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Credentials

Education ?

Medical School Score
Thomas Jefferson University (1977)
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Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Abdominal Aortic Aneurysm
Angioplasty
Blood Vessel Prosthesis Implantation
Thoracic Aortic Aneurysm
Vascular Surgical Procedures
Castle Connolly America's Top Doctors® (2005 - 2008, 2010 - 2015)
Appointments
University of Pennsylvania
Clyde F. Barker-William Maul Measey Professor of Surgery Chief, Vascular Surgery and Endovascular Therapy
Associations
American College of Surgeons
American Board of Surgery

Affiliations ?

Dr. Fairman is affiliated with 12 hospitals.

Hospital Affiliations

Score

Rankings

  • Hospital of the University of PA *
    3400 Spruce St, Philadelphia, PA 19104
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    Top 25%
  • Pennsylvania Hospital University PA Health System
    800 Spruce St, Philadelphia, PA 19107
    •  
    Top 25%
  • University of PA Medical Center/Presbyterian
    51 N 39th St, Philadelphia, PA 19104
    •  
    Top 50%
  • Jeanes Hospital
    7600 Central Ave, Philadelphia, PA 19111
    •  
    Top 50%
  • Graduate Hospital
    1800 Lombard St, Philadelphia, PA 19146
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  • American Oncologic Hospital TA Fox Chase Cancer Center
  • Clinical Practices of the University of Pennsylvania
  • Presbyterian Hospital
  • Fox Chase Cancer Center
    333 Cottman Ave, Philadelphia, PA 19111
  • Pennsylvania Hospital
  • Presbyterian Medical Center Of The University Of Pennsylvania Health System
  • University of Penn Med Center-Presb Med Group
  • * This information was reported to Vitals by the doctor or doctor's office.

    Publications & Research

    Dr. Fairman has contributed to 105 publications.
    Title Impact of Intercostal Artery Occlusion on Spinal Cord Ischemia Following Thoracic Endovascular Aortic Repair.
    Date December 2011
    Journal Vascular and Endovascular Surgery
    Excerpt

    To evaluate intercostal artery patency following thoracic endovascular aortic repair (TEVAR) and its relationship with spinal cord ischemia (SCI).

    Title ''relining'' of Thoracic Aortic Stent Grafts for Patients Presenting with Rupture/impending Rupture.
    Date October 2011
    Journal Vascular and Endovascular Surgery
    Excerpt

    To report a series of patients following thoracic endovascular aortic repair (TEVAR) presenting with rupture, who were effectively treated with TEVAR relining.

    Title Thoracic Endovascular Aortic Repair: Evolution of Therapy, Patterns of Use, and Results in a 10-year Experience.
    Date October 2011
    Journal The Journal of Thoracic and Cardiovascular Surgery
    Excerpt

    The introduction of aortic stent grafting in the treatment of thoracic aortic disease has pioneered unique treatment options and gained rapid clinical adoption despite a paucity of long-term outcome data. The purpose of this analysis is to examine all operations performed using thoracic aortic stent grafts at the University of Pennsylvania Health System.

    Title Endovascular Repair of Traumatic Thoracic Aortic Injury: Clinical Practice Guidelines of the Society for Vascular Surgery.
    Date January 2011
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    The Society for Vascular Surgery® pursued development of clinical practice guidelines for the management of traumatic thoracic aortic injuries with thoracic endovascular aortic repair. In formulating clinical practice guidelines, the Society selected a panel of experts and conducted a systematic review and meta-analysis of the literature. They used the Grading of Recommendations Assessment, Development and Evaluation methods (GRADE) to develop and present their recommendations. The systematic review included 7768 patients from 139 studies. The mortality rate was significantly lower in patients who underwent endovascular repair, followed by open repair, and nonoperative management (9%, 19%, and 46%, respectively, P < .01). Based on the overall very low quality of evidence, the committee suggests that endovascular repair of thoracic aortic transection is associated with better survival and decreased risk of spinal cord ischemia, renal injury, graft, and systemic infections compared with open repair or nonoperative management (Grade 2, Level C). The committee was also surveyed on a variety of issues that were not specifically addressed by the meta-analysis. On these select matters, the majority opinions of the committee suggest urgent repair following stabilization of other injuries, observation of minimal aortic defects, selective (vs routine) revascularization in cases of left subclavian artery coverage, and that spinal drainage is not routinely required in these cases.

    Title Comparative Effectiveness of the Treatments for Thoracic Aortic Transaction.
    Date January 2011
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    To synthesize the available evidence regarding the outcomes associated with nonoperative management, open repair, and endovascular repair of thoracic aortic transection.

    Title Thoracic Aortic Endograft Explant: a Single-center Experience.
    Date January 2011
    Journal Vascular and Endovascular Surgery
    Excerpt

    We report our experience following thoracic aortic endovascular repair (TEVAR) explant.

    Title Carotid Artery Stenting: Clinical Trials and Registry Data.
    Date December 2010
    Journal Seminars in Vascular Surgery
    Excerpt

    Despite the lack of Level I evidence, carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA). Furthermore, CAS has been met with considerable enthusiasm due to its minimally invasive nature and potential application to high-risk patient populations. Several investigations including multicenter registries and randomized controlled trials have been established and are currently underway in an effort to evaluate the noninferiority and efficacy of CAS as compared to CEA. To date, no trial has definitively shown equivalence of CAS to CEA for the treatment of carotid stenosis and consensus recommendations for use of CAS remain very restricted. Nevertheless, the existing data have provided useful information with respect to differential outcomes in subgroups, including symptom status, age, gender, and high-risk patient populations. Until the noninferiority of CAS is clearly demonstrated in a randomized controlled setting, CEA remains the gold standard for treatment of carotid stenosis and use of CAS must be carefully considered on an individual patient basis.

    Title Thoracic Endovascular Aortic Repair for Acute Complicated Type B Aortic Dissection: Superiority Relative to Conventional Open Surgical and Medical Therapy.
    Date December 2010
    Journal The Journal of Thoracic and Cardiovascular Surgery
    Excerpt

    This study compared outcomes between thoracic endovascular aortic repair and conventional open surgical and medical therapies for acute complicated type B aortic dissection.

    Title Limb Ischemia During Femoral Cannulation for Cardiopulmonary Support.
    Date October 2010
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    Extracorporeal membrane oxygenation and extracorporeal cardiopulmonary support (ECMO/CPS) are potentially life-saving techniques for patients with cardiopulmonary collapse. Complications include lower extremity ischemia from femoral artery cannulation. We examined the outcomes of patients placed on ECMO/CPS, including the rate of limb ischemia.

    Title Endovascular Repair of Extent I Thoracoabdominal Aneurysms with Landing Zone Extension into the Aortic Arch and Mesenteric Portion of the Abdominal Aorta.
    Date August 2010
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative for patients at prohibitive risk for open thoracic or thoracoabdominal surgery, decreasing perioperative morbidity and mortality. Aneurysms that involve both the left subclavian artery (LSA) proximally and the celiac artery (CA) distally present a unique challenge to the use of TEVAR. We report a series of six high-risk patients presenting with extent I thoracoabdominal aortic aneurysms who were successfully treated with TEVAR including coverage of the LSA and the CA.

    Title Incidence of and Outcomes After Misaligned Deployment of the Talent Thoracic Stent Graft System.
    Date May 2010
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    Various types of device-specific adverse events can occur during deployment of thoracic stent grafts due to the high flow rate and severe aortic angulation that is often encountered in the thoracic aorta. This study assessed the incidence, etiology, and overall effect of misaligned deployment of the Talent Thoracic Stent Graft (TSG) System. Techniques to predict and avoid this complication are discussed.

    Title Revised Cardiac Risk Index (lee) and Perioperative Cardiac Events As Predictors of Long-term Mortality in Patients Undergoing Endovascular Abdominal Aortic Aneurysm Repair.
    Date May 2010
    Journal Journal of Cardiothoracic and Vascular Anesthesia
    Excerpt

    To determine if the Revised Cardiac Risk Index (Lee) is useful for stratification of patients by risk of both perioperative cardiac morbidity and long-term all-cause mortality in the setting of endovascular repair of abdominal aortic aneurysms.

    Title A Composite Approach to Thoracic Aortic Stent Grafting.
    Date March 2010
    Journal Vascular and Endovascular Surgery
    Excerpt

    Thoracic endovascular aortic repair has become the preferred modality for the treatment of diverse aortic pathologies of the thoracic aorta. This report is the first to describe the use of 2 different devices for successful exclusion of a dissecting thoracic aneurysm.

    Title Celiac Artery Aneurysm Repair in Behcet Disease Complicated by Recurrent Thoracoabdominal Aortic Aneurysms.
    Date March 2010
    Journal Vascular and Endovascular Surgery
    Excerpt

    Behçet's disease is a chronic, relapsing multisystemic inflammatory disorder characterized by recurrent orogenital aphthous ulcers, uveitis, and skin lesions. Vascular involvement occurs in up to 38% of these patients. Herein, we report a 19-year-old male who initially presented with an isolated celiac artery aneurysm that was treated with open surgical repair. The patient was subsequently diagnosed with Behçet's disease after the development of oral aphthous ulcers and multiple recurrent postoperative deep venous thromboses and thoracoabdominal arterial aneurysms. Ultimately, a hybrid approach was undertaken. This is the fifth celiac artery aneurysm ever reported in this patient group and the first to present with an isolated celiac artery aneurysm as the initial manifestation of Behçet's disease.

    Title The Society for Vascular Surgery Practice Guidelines: Management of the Left Subclavian Artery with Thoracic Endovascular Aortic Repair.
    Date November 2009
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    The Society for Vascular Surgery pursued development of clinical practice guidelines for the management of the left subclavian artery with thoracic endovascular aortic repair (TEVAR). In formulating clinical practice guidelines, the society selected a panel of experts and conducted a systematic review and meta-analysis of the literature. They used the grading of recommendations assessment, development, and evaluation (GRADE) method to develop and present their recommendations. The overall quality of evidence was very low. The committee issued three recommendations. Recommendation 1: In patients who need elective TEVAR where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest routine preoperative revascularization, despite the very low-quality evidence (GRADE 2, level C). Recommendation 2: In selected patients who have an anatomy that compromises perfusion to critical organs, routine preoperative LSA revascularization is strongly recommended, despite the very low-quality evidence (GRADE 1, level C). Recommendation 3: In patients who need urgent TEVAR for life-threatening acute aortic syndromes where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest that revascularization should be individualized and addressed expectantly on the basis of anatomy, urgency, and availability of surgical expertise (GRADE 2, level C).

    Title The Effect of Left Subclavian Artery Coverage on Morbidity and Mortality in Patients Undergoing Endovascular Thoracic Aortic Interventions: a Systematic Review and Meta-analysis.
    Date November 2009
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    Thoracic endografts (stent grafts) have emerged as a less invasive modality to treat various thoracic aortic lesions. The intentional coverage of the left subclavian artery (LSA) during the placement of these endografts is associated with several complications including stroke, spinal cord ischemia, and arm ischemia. In this review, we synthesize the available evidence regarding the complications associated with LSA coverage.

    Title The Phase I Multicenter Trial (staple-1) of the Aptus Endovascular Repair System: Results at 6 Months and 1 Year.
    Date April 2009
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    This phase I IDE study (STAPLE-1) evaluated the primary endpoints of safety (major device-related adverse events at 30 days) and feasibility (successful deployment of all endograft components) of the Aptus Endovascular abdominal aortic aneurysm (AAA) Repair System (Aptus Endosystems, Inc, Sunnyvale, Calif) to treat AAAs.

    Title The Outcome of Thoracic Endovascular Aortic Repair (tevar) in Patients with Renal Insufficiency.
    Date February 2009
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    We sought to determine the effects of renal insufficiency on thoracic endovascular aortic repair (TEVAR) outcome and to identify predictors for adverse events.

    Title The Role of Svs Volunteer Vascular Surgeons in the Care of Combat Casualties: Results from Landstuhl, Germany.
    Date February 2009
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    With a shortage of active duty vascular surgeons in the military, Society for Vascular Surgery (SVS) members have been called upon to perform short-term rotations at Landstuhl Regional Medical Center (LRMC), the US military's receiving facility for combat injuries sustained in the Iraq and Afghanistan conflicts. From September 2007 to May 2008, 20 SVS vascular surgeons have performed 2-week rotations at LRMC through American Red Cross and US Army sponsorship. Volunteers were surveyed for previous military and/or trauma experience. In addition to reporting number and types of procedures performed, volunteers were queried on their experience and impression of the rotation. Several volunteers have had prior military experience and all have had vascular trauma experience through residency, fellowship, and current practices. With most definitive vascular repairs being done in theater, SVS members were most often called upon for clinical expertise in the care of combat casualties and evaluation of revascularization procedures. The volunteers contributed to daily rounds, patient care, and teaching conferences, as well as actively participated in surgical procedures with the most common being wound examinations under anesthesia for which intraoperative vascular consultation was occasionally requested (5-20 per volunteer). Additional procedures that volunteers performed included: inferior vena cava (IVC) filter placement, thrombectomy, revision of lower and upper extremity interposition vein grafts, retroperitoneal spine exposures, diagnostic and therapeutic angiograms, iliac stenting, and duplex ultrasound scan interrogation of vascular repairs, suspected arterial injuries, and deep vein thrombosis. All volunteers described the experience as valuable and will return if needed. With a limited number of military vascular surgeons and the unpredictable need for a vascular specialist at LRMC, civilian volunteers are playing an important role in providing high-quality vascular care for the nation's wounded soldiers by expanding vascular and endovascular capability at LRMC and contributing to general surgical critical care. As volunteers, SVS members are carrying on a tradition started by our surgical forefathers during previous US military conflicts.

    Title Pivotal Results of the Medtronic Vascular Talent Thoracic Stent Graft System: the Valor Trial.
    Date September 2008
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: This report summarizes the 30-day and 12-month results of endovascular treatment using the Medtronic Vascular Talent Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, Calif) for patients with thoracic aortic aneurysms (TAA) who are considered candidates for open surgical repair. METHODS: The study was a prospective, nonrandomized, multicenter, pivotal trial conducted at 38 sites. Enrollment occurred between December 2003 and June 2005. Standard follow-up interval examinations were prescribed at 1 month, 6 months, 1 year, and annually thereafter. These endovascular results were compared with retrospective open surgical data from three centers of excellence. RESULTS: The Evaluation of the Medtronic Vascular Talent Thoracic Stent Graft System for the Treatment of Thoracic Aortic Aneurysms (VALOR) trial enrolled 195 patients, and 189 were identified as retrospective open surgical subjects. Compared with the open surgery group, the VALOR test group had similar age and sex distributions, but had a smaller TAA size. Patients received a mean number of 2.7 +/- 1.3 stent graft components. The diameters of 25% of the proximal stent graft components implanted were <26 mm or >40 mm. Left subclavian artery revascularization was performed before the initial stent graft procedure in 5.2% of patients. Iliac conduits were used in 21.1% of patients. In 33.5% of patients, the bare spring segment of the most proximally implanted device was in zones 1 or 2 of the aortic arch. In 194 patients (99.5%), vessel access and stent graft deployment were successful at the intended site. The 30-day VALOR results included perioperative mortality, 2.1%; major adverse advents, 41%; incidence of paraplegia, 1.5%; paraparesis, 7.2%; and stroke, 3.6%. The 12-month VALOR results included all-cause mortality, 16.1%; aneurysm-related mortality, 3.1%; conversion to open surgery, 0.5%; target aneurysm rupture, 0.5%; stent graft migration >10 mm, 3.9%; endoleak (12.2%), stent graft patency, 100%; stable or decreasing aneurysm diameter, 91.5%; and loss of stent graft integrity, four patients. No deployment-related events or perforation of the aorta by a graft component occurred. The Talent Thoracic Stent Graft showed statistically superior performance with respect to acute procedural outcomes (P < .001), 30-day major adverse events (41% vs 84.4%, P < .001), perioperative mortality (2% vs 8%, P < .01), and 12-month aneurysm-related mortality (3.1% vs 11.6%, P < .002) vs open surgery. CONCLUSIONS: The pivotal VALOR 12-month trial results demonstrate that the Medtronic Talent Thoracic Stent Graft System is a safe and effective endovascular therapy as an alternative to open surgery in patients with TAA who were considered candidates for open surgical repair.

    Title Left Subclavian Artery Coverage During Thoracic Endovascular Aortic Repair: a Single-center Experience.
    Date September 2008
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: This study was conducted to determine the results of left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR). METHODS: We retrospectively reviewed the results of 308 patients who underwent TEVAR from 1999 to 2007. The LSA was completely covered in 70 patients (53 men, 13 women), with a mean age of 67 years (range 41-89). Elective revascularization of the LSA was performed in 42 cases, consisting of transposition (n = 5), bypass and ligation (n = 3), or bypass and coil embolization (n = 34). Mean follow-up was 11 months (range, 1-48 months). The chi(2) test was used for statistical analysis. RESULTS: Indications for treatment included aneurysm in 47, dissection in 16, transection in 4, pseudoaneurysm in 2, and right subclavian aneurysm in 1, with 47 elective and 23 emergency operations. Aortic coverage extended from the left common carotid artery (LCCA) to the distal arch (n = 29), middle thoracic aorta (n = 9), or celiac artery (n = 32). Operative success was 99%. The 30-day mortality was 4% (intraoperative myocardial infarction, 1; traumatic injuries, 1; visceral infarction, 1). No paraplegia developed. The stroke rate was 8.6%; no strokes were related to LSA coverage because there were no posterior strokes. Stroke rates between the revascularization (7%) and non-revascularization (11%) groups were not significantly different (P = .6). All but one patient fully recovered by 6 months. No left arm symptoms developed in patients with LSA revascularization. All bypasses remained patent throughout follow-up. One complication (2%) resulted in an asymptomatic persistently elevated left hemidiaphragm, likely related to phrenic nerve traction. Left upper extremity symptoms developed in five (18%) patients without LSA revascularization. Two required LSA revascularization, one of which was for acute limb-threatening ischemia. No permanent left upper extremity dysfunction or ischemia developed in any patient. CONCLUSION: Zone 2 TEVAR with LSA coverage can be accomplished safely in both elective and emergency settings and with and without revascularization (with the exception of a patent LIMA-LAD bypass). Nevertheless, overall stroke rates are higher compared with all-zone TEVAR. Staged LSA revascularization and even urgent revascularization may be necessary but can be performed without long-term detriment to the left arm.

    Title Carotid Artery Stenting: Identification of Risk Factors for Poor Outcomes.
    Date August 2008
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVES: Age greater than 80 has been identified as a risk factor for complications, including stroke and death, in patients undergoing carotid artery angioplasty and stenting (CAS). This study evaluates other potential predictors of perioperative complications in patients undergoing CAS. METHODS: All cerebrovascular endovascular procedures performed by the vascular surgery division at our university hospital between July 2003 and December 2005 were retrospectively examined. During the course of 212 admissions, 198 patients underwent 215 procedures. Patient age, comorbidities, and admission status were analyzed as independent (predictor) variables. Complication rate, discharge disposition, and length of hospital stay were considered dependent (outcome) variables. Logistic regression and Fisher exact test or Student t test were performed, as appropriate. RESULTS: Complications included major and minor stroke, myocardial infarction, femoral artery pseudoaneurysm, and death. The rates of perioperative major and minor stroke were 0.5% and 2.8%, respectively. Chronic renal insufficiency was a predictor of perioperative complications, including stroke: patients with serum creatinine greater than 1.3 mg/dL had a 37% complication rate and a 11.1% stroke rate, while those with normal renal function had a 13% complication rate (P = .003) and a 0.6% stroke rate (P =.001). Similar association was seen between creatinine clearance and both stroke and complications. Obesity was a risk factor for complications, but not stroke: obese patients had a complication rate of 28%, while others had a 16% complication rate (P = .024). Emergency admission predicted both extended hospital stay (P < .001) and requirement for further inpatient care in a rehabilitation or nursing facility (P = .007). There was no significant difference in complication rate or stroke rate between octogenarians and others. CONCLUSION: This experience demonstrates that chronic renal insufficiency, obesity, and emergent clinical setting are risk factors for patients undergoing CAS.

    Title Results of a New Surgical Paradigm: Endovascular Repair for Acute Complicated Type B Aortic Dissection.
    Date July 2008
    Journal The Annals of Thoracic Surgery
    Excerpt

    BACKGROUND: Conventional open repair of acute complicated type B aortic dissection is associated with significant morbidity and mortality. This study examined the results of thoracic endovascular aortic repair (TEVAR) in acute type B aortic dissection complicated with rupture or malperfusion syndrome. METHODS: From 2004 through 2007, 35 patients (22 men) with acute complicated type B aortic dissection were treated with TEVAR. Indications included rupture in 18 (51.4%) and malperfusion syndrome in 17 (48.6%; mesenteric or renal, 5;lower extremities, 3; both, 9). Three types of endograft devices were used (mean per patient, 1.9 devices). Intravascular ultrasound imaging was used in 15 patients (42.8%). In patients with malperfusion syndrome, distal adjunct procedures to expand the true lumen included infrarenal aortic stents in 4, mesenteric/renal stents in 4, and iliofemoral stents in 7. Follow-up was 93.9% during a period of 18.3 months (range, 3 to 47 months). RESULTS: The mean age was 58.6 +/- 13.4 years. Technical success (coverage of the primary tear site) was achieved in 34 patients (97.1%). Coverage of the left subclavian artery was required in 25 patients (71.4%). Thirty-day mortality was 2.8%. One-year survival was 93.4% +/- 4.6%. Complications included permanent renal failure (2.8%), stroke (2.8%), spinal cord ischemia (transient [5.7%], permanent [(2.8%]), and vascular access (14.2%). The mean intensive care unit and hospital stay were 4.7 +/- 2.6 and 16.7 +/- 12.0 days, respectively. CONCLUSIONS: Endovascular repair of acute complicated type B aortic dissection is associated with low morbidity and mortality and has emerged as the surgical therapy of choice.

    Title Risk Factors for Perioperative Stroke After Thoracic Endovascular Aortic Repair.
    Date December 2007
    Journal The Annals of Thoracic Surgery
    Excerpt

    BACKGROUND: Stroke has emerged as an important complication of thoracic endovascular aortic repair (TEVAR). Identifying risk factors for stroke is important to define the risks of this procedure. METHODS: All neurologic complications were analyzed in a prospective database of patients in thoracic aortic stent graft trials from 1999 to 2006. Serial neurological examination was performed. Stroke was defined as any new onset focal neurologic deficit. RESULTS: The TEVAR was performed on 171 patients; 52 had lesions requiring coverage of the proximal descending thoracic aorta (extent A), 50 requiring coverage of the distal descending aorta (extent B), and 69 requiring coverage of the entire descending thoracic aorta (extent C). The incidence of stroke was 5.8%. Eighty-nine percent (8 of 9) of strokes occurred within 24 hours of operation. Stroke was associated with a 33% in-hospital mortality rate. Risk factors identified for stroke included prior stroke (odds ratio [OR] 9.4, confidence interval [CI] 2.3 to 38.1, p = 0.002) and extent A or C coverage (OR 5.5, CI 1.7-12.5, p = 0.001). The stroke rate in patients with both prior stroke and extent A or C coverage was 27.7%. Severe atheromatous disease involving the aortic arch by computed tomographic scan was strongly associated with perioperative stroke (OR = 14.8, CI 1.7 to 675.6, p = 0.0016). Transesophageal echocardiography demonstrated mobile atheroma in two patients with stroke. CONCLUSIONS: Stroke after TEVAR was associated with a high mortality. The TEVAR of the proximal descending aorta (extent A or C) in patients with a history of stroke had the highest perioperative stroke rate. These risk factors, together with high grade aortic atheroma of the aortic arch, predicted a high probability for cerebral embolization and can be used to identify patients at high risk for stroke as a consequence of TEVAR.

    Title Spinal Cord Ischemia May Be Reduced Via a Novel Technique of Intercostal Artery Revascularization During Open Thoracoabdominal Aneurysm Repair.
    Date October 2007
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: To describe a novel technique for maximal reimplantation of intercostal arteries during thoracoabdominal aortic aneurysm repair. METHODS: Eight patients underwent thoracoabdominal aortic aneurysm (TAAA) repair with this new technique from 2005 to 2006. Follow-up ranged from 6 to 14 months. All patients had a previous type B dissection with subsequent aneurysmal degeneration into an extent I TAAA. Aneurysm repair was performed through a thoracoabdominal incision and circulatory arrest in seven and left atrial-left femoral (LA-FA) bypass in one. The grafts extended from the distal arch at the subclavian artery to the visceral and renal arteries. An 8 mm graft was then extended from the proximal to the distal graft with a spatulation of the graft allowing a side-to-side anastomosis of the graft to the posterior aortic wall incorporating multiple pairs of intercostal arteries. Intraoperative electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) were monitored during each operation. RESULTS: All patients were ambulatory at the time of admission. One patient had suffered a previous spinal cord infarction from the original dissection and had residual unilateral leg weakness prior to the TAAA repair. There was an average of seven pairs of patent intercostal arteries upon opening the aorta. We reimplanted an average of five pairs of vessels. There were no perioperative complications. No patients sustained transient or permanent paraplegia in the postoperative or follow-up period. The one patient with preoperative leg weakness had reported subjective increased strength in the affected leg after the operation. In four cases, normalization of SSEP waveforms did not occur until after reimplantation of the intercostal arteries despite full return of EEG waveforms, restoration of lower extremity perfusion, and rewarming of the patient. Follow-up CT scan angiogram demonstrated that all reconstructions were patent through the follow-up period. CONCLUSIONS: Paraplegia is an extremely morbid complication associated with TAAA repair. We describe a technique that allows reimplantation of almost all intercostal arteries as one patch circumventing the need for selective reimplantation. Furthermore, our technique ensures continued patency of this patch graft as the outflow resistance is decreased by creating a continuous flow loop. Although this is a small case series, we had no incidence of acute or delayed paraplegia in this high risk group. Our technique of intercostal reimplantation is applicable to all open TAAA repair at high-risk for paraplegia and may be an important adjunct in preventing spinal cord ischemia.

    Title The Hybrid Total Arch Repair: Brachiocephalic Bypass and Concomitant Endovascular Aortic Arch Stent Graft Placement.
    Date August 2007
    Journal Journal of Cardiac Surgery
    Excerpt

    BACKGROUND: Repair of aortic arch aneurysm is technically demanding, requiring complex circulatory management. Very large atherosclerotic saccular aneurysms of the arch are grave markers of extensive arch and brachiocephalic atheromatous disease and represent high surgical risks for perioperative neurologic complications. Operative morbidity and mortality may be prohibitive with traditional surgical intervention. We described our experience with a hybrid procedure for total arch repair with a brachiocephalic bypass with a trifurcated graft followed by concomitant placement of a stent graft in the arch. METHODS: Since June 2005, we have performed the hybrid total arch repair in eight patients. A retrospective review was performed to evaluate the new technique. RESULTS: The mean age of the patients was 67 years with a mean aneurysm size of 8 cm (range, 4.4 to 10 cm). Significant comorbidities included carotid stenosis, chronic renal insufficiency, peripheral vascular disease, hypertension, and coronary artery disease. Two patients had previous Abdominal aortic aneurysm (AAA) repairs. Three patients had previous sternotomy for type A dissection, ascending aortic aneurysm repair, and coronary artery bypass grafting. Transesophageal echocardiogram demonstrated grade IV or V atheromatous disease in the arch and ascending aorta. Stent grafts were deployed antegrade directly into the ascending aorta in three patients and retrograde from the femoral artery in five patients. Technical success with complete aneurysmal exclusion was achieved in all patients (100%). At a mean follow-up period of 11.7 months, there was no incidence of endoleak. There was one death resulting from a perioperative myocardial infarction (first patient). Documented perioperative neurologic events (stroke) occurred in two patients, with both patients demonstrating no residual deficit at the time of discharge. CONCLUSIONS: Saccular arch aneurysms can be technically treated by total arch repair with brachiocephalic bypass and concomitant aortic arch stent graft placement. Hybrid arch repair provides an alternative to patients otherwise considered prohibitively high risk for traditional open arch repair.

    Title Differential Effects of Carotid Artery Stenting Versus Carotid Endarterectomy on External Carotid Artery Patency.
    Date July 2007
    Journal Journal of Endovascular Therapy : an Official Journal of the International Society of Endovascular Specialists
    Excerpt

    PURPOSE: To determine the effect of stent coverage of the external carotid artery (ECA) after carotid artery stenting (CAS) compared to eversion endarterectomy of the ECA after carotid endarterectomy (CEA). METHODS: The records of 101 CAS and 165 CEA procedures performed over 2 years were reviewed. Duplex velocities and history and physical examinations were taken prior to the procedure, at 1 month, and at 6-month intervals subsequently. CAS was performed by extending the stent across the internal carotid artery (ICA) lesion into the common carotid artery (CCA) thereby covering the ECA. CEA was performed with eversion endarterectomy of the ECA. RESULTS: The mean peak systolic velocities (PSV) in the ICA pre-CAS and pre-CEA were 361 and 352 cm/s, respectively. In terms of CAS, there was a significant increase in ECA velocities versus baseline at 12 (p = 0.009), 18 (p = 0.00001), and 24 (p = 0.005) months. In the CEA group, there was a significant decrease in ECA velocities versus baseline at 1 (p = 0.01) and 6 (p = 0.004) months. There were 2 occluded ECAs in follow-up in the CAS group and none in the CEA group. No significant differences were noted when comparing preprocedural ICA or ECA velocities. However, at the 1-, 6-, and 12-month intervals, the ECA velocities in the CAS group were significantly higher than in the CEA group (p = 0.03, p = 0.001, and p = 0.0004, respectively). There were no neurological symptoms in any patients during the study period. CONCLUSION: Although progressive stenosis of the ECA is noted during CAS, the ECA usually does not occlude. Furthermore, there are no associated neurological symptoms. Thus, apprehension for progressive ECA occlusion should not be a contraindication to CAS. In addition, concern for ECA coverage should not deter stent extension from the ICA to the CCA during CAS.

    Title Anatomic Exclusion from Endovascular Repair of Thoracic Aortic Aneurysm.
    Date May 2007
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVES: We sought to define the current anatomic barriers to thoracic aortic aneurysm (TAA) stent grafting to guide future device development. METHODS: All patients presenting with TAA requiring repair were evaluated for endovascular repair during a 4-year period (2000 to 2004). The TAAs evaluated were those beginning distal to the left common carotid artery (LCCA) and ending proximal to the celiac artery. All patients in whom endovascular repair was indicated underwent cross-sectional imaging by computed tomography angiography and three-dimensional modeling of their thoracic and abdominal arterial anatomy. Patients were evaluated for endovascular TAA repair in the context of the inclusion/exclusion criteria of pivotal United States Food and Drug Administration trials of the Gore TAG and Medtronic Talent devices. Anatomic requirements included >or=20 mm of suitable proximal and distal neck length, and proximal and distal neck diameters of 20 to 42 mm. These trials allowed the use of femoral or iliac access, including the use of conduits, and permitted stent graft coverage of the left subclavian artery (LSA) after preliminary carotid-subclavian bypass. Patients rejected for medical reasons or who died during evaluation were not included in the review. RESULTS: A total of 126 patients (73 men, 53 women) with TAA located between the LCCA and celiac artery were screened for endovascular repair, and 33 (26%) were rejected for anatomic reasons. The remaining 93 patients underwent endografting (59 Talent, 34 TAG). Rejection was not significantly different by gender (16/73 men, 17/53 women, P = .22, NS). Most patients (28/33) were rejected for more than one criterion. Hostile proximal neck characteristics were the most prevalent reason for disqualification, despite the ability to cover the LSA to extend the proximal seal zone. Many of these patients (16/28) also had distal neck anatomy unsuitable for grafting. Overall, 19 patients had hostile distal necks. Difficulties with vascular access (diseased or tortuous iliac arteries, or a small caliber aorta) that could not be overcome even by use of conduits occurred in a significant fraction of patients (10/33). CONCLUSIONS: Most patients with a TAA located between the LCCA and the celiac artery can be treated by endovascular repair. Patients excluded from TAA stent graft protocols for anatomic reasons most commonly have hostile proximal neck features that preclude endovascular repair with currently available devices. Transposition of arch vessels to facilitate greater use of existing stent grafts or development of new stent graft designs are needed to expand the applicability of TAA endovascular repair.

    Title Detection of Endoleaks After Endovascular Aneurysm Repair with Use of Technetium-99m Sulfur Colloid and (99m)tc-labeled Red Blood Cell Scans.
    Date March 2007
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: This study was performed to determine whether endoleaks could be detected after endovascular aneurysm repair (EVAR) with use of technetium-99m sulfur colloid and (99m)Tc-labeled red blood cell (RBC) nuclear medicine scans. MATERIALS AND METHODS: There were 13 patients enrolled in this study: nine with endoleaks seen on computed tomographic (CT) angiography and four with no endoleak on CT angiography. All patients underwent regularly scheduled surveillance CT angiography examination after EVAR to evaluate for endoleak. Endoleak detection was then attempted in each patient with two nuclear medicine scans: a (99m)Tc sulfur colloid scan and a (99m)Tc-labeled RBC scan. Flow images (5 seconds per frame) were obtained for 1 minute after intravenous administration of 555 MBq (15 mCi) (99m)Tc sulfur colloid. Sequential dynamic images were then obtained every minute for 30 minutes. Next, a (99m)Tc-labeled RBC study was performed after the intravenous administration of 370-1,073 MBq (10-29 mCi) in vitro labeled (99m)Tc RBCs. Flow images were obtained, followed by sequential dynamic images obtained every minute for 30 minutes. Single photon emission CT images of the abdomen were then acquired. The nuclear medicine scans were evaluated for the presence or absence of endoleak independent of the CT angiography findings. RESULTS: Of the nine patients with endoleaks on CT angiography, seven (78%) had them detected by nuclear medicine examinations. Two of the nine endoleaks seen on CT angiography (22%) were not seen on either scintigraphic examination. All patients with no endoleak on CT angiography had their nuclear medicine scans correctly interpreted as showing no endoleak present (n = 4; 100%). No complications occurred as a result of the nuclear medicine scans. CONCLUSIONS: Endoleaks can be detected with (99m)Tc sulfur colloid and (99m)Tc-labeled RBC nuclear medicine scans. This initial work suggests that the sensitivities of these scintigraphic scanning methods for endoleak detection are lower than that of CT angiography.

    Title Femoral Neuropathy Following Retroperitoneal Hemorrhage: Case Series and Review of the Literature.
    Date January 2007
    Journal Annals of Vascular Surgery
    Excerpt

    Femoral neuropathy due to retroperitoneal hematoma has been infrequently described in the literature. While occasionally due to trauma, it has been most commonly reported in association with various bleeding diatheses and therapeutic anticoagulation. As the indications for the use of anticoagulants and antiplatelet agents increase, associated hemorrhagic complications will likely also increase. The management of retroperitoneal hematoma with consequent femoral nerve palsy remains controversial. We present a series of four cases of femoral nerve palsy due to retroperitoneal hematoma managed by surgical decompression. Hematoma evacuation at the time of the development of femoral neuropathy results in immediate benefit, with greater likelihood of a return to pre-event neurological status. Delays in operative treatment, despite the presence of a neurological deficit, may lead to significant and prolonged neurological dysfunction. Surgical decompression should be highly considered in all patients who develop femoral neuropathy from a retroperitoneal hematoma.

    Title Techniques for Preserving Vertebral Artery Perfusion During Thoracic Aortic Stent Grafting Requiring Aortic Arch Landing.
    Date January 2007
    Journal Vascular and Endovascular Surgery
    Excerpt

    Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.

    Title Risk Factors for Restenosis After Carotid Artery Angioplasty and Stenting.
    Date November 2006
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVES: With carotid artery stenting (CAS) becoming an ever-increasing procedure, we sought to determine risk factors for in-stent restenosis after CAS. METHODS: Consecutive patients undergoing CAS between January 2002 and October 2004 at a tertiary care hospital were retrospectively reviewed. Patient, filter, and stent selection were left to the discretion of the attending surgeon. High-risk patients were defined by significant comorbidities or a hostile neck (prior surgery or radiation, or both), and risk factor analysis was performed. In-stent restenosis was defined as >60%, and selective angiography was performed on patients with an in-stent restenosis >80% by duplex ultrasound imaging. RESULTS: Reviewed were 101 patients (55 men, 46 women) who underwent 109 CAS procedures. Comorbidities were typical for patients with atherosclerosis. In addition, 38% (n = 41) of procedures were performed in patients who had prior neck surgery, of which 29% (n = 32) had previous ipsilateral carotid endarterectomy. Seventeen patients (16%) had a history of neck cancer, and all had prior neck radiation. Median follow-up was 5 months (range, 0 to 30 months). Neurologic complications included three transient ischemic attacks (2.8%) and one nondisabling stroke (0.9%). There were two myocardial infarctions (1.9%) and no periprocedural deaths (30 days), for a combined stroke, myocardial infarction, and death rate of 2.9%. Asymptomatic in-stent restenosis developed in 12 carotids (11%), five of which required endovascular intervention, with a mean of 6 months to restenosis. Univariate Cox proportional hazard regression models were used to determine risk factors for the development of restenosis. Prior stroke, transient ischemic attack, amaurosis fugax, and prior neck cancer were all significant risk factors. When these significant risk factors from univariate analysis were put into multivariate analysis, however, the only marginally significant risk factor was prior neck cancer (P = .06). Kaplan-Meier analysis revealed a cumulative freedom from in-stent restenosis at 24 months of 88% +/- 6% in patients without neck cancer compared with 27% +/- 17% (P = .02) in patients with neck cancer. CONCLUSIONS: CAS has been shown to be safe and effective in high-risk patients, with minimal adverse events.

    Title Barriers to Endovascular Aortic Aneurysm Repair: Past Experience and Implications for Future Device Development.
    Date October 2006
    Journal Vascular and Endovascular Surgery
    Excerpt

    Despite improvements in endovascular aortic aneurysm repair (EVAR) devices and techniques, significant anatomic constraints still preclude successful EVAR in a large number of patients. The authors sought to identify the current barriers to EVAR and examine their evolution over time. Patients were evaluated for potential endovascular repair by computed tomography angiography (CTA) with or without supplemental conventional arteriograms. The patient population was separated into 2 groups (A and B) based on early and late time periods in the experience with EVAR, corresponding to the availability of various devices. Group A (early) consisted of the Guidant Ancure, Medtronic Talent, and AneuRx devices and comprised patients presenting between April 1997 through June 2000. Group B (late) consisted of the Medtronic AneuRx, Cook Zenith, Edwards Lifepath, Gore Excluder, and Endologix PowerLink devices and comprised patients presenting between July 2000 and December 2003. Patient demographics and anatomic reasons for rejection were recorded in a database for statistical analysis. In total, 547 patients were evaluated (463 men, 84 women). Of these, 346 patients (63%; 312 men, 34 women) were deemed suitable candidates for EVAR and 201 (37%; 151 men, 50 women) were rejected. There was no significant difference in the overall rate of rejection in the early vs the late time period (34% A, 41% B, p = 0.08), but the number of exclusion criteria per patient decreased over time; patients rejected for EVAR had an overall average of 1.6 exclusion criteria (Group A, 1.9; Group B, 1.2). The reasons for rejection did significantly change over time. Specifically, rejection on the basis of inadequate arterial access, presence of extensive iliac artery aneurysms, or an inadequate proximal neck decreased. A disproportionate number of women were excluded throughout the study: Group A, 56% of women compared to 30% of men (p = 0.0003); Group B, 63% of women compared to 36% of men (p = 0.0022). Women were more likely than men to have inadequate arterial access routes. In addition, patients with high operative risk were also more likely to be excluded from EVAR, a finding that persisted over time. Anatomic constraints continue to pose significant challenges to aortic endografting. Progress has been made in that technological advances have conquered some of the previous anatomic challenges, chiefly those of arterial access and treatment of concomitant iliac aneurysm disease. However, the overall rate of rejection for EVAR remains the same. The chief anatomic barriers continue to be the difficult aortic neck and management of branched vascular segments.

    Title A Comparison of Renal Function Between Open and Endovascular Aneurysm Repair in Patients with Baseline Chronic Renal Insufficiency.
    Date October 2006
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: Endovascular aneurysm repair (EVAR) is rapidly becoming the predominant technique for repair of abdominal aortic aneurysms. Results from current studies, however, are conflicting on the effect of EVAR on renal function compared with standard open repair. Furthermore, data for open repair in patients with baseline renal insufficiency suggests worse outcomes, including renal function. This analysis compared the effects of open repair vs EVAR on renal function in patients with baseline renal insufficiency. METHODS: We reviewed our records for patients with preoperative chronic renal insufficiency (serum creatinine, 1.5 mg/dL) who underwent open repair or EVAR between 1999 and 2004. The same group of vascular surgeons at a single institution performed aneurysm repair on 98 patients: 46 open (37 men, 9 women) and 52 EVAR (50 men, 2 women). Preoperative, postoperative, and follow-up serum creatinine and creatinine clearance were compared, as was the development of postoperative renal impairment (increase in serum creatinine >30%). RESULTS: Serum creatinine and creatinine clearance were not statistically different between the open and EVAR groups during any time period studied. Likewise when comparing the magnitude of change in serum creatinine in patients between the postoperative and follow-up times with preoperative values, no significant differences existed between the open and EVAR groups. When the change in serum creatinine over time within each group was compared, however, the open group had a significant increase in serum creatinine postoperatively (2.43 +/- 1.20 vs 2.04 +/- 0.64, P = .012), which returned to baseline during follow-up (1.96 +/- 0.94, P = .504). Although serum creatinine in the EVAR group increased compared with preoperative values of 2.04 +/- 0.55 (postoperative, 2.27 +/- 1.04; follow-up, 2.40 +/- 1.37), this failed to reach statistical significance for the postoperative (P = .092) or follow-up (P = .081) periods. A similar pattern was noted in creatinine clearance. Postoperative renal impairment was noted in 13 open (28%) and 15 EVAR patients (29%) and was not statistically different between groups. Overall, two patients (4.3%) from the open group and four (7.7%) from the EVAR group required hemodialysis; one in the EVAR group required permanent hemodialysis. This difference was not statistically significant (P = .681). CONCLUSIONS: Open and endovascular repair of abdominal aortic aneurysms in patients with pre-existent renal insufficiency can be performed safely with preservation of renal function. In contrast to previous reports, no significant differences existed between open repair and EVAR in postoperative alterations in renal function. Although a significant increase in serum creatinine develops in patients with renal insufficiency postoperatively with open repair, this appears to be transient, and preoperative renal dysfunction alone should not exclude either approach. After EVAR, patients with pre-existing renal insufficiency continue to be at risk for progressive renal dysfunction, and protective measures should be taken to preserve renal function in this patient population.

    Title Endoleaks After Endovascular Repair of Thoracic Aortic Aneurysms.
    Date October 2006
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: Endoleaks are one of the unique complications seen after endovascular repair of thoracic aortic aneurysms (TEVAR). This investigation was performed to evaluate the incidence and determinants of endoleaks, as well as the outcomes of secondary interventions in patients with endoleaks, after TEVAR. METHODS: Over a 6-year period, 105 patients underwent TEVAR in the context of pivotal Food and Drug Administration trials with the Medtronic Talent (n = 64) and Gore TAG (n = 41) devices. The medical and radiology records of these patients were reviewed for this retrospective study. Of these, 69 patients (30 women and 39 men) had follow-up longer than 1 month and were used for this analysis. The patients were evaluated for the presence of an endoleak, endoleak type, aneurysm expansion, and endoleak intervention. RESULTS: The mean follow-up in this patient cohort was 17.3 +/- 14.7 months (range, 3-71 months). Endoleaks were detected in 29% (20/69) of patients, of which 40% (8/20) were type I, 35% (7/20) were type II, 20% (4/20) were type III, and 5% (1/20) had more than one type of endoleak. Patients without endoleaks experienced greater aneurysm sac regression than those with endoleaks (-2.89 +/- 9.1 mm vs -0.13 +/- 7.2 mm), although this difference was not statistically significant (P = .232). All but 2 endoleaks (90%; 18/20) were detected on the initial postoperative computed tomographic scan at 30 days. Two endoleaks (10%; 2/20) developed late. The endoleak group had more extensive aneurysms with significantly larger aneurysms at the time of intervention (69.4 +/- 10.5 mm vs 60.6 +/- 11.0 mm; P = .003). Factors predictive of endoleak included male sex (P = .016), larger aneurysm size (P = .003), the length of aorta treated by stent grafts (P = .0004), and an increasing number of stents used (P < .0001). No open conversions were performed for treatment of endoleaks. Four (50%) of the eight type I endoleaks were successfully repaired by using endovascular techniques. None of the type II endoleaks was treated by secondary intervention. During follow-up, the maximum aneurysm diameter in the type II endoleak patients increased a mean of 2.94 +/- 7.2 mm (range, -4.4 to 17 mm). Spontaneous thrombosis has occurred in 29% (2/7) of the type II endoleaks. Patients with type III endoleaks experienced a decrease in mean maximal aneurysm diameter of 0.78 +/- 3.1 mm during follow-up. CONCLUSIONS: Endoleaks are not uncommon after TEVAR. Many type I endoleaks may be treated successfully by endovascular means. Short-term follow-up suggests that observational management of type II endoleaks is associated with continued sac expansion, and these patients should be monitored closely.

    Title Strategies to Manage Paraplegia Risk After Endovascular Stent Repair of Descending Thoracic Aortic Aneurysms.
    Date September 2006
    Journal The Annals of Thoracic Surgery
    Excerpt

    BACKGROUND: Paraplegia is a recognized complication after endovascular stent repair of descending thoracic aortic aneurysms. A management algorithm employing neurologic assessment, somatosensory evoked potential monitoring, arterial pressure augmentation, and cerebrospinal fluid drainage evolved to decrease the risk of postoperative paraplegia. METHODS: Patients in thoracic aortic aneurysm stent trials from 1999 to 2004 were analyzed for paraplegic complications. Lower extremity strength was assessed after anesthesia and in the intensive care unit. A loss of lower extremity somatosensory evoked potential or lower extremity strength was treated emergently to maintain a mean arterial pressure 90 mmHg or greater and a cerebrospinal fluid pressure 10 mm Hg or less. RESULTS: Seventy-five patients (male = 49, female = 26, age = 75 +/- 7.4 years) had descending thoracic aortic aneurysms repaired with endovascular stenting. Lumbar cerebrospinal fluid drainage (n = 23) and somatosensory evoked potential monitoring (n = 15) were performed selectively in patients with significant aneurysm extent or with prior abdominal aortic aneurysm repair (n = 17). Spinal cord ischemia occurred in 5 patients (6.6%); two had lower extremity somatosensory evoked potential loss after stent deployment and 4 developed delayed-onset paraplegia. Two had full recovery in response to arterial pressure augmentation alone. Two had full recovery and one had near-complete recovery in response to arterial pressure augmentation and cerebrospinal fluid drainage. Spinal cord ischemia was associated with retroperitoneal bleed (n = 1), prior abdominal aortic aneurysm repair (n = 2), iliac artery injury (n = 1), and atheroembolism (n = 1). CONCLUSIONS: Early detection and intervention to augment spinal cord perfusion pressure was effective for decreasing the magnitude of injury or preventing permanent paraplegia from spinal cord ischemia after endovascular stent repair of descending thoracic aortic aneurysm. Routine somatosensory evoked potential monitoring, serial neurologic assessment, arterial pressure augmentation, and cerebrospinal fluid drainage may benefit patients at risk for paraplegia.

    Title Endovascular Therapy of Symptomatic Innominate-subclavian Arterial Occlusive Lesions.
    Date June 2006
    Journal Vascular and Endovascular Surgery
    Excerpt

    The purpose of this study was to determine the safety and efficacy of angioplasty and stenting for symptomatic innominate-subclavian lesions by review of records of symptomatic patients undergoing angioplasty and stenting of high-grade lesions (>80%) of the innominate and subclavian arteries. Follow-up consisted of history (symptoms) and physical examination (pulses and blood pressures) at 1, 3, 6, and then every 12 months plus an annual duplex ultrasound examination. Between 1998 to 2003, 25 patients (27 lesions) were treated. Ages ranged from 48 to 89 years. Symptoms included vertebrobasilar/steal (15), claudication (6), ischemia (4), and coronary artery bypass grafting/left internal mammary artery (2). There were 7 occlusions and 20 high-grade stenoses. Access was attempted via brachial cutdown (19) or percutaneous puncture of the brachial (2) or femoral arteries (10). Twenty-two lesions were stented with either self-expanding (13) or balloon-expandable (9) stents. Technical success was 89%; 3 occluded lesions could not be crossed owing to complete occlusion. The remaining 4 occlusions were all crossed via a retrograde approach. The mean difference in systolic blood pressure between upper limbs decreased from 36 mm Hg (preprocedure) to 10 mm Hg (postprocedure). There were no procedure-related complications. Mean follow-up was 18 months (range 1-62 months). One patient died 4 months after the procedure secondary to complications from pulmonary surgery unrelated to the percutaneous transluminal angioplasty/stent. Of the 4 successfully treated occlusions, 2 were followed up to 3 years with continued patency. Three patients developed recurrent stenoses documented by duplex examination. However, these patients remained asymptomatic and were not treated. Endovascular management of high-grade lesions of the subclavian or innominate arteries is safe and efficacious and may be considered as a first line of therapy. Continued follow-up is needed to assess long-term patency.

    Title Structural Mri of Carotid Artery Atherosclerotic Lesion Burden and Characterization of Hemispheric Cerebral Blood Flow Before and After Carotid Endarterectomy.
    Date May 2006
    Journal Nmr in Biomedicine
    Excerpt

    Collateral circulation plays a major role in maintaining cerebral blood flow (CBF) in patients with internal carotid artery (ICA) stenosis. CBF can remain normal despite severe ICA stenosis, making the benefit of carotid endarterectomy (CEA) or stenting difficult to assess. Before and after surgery, we assessed CBF supplied through the ipsilateral (stenotic) or contralateral ICA individually with a novel hemisphere-selective arterial spin-labeling (ASL) perfusion MR technique. We further explored the relationship between CBF and ICA obstruction ratio (OR) acquired with a multislice black-blood imaging sequence. For patients with unilateral ICA stenosis (n = 19), conventional bilateral labeling did not reveal interhemispheric differences. With unilateral labeling, CBF in the middle cerebral artery (MCA) territory on the surgical side from the ipsilateral supply (53.7 +/- 3.3 ml/100 g/min) was lower than CBF in the contralateral MCA territory from the contralateral supply (58.5 +/- 2.7 ml/100 g/min), although not statistically significant (p = 0.09). The ipsilateral MCA territory received significant (p = 0.02) contralateral supply (7.0 +/- 2.7 ml/100 g/min), while ipsilateral supply to the contralateral side was not reciprocated. After surgery (n = 11), ipsilateral supply to the MCA territory increased from 57.3 +/- 5.7 to 67.3 +/- 5.4 ml/100 g/min (p = 0.03), and contralateral supply to the ipsilateral MCA territory decreased. The best predictor of increased CBF on the side of surgery was normalized presurgical ipsilateral supply (r(2) = 0.62, p = 0.004). OR was less predictive of change, although the change in normalized contralateral supply was negatively correlated with OR(excess) (=OR(ipsilateral) - OR(contralateral)) (r(2) = 0.58, p = 0.006). The results demonstrate the effect of carotid artery stenosis on blood supply to the cerebral hemispheres, as well as the relative role of collateral pathways before surgery and redistribution of blood flow through these pathways after surgery. Unilateral ASL may better predict hemodynamic surgical outcome (measured by improved perfusion) than ICA OR.

    Title Emergency Endovascular Deployment of Stent Graft in the Ascending Aorta for Contained Rupture of Innominate Artery Pseudoaneurysm in a Pediatric Patient.
    Date May 2006
    Journal The Annals of Thoracic Surgery
    Excerpt

    Endovascular approaches to treat aortic diseases have become an important alternative to open surgical intervention in aortic pathologies. We report a case of an emergency placement of a stent graft in a 16-year-old boy with a contained rupture of an innominate artery pseudoaneurysm. This patient had been previously treated for a mediastinal T-cell lymphoma and underwent mediastinal chemoradiation. He developed tracheal stenosis, requiring multiple tracheal reconstructive surgical procedures, and subsequently emergency ligation of a tracheal-innominate fistula. A pseudoaneurysm of the previously ligated innominate artery developed. Despite coil embolization, it continued to enlarge, requiring emergency endovascular intervention. A pseudoaneurysm of the previously ligated innominate artery subsequently developed, and despite coil embolization, it continued to enlarge, which required emergency endovascular intervention.

    Title Thoracic Aortic Stent Grafting: Improving Results with Newer Generation Investigational Devices.
    Date May 2006
    Journal The Journal of Thoracic and Cardiovascular Surgery
    Excerpt

    OBJECTIVE: Six years ago an endovascular program for repair of descending thoracic aneurysms was established at the University of Pennsylvania. We report on the hypothesis that results are improving with new stent design iterations and describe our experience and lessons learned. METHODS: From April 1999 to March 2005, 99 patients with descending thoracic aneurysms underwent repair with a first or second-generation commercially produced endograft; 24 patients had an early-generation device, and 75 patients had a late-generation device. Each patient was enrolled as part of 3 distinct Phase I or Phase II Food and Drug Administration-approved clinical trials in accordance with strict inclusion and exclusion criteria. RESULTS: Mean age was 73.1 years. Symptomatic aneurysms accounted for 42% of the cohort. Mean aneurysm size was 63.7 mm (range: 30-105 mm). Twenty percent of the patients underwent a subclavian carotid transposition or bypass preoperatively to obtain an adequate proximal landing zone. No procedures had to be aborted. In-hospital or 30-day mortality was 5.0%. The incidence of permanent spinal ischemia was 2%. Perioperative vascular complications requiring interposition graft, stent repair, or patch angioplasty occurred in 27% and seemed to be less frequent in the late-generation cohort than the early-generation cohort (22.7% vs 41.7%, respectively, P = .069). At the 30-day follow-up, 23 endoleaks were detected in 22 patients (14.7% in late-generation cohort vs 45.8% in early-generation cohort, P = .001). During the follow-up period, 3 new endoleaks were detected, 3 patients died of aortic rupture, and 10 patients underwent aneurysm-related reintervention. Kaplan-Meier estimated 1, 3, and 5-year survival was 84.5%, 70.5%, and 52.4%, respectively. Freedom from aneurysm-related event, defined as freedom from endoleak, aortic rupture, dissection, or any reintervention on the aorta, was 73%, 69%, and 64% at 1, 3, and 5 years, respectively. CONCLUSION: Thoracic aortic stent grafting is a safe procedure in selected patients with the added benefit of a low incidence of paraplegia. However, there is an incidence of late complications and reinterventions. This risk requires further quantification and must be balanced against the benefits of a minimally invasive approach with low perioperative morbidity and mortality. Results are improving as technology evolves and our level of experience increases. Radiologic follow-up is mandatory.

    Title Factors Predictive of Early or Late Aneurysm Sac Size Change Following Endovascular Repair.
    Date May 2006
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: The purpose of this study was to determine the relationship between aneurysm sac size change at 1, 6, 12, and 24 months and a set of 10 independent "predictive" variables by using a general linear model analysis. METHODS: In a multicenter trial, 351 patients received the Zenith tri-modular bifurcated endograft. The predictive variables used for this analysis were endoleak by type, age, gender, smoking status, and the preprocedure variables of maximum aneurysm major diameter, minor neck diameter, proximal neck length, neck plaque/thrombus, and neck shape; and patent inferior mesenteric artery at predischarge. The aneurysm change was calculated as the difference from the predischarge (< or = 7 days of implant) maximum aneurysm major diameter measurement to the maximum aneurysm major diameter measurement at follow-up examination periods of 1, 6, 12, and 24 months. The same 10 predictive variables were used to assess the absolute change in maximum aneurysm minor diameter and aneurysm area. Additionally, the percent change from predischarge was also assessed for the major diameter, minor diameter, and aneurysm area. RESULTS: None of the independent variables were predictive of absolute sac size change or percent change at 1 month. At 6 months, the presence of an endoleak (P < .01) and preprocedure neck thrombus/plaque (P = .01) were significant predictors of absolute and relative aneurysm size change for all measurements (major diameter, minor diameter, and area) and were more likely to be associated with less sac shrinkage or to have sac growth. Additionally, preoperative maximum aneurysm major diameter was a significant predictor for absolute change in area (P < .01). Larger preprocedure aneurysm diameters were more likely to experience more shrinkage. The significant predictors of size change at 12 months included preprocedure maximum aneurysm major diameter, the presence of endoleak at 12 months, preoperative neck thrombus/plaque, and gender. At 24 months, significant predictors of aneurysm size change included preprocedure maximum aneurysm major diameter, endoleak at 24 months, and preprocedure neck thrombus/plaque. When the longitudinal model was used, the presence of an endoleak, thrombus/plaque within the proximal neck at preprocedure, and preprocedure maximum aneurysm major diameter were found to be significantly related to the size of the maximum aneurysm major diameter over time. CONCLUSIONS: This study supports the concept that early and late sac size change following EVAR is influenced by identifiable independent predictive variables.

    Title Recurrent Endoleak Detection and Measurement of Aneurysm Size with Cta After Coil Embolization of Endoleaks.
    Date March 2006
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: The optimal modality for following aneurysm size and detecting endoleaks after endovascular aneurysm repair (EVAR) remains controversial. Computed tomographic angiography (CTA) has been widely employed but can be limited by metal artifact from stents, which is exacerbated by embolization coils placed during the treatment of type 2 endoleaks. The authors assessed interobserver agreement of CTA for measuring aneurysm size and presence of recurrent endoleak in patients with prior coil embolization of type 2 endoleaks. MATERIALS AND METHODS: A total of 65 CTAs were retrospectively reviewed in a cohort of 27 patients (25 men; two women; mean age, 77.4 years) who had prior endoleak embolization after EVAR. Endoleak embolizations included transarterial (n=8) and translumbar (n=19) approaches. In each patient, maximal aneurysm diameter and presence/absence of recurrent endoleak was measured independently by two observers. Cohen's Kappa statistic was used to assess interobserver agreement, as well as paired two-tailed Student t tests for aneurysm diameter. RESULTS: Recurrent type 2 endoleaks were detected with CTA in eight of 27 patients (30%) and on 13 of 65 CTAs (20%). A high degree of correlation (98.5%) was also seen between the two observers for presence of endoleak (Kappa=0.95). Mean aneurysm diameter for the entire cohort correlated closely between both observers: 54.8 mm+/-1.1 for observer A and 54.9 mm+/-1.1 for observer B (P=.66). There was a disagreement between the readers of greater than 2 mm regarding aneurysm size in 13.8% of the CTAs (nine of 65 CTAs). CONCLUSION: Despite the presence of streak artifact on CTA following coil embolization of type 2 endoleaks, CTA remains a useful study for following patients. The presence of embolization coils does not prevent CTA measurement of aneurysm diameter and detection of recurrent endoleak with a high degree of interobserver agreement.

    Title Outcomes of Accessory Renal Artery Occlusion During Endovascular Aneurysm Repair.
    Date February 2006
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: Accessory renal arteries are frequently encountered when patients are evaluated for endovascular abdominal aortic aneurysm repair (EVAR). Some have considered their presence a contraindication to EVAR in fear of endoleak and the end result of renal function. We sought to determine whether the coverage of accessory renal arteries during EVAR was associated with any adverse sequelae. METHODS: Retrospective review of the medical records and computed tomographic scans of all patients undergoing EVAR (1998 to 2003) was performed. Note was made of the presence or absence of accessory renal arteries, hypertension, and renal function. Preoperative computed tomographic images were compared with postoperative images to determine the presence of renal infarction. A control group of 26 consecutive patients without accessory renal arteries was used for comparison of the results of EVAR. RESULTS: EVAR was performed in 550 patients over the study interval. The mean follow-up was 16 months (range, 1-48 months). The average age was 74 years (range, 57-90 years). Thirty-five patients (6.6%; 32 male and 3 female) were documented to have accessory renal arteries; the average number of accessory arteries was 2 (range, 1-4). Bilateral accessory arteries were present in 13 patients: all but 1 patient (n = 34) had a left-sided accessory renal artery, and 23 had a right-sided accessory renal artery. EVAR was performed with a variety of endografts: AneuRx (n = 10), Talent (n = 7), PowerLink (n = 7), Zenith (n = 5), LifePath (n = 4), and Ancure (n = 2). There were no mortalities. Twelve endoleaks were documented: three type I, eight type II, and one type III. The accessory renal arteries were not implicated in any of the endoleaks, and none of these accessory vessels was embolized before or after EVAR. Seven patients (20%) had renal infarcts associated with EVAR that were noted on follow-up computed tomographic scans. The mean follow-up for patients with segmental infarction was 23 months (range, 8-48 months). Hypertensive status did not change in any patient in whom an accessory renal artery had been covered. The average serum creatinine was 1.08 mg/dL (range, 0.6-1.8 mg/dL) before EVAR in patients with accessory renal arteries covered by an endovascular graft and did not change significantly in response to EVAR. Serum creatinine increased almost twofold in two patients but spontaneously resolved in follow-up. The average preoperative creatinine clearance was 79 mL/min (range, 35-166 mL/min) in patients without an accessory renal artery and was 80 mL/min (range, 35-167 mL/min) after EVAR. The average preoperative creatinine clearance was 67 mL/min (range, 31-137 mL/min) in patients with an accessory renal artery and 68 mL/min (range, 45-83 mL/min) in patients with renal infarcts. None of the patients required temporary or permanent dialysis. There was no difference between control patients and patients with covered accessory renal arteries with respect to hypertensive status, presence of renal infarcts, serum creatinine, or creatinine clearance after EVAR. CONCLUSIONS: Occlusion of accessory renal arteries is not associated with clinically significant signs or symptoms, even in patients with mild or moderate renal insufficiency. Sacrifice of accessory renal arteries most commonly does not lead to detectable renal infarction, either clinically or radiographically. When segmental infarction of the kidney does result, it seems to be well tolerated in this group of patients. Accessory renal arteries were not found to contribute to endoleaks and should not be prophylactically embolized.

    Title Mineral Volume and Morphology in Carotid Plaque Specimens Using High-resolution Mri and Ct.
    Date December 2005
    Journal Arteriosclerosis, Thrombosis, and Vascular Biology
    Excerpt

    OBJECTIVE: High-resolution MRI methods have been used to evaluate carotid artery atherosclerotic plaque content. The purpose of this study was to assess the performance of high-resolution MRI in evaluation of the quantity and pattern of mineral deposition in carotid endarterectomy (CEA) specimens, with quantitative micro-CT as the gold standard. METHODS AND RESULTS: High-resolution MRI and CT were compared in 20 CEA specimens. Linear regression comparing mineral volumes generated from CT (VCT) and MRI (VMRI) data demonstrated good correlation using simple thresholding (VMRI=-0.01+0.98VCT; R2=0.90; threshold=4xnoise) and k-means clustering methods (VMRI=-0.005+1.38VCT; R2=0.93). Bone mineral density (BMD) and bone mineral content (BMC [mineral mass]) were calculated for CT data and BMC verified with ash weight. Patterns of mineralization like particles, granules, and sheets were more clearly depicted on CT. CONCLUSIONS: Mineral volumes generated from MRI or CT data were highly correlated. CT provided a more detailed depiction of mineralization patterns and provided BMD and BMC in addition to mineral volume. The extent of mineralization as well as the morphology may ultimately be useful in assessing plaque stability.

    Title Embolization of Type 2 Endoleaks After Endovascular Repair of Abdominal Aortic Aneurysms with Use of Cyanoacrylate with or Without Coils.
    Date November 2005
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    Translumbar embolization was used to treat 11 type 2 endoleaks in nine patients with the liquid embolic agent n-butyl cyanoacrylate (NBCA). Nine of the embolizations were performed with a combination of stainless-steel coils and NBCAJ and the other two were performed with NBCA alone. There was complete occlusion on initial computed tomographic (CT) angiography in six of nine patients (66%), including the two cases treated with NBCA alone. Persistent endoleak on initial CT angiography occurred in three of nine patients (33%). Two of these patients underwent successful repeated embolization with NBCA. Aneurysm size remained unchanged in four patients (44%), decreased in four patients (44%), and increased in one patient (11%). No complications occurred. Initial results with the use of NBCA for endoleak embolization are encouraging.

    Title Use of Ct Angiography to Classify Endoleaks After Endovascular Repair of Abdominal Aortic Aneurysms.
    Date September 2005
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: Accurate endoleak detection and classification is critical for the follow-up of patients who have undergone endovascular aneurysm repair (EVAR). This determination is often made with computed tomography angiography (CTA). This investigation was performed to determine the accuracy of CTA in the classification of endoleaks in patients who have undergone EVAR. MATERIALS AND METHODS: Thirty-six patients with endoleaks underwent both CTA and conventional contrast digital subtraction angiography (DSA) to determine endoleak etiology. Two independent radiologists determined the source of the endoleak based on a retrospective review of the CTA. The results of the CTA-based endoleak classification were compared to the reference standard, contrast DSA. RESULTS: There was agreement regarding endoleak classification between CTA and DSA on 86% of the patients (31 of 36 patients). Correlation between the CTA reading of the two readers was 94% (34 of 36 patients), yielding a kappa statistic of 0.8. In three patients, the CTA reading incorrectly classified endoleaks as type 2 when the endoleaks were actually type 1 endoleaks on DSA. One patient was incorrectly classified as having a type 1 endoleak on CTA when it was a type 2 endoleak on DSA. Finally, one patient had a type 1 endoleak on DSA that was incorrectly classified as a type 3 endoleak on CTA. The change in CTA endoleak classification based on the DSA resulted in a significant change in patient management in four of the 36 patients (11%). CONCLUSIONS: Endoleak classification based on CTA correlates fairly well with DSA findings. However, optimal endoleak management requires performance of selective angiograms with DSA to classify endoleaks that are detected on CTA.

    Title Midterm Pivotal Trial Results of the Talent Low Profile System for Repair of Abdominal Aortic Aneurysm: Analysis of Complicated Versus Uncomplicated Aortic Necks.
    Date March 2005
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: This study was undertaken to determine whether a complicated aortic neck is associated with unfavorable outcome after abdominal aortic aneurysm (AAA) endografting. METHODS: In a prospective pivotal clinical trial, 237 consecutive patients underwent implantation of the bifurcated Talent Low Profile System. Patients were divided into 2 groups, those with complicated aortic necks (short, <15 mm; very short, < or =10 mm; dilated, >28 mm; angulated, >45 degrees; calcified; and thrombus-lined) versus those with uncomplicated neck anatomy. Major outcome parameters included procedure time, operative blood loss, transfusion requirements, volume of contrast medium used during the implant procedure, endoleaks, migration, limb patency, AAA regression, conversion to open repair, morbidity, and mortality. Mean follow-up was 620.5 days. RESULTS: Overall, 32% of aortic necks were short, 19% were very short, 20% were dilated, 18% were calcified, 8.5% were thrombus-lined, and 19.9% were angulated. Thirty percent and 70% of patients, respectively, were stratified to the uncomplicated and complicated groups ( P < .01. Procedure time, operative blood loss, transfusions, volume of contrast medium used in the implant procedure, migration, endograft patency, AAA sac regression, conversion to open repair, and mortality were not significantly different in necks with complicated versus uncomplicated anatomy. At 21 months, sacs were regressing or stable in 98% (complicated) versus 96% (uncomplicated). Primary graft limb patency was 100% in both groups. The endoleak rate was 4.3% (complicated) versus 17% (uncomplicated) at 18 months, but this difference was not statistically significant. Adverse renal events, however, occurred in 27.5% (complicated) versus 13.6% (uncomplicated; P = .04). CONCLUSIONS: Complicated aortic neck is not associated with unfavorable outcome at midterm follow-up after AAA endografting. However, statistically more adverse renal events occur in patients with complicated neck anatomy.

    Title Magnetic Resonance Imaging for Planning Aortic Endograft Procedures.
    Date September 2004
    Journal Seminars in Vascular Surgery
    Excerpt

    Patients with aortic aneurysms and renal insufficiency are at an increased risk when conventional imaging modalities (contrast enhancing computed tomography and arteriography) are used for aortic endograft design. Magnetic resonance imaging (MRI) provides a nonionizing, noninvasive alternative to standard measurement techniques. Reliable diameter and length measurements can be obtained with MRI at a computer workstation without the use of iodinated radiologic contrast agents. The authors describe their experience with the use of magnetic resonance angiography as the sole imaging modality for aortic endograft design. Although not without limitations, MRI can be an effective measurement tool, particularly in patients who are at high risk of complications related to conventional imaging.

    Title Decreased Use of Iliac Extensions and Reduced Graft Junctions with Software-assisted Centerline Measurements in Selection of Endograft Components for Endovascular Aneurysm Repair.
    Date September 2004
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: The purpose of this study was to determine the impact of using computerized software-assisted centerline measurements for extensions and graft junctions during the selection of endograft components for modular aortic endografts in endovascular repair of abdominal aortic aneurysms. METHODS: From April 1998 to December 2002, 289 modular aortic endografts were implanted at our institution. These included 248 grafts (prior to 2002, group 1) with components selected on the basis of manual caliper measurements from combined contrast computed tomography (CT) and marker-catheter arteriography data, and 41 grafts (2002, group 2) with components selected with the use of computerized software that allowed for centerline measurements on 3-dimensional reconstructions based on CT data. These 2 groups were compared for the number and type of extensions required per case. Seventeen other relevant variables were analyzed for their potential influence on selection of endograft components. These variables included age, gender, maximum aneurysm size, level of distal fixation, length and diameter at the fixation points, endograft manufacturer (make), and configuration. The significance of the observed differences was analyzed with a multivariate regression model, adjusting for potentially confounding preoperative measures. RESULTS: Multivariate analysis demonstrated that the number of right iliac extensions, left iliac extensions, total extensions, and total graft junctions was significantly reduced by the use of computerized software-assisted centerline measurements (group 2) compared with caliper measurements (group 1), independent of all other 17 preoperative variables. Notably, the mean number of required right iliac extensions was double in group 1 versus group 2. CONCLUSIONS: Centerline software-assisted measurements can significantly reduce the need for iliac extensions and, concomitantly, the number of required endograft junctions. On average, twice as many extensions were required for right iliac fixation when the manual caliper measurements were used compared with software-assisted measurements. These findings are highly relevant to issues of total endograft cost and long-term endograft integrity and focus attention on the tools that may need to be considered standards of care rather than optional for selection of endograft components.

    Title The Utility of Commercially Available Endografts in the Treatment of Contained Ruptured Abdominal Aortic Aneurysm with Hemodynamic Stability.
    Date July 2004
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    PURPOSE: Food and Drug Administration-approved endografts are suitable for the elective repair of abdominal aortic aneurysms (AAAs) with favorable aneurysm anatomy. Our aim is to illustrate the feasibility and versatility of commercially available endografts for emergency AAA repair in hemodynamically stable AAA rupture. METHODS: From June 2001 to July 2002, five patients presented with severe abdominal pain and were diagnosed with contained rupture of an infrarenal AAA. In all cases, patients were deemed unfit to withstand conventional open repair by both the referring outside medical center as well as our center's team. All patients were hemodynamically stable on arrival at our medical center. Measurement and selection of endovascular devices were based on computed tomography (CT) scans performed emergently at the outside referring center. The required emergently procured endografts were obtained within 2 to 4.5 hours (mean, 3.1 hours) of presentation. Complex anatomy at the proximal and distal fixation zones or difficult access was present in every case. RESULTS: All patients survived endograft repair and had successful exclusion of their aneurysm sac on the basis of intraoperative arteriography and postoperative CT surveillance. All were discharged to home at baseline function within a mean of 6.8 days (range, 2-13 days). There were no deaths. There was one postoperative pulmonary embolism, one myocardial infarct, and one type 2 endoleak. Mean operative time and blood loss were 4.67 hours and 217 mL, respectively. At a mean follow-up of 18 months, CT scans showed stable or shrinking aneurysm sacs. CONCLUSIONS: In patients with contained ruptured AAAs who present with hemodynamic stability and comorbidities that preclude open surgery, commercially available endografts are a versatile treatment option even in the face of complicated aneurysm anatomy.

    Title Treatment of Multiple Visceral Aneurysms in a 20-year-old Patient.
    Date July 2004
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    A 20-year-old man with a history of cerebral aneurysm and a contained rupture of an intrasplenic aneurysm had a fusiform celiac and splenic artery aneurysm at presentation. This was repaired with excision of the celiac artery, aortohepatic bypass grafting, splenic artery ligation, and splenectomy.

    Title Endovascular Repair of a Ruptured Thoracic Aortic Aneurysm with the Use of Aortic Extension Cuffs.
    Date May 2004
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Title Endoleaks After Endovascular Repair of Abdominal Aortic Aneurysms.
    Date February 2004
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    Endovascular repair of abdominal aortic aneurysms shows promising initial results. Endoleaks represent one of the unique causes of endovascular repair failure not seen with traditional abdominal aortic aneurysm repair. Endoleaks occur when there is blood flow outside the stent-graft lumen but within the aneurysm sac. They can be difficult to diagnose and treat, and their management is a source of continued controversy. This review further defines endoleaks and the clinical challenges that they create. Current methods for endoleak detection, classification, and management are reviewed.

    Title Inferior Vena Cava Traversal for Translumbar Endoleak Embolization After Endovascular Abdominal Aortic Aneurysm Repair.
    Date February 2004
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    When embolization of a collateral (type II) endoleak after endovascular repair of an abdominal aortic aneurysm is indicated, endoleak embolization with a translumbar approach is often the procedure of choice. Because of the position of the endoleak, it is sometimes necessary to use a right-sided translumbar approach and traverse the inferior vena cava when accessing the endoleak. Twelve type II endoleaks in nine patients were treated with transcaval translumbar embolization during a 34-month period. No clinically significant hemorrhage occurred. Embolizing type II endoleaks with a right translumbar approach is feasible. Long-term follow-up with more patients is necessary to fully evaluate the durability of this procedure.

    Title Supported Endograft Limb Occlusion Likely Occurring Secondary to Hip Arthroplasty.
    Date February 2004
    Journal Journal of Endovascular Therapy : an Official Journal of the International Society of Endovascular Specialists
    Excerpt

    PURPOSE: To report an acute endograft limb occlusion immediately subsequent to a total hip replacement. CASE REPORT: A 62-year-old man underwent successful placement of a bifurcated stent-graft for a 5-cm abdominal aortic aneurysm (AAA). Surveillance imaging documented a satisfactory outcome and no defects in the stent-graft. Three months after the endograft procedure, he underwent left total hip arthroplasty, at which time the left endograft limb acutely thrombosed. He was successfully treated with thrombectomy and dilation/stenting of the thrombosed graft limb. CONCLUSIONS: Patients with aortoiliac stent-grafts need careful surveillance around the time of a procedure that may require extreme manipulation of the pelvis and hips. Even fully supported, widely patent endograft limbs may be vulnerable to acute thrombosis in this setting.

    Title Vegf-a and Alphavbeta3 Integrin Synergistically Rescue Angiogenesis Via N-ras and Pi3-k Signaling in Human Microvascular Endothelial Cells.
    Date November 2003
    Journal The Faseb Journal : Official Publication of the Federation of American Societies for Experimental Biology
    Excerpt

    We recently showed that normal fibroblasts mediate capillary-like differentiation of human microvascular endothelial cells (HMVEC) in a 3-D angiogenesis model. Here, we show that a collaborative effect of VEGF-A and alphaVbeta3 integrin is critical in fibroblast-mediated angiogenesis because enhancement of both VEGF production by fibroblasts and beta3 integrin expression in HMVEC can rescue capillary-like endothelial differentiation under reduced serum conditions. To investigate the downstream signaling mechanisms, we compared N-Ras and Rho/Rac/Cdc42, as well as phosphatidylinositol 3-kinase (PI3-K) and Akt, for their involvement in the capillary-like network formation. The dominant-negative mutant of N-Ras (N-RasN17), but not the mutants of Rho/Rac/Cdc42, suppressed network formation. Overexpression of a constitutively active form of PI3-K rescued the network formation, which was inhibited by a dominant-negative >beta3 integrin; however, an active form of Akt failed to rescue the inhibition but induced a phenotypic change in HMVEC. Moreover, PI3-K is a downstream target of N-Ras because it could be co-immunoprecipitated with N-Ras, and its active form could rescue the inhibitory effect of N-Ras N17. Thus, our data indicate the existence of N-Ras- and PI3-K-dependent but Rho/Rac/Cdc42- and Akt-independent signaling mechanisms for the synergistic effect of VEGF-A and alphaVbeta3 on fibroblast-mediated microvascular network formation.

    Title Mr Imaging for the Detection of Endoleaks in Recipients of Abdominal Aortic Stent-grafts with Low Magnetic Susceptibility.
    Date September 2003
    Journal Academic Radiology
    Excerpt

    RATIONALE AND OBJECTIVES: This study was performed to assess the efficacy of magnetic resonance (MR) imaging for the detection of endoleaks in recipients of abdominal aortic stent-grafts with low magnetic susceptibility. MATERIALS AND METHODS: A retrospective search was conducted in radiology department records for cases of patients with low-susceptibility stent-grafts who had been evaluated with MR imaging and either computed tomography (CT) or conventional angiography within a 1-month time frame. Any endoleaks previously confirmed and classified with the use of CT and/or conventional angiography were compared with findings from MR imaging. RESULTS: Nine patients fit the selection criteria. Images of five of those patients depicted six different endoleaks. Two endoleaks had been confirmed with CT, another two had been confirmed with CT and angiography, and two had been confirmed with angiography alone. All endoleaks visualized at CT and/or angiography were accurately detected and classified also with MR imaging. In some cases, the endoleak was more clearly visualized with MR imaging than with CT. In four patients in whom no endoleaks were found at CT, MR imaging also indicated no endoleaks. CONCLUSION: MR imaging is a suitable modality for identifying endoleaks in patients with low-susceptibility stent-grafts. Moreover, MR imaging may be more sensitive than CT for the detection of small endoleaks.

    Title A New Endovascular Approach to Treatment of Acute Iliac Limb Occlusions of Bifurcated Aortic Stent Grafts with an Exoskeleton.
    Date June 2003
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    Endovascular aneurysm repair continues to become increasingly popular. As the number of implanted endografts increases, complications will increase as well. We report a new approach to endovascular treatment in two patients with acute iliac limb occlusions of a bifurcated aortic endograft with an endoskeleton. Neither patient required femoral-femoral bypass grafting because of unilateral limb ischemia. We believe this is the optimal primary approach in patients with a bifurcated stent graft with an endoskeleton.

    Title Successful Pta and Stenting for Acute Iliac Arterial Injury Following Pancreas Transplantation.
    Date June 2003
    Journal American Journal of Transplantation : Official Journal of the American Society of Transplantation and the American Society of Transplant Surgeons
    Excerpt

    Iliac artery injuries may occur during solid organ transplantation. We describe an approach to an iliac artery clamp injury after pancreatic allotransplantation. The patient is a 48-year-old diabetic male who underwent successful cadaveric pancreatico-duodenal transplantation complicated by a left common iliac artery clamp injury. The injury resulted in both graft and lower leg ischemia. The injury was recognized promptly and diagnosed by magnetic resonance angiogram (MRA). The lesion was successfully treated with percutaneous transluminal angioplasty and stenting with resolution of both graft and leg ischemia. We propose this technique as a minimally invasive approach to an iliac injury that can be used to treat vascular injuries during solid organ transplantation.

    Title Early Changes in Abdominal Aortic Aneurysm Diameter After Endovascular Repair.
    Date May 2003
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: Endovascular repair of abdominal aortic aneurysm (AAA) is expected to alter the natural progression of diameter increase and rupture. The purpose of this study is to determine the rate of diameter change in AAA treated by endovascular repair. MATERIALS AND METHODS: Sixty-three patients underwent endovascular repair of AAA and 12-month median follow-up by computed tomographic (CT) angiography or magnetic resonance (MR) angiography. The maximum cross-sectional outer diameters of aneurysms were measured with serial CT angiography and MR angiography. Immediate postrepair CT angiography and MR angiography were used for comparison to follow-up studies. Endoleak was also evaluated. RESULTS: The mean and median follow-up interval was 12 months (range, 7-21 mo). There was a significant decrease in maximum diameter at follow-up (6.0 cm vs 5.1 cm; P <.001). The mean annual decrease of AAA diameter was 8.4 mm. Endoleak occurred immediately after repair in 12 patients (19%). Endoleak was detected in four patients at follow-up examination (6%). Two patients with persistent endoleaks had a mean diameter increase of 2.1 mm per year. Ten patients (16%) with successfully treated endoleak had a mean decrease in diameter of 11 mm per year. There is a significant difference in mean annual diameter change between patients with treated endoleak and those with persistent endoleak (P <.05). There was no difference in mean annual rate of change between patients with no endoleak and those with treated endoleak (8.4 mm/y vs 11 mm/y; P = NS). Seventeen of 21 patients without an appreciable decrease in aneurysm diameter had no endoleak. CONCLUSIONS: Patients with resolved endoleak exhibit a similar shrinkage rate to patients who never had endoleak during imaging follow-up. There remains a group of patients without significant sac shrinkage after endovascular aneurysm repair (EVAR) yet have no endoleak on follow-up imaging (ie, endotension). It is still unclear whether these patients have received protection from AAA rupture from EVAR.

    Title Talent Lps Aaa Stent Graft: Results of a Pivotal Clinical Trial.
    Date May 2003
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    PURPOSE: We report results of a pivotal prospective clinical trial that compared standard surgical repair with endovascular exclusion of abdominal aortic aneurysm (AAA) with the Talent LPS stent graft system. METHODS: Between March 24, 1999, and September 19, 2000, 240 patients with AAA who underwent stent graft placement and 126 patients who concurrently underwent surgery to treat AAA were enrolled at 17 centers in the United States. All patients were considered to be at low risk from aortic surgery. Patients who underwent endovascular repair received a bifurcated Talent LPS stent graft; surgical control subjects underwent standard operative techniques. Inclusion criteria were AAA larger than 4.0 cm in diameter, with proximal neck > 5 mm long and 14 to 32 mm in diameter, and a 15 mm landing zone in at least one common iliac artery. Access requirements included one external iliac artery of 7 mm caliber or larger. Preoperative anatomic evaluation included computed tomography and angiography. After stent-graft placement, evaluation involved plain radiography and computed tomography performed before discharge and at 1, 6, and 12 months and yearly thereafter. RESULTS: There was no significant difference in early (<30 days) or late mortality between the two groups. Complications were slightly higher in the surgical cohort. The stent graft group did better in terms of procedure duration, requirement for general anesthesia and blood transfusion, and intensive care unit and hospital stay. There were three access or deployment failures. Immediate surgical conversion was necessary in only 1 patient, and late conversion in 5 additional patients. There were no aneurysm ruptures. Endoleak rate detected at CT (core laboratory validated) was 14% at 1 month, 12% at 6 months, and 10% at 12 months. CONCLUSIONS: Compared with surgical control subjects, patients with AAA treated with the Talent LPS stent graft had fewer complications and the same low operative mortality. Likewise, endovascular repair performed better than surgery in the perioperative period, as measured with several key procedural indicators. Long-term follow-up of patients with the stent graft will be essential to assess durability of these early results.

    Title Abdominal Aortic Aneurysm Size Regression After Endovascular Repair is Endograft Dependent.
    Date May 2003
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: This study was performed to determine whether abdominal aortic aneurysm (AAA) regression is different with various endografts after endovascular repair. METHODS: A four-center retrospective review of size change after endovascular AAA repair was performed. Consecutive patients with at least 1-year follow-up and available imaging studies were included. Three hundred ninety patients received either the Ancure, AneuRx, Excluder, or Talent endograft. AAA size and endoleak status were recorded from computed tomography (CT) scans at the initial postoperative follow-up visit and at 1 and 2 years thereafter. AAA size was defined as the minor axis of the infrarenal aorta on the largest axial section on the two-dimensional CT scan. A change in AAA size of 0.5 cm or greater from baseline was considered clinically significant. The effect of initial size, endoleak, and type of endograft on AAA regression was analyzed. RESULTS: Mean baseline size was significantly greater with Talent endografts and smaller with Excluder endografts. Clinically significant regression in AAA size occurred in nearly three fourths of patients with Ancure and Talent endografts at 2 years. Regression in AAA size was less frequent with the AneuRx (46%) and Excluder (44%) devices. Initial size, endoleak, and endograft type were significant predictors of regression at multivariate analysis at 1 year. However, by 2 years only endograft type was still an independent predictor of AAA shrinkage. CONCLUSIONS: Long-term morphologic changes after endovascular aneurysm repair depend on endograft type.

    Title The Calibration and Validation of a Phase-modulated Near-infrared Cerebral Oximeter.
    Date February 2003
    Journal Journal of Clinical Monitoring and Computing
    Excerpt

    OBJECTIVE: This study was undertaken to compare the cerebral oxygenation measured by an experimental phase-modulated near-infrared (NIR) spectroscopy system with capillary saturation estimated from jugular venous oxygen saturation. METHODS: Jugular venous catheters were placed in 30 patients undergoing carotid endarterectomy and 194 measurements of venous oxygen saturation were obtained intra operatively. Simultaneous measurement of optical path length at 754, 785, and 816 nm was performed using a phase-modulated near-infrared spectroscopy system. Optical calibration was performed using both an optical bench and a scattering mold. Hemoglobin saturation was calculated from NIR measurements using equations derived from diffusion theory. Capillary saturation was calculated from the arterial and venous saturations. RESULTS: Jugular venous saturations ranged from 41 to 92%. When calibrated using the optical bench, the NIR estimates of hemoglobin saturation deviated from estimated capillary values by an average of 2.6% bias and 4.3% deviation. No systematic bias was noted. NIR values derived from mold calibration were less accurate and precise (4.6% bias and 6.9% deviation.) Use of the initial venous sample as an in vivo calibration improved the accuracy of the mold calibration but did not alter the performance of the bench calibration. CONCLUSIONS: Under the conditions tested, an experimental phase-modulated near-infrared spectroscopy system calibrated using an optical bench agreed with capillary saturation estimated from jugular venous samples. Further work is necessary to demonstrate valid performance of the system under other conditions.

    Title Regulation of Notch1 and Dll4 by Vascular Endothelial Growth Factor in Arterial Endothelial Cells: Implications for Modulating Arteriogenesis and Angiogenesis.
    Date January 2003
    Journal Molecular and Cellular Biology
    Excerpt

    Notch and its ligands play critical roles in cell fate determination. Expression of Notch and ligand in vascular endothelium and defects in vascular phenotypes of targeted mutants in the Notch pathway have suggested a critical role for Notch signaling in vasculogenesis and angiogenesis. However, the angiogenic signaling that controls Notch and ligand gene expression is unknown. We show here that vascular endothelial growth factor (VEGF) but not basic fibroblast growth factor can induce gene expression of Notch1 and its ligand, Delta-like 4 (Dll4), in human arterial endothelial cells. The VEGF-induced specific signaling is mediated through VEGF receptors 1 and 2 and is transmitted via the phosphatidylinositol 3-kinase/Akt pathway but is independent of mitogen-activated protein kinase and Src tyrosine kinase. Constitutive activation of Notch signaling stabilizes network formation of endothelial cells on Matrigel and enhances formation of vessel-like structures in a three-dimensional angiogenesis model, whereas blocking Notch signaling can partially inhibit network formation. This study provides the first evidence for regulation of Notch/Delta gene expression by an angiogenic growth factor and insight into the critical role of Notch signaling in arteriogenesis and angiogenesis.

    Title Embolization of the Internal Iliac Artery: Still More to Learn.
    Date October 2002
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Title Endoleak: Predictive Value for Aneurysm Growth at 3 Years.
    Date October 2002
    Journal Annals of Vascular Surgery
    Excerpt

    Endoleak is a unique radiographic finding after endovascular aneurysm repair. The prognostic implication of endoleak on aneurysm therapy outcome is unknown. Patients with 3 years of follow-up were examined to determine the predictive value of endoleak, as determined by the treating physician, for aneurysm growth. Patients enrolled in a clinical trial for a unibody, bifurcated endovascular graft (Ancure-Guidant/EVT, Menlo Park, CA) were examined with respect to endoleak, as determined by the primary investigator, and aneurysm diameter change. A total of 80 patients were available at 3 years for evaluation. CT scans and ultrasound were used to determine endoleak at discharge, at 6 months, and annually. Patients were categorized as no leak (NL; n = 59), early leak (EL, leak identified by 6 months; n = 15), and late leak (LL, leak identified at 12 months or later; n = 6). A change of 5 mm in transverse diameter relative to the original diameter was used to determine an increase or decrease. Therapeutic intervention for endoleak was analyzed separately in each group. From the results we were able to determine that most patients with distal type 1 or type 2 endoleak have shrinking or stable aneurysms. Endoleak is a poor predictor of aneurysm growth but is statistically associated with enlargement. Absence of endoleak is strongly, but not entirely, predictive of lack of aneurysm growth. Endoleak is a risk factor for aneurysm enlargement, warranting further investigation to examine the etiology of the image, but cannot be used as an endpoint for effective endovascular aneurysm treatment.

    Title Fibroblast-dependent Differentiation of Human Microvascular Endothelial Cells into Capillary-like 3-dimensional Networks.
    Date September 2002
    Journal The Faseb Journal : Official Publication of the Federation of American Societies for Experimental Biology
    Excerpt

    An in vitro model has been developed to study migration, survival, proliferation, and capillary-like differentiation of human microvascular endothelial cells (HMVECs) in an environment that avoids tumor promoters and complex matrices. HMVEC monolayers were plated, then induced to form three-dimensional, capillary-like networks by overlaying with human type I collagen followed by a second overlay of collagen with embedded fibroblasts. Detachment and migration of endothelial cells into the matrix was triggered within hours by the overlaying collagen, and the fibroblasts stimulated survival and formation of cords, vacuoles, tubes, and, after 4 to 5 days, capillary networks. The differentiation into branching capillary-like structures was dependent on direct fibroblast-endothelial cell contact and was not achieved when fibroblasts were replaced by seven types of melanoma cells, which included radial and vertical growth phase primary and metastatic stages. Vascular endothelial growth factor (VEGF), when overexpressed in fibroblasts, stimulated endothelial cell proliferation and migration, whereas angiopoietin-1 (Ang-1) had only motogenic effects. Neutralizing antibodies against VEGF and blocking antibodies for VEGF-receptor 2 (VEGFR2) significantly inhibited but not completely obliterated capillary network formation, suggesting that the VEGF signaling pathway is important but not exclusive and that other fibroblast-derived soluble factors and fibroblast-endothelial cell contact are essential for endothelial cell survival and differentiation.

    Title Limb Interventions in Patients Undergoing Treatment with an Unsupported Bifurcated Aortic Endograft System: a Review of the Phase Ii Evt Trial.
    Date July 2002
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    INTRODUCTION: Both supported and unsupported bifurcated endograft limbs develop flow-restricting lesions, including kinks, stenoses, and occlusions, which can be identified during or after surgery. Recognition and intervention are essential to achieve long-term graft patency and a satisfactory functional result. This report represents a comprehensive retrospective review of graft limb interventions from the Phase II EVT Trial with the Endovascular Grafting System unsupported bifurcated endograft (Guidant/EVT, Menlo Park, Calif). METHODS: The study population consists of 242 patients who underwent treatment with bifurcated endografts implanted during the EVT Phase II Trial. Graft limb interventions have been divided into two groups: those in whom the intervention occurred during surgery versus those in whom the intervention occurred after surgery. Parameters studied included type, incidence, and timing of graft limb intervention, indications for intervention, procedures performed, and overall patient outcome. RESULTS: The mean follow-up period was 31 months. Primary, primary assisted, and secondary limb patency rates were 61.6%, 93.7%, and 97.1%, respectively. Technical success rate at case completion was 97.5%. In 68 of the 242 cases, limb interventions were performed during surgery to assure patency (28.1%). In 28 cases, interventions were performed after surgery (11.6%). Of these postoperative limb problems, 82% occurred during the first 6 months. Repeat limb interventions were necessitated in three patients (1.2%). Within the intraoperative intervention group, perceived indications included kinks (15%), stenosis (57%), dissection (6%), graft redundancy (12%), and instances of twists, thrombosis, and pressure gradients (10%). These findings were successfully managed with percutaneous transluminal angioplasty only (41%), percutaneous transluminal angioplasty and stent (50%), and various combined interventions. Within the postoperative intervention group, symptomatic indications included stenosis (46%) and thrombosis/occlusion (54%). These postoperative limb events were successfully managed with stent (64%), thrombolysis (32%), and femoral-femoral bypass (21%). When limb dysfunction developed in the postoperative setting, it most often occurred within the first 6 months of implantation. Only one patient in this Phase II cohort had a lower extremity amputation unrelated to a graft limb abnormality. CONCLUSION: The unsupported bifurcated limbs of this endograft necessitated primary adjunctive intervention in 40% of cases. Primary intervention was two times more likely to be performed at the time of the implant rather than after surgery. Repeat limb interventions were not common. Endograft limb flow problems were successfully treated with standard endovascular or surgical interventions or both. These data may support prophylactic stenting of unsupported Ancure graft limbs. A strategy that includes both intraoperative and early postoperative graft limb surveillance is essential to detect reduced limb flow.

    Title Nature and Significance of Endoleaks and Endotension: Summary of Opinions Expressed at an International Conference.
    Date June 2002
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: Endoleaks and endotension are critically important complications of some endovascular aortic aneurysm repairs (EVARs). For the resolution of controversial issues and the determination of areas of uncertainty relating to these complications, a conference of 27 interested leaders was held on November 20, 2000. METHODS: These 27 participants (21 vascular surgeons, five interventional radiologists, one cardiologist) had previously answered 40 key questions on endoleaks and endotension. At the conference, these 40 questions and participant answers were discussed and in some cases modified to determine points of agreement (consensus), near consensus (prevailing opinion), or disagreement. RESULTS: Conference discussion added two modified questions for a total of 42 key questions for the participants. Interestingly, consensus was reached on the answers to 24 of 42 or 57% of the questions, and near consensus was reached on 14 of 42 or 33% of the questions. Only with the answers to four of 42 or 10% of the questions was there persistent controversy or disagreement. CONCLUSION: The current endoleak classification system with some important modifications is adequate. Types I and II endoleak occur after 0 to 10% and 10% to 25% of EVARs, respectively. Many (30% to 100%) type II endoleaks will seal and have no detrimental effect, which never or rarely occurs with type I endoleaks. Not all endoleaks can be visualized with any technique, and increased pressure (endotension) can be transmitted through clot. Aneurysm pulsatility after EVAR correlates poorly with endoleaks and endotension. An enlarging aneurysm after EVAR mandates surgical or interventional treatment. These and other conclusions will help to resolve controversy and aid in the management of these vexing complications and should also point the way to future research in this field.

    Title Potential Impact of Therapeutic Warfarin Treatment on Type Ii Endoleaks and Sac Shrinkage Rates on Midterm Follow-up Examination.
    Date May 2002
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: Successful endovascular aortic aneurysm repair depends on exclusion and spontaneous thrombosis of the aneurysm sac. The need for chronic postoperative anticoagulation therapy could limit the applicability of this technology with delay or prevention of sac thrombosis resulting in endoleak formation and altered remodeling of the aneurysm sac. The purpose of this study was the determination of whether chronic therapeutic anticoagulation therapy with warfarin was associated with an increased incidence rate of early or delayed postoperative endoleaks or altered rates of reduction in aneurysm sac maximum diameter. METHODS: Two hundred thirty-two consecutive patients underwent abdominal aortic endografting during a 32-month period. The data were recorded prospectively with a current mean follow-up period of 18 months. The patients with endoleaks identified with 30-day postoperative computed tomographic scan angiograms subsequently underwent selective arteriography to characterize the source. The patients who underwent chronic warfarin therapy that resulted in a therapeutic internationalized normalized ratio comprised the study group. The control group was defined as all the patients with healthy coagulation profiles. RESULTS: Thirty-six patients (15%) were undergoing warfarin therapy after surgery, and their conditions were chronically maintained with a therapeutic international normalized ratio. Forty-three patients (18%) had endoleaks on 30-day computed tomographic scan angiographic results. There were 39 patients with type II endoleaks and four patients with type I endoleaks. None of the type I endoleaks occurred in patients who were undergoing warfarin therapy, and all endoleaks were repaired with either proximal or distal covered extensions. At 30 days, seven patients (19.4%) undergoing chronic warfarin therapy had type II endoleaks as compared with 36 controls (18.4%; P =.798). Four patients had delayed type II endoleaks develop, two in the control group and two in the warfarin group (P =.3). Ten control individuals (31%) had spontaneous resolution of type II endoleaks develop, whereas spontaneous endoleak thrombosis was not observed in the warfarin group (P =.33). Aneurysm sac remodeling assessed with mean percent reduction in maximum sac diameter at 12 months revealed a statistical difference between the control group (17.5%) and the warfarin group (7.6%; P =.04). CONCLUSION: Warfarin treatment is not associated with an increase in the incidence rate of early or delayed postoperative endoleaks. However, the rate of reduction in maximum aneurysm sac diameter after aortic endografting is slower in patients who undergo therapeutic warfarin therapy at 1-year follow-up examination, a statistically significant difference from the control group. In addition, type II endoleaks may be less likely to undergo spontaneous thrombosis in patients who undergo warfarin therapy.

    Title Diagnosis and Management of Type 2 Endoleaks After Endovascular Aneurysm Repair.
    Date April 2002
    Journal Techniques in Vascular and Interventional Radiology
    Excerpt

    Endovascular repair is a major treatment advance in patients with large infrarenal abdominal aortic aneurysms. Since the FDA approved two commercial devices 2.5 years ago, over 40,000 patients have undergone this procedure in the United States. Although we have learned a great deal, more than a few mysteries relating to the long-term performance of these devices remain. This results in never-ending surveillance protocols searching for graft failure and aneurysm expansion. One of the especially contentious issues is the management of type 2 endoleaks. Unlike other endoleaks that are related to problems with the graft and/or fixation, this type of leak occurs in patients with properly functioning devices. This is why so much controversy exists about whether or not these patients must be treated. Some advocate "watchful-waiting" intervention only when there is aneurysm expansion. Others routinely treat patients with type 2 endoleaks in an attempt to prevent expansion. As with most controversial topics, if you look carefully, there is more agreement than disagreement between the two groups. In this review, we will first describe the methods used for endoleak diagnosis and treatment. We will then review our current endoleak treatment algorithm and explain its rationale for use.

    Title Durability of Benefits of Endovascular Versus Conventional Abdominal Aortic Aneurysm Repair.
    Date March 2002
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    PURPOSE: Endovascular abdominal aortic aneurysm (AAA) repair is reported to result in less initial patient morbidity and a shorter hospital length of stay (LOS) when compared with conventional AAA repair. We sought to examine the durability of this result during the intermediate follow-up interval. METHODS: The records of all admissions for all patients who underwent AAA repair during a 26-month interval were reviewed. RESULTS: Three hundred thirty-seven (337) patients underwent procedures to repair AAAs (163 open and 174 endovascular). Endovascular procedures were performed with a variety of devices (Talent, 108; Ancure, 36; AneuRx, 26; Zenith, 2; and Cordis, 2) and configurations (141 bifurcated and 33 aortomonoiliac). The mean follow-up period was 10.6 months (endovascular repair) and 12.3 months (open repair). LOS did not significantly vary by device (P =.24 to P =.92) or configuration (P =.24). The initial median LOS for procedures was significantly shorter (P =.009) for endovascular repairs (5 days) than for open procedures (8 days). However, the patients who underwent endovascular repair were more likely to be readmitted during the follow-up interval when compared with patients who underwent open procedure. The readmission-free survival rate after AAA repair at 12 months was 95% for patients for open AAA repair versus 71% for patients for endovascular repair (P <.001). If the total hospital days were compared, including the initial and all subsequent AAA-related admissions, there was no significant difference for mean LOS for patients who underwent endovascular versus open AAA procedures (11 days versus 13.6 days; P =.21). The patients for endovascular AAA repair most commonly needed readmission for treatment of endoleak (n = 31), wound infection (n = 12), and graft limb thrombosis (n = 9). Although women had similar LOS to men for endovascular repair (P =.44), they had longer initial LOS for open AAA repair (15 versus 10 days; P =.03). After endovascular repair, women were more likely than men to be readmitted by 12 months (51% versus 71% readmission-free survival rate; P =.03) and they had longer LOS on readmission (13.2 versus 5.2 days; P =.006). No gender differences were identified for patients after open AAA repair regarding readmission-free survival rate (P =.09) or LOS on readmission (P =.98). CONCLUSION: Although initial LOS was shorter for the patients who underwent endovascular as compared with conventional AAA repair, this advantage was lost during the follow-up interval because of frequent readmission for the treatment of procedure-related complications, chiefly endoleak. These readmissions frequently involved the performance of additional invasive procedures. Gender differences existed regarding LOS and the likelihood of complications after open and endovascular AAA repair.

    Title Thoracic Aortic Stent Grafts.
    Date March 2002
    Journal Seminars in Roentgenology
    Title Treatment of Type 2 Endoleaks After Endovascular Repair of Abdominal Aortic Aneurysms: Comparison of Transarterial and Translumbar Techniques.
    Date March 2002
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: The exact significance of collateral endoleaks is unknown and a topic of great debate. Because of this uncertainty, some physicians choose to watch and wait while others aggressively treat these leaks. The purpose of this investigation was the evaluation of the efficacy of the two techniques used in the treatment of collateral endoleaks that occur after endovascular aneurysm repair. METHODS: Patients with 33 angiographically proven type 2 endoleaks underwent treatment with either transarterial inferior mesenteric artery embolization (n = 20) or direct translumbar embolization (n = 13) during an 18-month period. Embolization success was defined as resolution of endoleak on all subsequent computed tomography angiogram results. The likelihood of embolization failure between the two treatments was expressed as a risk ratio and was compared with Fisher exact test. RESULTS: Sixteen of 20 transarterial inferior mesenteric artery embolizations (80%) failed with recanalization of the original endoleak cavity over time. A single failure (8%) in the direct translumbar embolization group occurred in a patient in whom a new attachment site leak developed. The remaining 12 translumbar endoleak embolizations (92%) were successful and durable, with a median follow-up period of 254 days. The patients who underwent transarterial inferior mesenteric artery embolization were significantly more likely to have persistent endoleak than were the patients who underwent treatment with direct translumbar embolization (risk ratio, 4.6; 95% confidence interval, 1.9 to 11.2; P =.0001). CONCLUSION: The transarterial embolization of inferior mesenteric arteries for the repair of type 2 endoleaks is ineffective and should not be performed. Direct translumbar embolization of the endoleak is effective in the elimination of type 2 leaks and should be the therapy of choice when aggressive endoleak management is indicated.

    Title Impact of Exclusion Criteria on Patient Selection for Endovascular Abdominal Aortic Aneurysm Repair.
    Date January 2002
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    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.

    Title Endovascular Aaa Repair in Patients with Renal Insufficiency: Strategies for Reducing Adverse Renal Events.
    Date December 2001
    Journal Cardiovascular Surgery (london, England)
    Excerpt

    Vascular imaging, usually employing nephrotoxic contrast agents is relied upon for all aspects of endovascular AAA repair causing some to consider renal insufficiency a relative contraindication. We sought to determine if endovascular AAA evaluation and repair could be successfully accomplished by minimally or non-nephrotoxic modalities.Records and results for 98 consecutive patients undergoing endovascular AAA repair were reviewed. Patients requiring dialysis preoperatively were excluded (N=3).The average volume of iodinated contrast agent employed for intraoperative imaging was 152 cc (35-420 cc). Twenty patients (20%) had baseline renal insufficiency (serum creatinine > or =1.3 mg/dl). A rise in serum creatinine above baseline was observed in 23 (24%) patients following repair; for 15 (16%) this was permanent. Creatinine rise occurred in patients with both normal (15) and abnormal (8) baseline values (P=0.09). Rise in creatinine was independent of contrast volume employed and of the use of infrarenal vs suprarenal device fixation (P>0.05). Two (2%) patients required permanent dialysis, one of which had a normal baseline creatinine and unclear etiology for renal failure, the other had a baseline creatinine of 2 and required device placement over an accessory renal artery. Strategies to minimize the use of nephrotoxic contrast for patients with renal insufficiency included the use of MRA, rather than contrast-CT for pre and postoperative imaging (7, 35%) and use of Gadolinium rather than iodinated contrast for performance of intraoperative arteriography (5, 25%). Endovascular grafts were successfully designed and implanted based upon MRA as the sole preoperative imaging modality in every case in which it was attempted (7). Mortality was not significantly different between those with and without abnormal baseline renal function (P>0.05). Adverse events (access failures, arterial injuries, blood loss, endoleaks) were not significantly correlated with baseline renal insufficiency, rise in creatinine from baseline, use of MRA or intraoperative Gadolinium angiography (P>0.05).Pre- and postoperative evaluation and performance of endovascular AAA repair can be accomplished in patients with renal insufficiency without increasing the rate of mortality or adverse events employing a strategy which minimizes the use of nephrotoxic contrast agents, relying upon Gadolinium arteriography and MRA. Endovascular grafts can be successfully planned and followed employing MRA as the sole imaging modality.

    Title Balloon Embolization of the Internal Iliac Artery Before Aneurysm Endograft Deployment.
    Date August 2001
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    Six patients, ranging from 69 to 81 years of age, underwent iliac artery embolization with use of Detachable Silicon Balloons (DSB) 11-14 days before stent-graft repair of aneurysms. Balloons of 8.8-mm, 9.4-mm, and 9.9-mm sizes were used with 20-30 g of release force. Deployment difficulty was experienced in three cases. Five of six cases were successful, with the iliac artery remaining occluded at the time of endografting; one case required subsequent coil replacement. The average operative time for balloon embolization (75 min +/- 28) was shorter than that in 18 cases of coil embolization performed within the same time period (111 min +/- 105), but the difference was not significant (P = .21). Postoperatively, one patient (17%) reported buttock claudication after the procedure. Use of the DSB represents an alternative to use of coils for embolization of large and tortuous iliac arteries.

    Title Endovascular Repair of Aortic Aneurysms: Critical Events and Adjunctive Procedures.
    Date July 2001
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: We sought to define the learning curve relative to the incidence and range of intraoperative problems and to establish guidelines for troubleshooting during the endovascular repair of infrarenal aortic aneurysms. METHODS: We prospectively evaluated our first 75 consecutive cases over a 12-month period and focused on perioperative critical events and adjunctive procedures as categorical outcome measures collected during the operation. Patients were separated into three groups on the basis of the date of their operation, such that group 1 consisted of our first 25 cases, group 2 our next 25 cases, and group 3 our last 25 cases. RESULTS: At least one critical event and adjunctive procedure marked 67 (89%) of 75 cases. In 51%, there were at least two critical events and adjunctive procedures. There were no immediate open conversions or intraoperative deaths. Access problems occurred in 28% of the 75 cases and were addressed by use of brachial-femoral artery access (30%), iliac artery/aortic bifurcation balloon angioplasty (8%), and iliofemoral conduits (4%). Graft foreshortening was the most common deployment event (44%), necessitating distal covered extensions. Iliac graft limb twists and kinks occurred in 12% of cases and were managed with balloon angioplasty and uncovered stents. General incidents included balloon ruptures (10%), arterial dissections (6%), iliac artery rupture (2.6%), and lower extremity ischemia (4%). The two cases of iliac artery rupture were managed with distal covered extensions, and there were no cases of atheroemboli. Intraoperative endoleaks were encountered in 44% of the cases and included proximal attachment sites (15%), distal attachment sites (9%), type 2 sources, and "blushes." Management of intraoperative endoleaks included proximal/distal covered extensions and re-ballooning. Our 30-day endoleak rate was 20%. The incidence of critical events did not decrease in the latter one third compared with the first two thirds of cases. CONCLUSIONS: Critical events occur frequently during endovascular repair of aortic aneurysms. The intraoperative problems range from the common endoleaks, access and deployment issues, and balloon ruptures, to rare but life-threatening complications such as iliac artery rupture. A toolbox of accessories that includes wires, catheters, large balloons, covered proximal and distal extensions, and uncovered stents is essential given the frequency of adjunctive procedures. Successful aortic endografting requires more than mere familiarity with basic endovascular techniques.

    Title Translumbar Embolization of Type 2 Endoleaks After Endovascular Repair of Abdominal Aortic Aneurysms.
    Date May 2001
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Title The Role of Magnetic Resonance Angiography for Endoprosthetic Design.
    Date April 2001
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVES: Many patients with aortic aneurysms have renal insufficiency and may be at increased risk when conventional imaging modalities (contrast-enhanced computed tomography and arteriography) are used for aortic endograft design. Our objective was to determine if magnetic resonance angiography (MRA) could be used as the sole imaging modality for endoprosthetic design. METHODS: A total of 96 consecutive patients who underwent endovascular repair of thoracic (5) and abdominal (91) aortic aneurysms (April 1998-December 1999) were included in this study. Data were collected prospectively. Gadolinium-enhanced MRA was used preoperatively in place of conventional imaging if renal insufficiency or a history of severe contrast reaction was present. The control group underwent conventional imaging. Endografts used included Ancure, AneuRx, and Talent. RESULTS: Fourteen patients (14.6%) had their endografts designed solely with MRA. Intraoperative access failure; proximal and distal extensions (unplanned); conversion to open, aborted procedures; and endoleaks occurred with equal frequency in both the MRA-designed and control groups (16.7% vs 18.3%, respectively; P =.33). Despite baseline renal insufficiency, there was no significant rise in the creatinine level after endograft implantation in patients with an MRA design (preoperative level, 1.8; postoperative level, 1.9; P =.5). CONCLUSION: MRA may be successfully used as the sole modality for aortic endograft design. The use of MRA for this purpose is noninvasive and minimizes nephrotoxic risk.

    Title Failure of Endovascular Abdominal Aortic Aneurysm Graft Limbs.
    Date March 2001
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVE: Endovascular abdominal aortic aneurysm (AAA) grafts are subject to subsequent failure of endograft limbs. We sought to determine what device-related factors could be identified that might contribute to limb failure. METHODS: We reviewed the records of patients who had undergone endovascular AAA repair and femorofemoral bypass grafting at a single institution. RESULTS: Endovascular AAA repair was performed in 173 patients. There were 137 bifurcated endografts and 36 aortomonoiliac grafts combined with femorofemoral bypass grafts, yielding a total population of 310 aortic graft limbs and 36 femorofemoral grafts. Thirty-nine additional patients underwent femorofemoral bypass grafting for occlusive disease. The cumulative primary patency of all endografts performed for AAA was 92% at 21 months. Secondary patency was achieved for all failed endograft limbs. There were 24 aortic graft limb "failures" that required intervention: seven limbs underwent thrombosis requiring revision; kinked limbs requiring stenting either at the time of graft placement (17) or subsequently (7) were identified. Fully supported endograft limbs had better primary patency (97% at 18 months) than unsupported limbs (69% at 18 months, P <.001). The aortomonoiliac grafts with femorofemoral bypass grafts tended to have better patency (97% at 18 months) than bifurcated endografts (90% at 18 months), but this did not reach statistical significance (P =.28, not significant). Femorofemoral grafts performed for occlusive disease were found to have somewhat lower patency than those performed for AAA (83% vs 92% at 18 months of follow-up, P =.37, not significant). CONCLUSIONS: Fully supported AAA endografts provide superior endograft limb patency compared with unsupported designs. Consideration should be given to routine stenting of all unsupported endograft limbs. Aortomonoiliac grafts and bifurcated grafts provide similar results for endograft limb patency. Femorofemoral bypass grafts performed in conjunction with aortomonoiliac grafts for AAA disease provide excellent short-term patency.

    Title Gender-related Differences in Infrarenal Aortic Aneurysm Morphologic Features: Issues Relevant to Ancure and Talent Endografts.
    Date March 2001
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    PURPOSE: The purpose of this study was to determine whether gender-related anatomic variables may reduce applicability of aortic endografting in women. METHODS: Data on all patients evaluated at our institution for endovascular repair of their abdominal aortic aneurysm were collected prospectively. Ancure (Endovascular Technologies (EVT)/Guidant Corporation, Menlo Park, Calif) and Talent (World Medical/Medtronic Corporation, Sunrise, Fla) endografts were used. Preoperative imaging included contrast-enhanced computed tomography and arteriography or magnetic resonance angiography. RESULTS: One hundred forty-one patients were evaluated (April 1998-December 1999), 19 women (13.5%) and 122 men (86.5%). Unsuitable anatomy resulted in rejection of 63.2% of the women versus only 33.6% of the men (P = .026). Maximum aneurysm diameter in women and men were similar (women, 56.94 +/- 8.23 mm; men, 59.29 +/- 13.22 mm; P = .5). The incidence of iliac artery tortuosity was similar across gender (women, 36.8%; men, 54.9%; P = .2). The narrowest diameter of the larger external iliac artery in women was significantly smaller (7.29 +/- 2.37 mm) than in men (8.62 +/- 2.07 mm; P = .02). The proximal neck length was significantly shorter in women (10.79 +/- 12.5 mm) than in men (20.47 +/- 19.5 mm; P = .02). The proximal neck width was significantly wider in women (30.5 +/- 2.4 mm) than in men (27.5 +/- 2.5 mm; P = .013). Proximal neck angulation (>60 degrees) was seen in a significantly higher proportion of women (21%) than men (3.3%; P = .012). Of the patients accepted for endografting, a significantly higher proportion of women required an iliofemoral conduit for access (women, 28.6%; men, 1.2%; P = .016). CONCLUSION: Gender-related differences in infrarenal aortic aneurysm morphologic features may preclude widespread applicability of aortic endografting in women, as seen by our experience with the Ancure and Talent devices. In addition to a significantly reduced iliac artery size, women are more likely to have a shorter, more dilated, more angulated proximal aortic neck.

    Title Update on the Talent Aortic Stent-graft: a Preliminary Report from United States Phase I and Ii Trials.
    Date March 2001
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    PURPOSE: Phase I and phase II trials were conducted to determine the safety and efficacy of the Talent aortic stent-graft (Medtronic World Medical, Sunrise, Fla) in the treatment of infrarenal abdominal aortic aneurysms (AAA). This is a preliminary report of the technical results and 30-day clinical outcome of these trials. METHODS: Multicenter prospective trials were conducted to test the Talent stent-graft in high-risk and low-risk patient populations with AAA, including phase I feasibility and phase II clinical trials. The low-risk study included concurrent surgical controls. RESULTS: In the phase I trial, deployment success was achieved in 92% (23/25 patients), and initial technical success was 78% (18/23 implants without endoleak). The 30-day technical success rate was 96%, with six endoleaks that resolved spontaneously (without need for further intervention); and the 30-day mortality rate was 12% (3/25 patients). The phase II high-risk trial demonstrated a deployment success of 94% (119/127 patients) and an initial technical success of 86% (102/119 implants). The 30-day technical success rate was 96%, and the 30-day mortality rate was 1.5% (2/127 patients). The phase II low-risk trial included a first-generation and a second-generation Talent stent-graft. Deployment success rates were 97% and 99%, respectively, and technical success rates at 30 days were 97% and 96%, respectively. The 30-day mortality rate was 2% in the phase II low-risk first-generation device trial, and the adverse-event rate was 20%. Corresponding figures for the second-generation device were 0% and 1.8%, respectively. CONCLUSION: The Talent stent-graft can be deployed successfully and achieves endovascular exclusion in a large proportion of patients with AAA. Morbidity and mortality rates are acceptable. One-year clinical results and the comparison with concurrent surgical control subjects remain to be evaluated.

    Title Limb Kinking in Supported and Unsupported Abdominal Aortic Stent-grafts.
    Date February 2001
    Journal Journal of Vascular and Interventional Radiology : Jvir
    Excerpt

    PURPOSE: The occurrence of kinking of stent-graft limbs depends on the patient's anatomy and the device used. The purpose of this investigation was to determine the rates of limb kinking in supported and unsupported aortic stent-grafts. MATERIALS AND METHODS: The authors performed a retrospective review of patients undergoing placement of either a Guidant Ancure/EGS or Medtronic Talent aortic stent-graft for the treatment of abdominal aortic aneurysm as part of separate phase II and phase III clinical trials. The records of 91 consecutive patients with 149 limbs were reviewed. The type and configuration of each device and any procedure performed specifically relating to limb patency was recorded. An analysis was then performed comparing the rates of kinking in supported and unsupported groups. A review of the literature was also performed. RESULTS: Overall, there was kinking in 18 of 149 limbs (12%). In the supported stent-graft group, 48 bifurcated and 26 aortomonoiliac grafts were placed, with a total of 122 limbs at risk. Six limbs (5%) in five patients required intervention as a result of limb kinking. Stents were placed intraoperatively in two limbs (2%) and postoperatively in four limbs (3%) for thrombosis or severe stenosis. In the unsupported group, 12 bifurcated and three aortomonoiliac grafts were placed, with a total of 27 limbs at risk. Twelve limbs (44%) in eight patients required some type of intervention as a result of limb kinking. Stents were placed intraoperatively in seven limbs (26%) and postoperatively in five limbs (19%) for thrombosis or severe stenosis. Rates of limb kinking were significantly different between the supported and unsupported groups (P < .0001). CONCLUSIONS: The use of supported versus unsupported stent-grafts impacts the occurrence of limb kinking. A direct comparison of the groups suggests that an unsupported stent-graft will be more than 15 times more likely than a supported system to require intervention because of kinking.

    Title Aneurysm Sac Pressure Measurements After Endovascular Repair of Abdominal Aortic Aneurysms.
    Date February 2001
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVES: The goal of endovascular grafting of abdominal aortic aneurysms (AAAs) is to exclude the aneurysm sac from systemic pressure and thereby decrease the risk of rupture. Unlike conventional open surgery, branch vessels in the sac (eg, lumbar artery and inferior mesenteric artery [IMA]) are not ligated and can potentially transmit pressure. The purpose of our investigation was to evaluate the feasibility of various interventional techniques for measuring pressure within the aneurysm sac in patients who had undergone endovascular repair of AAAs. METHODS: Sac pressure measurements were performed in 21 patients who had undergone stent graft repair of AAAs. Seventeen of 21 patients had endoleaks demonstrated on 30-day computed tomographic (CT) scans. Access to the aneurysm sac in these patients was through direct translumbar sac puncture (5 patients), through a patent IMA accessed via the superior mesenteric artery (SMA) (9 patients), or by direct cannulation around attachment sites (3 patients). Four patients had perioperative pressure measurements obtained through catheters positioned along side of the endovascular graft at the time of its deployment. Two of these catheters were left in position for 30 hours during which time CT and conventional angiography were performed. Pressures were determined with standard arterial-line pressure transduction techniques and compared with systemic pressure in each patient. RESULTS: Elevated sac pressure was found in all patients. The sac pressure in patients with endoleaks was found to be systemic (15 patients) or near systemic (2 patients) and all had pulsatile waveforms. Elevated sac pressures were also found in patients without CT or angiographic evidence of endoleak (2 patients). Injection of the sacs in two of these patients revealed a patent lumbar artery and an IMA. CONCLUSIONS: It is possible to measure pressures from within the aneurysm sac in patients with stent grafts with a variety of techniques. Patients may continue to have pressurized AAA sacs despite endovascular AAA repair. Endoleaks transmit pulsatile pressure into the aneurysm sac regardless of the type. It is possible to have systemic sac pressures without evidence of endoleaks on CT or angiography.

    Title Safety of Coil Embolization of the Internal Iliac Artery in Endovascular Grafting of Abdominal Aortic Aneurysms.
    Date November 2000
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    PURPOSE: During endovascular grafting of an abdominal aortic aneurysm (AAA), iliac limb extension to the external iliac artery may be indicated when the common iliac artery is ectatic or aneurysmal. Preliminary or concomitant coil embolization of the internal iliac artery (IIA) is thus necessary to prevent potential reflux and endoleak. We sought to determine the safety of hypogastric flow interruption in this setting. METHODS: We retrospectively reviewed 156 patients who underwent stent-graft AAA repair at two institutions between February 1, 1998, and January 31, 1999. Coil embolization of one or both IIAs was undertaken when the diameter of the common iliac artery was more than 20 mm to enable limb endograft extension to the external iliac artery. Bilateral procedures were staged. RESULTS: Thirty-nine (25%) of 156 patients were selected for coil embolization of one (n = 28) or both (n = 11) IIAs. The interventions were performed before (n = 31) or during (n = 8) the stent-graft procedure. Complications included groin hematomas in 3 patients, iliac artery dissection in 1, failure to catheterize the IIA in 2, and transient rise in the serum creatinine level in 3. One patient had erectile dysfunction, and five patients (13%) had buttock claudication after unilateral occlusion. Serious ischemic complications were not observed. CONCLUSION: Coil embolization of one or both IIAs appears to be safe in the setting of endovascular grafting of AAA. Buttock claudication is a relatively significant problem and may limit applicability of this strategy to patients who are unfit for standard open repair.

    Title Relationship Between Preoperative Patency of the Inferior Mesenteric Artery and Subsequent Occurrence of Type Ii Endoleak in Patients Undergoing Endovascular Repair of Abdominal Aortic Aneurysms.
    Date November 2000
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    OBJECTIVES: The purpose of this study was (1) to find out whether preoperative inferior mesenteric artery (IMA) patency (on radiographic imaging) predicts IMA-related endoleaks after endovascular repair of infrarenal abdominal aortic aneurysms, (2) to determine feasibility of measuring aneurysm sac pressures in patients with endoleaks, and (3) to report early evidence of effective endovascular obliteration of IMA endoleaks. METHODS: We studied 76 consecutive cases of infrarenal aortic aneurysms that were repaired with an endovascular approach (March 1998-April 1999). RESULTS: There were 13 (17%) endoleaks persistent 30 days after the procedure. Eleven (85%) of these 13 were IMA-related endoleaks, which were documented with selective superior mesenteric artery angiography. The preoperative finding (on computed tomographic scan) of a patent IMA does not always predict an IMA-related endoleak, but results in a statistically and clinically significant higher ratio of patients with IMA-related endoleaks in the immediate postoperative period (24% versus 3%, P <.035). In eight of the 11 patients with persistent IMA-related endoleaks, measurement of intra-aneurysm sac pressures was possible, and six of these patients had systemic pressures within the excluded aneurysm sac. Nine (82%) of 11 IMA-related endoleaks were successfully obliterated by means of selective IMA embolization. CONCLUSIONS: Many endoleaks are caused by a patent IMA, and this can result in persistence of systemic pressure within the aneurysm sac. The preoperative finding (on computed tomographic scan) of a patent IMA is a predictor of increased rates of IMA endoleaks, and IMA endoleaks can be successfully obliterated through endovascular procedures, after endovascular abdominal aortic aneurysm repair.

    Title Diagnosis and Treatment of Inferior Mesenteric Arterial Endoleaks After Endovascular Repair of Abdominal Aortic Aneurysms.
    Date May 2000
    Journal Radiology
    Excerpt

    PURPOSE: To review the incidence and repair of inferior mesenteric arterial (IMA) type II endoleaks after endovascular repair of abdominal aortic aneurysms. MATERIALS AND METHODS: Fifty patients who underwent endovascular repair of abdominal aortic aneurysms were examined. If an endoleak was identified at 30-day postoperative computed tomography, conventional arteriography was performed to identify and eliminate its source. After the exclusion of attachment site leaks, a catheter was placed selectively in the superior mesenteric artery (SMA). If retrograde filling of the IMA and aneurysm was identified, coil embolization was attempted through the SMA and middle colic artery. Intrasac pressures were measured at embolization. RESULTS: Eight of 50 patients (16%) had type II endoleaks that were attributed to retrograde flow in the IMA. Intrasac measurements demonstrated systemic pressure in six patients and one-half systemic pressure in two patients. The IMA was embolized through the SMA and left colic artery in seven patients and through the translumbar aorta in one patient. CONCLUSION: Retrograde flow in the IMA is responsible for many type II endoleaks. Systemic pressures are transmitted into the aneurysm sac from the IMA. The IMA can be embolized successfully with an SMA approach in most patients.

    Title Perigraft Air, Fever, and Leukocytosis After Endovascular Repair of Abdominal Aortic Aneurysms.
    Date November 1999
    Journal American Journal of Surgery
    Excerpt

    BACKGROUND: The postimplantation syndrome of fever and leukocytosis after endovascular repair of infrarenal aortic aneurysms has not been previously characterized and its etiology is not known. METHODS: We studied the first 12 patients who underwent successful endovascular repair of infrarenal aortic aneurysms with Dacron-covered stent-grafts, as part of an ongoing phase II clinical trial. Sepsis syndrome evaluations (physical examination, urinalysis, chest radiograph, urine cultures, and blood cultures) were performed for all patients with postoperative temperature (T) greater than 101.4 degrees F. Computed tomography scans of the abdomen were performed, as part of the clinical protocol, on postoperative days 2 and 30. RESULTS: Fever (T > 101.4 degrees F) was seen in 8 of 12 (67%) patients (P < 05). An additional 2 of 12 (17%) patients had low-grade fevers (100.3 degrees F, 100.6 degrees F). Only 2 of 12 (17%) patients remained afebrile postoperatively. Leukocytosis with counts over 11,000 white blood cells (WBC)/dL was observed in 7 of 12 (58%) patients (P < 05). Sepsis evaluations failed to identify any source of infection in 11 of 12 (97%) patients. Computed tomography scan evidence of perigraft air was noted in 8 of 12 (67%) patients. All patients were afebrile, had normal white blood cell counts, and were discharged within 1 week postoperatively. There has been no evidence of graft infection after 1 to 6 months of follow-up. CONCLUSIONs: Fever and leukocytosis after stent-graft repair of aortic aneurysms does not represent evidence of systemic or graft infection and is not clearly related to nonspecific causes of postoperative fever and leukocytosis. Moreover, the finding of early postoperative perigraft air is not necessarily an indication of graft infection even when concurrently present with fever and leukocytosis.

    Title Thin-walled Polytetrafluoroethylene Graft Failure is a Cause of Axillary Pullout Syndrome.
    Date February 1995
    Journal Surgery
    Title Stationary Arterial Wave Phenomena.
    Date July 1994
    Journal Annals of Vascular Surgery
    Excerpt

    The case of a 38-year-old woman who was struck by an automobile is presented. The workup for lower extremity injuries revealed stationary arterial waves. Recognition of this arteriographic finding may avoid unnecessary confusion or exploration.

    Title Case Report 723. Popliteal Artery Aneurysm.
    Date July 1992
    Journal Skeletal Radiology
    Excerpt

    An unusually large, noncalcified popliteal artery aneurysm causing cortical erosion was erroneously diagnosed as a soft-tissue sarcoma. The case stresses the importance of excluding a vascular cause of a mass whenever biopsy is considered. We review the clinical and radiological features of popliteal artery aneurysm and describe the appearance of the aneurysm on MR.

    Title Airway Compromise After Carotid Surgery in Patients with Cervical Irradiation.
    Date February 1990
    Journal The Journal of Cardiovascular Surgery
    Excerpt

    Symptomatic carotid atherosclerotic disease occurring as a result of cervical irradiation often requires surgical intervention. Airway obstruction is an uncommon problem after most carotid surgery and has not been described for patients with cervical irradiation. Airway obstruction developed after two of five carotid endarterectomy procedures in previously irradiated necks requiring emergency tracheostomy or reintubation. Mechanisms of obstruction included endotracheal tube trauma to the fixed irradiated vocal cords and laryngeal edema caused by surgical dissection in an irradiated field. In addition, one patient in our series demonstrated hypercarbia as a result of bilateral carotid body ablation, a process known to impair the ventilatory response to hypoxia. An increased risk of airway obstruction after carotid surgery exists in patients with prior cervical irradiation. Preventive methods include the use of perioperative steroids and either carotid surgery with local anesthesia or bronchoscopic vocal cord visualization and intubation.

    Title Why Does Subclavian Vein Thrombosis Happen and Can It Be Prevented or Treated?
    Date September 1989
    Journal Anna Journal / American Nephrology Nurses' Association
    Title Surgery for Radiation-induced Symptomatic Carotid Atherosclerosis.
    Date June 1989
    Journal Annals of Vascular Surgery
    Excerpt

    Carotid atherosclerosis occurring secondary to cervical irradiation is known to produce stroke. Transient neurologic symptoms have necessitated surgical intervention to prevent stroke despite concern over technical problems, wound healing, operative risks, and uncertain therapeutic outcome. With this report, 26 surgical procedures in 20 patients are now documented in the literature (12 men--60%; eight women--40%). Mean age of these patients (56 years) was 10 years younger than carotid surgery patients with no prior radiation history. No relationship was noted between elevated serum cholesterol and the subsequent development of radiation-induced carotid atherosclerosis. Surgical procedures performed included carotid endarterectomy in 17 cases (65%) and arterial bypass in nine (35%). The combination of radiation therapy and previous neck surgery, including prior radical neck dissection, did not adversely influence operability. Surgical outcome was uniformly good with only one stroke (4%) documented in the perioperative period. Longer follow-up on our six cases (mean two years) disclosed neither new clinical symptoms nor the development of hemodynamically significant restenosis.

    Title A New Approach to the Treatment of Vertebral Arteriovenous Fistulas.
    Date February 1984
    Journal Surgery
    Title Prehepatic Total Parenteral Nutrition in the Chair-adapted Primate.
    Date August 1983
    Journal Jpen. Journal of Parenteral and Enteral Nutrition
    Excerpt

    The relative efficacy of prehepatic and central venous infusion of total parenteral nutrition (TPN) was evaluated in a chair-adapted primate model. Four adult male monkeys (Macaca fascicularis) underwent surgical placement of a silastic catheter in both the portal vein (PV) and superior vena cava (SVC). Following recovery (10 days), each animal received two courses of TPN (100 kcal and 4 g of protein/kg/day) for 10 days each via the PV and SVC in an alternating crossover manner. The prehepatic (PV) infusion of TPN in the well nourished, chair-adapted primate results in maintenance of weight (PV: delta - 0.07 kg; SVC:delta - 0.07 kg), nitrogen equilibrium (PV:+ 0.8 g N/day; SVC: + 0.7 g N/day), and trends in serum albumin (PV:delta - 0.35 g %; SVC: delta - 0.38 g %), and total iron binding capacity (PV:delta + 44 mg %; SVC:delta + 8.67 mg %) comparable to the SVC route. No significant abnormalities in liver enzyme production were observed with either route of infusion. Whole body protein synthesis rates using 15N-glycine tracer were likewise comparable (PV = 2.05 g N/kg/day; SVC = 2.18 g N/kg/day). Prehepatic delivery and primary hepatic modulation of substrates does not substantially improve the efficacy of parenteral nutrient administration. Intestinal modification of substrates may be the most important contributing factor in the supposed superiority of enteral alimentation.

    Title Emergency Thoracotomy in the Surgical Intensive Care Unit After Open Cardiac Operation.
    Date January 1982
    Journal The Annals of Thoracic Surgery
    Excerpt

    Since January, 1977, 64 patients (3%) out of 2,112 who underwent open cardiac operation had 74 emergency thoracotomies in the surgical intensive care unit 10 minutes to 12 days after operation. In all instances thoracotomy was performed for inadequate circulation. Patients were divided into two groups. In Group 1, 44 patients suddenly and unexpectedly became hypotensive due to an arrhythmia (13 patients), sudden massive bleeding (15), suspected tamponade (6), or unexplained reasons (10). In Group 2 (20 patients), circulatory insufficiency was progressive despite maximum pharmacological and intraaortic balloon support. Circulation was restored after 37 of the 74 thoracotomies (50%), including 8 in Group 2. Nineteen patients (30%) were ultimately discharged; however, no patient in Group 2 survived hospitalization. Of the 19 survivors in Group 1, only 2 of the 13 with a sudden arrhythmia and 3 of the 10 with unexplained hypotension survived. However, 5 of the 6 with tamponade and 9 of the 15 with sudden massive bleeding survived. Overall, 43% of Group 1 patients survived. We conclude that emergency thoracotomy in the surgical intensive care unit after open-heart operation may be lifesaving if performed promptly in patients with sudden, unexpected hypotension. The incidence of wound infection in survivors in 5% whether or not the chest is closed in the operating room.

    Title Influence of Hormones on the Release of Iron by Macrophages.
    Date June 1981
    Journal Journal of the Reticuloendothelial Society
    Title Inadvertent Transplantation of a Melanoma.
    Date March 1981
    Journal Transplantation
    Excerpt

    A cadaver renal allograft recipient with normal function for over 3 years developed metastatic melanoma and died within months despite cessation of immunosuppression and allograft nephrectomy. Two additional immunotherapeutic modalities were attempted when it became obvious that the tumor was not a de novo malignancy but rather an inadvertently transplanted one. Neither reexposure to the allograft antigens nor administration of alloantiserum from the patient who had received and rejected the mate of the kidney from the same donor affected the rapid growth of the melanoma in our patient. Of extreme interest is that a focus of melanoma was found in the allograft removed from the surviving patient.

    Title Single-center Experience of Caval Thrombectomy in Patients with Renal Cell Carcinoma with Tumor Thrombus Extension into the Inferior Vena Cava.
    Date
    Journal Vascular and Endovascular Surgery
    Excerpt

    The objective of this study is to describe a single-center experience of caval thrombectomy in patients with renal cell carcinoma (RCC) and tumor thrombus extension into the inferior vena cava (IVC). We retrospectively reviewed 23 patients undergoing radical nephrectomy with caval thrombectomy. Follow-up included an office visit and computed tomography scan. Statistical comparisons were made using 2-sample t tests. Patients' ages ranged from 32 to 83 years (mean, 62 years; 18 male, 5 female). Tumor size ranged from 3 to 21 cm (mean, 8.6 cm). Tumor thrombus staging was based on the Nevus classification: level I (2/23), II (6/23), III (13/26), IV (2/23). Tumor thrombi were removed by means of digital extraction (20), Fogarty embolectomy (2), or endarterectomy (1-caval wall invasion). Lateral venorrhaphy was used for IVC repair in all cases. Hepatic mobilization and suprahepatic clamping were necessary in 14 patients. Clamp times were significantly different between the suprahepatic (SH) and infrahepatic (IH) groups (15 vs 9.4 minutes, P < .012). Mean blood loss was also significantly different (3.2 L vs 2 L, P < .045). In the SH group, 2 patients developed postoperative atrial fibrillation and 2 patients died (respiratory failure; missed enterotomy). The IH group had no perioperative morbidity or mortality. Median followup was 15 months (range, 1-54 months). Follow-up imaging was available for 19/23 patients. Ninety-five percent of patients had a patent IVC (18). One SH patient developed an IVC stenosis/thrombosis 12 months postoperatively with successful thrombolysis and stenting. There was a 16% (3/19) recurrence rate in follow-up, with all patients demonstrating renal vascular invasion and high Fuhrman grade upon final pathologic evaluation. Caval thrombectomy can be performed safely during radical nephrectomy for RCC with tumor thrombus extension. The need for suprahepatic clamping is associated with longer clamp times, increased blood loss, and increased morbidity and mortality. Lateral venorrhaphy with primary repair avoids complicated caval reconstructions and results in high patency rates, despite a not insignificant recurrence rate.

    Title Open Abdominal Aortic Aneurysm Repair is Feasible and Can Be Done with Excellent Results in Octogenarians.
    Date
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    The purpose of this study was to determine the feasibility of open abdominal aortic aneurysm (AAA) repair in octogenarians during a time period of multiple commercially available endografts, in which only proximal aneurysms or the most challenging anatomy are not stented.

    Title Aneurysmal Iliac Arteries Do Not Portend Future Iliac Aneurysmal Enlargement After Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm.
    Date
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    The purpose of this study was to examine the fate of aneurysmal iliac arteries managed during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA).

    Title Predictors of Early and Late Mortality Following Open Extent Iv Thoracoabdominal Aortic Aneurysm Repair in a Large Contemporary Single-center Experience.
    Date
    Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
    Excerpt

    The primary purpose of this study was to examine outcomes following open repair of extent IV thoracoabdominal aortic aneurysms (TAAAs) at a single university hospital. As a secondary aim, comparison was made to patients who underwent open abdominal aortic aneurysm (AAA) repair with supraceliac clamping but without left renal artery bypass to assess the effect of left renal artery bypass on outcomes.

    Title Endovascular Repair of the Thoracic Aorta.
    Date
    Journal Seminars in Interventional Radiology
    Excerpt

    The emergence of endovascular repair of the thoracic aorta (TEVAR) quickly followed the development of technology for the exclusion of infrarenal abdominal aortic aneurysms. Stent grafts comprised of metal struts covered with fabric made of Dacron/polyester or polytetrafluoroethylene were developed for the purpose of achieving an adequate seal at the proximal and distal aspects of thoracic aneurysms, thus excluding sac flow. The recognition of the decreased morbidity of this approach compared with open repair was readily apparent, as it avoided left thoracotomy, aortic cross-clamping, and left heart bypass. Since then, TEVAR is increasingly being used for other aortic pathologies such as complicated type B dissection, traumatic aortic transection, and aneurysmal disease extending into the arch or visceral segment, requiring debranching procedures.

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