Historically, the diagnosis of acute mesenteric ischemia (AMI) was primarily based on the history and physical exam obtained by an experienced surgeon. The immediate availability of high-quality helical computed tomography angiography (CTA) imaging in many medical centers has made this a routine examination in the suspected AMI patient. Diagnosis of chronic mesenteric ischemia may be arrived at by several avenues, although detailed imaging with catheter angiography, CTA, or magnetic resonance angiography is generally obtained prior to angiographic or surgical intervention.

Purpose: To review the protected carotid stenting experience at two major referral centers to evaluate the frequency of clinically significant intraprocedural thromboembolic events, use of neurorescue techniques, and ultimate clinical outcomes. Methods: A retrospective review was conducted of 254 cases of protected transfemoral carotid stenting performed at the Washington University-Barnes Hospital and The Fleni Institute of Buenos Aires in a 6-year period. Medical records of patients with periprocedural thromboembolic events were reviewed to determine the type of complication, method of treatment, and outcome. Results: Among the 254 cases in which a carotid protection device was used, 2 (0.79%) episodes of witnessed, symptomatic thromboembolism occurred. Both patients suffered thromboembolic occlusion of the M1 branch of the middle cerebral artery (MCA) immediately following crossing of the internal carotid lesion with the protection device. Neurological symptoms consisted of agitation, aphasia, and hemiplegia in both patients. After rapid stent deployment across the carotid lesion, the MCA was cannulated and the occlusion treated with balloon angioplasty. This was followed by selective intra-arterial delivery of urokinase and intravenous abciximab. These maneuvers resulted in excellentrestoration of blood flow in the MCA and its branches. With the exception of minor word-finding difficulties in one, both patients demonstrated full neurological recovery within the perioperative period. Conclusions: In our experience, intraprocedural thromboembolic events occur despite the use of cerebral protection devices, but are rare. Notably these complications appeared to occur at the time of lesion crossing by distal cerebral protection devices. These thromboembolic events can be successfully treated if the complication is rapidly identified and the physician is adequately prepared and proficient in neurorescue techniques.

Staged visceral artery revascularization with occlusion of the proximal lumen enables endovascular exclusion of the entire thoracoabdominal aneurysm from a femoral approach. This technique has been successfully used in three patients at high risk for conventional repair.

Objectives: The conservative versus therapeutic approach to type II endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) has been controversial. The purpose of this study was to evaluate the safety and cost-effectiveness of the conservative approach of embolizing type II endoleak only when persistent for more than 6 months and associated with aneurysm sac growth of 5 turn or more.Methods: Data for 486 consecutive patients who underwent EVAR were analyzed for incidence and outcome of type II endoleaks. Spiral computed tomography (CT) scans were reviewed, and patient outcome was evaluated at either office visit or telephone contact. Patients with new or late-appearing type II endoleak were evaluated with spiral CT at 6-month intervals to evaluate both persistence of the endoleak and size of the aneurysm sac. Persistent ( 6 months) type II endoleak and aneurysm sac growth of 5 mm or greater were treated with either translumbar glue or coil embolization of the lumbar source, or transarterial coil embolization of the inferior mesenteric artery.Results: Type II endoleaks were detected in 90 (18.5%) patients. With a mean follow-up of 21.7+/-16 months, only 35 (7.2%) patients had type II endoleak that persisted for 6 months or longer. Aneurysm sac enlargement was noted in 5 patients, representing 1% of the total series. All 5 patients underwent successful translumbar sac embolization (n = 4) or transarterial inferior mesenteric artery embolization (n = 4) at a mean follow-up of 18.2+/-8.0 months, with no recurrence or aneurysm sac growth. No patient with treated or untreated type II endoleak has had rupture of the aneurysm. The mean global cost for treatment of persistent type H endoleak associated with aneurysm sac growth was $6695.50 (hospital cost plus physician reimbursement). Treatment in the 30 patients with persistent type II endoleak but no aneurysm sac growth would have represented an additional cost of $200,000 or more. The presence or absence of a type II endoleak did not affect survival (78% vs 73%) at 48 months.Conclusions: Selective intervention to treat type II endoleak that persists for 6 months and is associated with aneurysm enlargement seems to be both safe and cost-effective. Longer follow-up will determine whether this conservative approach to management of type II endoleak is the standard of care.

PurposeThe purpose of this study was to develop a reliable in vivo porcine model of type II endoleak resulting from endovascular aortic aneurysm repair (EVAR), for the study and treatment of type II endoleak.MethodsEight pigs underwent creation of an infrarenal aortic aneurysm, with a Dacron patch with preservation of lumbar branches. An indwelling pressure transducer was placed in the aneurysm sac. After 1 week the animals underwent EVAR with a custom-made Talent endograft. After another week the animals underwent laparoscopic lumbar artery ligation. Abdominal and pelvic computed tomography was performed after each procedure. Aneurysm sac pressure was measured in sedated and awake animals.ResultsAll eight animals underwent successful creation of an aortic aneurysm and EVAR resulting in exclusion of the aneurysm sac. After creation of the aneurysm the sac mean arterial pressure (MAP) was 72.5 ± 6.1 mm Hg and the sac pulse pressure was 44.8 ± 8.7 mm Hg. Postoperative computed tomography scans demonstrated a type II endoleak from the lumbar branches in all animals. While aneurysm sac MAP (56.5 ± 7.9 mm Hg; P < .01) and pulse pressure (13.6 ± 4.1 mm Hg; P < .01) decreased after EVAR, sac pulse pressure remained, with type II endoleak. All animals underwent laparoscopic lumbar artery ligation, which resulted in further reduction in the sac MAP (38.3 ± 4.6 mm Hg; P < .02) and immediate absence of sac pulse pressure (0 mm Hg; P < .01). Necropsy confirmed the absence of collateral flow in the aneurysm sac, with fresh thrombus formation in all animals.ConclusionWe present a reliable and clinically relevant in vivo large animal model of type II endoleak.

Objective: Controversy exists as to the cause of ischemic colitis complicating endovascular aneurysm repair. Occlusion of the hypogastric arteries (HAs) during enclovascular repair of aortoiliac aneurysms (AIAs) results in a significant incidence of buttock claudication, and has been suggested as a causative factor in the development of postprocedural colonic ischeinia, in addition to factors such as systemic hypotension, embolization of atheromatous debris, and interruption of inferior mesenteric artery inflow. To analyze the relationship between perioperative HA occlusion and postoperative ischemic colitis, we reviewed our experience over 2 years with Food and Drug Administration-approved endovascular graft devices for treatment of AIAs.Methods: Elective repair of AIAs with bifurcated enclovascular grafts was performed in 233 patients over a 2-year period. These included 184 AneuRx grafts, 17 Ancure grafts, and 32 Excluder grafts. During the experience, 44 patients (18.9%) underwent unilateral perioperative HA occlusion (28 right, 16 left) during the course of endovascular AIA repair, and 1 patient (0.4%) underwent bilateral HA occlusion.Results: In 4 patients (1.7%) signs and symptoms of ischemic colitis developed 2.0 +/- 1.4 days postoperatively. In all patients the diagnosis was confirmed at signioidoscopy, and initial treatment included bowel rest, hydration, and intravenous antibiotic agents. Three patients with bilateral patent HAs required colonic resection 14.7 +/- 9.7 days after the initial diagnosis, and 2 of these 3 patients died in the postoperative period. Pathologic findings confirmed the presence of atheroemboli in the colonic vasculature in all 3 patients who underwent colonic resection. The fourth patient had undergone multiple manipulations of the left HA in an unsuccessful attempt to preserve patency of this vessel during AIA repair. This patient recovered completely with nonoperative management. Perioperative unilateral HA occlusion was not associated with a significantly higher incidence of postoperative ischemic colitis.Conclusion: Perioperative HA occlusion during aortoiliac open or endovascular surgery may contribute to development of the rare but potentially lethal complication of ischemic colitis. However, our extensive experience suggests that embolization of atheromatous; debris to the HA tissue beds during endovascular manipulations, rather than proximal HA occlusion, is the primary cause of clinically significant ischemic colitis after endovascular aneurysm repair.

Elective open repair of abdominal aortic aneurysm (AAA) is a proven surgical therapy with acceptable rates of perioperative mortality. Open AAA repair in elderly and high-risk patients, however, carries a significantly greater risk of surgical mortality and perioperative complications. Given the steady increase of life expectancy in developed nations, assessment of surgical outcomes and clarification of the role of emerging therapies in the aging population are of significant interest to the vascular surgeon. Selection of treatment options for these patients must be based on an individual approach, and assessment of outcomes must include more subtle parameters, such as quality of life, in addition to operative survival. Recent studies assessing the applicability of endoluminal graft repair in the elderly demonstrate that this avenue of treatment may offer substantial benefit to selected patients. We review the historical data regarding operative aneurysm repair in the high-risk and elderly population, and examine the impact of endoluminal therapy of AAAs in these challenging patients.

Purpose: To assess whether women suffer more delayed complications or require more interventions after endovascular abdominal aortic aneurysm (AAA) repair.Methods: Over a 2-year period, 245 patients (203 men, 42 women) underwent endovascular repair with the AneuRx stent-graft at our institution. Baseline, operative, and follow-up data were reviewed and outcomes compared between men and women for complications or secondary procedures beyond the 30-day postoperative period.Results: The 42 (17.1%) women treated with the AneuRx graft experienced more technical complications (17% versus 8.3%; p<0.05) and acute conversions to open repair (6/7, 86%; p=0.0005). At 30 days, systemic morbidity was significantly higher in women (26% versus 5.3%; p=0.001.) However, mortality (2.3% versus 1.5%), length of hospital stay (2.6 versus 2.9 days), and major endoleaks at discharge (0% versus 1.6%) were similar. Over a mean follow-up of 11.3 months (range 1-26), graft limb occlusion occurred more frequently in female patients (12.2% versus 2.5%; p=0.05), and secondary procedures were required in a significantly higher number of women (29% versus 9%; p<0.05). Three patients in each group (25% of women versus 17% of men) who had secondary procedures required additional interventions. Although not statistically significant, the mortality in women during follow-up was higher (9.7% versus 5%); 2 deaths were directly related to graft complications in the female group.Conclusions: Endoluminal AAA repair in women presents a technical challenge at the time of operation and may cause more frequent late complications, necessitating close postprocedural surveillance and prompt correction of complications to avoid potentially catastrophic outcomes. Reassessment of inclusion criteria for women may be necessary.

This review focuses on the surgical treatment of primary cutaneous melanoma. Interpretation of biopsy results and a rational approach to preoperative screening methods for metastases are examined. The marked changes in operative approach to melanoma over the past century are reviewed, with emphasis on the impact of prospective, randomized trials upon the width of surgical margins for melanoma, General principles of current surgical technique are discussed, with attention given to modifications of technique dictated by unique anatomic tumor sites. (C) 1996 Wiley-Liss, Inc.

Advances in gene delivery systems have made possible the development of strategies to eradicate cancers via genetic manipulation. Although the strategy of 'gene therapy' remains in its infancy, experimental tumour models have produced encouraging results and have demonstrated that tumour growth or development can be altered by genetic manipulations. Investigators are hopeful that current and future human trials will confirm the role of these modalities in cancer treatment. This review focuses on several aspects of gene therapy that provide clinicians with a framework to understand the rationale and basic principles underlying current gene therapy protocols being conducted for cancer treatment. The relative merits of different gene delivery systems and the mechanisms underlying clinical gene therapy strategies are reviewed. In addition, we discuss the relevance of these new techniques to the oncologic surgeon.