We report our initial experience using the intraoperative positioning system (IOPS), a novel endovascular navigation system that does not require contrast or radiation, in the treatment of chronic mesenteric ischemia (CMI). We used IOPS to help treat three of four consecutive patients with CMI. Technical problems prevented successful use in one patient. For the patients for whom IOPS was used effectively, catheterization of the mesenteric artery was accomplished more quickly than for the patient for whom IOPS was not effective. Our experience has shown that IOPS can be safely and effectively used for CMI and can reduce the contrast load and radiation dose.

BACKGROUND:Stroke and transient ischemic attack after transcatheter aortic valve replacement results in significantly higher morbidity and mortality. Severe carotid artery disease may be a contributing factor to this increased risk. We report our technique and outcomes of combined carotid endarterectomy (CEA) with transcatheter aortic valve replacement (TAVR).METHODS:From March 2013 to November 2017 a total of 753 TAVRs were performed at our institution for symptomatic severe aortic stenosis. Of this group, 16 patients underwent concomitant TAVR and CEA. A retrospective review was performed to assess risk, outcomes, and short-term survival.RESULTS:Sixteen patients underwent concomitant CEA/TAVR procedures for severe carotid and severe aortic stenosis. The mean Society of Thoracic Surgeons (STS) Risk Score was 7.0 ± 4.7. All patients had severe carotid artery stenosis and aortic stenosis. Nine patients had a transfemoral TAVR approach and eight patients had a transapical TAVR approach. The mean length of stay was 6.4 ± 3.7 days. At 30 days there were no cerebrovascular events and no mortalities.CONCLUSIONS:The use of concomitant CEA and TAVR in patients with severe aortic stenosis and severe carotid stenosis can be done safely without increased risk of complications. This approach may reduce the risk of stroke associated with TAVR in appropriately selected patients.

Background: There is evidence to support that bacteria present in atherosclerotic plaque may play a role in disease pathogenesis. Several studies utilizing antibiotics to inhibit progression of atherosclerotic disease have been unsuccessful. Biofilms are complex microenvironments of bacterial colonies encased within a matrix that firmly adheres to surfaces. They exhibit extensive genotypic and phenotypic diversity and are 100 to 1000 times more resistant to antibiotics than planktonic cultures. We hypothesized that bacterial biofilms are present in carotid atheroma. Methods: The IBIS Biosensor- Florescent in situ hybridization (FISH) pipeline for microbial discovery was applied to atherosclerotic samples obtained from 8 patients who underwent open CEA at Allegheny General Hospital. The extracted nucleic acid from CEA samples were aliquoted into wells of a microtiter plate containing broad range primers for PCR. The products were desalted in a 96-well plate format, sequentially electrosprayed into a mass spectrometer and the spectral signals processed to determine the masses of each of the PCR products present. The base composition of each amplicon was therefore unambiguously deduced. Using combined base compositions from multiple PCRs; the identities of the pathogens and their relative concentrations in the starting sample were determined. FISH using fluorescent probes targeted to the 16s rRNA, designed for each sample based on the result from the IBIS, was then performed. Confocal microscopy of the FISH stained samples allowed visualization of the specific bacterial species. Results: One or more bacterial species were present in four of the eight CEA samples analyzed (50%). Species present were Staphylococcus capitis/ caprae, Staphylococcus warneri, Propionibacterium acnes, and Staphylococcus epidermidis. Further analyses in an attempt to correlate these findings with oral microbiota, dental and clinical history is currently ongoing. Conclusion: In our ongoing study 50% of analyzed carotid atherosclerotic samples contained the highly antibiotic resistant bacterial biofilms. Mechanisms of biofilm formation in atheroma need to be explored.

Focal infrarenal aortic stenosis is relatively rare. Traditionally, aortic endarterectomy and aortic bypass surgery have been used to treat these lesions. However, percutaneous transluminal angioplasty and stenting have become well-defined alternatives. A 62-year-old woman presented with bilateral ischemic rest pain. Angiography revealed a mid-infrarenal aortic stenosis adjacent to an enlarged, patent inferior mesenteric artery. Celiac artery and superior mesenteric artery stenoses were also present. The kissing-stent technique is a viable option for ensuring inferior mesenteric artery patency when treating distal aortic lesions by endovascular means in patients with asymptomatic multivessel mesenteric artery disease. (J Vasc Surg 2012;56:212-5.)

Le but de cette étude était de déterminer quelles caractéristiques de la zone d’ancrage proximale étaient prédictives de l’apparition d’endofuite de type IA précoce et tardive après le traitement endovasculaire d’un anévrysme de l’aorte abdominale sous-rénale (EVAR). Nous avons évalué 146 patients qui ont eu une EVAR entre janvier 2006 et mars 2007. Dans la cohorte, les angioscanners de 100 (68,5%) patients étaient disponibles, montrant la mesure détaillée des paramètres proximaux du collet, incluant le diamètre, la longueur, les calcifications, le thrombus, l’angulation sus et sous-rénal, et la morphologie conique. L’ensemble des données numériques ont été traitées pour obtenir des mesures de ligne centrale. Les dossiers médicaux et les angioscanners de suivi ont été revus. L'âge moyen des patients était de 72,7 ans, avec 78% d’hommes. Parmi ces patients, 66% ne complétaient pas les instructions d'usage du dispositif d’EVAR Zenith, et 50% ne complétaient pas les instructions d'usage pour du dispositif AneuRx. Neuf patients ont eu une endofuite de type IA peropératoire. Un taux de succès technique primaire assisté de 100% a été obtenu avec l'utilisation supplémentaire d’angioplasties (n = 4), de stents nus (n = 3), et d’extension couverte (n = 2). Il y avait une association significative entre l’apparition d’une endofuite de type IA et l’ampleur de l'angle sous-rénal (p < 0,01) ; les autres paramètres n'étaient pas significatifs. Au cours du suivi (moyen 587 jours), aucun patient n'a développé une endofuite de type IA, et il n'y a eu aucun décès lié à l’anévrysme. Nos données indiquent que l'angulation sous-rénale est liée à l’incidence d’endofuite de type IA peropératoire, mais les autres facteurs souvent indicateurs d’une l'anatomie défavorable du collet ne sont pas des facteurs prédictifs significatifs. D'ailleurs, toutes les endofuites de type IA dans cette cohorte ont été éliminées avec succès en peropératoire, et la durabilité a été confirmée par la surveillance postopératoire. Ces données démontrent que l'anatomie difficile du collet est associée au recours de gestes supplémentaires endovasculaires peropératoires, et qu’une exclusion efficace et durable de l'anévrysme peut alors être obtenue.

BACKGROUND:The purpose of this study was to determine which proximal seal zone characteristics were predictive of early and late type Ia endoleak development after endovascular aortic aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysmal disease.METHODS:We evaluated 146 patients who underwent EVAR between January 2006 and March 2007. In the cohort, high-resolution computed tomography images of 100 (68.5%) patients were available, which showed detailed measurement of proximal neck parameters, including diameter, length, calcification, thrombus, suprarenal and infrarenal angles, and reverse taper morphology. Postprocessing of digital data sets was performed to obtain centerline-of-flow measurements. Relevant medical records and follow-up computed tomography scans were reviewed.RESULTS:Mean age of the patients was 72.7 years, with 78% being male. Of these patients, 66% did not satisfy the instructions for use for the Zenith EVAR device, and 50% did not satisfy the instructions for use for the AneuRx device. Nine patients had intraoperative type Ia endoleaks. A 100% assisted primary technical success rate was achieved with the adjunctive use of angioplasty (n = 4), uncovered stent (n = 3), and extension cuff (n = 2) placement. There was a significant association between type Ia endoleak development and magnitude of the infrarenal angle (p < 0.01); however, other parameters were not significant. At follow-up (mean, 587 days), no patient had a type Ia endoleak, and there were no aneurysm-related deaths.CONCLUSIONS:Our data indicate that infrarenal angle is related to intraoperative type Ia endoleak occurrence, but other factors often thought to be indicative of adverse neck anatomy are not significant predictors. Moreover, all type Ia endoleaks in this cohort were successfully eliminated intraoperatively, and durability was confirmed on postoperative surveillance. These data demonstrate that challenging neck anatomy is associated with the need for intraoperative endovascular adjuncts, and that effective and durable aneurysm exclusion should still be expected.

The purpose of this study was to determine which proximal seal zone characteristics were predictive of early and late type Ia endoleak development after endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysmal (AAA) disease. We evaluated 146 patients who underwent EVAR between January 2006 and March 2007. Of the cohort, 100 (68.5%) patients had high-resolution CT images that allowed detailed measurement of proximal neck parameters, including diameter, length, calcification, thrombus, suprarenal and infrarenal angles, and reverse cone morphology. Post-processing of digital data sets (Aquarius Workstation, TeraRecon Inc, San Mateo, CA) was performed to obtain centerline-of-flow measurements. Relevant medical records and follow-up CT scans were reviewed. Mean patient age was 72.7 years with 78% being male. Fifty-two percent of patients did not satisfy the indications for use (IFU) for the Zenith EVAR device (Cook Medical Inc, Bloomington, IN), and 67% of patients did not satisfy the IFU for the Aneurx device (Medtronic Inc, Minneapolis, MN). Neck morphology data are shown in the table. Nine patients had intraoperative type Ia endoleaks. A 100% assisted primary technical success rate was achieved with adjunctive maneuvers. There was a significant association between type Ia endoleak development and magnitude of the infrarenal angle (p<0.01); however, other parameters were not significant. No type Ia endoleaks were detected during follow up (mean 587 days), and no aneurysm related deaths occurred.Tabled 1Neck and aneurysm characteristicsMeanRangeIncidenceNeck diameter23.1 mm16.2 - 41.3 mmN/ANeck length15.7 mm1.5 - 21 mmN/ANeck CalcificationN/AN/A48%Neck ThrombusN/AN/A26%Suprarenal angle18.5°3 - 41°N/AInfrarenal angle32.5°6 - 85°N/AReverse coneN/AN/A33%Max AAA diameter53 mm23 - 100 mmN/A Open table in a new tab Our data indicate that infrarenal angle is related to intraoperative type Ia endoleak occurrence. Moreover, all type Ia endoleaks in this cohort were successfully eliminated intraoperatively, and durabilitywas confirmed on postoperative surveillance. These data demonstrate that effective and durable aneurysm exclusion is the rule, not the exception, even in the presence of challenging neck anatomy.

A case of a symptomatic 5.1-cm left subclavian venous aneurysm, which was treated with surgical excision, is presented. Most venous aneurysms in the head and neck region involve the internal or external jugular veins and are asymptomatic. Aneurysms involving the subclavian or axillary veins are rare. The natural history of these aneurysms is benign with no reported instances of rupture or thromboembolic events. Operative treatment is most often undertaken for cosmetic reasons or for the development of symptoms.

The natural history of infected aneurysms or arterial infections is characterized by rapid expansion leading to rupture, pseudoaneurysm formation, and sepsis. Treatment options include in situ grafting either with prosthetic or autogenous grafts or with cryopreserved allografts (CPAs), resection of the aneurysm with remote bypass grafting, and ligation. The purpose of this study was to review our recent experience with these infections and to present long-term follow-up with in situ CPAs. From January 2000 through June 2005, we treated nine patients with infected aneurysms and one patient with an infection without aneurysm formation. The infection involved the infrarenal abdominal aorta in six patients and the femoral artery in three patients. One patient had an infected splenic artery aneurysm. Aortic rupture occurred in five of the six patients with infected aortas. Two of the three patients with infected femoral aneurysms presented with recurrent hemorrhage. Of the six patients with aortic infections, five were treated with in situ CPAs. One patient was treated with aortic resection and axillofemoral grafting. Two patients with femoral aneurysms were treated with in situ CPAs, and the third patient underwent aneurysm resection and prosthetic grafting through the obturator foramen. The patient with the splenic aneurysm underwent combined valve replacement, aneurysm resection, and splenectomy. Three of the six patients with aortic infections died postoperatively, all of whom were septic at presentation. The cause of death in these three patients was multiple organ failure in two and overwhelming sepsis in one. The three survivors are alive and well with up to 5-year follow-up. The three patients with infected femoral aneurysms are alive and well with follow-up extending to 44 months. The patient with the splenic aneurysm is doing well. No recurrent infections have been noted among the survivors. The CPAs have remained structurally intact in all. The mortality rate among patients with abdominal aortic infections remains high and is likely related to their preoperative septic state. In situ grafting with CPAs appears to be a reasonable treatment option for arterial infections. CPAs appear to maintain their structural integrity and to be resistant to recurrent infection.