We describe a multidisciplinary treatment option for a challenging carotid body tumor, Shamblin type III, resection via preoperative embolization and surgical resection. Postoperative vocal cord paralysis and cricopharyngeal achalasia were resolved with botulinum toxin and hyaluronic acid gel injections.

Background: Preventative strategies that minimize hemodialysis access complications remain limited. Objective: This study aimed to address this gap by developing a Caprine cannulation model to investigate the impact of repeated cannulations on vascular access patency rates. Research design and measures: In this pilot study, a meta-analysis was conducted using experimental control data from four trials to explore the impact of Caprine breed (independent variable) on the dependent variables that affect hemodialysis cannulation, including AVF growth, AVF depth, and flow rate. Subjects: Arteriovenous Fistulas (AVFs) were created using the carotid artery and jugular vein in the necks of seven goats from the French alpine, dwarf, and pygmy breeds. All seven AVFs exhibited vessel remodeling patterns similar to that observed in humans and remained patent, enabling hemodialysis access over the 6 month study. Results: Over the course of 18 weeks, a total of 291 cannulations were completed using standard 15 g dialysis needles without complications demonstrating the feasibility of using the Caprine species as a cannulation model. The ease of access coupled with the animals’ cooperative behavior further contributes to the suitability of the Caprine species for hemodialysis investigations. Notably, no infections or clinically significant incidents were observed throughout the study. Conclusions: The stability of AVF patency and flow underscores the viability and potential of the Caprine species animal model as a valuable research platform for exploring interventions aimed at improving vascular access survival in hemodialysis patients.

Objective: The Ark is a 3-D printed titanium device designed to be implanted around the draining vein of an arteriovenous fistula (AVF) to facilitate vascular access. The purpose of this study was to assess AVF maturation after Ark implantation in a large animal model. Methodology: End-to-side AVFs were created between the carotid artery and jugular vein in nine pygmy goats that included three control (AVF only) and six experimental (AVF and Ark device) animals. For experimental animals, an Ark device was implanted approximately 10 cm downstream of the anastomosis at the time of AVF creation. Postoperative ultrasounds and cannulations of the jugular vein fistula were performed over 12 months. At the conclusion of the study, the AVF was ligated and Ark devices along with a segment of the arterialized vein and surrounding tissues were explanted for gross and histological assessment. Results: The control and experimental Ark groups exhibited increased dilation and flow as well as diminished depth underscoring the parallel developments in vascular attributes and AVF maturation between the two groups. Gross pathology, histology, and micro-CT imaging revealed intact endothelium, mature tissue integration throughout the porous Ark device, and no underlying stenosis. No adverse events such as foreign body reaction, skin or vessel erosion were identified. Conclusion: The study showed maturation without stenosis of the fistula in all animals. This study confirmed that the Ark device functions as a scaffold around the access vein, allows fistula maturation, and can be consistently cannulated without infiltrations over a 12-month period in a large animal model.

OBJECTIVE:We report the 6-month outcomes of the Ark Cannulation Trial (ACT) I early feasibility study. This investigation examined the Ark as a potential innovative access tool for overcoming cannulation-related challenges and improving arteriovenous fistula (AVF) dependent hemodialysis through targeted cannulation. METHODS:During this first-in-human, interventional, prospective, single arm, single site investigation, 13 patients were treated. Cohort 1 included patients with existing fistulas meeting the criteria for Ark implantation at planned sites, including depth (4-15 mm), diameter (⩾4 mm), flow (⩾500 mL/min) and a poorly accessible cannulation zone. Cohort 2 included patients who underwent AVF creation and implantation of Arks at time of initial surgery. For both Cohorts, clinical need determined if one or two Arks were implanted. The primary endpoint was effective initial cannulation of the access site after Ark implantation. The secondary endpoint was continued access of the Ark cannulation zone for hemodialysis and evaluation of device or procedure-related adverse events collected for 6 months post-implantation. The exploratory endpoint evaluated the Ark implantation procedure. RESULTS:Of 13 patients, 2 were withdrawn prior to initial cannulation through the Ark-1 patient due to an exacerbated baseline condition and the other patient due to loss of follow-up. In the efficacy analysis, 11 of 13 treated patients demonstrated successful primary and secondary outcomes. Of the 11 treated patients who initiated cannulation through the Arks, 100% experienced successful primary and secondary outcomes. None of the patients experienced adverse events related to the Ark and surgeons had the necessary skills to implant Arks. CONCLUSION:The results demonstrated the Ark could be used successfully in End-Stage Renal Disease (ESRD) patients undergoing hemodialysis three times a week. These results suggest preliminary safety and efficacy of the Ark as a promising cannulation tool for dialysis vascular access and warrant further exploration of long-term safety and effectiveness through a pivotal clinical study involving a larger population and extended follow-up.

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

Endovascular arteriovenous fistulas (eAVFs) are a new and less invasive type of creation for dialysis access. The anastomosis for eAVFs often occurs between the ipsilateral proximal radial artery and vein or proximal ulnar artery and vein. As eAVF creations are in locations that are not traditionally used for surgical AVF creations, the question of how to approach reversal of these fistulas arises. Here we present a case of closure of an ulnar artery to ulnar vein eAVF.

Percutaneous endovascular arteriovenous fistula (Endo-AVF) is a minimally invasive alternative to conventional surgical dialysis access. Endo-AVF may represent a significant advance in the creation of dialysis access but may require a variety of additional procedures to achieve adequate flow. To maximize flow through the cephalic vein, usually the preferred vessel, it may be necessary to permanently occlude competing outflow branches such as the brachial or basilic vein. Ultrasound monitoring of cephalic vein flow in the vascular lab can be used to predict the efficacy of basilic vein ligation but requires 2 operators to perform. We developed a simple technique to temporarily obstruct basilic vein outflow using a standard dialysis clamp that can be performed by a single vascular technologist. With the patient in the supine position, the spring-loaded dialysis clamp is positioned over the basilic vein in the upper arm using ultrasound guidance. The clamp applies mild, painless obstruction of the basilic vein without interfering with arterial inflow or cephalic vein outflow. Cephalic vein peak systolic velocity, intraluminal diameter, and flow volume are recorded. This technique was used in 6 patients, 4 to 6 weeks, following the initial Endo-AVF procedure. Ultrasound surveillance confirmed that the basilic vein outflow was effectively occluded in all 6 cases. The same ultrasound machine was used in all 6 studies. Cephalic vein flow increased significantly in each case (pre-clamp cephalic flow volume 301 ± 66.8 mL/min vs post-clamp 702 ± 156.5 mL/min after, P = 1.0). Ultrasound observation of the basilic vein post-clamp application concluded there were no complications related to the use of the dialysis clamp. The average duration of the procedure was less than 20 minutes. We have successfully developed a simple non-invasive technique to predict the effect of basilic vein occlusion on cephalic vein flow that can be accomplished by a sole vascular technologist. This technique can be used to guide the need for embolization of the basilic vein.

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

This case report summarizes the clinical course of a patient who developed diaphragmatic fenestrations leading to hydrothorax after the initiation of peritoneal dialysis. We will discuss the interesting disease process in the setting of patient presentation, diagnosis, treatment, and outcome.

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

Patients undergoing endovascular repair (EVAR) of aortoiliac or iliac artery aneurysm may require sacrifice of one or both internal iliac arteries. Until FDA approved commercial grafts are available, internal iliac artery (IIA) preservation has been accomplished using the "sandwich" technique (ST) or surgeon modified grafts, but limited information is available regarding their results. After obtaining IRB approval, we identified patients undergoing IIA preservation with the ST during EVAR at our institution. The patients have been followed up prospectively since being identified to record patency rates and vascular symptoms or events. Twenty-four procedures (22 men, 2 women) were performed from 2011 to 2015 to treat iliac artery aneurysms. The mean age was 74 years. Fourteen of these were done with concomitant EVAR using different endografts (Gore, 11; Endologix, 2; Cook, 1). Five were done to extend a previous EVAR that had developed a type Ib endoleak, 2 for an isolated external iliac artery aneurysm, 3 for an anastomotic aneurysm from a previous aortobiiliac graft, and 2 were for isolated iliac aneurysm repair. There were 25 sandwich grafts (unilateral in 19, bilateral in 6). Contralateral embolization was performed in 5 cases. Percutaneous femoral access was possible in 19, contralateral embolization was necessary in 5, and brachial delivery was needed in 18. Immediate technical success was 100%, average values for operative time was 210 minutes, estimated blood loss was 381 mL, fluoroscopy time was 45 minutes, contrast volume was 145 mL, and length of stay was 2.2 days. Mean follow-up time was 19 months (1-47). There were nine type III endoleaks observed on completion angiography, eight resolved on follow-up CTA, and one required endoprosthetic extension. Six patients have stable type II endoleaks. Two patients were lost to follow-up but of the remaining, 96% of the external iliac limbs were patent and 96% of internal iliac limbs were patent. No patient had buttock claudication or bowel ischemia. Endovascular IIA preservation is feasible with currently available devices using this technique. Immediate success rates are high and patency rates are excellent at intermediate followup. Intraoperative type III endoleaks are not uncommon but usually resolve postoperatively. This procedure is recommended for preservation of the IIA during endovascular treatment of aortoiliac and iliac artery aneurysms when anatomy requires internal iliac artery salvage.

Persistent sciatic artery is a rare developmental anomaly. In its complete form, it provides the major arterial supply to the lower leg since the femoral system is hypoplastic. These unique arteries are prone to aneurysm formation and most commonly present with complications related to aneurysm formation, which can lead to limb loss. We encountered a 68-year-old man presenting with bilateral lower-extremity ischemia who was found to have bilateral persistent sciatic artery aneurysms. One aneurysm had already thrombosed, but the other was still patent. We treated this patient with a hybrid open and endovascular repair on the patent side. The aneurysm was excluded with an Amplatzer™ plug (St. Jude Medical, Inc., St. Paul, MN) followed by a femoropopliteal bypass with saphenous vein in situ to revascularize the lower leg. To our knowledge, this is only the second report of a persistent sciatic artery aneurysm successfully treated with Amplatzer plug occlusion.

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

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

The use of thermoregulatory catheters (TRCs) in critically ill patients has become increasingly popular. TRCs have been shown to be effective in regulating patient body temperature with improved outcomes. Critically ill patients, especially multitrauma patients and those with femoral catheters, are at high risk for deep vein thrombosis (DVT). Among patients for whom chemical DVT prophylaxis is not an option, inferior vena cava (IVC) filters are often placed prophylactically. The development of intravascular ultrasound (IVUS) has allowed placement of IVC filters at the bedside for patients who are too ill for transport to the operating room or cardiac catheterization lab. After encountering several patients with occult DVT of the IVC during bedside IVC filter placement, we performed a retrospective review to determine the incidence of DVT or pulmonary embolus (PE) in patients who had been treated with a TRC at Baylor University Medical Center at Dallas. Since 2008, IVC filters have been deployed at the bedside with the use of IVUS at Baylor University Medical Center. During that same time period, 83 patients had a TRC placed for either intravascular warming or cooling during their resuscitation. Forty-seven out of 83 patients who had a TRC placed survived their injuries. Ten of 47 patients (21%) were diagnosed with DVT or PE, and 6 of these 10 (60%) were found to have caval thrombus. We present this case series as evidence that undiagnosed IVC thrombus associated with TRCs may be higher than previously suspected, given that 5 out of 10 patients who had IVUS of their IVC for prophylactic IVC filter placement, as well as one patient diagnosed with PE, were found to have caval thrombus.

Vascular closure devices were introduced in the early 1990s in an effort to reduce time to hemostasis, enable early ambulation, and improve the comfort of patients undergoing femoral artery access for endovascular procedures. Many of these devices leave a foreign component in or around the artery, which can lead to complications such as hematoma, pseudoaneurysm, infection, or limb ischemia. Here we present a case where device embolization led to arterial occlusion and critical limb ischemia.

A 47-year-old woman complained of abdominal pain, and a computed tomography scan indicated compressive obstruction of the celiac axis and a 4-cm retropancreatic aneurysm. An angiogram identified the aneurysmal vessel as the posterior pancreaticoduodenal artery. All foregut structures were supplied by this aneurysmal vessel. Via an open approach, the inflow and outflow of the aneurysm were ligated, and blood flow to the celiac axis was reconstructed via a bypass from the supraceliac aorta. A follow-up scan indicated complete thrombosis of the aneurysm. The patient is now symptom free. Open reconstruction of the celiac axis is mandatory when ligation of a pancreaticoduodenal aneurysm results in foregut ischemia. Ligation and reconstruction can be done safely and effectively in the elective setting.