Journal of Vascular Surgery - Articles in Press

Volume changes in aortic true and false lumen after the “PETTICOAT” procedure for type B aortic dissection - Corrected Proof

2012-01-30

Background: The PETTICOAT (Provisional ExTension to Induce COmplete ATtachment) technique may be employed during endovascular treatment of type B aortic dissection (TBD) using self-expandable bare stents distal to the covered stent graft placed over the proximal entry tear. The aim of this study is to evaluate the volume changes of the true (TL) and false lumen (FL) on computed tomography (CT) scans. Methods: Since 2005, 25 selected patients received endovascular treatment for complicated TBD with the PETTICOAT technique employing the Zenith Dissection Endovascular System (William Cook Europe, Bjaerverskov, Denmark). Indications to the use of the PETTICOAT technique were the evidence of clinical manifest dynamic malperfusion in five cases (20%) and/or radiologic evidence of TL collapse in 20 cases (80%). Five patients were treated within 2 weeks from onset, 13 patients between 2 weeks and 3 months, and seven patients over 3 months after the initial acute event. The volumetric analysis of the changes of TL and FL obtained from CT scan performed before endovascular treatment of TBD, postoperatively and yearly thereafter were analyzed using the OsiriX software v 3.9 (Pixmeo sarl, Bernex, Switzerland). Results: Initial clinical (30 days) and midterm clinical success was observed in 21 cases (84%) and in 23 cases (92%), respectively. The volumes of the aortic TL and FL were evaluated at 30 days and midterm follow-up (mean, 38 ± 17 months). The following TL volumes were recorded: baseline 84 ± 29 cm3, postoperative 167 ± 31 cm3 (+98%), 1 year 193 ± 46 cm3 (+131%), and 2 years 216 ± 54 cm3 (+140%). The following FL volumes were recorded: baseline 332 ± 86 cm3, postoperative 286 ± 85 cm3 (−14%), 1 year 233 ± 81 cm3 (−30%), and 2 years 248 ± 112 cm3 (−32%). Progressive remodeling of the TL was recorded over time in both thoracic and abdominal segments with shrinkage of the FL mainly in the thoracic segment. Conclusions: These data provide insight into potential therapeutic benefit of the PETTICOAT technique. A significant immediate increase in TL could be achieved with resolution of all cases of dynamic malperfusion and TL collapse. A different behavior of volumes in the thoracic and abdominal segments was observed.

Elevated cardiac troponin T contributes to prediction of worse in-hospital outcomes after endovascular therapy for acute limb ischemia - Corrected Proof

2012-01-27

Introduction: The present study evaluated whether elevated cardiac troponin T (cTnT) was predictive of an increased risk for death or amputation in patients with acute lower limb ischemia (ALI). ALI is one of the most frequent causes of amputation, with mortality rates for ALI ranging from 15% to 20%. Methods: This study included 254 consecutive ALI patients (155 men, 99 women; mean age, 71.6 ± 13.2 years) presenting with Rutherford categories I, IIA, or IIB according to the classification for ALI. Results: ALI was caused by thromboembolism (29.5%), local arterial thrombosis (53.1%), or bypass graft occlusion (16.9%). Restoration of arterial blood flow was obtained by an endovascular approach, with a primary success rate of 98.4%. Rates were low for in-hospital mortality (3.9%) and amputation (5.1%). Patients who died or required amputation more frequently presented with elevated cTnT ≥0.01 ng/mL (52.2% vs 25.5%, P = .01) and impaired renal function (chronic kidney disease stage 3-5; 60.9% vs 38.1%; P = .04). After controlling for age, sex, C-reactive protein, renal function, presence or absence of coronary artery disease, and traditional vascular risk factors, as well as the interval between symptom onset and revascularization, the relationship between cTnT and a worse in-hospital outcome remained significant (hazard ratio, 3.4; 95% confidence interval, 1.3-8.5; P = .010). Conclusions: ALI patients frequently have elevated cTnT, which is associated with increased in-hospital mortality and amputation. Even small cTnT elevations predict a markedly increased risk of worse in-hospital outcome; however, the overall mortality and amputation rate in our study was low.

Intraoperative blood product resuscitation and mortality in ruptured abdominal aortic aneurysm - Corrected Proof

David S. Kauvar, Mark R. Sarfati, Larry W. Kraiss — 2012-01-27

Objectives: The resuscitation of patients with ruptured abdominal aortic aneurysms (RAAAs) has not been well studied, and the potential benefit of autotransfusion (AT) is unknown. The increased use of fresh-frozen plasma (FFP) has been associated with decreased mortality rates in trauma patients and may also improve RAAA survival. We explored the influence of intraoperative AT and FFP resuscitation on mortality rates in massively transfused RAAA patients. Methods: A single-center review of RAAA patient records from April 1989 to October 2009 was undertaken. Clinical data and outcomes were studied. Operative and anesthesia records were queried for intraoperative transfusion totals. Massive transfusion was defined as ≥10 units of red blood cells (RBCs) inclusive of AT units. Results: We identified 151 RAAA patients, of which 89 (60%) received a massive transfusion and comprised the study population. These 89 patients had an in-hospital mortality rate of 44%. Univariate predictors of mortality included increased age, preoperative hypotension, operative blood loss, and crystalloid, RBCs, and FFP volume. AT was used in 85 patients, with an increased ratio of AT:RBC units associated with survival. Mortality was 34% with AT:packed RBCs (PRBC) ≥1 (high AT) and 55% with AT:PRBC of <1 (low AT; P = .04). On multivariate analysis, age > 74 years (P = .03), lowest preoperative systolic blood pressure (SBP) <90 mm Hg (P = .06), blood loss >6 liters (P = .06), and low AT (P = .02) independently predicted mortality. The mean RBC:FFP ratio was similar in those that died (2.7) and in those that lived (2.9; P = .66). RBC:FFP ≤2 (high FFP) was present in 38 (43%) patients, with mortality of 49%. RBC:FFP >2 (low FFP) had 40% mortality (P = .39). RBC:FFP ratios decreased over time from 3.6 (years 1989 to 1999) to 2.2 (years 2000 to 2009; P < .001), but more liberal use of FFP was not associated with decreased mortality (47% vs 41%; P = .56). AT:PRBC ratios were stable over time (range, 1.4-1.2; P = .18). Conclusions: Greater use of AT but not of FFP was associated with survival in massively transfused RAAA patients. No mortality benefit was seen with increased FFP, but few patients had high FFP transfusion ratios. Further study to identify RAAA patients at risk for massive transfusion should be undertaken and a potentially greater role for AT in RAAA resuscitation investigated.

Postthrombotic morbidity correlates with residual thrombus following catheter-directed thrombolysis for iliofemoral deep vein thrombosis - Corrected Proof

2012-01-27

Background: Iliofemoral deep vein thrombosis (DVT) is associated with severe postthrombotic morbidity when treated with anticoagulation alone. Catheter-directed thrombolysis (CDT), with or without the addition of mechanical techniques, is increasingly recommended for patients with iliofemoral DVT, although its effect on postthrombotic syndrome is not established. This study examined the correlation of residual thrombus with postthrombotic syndrome after catheter-based attempts at thrombus removal in patients with iliofemoral DVT. Methods: Seventy-one consecutive patients with iliofemoral DVT were treated with CDT. Pretreatment and posttreatment phlebograms were evaluated for quantity of residual thrombus by physicians blinded to clinical patient outcomes. Postthrombotic syndrome was assessed using CEAP and Villalta scores by examiners blinded to phlebographic results. Patients were grouped by the amount of residual thrombus in treated vein segments (group 1, ≤50%; group 2, >50%). Clinical score and postthrombotic outcomes were plotted vs residual thrombus. Results: Sixty-three of 71 patients completed CEAP and Villalta analyses. Groups 1 and 2 had median CEAP scores of 1 and 4 (P = .025) and mean Villalta scores of 2.21 and 7.13, respectively (P = .011). There was a direct and significant correlation of clinical class of CEAP with residual thrombus (R2 = .74; P = .004) and a direct linear correlation of Villalta score with residual thrombus (R2 = .61; P = .0014). Conclusion: In patients with iliofemoral DVT treated with catheter-based techniques of thrombus removal, postthrombotic morbidity is related to residual thrombus. When thrombus clearance was complete, the postthrombotic syndrome was avoided. Residual thrombus is associated with an increasing risk of postthrombotic syndrome.

Increased activation of the hypoxia-inducible factor pathway in varicose veins - Corrected Proof

Chung S. Lim, Serafim Kiriakidis, Ewa M. Paleolog, Alun H. Davies — 2012-01-27

Background: Venous hypoxia has been postulated to contribute to varicose vein (VV) formation. Direct measurements of vein wall oxygen tension have previously demonstrated that the average minimum oxygen tensions were significantly lower in VVs compared with non-varicose veins (NVVs). Hypoxia-inducible factors (HIFs) are nuclear transcriptional factors that regulate the expression of several genes of oxygen homeostasis. This study aimed to investigate if hypoxia was associated with VVs by assessing the expression of HIF-1α, HIF-2α, HIF target genes, and upstream HIF regulatory enzymes in VVs and NVVs, and their regulation by hypoxia. Methods: VVs and NVVs were surgically retrieved and immediately snap-frozen or used for organ culture preparation. The relative expression of HIF-1α, HIF-2α, HIF target genes, and HIF regulatory enzymes in VVs and NVVs was analyzed with quantitative polymerase chain reaction (Q-PCR) and Western blot. VV and NVV organ ex vivo cultures were exposed to 16 hours of normoxia, hypoxia (oxygen tension 1%), or the hypoxia mimetic dimethyloxallyl glycine (DMOG) 1 mM in normoxia. The vein organ cultures were then analyzed for HIF-1α, HIF-2α, and their target gene expression with Q-PCR and Western blot. Results: HIF-1α and HIF-2α mRNA were significantly upregulated in VVs compared with NVVs (89.8 ± 18.6 vs 10.4 ± 7.2 and 384.9 ± 209.4 vs 8.1 ± 4.2, respectively). HIF target gene mRNA expression was also significantly elevated in VVs compared with NVVs, namely glucose transporter-1 (GLUT-1; 8.7 ± 2.1 vs 1.0 ± 0.3), carbonic anhydrase-9 (CA9; 8.5 ± 2.1 vs 2.8 ± 1.2), vascular endothelial growth factor (VEGF; 7.5 ± 2.1 vs 0.9 ± 0.2), and BCL2/adenovirus E1B 19-kDa protein-interacting protein 3 (BNIP-3; 4.5 ± 0.7 vs 1.4 ± 0.3). The upregulation of HIF-1α, HIF-2α, and HIF target genes in VVs was also reflected at protein level. Of the HIF regulatory enzymes, the expression of prolyl-hydroxylase domain (PHD)-2 and PHD-3 was found to be elevated in VVs compared with NVVs. Exposure of VV and NVV organ cultures to hypoxia or DMOG was associated with increases in HIF-1α and HIF-2α protein and HIF target gene expression compared with normoxia only. Conclusion: The study concluded, we believe for the first time, an increased activation of the HIF pathway, with upregulation of the expression of HIF-1α and HIF-2α transcription factors, and HIF target genes, in VVs compared with NVVs. Exposure of VVs and NVVs to hypoxic conditions was associated with increased expression of HIF-1α and HIF-2α protein, and HIF target genes. The data suggest that the HIF pathway may be associated to several pathophysiologic changes in the VV wall, and that hypoxia may be a feature contributing to VV pathogenesis. Clinical Relevance: Varicose veins (VVs) cause debilitating symptoms, including pain, skin changes, and ulceration to patients. Despite the burden, the pathophysiology of VVs remains incompletely understood. Vein wall changes are now thought to be the primary events of VV formation. Understanding the upstream regulation of these changes may help to identify new therapeutic targets for VVs. This study examined hypoxia as a potential factor associated with VV wall changes by assessing the hypoxia-inducible factor (HIF) pathway in VVs. The results demonstrate an increased activation of the HIF pathway in VVs which could be regulated by hypoxia, suggesting it as an attractive therapeutic target for the disease.

Time for radiation safety program guidelines for pregnant trainees and vascular surgeons - Corrected Proof

Palma M. Shaw, Ageliki Vouyouka, Amy Reed — 2012-01-27

Objectives: The evolution of endovascular surgery has increased the vascular surgeon's exposure to radiation, raising concern for female vascular trainees and staff of childbearing years. We developed surveys for female trainees, established vascular surgeons, and program directors in vascular surgery to determine current practices with respect to pregnancy and radiation exposure guidelines. Methods: Two surveys were conducted to evaluate radiation exposure during pregnancy. A survey of the members of the Association of Program Directors in Vascular Surgery was conducted in an attempt to gather information about existing program and institutional radiation policies and assess the need for standard guidelines. A second survey was given to women in vascular surgery in an effort to obtain opinions among concerned groups regarding establishment of a policy from women who were exposed to radiation during and after completion of vascular training. Results: Fifty-three of 181 female vascular surgeons (29% response rate) responded to the survey, with the majority (53% [28/53]) pregnant during training or practice. Though 68% of trainees and 82% of faculty performed endovascular procedures during pregnancy, only 42% of trainees and 50% of faculty wore a fetal badge. One trainee (3.7%) had complications during pregnancy that necessitated cessation of fluoroscopic procedures or limiting call. There were four practicing surgeons who had complications during their pregnancy. Of these, one was hospitalized with fetal decelerations secondary to excessive on-call obligations with double leading and heavy endovascular call coverage. The majority of women (>60%) felt supported by the program and that they were treated fairly. Over 90% of female trainees and faculty felt that establishment of guidelines for radiation safety for all vascular surgeons would be beneficial. Many (77%) felt that a policy would aid in the recruitment of talented women into the field. Thirty-two of 99 Association of Program Directors in Vascular Surgery program directors responded to the survey. Of the 32 program directors that responded (32% response rate), 75% would allow the pregnant trainee flexibility in rotation schedule. Finally, 75% of program directors support development of a national policy, and 81% would incorporate one into their program. Conclusions: There is compelling interest to establish radiation safety guidelines for the pregnant trainee or vascular surgeon. Consideration should be given at the Society leadership level to develop and support radiation safety guidelines for all vascular surgeons.

Endografts with suprarenal fixation do not perform better than those with infrarenal fixation in the treatment of patients with short straight proximal aortic necks - Corrected Proof

2012-01-27

Objectives: To determine if there are any differences in outcomes between infrarenal fixation (IF) and suprarenal fixation (SF) endograft systems for the endovascular treatment (endovascular aneurysm repair [EVAR]) of abdominal aortic aneurysms (AAAs) with short, straight proximal aortic necks (<1.5 cm). Methods: A retrospective review of 1379 EVAR procedures was performed between the years of 2002 and 2009 at a single institution. The charts and radiographic images of all patients were reviewed. Patients who underwent EVAR with AAA morphology with short proximal necks were stratified into two groups: IF, Gore Excluder (W. L. Gore, Flagstaff, Ariz) group and SF, Cook Zenith (Cook, Bloomington, Ind) group. The primary endpoint for the study was the presence of proximal type 1 endoleaks. Secondary endpoints were graft migration at 1- and 2-year follow-up and aneurysm sac regression. The groups' demographics and comorbidities were also compared. Results: A total of 1379 EVARS were performed during the study period and 84 were identified as having a short proximal aortic neck. Sixty patients were in the IF group and 24 in the SF group. The average follow-up period was 18.6 months (IF) and 18.5 months (SF). There was no difference in the average proximal neck length (1.19 cm IF vs 1.14 cm SF; P = not significant [NS]) or the preoperative AAA size (5.8 cm IF vs 5.9 cm SF; P = NS). There were no significant differences in age (76.6 years IF vs 74.8 years SF; P = .32), gender (IF 66.7% vs SF 21.88% men; P = .053), or length of stay (2.2 days IF vs 1.9 days SF; P = .39). The comorbidities (diabetes, hypertension, and warfarin use) were also similar. There were five type 1a endoleaks in group IF and one in group SF (P = .44) identified at the 1-month follow-up, however, only one patient in the IF group underwent intervention for enlargement of the AAA sac. At 1 year, there was persistence of one type 1a endoleak in both groups, but were deemed dead-end leaks as they did not fill the sac nor lead to aneurysm growth. There were no migrations (>0.5 cm) noted in either group. Sac regression was observed at an average rate of 0.24 cm/year in the IF group and 0.26 cm/year in the SF group (P = NS). There were no aneurysm ruptures during the study period. Conclusion: There are no significant differences in endograft migration or in the incidence of early and late type 1a endoleaks between endografts that use IF (Gore Excluder) and SF (Cook Zenith) fixation for patients with short aortic necks undergoing EVAR.

Endovascular repair of a traumatic arteriovenous fistula involving the iliac bifurcation using an iliac branch device - Corrected Proof

2012-01-27

Endovascular techniques have shown to be useful in the management of vascular injuries because they transform a complex and potentially dangerous procedure into a safe one. We present the case of a 39-year-old man with congestive heart failure and abdominal bruit 11 years after an abdominal gunshot wound. Imaging studies revealed an arteriovenous fistula involving the left iliac artery bifurcation, and an iliac branch device was used to treat it. Symptoms resolved, and follow-up imaging showed patency of the graft and closure of the arteriovenous communication. To our knowledge, this is the first report of a nonaneurysmal disease treated with this device.

The use of a silicon sheet for gradual wound closure after fasciotomy - Corrected Proof

Tobias Walker, Miriam Gruler, Gerhard Ziemer, Dorothee H.L. Bail — 2012-01-27

We present a silicon sheet for temporary wound covering and gradual wound closure after open fasciotomy. Fasciotomy was performed in a total of 70 limbs with compartment syndrome (CS). The main etiology of CS was predominantly vascular. All patients were treated with a silicon sheet to cover the soft tissue defect and gradually reapproximate the skin margins. In 53% of the patients, a delayed final wound closure was achieved after a mean of 11.9 days. This method allows final closure of fasciotomy wounds without scar contractures, marginal necrosis, infection, or significant pain.

Longitudinal changes in kidney parenchymal volume associated with renal artery stenting - Corrected Proof

2012-01-24

Objective: This study assessed the longitudinal changes in renal volume after renal artery stenting (RAS) to determine if renal mass is preserved by stenting. Methods: The study cohort consisted of 38 patients with longitudinal imaging available for renal volume quantification before and after RAS. Renal volume was estimated as (kidney length) × (width) × (depth/2) based on preoperative renal imaging. For each patient, the clinical response of blood pressure (BP) and renal function to RAS was categorized according to modified American Heart Association guidelines. Changes in renal volume were assessed using paired nonparametric analyses. Results: The cohort was a median age of 69 years (interquartile range [IQR], 60-74 years). A favorable BP response was observed in 11 of 38 patients (28.9%). At a median interval between imaging studies of 21 months (IQR, 13-32 months), ipsilateral renal volume was significantly increased from baseline (146.8 vs 133.8 cm3;P = .02). This represents a 6.9% relative increase in ipsilateral kidney volume from baseline. A significant negative correlation between preoperative renal volume and the relative change in renal volume postoperatively (r = −0.42; P = .0055) suggests that smaller kidneys experienced the greatest gains in renal volume after stenting. It is noteworthy that the 25 patients with no change in BP or renal function—clinical failures using traditional definitions—experienced a 12% relative increase in ipsilateral renal volume after RAS. Multivariate analysis determined that stable or improved renal volume after stenting was an independent predictor of stable or improved long-term renal function (odds ratio, 0.008; 95% confidence interval, 0.000-0.206; P = .004). Conclusions: These data lend credence to the belief that RAS preserves renal mass in some patients. This benefit of RAS even extends to those patients who would be considered treatment failures by traditional definitions. Patients with stable or increased renal volume after RAS had more stable renal function during long-term follow-up, whereas patients with renal volume loss after stenting were prone to deterioration of renal function.

Discussion - Corrected Proof

2012-01-24

Dr Astrid Moise (Cleveland, Ohio). I would like to thank the Society and Dr Modrall and his group for the opportunity to review this manuscript. In a retrospective study of 38 patients, the authors sought to assess the longitudinal changes in renal volume after renal artery stenting in an attempt to determine if renal mass is preserved by stenting. As we know, a number of studies have stated that renal artery stenting does not have any benefit, but we do know that in a certain subset of patients it does. So I believe this is a very important study to help further elucidate this.

The accuracy of computed tomography central luminal line measurements in quantifying stent graft migration - Corrected Proof

2012-01-24

Purpose: This study evaluated the accuracy of central luminal line (CLL) measurements in quantifying stent graft migration. The bias of the CLL technique together with observer variability were assessed. Methods: Stent grafts were deployed in plastic aortic phantoms at fixed locations from two side branches. Each phantom was filled with iodinated contrast, and a 2-mm multislice computed tomography (CT) scan was performed. The stent graft was then displaced caudally, its new location determined, and again, a CT scan performed. This created a series of 15 cases with known stent graft migration. CLLs were used to measure stent graft position on the CT scans and calculate migration (3 observers). In vivo stent graft migration was then evaluated in a similar manner using a series of follow-up CT scans from nine patients (2 observers). All CLL measurements were performed independently and were repeated on a separate occasion. Results: The mean difference in CLL migration between the actual and observed measurements (bias) in the aortic phantoms was <1 mm. The 95% confidence intervals for the bias were within the interval (−1 and 1 mm), and the 95% limits of agreement were within −3 mm and +3 mm. The 95% limits of agreement for measurements within and between observers were −4 to 2 mm and −2 to 2 mm, respectively. The phantom study generated a coefficient of repeatability (RC) of 1 mm for within-observer measurements. Clinically, CLLs generated 95% limits of agreement within and between observers of −3 to 4 mm (RC, 2 mm) and −3 to +3 mm, respectively. Conclusions: Bias from CLL-determined migration is small and insignificant from a practical point of view. A small amount of measurement variability within and between observers does exist; it should be feasible to detect changes in stent graft position that are ≥4 mm.

Pararenal aortic aneurysm repair using fenestrated endografts - Corrected Proof

2012-01-24

Objective: We performed a systematic review of the current literature to analyze the immediate and follow-up results of fenestrated endovascular aortic aneurysm repair (F-EVAR) in patients with pararenal abdominal aortic aneurysms (AAAs). Methods: The Medline, Embase, and Cochrane databases were searched to identify all studies reporting F-EVAR of pararenal AAAs published between January 2000 and May 2011. Two independent observers selected studies for inclusion, assessed the quality of the included studies, and performed the data extraction. Studies were selected based on specific predefined criteria. Outcomes were technical success (successfully completed procedure with endograft patency, preservation of target vessels, and no evidence of type I or III endoleak at postprocedural imaging), 30-day mortality, all-cause mortality, branch vessel patency, renal impairment, and secondary interventions. Between-study heterogeneity was calculated using I2 statistics. Pooled estimates were calculated using a fixed-effects (I2 <25%) or a random-effects (I2 >25% to <50%) model. Results: Nine studies were included reporting 629 patients who underwent F-EVAR for a pararenal AAA, of which 1622 target vessels were incorporated in an endograft design. Between-study heterogeneity was ≤41% for all outcomes. The pooled estimate (95% confidence interval [CI] was 90.4% (87.7%-92.5%) for technical success, 2.1% (1.2%-3.7%) for 30-day mortality, and 16% (12.5%-20.4%) for all-cause mortality. Follow-up was 15 to 25 months. The pooled estimate (95% CI) during follow-up was 93.2% (90.4%-95.3%) for branch vessel patency, 22.2% (16%-30.1%) for renal impairment, and 17.8% (13.5-22.6%) for secondary interventions. Conclusions: Promising immediate and midterm results (up to 2 years) support F-EVAR as a feasible, safe, and effective treatment in a relatively high-risk cohort of patients with pararenal AAAs.

Comparison of aortic neck dilatation after open and endovascular repair of abdominal aortic aneurysm - Corrected Proof

2012-01-24

Objective: This study evaluated the changes of the aortic diameter at the suprarenal and infrarenal segment after open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). Methods: This was a retrospective analysis of all patients undergoing AAA repair between 1997 and 2008. Inclusion criteria were at least 3 months of follow-up at our institution, elective aneurysm repair, and absence of false, mycotic, or inflammatory aneurysms. For EVAR, standard computed tomography (CT) scans from follow-up were used; in the OR group, CT scans performed for unrelated nonvascular indications were used. Diameters of the aorta were measured at the first slice below the lowest renal artery and at the first slice above the highest renal artery. A 2-mm change was defined as measurable aortic neck dilatation. Results: Inclusion criteria were met by 46 patients in the OR group and 103 in the EVAR group. After a follow-up of 34.1 months (range, 5.5-131.7 months) in the OR group and 39.4 months (range, 3-108.9 months) in the EVAR group, the mean changes were 1.75 ± 3.50 mm (OR) and 0.9 ± 2.3 mm (EVAR; P = .305) in the suprarenal diameters and 0.8 ± 2.9 mm (OR) and 1.2 ± 2.5 mm (EVAR; P = .311) in the infrarenal diameters. The absolute suprarenal vs infrarenal sizes were 29.7 ± 7.1 and 28.7 ± 6.8 mm in the OR group and 28.7 ± 3.2 and 28.5 ± 3.6 mm, respectively, in the EVAR group (suprarenal, P = .749; infrarenal, P = .273). Increase of the aortic diameter >2 mm, defined as aortic neck dilatation, was found in 23 of 103 EVAR patients (22.3% ± 0.862%), and in nine of 46 OR patients (19.57% ± 0.484%; P = .870). Increase in the suprarenal change >2 mm occurred in 21 of 103 EVAR patients (20.39% ± 1.04%) group and in 14 of 46 OR patients (30.4% ± 0.446%; P = .260). Reintervention rate of patients with an increase >2 mm was 31% (seven of 23) in EVAR and 11.1% (one of nine) in the OR group (P = .386). Conclusions: The AAA groups treated with EVAR or OR demonstrated similar increases of aneurysmal neck diameters. This suggests that aortic neck dilatation may be caused by a natural progression of the disease rather than by deviating therapeutic strategies.

Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair - Corrected Proof

2012-01-24

Purpose: Retrograde ascending aortic dissection (rAAD) is a potential complication of thoracic endovascular aortic repair (TEVAR), yet little data exist regarding its occurrence. This study examines the incidence, etiology, and outcome of this event. Methods: A prospective institutional database was used to identify cases of acute rAAD following TEVAR from a cohort of 309 consecutive procedures from March 2005 (date of initial Food and Drug Administration approval) to September 2010. The database was analyzed for the complication of rAAD as well as relevant patient and operative variables. Results: The incidence of rAAD was 1.9% (6/309); all cases occurred with proximal landing zone in the ascending aorta and/or arch (zones 0-2). All were identified in the perioperative period (range, 0-6 days) with 33% (2/6) 30-day/in-hospital mortality. Eighty-three percent (5/6) underwent emergent repair; one patient died without repair. rAAD patients were similar to the non-rAAD group (n = 303) across pertinent variables, including age, gender, race, and device size (all P > .1). rAAD incidence by aortic pathology was 1.0% (2/200) for aneurysm, 4.4% (4/91) for dissection, and 0% (0/18) for transection; P = .08. rAAD incidence by device was TAG (Gore) 1.0% (2/205), Talent (Medtronic) 4.7% (2/43), and Zenith TX2 (Cook) 3.6% (2/55). rAAD incidence was observed to be higher among patients with an ascending aortic diameter ≥4.0 cm (4.8% vs 0.9% for ascending diameter <4.0 cm); P = .047. Incidence was also higher with proximal landing zone in the native ascending aorta (zone 0) 6.9% (2/29) versus 1.4% for all others (4/280); P = .101. For patients with dissection pathology and an ascending aortic diameter ≥4.0 cm, 11% (3/28) suffered rAAD; with the combination of native ascending aorta (zone 0) landing zone measuring ≥4.0 cm, the incidence was 25% (2/8). Definitive diagnosis was by computed tomography angiography (n = 1), intraoperative transesophageal echocardiography (n = 3), intraoperative arteriography (n = 1), or postmortem autopsy (n = 1). Conclusions: rAAD is a lethal early complication of TEVAR, which may be more common when treating dissection, with devices utilizing proximal bare springs or barbs for fixation, with native zone 0 proximal landing zone and with ascending aortic diameter ≥4 cm. Combinations of these risk factors may be particularly high risk. Intraoperative imaging assessment of the ascending aorta should be conducted following TEVAR to avoid under-recognition. National database reporting of this complication is needed to ensure safety and proper application of emerging TEVAR technology.

Endovascular retrieval of a dislodged femoral arterial closure device with Alligator forceps - Corrected Proof

2012-01-24

The Angio-Seal (St. Jude Medical, Minnetonka, Minn) is a frequently used percutaneous femoral artery closure device to obtain hemostasis after arterial catheterization. Separation and migration of the device, leading to distal embolization and limb-threatening ischemia necessitating emergency surgery, is reported but extremely rare. We present a unique case of successful endovascular bailout management of a dislocated Angio-Seal with use of an Alligator Tooth Retrieval forceps (Cook Medical, London, United Kingdom).

Ultrasound-guided angioplasty of autogenous arteriovenous fistulas in the office setting - Corrected Proof

Daniel R. Gorin, Lisa Perrino, Donna M. Potter, Tarik Z. Ali — 2012-01-24

Objectives: There has been an increasing awareness of the superiority of native arteriovenous fistulas (AVFs) over prosthetic grafts for dialysis access. Many AVFs fail to mature, however, and others develop stenosis while in use. There is growing experience in treating these patients in the interventional suite with percutaneous balloon angioplasty. These procedures, however, are expensive, uncomfortable, and inconvenient for patients and physicians, and involve exposure to radiation and intravenous contrast in patients who are often not on dialysis. This study reviews our experience with ultrasound-guided angioplasty of AVFs in the office setting. Methods: A retrospective review was performed of all patients treated in our practice with ultrasound-guided AVF angioplasty, from May 2009 to April 2011. The need for intervention was determined by examination and duplex ultrasound. All patients referred to the practice with failing or nonmaturing AVFs were treated in the office under ultrasound guidance, unless a central venous stenosis was suspected. All procedures were performed with the patient under local anesthesia by a single surgeon, and preprocedure, periprocedure, and postprocedure ultrasounds were performed in a single vascular laboratory. Results: There were 31 AVFs in 30 patients in the study. Fifty-five interventions were performed, 48 for AVFs failing to mature and seven for stenosis in functioning AFVs. The 90-day patency was 93%. The overall complication rate was 11%. Two patients had proximal stenosis that could not be crossed, (one patient required surgical revision and one patient refused further treatment and thrombosed). There were four perifistular hematomas; three of these resulted in AFV thrombosis. No patients required hospitalization or urgent surgical intervention. Eighty-five percent of patients treated for AVF failing to mature achieved a functional fistula. Conclusion: AVF intervention can be performed safely and effectively under ultrasound guidance in the office setting, and is a valuable tool in the management of dialysis access patients.

A morphologic study of chronic type B aortic dissections and aneurysms after thoracic endovascular stent grafting - Corrected Proof

Kai-xiong Qing, Wai-ki Yiu, Stephen W.K. Cheng — 2012-01-18

Background: The long-term results of treating chronic aortic dissections and aneurysms in association with dissections with thoracic endovascular aortic repair (TEVAR) are unknown, and the timing for intervention is uncertain. We evaluated the morphology of stent graft and aorta remodeling and the volumetric changes in these patients after successful TEVAR. Methods: Serial computed tomography scans of 32 patients who underwent TEVAR for uncomplicated chronic dissections (group A, n = 17) and chronic dissections with aneurysms (group B, n = 15) were analyzed at 1, 6, 12, and 36 months. Stent graft diameter changes and positional migration were assessed 3-dimensionally using Mimics 14.0 (Materialize, Leuven, Belgium). Volumetric data for true lumen, false lumen, thrombus load, and aortic size were measured by Aquarius iNtuition 4.4 software (TeraRecon, San Mateo, Calif). Results were compared between the two groups and with stent graft diameter, length, and oversizing. Results: Aortic stent grafts remodeled progressively, with inlet area increasing 4.4%, 10.1%, 14.2% and outlet area increasing 42.6%, 67.2%, 72.3%, respectively, at 6, 12, and 36 months. True lumen volume increased progressively in group A (114 to 174 mL) and group B (124 to 190 mL) from baseline to 36 months. False lumen volume decreased in group A (150 to 88 mL) and group B (351 to 250 mL), whereas thrombus load in the false lumen increased from 73% to 80% in group A and 84% to 87% in group B in 3 years. Eight patients (4 in each group) showed an increase in total aortic volume of >10%, 12 showed a static volume, and 12 showed shrinkage. Aortic volume change had no relationship to pathology, stent graft sizing, and thrombus load but was positively associated with the placement of a longer graft. A small but progressive distal migration of stent grafts was noted in all patients (3.1, 4.5, and 5.1 mm at 6, 12, and 36 months) but was more prominent in shorter stent grafts (≤162 mm). No deaths, rupture, or secondary interventions occurred during follow-up. Conclusions: Aortic remodeling after TEVAR in chronic dissection is a continuous process. There were no significant differences between chronic dissections and aneurysms in all volumetric parameters. Treating chronic dissections early, before aneurysm formation, did not appear to have a morphologic advantage.

Discussion - Corrected Proof

2012-01-18

Dr Vincent Rowe (Los Angeles, Calif). Thank you for allowing me to review this interesting manuscript. Dr Cheng and his team from Hong Kong did a magnificent job of detailing changes seen in chronic uncomplicated type B aortic dissections with and without aneurysmal degeneration. The authors utilized CT scans and imaging software to provide volumetric data of the aorta over a 36 month period poststenting. I believe this manuscript holds significant merit because the radiologic findings found in this study may help answer the question as to whether endografting should become the primary treatment for type B aortic dissections. I do have the following questions for the authors:

Association between periodontal disease and stroke - Corrected Proof

2012-01-16

Objective: Periodontitis is a very common human infection. There is evidence that periodontitis is associated with cerebrovascular disease (CVD) and stroke. The aim of this study is to examine the relationship between periodontal disease and CVD in observational studies. Method: An electronic search of the English literature using PubMed was conducted. A meta-analysis of the studies reporting on the risk of stroke in patients with periodontitis was performed. Results: Six prospective and seven retrospective studies met the inclusion criteria. Patients with both hemorrhagic and ischemic cerebrovascular events, fatal and nonfatal, were included. Definition of periodontitis was taken directly from included studies. Most studies have been adjusted for common cardiovascular risk factors. Separate statistical analysis was performed for prospective and retrospective studies. Overall adjusted risk of stroke in subjects with periodontitis was 1.47 times higher than in subjects without (95% confidence interval, 1.13-1.92;P = .0035) in prospective and 2.63 times (95% confidence interval, 1.59-4.33;P = .0002) in retrospective studies. The application of the trim and fill algorithm does not change the initial significant inference. Conclusions: There is evidence that periodontitis is associated with increased risk of stroke. However, the results of this meta-analysis should be interpreted with caution because of the heterogeneity of the studies as well as the differences in periodontitis definition.

Aspirin prevents resistin-induced endothelial dysfunction by modulating AMPK, ROS, and Akt/eNOS signaling - Corrected Proof

2012-01-16

Background: Resistin, an adipocytokine, plays a potential role in cardiovascular disease and may contribute to increased atherosclerotic risk by modulating the activity of endothelial cells. A growing body of evidence suggests that aspirin is a potent antioxidant. We investigated whether aspirin mitigates resistin-induced endothelial dysfunction via modulation of reactive oxygen species (ROS) generation and explored the role that AMP-activated protein kinase (AMPK), a negative regulator of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, plays in the suppressive effects of aspirin on resistin-induced endothelial dysfunction. Methods: Human umbilical vein endothelial cells (HUVECs) were pretreated with various doses of aspirin (10-500 μg/mL) for 2 hours and then incubated with resistin (100 ng/mL) for an additional 48 hours. Fluorescence produced by the oxidation of dihydroethidium (DHE) was used to quantify the production of superoxide in situ; superoxide dismutase (SOD) and catalase activities were determined by an enzymatic assay; and protein levels of AMPK-mediated downstream signaling were investigated by Western blot. Results: Treatment of HUVECs with resistin for 48 hours resulted in a 2.9-fold increase in superoxide production; however, pretreatment with aspirin resulted in a dose-dependent decrease in production of superoxide (10-500 μg/mL; n = 3 experiments; all P < .05). Resistin also suppressed the activity of superoxide dismutase and catalase by nearly 50%; that result, however, was not observed in HUVECs that had been pretreated with aspirin at a concentration of 500 μg/mL. The membrane translocation assay showed that the levels of NADPH oxidase subunits p47phoxand Rac-1 in membrane fractions of HUVECs were threefold to fourfold higher in cells that had been treated with resistin for 1 hour than in untreated cells; however, pretreatment with aspirin markedly inhibited resistin-induced membrane assembly of NADPH oxidase via modulating AMPK-suppressed PKC-α activation. Application of AMPKα1-specific siRNA resulted in increased activation of PKC-α and p47phox. In addition, resistin significantly decreased AMPK-mediated downstream Akt/endothelial nitric oxide synthase (eNOS)/nitric oxide (NO) signaling and induced the phosphorylation of p38 mitogen-activated protein kinases, which in turn activated NF-κB-mediated inflammatory responses such as the release of interleukin (IL)-6 and IL-8, the overexpression of adhesion molecules, and stimulation of monocytic THP-1 cell attachment to HUVECs (2.5-fold vs control; n = 3 experiments). Furthermore, resistin downregulated eNOS and upregulated inducible NO synthase (iNOS) expression, thereby augmenting the formation of NO and protein nitrosylation. Pretreatment with aspirin, however, exerted significant cytoprotective effects in a dose-dependent manner (P < .05). Conclusion: Our findings suggest a direct connection between adipocytokines and endothelial dysfunction and provide further insight into the protective effects of aspirin in obese individuals with endothelial dysfunction.

The number of patent tibial vessels does not influence primary patency after nitinol stenting of the femoral and popliteal arteries - Corrected Proof

Jenny J. Lee, Steven G. Katz — 2012-01-16

Objective: Initial TransAtlantic Inter-Society consensus (TASC) II classification has been shown to influence the patency of stented femoral and popliteal arteries. Although several studies have shown the effect of the number of runoff vessels on the durability of infrainguinal angioplasty without stenting, the influence of tibial vessel runoff on the patency of primarily stented femoral and popliteal arteries has not been as well defined. The purpose of this study was to determine whether the number of patent tibial vessels affects primary patency after primary stenting of the femoral and popliteal arteries. Methods: The records of all patients undergoing angioplasty and primary nitinol stenting of the femoral and popliteal arteries, by or under the supervision of one vascular surgeon, were reviewed. Results were analyzed by both the number of patent tibial vessels documented on periprocedural angiography and by using a modified Society for Vascular Surgery runoff score. TASC II classification was also recorded. Kaplan-Meier survival curves were plotted and differences between groups tested by log-rank method. Fisher exact and χ2 tests were used to compare categoric factors. Results: During a 7-year period, 289 limbs in 236 patients underwent primary stenting of the femoral and popliteal arteries. Overall primary patency was 70.3% at 12 months, 52.4% at 24 months, and 39.1% at 36 months. Limbs classified as TASC A or B had significantly better patency rates than those classified as TASC C or D (P < .001). While the number of runoff vessels decreased with worsening of the TASC classification (P = .024), overall (P = .355), and within individual TASC classes (P ≥ .092 for each), there was no difference in the primary patency of stented segments with good runoff and those with compromised runoff. Limbs with poor runoff (one or no vessels) were no more likely to fail with occlusion than their counterparts with two or three patent tibial vessels (P = .383). The number of patent tibial vessels at the time of initial stenting did not impact ultimate limb salvage (P = .063). Conclusions: The number of patent tibial vessels does not influence the primary patency of primarily stented femoral and popliteal arteries. TASC II classification appears to be significantly more predictive of initial failure after angioplasty and stenting of these vessels.

Self-reported symptoms on questionnaires and anatomic lesions on duplex ultrasound examinations in patients with peripheral arterial disease - Corrected Proof

2012-01-16

Objective: Whether a typical patient and symptom profile is associated with proximal or distal lesions in lower extremity peripheral arterial disease (PAD) is unknown. Knowing which patient characteristics, exertional leg symptoms, and cardiovascular risk profile accompany the anatomic lesion location may facilitate a more tailor-made management of PAD. Methods: This cross-sectional study comprised 701 patients from two vascular surgery outpatient clinics with new-onset symptoms of PAD (Fontaine 2) who underwent duplex ultrasound (DUS) examinations from March 2006 to March 2011. The main outcome measures were patient characteristics, self-reported leg symptoms, and cardiovascular risk factors as documented from questionnaires and medical records. Peripheral lesion information, categorized by proximal and distal lesions, was obtained from DUS examinations. Multivariable logistic regression analyses were performed of proximal vs nonproximal lesions, distal vs nondistal lesions, and proximal and distal vs absence of having both lesions to assess relationships between patient characteristics, leg symptom categories (typical vs atypical leg symptoms), cardiovascular risk factors, and anatomic lesion location. Results: Lesions were proximal in 270 (38.5%), distal in 441 (62.9%), and proximal and distal in 94 (13.4%). Patients with proximal lesions were younger (odds ratio [OR], 0.94; P < .0001) and less likely to be obese (OR, 0.34; P < .0001) than those without proximal lesions. Older age (OR, 1.07; P < .0001), male sex (OR, 1.96; P = .003), being without a partner (OR, 2.24; P = .004), and lower anxiety scores (OR, 0.42; P = .003) were associated with distal lesions. Patients with both lesions were more likely to be single (OR, 2.30; P = .010) and less likely to be obese (OR, 0.24; P = .009). No distinguishing leg symptom pattern was observed for patients with proximal lesions. Intermittent claudication was more frequently reported in those with distal lesions (P = .011). Although buttock and thigh pain seemed to be somewhat more present in proximal lesions (P < .01) and calf pain more in distal lesions (P < .001), patients still reported pain at a variety of levels throughout their legs, regardless of the anatomic lesion location. Conclusions: Two distinctive PAD phenotypes—each with its own characteristics and risk factors—emerged by anatomic lesion location; however, PAD-specific leg symptoms did not always reflect the anatomic lesion location. These findings may open new opportunities to better tailor PAD management to these two PAD subgroups and may raise awareness about not relying on self-reported symptoms to guide further diagnostic imaging and peripheral lesion management.

Discussion - Corrected Proof

2012-01-16

Dr Ahmed M. Abou-Zamzam, Jr (Loma Linda, Calif). I would like to congratulate the authors on a nice presentation and a well-written manuscript. This single-center, retrospective study seeks to analyze the effect of tibial runoff on outcomes following primary stenting of superficial femoral (SFA) and popliteal artery disease. In a retrospective study of nearly 300 cases performed over 7 years, the authors have found that tibial runoff does not appear to influence overall outcomes. Primary patency and limb salvage were equivalent in patients with zero or one patent tibial arteries compared to patients with two or three patent tibial arteries. Not surprisingly, the Trans-Atlantic InterSociety (TASC) II classification did predict outcome. These results agree to some degree with numerous reports in the literature and add to the growing, and confusing, data regarding percutaneous treatment of infrainguinal disease. The one take-home message I can agree with is that TASC II classification trumps outflow. I have four questions:

Early experience with the snorkel technique for juxtarenal aneurysms - Corrected Proof

Jason T. Lee, Joshua I. Greenberg, Ronald L. Dalman — 2012-01-16

Objective: The lack of readily available branched and fenestrated endovascular aneurysm repair (EVAR) options has created an opportunity for creative deployment of endograft components to treat juxtarenal aneurysms. We present our early experience with “snorkel” or “chimney” techniques in the endovascular management of complex aortic aneurysms. Methods: We retrospectively reviewed planned snorkel procedures for juxtarenal aneurysms performed from September 2009 to August 2011. Our standardized technique included axillary or brachial cutdown for delivery of covered snorkel stents and mostly percutaneous femoral access for the main body endograft. Results: Fifty-six snorkel grafts were successfully placed in 28 consecutive patients (mean age, 75 years) with juxtarenal aneurysms. Mean aneurysm size was 64.8 mm (range, 53-87 mm). The snorkel configuration extended the proximal seal zone from an unsuitable infrarenal neck for standard EVAR (median diameter, 33.5 mm; length, 0.0 mm) to a median neck diameter of 24.5 mm and length of 18.0 mm. Five patients had unilateral renal snorkels, 17 had bilateral renal snorkels, and 6 had celiac/superior mesenteric artery/renal combinations. Technical success of snorkel placements was 98.2%, with loss of wire access leading to one renal stent deployment failure. Thirty-day mortality was 7.1%: one patient was readmitted 1 week postoperatively with pneumonia and died of sepsis; one patient died at 1 week of a right hemispheric stroke. Other major complications included perinephric hematomas, 7.1%; permanent hemodialysis, 3.6%; iliac artery injury requiring endoconduit placement, 3.6%; and brachial plexus nerve injury, 3.6%. Cardiac complications included self-limited arrhythmias (14.3%) and one non-Q-wave myocardial infarction (3.6%), with all recovering without coronary intervention. Mean follow-up was 10.7 months (range, 3-25 months). One patient died of nonaneurysmal-related causes at 3 months (89.3% survival). Postoperative imaging revealed one renal snorkel graft occlusion occuring at 3 months (98.2% overall primary patency). Seven (25%) early endoleaks were noted on the first follow-up computed tomography angiography: two type I, three type II, and two type III (25%), leading to one secondary intervention (3.6%) with bridging cuff placement (type III). The small type Ia endoleaks and other type III endoleak resolved at the 6-month scan. Mean sac regression at the latest follow-up was 7.3 mm. No aneurysm has enlarged on postoperative imaging. Conclusions: Early success with the snorkel technique for juxtarenal aneurysms has made it our procedure of choice for complex short-neck to no-neck EVAR. Although long-term follow-up is needed, the flexibility of the snorkel technique and lack of requirement for custom-built devices may make this approach more attractive than branched or fenestrated stent grafts.

Population-based analysis of inpatient vascular procedures and predicting future workload and implications for training - Corrected Proof

Jeffrey Jim, Pamela L. Owens, Luis A. Sanchez, Brian G. Rubin — 2012-01-16

Objective: The purpose of this study was to analyze the trend in inpatient vascular procedures in the United States over the past decade and predict the future demand for vascular surgeons. Method: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried to determine the weighted national estimates of inpatient vascular procedures performed on adult patients (age ≥18) between 1997 and 2008. Using population estimates from the United States Census Bureau, the per capita rates of inpatient procedures were calculated for age-specific groups (18-64 years, 65-84 years, and ≥85 years). The change in per capita rates over the past decade along with population forecasts were used to predict future workload. Results: There was a net increase of 22% from 971,046 inpatient vascular procedures for all adults in 1997 to 1,188,332 in 2008. During the same time period, the adult population increased by 16% from 198 to 230 million. The age-stratified per capita rates of all vascular procedures were +21% for age 18 to 64; −4% for age 65 to 84; and +18% for age ≥85. This resulted in a net increase of 5% (490 to 515 procedures per 100,000 capita) in the per capita rate for all adults. Based on the assumption that trends in age-specific rates remain constant, there is a predicted inpatient workload increase (compared to 2008) of 18% by 2015, 34% by 2020, and 72% by 2030. The vascular workload is predicted to more than double by the year 2040. Conclusion: Despite a conservative approach of using a population-based analysis of only inpatient procedures, there is a dramatic increase in the predicted vascular workload for the future. The vascular surgery training process will need to adapt to ensure an adequate number of fellowship-trained vascular surgeons is available to provide quality vascular care in the future.

Repetitive progressive thermal preconditioning hinders thrombosis by reinforcing phosphatidylinositol 3-kinase/Akt-dependent heat-shock protein/endothelial nitric oxide synthase signaling - Corrected Proof

Ping-Chia Li, Chih-Ching Yang, Shih-Ping Hsu, Chiang-Ting Chien — 2012-01-16

Objective: We compared the effects of modified progressive thermal preconditioning (PTP) and whole-body thermal preconditioning (TP) on stress responses, oxidative stress biomarkers, and arterial thrombosis formation, and explored their possible actions through phosphatidylinositol 3-kinase (PI3K)/Akt-dependent heat-shock protein (Hsp)/endothelial nitric oxide synthase (eNOS) pathways. Methods: We divided four groups of 249 male Wistar rats into nonimmersed controls, TP, and one (1-PTP) and three consecutive cycles (3-PTP) of PTP in a 42°C water bath. We evaluated the stress responses, including hemodynamics, total energy transfer, endoplasmic reticulum (ER) stress marker glucose-regulated protein (GRP78), and blood reactive oxygen species level during TP or PTP treatment. We compared 1-PTP, 3-PTP, or TP effects on oxidative stress, intercellular adhesion molecule 1 (ICAM-1), Hsp70, tissue plasminogen activator (t-PA) and plasminogen activator inhibitor type 1 (PAI-1) activity, and vascular phosphorylated Akt (p-Akt) and eNOS (p-eNOS) expressions in a model of topical ferric chloride (FeCl3)-induced carotid artery thrombosis. Results: PTP significantly (P < .05) induced less hemodynamic fluctuations, total energy transfer, ER, and oxidative stress than TP did. After 24 or 72 hours of treatment, 1-PTP, 3-PTP, and TP significantly (P < .05) elevated carotid arterial Hsp70, p-Akt, and p-eNOS expression, significantly (P < .05) depressed FeCl3-enhanced vascular 2′,7′-dichlorodihydrofluorescein diacetate, chemokine (C-X3-C motif) ligand 1 (CX3CL1), 3-nitrotyrosine, 4-hydroxynonenal, and ICAM-1 stain, PAI-1, and t-PA activity, leukocyte infiltration and thrombus size, and significantly (P < .05) delayed thrombus formation compared with controls. 3-PTP and TP had a higher (P < .05) protection than 1-PTP. PI3K/Akt, Hsp70, or N(G)-nitro-l-arginine methyl ester hydrochloride (L-NAME) inhibitors significantly (P < .05) depressed 3-PTP and TP-induced vascular protection. Conclusions: Repetitive PTP is better than single PTP to hinder thrombosis formation via reinforcing PI3K/Akt-dependent Hsp70/eNOS signaling. Clinical Relevance:: This study implicates that a modified progressive thermal preconditioning (PTP) evokes less endoplasmic reticulum and oxidative stress in blood vessels than whole-body thermal preconditioning (TP). TP and PTP confer vascular protection via phosphatidylinositol 3-kinase (PI3K)/Akt-dependent heat-shock protein (Hsp)/endothelial nitric oxide synthase (eNOS) signaling. However, the vascular protection of three consecutive cycles of PTP (3-PTP) treatment is similar to TP but is more efficient than one PTP (1-PTP) cycle to hinder oxidative stress-induced thrombosis. 3-PTP provides more vascular protection than 1-PTP by inhibiting oxidative stress, chemokine, and adhesion molecule production in blood vessels through the reinforcement of PI3K/Akt-dependent Hsp/eNOS signaling. This study demonstrates that repetitive PTP is a safe, effective, and available strategy to protect against oxidative stress-induced thrombosis by reinforcing PI3K/Akt-dependent Hsp70/e-NOS signaling. We suggest that these preclinical data are sufficient to conduct a small, phase I proof-of-concept study and we may validate the outcome variables, including plasma and urinary nitrite and nitrate, or evaluate other physiologic parameters before and after surgery. PTP may be used as prophylaxis against vascular disease.

Discussion - Corrected Proof

2012-01-16

Dr Julie Ann Freischlag (Baltimore, Md). I had a question about risk factor modification and prevalence of disease, such as we think there is going to be more diabetes and more obesity but the impact of less smoking and perhaps better control of lipids. How do you even try to attempt that in your analysis? Is there a way we can look at that?

Discussion - Corrected Proof

2012-01-16

Dr Linda M. Reilly (San Francisco, Calif). The authors report a retrospective series of 22 patients who underwent placement of snorkels to create a more proximal aortic seal zone and allow successful treatment of juxtarenal aortic aneurysms with conventional, commercially available endovascular stent grafts. Most of the patients had snorkels inserted into two or more visceral branches. The authors used covered stents exclusively and balloon expandable stents in most patients. The overall “bad” event rate (death, dialysis, branch occlusion) was three of 22, or 14%. There were two type I endoleaks that resolved spontaneously. The authors acknowledge that their follow-up remains relatively short and appropriately caution about the need for careful follow-up assessment. This series is slightly bigger than other published series (by one patient) and the results are comparable.

Stent grafting for aneurysmal degeneration of chronic descending thoracic aortic dissections - Corrected Proof

2012-01-13

Objective: The objective of this study was to examine the results of thoracic endovascular aneurysm repair (TEVAR) for chronic descending thoracic aortic (DTA) dissections with aneurysmal degeneration. Methods: Over 70 months at a single institution, 27 patients underwent TEVAR for aneurysms related to chronic (>6 weeks) DTA dissections. Results: Mean patient age was 67.5 ± 9.6 years; 18 were men. Primary indications for repair were aneurysm size (n = 20), rapid aneurysmal growth (n = 5), saccular aneurysm (n = 1), and rupture (n = 1). Preoperative false lumen status was patent in 18 patients, partially thrombosed in 8 patients, and unknown in the patient whose aneurysm ruptured. The proximal entry tear was covered in all 27 patients. Fourteen patients required coverage of the left subclavian artery, of which 9 patients underwent prophylactic revascularization. On completion angiogram, no patient had antegrade perfusion of the aneurysmal false lumen. There were three procedural complications: 2 patients sustained paraparesis (one resolved and one improved), and 1 patient had an access injury requiring stent graft placement. Thirty-day mortality was 3.7% (1 of 27); the one death was in the patient whose aneurysm ruptured. Of the 26 surviving patients, 23 (88.5%) had thrombosis of the aneurysmal false lumen. Twenty-two patients (84.6%) had stability or decrease in maximal aneurysm diameter on last radiographic follow-up at 18 ± 20 months. Three-year Kaplan-Meier survival was 90.3% ± 6.5% in the 26 patients who survived to hospital discharge, with a mean follow-up of 27.3 ± 22.1 months. In patients with preoperatively partially thrombosed false lumens (n = 8), 3-year survival was 100%. Conclusion: TEVAR for aneurysms due to chronic dissections of the DTA can be performed safely and effectively at midterm follow-up according to this single-institution study. Stent graft therapy may be of particular benefit in patients presenting with partially thrombosed false lumens.

The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies - Corrected Proof

2012-01-12

Objective: Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The “chimney graft” or “snorkel” technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique. Methods: Studies were included in the present review if visceral revascularization during endovascular treatment of aortic pathologies was achieved via a CG implantation. Reports on the chimney technique for aortic arch branches revascularization were excluded. A multiple electronic health database search was performed on all articles published until April 2011. Results: The electronic literature search yielded 15 reports that fulfilled the inclusion criteria. A total of 93 patients (81.3% male; mean age, 71.9 ± 0.9 years) were analyzed. In 77.4% of the patients, the CG procedure was applied for the treatment of abdominal aortic aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent setting (symptomatic or ruptured aneurysm). A total of 134 CGs were implanted: 108 to the renal arteries, 20 to the superior mesenteric artery, five to the celiac trunk, and one to the inferior mesenteric artery. In 57 patients, a single CG was deployed; in 32 patients, two CGs; in three patients, three CGs; and in one patient, four CGs were deployed. Ninety-four percent of CGs were directed proximally, whereas 6.0% were directed caudally. Primary technical success was achieved in all patients. A total of 13 patients (14.0%) developed a type I endoleak. Three were detected and treated intraoperatively. Postoperatively, 10 type I endoleaks were revealed, four of which required secondary intervention. During a mean follow-up period of 9.0 ± 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the renal arteries and one to the superior mesenteric artery occluded. Postoperatively, 11.8% of patients suffered renal function impairment and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of patients. The 30-day in-hospital mortality was 4.3%. Conclusions: The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. This technique has relatively good results, considering the anatomic limitations of the aortic neck. However, long-term endograft durability and proximal fixation remains a significant concern. Thus, there is a reasonable hesitation to embrace the method for widespread use in the absence of long-term data.

The importance of antegrade completion angiography in aortobifemoral bypass limb revision - Corrected Proof

Ryan A. Helmick, Charles L. Mesh — 2012-01-12

Aortobifemoral bypass is a durable arterial reconstruction with well-defined failure modes. Management of graft limb thrombosis requires restoration of inflow and correction of any causative outflow lesions. Successful, minimally invasive inflow restoration with catheter thrombectomy can become problematic if assessment of technical adequacy is deficient or reveals causal lesions within the graft body. We describe a case illustrating the potential shortfall of retrograde graft limb completion angiography in depicting neointimal flaps, the benefit of antegrade angiography in depicting these flaps, and a novel utilization of a standard endovascular method to correct flaps that involve the graft body.

Results of carotid artery stenting with distal embolic protection with improved systems: Protected Carotid Artery Stenting in Patients at High Risk for Carotid Endarterectomy (PROTECT) trial - Corrected Proof

2012-01-11

Objective: The Protected Carotid Artery Stenting in Patients at High Risk for Carotid Endarterectomy (PROTECT) study was performed to evaluate the safety and effectiveness of two devices for carotid artery stenting (CAS) in the treatment of carotid artery stenosis in patients at high risk for carotid endarterectomy (CEA): (1) a new embolic protection device, the Emboshield Pro (Abbott Vascular, Abbott Park, Ill), using the periprocedural composite end point of 30-day death, stroke, and myocardial infarction (DSMI), and (2) a carotid stent in conjunction with an embolic protection device (EPD) using the DSMI periprocedural composite end point plus ipsilateral stroke at up to 3 years for long-term evaluation. Methods: This prospective, multicenter clinical trial enrolled 220 consecutive participants between November 29, 2006, and January 14, 2008, followed by a second cohort of 102 participants between January 14 and June 18, 2008. Enrolled participants had carotid stenosis (symptomatic >50% or asymptomatic >80%). The first 220 subjects underwent distal EPD placement with a new large-diameter filter, and the second cohort of 102 underwent placement of an older EPD that is no longer manufactured. All 322 participants were to be treated with a dedicated carotid stent with a tapered, small, closed-cell design (Xact; Abbott Vascular) and were to be included in the long-term evaluation. Independent neurologic assessment was performed before CAS and at 1 day, 30 days, and annually after CAS. All primary end point events were independently adjudicated by a central committee. Results: The periprocedural composite end point of DSMI (95% confidence interval) in the first 220 participants was 2.3% (0.74%, 5.22%), with a combined death and stroke rate of 1.8% (0.50%, 4.59%) and a rate of death and major stroke of 0.5% (0.01%, 2.51%). As of January 3, 2011, the median follow-up for the entire 322-subject cohort for the long-term evaluation was 2.8 years. Freedom from the periprocedural composite of DSMI plus ipsilateral stroke thereafter was 95.4%, with an annualized ipsilateral stroke rate of 0.4%. Conclusions: CAS outcomes in patients at high risk for CEA have improved from earlier carotid stent trials. With periprocedural rates of DSMI of 2.3%, death or stroke at 1.8%, and death or major stroke rate of 0.5%, PROTECT has the lowest rate of periprocedural complications among other comparable single-arm CAS trials in patients at high risk for CEA.

Paclitaxel coating of the luminal surface of hemodialysis grafts with effective suppression of neointimal hyperplasia - Corrected Proof

2012-01-09

Objectives: Paclitaxel coating of hemodialysis grafts is effective in suppressing neointimal hyperplasia in the graft and vascular anastomosis sites. However, paclitaxel can have unwanted effects on the surrounding tissues. To reduce such problems, we developed a method to coat the drug only on the luminal surface of the graft, with little loading on the outer surface. Methods: A peristaltic pump and a double-solvent (water and acetone) system were used to achieve an inner coating of paclitaxel. At the ratio of 90% acetone, paclitaxel was homogeneously coated only on the luminal surface of the graft without changing the physical properties. To determine its effect, grafts were implanted between the common carotid artery and the external jugular vein in pigs using uncoated control grafts (n = 6) and low-dose (n = 6, 0.22 μg/mm2) and high-dose (n = 6, 0.69 μg/mm2) paclitaxel inner-coated grafts. Cross-sections of graft–venous anastomoses were analyzed histomorphometrically 6 weeks after placement to measure the patency rate, percentage of luminal stenosis, and neointimal area. Results: No signs of infection or bacterial contamination were observed in the paclitaxel inner-coated groups. Only one of the six control grafts was patent, but all of the paclitaxel-coated grafts were patent, with little neointima. The mean ± standard error values of percentage luminal stenosis were 75.7% ± 12.7% (control), 17.5% ± 3.1% (low dose), and 19.7% ± 3.0% (high dose). The values for the neointimal area (in mm2) were 8.77 ± 1.66 (control), 3.53 ± 0.73 (lose dose), and 4.24 ± 0.99 (high dose). Compared with the control group, paclitaxel inner-coated vascular grafts significantly suppressed neointimal hyperplasia (low dose, P = .001; high dose, P = .002). Myofibroblast proliferation and migration into the graft interstices confirmed the firm attachment of the implanted graft to the surrounding tissue. Conclusions: Paclitaxel coating on the inner luminal surface of vascular grafts was effective in suppressing neointimal hyperplasia, with little inhibition of myofibroblast infiltration within the graft wall. Clinical Relevance: Paclitaxel-coated vascular grafts effectively inhibited the neointimal hyperplasia of hemodialysis grafts. However, paclitaxel on the outer surface of expanded polytetrafluoroethylene grafts might prevent myofibroblast proliferation, which might cause hematomas, seromas, infections, or pseudoaneurysms in the space between the graft and surrounding tissue and result in incomplete hemodialysis needle insertion. Therefore, paclitaxel inner-coated expanded polytetrafluoroethylene grafts can reduce the coated amount of this potentially toxic drug to avoid such unwanted effects, whilst preserving its efficacy in inhibiting stenosis.

The impact of adjunctive iliac stenting on femoral-femoral bypass in contemporary practice - Corrected Proof

2012-01-09

Objectives: Most reports of femoral-femoral bypass (FFB) were published before the era of endovascular intervention. This study examines the utilization and impact of adjunctive endovascular intervention on FFB in contemporary practice. Methods: We reviewed 253 FFB performed in 247 patients between 1984 and 2010. Primary endpoints, including graft patency, primary-assisted patency, limb salvage, and survival, were assessed using Kaplan-Meier life-table analysis. Univariate and multivariate analyses were performed to determine predictors of primary endpoints. Results: The indication for FFB included claudication (27%; n = 69) and critical limb ischemia (72%; n = 184). Forty-eight patients (19%) were treated urgently for acute ischemia. Mean follow-up was 5.6 ± 5.5 years. Over the study interval, adjunctive iliac percutaneous transluminal angioplasty (PTA)/stent placement increased significantly from 0% to 54% (P trend < .001), while the rate of axillofemoral bypass or no inflow procedure decreased from 100% to 46% (P trend < .001). Despite increased utilization, iliac PTA/stenting was associated with decreased 5-year primary graft patency of 44% compared with 74% for axillofemoral bypass patients and 71% in patients with no adjunctive inflow procedure (P = .004). Patients with inflow iliac PTA/stents also had diminished 5-year assisted primary patency of 61% compared with 85% for axillofemoral bypass patients and 87% in patients without inflow revascularization (P = .002). Adjunctive iliac PTA/stenting did not impact limb salvage or overall survival. Five-year primary patency among claudicants and critical leg ischemia patients was 65% and 68%, respectively. Conclusions: The incidence of iliac PTA/stent placement in conjunction with FFB has increased significantly over time in contemporary practice. Reliance on iliac stent placement for FFB inflow is paradoxically associated with both diminished primary and assisted primary graft patency when compared with historical controls. These findings highlight the importance of patient selection and inflow consideration when performing FFB.

Discussion - Corrected Proof

2012-01-09

Dr Kelley Hodgkiss-Harlow (Tampa, Fla). I would like to congratulate Dr. Huded and colleagues for a very well-written paper. Thank you for providing it to me well in advance of the meeting.

Endovascular creation of aortic dissection in a swine model with technical considerations - Corrected Proof

2012-01-09

Objective: Creating an experimental model of a type B aortic dissection with a minimally invasive endovascular procedure in swine to help future evaluation of therapies for aortic dissection. Methods: Aortic dissection was created in 14 swine using endovascular procedures only. Under fluoroscopy, a modified 10F outer catheter with a 14 G stiffening inner metallic cannula was forced via the femoral artery into the aortic vessel wall to create an initial dissection. A .035-inch guidewire and a 4F straight catheter were advanced into the dissected space, and the dissection was extended in a retrograde direction using a technique, including loop formation of the guidewire, which was placed carefully against the transmural penetration and extended as far as possible in the descending thoracic aorta up to the point where loop formation of the guidewire reached smoothly. An 8F introducer sheath was advanced with a Brockenbrough needle into the dissected space, and a proximal fenestration was created by puncturing the intima. If required, balloon dilatation was performed to enlarge the proximal and distal tears. Aortography and contrast enhanced cone beam computed tomography (CBCT) were performed in addition to a detailed histologic evaluation of the dissected portion. Results: Aortic dissection was successfully created in 11 of the 14 swine (78.6%). Among the 11 dissections, nine were located in the thoracoabdominal aorta and two in the abdominal aorta. The initial aortic diameter at the middle portion of the created dissection ranged from 7.4 to 16.8 mm (mean ± standard deviation, 10.9 ± 2.9), while after dissection, it ranged from 7.8 to 19.3 mm (12.9 ± 3.8 mm). The dissected length ranged from 4.4 to 17.7 cm (10.7 ± 4.6 cm). Aortography and CBCT revealed seven dissections (63.6%) with a smooth and patent false lumen. Histologic evaluation revealed that the outer one-third of the media was separated from the inner two-thirds. In the remaining four dissections (36.4%), imaging procedures revealed the formation of a rough and patent false lumen beside the true lumen, and histologic evaluation revealed greater separation of the outer media. Five animals were chronic dissection models. Three (60%) of these survived for more than 14 days without any symptoms. Moreover, completely patent true and false lumens without thrombus formation were observed in these three animals. The aortic diameter at the dissected portion tended to be dilated compared with the initial diameter. Conclusions: This new technique of creating an experimental aortic dissection model in swine is promising and should contribute to the development of future therapies for aortic dissection. Clinical Relevance: This study demonstrates the development of a new and attractive experimental model of type B aortic dissection using a minimally invasive endovascular procedure in swine, which should develop new therapies and improve the currently practiced endovascular therapies for type B aortic dissection such as stent graft placement. Previous attempts to surgically create animal models have also had contributions but were hardly applicable due to their invasiveness. Another advantage of this study is that it uses CT as a clinically indispensable tool for the diagnostic evaluation of hemodynamic pathology in the created aortic dissection.

Single-center review of trends in management of abdominal aortic aneurysms over the last decade - Corrected Proof

2012-01-09

Objective: The purpose of this study was to evaluate patients undergoing elective repair of infrarenal abdominal aortic aneurysms (AAAs) and the longitudinal trends in surgical management (open repair vs endovascular aneurysm repair [EVAR]), factors associated with the choice of surgical technique, and differences in the rate of in-hospital mortality at a single large-volume Canadian center. Method: This retrospective cohort study used data from a prospectively collected vascular surgery database and reviewed all patients undergoing elective repair of an infrarenal AAA over a recent 10-year period (June 2000-May 2010). Information was reviewed regarding surgical techniques, patient demographics, and short-term outcomes. Subsequent analysis included univariate statistics and multivariable logistic regression with data presented as odds ratios (ORs) and 95% confidence intervals (CIs). Results: A total of 1942 patients underwent elective AAA repair over this 10-year study period, 1067 (54.9%) via open repair and 875 (45.1%) via EVAR. The proportion of patients undergoing EVAR was significantly higher in the latter half of the study period compared to the first half (55.8% vs 33.9%; P < .01). Older patients (75 vs 71; P < .01) and those with higher American Society of Anesthesiologists classifications (P < .01) were more likely to receive endovascular repair than open repair. The overall in-hospital mortality rate in the entire cohort was low (2.3% for EVAR and 3.9% for open repair), and after multivariable logistic regression and adjustment for preoperative factors, in-hospital mortality was significantly higher in patients with open AAA repair (OR, 1.8; 95% CI, 1.04-3.13; P = .04). Conclusion: This 10-year analysis shows a significant shift toward an endovascular approach in the repair of infrarenal AAAs at our Canadian center. Similar to other jurisdictions, higher risk and older patients are more likely to be treated with an endovascular repair resulting in a survival advantage in these patients compared to standard open repair.

Placement of a retrievable inferior vena cava filter for deep venous thrombosis in term pregnancy - Corrected Proof

Yang Liu, Yan Sun, Shiyi Zhang, Xing Jin — 2012-01-09

Objective: Venous thromboembolism is a significant cause of morbidity and death in pregnant women. Retrievable vena cava filters were placed right before labor as prophylaxis for peripartum pulmonary embolism. We reviewed the experience of caval filter placement and retrieval in term pregnancy in this study. Methods: We reviewed 15 patients with deep venous thrombosis (DVT) of the lower extremity who underwent OptEase (Cordis Corp, New Brunswick, NJ) retrievable vena cava filter placement. DVT was diagnosed by clinical symptoms and Doppler ultrasound imaging. Subcutaneous low-molecular-weight heparin was eased 12 hours before cesarean delivery and restarted 12 hours after delivery. The caval filters were placed suprarenally from the jugular approach and retrieved from the femoral approach. Results: The filters were successfully placed in all patients on the day of cesarean delivery. No placement-related complications occurred. The caval filter was left in situ as a permanent device in one patient because the captured thrombus within the filter was not eliminated after the thrombolytic therapy. Filters in other 14 patients were retrieved successfully, without difficulty, including in one patient after complete lysis of captured thrombus by the thrombolytic therapy. Oral warfarin therapy was recommended for at least 3 months after hospital discharge, and for at least 6 months in the patient with a caval filter left in situ. All patients were examined by Doppler ultrasound imaging during the follow-up. None presented with symptomatic pulmonary embolism or filter-related complications. Conclusions: OptEase retrievable vena cava filter placement and retrieval in term pregnant patients with extensive DVT of the lower extremities is safe, effective, and feasible. The results in our study may justify prophylactic filter placement use right before labor.

Failed superficial femoral artery intervention for advanced infrainguinal occlusive disease has a significant negative impact on limb salvage - Corrected Proof

2012-01-09

Objective: Endovascular treatment of superficial femoral artery (SFA) lesions is a well-established practice. The repercussions of failed SFA interventions are unclear. Our goal was to review the efficacy of SFA stenting and define negative effects of its failure. Methods: A retrospective chart review was conducted from January 2007 to January 2010 that identified 42 limbs in 39 patients that underwent SFA stenting. Follow-up ankle-brachial index and a duplex ultrasound scan was performed at routine intervals. Results: Mean patient age was 68 years (range, 43-88 years), there were 22 men (56%) and 17 women (44%). Intervention indication was claudication in 15 patients (36%), rest pain in seven patients (17%), and tissue loss in 19 patients (45%). There were 15 patients (36%) with TransAtlantic Inter-Society Consensus (TASC) A, nine patients (21%) with TASC B, five patients (12%) with TASC C, and 13 patients (31%) with TASC D lesions. The majority of lesions intervened on were the first attempt at revascularization. Three stents (7.7%) occluded within 30 days. One-year primary, primary-assisted, and secondary patency rates were 24%, 44%, and 51%, respectively. Limb salvage was 93% during follow-up. Seventeen interventions failed (40%) at 1 year. Of these, seven patients (41%) developed claudication, seven patients (41%) developed ischemic rest pain, and three patients (18%) were asymptomatic. During follow-up, three patients (7.7%) required bypass and three patients (7.7%) major amputation, one after failed bypass. All limbs requiring bypass or amputation had TASC C/D lesions. Thirty-day and 1-year mortality was 2.6% and 10.3%, respectively. Conclusion: Interventions performed for TASC C/D lesions are more likely to fail and more likely to lead to bypass or amputation. Interventions performed for TASC C/D lesions that fail have a negative impact on limb salvage. This should be considered when performing stenting of advanced SFA lesions.

Discussion - Corrected Proof

2012-01-09

Dr Peter Rossi (Milwaukee, Wisc). Thank you, Dr Al-Nouri, for the nice presentation. I would like to thank the program committee for giving me the opportunity to review this and thank Dr Al-Nouri for getting me the article several weeks ago. The article is a nice summary of isolated superficial femoral artery stenting for infrainguinal disease, and, despite the small number of patients in the series and the small number of limbs, I think it does give us some valuable insights. The 93% overall limb salvage rate in your article is laudable. It is interesting, though, that 31% of the cases that were done here were for TASC D lesions and 36% overall were done for claudication. When I examined the data and just sat down with a calculator, if I eliminated the claudication patients, the actual limb salvage rate for patients with chronic limb ischemia was down to 77%, and that's pretty comparable to previously published articles for redo infrainguinal bypass procedures. I'm a little bit curious. Could you comment on that? I have four overall questions regarding your manuscript. One, in your results in the manuscript, you mentioned that there were “500 lower extremity angioplasty and diagnostic angiogram procedures,” so if I take it that you stented 42 of these, that gives you a 92% rate of isolated percutaneous transluminal angioplasty and you only stented about 8%. I'm wondering what your criteria were for actually placing stents and whether the fact that you stented a lesion meant that it was a higher-risk lesion and perhaps more likely to fail. Our group has previously shown that the number of patent runoff vessels is directly proportional to the rate of success of these procedures. You mentioned in your manuscript that you had an average of 2.1 patent tibial vessels in your procedures here, and I'm wondering if you examined the patency of the runoff in terms of the success of the intervention. The third question is about your medical management. You did mention that the patients were on aspirin and Plavix, or one of the two. I'm curious as to whether you put these patients on statins or how involved you get in the medical management. There are certainly data that suggest improved patency and better outcomes with patients who are on statins and angiotensin-converting enzyme (ACE) inhibitors. I don't know if you're involved with that. Probably my only concern with the manuscript is that you do make the statement that the failure of these procedures for TASC C and D lesions leads to a decrease in limb salvage, and I'm not really sure that you showed that. The reason I say that is that they are moving on to having open revascularization, and at that point, your limb salvage rate is still very similar to previously published data for redo procedures. So I don't know if it's really that the failure of the procedure leads to a problem or if it just indicates more severe disease and they have to go on to another procedure, like they might traditionally have to. Thanks for allowing me to review this. I look forward to your responses.

A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation - Corrected Proof

2012-01-09

Introduction: A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability. Methods: Patients with CIAA who underwent EVAR were identified in two teaching hospitals. Bell-bottom technique (BBT; iliac limb ≥20 mm) or internal iliac artery embolization and limb extension to the external iliac artery (IIE + EE) were used. Outcome between these two approaches was compared. Results: We identified 185 patients. Indication for EVAR included asymptomatic abdominal aortic aneurysm (AAA) in 157, symptomatic or ruptured aneurysm in 19, and CIAA in 9. Mean AAA diameter was 59 mm. Among 260 large CIAAs that were treated, BBT was used to treat 166 CIAA limbs, and 94 limbs underwent IIE + EE. Total reintervention rates were 11% for BBT (n = 19) and 19.1% for IIE + EE (n = 18, P = .149). Rates of reintervention for type Ib or III endoleak were 4% for BBT (n = 7) and 4% for IIE + EE (n = 4; P > .99). The difference in limb patency rates was not significant. The 30-day mortality rate was 1%. Median follow-up was 22 months. Complications did not differ significantly between the two groups; however, the combined incidence of perioperative complications and reinterventions was higher in the IIE + EE group (49% vs 22%, P = .002). Conclusions: The combined incidence of perioperative complications and reinterventions is significantly higher with IIE + EE than with BBT; therefore, when feasible, BBT is desirable.

Changing practice paradigms: negotiating your future - Corrected Proof

2012-01-09

There are many recent and ongoing changes in the practice of medicine from a business standpoint as well as in overall practice management. Economic and lifestyle desires have pushed many physicians to a decision point of whether or not to join a large multispecialty group or to sell their practice and become an employee of a hospital system. There are advantages and disadvantages to both options; however, deciding on the most appropriate path for each individual can be a daunting task. At our recent breakfast session at the vascular annual meeting in Chicago, Illinois, in June 2011, we brought to light these topics to try and help enlighten physicians on which option may be right for them. There is no single answer/option that will fit every practice, but discussion for various practice management designs are outlined and critiqued. This article cannot fully discuss each view in the allotted space, but it is designed to encourage thought and discussion among the vascular surgical community as a whole.

Loss of lymphatic vessels and regional lipid accumulation is associated with great saphenous vein incompetence - Corrected Proof

2012-01-06

Objectives: Recent studies suggest that biologic changes in the vein wall associated with varicose veins (VVs) occur not only in valvular tissue but also in nonvalvular regions. We previously used imaging mass spectrometry (IMS) to determine the distribution of lipid molecules in incompetent valve tissue. In this study, we used IMS to analyze incompetent great saphenous veins (GSVs) in patients with varicose vein (VV) to assess the distribution of lipid molecules. Methods: We obtained GSV tissue from 38 VV patients (50 limbs) who underwent GSV stripping. For the control veins (CV), we obtained GSV samples from 10 patients undergoing infrainguinal bypass with reversed GSV grafting for peripheral artery occlusive disease (10 limbs). Conventional and immunofluorescence staining were performed for histopathologic examination. The total lipid content in the homogenized vein tissue was determined. The localization of each lipid molecule in the vein wall was assessed by IMS. Results: The histologic examination showed the VV walls were significantly thicker than the CV walls, and only the VV adventitia was positive for lipid staining. The VV wall had higher concentrations of phospholipids and triglycerides than the CV wall. IMS revealed an abnormal accumulation of lysophosphatidylcholine (LPC; 1-acyl 16:0) and phosphatidylcholine (diacyl 16:0/20:4) in the VV intima and media. Triglyceride was found only in VV adventitia. The number of lymphatic vessels, as measured by staining with D2-40, a lymphatic vessel-specific marker, was significantly lower in the VV adventitia than in the CV adventitia. Lymphatic vessel reduction may be associated with insufficient lymphatic drainage in the VV adventitia causing histologic changes in VV tissue. Conclusions: The accumulation of LPC (1-acyl 16:0) and PC (diacyl 16:0/20:4) in the VV intima and media may be associated with chronic inflammation, leading to VV tissue degeneration. Furthermore, insufficient lipid drainage by lymphatic vessel may be responsible for accumulation of lipid molecules and subsequent vein wall degeneration. Clinical Relevance: Abnormal distribution of lipid molecules in varicose vein (VV) tissue in patients at CEAP class C2-3 and C4-5 suggests that VV-associated accumulation of lipid molecules begins in the early clinical stages of the disease and continues through the advanced stages. In particular, the accumulation of both lysophosphatidylcholine (1-acyl 16:0) and phosphatidylcholine (diacyl 16:0/20:4) in the media was significantly higher in VV tissue from patients in advanced clinical stages, suggesting an association between lipid accumulation and chronic inflammation of skin and subcutaneous tissues. Further study is needed to clarify the effect of lymph stasis on VVs and chronic inflammation. The mechanism whereby adventitial lymphatic vessels are damaged is also unknown. Consistent venous hypertension and subsequent overload to the lymphatics may account for the lymphatic damage. In addition, accumulation of possible proinflammatory lipid molecules in VV walls may further damage the adventitial lymphatic vessels.

Intermediate-term outcome of carotid endarterectomy with bovine pericardial patch closure compared with Dacron patch and primary closure - Corrected Proof

Karen J. Ho, Louis L. Nguyen, Matthew T. Menard — 2012-01-06

Objective: Multiple studies have established that patch angioplasty following carotid endarterectomy (CEA) reduces the risk of subsequent stroke and restenosis compared with primary closure. Previous reports have also demonstrated bovine pericardium to be associated with similar rates of postoperative complications and restenosis compared with other patch materials. Due to favorable handling and sonographic properties, bovine pericardium has become increasingly popular as a patch option in recent years. However, the intermediate- and long-term performance of this material remains incompletely defined. Through a retrospective analysis of our carotid endarterectomy experience, we sought to compare the bleeding, infection, and pseudoaneurysm rates with bovine pericardium patch closure to those with Dacron patch and primary closure. In this study, 1331 primary carotid endarterectomies performed in our institution between 1996 and 2008 were grouped according to the method of arteriotomy closure: primary closure (PC) (216, 16.3%), Dacron patch angioplasty (DPA) (642, 48.2%), and bovine pericardial patch angioplasty (BPA) (457, 34.3%). Demographic variable and postoperative outcome measures collected real-time via a designated database manager were assessed by univariate and multivariate analysis. Results: Mean follow-up for the entire cohort was 46.1 months. There were no statistically significant differences in rates of postoperative wound infection, hematoma, pseudoaneurysm formation, or 30-day stroke or 30-day mortality among the three groups. Combined 30-day stroke and death was significantly lower in the PC cohort (0.5% vs 2.3% DPA vs 2.4% BPA; P = .94, BPA vs DPA; P = .001, BPA vs PC; P = .001, DPA vs PC), while 5-year restenosis after both DPA (2.0% ± 0.6%) and BPA (1.1% ± 0.6%) was significantly lower compared with PC (5.2% ± 1.6%) (P = .03, DPA vs PC; P = .008, BPA vs PC; P = .14, BPA vs DPA). Five-year survival following BPA (77.9% ± 3.6%) was significantly improved compared with PC (66.9% ± 3.5%) and DPA (60.8% ± 2.1%) in univariate analysis (P = .24, DPA vs PC; P = .01; BPA vs PC; P = .03, BPA vs DPA), with statin use (P = .004) and male gender (P = .05) being positive predictors of enhanced survival on multivariate analysis. Conclusions: This single-institution, retrospective review represents the largest reported experience with BPA after CEA to date and is the only report comparing outcomes after BPA to PC or to DPA. Our experience further demonstrates that patch angioplasty is protective against restenosis after CEA compared with PC. Equivalent rates of perioperative bleeding, infection, and pseudoaneurysm formation were seen with each closure strategy in this study.

Expression of cytoskeleton and energetic metabolism-related proteins at human abdominal aortic aneurysm sites - Corrected Proof

2012-01-06

Objective: The purpose of this study was to evaluate the expression of proteins related to cytoskeleton and energetic metabolism at abdominal aortic aneurysm (AAA) sites using proteomics. Several remodeling-related mechanisms have been associated with AAA formation but less is known about the expression of proteins associated with cytoskeleton and energetic metabolism in AAAs. Methods: AAA samples (6.73 ± 0.40 cm size) were obtained from 13 patients during elective aneurysm repair. Control abdominal aortic samples were obtained from 12 organ donors. Proteins were analyzed using two-dimensional electrophoresis and mass spectrometry. Results: The expression of filamin was increased in the AAA site compared to control abdominal aortic samples while microfibril-associated glycoprotein-4 isotype 1, annexin A5 isotype 1, and annexin A2 were reduced compared with control abdominal aortic samples. Reduction in expression level of energetic metabolism-associated proteins such as triosephosphate isomerase, glyceraldehyde 3-phosphate dehydrogenase, and cytosolic aldehyde dehydrogenase was also observed in AAAs compared to controls. Reduction of triosephosphate isomerase expression was also observed by Western blot, which was accompanied by diminished triosephosphate isomerase activity. At the AAA site, pyruvate dehydrogenase expression was reduced and the content of both lactate and pyruvate was increased with respect to controls without changes in lactate dehydrogenase activity. Conclusion: The present results suggest that an anaerobic metabolic state may be favored further to reduce the expression of cytoskeleton-related proteins. The better knowledge of molecular mechanism involved in AAAs may favor development of new clinical strategies. Clinical Relevance: The present study shows the possibility of promotion of anaerobic metabolism at human abdominal aortic aneurysm (AAA) sites in addition to providing new data about reduction in the expression of cytoskeleton-related proteins in AAAs, which could be involved in abdominal aortic aneurysm distensibility and rupture. These findings could help to know more indepth undescribed molecular mechanisms associated with AAAs and may favor development of new clinical strategies.

Unusual course of an abdominal aortic aneurysm in a patient treated with chemotherapy for gastric cancer - Corrected Proof

Juergen Zanow, Yvonne Leistner, Stephan Ludewig, Falk Rauchfuss, Utz Settmacher — 2012-01-03

Most aortic aneurysms have a degenerative genesis and show a slow expansion over years. Only a few patients with a rapid progression of mycotic or inflammatory aneurysm during some weeks or months have been reported. We report a patient with a rapidly growing symptomatic infrarenal aneurysm with a maximal diameter of 53 mm, which developed over a 5-month period from a normal aorta and did not feature typical signs of degenerative, inflammatory, or mycotic aneurysm. The aneurysm was successfully treated by endovascular repair. A complete shrinking of the aneurysm sac was demonstrated during a few weeks postoperatively. Because the patient received chemotherapy with docetaxel, cisplatin, and 5-fluorouracil for metastatic gastric carcinoma 1 year before the aneurysm occurred, we postulate that chemotherapy induced a rapid expansion of the aorta in this patient.

Predictive factors for mortality after open repair of paravisceral abdominal aortic aneurysm - Corrected Proof

2012-01-03

Objective: The use of fenestrated and branched stent graft technology for paravisceral abdominal aortic aneurysms (PAAA) is on the rise; however, its application is limited in the United States to only a few selected centers. Most PAAAs are currently repaired using an open approach. The objective of this study was to determine which patients are at highest risk with open PAAA repair and might benefit most from endovascular repair using fenestrated or branched stent grafts. Methods: This was a retrospective cohort study using data from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) hospitals. We identified 598 patients (27.5% women) who underwent elective open PAAA repair from the 2007 to 2009 NSQIP, a prospective database maintained at >250 centers. The main outcome measure was 30-day postoperative mortality. Results: The median patient age was 73 years. The 30-day major morbidity rate was 30.1%, and the mortality rate was 4.5%. Major complications included reintubation (10.0%), sepsis (10.7%), return to operating room (9.2%), new dialysis requirement (5.9%), cardiac arrest or myocardial infarction (4.5%), and stroke (1.2%). Multivariate analyses identified four predictors of postoperative mortality after open PAAA repair: peripheral arterial disease (PAD) requiring revascularization or amputation, chronic obstructive pulmonary disease (COPD), anesthesia time, and female sex. PAD and COPD were present in only 5.2% and 20.4% of patients but were associated with a 16.1% and 9.0% mortality rate, respectively. The mortality rate in women was 7.3% vs 3.5% for men (P = .045). Conclusions: PAD, COPD, and female sex are major risk factors for postoperative mortality after open PAAA repair. Fenestrated or branched stent graft repair may be a more valuable alternative to open repair for patients with one or more of these characteristics who have suitable access vessels.

A systematic review of symptomatic duodenal perforation by inferior vena cava filters - Corrected Proof

Rafael D. Malgor, Nicos Labropoulos — 2012-01-03

Objective: A systematic review of the literature on symptomatic duodenal perforation caused by inferior vena cava (IVC) filters. Method: Three databases, PubMed MEDLINE, Web of Sciences, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), reference lists of review articles and conference proceedings were searched. All articles containing data on clinical presentation, diagnostic strategy, and available treatment of symptomatic duodenal perforation caused by an IVC filter were included regardless of design, language, size, or length of follow-up. Results: Seventy-two articles were selected for full-text screening, being 21 case reports were selected. The median age was 46 years old (range, 21-83 years old). Abdominal pain was reported in 11 patients and gastrointestinal bleed in 5 patients. The indications for IVC filter placement in this cohort of patients were contraindication of anticoagulation and recurrent pulmonary embolism (PE) despite therapeutic levels in 8 and 5 patients, respectively. Three different imaging modalities were obtained in 9 patients (43%) before confirming the diagnosis. All but 1 patient underwent open approach through laparotomy with or without removal of the filter. No PEs or deaths were reported and only 1 patient had a severe clinical complication of IVC and bilateral iliac vein thrombosis with massive lower extremities edema. Conclusion: Duodenal perforation caused by IVC filters is a rare complication that frequently requires extensive workup. Excellent outcomes with low complication rate have been reported in cases where an open procedure was performed with either extraction of the filter or removal of the offending struts.

A meta-analysis of anticoagulation for calf deep venous thrombosis - Corrected Proof

2012-01-03

Purpose: This meta-analysis was initiated to assess the efficacy and safety of anticoagulation therapy for adult patients with isolated calf vein deep venous thrombosis (DVT). Methods: We searched MEDLINE (1950-October 2010), the Cochrane Library (1993-October 2010), trial registries, meeting abstracts, and selected references, using no limits. Included studies compared the results of anticoagulation (vitamin K antagonist or therapeutic heparin) for a minimum of 30 days vs the results of no anticoagulation in adults with calf vein DVT proved by ultrasound imaging or venograph who were monitored for at least 30 days. Two independent reviewers extracted data using a piloted standardized form. Methodologic quality was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Ottawa-Newcastle Quality Assessment Scale for cohort and case-control studies. Discrepancies were resolved by consensus or by a third reviewer. Authors were contacted for additional information if necessary. Outcomes were pooled using Peto fixed-effects models. Results: Of 2328 studies identified, two RCTs and six cohorts (126 patients treated with anticoagulation and 328 controls) met selection criteria. The methodologic quality of most studies was poor. Pulmonary embolism (PE; odds ratio, 0.12; 95% confidence interval, 0.02-0.77, P = .03) and thrombus propagation (odds ratio, 0.29; 95% confidence interval, 0.14-0.62, P = .04) were significantly less frequent in those who received anticoagulation. Significant heterogeneity existed in studies reporting mortality rates, but these demonstrated a trend toward fewer deaths with anticoagulation. When limited to randomized trials, the protective effect of anticoagulation for PE was no longer statistically significant, but the benefit for preventing thrombus progression persisted. Adverse events such as bleeding were sparsely reported, but favored controls (P = .65). Conclusions: Our review suggests that anticoagulation therapy for calf vein DVT may decrease the incidence of PE and thrombus propagation. However, due to poor methodologic quality and few events among included studies for PE, this finding is not robust. Thrombus propagation appears reduced with anticoagulation treatment. A rigorous RCT will assist in treatment decisions for calf vein DVT.