To assess the safety and efficacy of access to the radial, distal radial and pedal arteries and small veins using a novel, FDA cleared, articulating-tip micro guidewire. The wire sizes were 0.018 in. and 0.021 in. that tapers to an 0.018 in. Guidewire-facilitated access to peripheral vessels is commonplace in endovascular procedures, and is gaining popularity in peripheral vascular interventions. Guidewire insertion into small vessels, such as the radial, distal radial and pedal arteries, is often challenging, with first-attempt success rate of 45% without and up to 65% with ultrasound guidance. With small veins, the problem also exists causing repeat access attempts. Failure to gain access on first attempt is associated with an increased risk of complications, such as vessel dissection, spasm, hematoma, and vessel occlusion. 250 patients who had endovascular procedures that necessitated small vessel access were included. These procedures included cardiac catheterization, peripheral arterial interventions, endovascular vein ablation and dialysis access interventions. An articulating-tip micro guidewire was used for arterial and venous access. Guidewire insertion was attempted at 93 radial and 97 distal radial, 28 pedal arteries, and 32 veins. Minimal vessel diameter accessed was 1.2 mm. First-attempt placement success was 92% (230/250) and differences in the success rate between the radial and distal radial arteries or between vessels with diameter smaller or larger than 2 mm were not observed. Four of the five reported adverse events were unrelated to the wire or the procedure. Two of the three distal radial artery spasms occurred before the guidewire was used. The other two events were a radial artery spasm and a distal radial artery site hematoma. All spasms and the hematoma resolved spontaneously. No vascular occlusion or dissection was noted. The articulating-tip micro guidewire showed high rate of first-attempt placement in the radial, distal radial, pedal arteries, and small veins and was not associated with safety concerns.

PURPOSE:Inpatient surgery costs have risen 30% over the past 5 years, and the operating room accounts for up to 60% of total hospital operational expense. On average, only 13.0% to 21.9% of instruments opened for a case are used, contributing to significant avoidable reprocessing, repurchase, and labor expense.METHODS:A comprehensive review of 40 major instrument trays at UNC Rex Hospital was conducted using a technology service (OpFlow; Operative Flow Technologies, Raleigh, NC). Among the full scope of the project, the general plastics tray and breast reconstruction tray were evaluated for the plastic surgery service line over a 3-month period. Intraoperative data collection was performed on the exact instruments used across a standard breadth of cases. Data analytics were conducted stratifying instrument usage concordance among surgeons by tray and procedure type. After a surgeon-led review of the proposed new tray configurations, the optimized versions were implemented via a methodical change management process.RESULTS:A total of 183 plastic surgery cases were evaluated across 17 primary surgeons. On average, the instrument usage per tray was 15.8% for the general plastics tray and 23.5% for the breast reconstruction tray. After stakeholder review, 32 (45.1%) of 71 instruments were removed from the general plastics tray and 40 (36.7%) of 109 were removed from the breast reconstruction tray, resulting in a total reduction of 2652 instruments. This resulted in a decrease of 81,696 instrument sterilization cycles annually. The removal of the instruments yielded an estimated cost avoidance of US $163,800 for instrument repurchase and US $69,441 in annual resterilization savings. The instrument volume reduction is projected to save 383.5 hours of sterile processing personnel time in tray assembly annually.CONCLUSIONS:An analytics-driven method applying empirical data on actual case-based instrument usage has implications for better efficiency, improved quality, and cost avoidance related to instrument repurchase and sterile processing. Given increasing cost constraints and the transition to value-based care models, leveraging a technology-based solution enables meaningful change in the sterile processing department as a source for cost reduction and quality of care improvement.

The Sentry inferior vena cava (IVC) filter is designed to provide temporary protection against pulmonary embolism (PE) during transient high-risk periods and then to bioconvert after 60 days after implantation. At the time of bioconversion, the device's nitinol arms retract from the filtering position into the caval wall. Subsequently, the stable stent-like nitinol frame is endothelialized. The Sentry bioconvertible IVC filter has been evaluated in a multicenter investigational-device-exemption pivotal trial (NCT01975090) of 129 patients with documented deep vein thrombosis (DVT) or PE, or at temporary risk of developing DVT or PE, and with contraindications to anticoagulation. Successful filter conversion was observed in 95.7% of patients at 6 months (110/115) and 96.4% at 12 months (106/110). Through 12 months, there were no cases of symptomatic PE. The rationale for development of the Sentry bioconvertible device includes the following considerations: (1) the period of highest risk of PE for the vast majority of patients occurs within the first 60 days after an index event, with most of the PEs occurring in the first 30 days; (2) the design of retrievable IVC filters to support their removal after a transitory high-PE-risk period has, in practice, been associated with insecure filter dynamics and time-dependent complications including tilting, fracture, embolization, migration, and IVC perforation; (3) most retrievable IVC filters are placed for temporary protection, but for a variety of reasons they are not removed in any more than half of implanted patients, and when removal is attempted, the procedure is not always successful even with advanced techniques; and (4) analysis of Medicare hospital data suggests that payment for the retrieval procedure does not routinely compensate for expense. The Sentry device is not intended for removal after bioconversion. In initial clinical use, complications have been limited. Long-term results for the Sentry bioconvertible IVC filter are anticipated soon.

Purpose: This study sought to assess the performance of the LIFESTREAM balloon-expandable covered stent for the treatment of iliac artery atherosclerotic lesions. Methods: A total of 155 patients were treated in a prospective, single-arm study at 17 centers in the United States, Europe, and New Zealand. The primary endpoint was a composite of device- or procedure-related death or myocardial infarction (MI) over the course of 30 days, or target lesion revascularization (TLR), major amputation of the target limb, or re-stenosis through 9-months. Secondary endpoints included primary patency, TLR, sustained clinical success, quality of life, and major adverse events (MAE). Results: At 9 months, the primary composite endpoint rate was 16.2% (93.5% confidence interval [CI]: 10.6%-23.2%), primary patency was 89.1% (95% CI: 82.6%-93.7%), and freedom from TLR was 96%. There was a cumulative clinical improvement of at least one Rutherford category from baseline to 9 months of 90.5% (95% CI: 84.3%-94.9%). Quality of life, assessed by using the Walking Impairment Questionnaire (WIQ), demonstrated a mean change in total score from baseline through 9 months of 32.1 +/- 26.84; overall, improvements were noted from baseline in each WIQ category. Seven of one-hundred fifty patients (4.7%; 95% CI: 1.9%-9.4%) experienced MAEs, but none were determined to be related to device or procedure. Conclusions: The LIFESTREAM balloon-expandable covered stent provided satisfactory 9-month clinical outcomes including a low rate of target lesion revascularization for the treatment of stenotic and occlusive lesions of the iliac arteries.

Purpose: To report final 2-year outcomes with the Sentry bioconvertible inferior vena cava (IVC) filter in patients requiring temporary protection against pulmonary embolism (PE). Materials and Methods: In a prospective multicenter trial, the Sentry filter was implanted in 129 patients with documented deep vein thrombosis (DVT) and/or PE (67.5%) or who were at temporary risk of developing DVT/PE (32.6%). Patients were monitored and bioconversion status ascertained by radiography, computed tomography (CT), and CT venography through 2 years. Results: The composite primary 6-month endpoint of clinical success was achieved in 97.4% (111/114) of patients. The rate of new symptomatic PE was 0% (n = 126) through 1 year and 2.4% (n = 85) through the second year of follow-up, with 2 new nonfatal cases at 581 and 624 days that were adjudicated as not related to the procedure or device. Two patients (1.6%) developed symptomatic caval thrombosis during the first month and underwent successful interventions without recurrence. No other filter-related symptomatic complications occurred through 2 years. There was no filter tilting, migration, embolization, fracture, or caval perforation and no filter-related deaths through 2 years. Filter bioconversion was successful for 95.7% (110/115) of patients at 6 months, 96.4% (106/110) of patients at 12 months, and 96.5% (82/85) of patients at 24 months. Through 24 months of follow-up, there was no evidence of late-stage IVC obstruction or thrombosis after filter bioconversion or of thrombogenicity associated with retracted filter arms. Conclusions: The Sentry IVC filter provided safe and effective protection against PE, with a high rate of intended bioconversion and a low rate of device-related complications, through 2 years of follow-up.

PURPOSE:To prospectively assess the Sentry bioconvertible inferior vena cava (IVC) filter in patients requiring temporary protection against pulmonary embolism (PE). MATERIALS AND METHODS:At 23 sites, 129 patients with documented deep vein thrombosis (DVT) or PE, or at temporary risk of developing DVT or PE, unable to use anticoagulation were enrolled. The primary end point was clinical success, including successful filter deployment, freedom from new symptomatic PE through 60 days before filter bioconversion, and 6-month freedom from filter-related complications. Patients were monitored by means of radiography, computerized tomography (CT), and CT venography to assess filtering configuration through 60 days, filter bioconversion, and incidence of PE and filter-related complications through 12 months. RESULTS:Clinical success was achieved in 111 of 114 evaluable patients (97.4%, 95% confidence interval [CI] 92.5%-99.1%). The rate of freedom from new symptomatic PE through 60 days was 100% (n = 129, 95% CI 97.1%-100.0%), and there were no cases of PE through 12 months for either therapeutic or prophylactic indications. Two patients (1.6%) developed symptomatic caval thrombosis during the first month; neither experienced recurrence after successful interventions. There was no filter tilting, migration, embolization, fracture, or caval perforation by the filter, and no filter-related death through 12 months. Filter bioconversion was successful for 95.7% (110/115) at 6 months and for 96.4% (106/110) at 12 months. CONCLUSIONS:The Sentry IVC filter provided safe and effective protection against PE, with a high rate of intended bioconversion and a low rate of device-related complications, through 12 months of imaging-intense follow-up.

Purpose: To evaluate the safety and effectiveness of the Crux vend cave filter in patients at risk fur pulmonary embolism (PE).Materials and Methods : The Crux Biomedical Evaluation of the Crux Inferior Vena Cava Filter System trial was an international prospective, multicenter, single-arm clinical trial in 125 patients implanted with the Crux filter between June 2010 and June Follow-up was 180 days after filter Placement and 30 days after filter retrieval. The primary objective was to determine Whether the clinical success rate was at least 80%. Clinical success was defined as technical success of deployment and freedom from definite PE, filter migration, and device-related adverse events requiring intervention.Results: The clinical success rate was 96.0% (120 of 125), with a one-sided lower limit of the 95% confidence interval of 91.8%. The rate of technical success was 98.4% (123 of 125). There were three cases of definite PE (2.4%), two cases of deployment failure, and no cases of device migration, embolization, fracture, or tilting. Investigators observed nine cases of trombus, (all nonocclusive) in Or near the filter (six during retrieval evaluation vena cavography, two during computed tomography [CT] scans, for PE symptoms, and one during CT for cancer management) and 13 cases of deep vein thrombosis. Device retrieval was attempted at a mean of 84.6 days +/- 57.6 (range, 6-190 d) after implantation and was successful for 98.1% of patients (53 of 54). All deaths (n = 14) were determined to be unrelated, to the filter or PE.Conclusions: The Crux vena cava filter performed safely, with high rates of Clinical, technical, and retrieval success.

Since the initial report1Semba C.P. Kato N. Kee S.T. Lee G.K. Mitchell R.S. Miller D.C. et al.Acute rupture of the descending thoracic aorta: repair with use of endovascular stent grafts.J Vasc Intervent Radiol. 1997; 8: 337-342Abstract Full Text PDF PubMed Scopus (217) Google Scholar of treating blunt aortic injuries (BAI) with endovascular methods, its application in the traumatically injured patient has continued to gain acceptance and use. This may be attributed to an increase in the number of available thoracic stent grafts as well as the accumulation of experience by endovascular specialists. Additionally, experience has revealed several important procedural details that help ensure a successful result. This article describes the techniques and tips that may be useful to optimize outcomes for this high-risk group of patients. Over the past decade, diagnostic evaluation associated with trauma patients has rapidly progressed to multidetector spiral computed tomography (CT) imaging for the vast majority of injuries. While a recent report claims that CT scanning has supplanted aortography as the gold standard for diagnosing BAI2Demetriades D. Velmahos G.C. Scalea T.M. Jurkovich G.J. Karmy-Jones R. Teixeira P.G. et al.Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study.J Trauma. 2008; 64 (discussion 570-1.): 561-570Crossref PubMed Scopus (318) Google Scholar, there are shortcomings of axial imaging that warrant mention. CT imaging should be performed with 1-2 mm intervals to optimize the detection and evaluation of intimal defects of the aorta. However, due to emergent conditions and the need to obtain images of multiple body regions (head, neck, chest, abdomen/pelvis) this sometimes cannot be accomplished, and 3-5 mm intervals are used. As such, axial images can be misleading or suboptimal when evaluating the aorta in the typical location for BAI, the isthmus. Therefore, it is critical that three-dimensional and centerline reconstructions be performed to identify not only the location of the injury but also accurately measure the aortic diameter and the distance from branched vessels. In cases where thoracic imaging is suboptimal or pelvic imaging (to appropriately evaluate the iliac arteries) is missing, it has been our practice to perform a second, more detailed CT. In instances where femoral access is felt to be too small for delivery of the stent graft, iliac or aortic conduits can be utilized. Conduits should be avoided, however, in patients with pelvic fractures or hematomas. If the lesion location requires coverage of the left subclavian artery (SCA), then additional imaging will be required to determine if the patient possesses dominant left vertebral artery (VA) architecture. This will either involve additional CT imaging of the head and neck or intraoperative bilateral vertebral angiography. Whether left SCA coverage is required will depend upon the location of the lesion and the degree of aortic curvature. The absolute and relative indications for left SCA revascularization at our institution are listed in the Table. It has been our practice to maintain left SCA antegrade perfusion in cases where the patient has left VA dominance. Our approach is to use a parallel stent technique (Fig 1) instead of performing a carotid to SCA bypass or transposition. This technique has been successful as most lesions from BAI are along the inferior curve of the aorta and placing a bare stent from the subclavian along the superior aspect of the aorta has not increased the incidence of type Ia endoleaks in our experience.TableIndications for left subclavian revascularizationAbsolute indicationsLeft inferior mammary artery bypassStenotic or occluded right vertebral arteryLeft vertebral terminating in the posterior inferior cerebellar arteryLeft vertebral arising from the archRelative indicationsLeft-hand dominant individualsLarge left vertebral in comparison to the rightExtensive thoracic coverage Open table in a new tab Access for intraprocedural angiographic visualization also warrants some discussion. In most cases, access through the left brachial artery provides excellent interrogation of the great vessel origins and the vertebral arteries. If parallel stenting is necessary, sheath access is already established prior to stent graft deployment. In cases where the left SCA perfusion is not a concern, access can be accomplished by either the ipsilateral or contralateral femoral artery depending upon the vessel diameter and delivery catheter size. Until recently (June 2008), only the Gore TAG device (W. L. Gore and Associates, Flagstaff, Ariz) was approved for implantation in to the thoracic aorta for aneurysmal disease. While its use for BAI is considered off-label, it has been used successfully with few exceptions or complications. There are now three devices commercially approved for thoracic aortic aneurysmal disease, enabling the treatment of aortic sizes between 18 mm and 42 mm in diameter. While each of the three devices has different proximal and distal configurations, none of them has a disease specific indication for treating aortic transections. As such, they are prone to certain device specific complications. Prior to June 2008, when the endovascular specialist encountered a patient with an aortic intimal diameter less than 23 mm, infrarenal aortic cuffs were typically utilized to exclude the lesion.3Rosenthal D. Wellons E.D. Burkett A.B. Kochupura P.V. Hancock S.M. Endovascular repair of traumatic thoracic aortic disruptions with “stacked” abdominal endograft extension cuffs.J Vasc Surg. 2008; 48: 841-844Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 4Riesenman P.J. Farber M.A. Rich P.B. Sheridan B.C. Mendes R.R. Marston W.A. et al.Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury.J Vasc Surg. 2007; 46: 934-940Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar This allowed better device apposition against the inferior wall of the aortic arch and eliminated oversizing that in certain instances lead to device collapse.5Muhs B.E. Balm R. White G.H. Verhagen H.J.M. Anatomic factors associated with acute endograft collapse after Gore T.A.G.treatment of thoracic aortic dissection or traumatic rupture.J Vasc Surg. 2007; 45: 655-661Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar While criteria for oversizing and neck lengths have not been established through clinical trials, endovascular experts consider the traditional oversizing seen with aneurysmal disease not as crucial since device migration is not a significant concern. Typically, devices are oversized approximately 10% for the treatment of BAI. Proximal neck length should be adequate to achieve exclusion of the lesion and may be impacted by the radius of curvature of the aorta. This can be achieved with less proximal neck length than the instructions for use recommends. Device positioning is governed by aortic curvature to ensure that the device aligns parallel to the aortic centerline rather than the specific position relative to the left SCA. While the addition of two new devices extends the treatment options for BAI, adequate devices with tapered configurations to treat small aortas are still not available. The patient is typically taken to the operating room in an expeditious fashion. While the procedure can be undertaken with local or regional anesthesia, most patients receive general anesthesia, unless contraindications exist, allowing for better control of breathing patterns during subtracted angiography of the chest. The procedure can be performed with or without heparin if necessary. In our institution, heparin is given at 80 units/kg unless contraindicated (associated closed head injury or other high risks for bleeding). Typically, stiff wires are used during the procedure (Lunderquist [Cook Inc, Bloomington, Ind] or Meier [Boston Scientific, Natick, Mass]) and retroflexed off the aortic valve. Once this has been established, the device can be brought up near the intended implantation site. Once appropriate angles and orientation is determined, then the device is deployed under fluoroscopic guidance. Correct image intensifier orientation and angle is critical for precise device placement. Angiographic delineation of the anatomy is achieved with a perpendicular view to the aortic arch (usually 35to 50 degrees left anterior oblique views). If necessary, vertebral angiography can also be conducted prior to device insertion if intracranial imaging was not obtained prior to surgery and left SCA coverage is planned. The final device orientation should approach a parallel configuration of the proximal stents with respect to the aortic centerline and achieve lesion exclusion (Fig 2). While some vascular specialists advocate reducing the mean blood pressure during deployment of thoracic devices, we have found it to be both device and disease specific and do not routinely employ its use. In cases where the patient is very hyperdynamic and the device cannot be positioned along the outer curve to enable precise deployment, reducing blood pressure with either inflow occlusion balloons or pharmacologic means may be helpful in achieving a more accurate deployment. While there is no published follow-up protocol currently, we routine follow our patients at 1, 6, and 12 months and then yearly for the first 5 years. After 5 years, we have been more liberal with our follow-up intervals and have extended it to every 2 to 3 years with noncontrasted imaging to reduce the life-long radiation exposure to the patient. Prior to the advent of endovascular therapy for BAI, there was a trend to delay the open repair of some injuries until the patient was relatively stable. However, this was not without some increased risk for rupture.6Hemmila M.R. Arbabi S. Rowe S.A. Brandt M. Wang S.C. Taheri P.A. et al.Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair?.J Trauma. 2004; 56: 13-23Crossref PubMed Scopus (63) Google Scholar Since the advent of thoracic endovascular aneurysm repair (TEVAR), we have rarely delayed the repair of a blunt aortic injury. On occasion when there is no periaortic hematoma and a small intimal defect is seen on CT imaging, we have observed and re-imaged the patient several days later to monitor the lesion. We have now performed over 25 endovascular aortic repairs for aortic transection with several different devices.4Riesenman P.J. Farber M.A. Rich P.B. Sheridan B.C. Mendes R.R. Marston W.A. et al.Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury.J Vasc Surg. 2007; 46: 934-940Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar A recent meta-analysis of open vs endovascular repair reported several significant findings that are import to highlight.7Xenos E.S. Abedi N.N. Davenport D.L. Minion D.J. Hamdallah O. Sorial E.E. et al.Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture.J Vasc Surg. 2008; 48: 1343-1351Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar Seventeen retrospective studies were reviewed over a 4-year period between 2003 and 2007. While all the studies were nonrandomized, there were a total of 589 patients treated (369 open and 220 endovascular). The average time to repair was 1.5 vs 1 day, respectively, and was not statistically different between the two groups. Even though injury severity score was higher for the endovascular (EV) patients, the procedural mortality, 30-day mortality, and the paraplegia risk was lower for the EV group. These combined data are similar to our published series.4Riesenman P.J. Farber M.A. Rich P.B. Sheridan B.C. Mendes R.R. Marston W.A. et al.Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury.J Vasc Surg. 2007; 46: 934-940Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar While there are no devices approved for treating thoracic transections, endovascular repair has rapidly become the preferred method of management for BAI at most major medical centers. Whether this is a result of the decreased incidence of spinal cord ischemia, morbidity or mortality is difficult to determine. Several technical tips should be discussed to avoid acute complications of device collapse and treatment failure. Device selection (diameter, conformability, and configuration) is critical in obtaining treatment success. Devices should be oversized approximately10%, however, current devices do not address aortic diameters that are less than 18 mm in diameter (frequently seen in the younger population). In addition, current devices lack distal aortic arch conformity. Both of these issues may contribute to device failure via device collapse and nonexclusion of the lesion.5Muhs B.E. Balm R. White G.H. Verhagen H.J.M. Anatomic factors associated with acute endograft collapse after Gore T.A.G.treatment of thoracic aortic dissection or traumatic rupture.J Vasc Surg. 2007; 45: 655-661Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar It is for this reason that some vascular specialists prefer to use infrarenal aortic cuffs in an attempt to obtain better outcomes. Understand, however, that multiple components may also lead to treatment failure. Left SCA coverage is not always required, and device positioning should be based upon ideal device location to ensure exclusion of the injury. This may require coverage in a significant number, but not all patients. It is therefore critical to have adequate vertebral imaging to avoid posterior strokes. One must also keep in mind that more proximal device deployments have been associated with an increased incidence of stroke in patients being treated for aneurysmal disease.8Fairman R.M. Criado F. Farber M. Kwolek C. Mehta M. White R. et al.Pivotal results of the Medtronic Vascular Talent Thoracic Stent Graft System: the VALOR trial.J Vasc Surg. 2008; 48: 546-554Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar While SCA revascularization may reduce paraplegia risks for patients with aneurysmal disease, the risk of paraplegia with EV repair of BAI is almost nonexistent with only one reported case.9Doss M. Wood J.P. Balzer J. Martens S. Deschka H. Moritz A. Emergency endovascular interventions for acute thoracic aortic rupture: four-year follow-up.J Thorac Cardiovasc Surg. 2005; 129: 645-651Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar As a result of the limited invasiveness of the procedure, certain trauma patients can be treated in a more expeditious fashion. In patients with concomitant head injuries, there may be a benefit compared with delayed open repair, by allowing more aggressive management of blood pressure to maximizing cerebral perfusion. Whether this will result in improved outcomes remains to be seen. Repair of BAI has undergone significant change in the past 5 years. Imaging and device selection are critical to obtain successful outcomes. Disease specific devices that will accommodate the smaller aortic sizes and distal arch conformity that are encountered in this distinct patient population is crucial in allowing this therapy to move forward in the future.

By definition, an infrarenal abdominal aortic aneurysm (AAA) is located in the distal portion of the abdominal aorta, inferior to the renal arteries. The segment of aorta between the renal arteries and an infrarenal aneurysm is commonly referred to as the "neck" of the aneurysm. The anatomic characteristics of this area are of critical importance when considering therapeutic strategies for both open and endoluminal interventions. Prior to the endovascular era, optimal management of coexistent aortic aneurysmal disease and visceral pathology was somewhat controversial. While some centers advocated open endarterectomy for stenotic ostial lesions of the renal and visceral vessels at time of aneurysm repair, others preferred reimplantation or bypass for similar lesions. The choice of intervention was often individualized and based somewhat upon surgeon preference.With the advent and the widespread uptake and utilization of endovascular techniques, it is readily evident that many infrarenal and thoracic aortic aneurysms can be repaired using intraluminal stent-graft devices. Furthermore, the successful deployment of fenestrated or branched stent-graft devices are expanding the limits of endoluminal aneurysm repair. Currently, the treatment of juxtarenal, suprarenal, or even thoraco-AAAs may now be performed solely via endoluminal techniques, albeit in clinical trials.Optimal management of aortic aneurysm and coexisting arterial branch-vessel occlusive disease is predicated on a thorough knowledge of the anatomy, pathophysiology, clinical picture, natural history, and therapeutic options that are available for each of the underlying disease processes. A logical platform from which to commence evaluating these processes is to review the current understanding of stenotic lesions affecting the renal arteries, superior mesenteric artery, and the celiac artery.

Introduction: Twenty to thirty percent of patients with symptomatic chronic venous insufficiency (CVI) are found to have combined superficial and deep venous reflux on duplex testing. It is currently unclear whether endovenous; ablation (EVA) of the saphenous vein will result in correction of CVI without addressing the deep venous reflux. In this study, we examined deep venous reflux velocities to determine whether these would predict outcome after endovenous ablation.Methods. Patients with symptomatic CVI and both saphenous and deep venous reflux were identified using duplex ultrasonography. Reflux times and maximal reflux velocity (MRV) in each examined vein segment were determined. In each limb, the venous filling index (VFI) and the venous clinical severity score (VCSS) were obtained both before and after laser ablation of the great and/or small saphenous veins. Preoperative venous reflux velocities were correlated with improvement in VFI and VCSS after ablation.Results. 75 limbs with both deep and superficial venous reflux were identified. Seventy-five percent of limbs were CEAP clinical class 3 or 4 and the other 25% were class 5 or 6. Forty limbs demonstrated deep venous reflux in the femoral and/or popliteal vein. After EVA, significant improvements in VFI and VCSS were seen, but this depended on MRV in the deep vein. When MRV in the popliteal or femoral vein was < 10 cm/sec, limbs had significantly better outcomes than limbs with MRV > 10 cm/sec as measured by both VFI (P = .01) and VCSS (P = .03). In 35 limbs, deep venous reflux was identified only in the CFV. In this group, the average pre-procedure VFI (6.54 +/- 3.9 cc/sec) decreased significantly to 2.2 +/- 1.9 cc/sec (P < .001) and the VCSS improved markedly from 7.0 +/- 2.8 to 1.3 +/- 1.4 (P < .001).Conclusions. EVA of the saphenous veins can be performed in patients with concomitant deep venous insufficiency with hemodynamic and clinical improvement in most cases. Patients with popliteal or femoral reflux velocities lower than 10 cm/sec usually experience marked improvement in both the VFI and the VCSS. Patients with femoral or popliteal reflux velocities greater than 10 cm/sec have a high incidence of persistent symptoms after EVA.

Background Thoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subdavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions.Methods: Between October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone I deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia.Results: Mean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subdavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subdavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type TA and type 111) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures.Conclusion: Intentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions.

Aneurysmal lesions of the external carotid artery are extremely rare. A case is presented of a 3.8 cm right external carotid artery pseudoaneurysm treated by transluminal exclusion using an endovascular stent-graft. Following stent-graft placement, complete occlusion of the aneurysmal sac and main vessel lumen patency was successfully demonstrated. This report demonstrates the technical feasibility of utilizing stent-grafts to treat aneurysmal lesions involving the external carotid artery.

BACKGROUND:Acute thoracic aortic injury resulting from blunt trauma is a life-threatening condition. Endovascular therapy is a less invasive treatment modality that may potentially improve patient outcomes. We reviewed our experience with patients who sustained blunt thoracic aortic injuries distal to the left subclavian artery and presented for open surgical or endovascular repair.METHODS:Between August 1993 and August 2006, 62 patients sustained blunt thoracic aortic injuries distal to the origin of the left subclavian artery and proceeded to undergo open surgical (n = 48, 77%), or endovascular repair (n = 14, 23%). Revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS), individual associated traumatic injuries, as well as operative and postoperative outcomes were compared between open surgical and endovascular groups.RESULTS:Age, gender, race, and mechanism of injury did not differ between open surgical and endovascular groups. Additionally, RTS, ISS, and NISS values were not significantly different. The proportion of patients with sternal fractures (14% vs 0%), or unstable spinal fractures (36% vs 10%) was significantly greater in the endovascular group. Of the patients who received endografts, 93% (n = 13) were evaluated by a cardiothoracic surgeon and assessed to be prohibitive to operative intervention. Endografts utilized included commercially manufactured thoracic endografts (n = 6; 43%) and abdominal aortic endograft components (n = 8; 57%). Forty-one interposition grafts were placed in the open surgical group. Renal complications (32% vs 7%), and urinary tract infections (35% vs 7%) approached significance between surgical and endovascular groups (P = .082 and P = .077, respectively). Intraoperative mortality for the surgical and endovascular groups was 23% and 0%, respectively (P = .056). Endovascular repair was associated with significant reductions in operative time (118 vs 209 minutes), estimated blood loss (77 vs 3180 ml), and intraoperative blood transfusions (0.9 vs 6.1 units). No endoleaks were detected during a mean follow-up of 9.4 months in the endovascular group.CONCLUSION:Endovascular repair of blunt descending thoracic aortic injuries utilizing thoracic or abdominal endographs is a technically feasible modality that is at least equivalent to open therapy in the short term and associated with a lower intraoperative mortality (P = .056). Endovascular therapy has advantages in operative time, operative blood loss, and intraoperative blood transfusions.

Objectives. The natural history of limbs affected by ischemic ulceration is poorly understood. In this report, we describe the outcome of limbs with stable chronic leg ulcers and arterial insufficiency that were treated with wound-healing techniques in patients who were not candidates for revascularization.Methods. A prospectively maintained database of limb ulcers treated at a comprehensive wound center was used to identify patients with arterial insufficiency, defined as an ankle-brachial index (ABI) < 0.7 or a toe pressure < 50 mm Hg. Patients were treated without revascularization when medical comorbidity or anatomic considerations did not allow revascularization with acceptable risk. Ulcers were treated with a protocol emphasizing pressure relief, debridement, infection control, and moist wound healing. Risk factors analyzed for their affect on healing and amputation risk included age, gender, diabetes mellitus, chronic renal insufficiency (serum creatinine > 2.5 mg/dL), severity of ischemia measured by ABI or toe pressure, wound grade, wound size, and wound location.Results. Between January 1999 and March 2005, 142 patients with 169 limbs having arterial insufficiency and full-thickness ulceration were treated without revascularization. Mean patient age was 70.8 +/- 4.5. Diabetes mellitus was present in 70.4% of limbs and chronic renal insufficiency in 27.8%. Toe amputations or other foot-sparing procedures were performed in 28% of limbs. Overall, limb loss occurred in 37 patients. By life-table analysis, 19% of limbs required amputation <= 6 months of initial treatment and 23% at 12 months. Complete wound closure was achieved in 25% by 6 months and in 52% by 12 months. Statistical analysis showed a correlation between ABI and the risk of limb loss. In patients with an ABI < 0.5, 28% and 34% of limbs experienced limb loss at 6 and 12 months, respectively, compared with 10% and 15% of limbs in patients with an ABI > 0.5 (P =.01). The only risk factor associated with wound closure was initial wound size (P <.005).Conclusions. Limb salvage can be achieved in most patients with arterial insufficiency and uncomplicated chronic nonhealing limb ulcers using a program of wound management without revascularization. Healing proceeds slowly, however, requiring more than a year in many cases. Patients with an ABI < 0.5 are more likely to require amputation. Interventions designed to improve outcomes in critical limb ischemia should stratify outcomes based on hemodynamic data and should include a comparative control group given the natural history of ischemic ulcers treated in a dedicated wound program. (J Vasc Surg 2006;44:108-14.)