Endovenous ablation for the treatment of symptomatic venous insufficiency was first introduced in 2003. Patients undergoing this procedure avoid the morbidity associated with traditional saphenous stripping procedures. The purpose of this investigation was to determine long-term results and patient satisfaction in patients having the procedure more than five years ago. Institutional review board approval was obtained for a retrospective review as well as a prospective reevaluation via ultrasonography of previously treated areas. A survey instrument was sent to all patients that had venous ablation procedures over five years ago (2640 patients; 544 men, 2096 women). The 24-question survey scored pre-procedure symptoms and quality of life, as well as post procedure satisfaction, symptom recurrence, and quality of life immediately after the procedure, one year later, five years later, and ten years later. 6140 procedures were performed on 4087 individual patients over an eleven-year period. Of these, 4063 procedures were performed five years ago or longer, consisting of 2640 patients. At this point in time we have received 226 completed surveys (35 men, 191 women), and we continue to receive responses. The results of the survey were broken down into two groups, those having the procedure five to nine years ago and those having the procedure ten or more years ago. Patient satisfaction was assessed one year, five years, and ten years after the procedure. Patients were generally satisfied following the procedure (83% satisfied, 12% dissatisfied, 5% neither satisfied nor dissatisfied at one year), with an increased chance of being unsatisfied as more time elapsed (62% satisfied, 32% dissatisfied, 6% neither satisfied nor dissatisfied at ten years). Endovenous ablation is an effective treatment for symptomatic venous insufficiency with excellent long-term results. However recurrent symptoms do occur the more time that passes. Our next step is to reexamine those unsatisfied patients to determine if the treated vein recanalized or additional insufficient veins developed over time.

Purpose Catheter related infections (CRIs) are an important cause of morbidity and mortality in immunocompromised patients in need of long term central venous access.1 Chlorhexidine impregnated sponges have been shown to decrease infection rates in nontunneled central venous catheters (CVCs).1 The purpose of this study is to evaluate the efficacy of Biopatch™when used with a tunneled, cuffed CVC to reduce CRIs. Materials and Methods All large bore tunneled, cuffed CVCs placed in our department between December 1, 2008 and August 31, 2012 were included in this study. HiIQ™ is used to track all procedural complications and was queried for occurences of local infection and septicemia/bacteremia for all patients who had catheters placed in this period. Endpoints were clinically based: a local or site infection was generally recognized as an erythematous exit site and septicemia/bacteremia was defined as those cases which required catheter removal due to positive blood cultures. This data was analyzed using a Chi Square test. Results Between December 1, 2008 and August 31, 2012, 2491 patients had catheters placed. 1348 patients had catheters placed before the intervention and 1237 after. For the 2 years before the intervention, there were 69 episodes of septicemia/bacteremia with an overall prevalence of 5.1%. After Biopatch™ was employed, there were 51 episodes of septicemia/bacteremia for an overall prevalence of 4.1%. This difference was not statistically significant (P=0.23). With regards to local infection, there were 28 patients who experienced local infection before Biopatch™ and 13 after, for an overall prevalence of 2.0% and 1.0% respectively. This result was statistically significant with a P=0.03. Conclusion There is good historical evidence to support the use of Biopatch™ to reduce CRIs in nontunneled CVCs. Based on our results in this retrospective study, Biopatch™ is also useful in reducing local exit site infections in patients who have tunneled, cuffed catheters. Reference 1. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009; 301:1231-41.

Hepatic graft versus host disease (GVHD), veno-occlusive disease (VOD) and other causes of liver dysfunction are among the leading causes of morbidity and mortality in hematopoietic stem cell transplant (HSCT) recipients and liver biopsy is often necessary for diagnosis. HSCT patients are commonly referred to transjugular liver biopsy secondary to comorbid coagulopathy and ascites. The purpose of our study was to assess the safety and utility of transjugular liver biopsy in this high-risk patient population.

1) Highlight best practices in operational efficiency at a hospital based interventional radiology (IR) practice. 2) Demonstrate operational metrics that can establish value creation. 3) Introduce the concept of value stream mapping as a tool to visually display operational information and process flow. Achieving operational efficiency provides clinical and financial benefits to hospital based IR services. Based upon analysis of an expanding IR practice with 8 attending staff and 4 midlevel clinicians, we present an IR practice model that pictorially illustrates the critical drivers of efficiency in the areas of staffing, information technology (IT), and communication. The model utilizes value stream mapping, a lean manufacturing tool that assists in the development of a detailed operational flowchart. Applied to an IR practice, this technique identifies and highlights opportunities for growth and improved operational efficiency. Analysis of specific operational metrics captures an accurate picture of operational flow that can demonstrate value creation. Key best practices were identified in several categories. Staffing strategy includes using lead technologist and charge nurse in triage roles, promoting case flow and room utilization in a manner analogous to air traffic controllers. Mandatory use of high performance IT including Hi-IQ, computerized order entry, and electronic medical records ensures fast and accurate data transfer and recording. Improved communication through work rounds including all anesthesia, tech, and nursing staff promotes global coordination and limits delays. Among the metrics used to capture operation efficiency, room utilization rate and annual procedure volume growth rate were found to be >90% and 29% respectively for this practice. Maximizing operational efficiency in a hospital based IR practice can be achieved with implementation of best practices in the categories of staffing, information technology, and communication. The utility of making key changes can be determined with multiple metrics, thus demonstrating value creation. A value stream map provides a visual roadmap to faciliate analysis of current operational flow.

Learning ObjectivesHighlight best practices in brand development within a nascent market, drawing from the experience of an academic interventional radiology (IR) outpatient vein clinic.BackgroundInterventional radiologists are facing increasing competition from other specialties within traditional markets such as peripheral vascular disease. However, as a technologically driven specialty, IR practices are uniquely suited for taking advantage of new markets, which can arise when disruptive technologies create treatments that benefit previously unreached patient populations. A well-formed plan for building brand equity can help IR practices win and maintain these emerging markets.Clinical Findings/Procedure DetailsEndovascular laser therapy created a new market in the area of venous reflux disease, providing a minimally invasive outpatient treatment for a common medical condition. Capturing the nascent market required establishing a presence as venous experts within the minds of referring physicians and patients. The critical components of building this brand equity involved active education and networking with referring physicians, the creation of dedicated centers of excellence in venous care in strategic geographic locations, affiliation of the centers with the full service hospital practice, and direct patient education and advertisement in the form of health fairs, print and radio advertisements. First mover advantage in brand development as venous care experts created a virtuous cycle of patient referral, which helped establish the practice as the highest volume in the region.Conclusion and/or Teaching PointsGrowth in emerging markets is increasingly relevant to interventional radiologists as traditional markets become crowded with other specialties. Our experience from establishing outpatient vein clinics illustrates how aggressive brand development is a key component to building an IR practice. Learning ObjectivesHighlight best practices in brand development within a nascent market, drawing from the experience of an academic interventional radiology (IR) outpatient vein clinic. Highlight best practices in brand development within a nascent market, drawing from the experience of an academic interventional radiology (IR) outpatient vein clinic. BackgroundInterventional radiologists are facing increasing competition from other specialties within traditional markets such as peripheral vascular disease. However, as a technologically driven specialty, IR practices are uniquely suited for taking advantage of new markets, which can arise when disruptive technologies create treatments that benefit previously unreached patient populations. A well-formed plan for building brand equity can help IR practices win and maintain these emerging markets. Interventional radiologists are facing increasing competition from other specialties within traditional markets such as peripheral vascular disease. However, as a technologically driven specialty, IR practices are uniquely suited for taking advantage of new markets, which can arise when disruptive technologies create treatments that benefit previously unreached patient populations. A well-formed plan for building brand equity can help IR practices win and maintain these emerging markets. Clinical Findings/Procedure DetailsEndovascular laser therapy created a new market in the area of venous reflux disease, providing a minimally invasive outpatient treatment for a common medical condition. Capturing the nascent market required establishing a presence as venous experts within the minds of referring physicians and patients. The critical components of building this brand equity involved active education and networking with referring physicians, the creation of dedicated centers of excellence in venous care in strategic geographic locations, affiliation of the centers with the full service hospital practice, and direct patient education and advertisement in the form of health fairs, print and radio advertisements. First mover advantage in brand development as venous care experts created a virtuous cycle of patient referral, which helped establish the practice as the highest volume in the region. Endovascular laser therapy created a new market in the area of venous reflux disease, providing a minimally invasive outpatient treatment for a common medical condition. Capturing the nascent market required establishing a presence as venous experts within the minds of referring physicians and patients. The critical components of building this brand equity involved active education and networking with referring physicians, the creation of dedicated centers of excellence in venous care in strategic geographic locations, affiliation of the centers with the full service hospital practice, and direct patient education and advertisement in the form of health fairs, print and radio advertisements. First mover advantage in brand development as venous care experts created a virtuous cycle of patient referral, which helped establish the practice as the highest volume in the region. Conclusion and/or Teaching PointsGrowth in emerging markets is increasingly relevant to interventional radiologists as traditional markets become crowded with other specialties. Our experience from establishing outpatient vein clinics illustrates how aggressive brand development is a key component to building an IR practice. Growth in emerging markets is increasingly relevant to interventional radiologists as traditional markets become crowded with other specialties. Our experience from establishing outpatient vein clinics illustrates how aggressive brand development is a key component to building an IR practice.

The purpose of this investigation is to review the types of postpartum vascular injuries associated with caesarian section surgery and to review the techniques and outcomes of endovascular treatment. This is a retrospective review of women who underwent endovascular treatment for vascular complications following C-section delivery at a single institution from 1/1/05 to 10/1/08. All imaging was reviewed along with clinical parameters, including patient age, prior pelvic surgery, time of presentation after C-section, type of vascular injury, type of endovascular treatment, and post-endovascular treatment clinical course. Thirteen women underwent endovascular treatment for postpartum hemorrhage following C-section during the time period specified. Mean age was 35.3 years old (range 28-44). Severity of bleeding ranged from mild (<500cc) to severe hemorrhage (>3000cc). Mean pre-embolization transfusion requirement was 3.2 units PRBC's (range 0-6). Five subjects had positive angiographic findings, including two pseudoaneurysms and three active arterial extravasations; in the remaining 8 subjects, no arterial bleed was found and prophylactic uterine artery embolization was performed to control presumed venous bleeding or vasospasm masking arterial bleeding. Onset of postpartum hemorrhage ranged from immediate to 16 days post C-section, with 9 of the 13 (69%) women presenting within 24 hours; however, both pseudoaneurysms presented after one week. Embolization agent choice included one hypogastric artery balloon occlusion, 2 coil embolizations, and 10 gelfoam embolizations. Mean post-embolization transfusion requirement was 0.45 units PRBC's (range 0-4) and mean length of stay after embolization was 5.2 days (range 1-12 days). Vascular injury during caesarian section delivery is an uncommon event that can result in significant bleeding, presenting immediately or up to several weeks after delivery. Pseudoaneurysms in particular tend to have a delayed time of presentation. Overall, regardless of clinical circumstances, hemorrhage following C-section can be embolized promptly and effectively with minimal post-embolization complications.

PurposeTo examine the benefits and risks of the free-standing IR practice and business model.Materials and MethodsA thorough search to identify existing IR practices utilizing the free-standing model was performed using word of mouth and SIR personnel. Phone interviews and analysis performed. A framework for evaluating entrepreneurial ventures will be introduced. The importance of service model development will be highlighted and a potential model introduced. Evaluation of procedures amenable to the free-standing model will be proposed including the service model implications. A simplified financial model will highlight the financial opportunity. A thorough risk analysis is essential prior to any new venture; a basic risk categorization and ways to mitigate downside risk will be presented.Teaching Points1) IR practice model is well suited to free-standing business model. 2) Free-standing model can be professionally and financially rewarding. 3) Excellent management team important for success. 4) Thorough risk assessment and understanding is crucial throughout implementation. PurposeTo examine the benefits and risks of the free-standing IR practice and business model. To examine the benefits and risks of the free-standing IR practice and business model. Materials and MethodsA thorough search to identify existing IR practices utilizing the free-standing model was performed using word of mouth and SIR personnel. Phone interviews and analysis performed. A framework for evaluating entrepreneurial ventures will be introduced. The importance of service model development will be highlighted and a potential model introduced. Evaluation of procedures amenable to the free-standing model will be proposed including the service model implications. A simplified financial model will highlight the financial opportunity. A thorough risk analysis is essential prior to any new venture; a basic risk categorization and ways to mitigate downside risk will be presented. A thorough search to identify existing IR practices utilizing the free-standing model was performed using word of mouth and SIR personnel. Phone interviews and analysis performed. A framework for evaluating entrepreneurial ventures will be introduced. The importance of service model development will be highlighted and a potential model introduced. Evaluation of procedures amenable to the free-standing model will be proposed including the service model implications. A simplified financial model will highlight the financial opportunity. A thorough risk analysis is essential prior to any new venture; a basic risk categorization and ways to mitigate downside risk will be presented. Teaching Points1) IR practice model is well suited to free-standing business model. 2) Free-standing model can be professionally and financially rewarding. 3) Excellent management team important for success. 4) Thorough risk assessment and understanding is crucial throughout implementation. 1) IR practice model is well suited to free-standing business model. 2) Free-standing model can be professionally and financially rewarding. 3) Excellent management team important for success. 4) Thorough risk assessment and understanding is crucial throughout implementation.

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.

Objective: This study was undertaken to determine whether a complicated aortic neck is associated with unfavorable outcome fter 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, :510 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.

Chemoembolization was performed in eight patients with liver metastasis from breast carcinoma. Five of eight patients had some radiographic regression of the liver tumors, one had stable liver disease, and two had disease progression. Two of four patients with pain showed clinical improvement of their symptoms. Only one patient with radiographic response or disease stabilization subsequently had intrahepatic progression (at 3 months). Five patients developed other metastasis, particularly brain metastasis, at a mean of 4.6 months after first chemoembolization (range, 2-12 months). All patients died within 13 months of treatment, with a mean survival of 49 months from primary diagnosis, 20 months from liver metastasis diagnosis, and 6 months from first chemoembolization.

PURPOSE:To evaluate the dose response and safety of gadofosveset trisodium-enhanced magnetic resonance (MR) angiography compared with nonenhanced two-dimensional time-of-flight MR angiography and with x-ray angiography as the standard.MATERIALS AND METHODS:In this randomized, 20-center, double-blind study, 238 men and women who had peripheral vascular disease or were suspected of having it received intravenous injection of placebo or gadofosveset (0.005, 0.01, 0.03, 0.05, or 0.07 mmol per kilogram of body weight). MR angiographic images were evaluated by three blinded readers, and x-ray angiographic images were evaluated by two readers. Hypothesis testing for the presence of a dose response was based on a linear test for trend for increase in area under the receiver operating characteristic curve as a function of dose for each reader of MR angiographic images independently.RESULTS:Gadofosveset administration resulted in a dose-dependent increase in diagnostic accuracy for detection of aortoiliac occlusive disease as reflected in the area under the receiver operating characteristic curve for each reader (P <.001). The plateau in effectiveness improvement began at the 0.03 mmol/kg dose. At doses of 0.03 mmol/kg and higher, gadofosveset-enhanced MR angiography provided an approximate 20% increase in accuracy over nonenhanced MR angiography for diagnosis of clinically significant aortoiliac occlusive disease. Gadofosveset exhibited a good safety profile in all dose groups. Three serious adverse events were possibly or probably related to gadofosveset administration. There were no dose-related trends in severe or serious adverse events in patients receiving gadofosveset.CONCLUSION:A dose of 0.03 mmol/kg of gadofosveset was safe and effective for evaluation of aortoiliac occlusive disease with MR angiography.

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.

INTRODUCTIONBoth 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).METHODSThe 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.RESULTSThe 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.CONCLUSIONThe 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.

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 warfaxin 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.

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. (J Vasc Surg 2002;35:222-8.)

OBJECTIVEEndoleaks 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.METHODSThese 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.RESULTSConference 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.CONCLUSIONThe 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.

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.

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.