There are unresolved questions regarding indications and outcomes of endovascular below-the-knee (BTK) interventions in patients with symptomatic peripheral artery disease (PAD) in real-world clinical practice. We analyzed 884 patients from the multicenter XLPAD registry between 2006 and 2023 with nonstent BTK PAD interventions. Primary outcome: freedom from major adverse limb events (MALE) at 1 year, a composite of all-cause death, major amputation, or clinically driven revascularization. Majority (62.8%) of the BTK interventions were performed for chronic limb threatening ischemia (CLTI), while remaining (37.2%) in patients with intermittent claudication (IC), performed together with an inflow femoropopliteal artery intervention in 58% or involving complex lesion crossings (11.8%). Nearly, 74% were men, mean age 68.0 ± 10.7 years. Mean Rutherford class was 4.65 in CLTI and 2.71 in IC groups. Moderate to severe calcification was present in 25% of cases. Significantly greater number of lesions were treated in the CLTI group (1.84 ± 1.52 vs 2.08 ± 1.61; p = 0.029). Lesion lengths (CLTI: 129.3 ± 85.1 mm vs IC: 115.5 ± 82.5; p = 0.075) were comparable. Nearly, 92% of lesions were treated with balloon angioplasty. Drug-coated balloon use was higher in IC (5% vs 15%, p <0.001), whereas atherectomy use was high in both groups (CLTI: 45.4% vs IC: 49.9%; p = 0.201). Procedural success was similar (CLTI: 92% vs IC: 88.8%; p = 0.098), however 1-year MALE was significantly higher in CLTI patients (30.5% vs 15.8% vs; p <0.0.001), driven by higher all-cause mortality (5.6% vs 2.1% vs; p = 0.014) and major amputations (14% vs 3.7%; p <0.001). Endovascular treatment for BTK PAD is more often performed in patients with CLTI compared with IC, where it is often combined with an inflow artery intervention or complex lesion crossings. Despite similar procedural success, 1-year MALE is significantly higher in CLTI, driven mainly by over a 2-fold increase in all-cause mortality and major amputations.

Anatomic location of infrainguinal peripheral arteries has continually challenged endovascular revascularization strategies based on the use of stent vs. nonstent strategies. The objective of our study is to compare stent vs. nonstent outcomes of patients enrolled in the multicenter, core laboratory adjudicated XLPAD registry (NCT01904851) between 2005 and 2023. We analyzed 12-month cumulative incidence of major adverse cardiac and vascular events (MACVE), a composite outcome of all-cause death, nonfatal myocardial infarction, stroke, lower limb revascularization and any amputation in patients treated with clinically indicated stent or nonstent interventions, analyzed within a competing risk framework; group differences assessed using the Gray's test. To minimize confounding bias, we also implemented propensity score matching. About 5,067 patients (5,876 lesions), mean age 67.2 ± 10.3 years, underwent stent (n = 2,571) or nonstent (n = 2,496) predominantly femoropopliteal artery (68%) interventions. 42.8% were current smokers, 57.3% diabetic; 17% had chronic kidney disease and 56.5% coronary artery disease. 50.7% presented with Rutherford class (II-III) symptoms, with mean ankle-brachial index 0.64 ± 0.24. 61% lesions in stent group and 38.6% in the nonstent group had chronic total occlusions (p <0.001). Significantly greater calcified (36.6% vs. 33%; p = 0.004) and longer lesions (142.9 ± 96.5 mm vs. 115.8 ± 91.3 mm; p <0.001) were treated in the stented group. Drug-coated balloon and atherectomy use were 18% and 34.2%, respectively. Procedural success was higher in the stent group (96.9% vs. 89.5%; p <0.001). Peri-procedural period flow-limiting dissections were higher in the stent (2.7% vs. 0.3%; p <0.001), and any amputation in the nonstent (3.0% vs. 4.4%; p = 0.008). 12-month MACVE was higher in the stent group (22.2% vs. 19.2%, p = 0.009) mainly driven by greater need for repeat endovascular revascularization (13.1% vs. 10.4%, p = 0.003), and this was consistent even after adjusting for chronic limb threatening ischemia presentation (adjusted odds ratio [OR], 1.193; 95% confidence interval [CI], 1.039 to 1.370; p = 0.013). The stented group had 29.6% increased odds of MACVE compared to nonstent (adjusted OR, 1.296, 95% CI: 1.115 to 1.506, p = 0.001), even after adjusting for residual confounders with propensity matching. Stent-based interventions are used to treat more complex infrainguinal PAD, with greater procedural success, but higher 12-month MACVE compared with nonstent interventions.

For endovascular treatment of below-the-knee (BTK) peripheral artery disease (PAD), independently adjudicated real-world outcomes comparing non-stent-based balloon angioplasty (percutaneous transluminal angioplasty) and adjunctive treatments with or without a concomitant ipsilateral femoropopliteal (FP) artery intervention are scarce. A total of 1,060 patients from the multicenter XLPAD registry who underwent non-stent-based BTK PAD intervention between 2006 and 2021 were included. The primary outcome was the 1-year incidence of major adverse limb events (MALEs), a composite of all-cause death, any amputation, or clinically driven repeat revascularization. A total of 566 patients underwent BTK and 494 BTK + FP interventions; 72% were men, with a mean age of 68.4 ± 10.9 years. Diabetes mellitus was more prevalent in the BTK-only group (76.5% vs 69%, p = 0.006). Mean Rutherford class was 4.2 ± 1.18; chronic limb-threatening ischemia was more frequent in the BTK group (55.3% vs 49%, p = 0.040). Moderate to severe calcification was more frequent in the BTK + FP group (21.2% vs 27.1%, p = 0.024), as was lesion length (110.6 ± 77.3 vs 135.4 ± 86.3 mm, p <0.001). Nearly 81% of lesions were treated with percutaneous transluminal angioplasty. Drug-coated balloon (1.6% vs 14%, p <0.001) and atherectomy (38% vs 58.5%, p <0.001) use was more frequent in the BTK + FP group. The rate of procedural success was higher in the BTK + FP group (86% vs 91%, p = 0.009), with amputation being the most common complication at 3.3% within 30 days after the procedure. The rates of 1-year MALE (21.2% vs 22.3%, p = 0.675) and mortality (4.6% vs 3.4%, p = 0.3) were similar between the BTK and BTK + FP groups. Nonstent treatment for BTK PAD with concomitant FP intervention leads to high procedural success and similar rates of 1-year MALE compared with isolated BTK intervention. Condensed Abstract: The vast majority of below-the-knee (BTK) peripheral artery disease (PAD) interventions are performed with balloon angioplasty. Presence of inflow femoropopliteal PAD in patients who undergo BTK interventions can affect the outcome of the procedure. This report explores immediate procedural success and major adverse limb events at 1 year after balloon angioplasty treatment for isolated BTK PAD and in patients who underwent an additional femoropopliteal PAD intervention.

We present a patient who exemplifies the interplay of factors contributing to the development of venous-type thoracic outlet syndrome. The patient was treated with both radiation and chemotherapy for squamous cell carcinoma in the head and neck region; radiation and chemotherapy have been known to damage the vascular system. Multimodality treatment is necessary to achieve good long-term results in these complex patients.

This editorial refers to 'Long-term cardiovascular changes following creation of arteriovenous fistula in patients with end stage renal disease'(dagger), by Y.N.V. Reddy et al., on page 1913.

We used the data in the Gore Global Registry for Endovascular Aortic Treatment (GREAT) to evaluate the treatment and results of endovascular repair (EVAR) of iliac artery aneurysms. This analysis was performed on GREAT EVAR subjects treated from August 2010 until an August 10, 2015, data export. The database was queried for demographics, comorbidities, aneurysm details, procedural data, 30-day serious adverse events (SAE), rates of reintervention, endoleak, and mortality. Patients treated with the Gore iliac branch device were excluded. There were 241 patients (217 males, 24 females) enrolled with an average age of 72 years (50-94 years). Complete data were available for 239 (Table I). The number of devices and types are listed in Table II. Arterial access, access method, procedure survival, and length of stay are detailed in Table III. An SAE occurred within the first 30 postoperative days in 5.4%. Mean follow-up was 309 days (5-1471 days). The 2-year reintervention rate was 5.4% and mortality rate was 7.1%. Endoleaks occurred in 2.5% (Ia, 0.4%; Ib, 0.8%; II, 1.2%). There were no type III or IV endoleaks, device migration, fracture, or compression. Endovascular iliac artery aneurysm repair is successful and durable, with low procedural mortality, SAE and endoleak rates, but frequently requires treatment of multiple aneurysms, the use of multiple devices, and a mildly prolonged in hospital convalescence.Table IInitial treatment dataDevice at initial procedureGore Excluder AAA Endoprosthesisa, No. (%)Other, No. (%)Total, No. (%)Subjects enrolled,b No.18158239Aortic pathology Common iliac aneurysmRight112 (61.9)21 (36.2)133 (55.6)Left98 (54.1)24 (41.4)122 (51.0) Abdominal aortic aneurysm102 (56.4)4 (6.9)106 (44.4) Internal iliac aneurysmLeft16 (8.8)12 (20.7)28 (11.7)Right18 (9.9)10 (17.2)28 (11.7)Other2 (1.1)3 (5.2)5 (2.1) Abdominal aortic aneurysm rupture2 (1.1)0 (0)2 (0.8) Descending thoracic aortic aneurysm0 (0)1 (1.7)1 (0.4) Pseudoaneurysm1 (0.6)0 (0)1 (0.4) Type B uncomplicated aortic dissection1 (0.5)0 (0)1 (0.4)Reason for treatment Primary procedure for endovascular treatment172 (95.0)48 (82.8)720 (92.1) Reintervention of a priorEndovascular procedure5 (2.8)9 (15.5)14 (5.9)Open surgical procedure5 (2.8)1 (1.7)6 (2.5)aOnly includes those with a Gore Excluder AAA Endoprosthesis.bOnly among those who reported device information and had a device implanted. Open table in a new tab Table IIInitial treatment Gore aortic device usageSubjects with aortic Gore devices implanted,a No.239Gore aortic devices per subject, No. Mean (SD)2.8 (1.1) Median (range)3.0 (1.0,8.0)Total Gore Aortic Devices Implanted,a No.668Gore Excluder endoprosthesis components Trunk-ipsilateral devices implanted, No. (%)191/668 (28.6) Contralateral legs implanted, No. (%)365/668 (54.6) Aortic extenders implanted, No. (%)21/668 (3.1) Iliac extenders implanted88/668 (0.0)Gore Excluder iliac branch endoprosthesis components Iliac branch component, No. (%)0/668 (0.0) Internal iliac component, No. (%)0/668 (0.0)Gore TAG thoracic endoprostheses, No. (%)1/668 (0.1)Conformable Gore TAG thoracic endoprostheses implanted, No. (%)2/668 (0.3)aOnly among those reporting device information. Open table in a new tab Table IIIInitial treatment dataSubjects enrolled, No.241Subjects with devices attempted/implanted241Access method Percutaneous, No. (%)107 (44.4) Cutdown, No. (%)149 (61.8) Surgical conduit, No. (%)4 (1.7) Endovascular conduit, No. (%)0 (0.0)Aortic branch vessel procedure, No. (%)82 (34.0)Access site, No. (%) Femoral artery236 (97.9) Iliac artery6 (2.5) Infrarenal aorta3 (1.2) Brachial7 (2.9) Other3 (1.2)Procedure survival, No. (%)241 (100.0)Hospital stay, days Patients, No.240 Mean (standard deviation)4.7 (5.4) Median (range)3.0 (0.0.39.0) Open table in a new tab

A 63-year-old female patient presented with transient right hand weakness and left amaurosis fugax. A computed tomography angiogram demonstrated a 75% to 90% internal carotid artery (ICA) stenosis and a persistent proatlantal intersegmental artery (PAIA) originating from the external carotid artery (ECA), passing lateral to the internal jugular vein (A), and joining the ipsilateral vertebral artery. The PAIA was the major contributor to the basilar artery. Also noted were an absent left cervical vertebral artery and a hypoplastic right vertebral artery terminating as the posterior inferior cerebellar artery. Intraoperatively, the PAIA was identified as a posterior-oriented branch of the ECA (B). A shunt was placed from the common carotid artery to the ICA. Pulsatile back-bleeding was seen from the ECA/PAIA origin, and this was not shunted. Endarterectomy and patch was performed, and the ECA/PAIA was treated with an eversion endarterectomy only. The patient had a normal convalescence and was discharged the following day. A follow-up three-dimensional computed tomography angiogram demonstrated a satisfactory patch repair with patency of all intracranial and extracranial arteries (C/Cover). The hindbrain in the 4-mm to 5-mm embryo is supplied by two longitudinal neural arteries connected to the carotid circulation by four named sets of transient arteries. The nearly eponymous superior three sets travel with three cranial nerves: the trigeminal (V), hypoglossal (XII), and otic (VIII). The fourth set, the PAIA, does not follow a cranial nerve. It passes via the suboccipital region, traverses the foramen magnum, and then fuses with the horizontal portion of the vertebral artery. The trigeminal, hypoglossal, and otic arteries involute as the neural arteries fuse to form the basilar artery.1Ouriel K. Green R.M. DeWeese J.A. Anomalous carotid-basilar anastomoses in cerebrovascular surgery.J Vasc Surg. 1988; 7: 774-777Abstract Full Text PDF PubMed Scopus (58) Google Scholar The PAIA persists until the cervical vertebral arteries have formed from transverse anastomoses between adjacent intersegmental arteries of the spine when the embryo is 7 to 12 mm.1Ouriel K. Green R.M. DeWeese J.A. Anomalous carotid-basilar anastomoses in cerebrovascular surgery.J Vasc Surg. 1988; 7: 774-777Abstract Full Text PDF PubMed Scopus (58) Google Scholar A PAIA may persist in the adult as an anomalous vascular connection between the carotid and ipsilateral vertebral arterial systems. Nomenclature of the PAIA has been divided according to the vessel of origin: type 1-ICA and type 2-ECA.2Lasjaunias P. Theron J. Moret J. The occipital artery, anatomy, normal arteriographic aspects, embryological significance.Neuroradiology. 1978; 15: 31-37Crossref PubMed Scopus (106) Google Scholar When a PAIA is present, associated expected anomalies include an aplastic ipsilateral and hypoplastic contralateral vertebral artery as well as an aberrant pattern of communicating arteries within the circle of Willis.2Lasjaunias P. Theron J. Moret J. The occipital artery, anatomy, normal arteriographic aspects, embryological significance.Neuroradiology. 1978; 15: 31-37Crossref PubMed Scopus (106) Google Scholar

Vertebral arterial disease (VAD) is a less commonly recognized and treated source of cerebrovascular ischemia compared with carotid artery disease. Patients are often referred for treatment after they have developed symptoms in the form of transient ischemic attacks or had a posterior hemispheric stroke. Traditional treatment of VAD has been surgical. More recently, endovascular treatment of VAD has been utilized. We performed a retrospective review of our institutional experience in treating VAD from 2001 to 2010. For treatment of proximal VAD, perioperative morbidity is lower for the endovascular group than for the surgical group, but six-week mortality was higher for the endovascular group. Complete resolution of symptoms occurred more frequently with surgery than with endovascular therapy. Therefore surgical reconstruction appears to be preferable to angioplasty and stenting for treatment of proximal vertebral artery occlusive disease.

Long-term hemodialysis patients are a difficult patient population because they have few remaining access options and may have disadvantaged vasculature in the upper extremities. Because of the increased infection rate with femoral access, surgeons may place an axillary artery-to-axillary vein arteriovenous graft (AAAVg). Few outcome reports of this technique exist. In this study, which is the largest reported to date, we investigate the results of the AAAVg configuration. At our institution, an AAAVg is a polytetrafluoroethylene (PTFE) graft in a loop configuration in the upper chest with anastomoses to the axillary artery and ipsilateral axillary vein. After Investigational Review Board approval was obtained, patients were retrospectively and then prospectively identified and followed up for a 2-year period. Sixty-three AAAVgs were reviewed. Patient were an average age of 55 years (range, 23-85 years), and 93% had documented prior access. Thirty-eight patients required graft interventions in the follow-up period. Twenty-one balloon angioplasties were performed for outflow venous stenosis. Fourteen grafts thrombosed at an average of 461 days after implant. Seven patients had bacteremia resulting in four graft removals (6%) as the infective source. Two wound complications (one hematoma, one superficial wound dehiscence) occurred, but the graft was preserved. Notably, no patient required treatment for steal. The average primary patency rate was 85% at 30 days, 51% at 6 months, and 33% at 1 year. Primary assisted patency was 90% at 6 months, 79% at 1 year, and 37% at 2 years. Secondary patency was 92% at 6 months and 58% at 1 year. Twenty-one patients required a new access at an average of 477 days after the initial placement. Since receiving their grafts, 25 of the 63 patients have died, and one patient received a transplant. AAAVgs are appropriate for patients who have few upper extremity access options. The patency rates for this “bailout” procedure are at least equivalent to other upper extremity AV grafts. The lack of symptomatic steal is an important benefit. The infection rate is lower than in femoral grafts, and correspondingly, AAAVgs can even be considered for primary use in patients that have disadvantaged upper extremity vasculature or who are at increased risk of steal syndrome.

Body: OBJECTIVES: Long-term hemodialysis patients are a difficult patient population as they have few remaining access options and may have disadvantaged vasculature in the upper extremities. Because of the increased infection rate with femoral access, surgeons may place an axillary artery to axillary vein arteriovenous graft (AAAVg). Few outcome reports of this technique exist. In this study, which is the largest reported to date, we investigate the results of the AAAVg configuration. METHODS: At our institution an AAAVg is a PTFE graft in a loop configuration in the upper chest with anastomoses to the axillary artery and ipsilateral axillary vein. After IRB approval was obtained, patients were retrospectively and then prospectively identified and followed for a two year period. RESULTS: Sixty-three AAAVgs were reviewed. The patient’s average age was 55 years (range 23-85). Ninety-three percent had documented prior access. Thirty-eight patients required graft interventions in the follow-up period. Twenty-one balloon angioplasties were performed for outflow venous stenosis. 14 grafts thrombosed at an average of 461days after implant; 7 patients had bacteremia resulting in 4 graft removals as the infective source (6%). Two wound complications (1 hematoma, 1 superficial wound dehiscence) occurred but the graft was preserved. Notably, no patient required treatment for steal. The average primary patency rate was 85% at 30 days, 51% at 6 months and 33% at 1 year. Primary assisted patency was 90% at 6 months, 79% at 1 year, and 37% at 2 years. Secondary patency was 92% at 6 months and 58% at 1 year. Twenty-one patients required a new access at an average of 477 days following initial placement. Twenty-five of the 63 patients have died since receiving their grafts and one patient was transplanted. CONCLUSIONS: Axillary AV grafts are appropriate for patients who have few upper extremity access options. The patency rates for this “bailout” procedure are at least equivalent to other upper extremity AV grafts. The lack of symptomatic steal is an important benefit. The infection rate is lower than femoral grafts and correspondingly, AAAVgs can even be considered for primary use in patients that have disadvantaged upper extremity vasculature or who are at increased risk of steal syndrome.

Background: Endovenous laser ablation (EVLA) of the saphenous vein has become one of the preferred treatments for treating saphenous vein reflux that has resulted in symptomatic lower extremity venous insufficiency or varicose veins. This procedure was noted during initial reports to have a low incidence of postoperative thrombosis of the femoral or popliteal vein adjacent to the treated great saphenous vein (GSV) or small saphenous vein (SSV). Later clinical experience suggested that the actual incidence of this event is higher and it was subsequently termed endothermal heat-induced thrombosis (EHIT).Methods: We reviewed the office records and the pre-and post-treatment ultrasounds of patients undergoing EVLA in our office from 2005 to 2010 to determine the frequency of EHIT in patients we had treated and then graded them according to a previously published classification.Results: There were 528 veins treated in 192 men and 336 women. The clinical, etiology, anatomy, pathophysiology (CEAP) class for these patients was 1 (0), 2 (291), 3 (65), 4 (104), 5 (26), and 6 (40), respectively. The GSV was treated in 496 patients, the SSV in 22, and both were treated in 10 patients. EHIT occurred in 29 of the legs treated for an incidence of 5.1%. The EHIT in the femoral vein were of level 3 (3), 4 (7), 5 (12), and 6 (3), respectively. Two patients developed EHIT in the popliteal vein after EVLA of the SSV. Treatment for the EHIT consisted of observation (13), anticoagulation (9), antiplatelet therapy (2), and nonsteroidal anti-inflammatory agents (1). Duration of therapy was usually 1 week, but 7 patients were treated for periods ranging from 1 to 7 weeks. No pulmonary emboli occurred in any of these patients. The EHIT resolved completely in all patients.Conclusions: EHIT after EVLA occurs frequently and mainly consists of low-risk level 3, 4, and 5 deep vein thrombosis. The risk of pulmonary embolism is low and the EHIT typically resolves after 1 week. It can be treated with a short course of antiplatelet or anticoagulation therapy, although observation appears to be sufficient as well for lesser grades of EHIT.

Background: Carotid artery stent placement (CAS) is becoming more popular among various specialties for the treatment of primary and recurrent carotid artery disease. The morbidity associated with this procedure is improving but the intermediate- and long-term follow-up remains unknown. We report our restenosis rates and follow-up associated with CAS.Methods: Thirty-one interventions on 29 patients from May 1998 to January 2002 were reviewed. All patients have undergone serial follow-up using Doppler ultrasound at 3 and 6 months and every 6 months thereafter. Ten interventions (32%) were performed on patients with recurrent carotid artery disease and 21 (68%) on patients with primary disease.Results: Five periprocedural complications occurred (transient ischemic attack, n = 3; major stroke, n = 1; immediate intrastent restenosis requiring lysis, n 1) for a total immediate complication rate of 16%. No deaths occurred. Follow-up was achieved in all 29 patients (mean 28 months; range 20 to 46). Twenty-seven patients (29 vessels; 94%) remain asymptomatic with less than 50% stenosis. Two vessels (6%) have been found to have a critical restenosis of greater than 90%. Both patients were symptomatic from their recurrence (transient ischemic attack, n = 1; acute stroke, n = 1). Cumulative major stroke and death rate including all follow-up was 6%.Conclusions: CAS can be performed with an acceptable stroke/death rate (3%) in a properly selected patient population. In our small series of patients, the restenosis rate at a mean of 28 months after CAS is 6%. (C) 2003 Excerpta Medica Inc. All rights reserved.

With the widespread use of endovascular surgery, aneurysms can be managed selectively with the use of stent grafts. Standard treatment of mycotic aneurysms usually requires resection and extraanatomic bypass. Although stent graft repair of a mycotic femoral aneurysm with autologous graft has been reported, we present a case of an infrarenal mycotic aneurysm in a patient with the human immundeficiency virus (HIV) that was successfully treated with a novel endovascular approach.

Carotid body tumors are rare neoplasms and must be considered in the evaluation of all lateral neck masses; early surgical removal has been recommended. In this study, the medical records of 29 patients with 34 carotid body paragangliomas who were treated at our institution between 1971 and 2001 were retrospectively reviewed. An overview is provided of this lesion, including diagnosis, classification, metastatic potential, possible secretory function, operative techniques, and nonsurgical methods of management. Carotid body tumors may be familial and are more often bilateral in these instances; five patients (17%) had bilateral tumors in this series. The criterion for malignancy is demonstrated by metastatic tumor in lymph nodes or distant organs. Three patients (10%) had malignant tumors, one with hepatic metastases. One patient (3%) in our series exhibited abnormal serotonin production. Vascular reconstruction was necessary in eight cases (28%). No stroke occurred, however, two arterial thromboses (7%), five permanent cranial nerve deficits (17%), and one death (3%) from massive pulmonary embolism were seen. Our experience demonstrates that early operative management is warranted to avoid the possibility of eventual metastasis and progressive local invasion to the point of inoperability.

The May–Thurner syndrome is an acquired stenosis of the left common iliac vein causing pain, edema, or deep venous thrombosis (DVT). The patency and behavior of endoluminal venous stents for this condition was evaluated in this study. Patients with the May–Thurner lesion treated with endoluminal stenting from 1997 to 2000 were evaluated according to an institutional review board–approved protocol. Wallstents (n = 14) or Smart stents (n = 1) were placed into the left common iliac. Patency was evaluated with duplex ultrasonography using a 5 mHz linear array probe (HP 4500) at 6-month intervals. Our results showed that treatment of the May–Thurner syndrome with endoluminal stenting is associated with low morbidity and high patency rates. Longitudinal evaluation of this group of patients is ongoing to confirm these findings.

PURPOSE:This report shows a method of treatment for life-threatening hemorrhage due to rupture of an aneurysm in the cervical internal carotid artery caused by neurofibromatosis.METHODS:Ten days after delivery of healthy twins, a 28-year-old woman with known neurofibromatosis had sudden massive swelling in the left neck. After initial tracheostomy, angiography confirmed rupture of the mid cervical internal carotid artery as well as contribution to the resultant pseudoaneurysm from external carotid branches. Treatment began with coil embolization of the external carotid branches. The internal carotid lesion, a defect approximately 1 cm in length, was then closed through use of two stent grafts, each made from Palmaz stents and 3-mm polytetrafluorethylene grafts predilated to 6 mm. The neck hematoma was then evacuated surgically.RESULTS:Completion angiography and computed tomographic scanning confirmed control of the hemorrhage. The patient survived neurologically intact with the exception of cranial nerve deficits caused by the hemorrhage. The tracheostomy tube was removed 3 weeks postoperatively. Follow-up computed tomographic scanning showed a gradual decrease in the size of the cervical soft tissue and no recurrent aneurysm.CONCLUSION:Neurofibromatosis is a rare cause of aneurysmal degeneration of blood vessels. Repair of a ruptured cervical internal carotid artery aneurysm, though feasible, is difficult with stent grafts; however, this is a better option than surgical intervention in inaccessible vessels.

Endovascular aneurysm repair is currently being developed as an alternative to traditional surgical repair for patients with abdominal aneurysms. The divisions of vascular surgery and interventional radiology are involved in a cooperative effort to develop, test, and implant the devices used for endovascular aneurysm repair. In the past 2 years, 15 patients have received endovascular aneurysm repair at Baylor University Medical Center. This report reviews the evaluation protocols, surgical devices, and methods used, as well as the results and complications, in our early experience with endovascular aneurysm repair.

Rupture of thoracoabdominal aortic aneurysm (TAAA) or abdominal aortic aneurysm (AAA) is a vascular emergency associated with high rates of morbidity and mortality. Rupture of AAA has been extensively studied, but the outcome of ruptured TAAA is less clearly defined.We retrospectively compared outcomes of ruptured TAAAs and AAAs seen at Baylor University Medical Center. Twenty-one patients presented with TAAA rupture from 1985 to 1995:15 of them underwent emergent repair, 10 of whom died (67% mortality). Of the other 6 patients, 3 did not have surgery because of their moribund conditions or prohibitive comorbidities on presentation, 1 patient was transferred elsewhere for treatment, and 2 patients died before surgery. In comparison, from 1990 to 1995, 31 patients presented with ruptured AAA; all received immediate operative repair, and 14 of them died (45% mortality). Multiple postoperative morbidities occurred in all 5 TAAA survivors (100%), including renal failure in 4 patients (80%). In comparison, the 17 ruptured AAA survivors had a 59% (10) morbidity rate; 23% (4) had renal insufficiency. Paraplegia occurred in 1 of the 5 TAAA survivors and in none of the AAA survivors.The morbidity and mortality rates for patients who have TAAA or AAA rupture remain high despite advances in operative and postoperative care. Comparison of the TAAA and AAA cohorts reveals a higher morbidity rate in the TAAA group-specifically, an increased incidence of paraplegia and renal failure.

PURPOSE:The purpose of this study was to compare the results of carotid endarterectomy (CEA) in a young population with premature atherosclerosis with the results of an older control group, examining perioperative morbidity and mortality data, recurrent stenosis and symptoms, late stroke, and survival data. METHODS:We retrospectively studied 26 patients less than 50 years old (mean, 43.2 +/- 3.8 years) and 30 patients greater than 55 years old (mean, 69.1 +/- 7.4 years) who underwent CEA during the same time period. Data were obtained regarding demographics, atherosclerotic risk factors, indication for CEA, perioperative complications, recurrent stenosis and symptoms, late stroke, and survival. RESULTS:Smoking was more prevalent among young patients who underwent CEA (92% vs 70%; p = 0.036). Young patients were also more likely to be symptomatic at presentation (92% vs 57%; p = 0.003). The perioperative mortality rate (0% vs 0%) and neurologic morbidity rate (0% vs 3%; p = 1.000) were low for the study patients. During a mean follow-up of 67 +/- 42.7 months, there was no significant difference in survival rate (5-year survival rate, 93% vs 81%; p = 0.373), rate of late ipsilateral (4% vs 3%) and contralateral (4% vs 3%) stroke, restenosis and occlusion (26.9% vs 14.3%), recurrent symptoms (22% vs 17%), reoperation (11.5% vs 5.7%), or contralateral disease (17% vs 23%) development that required surgery for the study or the control cohorts. CONCLUSIONS:Our data show that there is a high incidence of smoking and symptomatic presentation among young patients in whom carotid occlusive disease develops. CEA may be performed in young patients with low perioperative morbidity and mortality rates. Recurrent disease, late stroke, and survival rates are not significantly different than for older patients. Follow-up with serial duplex ultrasound and reoperation for symptomatic and high-grade asymptomatic restenosis may decrease the risk of late stroke.