Showing papers in "Perspectives in Vascular Surgery and Endovascular Therapy in 2008"

Fenestrated and branched stent grafts.

Abstract: It is estimated that 50% of patients with abdominal aortic aneurysms are not candidates for endovascular repair using the currently commercially available devices because of unfavorable anatomy. This includes patients with short or angulated necks, aneurysmal extension into either internal iliac artery, or complex aneurysmal involvement of the juxtarenal, paravisceral, and thoracoabdominal aorta. Good surgical candidates may tolerate open conventional repair of the aneurysm, but patients with large aneurysms and poor cardiac, pulmonary, or renal performance have limited options. Fenestrated and branched stent grafts were designed to extend the proximal sealing zone from the infrarenal segment to the juxta and suprarenal aorta, thereby circumventing the limitation of short or absent aortic necks. Since the first implantation of a fenestrated graft in 1996, there has been tremendous advancement in the development and technology of these devices. It is now possible to treat pathology of the entire aorta via a completely endovascular approach, with short-term results that compare favorably with those of open surgery. This review presents the current world experience with fenestrated and branched stent grafting. It encompasses the historical background of these devices, describes the techniques of fenestrated and branched grafting, summarizes the intermediate-term results for endovascular repair of pararenal, juxtarenal, thoracoabdominal, and aortoiliac aneurysms, and discusses the role of surgeon-modified fenestrated and branched devices.

Carotid artery stenting: technical issues and role of operators' experience.

Abstract: Major criticism of randomized clinical trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) focused on the incomplete learning curve of interventionists and the inadequate and outdated technology employed, which might have contributed to the high stroke and death rates in the CAS arm. The effect of the learning curve related to technical expertise and patient selection strongly influences the results of CAS. Due to the devastating potential complications when compared with other endovascular minimally invasive procedures, CAS requires a more strict analysis of operator training and outcome, because improvement in the learning curve is accompanied by a comparative reduction in complication rates. Today, there is a general agreement that requirements for training in CAS are higher than in other fields. In contrast to many endovascular peripheral arterial interventions, CAS represents a more challenging procedure because it involves complex catheter-based skills. Training experience attempts to sensibly reduce strokes that may occur during the unprotected phases of catheterization/approach to the target vessel and the protected phase of ballooning/stenting and cerebral protection device retrieval. Mandatory training, familiarity with the indications and contraindications, and knowledge of the technology and devices are paramount for the success of CAS, and preprocedure, intraprocedure, and postprocedure patient management is essential for reducing morbidity and mortality. These prerequisites are essential to allow CAS to be accepted as a potential alternative to CEA.

The return of tourniquets. Original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating extremity injuries.

Abstract: Jeffrey Kalish, MD, Peter Burke, MD, Jim Feldman, MD, Suresh Agarwal, MD, AndrewGlantz, MD, Peter Moyer, MD, Richard Serino, NREMT-P, Erwin Hirsch, MDAugust 2008 JEMS Vol. 33 No. 82008 Aug 1Uncontrolled hemorrhage from isolated penetrating extremity wounds can result in 100%mortality, but significant controversy still surrounds tourniquet use in civilian prehospitalcare. It’s been proposed that 10% of combat deaths in the Vietnam War resulted fromuncontrolled hemorrhage from extremity wounds; many of the deaths were due solely toineffective field hemorrhage control methods.1 Multiple U.S. and foreign military reportsconfirm the importance of tourniquets in controlling exsanguination on the battlefield.2,3As a result, the use of tourniquets is now actively promoted in the U.S. military, with allservice personnel carrying a tourniquet with their gear.2In the civilian trauma setting, the debate continues. In fact, numerous prehospital systemmedical personnel are specifically discouraged from utilizing tourniquets, and manyambulances don’t even carry them. Some of the reasons tourniquets haven’t beendeployed in the prehospital setting include the notions that: 1) Manual pressure shouldsuffice to control hemorrhage; 2) The proximity of urban trauma centers to the scene ofan injury should preclude exsanguination before the patient reaches definitive care; and

Experience With the Endologix Powerlink Endograft in Endovascular Repair of Abdominal Aortic Aneurysms With Short and Angulated Necks

Abstract: Endovascular aortic aneurysm repair (EVAR) for anatomically suitable abdominal aortic aneurysms (AAAs) has gained wide acceptance in the past decade, and EVAR for anatomically challenging or unsuitable AAAs such as short and angulated neck AAAs has become a hotly debated subject. The objective of this study is to summarize the unique experience of EVAR for short / angulated neck AAAs with Powerlink unibody bifurcated stent-graft. Data were retrospectively analyzed from 519 patients in our single unit from February 1999 to December 2007 who underwent EVAR using the Powerlink endograft, and had short or angulated necks. Short neck was defined as or = 60 degrees angulation between the longitudinal axis of infrarenal aorta and the aneurysm. The unique strategy of treating short / angulated neck AAAs is to build up the endoluminal exclusion system from the native aortic bifurcation to the renal artery level with suprarenal fixation. The Powerlink unibody bifurcated stent graft was implanted anatomically fixed on the aortic bifurcation and a long suprarenal cuff was built up to the renal arteries. A Palmaz stent can be used for proximal fixation and sealing enhancement in the most challenging necks. The follow-up imaging was performed at 1 month, 6 months, and yearly thereafter. The technical success rate was 97.4% (114/117). Intraoperative complications included 3 conversions due to delivery access problems, 6 proximal type I endoleaks, and 5 type II endoleaks. The 30-day mortality was 1.7% (2/117). The 2.6-year follow-up showed 4 (3.4%) proximal type I endoleaks, which were revised with proximal cuff and/or Palmaz stent. Limb occlusion occurred in 2 cases, and the total re-intervention rate was 5.3%. Three (2.6%) type II endoleaks were left in observation. There were 3 (2.6%) partial renal infarctions, no stent-graft distal migration, and no post-EVAR ruptures. Our experience demonstrates that building up the endoluminal exclusion system from the abdominal aortic bifurcation to the renal artery level using the Powerlink fully supported unibody bifurcated stent-graft with a long suprarenal cuff, and a Palmaz stent when needed, proved safe and effective in treating AAAs with short and angulated necks.

Kissing Stent Reconstruction of the Aortoiliac Bifurcation

Abstract: Kissing stent reconstruction of the aortoiliac bifurcation is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. New advances in delivery systems and stent design have enabled better anatomic results with kissing stenting. Long-term patency is generally excellent, although several factors may adversely affect patency and should be taken into account when devising the stenting configuration and selecting the device to be used. Geometric variables related to individual aortic anatomy and disease pattern (patient dependent) and stenting configuration (operator dependent) may have an impact on long-term patency. Kissing stent aortoiliac reconstruction is effective and durable, even with complex aortoiliac disease and long-segment occlusions. In our experience, TASC (TransAtlantic Inter-Society Consensus) C and D class disease is not necessarily a contraindication to aortoiliac stent reconstruction, especially in poor operative risk patients. Most restenoses are amenable to endovascular treatment, with excellent long-term assisted patency.

A review of the trials comparing carotid endarterectomy and carotid angioplasty and stenting.

Abstract: In the last decade, carotid artery angioplasty and stenting (CAS) has gained popularity as an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, particularly in patients who are at high operative risk. CAS offers the advantage of being a less invasive procedure, potentially minimizing the risks of wound complications and cranial nerve injury, which may translate into shorter length of hospitalization and less resource utilization. Since the advent of CAS, several randomized controlled trials and carotid stent registry trials have been conducted comparing the outcomes of CEA with those of CAS for the treatment of carotid stenosis in both symptomatic and asymptomatic patients. This review will summarize the results of randomized controlled trials (CAVATAS, WALLSTENT, SAPPHIRE, EVA-3S, SPACE, and CaRESS) as well as pivotal carotid registry studies (ARCHeR, BEACH, CAPTURE, CASES-PMS, CREATE, and CABernET) intended to evaluate the safety and efficacy of CEA and CAS in treatment of carotid stenosis. In addition, it will provide a preview of the current ongoing and future trials examining the safety, applicability, and indications of CAS and CEA (CREST, CAVATAS-2, ACT 1, and TACIT).

Perspectives in vascular surgery and endovascular therapy.

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Endovascular management of deep venous thrombosis.

Abstract: The past decade has witnessed new developments for the treatment of deep venous thrombosis (DVT) as well as more information about the virulent nature of DVT over the long term. Symptoms of pain, edema, skin changes, and/or ulceration can affect upwards of 70% of individuals to some degree. Studies have determined that early intervention of thrombus removal may help prevent postthrombotic syndrome in a significant number of patients. Several devices now specifically combine mechanical or ultrasound energy with chemical thrombolysis. These devices include the Trellis-8, Angiojet Power Pulse System, and the Ekos Endowave. Other important aspects central to successful endovascular removal of DVT include using ultrasound guidance for access, understanding venous anatomy and physiology in relation to endovascular techniques, knowing when to perform venous interventions, and using intravascular ultrasound. Endovascular removal of DVT is increasingly becoming the standard of care, particularly that affecting the iliofemoral segments.

Ambulatory phlebectomy in the office.

Abstract: Ambulatory phlebectomy is a minor, office-based surgical procedure designed to remove varicose veins. It is a perfect complement to endovenous thermal ablation of the saphenous vein. With this combination, patients can expect all varicose veins to vanish following a 1-hour procedure that employs only local anesthesia in the comfort of a physician's office. Advantages of office-based surgery are ease of scheduling for doctors and patients, less paperwork, elimination of travel time, and cost containment for the health care system. Furthermore, a procedure that is performed by the same staff daily is more streamlined and safe.

Aortic dissection with aortic side branch compromise: impact of malperfusion on patient outcome.

Abstract: The purpose of this study was to review the management and clinical outcome of patients with aortic dissection and symptomatic or asymptomatic aortic branch compromise. We identified 104 patients (30.7%) with aortic branch compromise from a group of 339 patients who underwent surgical management of aortic dissection from January 1971 to May 2003. Patients were divided into 2 groups: symptomatic and asymptomatic aortic branch compromise, based on the presence or absence of cerebral, extremity, spinal, renal, and visceral ischemia. Clinical data and outcome were reviewed and compared in both groups. There were 74 male (77%) and 30 female patients with a mean age of 58.5 (range, 23-81) years. Aortic dissection was classified as Stanford type A in 58.7%, acute in 58.7%, and was associated with asymptomatic aortic branch compromise in 44 patients (42.3%) and symptomatic aortic branch compromise in 60 patients (57.7%). Asymptomatic and symptomatic aortic branch compromise, respectively, were distributed in the extremity (30 and 33), carotid (5 and 4), renal (21 and 28), visceral (13 and 8), and spinal (0 and 5) arteries. In the asymptomatic aortic branch compromise group, all patients had aortic graft replacement, and 9 had branch reconstructions. In the symptomatic aortic branch compromise group, treatment was aortic graft replacement (48), open fenestration (6), and endovascular treatment (6). Operative mortality rate was 9.1% (4 of 44) in the asymptomatic and 38.3% (23 of 60) in the symptomatic aortic branch compromise during the 30-year study period (P = .001), decreasing from 35.1% (20 of 57) prior to 1990 to 14.9% (7 of 47) since 1990 (P = .04). In the symptomatic group, operative mortality decreased from 56.7% (17 of 30) to 20% (6 of 30) in the same interval (P = .003). Patients treated in both treatment eras were similar except for less aortic graft replacements and more aortic fenestrations and direct branch reconstructions since 1990. Multivariate analysis revealed symptomatic aortic branch compromise group, treatment prior to 1990, Marfan syndrome, age greater than 70 years, and postoperative complications to be independently associated with increased operative mortality. Asymptomatic aortic branch compromise was not associated with increased operative mortality, but organ malperfusion was an independent risk factor for operative death. The operative mortality significantly decreased since 1990, mostly because of changes in our surgical approach, with less aortic graft replacements and more complication-directed procedures.

Popliteal artery aneurysms: rationale, technique, and results of endovascular treatment.

Abstract: Endovascular repair of popliteal artery aneurysms has been used with increasing frequency in recent years. Advocates of the procedure claim a lower rate of complications, early return to work, no change in the quality of life, and long-term patency rates that are as favorable as those following open surgical repair. Unfortunately, data of only 1 prospective randomized study are available, and a recent meta-analysis showed a higher rate of early graft thromboses and more early reinterventions after endograft repair of popliteal artery aneurysms. Open, elective surgical repair with the vein graft has patency rates more than 90% in contemporary series. Current evidence only supports the use of stent grafts in those with high surgical risks and in the elderly.

Commentary. Gaps in public knowledge of peripheral arterial disease: The first national PAD public awareness survey.

Abstract: The study by Hirsch et al is a cross-sectional, population-based telephone survey of 2501 adults greater than 50 years of age, with oversampling of blacks and Hispanics, to measure the public awareness of lower-extremity peripheral arterial disease (PAD), its relationship to other kinds of vascular disease, and the risk factors associated with its cause. The authors concluded that the general public is poorly informed about PAD, with only 25% of respondents expressing familiarity with the entity, about one fourth aware of its association with stroke and heart attack, and fewer than one half appreciating the risk factors associated with PAD. Patient cohorts at highest risk for PAD (the elderly and minorities) were the least well informed. The authors offered these data as a population-based baseline in which to measure future national efforts toward public education.

New office-based vascular interventions.

Abstract: Objective: Following contemporary trend, various vascular interventions being performed in the office. We describe our office experience with radiofrequency ablation (RFA) of incompetent perforating veins (IPV) and duplex-guided balloon angioplasties of failing/nonmaturing arterio-venous fistulas (AVF). Duplex-guided balloon angioplasties of AVF: Eighteen patients with 20 failing arterio-venous (AV) fistulas underwent office duplex-guided balloon angioplasties. Thirteen procedures (65%) were on non-maturing fistulas and the remaining 7 (35%) - in dialyzed patients. Sheath insertion, wire and balloon passage and inflation were guided by duplex only. RFA of IPVs: We performed 25 radiofrequency ablations of 49 IPVs. Early follow-up scan confirmed total occlusion of 45 (92%) treated IPVs. Patients gender, CEAP class, perforator diameter or GSV patency did not correlate with current procedure failure. Conclusion: Excellent duplex imaging quality and technical advances in endovascular tools allowed us safely pe...

Diagnosis and Management of Venous Ulcers

Abstract: Venous ulceration of the lower extremities is a common and often disabling condition. Venous ulcers are the result of a chronic inflammatory condition caused by persistent venous hypertension. Therapy is directed at counteracting the chronic inflammation in the tissues and at decreasing ambulatory venous hypertension in the area. Compression therapy helps decrease the venous hypertension and aids healing. Topical agents may be used to help decrease the bacterial load in the wound, provide a moist healing environment for dry wounds, or absorb the exudate in wounds with a lot of drainage. Pharmacological adjuncts, such as pentoxifylline or flavanoids, may help counteract the chronic inflammation in the ulcerated area. Interventions to decrease the ambulatory venous hypertension can help patients with either active or healed ulcers. Ablation of incompetent superficial truncal veins and/or perforating veins using radiofrequency ablation, endovenous laser ablation, or foam sclerotherapy can speed ulcer healing and prevent recurrence.

Flow reversal for cerebral protection in carotid artery stenting: a review.

Abstract: Carotid artery stenting has established itself as a valid treatment option for carotid stenosis. Many neuroprotective devices have been developed to minimize the risk of embolic events and stroke. Of the devices available today, flow reversal is unique in its conceptual similarity to carotid endarterectomy shunting techniques that maintain cerebral flow. This review focuses on the technical aspects, results, advantages, and disadvantages of carotid flow reversal for embolic protection during carotid artery stenting.

Sclerotherapy: a truly minimally invasive technique.

Abstract: Foam sclerotherapy offers a treatment strategy with great potential. Recently, general and vascular surgery have become less invasive; so too, has the treatment of venous disorders. Sclerosants cause irreversible damage to the vascular endothelium by disrupting cell membranes resulting in sustained vasospasm and denudation of the venous monolayer. Prospective randomized outcome data support the hypothesis that foam sclerotherapy is superior to liquid sclerotherapy. All published reports of varicose vein treatment with foam describe efficacy in terms of immediate and primary venous occlusion of better than 80%. Severe complications of foam sclerotherapy are rare. Recurrent varices are in the 10% to 20% range. Use of foam sclerotherapy in our experience has proven to be effective, essentially pain-free, and durable in the short term. The treatment is quick, efficient, and cheap.

EVAR, TEVAR, FEVAR, too far?

Abstract: Endovascular aneurysm repair (EVAR) is the greatest technological advance in the field of vascular and endovascular surgery in the past 15 years. However, its widespread application has created potential problems, and EVAR may be overused in some circumstances. As long-term outcome data are being sought for EVAR, it is becoming apparent that complications (infection, device migration, and the development of late endoleaks, aneurysm growth, and rupture) are occurring at a higher rate than anticipated. It is also apparent that follow-up is not complete in a large proportion of patients after EVAR, and these are the patients most prone to present with late complications. Surgeons are placing devices in large numbers of patients with poor anatomy for EVAR, in part because of pressures from patients, families, and referring physicians. In patients with good anatomy, EVAR is an excellent option and will likely be durable. In those with unfavorable anatomical features, we need to better appreciate the potential for adverse long-term outcomes and advocate more strongly for open repair.

The impact of embolic protection device and stent design on the outcome of CAS.

Abstract: The importance of angioplasty and stenting in the treatment of carotid artery disease cannot be underestimated. Successful carotid stenting does not only depend on the operator's skills and experience but also on an adequate selection of cerebral protection devices, and carotid stents can help avoid neurological complications. A broad spectrum of carotid devices is currently on the market, and because each of them has its own advantages and disadvantages, it is virtually impossible to claim that one specific device is the best. The individual characteristics of each specific protection system or stent may make it an attractive choice in one circumstance but render it a less desirable option in other situations. The applicability depends primarily on the arterial anatomy and the specific details of the lesion being treated. But certainly, personal preferences and familiarity with a specific device may legitimately influence the decision to choose one over another.

The excluder aortic endograft.

Abstract: Since its introduction, more than 59 000 patients have been treated with Gore Excluder endoprosthesis (GORE) for abdominal aortic aneurysm (AAA) in the past 11 years. It has become clearer that dif...

Hemodynamic changes associated with carotid artery interventions.

Abstract: Carotid artery interventions can be associated with adverse hemodynamic changes, including bradycardia and hypotension. These hemodynamic changes are believed to be caused by direct stimulation of the carotid sinus baroreceptors, mimicking normal physiological response to rises in blood pressure. During open carotid surgery, these hemodynamic changes can be controlled by direct injection of medications that block fast voltage gated sodium channels in the neuron cell membrane, thus preventing depolarization of the presynaptic neuron in the carotid sinus. This form of control is difficult or impossible during percutaneous carotid interventions because direct access to the carotid artery and carotid sinus is not available. This discussion focuses on the cause, effects, and possible treatments for the hemodynamic changes associated with carotid artery stenting procedures.

Antiplatelet Therapy for Vascular Interventions

Abstract: The role of platelets and the importance of platelet inhibition are well established in patients with vascular disease. When physicians perform revascularization procedures in these patients, who typically have the most advanced atherosclerotic disease, they should be aware of both the generic benefits of platelet inhibition on patients' long-term health as well as the specific benefits relative to operative or endovascular revascularization. Platelet inhibition has not been well studied in the aortoiliac system, renal vascular bed, or the mesenteric arterial bed. Peripheral vascular beds that have been studied are predominantly the carotid circulation and the infrainguinal vasculature. This article reviews the basic mechanisms of platelet inhibition and suggests antiplatelet strategies for vascular interventions, including carotid endarterectomy, carotid angioplasty and stenting, infrainguinal bypass, and peripheral angioplasty and stenting.

Principles of EMS Systems

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Office-based surgery for vascular surgeons.

Abstract: Office-based procedures have witnessed a veritable explosion with more than 10 million procedures being performed in the United States yearly. This is partially because of improvements in technology that allow these procedures to be performed safely in the office. However, as the number of procedures has increased, the reports of significant morbidity and mortality that have been appearing in the media have captured the public's attention. Until recently, this new and growing field has been largely unregulated. This is changing nationwide. The authors review the new regulations in New York State as a model of the future of this rapidly evolving field and their effect on vascular surgery office procedures.

Endovascular aneurysm repair utilizing the AneuRx and Talent stent grafts.

Abstract: Favorable clinical results combined with increased patient demand for minimally invasive surgery have resulted in an increased application of endovascular aneurysm repair, and this treatment modality is now being extended to younger, healthier patients. While it seems that endovascular aneurysm repair is becoming a desirable option for many patients, it is essential to realize that the feasibility of the procedure may be limited at times by patient anatomy and technical difficulties. Specific anatomical difficulties can be imposed by difficult access, short, tortuous and calcified aortic and iliac landing zones, and the presence of coincident complex iliac aneurysms. This manuscript will discuss the use of 2 approved devices from a single manufacturer (Medtronic, Santa Rosa, Calif) and their clinical results in the treatment of infrarenal abdominal aortic aneurysms. We will discuss technical maneuvers and considerations when encountering difficult anatomical situations and how to avoid long-term complications.