No major perioperative complications or deaths occurred. During a mean follow-up of 28.2 months (range, 1-86 months), there was 100% primary patency of successfully recanalized iliac arteries. Aneurysm sac size decreased from a mean of 5.1 cm (range, 3.1-7.6 cm) preoperatively to 4.4 cm (range, 2.8-7.1 cm) at follow-up. No aneurysms grew or ruptured. Three type II endoleaks occurred, one of which required coiling at 15 months. Two late deaths occurred: one at 36 months secondary to complications from a coronary artery bypass graft/mitral valve replacement and one at 34 months from a myocardial infarction. CONCLUSIONS: The use of bifurcated endovascular devices after recanalization of an occluded iliac system is technically feasible and durable at midterm follow-up. This technique re-establishes aortoiliac inflow to both lower extremities, obviates the need for extra-anatomic bypass, and may preserve hypogastric perfusion in some patients.

Thrombin injection for the treatment of mycotic gluteal aneurysm.

Gluteal aneurysms are rare entity, whose surgical or endovascular management is traditionally challenging. Infectious source being increasingly more common as the underlying etiology. We herein describe successful implementation of direct thrombin injection as another therapeutic option for these patients.

Spontaneous superior mesenteric artery dissection: report of 2 patients and review of management recommendations.

Spontaneous superior mesenteric artery dissection is rare and presents with variable symptomatology. Optimal treatment depends on the presentation; asymptomatic patients can be managed expectantly. Endoluminal intervention or open reconstruction is warranted in patients with persistent symptoms or intestinal ischemia. As more of these patients are identified with increasing utilization of computed tomography (CT), our understanding of the pathophysiology and best treatment will improve.

Deglutition syncope: a manifestation of vagal hyperactivity following carotid endarterectomy.

A 61-year-old man with left amaurosis fugax and bilateral >80% internal carotid artery stenoses underwent a left carotid endarterectomy. On the first postoperative day, he developed hypotension, bradycardia, and chest pain with food ingestion. He was diagnosed as having deglutition syncope and was treated with oral anticholinergics. Similar symptoms occurred when he underwent a right carotid endarterectomy. Deglutition syncope is a neurally mediated situational syncope resulting from vagus nerve over-activity. This is the first report of deglutition syncope associated with carotid endarterectomy. It is important to recognize and differentiate these symptoms from other causes of postendarterectomy hemodynamic instability.

Variations in early outcomes of endovascular aneurysm repair with alternate endograft configurations.

BACKGROUND: Most endovascular abdomincal aortic aneurysm (AAA) repairs (EVARs) performed in the United States utilize a bifurcated configuration. The purpose of this study was to examine the effect of alternate graft configurations on early outcomes during EVAR. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective EVAR for AAA from 2005 to 2007 were stratified by configuration using CPT codes. Bifurcated configurations (CPT 34802, 34803, 34804) were compared to straight configurations such as tube or aortouni-iliac grafts (CPT 34800, 34805). Preoperative risk factors, intraoperative variables, 30-day outcome measures, and length of stay were compared. Composite morbidity included patients experiencing one or more of 21 complications defined by NSQIP protocol. Student's t-test and analyses of variance were used to compare variables. RESULTS: There were 3,264 patients who underwent EVAR, including 2,864 bifurcated endografts and 400 straight endografts. Composite morbidity was greater in patients receiving straight endografts compared to those receiving bifurcated endografts (15.2% vs. 9.3%, p < 0.001). Length of stay was greater in the "straight" cohort as well (4.9 + or - 6.9 vs. 3.3 + or - 5.6, p < 0.001). There was a trend toward increased mortality in the "straight" cohort, but it did not reach statistical significance (2% vs. 0.9%, p = 0.054). After controlling for the top 11 NSQIP predictors of mortality in vascular patients, graft configuration remained significant in the multivariable analysis for morbidity (odds ratio [OR] = 1.55, 95% confidence interval [CI[ 1.13-2.12, p = 0.006) and length of stay but not mortality (OR = 1.63, 95% CI 0.70-3.80, p = 0.263). CONCLUSION: EVAR using a tube or aortouni configuration is associated with increased complications and length of stay. These poorer outcomes may be related to factors that lead surgeons to choose these approaches.

Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization.

BACKGROUND: Little is known about the significance of blood transfusion in patients with peripheral arterial disease. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to examine the effect of intraoperative blood transfusion on the morbidity and mortality in patients who underwent lower extremity revascularization. METHODS: We analyzed data from the participant use data file containing vascular surgical cases submitted to the ACS NSQIP in 2005, 2006, and 2007 by 173 hospitals. Current procedural terminology codes were used to select lower extremity procedures that were grouped into venous graft, prosthetic graft, or thromboendarterectomy. Thirty-day outcomes analyzed were (1) mortality, (2) composite morbidity, (3) graft/prosthesis failure, (4) return to the operating room within 30 days, (5) wound occurrences, (6) sepsis or septic shock, (7) pulmonary occurrences, and (8) renal insufficiency or failure. Intraoperative transfusion of packed red blood cells was categorized as none, 1 to 2 units, and 3 or more units. Outcome rates were compared between the transfused and nontransfused groups using the chi(2) test and multivariable regression adjusting for transfusion propensity, comorbid and procedural risk. RESULTS: A total of 8799 patients underwent lower extremity revascularization between 2005 and 2007. Mean age was 66.8 +/- 12.0 years and 5569 (63.3%) were male. Transfusion rates ranged from 14.5% in thromboendarterectomy patients to 27.1% in prosthetic bypass patients (P < .05). After adjustment for transfusion propensity and patient and procedural risks, transfusion of 1 or 2 units remained significantly predictive of mortality, composite morbidity, sepsis/shock, pulmonary occurrences, and return to the operating room. The adjusted odds ratios for 30-day mortality ranged from 1.92 (95% confidence interval [CI] 1.36-2.70) for 1 to 2 units to 2.48 (95% CI 1.55-3.98) for 3 or more units. CONCLUSION: In a large number of patients undergoing lower extremity revascularization, we have found that there is a higher risk of postoperative mortality, pulmonary, and infectious complications after receiving intraoperative blood transfusion. Additional studies are necessary to better define transfusion triggers that balance the risk/benefit ratio for blood transfusion.

Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms.

BACKGROUND: The mortality of ruptured abdominal aortic aneurysm (rAAA) has decreased 3.5% per decade in the last 50 years to a current rate of 40%-50%. Reports have indicated that endovascular repair (EVAR) is feasible for rAAA and may offer potential benefits over open repair. We examined the National Surgical Quality Improvement Program (NSQIP) database to compare 30-day multicenter outcomes for EVAR vs open rAAA repair. METHODS: Patients that underwent rAAA repair in the NSQIP database from 2005 to 2007 were identified through a combination of Current Procedural Terminology (CPT) codes and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses. Preoperative comorbidities, operative duration and transfusion, and 30 day outcomes were evaluated using t tests or Chi-squared tests depending on the variable. A separate multivariable regression was performed for each outcome adjusting for all independently predictive preoperative and intraoperative risk factors. RESULTS: A total of 427 patients were identified and 76.8% of patients underwent open repair. The open repair groups exhibited lower albumin levels and higher percentage of patients with preoperative hematocrit (Hct) <38% and need for preoperative ventilation. The requirement for preoperative blood transfusion was similar. Patients undergoing open repair had much higher intraoperative transfusion requirements (11.8 +/- 8.9 vs 4.2 +/- 6.0 red blood cell units, P < .001). After adjustment for preoperative mortality risk factors, the mortality risk was higher for open repair versus EVAR (odds ratio 1.67, 95% confidence interval [CI] 0.91-3.05, P = .096) but did not reach significance. After similar adjustment the composite morbidity odds ratio for open repair versus EVAR was 1.82 (95% CI 1.11-2.99, P = .018) and the pulmonary adverse events odds ratio was 1.99 (95% CI 1.22-3.25, P = .006). Risks for the other outcomes were not significant. CONCLUSIONS: Composite 30-day morbidity risk is lower after EVAR vs open repair of rAAA. Open repair is associated with increased transfusion requirements. Performance of EVAR in rAAA patients with favorable anatomy could potentially result in improved outcome as compared with open repair.

Gender and 30-day outcome in patients undergoing endovascular aneurysm repair (EVAR): an analysis using the ACS NSQIP dataset.

PURPOSE: Prior studies have demonstrated higher in-hospital mortality in women undergoing open abdominal aortic aneurysm repair. The current study evaluates the relationship between gender and 30-day outcomes for endovascular aneurysm repair (EVAR) in a multicenter, contemporary patient population. METHODS: Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file that underwent EVAR of abdominal aortic aneurysm (AAA) from 2005 to 2007 were identified by CPT codes. Outcomes analyzed were 30-day mortality, morbidity (one or more of 21 complications defined by the ACS NSQIP protocol), length of hospital stay, and six complication subgroups. Preoperative risk factors, intraoperative variables, and outcomes were compared across genders using chi(2) (binary and categorical variables) and t tests (continuous variables). The relationship of gender to outcomes was further evaluated using multivariate logistic regressions to adjust for pre- and intraoperative risk variables. RESULTS: In 3662 EVAR patients, 647 (17.7%) were women and 3015 (82.3%) men with mean ages of 75.1 +/- 9.0 and 73.7 +/- 8.5 years (P < .001). Tube graft (360, 9.8%); bifurcated, one docking limb (1624, 44.3%); bifurcated, two docking limbs (1294, 35.3%); unibody (218, 5.9%); and aorto-uni-iliac/femoral (166, 4.4%) repairs were performed. Tube and aorto-uni-iliac/femoral grafts were more common in women (21.4% vs 12.8%, P < .001) than men, as were femoral/femoral crossovers (3.9% vs 1.8%, P = .011) and iliac or brachial exposures (2.8% vs 1.0%, P = .009). Overall morbidity and mortality were 11.9% and 2.1%, respectively. Mortality in women was significantly higher (3.4% vs 2.1%, P = .014), as was morbidity (17.8% vs 10.6%, P < .001). Of thirteen independent preoperative risk factors for mortality or morbidity, women had a higher incidence in five: emergent operation, functional dependence, recent weight loss, underweight status or morbid obesity, and severe chronic obstructive pulmonary disease (COPD). After adjustment for these variables, the odds ratio (OR) for mortality in women vs men was 1.52 (95% confidence interval [CI] 0.85-2.69, P = .157); OR for morbidity was 1.65 (95% CI 1.28-2.14, P < .001). Female gender was also found to be an independent risk factor for length of stay (Beta 0.7 days, 95% CI 0.2-1.2, P = .006), infectious complications (OR 1.49, 95% CI 1.10-2.03, P = .011), wound complications (OR 1.80, 95% CI 1.12-2.90, P = .015) and postoperative transfusion (OR 2.92, 95% CI 1.39-6.13, P = .002). CONCLUSIONS: Mortality and morbidity were higher in women than men undergoing EVAR. Multivariate analysis showed that the increased risk of mortality was related to women presenting more emergently, more debilitated (recent weight loss and functional dependence), and requiring iliac or brachial exposure. After adjustment for multiple preoperative and operative factors, women remained at significantly higher risk for the development of a broad range of complications and increased length of stay.

Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis.

Rupture of thoracic aneurysm, acute type B dissection, blunt thoracic trauma, and penetrating aortic ulcer can present with a similar clinical profile of thoracic aortic rupture. We report a meta-analysis of comparative studies evaluating endoluminal graft versus open repair of these lesions as well as the early experience from our institution. We searched the following databases for reports of endovascular versus open repair of acute descending thoracic aortic rupture: Medline/PubMed, OVID, EMBASE, CINAHL, ClinicalTrials.gov, the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. We used the random-effects model to calculate the odds ratio (OR) and 95% confidence intervals (CI) for mortality, paraplegia/paraparesis and stroke rates. Also, the medical records of the patients treated in our institution with this technique from 2000 to 2008 were reviewed. Demographics, comorbidities and operative procedure information were retrieved. Outcomes examined were mortality, paraplegia and stroke. Meta-analysis indicates that endoluminal graft repair is accompanied by lower procedure related mortality (OR 0.46, 95% CI 0.26-0.78, p=0.005) and paraplegia rates (OR 0.23, 95% CI 0.08-0.65, p=0.005), as compared to open repair. There was no difference in stroke rate between the two methods (OR 0.86, 95% CI 0.26-2.8, p=0.8). We have treated 13 patients with endoluminal stent-grafts. No conversion to open repair was necessary. Stroke rate was 15%, no patient died as a result of the stent-graft placement, one patient died as a result of massive head injury (overall 30-day mortality: 7.5%). There were no spinal cord ischemic complications. Our experience and meta-analysis indicate that thoracic endograft repair has low mortality and spinal cord complication rates for treatment of acute thoracic aortic rupture. If this method proves to be durable, it could replace open repair as the treatment of choice for these critically ill patients.

Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence of reflux.

BACKGROUND: Catheter-based minimally invasive techniques developed to treat saphenous vein insufficiency include endovenous laser and radiofrequency ablation. Their long-term results are under evaluation. A meta-analysis of trials was performed, comparing endovenous versus surgical saphenous vein ablation with focus on long-term (greater than 365 days) outcomes of recurrence of varicosities, reflux and symptomatic disease. METHODS: A systematic search of published studies reporting on the treatment of varicose veins was performed. The databases searched included Medline/PubMed, OVID, EMBASE, CINAHL, ClinicalTrials.gov, the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. Search terms included saphenous vein ligation, stripping, radiofrequency ablation, laser ablation and endovenous ablation. Reports in all languages from 1966 to 2009 were considered. The 'related articles' function was used to broaden the search. All article titles, abstracts and subject headings were screened by one reviewer for potential relevance. Abstracts of articles selected by title were read online to reduce the number of articles for full-text examination. Finally, additional titles were sought in the bibliographies of the retrieved articles. Only studies reporting outcomes after more than 365 days were selected. Analyzed outcomes included recurrence of varicosities and reflux, as documented by duplex ultrasound, and recurrence of signs and symptoms. Data extraction was performed from life tables, text or graphs. Statistical analysis was performed using the commercially available software CMA Version 2 (Biostat Inc, USA). The random effects model was used to calculate the ORs and 95% CIs. Statistical heterogeneity was evaluated using the Q value and considered present if P<0.05. RESULTS: Eight randomized controlled trials were included; these reported on 497 patients. Two hundred twenty-six patients underwent ligation and stripping and 271 underwent endoluminal thermal ablation. The mean (± SD) follow-up period was 584±182 days. There was no difference in the age and sex distribution between the groups. There was no difference in the long-term recurrence rate between the two techniques (OR 0.97, 95% CI 0.48 to 1.9, P=0.9). Statistical heterogeneity was not significant (Q value P=0.5) and publication bias was limited. CONCLUSIONS: The analysis indicates that catheter-based treatments and traditional venous stripping with high ligation have similar long-term results. Establishing preoperative criteria for each method may improve outcomes but presently neither technique appears to confer an advantage in terms of mid- to long-term freedom from recurrent symptoms.

Long-term outcome of infrapopliteal catheter-based intervention for critical limb ischemia.

CONTEXT: Percutaneous treatment of tibioperoneal occlusive disease is associated with decreased morbidity compared with bypass surgery. The long-term patency and limb salvage rates are not well documented. AIMS: To evaluate the long-term outcome of endoluminal interventions for tibioperoneal lesions. METHODS: A retrospective study was performed to determine the outcomes of patients undergoing infrapopliteal catheter-based intervention for critical limb ischemia. Collected data included demographics, comorbidities, clinical presentation, pre- and postintervention noninvasive vascular measurements (segmental pressure and waveforms, and ankle-brachial index [ABI]), type of intervention, limb loss rate, patient follow-up and need for surgical revascularization. Statistical analysis was performed with the two-tailed t test. P<0.05 was considered significant; results were reported as mean ± SD. Cox regression analysis and Kaplan-Meier limb survival analysis were performed to demonstrate freedom from amputation over time. RESULTS: Thirty-five patients underwent intervention from 2003 to 2008; technical success was achieved in 26 patients (75%). Arterial segmental pressure studies revealed a significant increase in ABI - preprocedure ABI was 0.62±0.24 versus a postintervention ABI of 0.81±0.29 (P=0.02). The limb salvage rate was 63% during the follow-up period. Limb salvage was better for patients who underwent isolated infrapopliteal intervention versus combined above and below the knee intervention. CONCLUSION: Percutaneous interventions for tibioperoneal occlusive disease offer an acceptable limb salvage rate and may be the preferred initial treatment for critical limb ischemia.

Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture.

OBJECTIVES: Traumatic thoracic aortic injuries are associated with high mortality and morbidity. These patients often have multiple injuries, and delayed aortic repair is frequently used. Endoluminal grafts offer an alternative to open surgical repair. We performed a meta-analysis of comparative studies evaluating endovascular vs open repair of these injuries. METHODS: A systematic search of studies reporting treatment of traumatic aortic injury was performed using the following databases: Medline/PubMed, CINAHL, Proquest, Up to Date, Database of Abstracts of Reviews of Effects (DARE), ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Search terms were thoracic aortic trauma, traumatic thoracic aortic injury, traumatic aortic rupture, stent graft repair, and endovascular repair. Outcomes analyzed were procedure-related mortality, overall 30-day mortality, and paraplegia/paraparesis rate using odds ratios (OR) and 95% confidence intervals (CI). Publication bias was investigated using funnel plots. Assessment of homogeneity was performed using the Q test; statistical heterogeneity was considered present at P < .05. Weighted averages of age, interval to repair, and injury severity score were compared with the Welch t test; P < .05 was considered statistically significant. RESULTS: Seventeen retrospective cohort studies from 2003 to 2007 were included. All were nonrandomized; no prospective randomized trials were found. These studies reported on 589 patients; 369 were treated with open repair, and 220 underwent thoracic stent graft placement. There was no significant difference in age (mean 38.8 years for both) or interval to repair (mean 1.5 days for endoluminal repair; 1 day for open repair). Injury severity score was higher for patients undergoing endoluminal repair (mean, 42.4 vs 37.4 for open repair, P < .001). Procedure-related mortality was significantly lower with endoluminal repair (OR, 0.31; 95% CI, 0.15-0.66; P = .002). Overall 30-day mortality was also lower after endoluminal repair (OR, 0.44; 95% CI, 0.25-0.78; P = .005). Sixteen studies reported data for postoperative paraplegia; 215 patients were treated with endograft placement and 333 with open repair. The risk of postoperative paraplegia was significantly less with endoluminal repair (OR, 0.32; 95% CI, 0.1-0.93; P = .037). The Q test did not indicate significant heterogeneity for the outcomes of interest; publication bias was limited. CONCLUSIONS: Meta-analysis of retrospective cohort studies indicates that endovascular treatment of descending thoracic aortic trauma is an alternative to open repair and is associated with lower postoperative mortality and ischemic spinal cord complication rates.

Endovascular retrieval of an intraaortic greenfield vena cava filter.

Aberrant placement of vena cava filters has been documented. Only one case of intraaortic deployment, in which the filter was left at the aortic bifurcation with no adverse effects over a 4-year follow-up period, has been reported. We describe the endovascular retrieval of an intraaortic Greenfield filter using a snare and large sheath to protect the aortic intima from injury during removal of the device.

The trifurcated endograft technique for hypogastric preservation during endovascular aneurysm repair.

Bilateral common iliac artery involvement remains a significant challenge for endovascular aneurysm repair. We describe a technique to overcome this obstacle that we have termed the trifurcated endograft. The technique involves the deployment of a second bifurcated endoprosthesis into an iliac limb to create a three-limbed graft. The third limb is then used as the origin for an extension into one hypogastric artery.