Perianeurysmal fibrosis: a relative contra-indication to endovascular repair.
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OBJECTIVE: Perianeurysmal fibrosis (PAF) with involvement of neighbouring viscera can render open repair of inflammatory aneurysms technically difficult and therefore hazardous. For this reason, endovascular repair (EVAR) has been advocated as the preferred approach for this condition. EVAR is known to induce a systemic inflammatory response in patients but the nature of the local response remains unknown. If significant, such a response could exacerbate rather than ameliorate PAF. The aim of the study was to examine the incidence, course and consequences of perianeurysmal fibrosis detected by computerised tomography (CT) before and after EVAR. MATERIAL AND METHODS: The clinical records of patients treated by EVAR and followed for at least 6 months were reviewed. Pre and post-operative CT images were independently graded for PAF by three radiologists according to a standard protocol. RESULTS: PAF was documented preoperatively in six out of a total of 61 patients. In two of these PAF worsened after EVAR resulting in ureteric obstruction and hydronephrosis requiring ureteric stents. In the remaining 4 patients PAF did not reduce postoperatively. PAF of low grade developed postoperatively in 10 out of 55 patients (18%) in whom there was no evidence of PAF on preoperative imaging. Median follow-up was 18 months (range 6-36 months). The development of periaortic fibrosis de novopostoperatively was statistically significant (McNemar's test p=0.002). CONCLUSION: EVAR does not seem to reverse PAF if this is present preoperatively and it induces this condition in approximately one sixth of patients without evidence of preoperative PAF. The potential for this adverse inflammatory local response should be taken into account when considering EVAR for treatment of aneurysms with perianeurysmal fibrosis and must be weighed against the perceived benefits of this approach. (+info)
Infrainguinal arterial reconstructions in patients with aortoiliac occlusive disease: the influence of iliac stenting.
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OBJECTIVE: Iliac artery angioplasty (IAA) is an effective adjunct when combined with infrainguinal arterial reconstructions (IARs) in appropriate patients with multilevel occlusive disease. However, the effect of iliac artery stenting (IAS) on the outcome of patients undergoing distal bypass procedures is not defined. The purpose of this study was to estimate the influence of previous IAS for iliac occlusive disease on the outcome of IARs, compared with those after IAA alone or aortofemoral bypass grafting procedures (AFBs). METHODS: During a 5-year period (1995-2000), 105 patients with previous intervention for iliac occlusive disease underwent 120 IARs. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed to define the variables. The TransAtlantic Inter-Society Consensus classification was used to characterize the type of iliac lesions. Univariate (Kaplan-Meier) and multivariate analyses (Cox proportional hazards model) were used to determine the association between preoperative variables and cumulative primary patency. RESULTS: Forty-five IARs were performed in patients with an earlier IAS repair, 33 in patients with an earlier IAA repair, and 42 in patients with an earlier AFB repair. There were not significant differences between patients in the IAS and IAA groups, except for a more frequent use of polytetrafluoroethylene grafts for IARs in the IAS group (40% vs 15%; chi(2) test, P = .03). The 5-year primary patency rate for IARs was 68% in the IAS group, 46% in the IAA group, and 61% in the AFB group. Univariate analyses revealed that primary patency rates for IARs in patients with previous IAS were significantly higher than those in the IAA group (Kaplan-Meier, log-rank test, P = .02). Previous IAA repair was associated with a two-fold increased risk of IAR graft failure (relative risk, 2.2; 95% CI, 1.1-4.8; P = .04). CONCLUSIONS: IARs in patients with previous IAS have significantly improved graft patency, compared with those in patients with previous IAA alone. Such graft patency for IAR after IAS is similar to that obtained after AFB repair. (+info)
Femoral artery infections associated with percutaneous arterial closure devices.
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Hemostasis obtained by manual compression after femoral artery catheterization results in consistently low rates of major complications. A rare complication of femoral artery catheterization is arterial infection. Its occurrence after diagnostic angiography using manual compression has not been reported. We report two cases of femoral arterial infection after uneventful diagnostic catheterization in nonimmunocompromised patients using the Perclose percutaneous arterial closure device. Our cases are representative of Perclose associated infections, with delayed presentation of a staphylococcal arterial infection requiring arterial debridement and reconstruction. This article indicates that Perclose use carries a risk of severe arterial infection. Surgeons should be aware of the potential infectious complications associated with Perclose use and the need for aggressive treatment. (+info)
Overt colon ischemia after endovascular aneurysm repair: the importance of microembolization as an etiology.
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OBJECTIVE: The purpose of this study was to analyze the incidence, severity, and etiologic factors of the development of colon ischemia after endovascular aortoiliac aneurysm repair (EVAR). METHODS: During the last 9 years we performed 278 elective EVARs using a variety of grafts. To facilitate these repairs, one hypogastric artery (HA) was coil embolized in 109 patients and both HAs were coil embolized in 13 patients. The preprocedural status of the inferior mesenteric, hypogastric, and iliac arteries as well as anatomical characteristics of the abdominal aortic aneurysm were determined arteriographically and by computerized tomographic scans. Postoperative colon ischemia was documented by colonoscopy or operative findings. RESULTS: Colon ischemia occurred in eight patients (2.9%). Three patients with colon ischemia died and had evidence of widespread (cutaneous, renal, small bowel, and/or lower extremity) microembolization. One of these three had a colectomy and microscopic emboli were present. One other patient who required a colectomy also had pathologic evidence of colonic microembolization but survived. Four other patients with colon ischemia were treated conservatively and survived. In one patient, previous colectomy with interruption of mesenteric collaterals may have been a contributory cause of colon ischemia. Of the eight patients with colon ischemia, only one had unilateral HA occlusion, and none had bilateral HA occlusion. The other 121 patients with unilateral and bilateral HA occlusion had no evidence of colon ischemia. CONCLUSIONS: Colon ischemia occurs after EVAR with an incidence approximating that of open repair. Colon ischemia was unrelated to HA interruption. Embolization appears to be a major cause of colon ischemia, although inadequate mesenteric collateral circulation may also play an etiologic role. Mortality with colon ischemia accompanied by widespread embolization was high, whereas colon ischemia without it was often mild and amenable to nonoperative management. (+info)
Risk of spinal cord ischemia after endograft repair of thoracic aortic aneurysms.
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BACKGROUND: Surgical repair of thoracoabdominal aneurysms may be associated with a significant risk of perioperative morbidity including spinal cord ischemia, which occurs at a rate of between 5% and 21%. Spinal cord ischemia after endovascular repair of thoracic aortic aneurysms (TAAs) has also been reported. This investigation reviews the occurrence of spinal cord ischemia after endovascular repair of descending TAAs at the Mount Sinai Medical Center. PATIENTS AND METHODS: Between May 1997 and April 2001, 53 patients underwent endovascular exclusion of their TAA. Preprocedure computed tomography scanning and angiography were performed on all patients. All were performed in the operating room using C-arm fluoroscopy. Physical examinations and computed tomography scans were performed at discharge and at 1, 3, 6, and 12 months postoperatively and then annually thereafter. Spinal cord ischemia developed in three of the 53 patients (5.7%) postoperatively. In one patient, cord ischemia developed that manifested as early postoperative left leg weakness occurring after concomitant open infrarenal abdominal and endovascular TAA repair. The neurologic deficit resolved 12 hours after spinal drainage, steroid bolus, and the maintenance of hemodynamic stability. The remaining two patients developed delayed onset paralysis, one patient on the second postoperative day and the other patient 1 month postrepair. Both of these patients had previous abdominal aortic aneurysm repair, and both required long grafts to exclude an extensive area of their thoracic aortas. Irreversible cord ischemia and paralysis occurred in both of these patients. CONCLUSIONS: Endovascular repair of TAA has shown a promising reduction in operative morbidity; however, the risk of spinal cord ischemia remains. Concomitant or previous abdominal aortic aneurysm repair and long segment thoracic aortic exclusion appear to be important risk factors. Spinal cord protective measures (ie, cerebrospinal fluid drainage, steroids, prevention of hypotension) should be used for patients with the aforementioned risk factors undergoing endovascular TAA repair. (+info)
Impact of reintervention for failing upper-extremity arteriovenous autogenous access for hemodialysis.
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PURPOSE: Although large published series have described their experience with the management of failed or failing prosthetic arteriovenous grafts for hemodialysis, there are scant data regarding failing arteriovenous fistulae (AVFs). To analyze the management of nonfunctioning or nonmaturing AVFs, we reviewed our experience with salvage procedures for these AVFs. MATERIALS AND METHODS: Of the 474 AVFs placed at our institution in 380 patients between June 1997 and March 2001, 75 revisions were performed in 46 patients (49 AVFs). Ages of these patients ranged from 29 to 94 years (mean, 68 +/- 1.4 years). Diabetic patients comprised 51%, and hypertensive patients comprised 75%. Twenty patients underwent 26 vein patch angioplasties, and 17 patients underwent 24 balloon angioplasties. Four patients required four vein interpositions, and 12 patients underwent 12 revisions of the fistula to a more proximal level. Extended salvage procedures consisted of four turn-downs to the basilic vein for proximal cephalic vein thrombosis or stenosis and five extension bypasses to the axillary or jugular vein for subclavian vein thrombosis. RESULTS: Follow-up ranged from 1 to 31 months (mean, 10 months). The patients who underwent open revisions tended to need fewer subsequent procedures. However, primary patency of the vein patch angioplasty was not significantly better as compared with balloon angioplasty (P = .8) by life table analysis. Patency after revision of a radial cephalic fistula and brachial cephalic fistula were not statistically different. One interposition failed during the follow-up, and one revision to a more proximal level thrombosed during the follow-up. Two of the turn-down procedures had thrombosed at 2 and 11 months. The remaining two turn-down procedures have remained functional at 1 and 24 months. One of the extensions thrombosed at 8 months whereas the other four have remained functional at 1, 6, and 8 months. CONCLUSIONS: Despite the limited follow-up data, this review suggests that simple and extended salvage procedures may allow maturation and add to the life span of AVFs for hemodialysis. In addition, these data suggest an advantage for open techniques as compared with percutaneous techniques but only in terms of requiring fewer subsequent procedures. (+info)
Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta.
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PURPOSE: The current therapy for type A aortic dissection is ascending aortic replacement. Operative mortality and morbidity rates have been markedly improved because of recent advances in surgical techniques and anesthesiology. However, type A aortic dissection with an entry tear in the descending thoracic aorta is still a surgical challenge because of the need for extensive aortic replacement. METHODS: Ten patients with type A aortic dissection were treated with endovascular stent-grafts. The false lumen of the ascending aorta was patent in five patients, and it was thrombosed in the other five patients. The entry tears were located in the descending thoracic aorta in all cases. Seven patients had acute dissection, and three patients had subacute dissection. Four patients had pericardial effusion. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Entry closure was achieved in all patients. Complete thrombosis of the false lumen of the ascending aorta was observed after stent-grafting in all patients. A second stent-graft was required in two patients to obtain complete thrombosis of the false lumen of the descending thoracic aorta. No procedure-related complications were observed, with the exception of a minor stroke in one patient. During a mean follow-up period of 20 months, no aortic rupture or aneurysm formation was noted in either the ascending or descending thoracic aorta, and all patients were alive and doing well. The abdominal aortic aneurysm enlarged after stent-grafting in one patient, and this was treated by closing the fenestrations of the abdominal aorta with stent-grafts. CONCLUSION: Stent-graft repair of aortic dissection with an entry tear in the descending thoracic aorta is a safe and effective method and may be an alternative to surgical graft replacement in highly selected patients. (+info)
Impact of exclusion criteria on patient selection for endovascular abdominal aortic aneurysm repair.
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PURPOSE: Wide-ranging predictions have been made about the usefulness of endovascular repair for patients with abdominal aortic aneurysms (AAAs). The availability of US Food and Drug Administration-approved devices has removed the restrictions on patient selection, which had been controlled by device trials. This study examined the applicability of endovascular AAA repair and identified the anatomic barriers to successful endovascular AAA repair that should guide future device development. METHODS: All patients who came to our institution for infrarenal AAA repair between April 1998 and June 2000 were offered evaluation for endovascular repair. Thin-cut spiral computed tomography scans and arteriograms were obtained on all patients, and their anatomic characteristics were prospectively entered into a database. A wide selection of available devices allowed the treatment of diverse AAA anatomic features. RESULTS: A total of 307 patients were examined (264 men, 43 women). Of these, 204 patients (66%; 185 men, 19 women) underwent endovascular repair, and 103 patients (34%, 79 men, 24 women) were rejected. Reasons for exclusion included short aneurysm neck (56, 54%), inadequate access because of small iliac arteries (48, 47%), wide aneurysm neck (41, 40%), presence of bilateral common iliac aneurysms extending to the hypogastric artery (22, 21%), excessive neck angulation (14, 14%), extensive mural thrombus in the aneurysm neck (10, 10%), extreme tortuosity of the iliac arteries (10, 10%), accessory renal arteries originating from the AAA (6, 6%), malignancy discovered during the examination (5, 5%), and death during the examination interval (2, 2%). Rejected patients had an average of 1.9 exclusion criteria (range, 1 to 4). A disproportionate number of women were excluded because of anatomic findings (P = .0009). Although 80% of patients who were at low risk for surgery qualified for endovascular repair, only 49% of our patients who were at high risk for surgery were acceptable candidates (P < .001). Of the 103 patients who were excluded, 34 (33%) underwent open surgical repair, and the remaining 69 (67%) were deemed to be unfit for open surgery. Three patients (1.4%) failed endograft placement because of inadequate vascular access. CONCLUSION: Most infrarenal AAAs (66%) can be treated with endovascular devices currently available commercially or through US Food and Drug Administration-approved clinical trials. However, patients who are at high risk for surgery and might benefit most from endovascular repair are less likely to qualify for the procedure (49%). Men (70%) are more likely than women (40%) to meet the anatomic criteria for endografting. Difficulties with vascular access and attachment site geometry predominate as reasons for exclusion. Our findings suggest that smaller profile devices, which can negotiate small and tortuous iliac arteries, are needed. Proximal and distal attachment site problems require devices that can accommodate wide and angulated attachment necks and achieve short seal zones. (+info)