The video demonstrates the anatomical relations and the important steps in the surgical treatment of type 3 popliteal entrapment. This is the second leg treated in this young adult. It concludes with this anomaly shown on magnetic resonance imaging in four of the patient's male relatives. http://www.conferenceabstracts.com/uploads/cfp2/attachments/ZRFDQHCR/ZRFDQHCR--285491-1-ANY (1).mp4

Percutaneous arterial access for endovascular aneurysm repair (PEVAR) is an accepted technique with good short-term results. Frequent common femoral artery (CFA) irregularities on follow-up computed tomography (CT) scans prompted us to evaluate midterm outcome. We reviewed our results with PEVAR via 367 femoral arteries in 201 patients with the Abbott Prostar XL closure device. Arteries with heavy circumferential calcification were not accessed percutaneously. Preoperative CFA diameter, distance of anterior arterial wall from skin (CFA-skin distance), calcification (fraction of circumference, anterior location, and 3 level overall grading), location of CFA bifurcation above the midfemoral head (high bifurcation), and presence of superficial femoral artery (SFA) occlusion, were correlated with clinical outcome and follow-up CT findings. Immediate failure rate of femoral access closure was 5% (19 of 367) for the entire group and decreased to 3% in the last 200 closures. Three femoral arterial occlusions were repaired surgically within 24 hours and 4 pseudoaneurysms (1 in the late group) were repaired within 6 weeks. During follow-up (24 ± 21 months), 3 additional limb occlusions were treated surgically. There were no other access-related operations. Morphologic changes seen on CT follow-up (18 ± 17 months) included minute anterior CFA wall disruptions producing a nipple-like neck-less space of extravasation (1-4 mm) in 28% (90 of 321) of arteries (Fig 1) and small pseudoaneurysms measuring 8 ± 2 mm in 5.6% of arteries, which were followed up uneventfully except for 2 early elective occlusions by thrombin injection. After percutaneous closure, CFA diameter did not change (0.3 ± 0.9 mm), there were no new SFA occlusions, and small nonocclusive dissections were observed in 2% (7 of 321) of external iliac arteries. Failure of arterial closure was associated with increased CFA-skin distance (44 ± 23 vs 34 ± 16 mm; P < .005), the presence of a high bifurcation (10% vs 4%; P < .005), and older age (77 ± 8 vs 72 ± 11; P < .05) but not with sheath caliber, any measure of calcification, CFA diameter, or SFA occlusion. In the last 200 closures, where we were less selective and began guiding puncture by ultrasound, only CFA-skin distance remained significantly associated with failure. Following PEVAR, a large proportion of common femoral arteries exhibit minor morphologic changes that are clinically inconsequential. With growing experience, groin obesity rather than CFA morphology, device caliber or moderate calcification, constitutes the main risk factor for failure of percutaneous femoral access closure.

Adequate cerebral blood flow during carotid endarterectomy (CEA) is critical. Currently, there is no accepted method to monitor it during the procedure. We performed an initial evaluation of a novel technology, ultrasound-tagged light near infrared technology (UT-NIR), to monitor changes in hemispheric blood flow during CEA. The CerOx monitor (Ornim medical) uses near-infrared light and ultrasound waves to monitor regional hemoglobin oxygen saturation and tissue microcirculation. Patients undergoing elective CEA were consecutively enrolled and monitored using UT-NIR. One sensor was placed frontally on each hemisphere. The mean and median signals were calculated for 60 seconds before and after clamping and declamping, without a shunt in place. All procedures were performed under general anesthesia with selective shunt placement. Normalized mean and median values were calculated for both hemispheres and compared with the Friedman test and post hoc Dunn test. Twenty-two patients were studied; of these, 40% were symptomatic, 86% had bilateral stenosis, and a shunt was placed in 27%. There were no neurologic complications. In the ipsilateral hemisphere, clamping resulted in a decrease in median flow (1.12 to 0.92, P = .017), followed during the clamping period by an increase in flow (0.92 to 1.09, P = .005) so that the predeclamping flow did not differ from preclamping levels. Following declamping flow further increased (1.30, P = .027). Changes in the mean mirrored these changes. No significant changes were detected in the contralateral hemisphere. Systolic stump pressure (n = 18, 74 ± 28 mm Hg) did not correlate with changes in flow. Cerebral flow, as monitored by UT-NIR, changes significantly in the ipsilateral hemisphere during CEA and remains unchanged in the contralateral hemisphere. Further studies to determine the clinical relevance of this technology are required.

endovascular devices and techniques will evolve to expand applicability and provide therapy for most aortic diseases, including a growing number of diseases of the arch and the ascending aorta [4]. Complex aortic aneurysms that involve major aortic branch origins include those juxtaposed or involving the renal arteries (juxtarenal, perirenal), the visceral arteries (thoraco-abdominal) and the great vessels to the upper body in the aortic arch (arch aneurysms). These complex aortic aneurysms pose difficult challenges for endovascular therapy, and several solutions have been emerging. One option to treat aneurysms involving branches without complicating the endovascular procedure has been to move the branches surgically to another location that is not covered by the aortic stent graft [Figure 1]. These so-called hybrid or de-branching procedures have largely fallen out of favor in the abdomen, mainly due to the high complication rate related to the open procedure, mitigating the benefit of the endovascular approach. These operations still play a role in the thorax in selected cases [5]. Currently, the most straightforward and available system for complete endovascular repair of thoraco-abdominal aneurysms consists of the custom-made fenestrated or branched Zenith stent grafts (Cook, Australia) as reported in this issue by Silverberg and co-authors [1]. Other options, besides custom-made stent grafts, do exist. However, the largest experience accumulated so far, involving several thousand cases worldwide, has been with these custom-made devices. Endovascular repair of thoraco-abdominal aneurysms with such endografts is associated with a published mortality rate of 0–27% (average 9%) and a mid-term branch patency i n this issue of IMAJ, Silverberg and colleagues describe their experience with fenestrated and branched stent grafts for complex abdominal aortic aneurysms [1]. This pathology, as well as the entire spectrum of aortic aneurysms, in both the abdomen and the thorax, constitutes an important and dynamic field in which significant progress has been made in the last decade and will surely continue in the next few years. Endovascular treatment of infrarenal aortic aneurysms has become a routine procedure, replacing over 50% of open surgical abdominal aortic aneurysm repairs in some large databases and constituting a much larger proportion in some “endo-competent” centers [2]. Complex aneurysms, such as thoraco-abdominal aneurysms and thoracic aortic aneuryms involving the arch and the ascending aorta, on the other hand, are still treated primarily with open surgical repair. These open procedures are extremely complicated and are associated with a significant rate of mortality and major morbidity. The published mortality rates for open repair of thoraco-abdominal aneurysms are 6–22%, but one has to keep in mind that these figures come from the world’s leading centers specializing in these procedures and these results are not usually achieved elsewhere [3]. Against this background, it is the prevailing opinion among endovascular specialists that in the coming years of over 90% [6]. These devices, however, are not without disadvantages, including a waiting period of at least 6 weeks, which makes them unsuitable for emergency cases, and very high cost. An alternative to custom-made grafts are the parallel stent grafts, including socalled chimneys, snorkels or periscope stent grafts. Inserted by endovascular means, they are used to create a landing zone for the aortic stent graft while preserving the aortic branches [Figures 2 and 3] [7]. aortic aneurysms, endovascular technique, thoraco-abdominal aneurysms, aortic stent graft

Background: The Chimney graft (CG) procedure is one of the novel modification techniques of the endovascular aneurysm repair (EVAR) surgery to treat suprarenal and juxtarenal abdominal aortic aneurysms. Other indications for the use of CG placement include thoracic and thoracoabdominal aneurysms with supraortic branches orifice involvement and cases of common iliac artery aneurysms with or without internal iliac artery involvement. The technique is used in patients who due to aortic-neck morphology and lack of adequate fixation and/or sealing zones are not eligible for standard EVAR. In this procedure, a parallel stent-graft is placed adjacent to the main body of the aortic endograft to maintain blood supply to renovisceral or supraortic branches, once the body of the aortic stent-graft is deployed. Symptomatic occlusions of the CG with novel renovascular hypertension were not described until now.Case presentation: A-64-year-old male patient, presented with new-onset malignant hypertension, 13 months after an EVAR operation with CG placement to the left renal artery. The patient was on preventive clopidrogel therapy, which was withheld temporarily for several days, one month before presentation. Imaging studies revealed a novel form of iatrogenic renovascular hypertension, caused by occlusion of the CG. Any attempt to recanalize the covered stent or revascularize the left kidney was rejected and conservative treatment was chosen. Seven months after presentation, blood pressure was within normal ranges with little need for antihypertensive therapy.Conclusions: Physicians should be aware that the novel emerging techniques of EVAR to overcome the limitations of the aortic-neck anatomy may still adversely influence the renal outcome with potential development of new-onset hypertension.

The Endurant Stent-graft System (Medtronic Vascular, Santa Rosa, CA) is a next-generation device intended to expand the applicability of endovascular aortic repair (EVAR). To date, the Endurant has been evaluated in 9 short- and intermediate-term studies, several in patients presenting with challenging aneurysm anatomies. Consistently, the device in these studies has been shown to be safe and effective, with an excellent rate of deployment success and with very low rates of type I/III endoleaks and reinterventions. Single center experience with Endurant in challenging anatomies with short kinked necks and calcified angulated iliac arteries in patients unfit for open repair and challenging anatomies show promising early results with no difference in mortality, morbidity and reintervention rates, but need cautious application for EVAR outside of the device-specific IFU. The Endurant Stent-graft Natural Selection Global Postmarket Registry (ENGAGE) is a long-term 1266-patient 80-site worldwide prospective postmarket study initiated to augment the knowledge base (poolable and comparable) about EVAR in a real-world population implanted with the Endurant. Technical and clinical data for ENGAGE patients will be reported through the expected completion of 5-year follow-up for all ENGAGE registry patients in 2018. We discuss the evolving challenges for EVAR that the Endurant and other next-generation stent-grafts are designed to address and review outcomes published with the Endurant since the CE marking of the device in July 2008.

Noninvasive imaging of the aorta has undergone consid­ erable refinement in recent years. This has been brought about by significant technologic advances in computed tomography (CT), magnetic resonance (MR) techniques, and duplex ultrasound (US) scanning. Three-dimensional techniques and shorter acquisition times for CT and MR imaging have made it possible to time the infusion of contrast medium to highlight the aorta and its branches. In addition, improvements in processing and rendering of three-dimensional images have increased the clinical utility of these examinations. As a result, the role of traditional angiography is being gradually restricted to special indica­ tions and to patients who may require catheter-based inter­ ventions. The utility of imaging tests to establish a diagno­ sis may not correspond with their value in planning the course of treatment, and the relative merits of these applica­ tions will be addressed.

The facedown position used for the posterior surgical approach to repair popliteal aneurysms limits access to the great saphenous vein. Using the basilic vein as the conduit of choice in five patients, we were able to harvest the vein conveniently and simultaneously with aneurysm exposure. On follow-up of 4 to 36 months, all grafts were functioning well.

OBJECTIVE:To define diameter at three levels along the popliteal artery and its relation to the inflow arteries in the normal state and in popliteal aneurysms. METHODS:The external diameter of the arteries was determined by duplex ultrasound scanning at the common femoral (CFA), superficial femoral artery (SFA), proximal popliteal artery (PPOP), mid-popliteal artery (MPOP), and distal popliteal artery (DPOP). Examinations were performed in 104 healthy men and 100 women. In addition, patients were screened for the presence of popliteal aneurysms (diameter >10 mm). Findings in healthy male subjects were compared with those with popliteal aneurysms. RESULTS:Mean arterial diameters in normal men were larger than in women, but the SFA/CFA ratio was smaller in women (0.74 +/- 0.08 vs 0.78 +/- 0.09; P < .001) and the MPOP/SFA ratio was larger (0.98 +/- 0.11 vs 0.94 +/- 0.12; P = .001). In both genders, normal popliteal artery diameter was not uniform throughout its length, with PPOP and MPOP being nearly identical, and DPOP was smaller. MPOP diameter correlated most closely with SFA diameter (r = 0.51; P < .001) and less with height, weight and body surface area (r = 0.2 to 0.3) and was not associated with age or the presence of hypertension. In 27 men with 45 patent, fusiform popliteal aneurysms (10 to 44 mm) the site of maximal dilatation was in the region of the MPOP in 39 cases and near the PPOP in only 6 cases. The DPOP was never the largest segment and only in one case was it >10 mm. Arterial diameter in aneurysm patients was larger than normal at all levels but was greatest near the MPOP level (15.7 +/- 6.9). Popliteal-to-SFA diameter ratios were increased in the aneurysm group at all three levels but were greatest at the MPOP level (1.85 vs 0.94, P < .001). Comparing 15 popliteal aneurysms >20 mm with smaller ones, distal popliteal artery changed to the least extent but did increase in diameter (6.1 +/- 1.2 vs 7.0 +/- 1.4, P < .04). In larger aneurysms the MPOP/SFA ratio increased from 1.54 to 2.5 (P < .001). CONCLUSION:The diameter of the normal popliteal artery is not uniform throughout its length. In popliteal aneurysms, the region of the MPOP is most commonly the largest diameter. The MPOP/SFA ratio is greater than normal in popliteal aneurysms and increases in larger aneurysms. DPOP does dilate but to a lesser extent then PPOP and MPOP, making endovascular repair anatomically feasible in most popliteal aneurysms.

A 24-year-old man was admitted after sustaining a single gunshot wound to the neck with an expanding hematoma on the left. Computed tomography angiography demonstrated bilateral internal carotid artery pseudoaneurysms, with disruption of flow on the left and a carotid-jugular fistula on the right. At operation, transection of the left internal carotid artery necessitated ligation of the artery. No injuries to the trachea or larynx were found, but the pharynx was lacerated and was repaired. The patient was transferred to the angiography suite where a stent graft was placed in the right internal carotid artery. This served to close the pseudoaneurysm and the arteriovenous fistula while preserving distal flow. The patient recovered with intact cerebral function and with mild paresis of the tongue related to hypoglossal nerve injury. He was discharged home after 7 days.

BACKGROUND:Ischemia on thallium scanning is a strong predictor of long-term mortality in CAD patients. Whether coronary revascularization (CR) in patients with significant ischemia on preoperative thallium scanning (PTS) improves long-term survival after major vascular surgery has not been determined.METHODS AND RESULTS:The perioperative data, including PTS and subsequent CR in patients with moderate to severe reversible ischemia on PTS, and long-term survival of 502 consecutive patients who underwent 578 major vascular procedures were analyzed retrospectively. Patients with PTS who ultimately did not undergo the planned vascular operation were also studied. Cox regression and propensity score analyses were used to analyze survival. A total of 407 patients (81.1%) had PTS: 221 (54.3%) had no or mild defects (group I); 50 (12.3%) had moderate-severe fixed defects (group II); 62 (15.2%) had moderate-severe reversible ischemia yet did not undergo CR (group III); and 74 (18.2%) had moderate-severe reversible ischemia and subsequent CR by CABG (36) or PTCA (38; group IV). Patients who sustained major complications as a result of the preoperative cardiac workup were included in group IV. By multivariate analysis, age, type of vascular surgery, presence of diabetes, previous myocardial infarction, and moderate-severe ischemia on PTS independently predicted mortality (P=0.001, 0.009, 0.039, 0.006, and 0.029, respectively), and preoperative CR predicted improved survival (OR 0.52, P=0.018). Group IV had better survival than group III even when subdivided according to normal and reduced left ventricular function (OR 0.40 and 0.41, P=0.035 and 0.021, respectively).CONCLUSIONS:Long-term survival after major vascular surgery is significantly improved if patients with moderate-severe ischemia on PTS undergo selective CR.

OBJECTIVES The aim of this study was to determine the long-term prognosis with postoperative markers of myocardial ischemia and infarction.BACKGROUND Cardiac troponins (cTn) are superior to creatine kinase-MB fraction (CK-MB) in detecting perioperative myocardial infarction (PMI). However, their threshold levels signifying PMI and their long-term prognostic value are not yet determined.METHODS A cohort of 447 consecutive patients who underwent 501 major vascular procedures was prospectively studied. Perioperative continuous 12-lead electrocardiogram monitoring, cardiac troponin-I (cTn-I) and/or cardiac troponin-T (cTn-T), and CK-MB levels on the first three postoperative days, and long-term survival were determined. The association of different cutoff levels of CK-MB, troponin, and ischemia duration with long-term survival was investigated.RESULTS Between 14 (2.9%) and 107 (23.9%) of the patients sustained PMI, depending on the biochemical criteria used. Elevated postoperative CK-MB, cTn, and prolonged (>30 min) ischemia, at all cutoff levels examined, predicted long-term mortality independent of the preoperative predictors: patient's age, type of vascular surgery, previous myocardial infarction, and renal failure (Cox multivariate analysis). Both CK-MB >10% and cTn-I >1.5 ng/ml and/or cTn-T >0.1 ng/ml independently predicted a 3.75-fold and 2.06-fold increase in long-term mortality (p = 0.006 and 0.012, respectively). Similarly, both CK-MB >5% and cTn-I >0.6 ng/ml and/or cTn-T >0.03 ng/ml independently predicted a 2.15-fold and 1.89-fold increase in mortality (p = 0.018 and 0.01, respectively). Patients with both these markers elevated had a 4.19-fold increase in mortality (p < 0.001).CONCLUSIONS Postoperative CK-MB and troponin, even at low cutoff levels, are independent and complementary predictors of long-term mortality after major vascular surgery. (C) 2003 by the American College of Cardiology Foundation.

Late onset graft or attachment site–related endoleaks may be hazardous, and early identification of patients at risk is important. We describe a patient who underwent implantation of a bifurcated stent graft 5.5 cm below the renal arteries because of a technical error with three extender cuffs implanted proximally to bridge the gap. During the 1st year, aneurysm diameter decreased from 68 to 52 mm. After 1 year, the patient had an acute endoleak develop, which originated between two of the extender cuffs and which was accompanied by severe abdominal pain and reexpansion of the aneurysm. This endoleak was treated with insertion of an additional bifurcated stent graft within the extender cuff segment. The patient has been subsequently followed for 6 months and has had no endoleak or symptoms, and aortic diameter has decreased once again to 55 mm. (J Vasc Surg 2002;35:580-3.)

Purpose: To determine whether increasing experience with endovascular abdominal aortic aneurysm (AAA) repair in a single institution will result in improved outcome. Methods: A retrospective review was undertaken of 150 consecutive cases of endovascular AAA repairs performed using the AneuRx device between October 1996 and April 2000 in a university-based medical center. The population was divided into early and late groups of 75 patients each. Endpoints included technical success; complications; early (#30-day) morbidity, mortality and rupture; endoleak at discharge and at 1 month; early secondary intervention; proximal neck and iliac tortuosity; extender cuff placement; femoral reconstructions beyond primary repair; total fluoroscopy time; and contrast load. Results: Baseline patient and aneurysm characteristics were similar between the 2 groups. Technical success was 98.7%; 2 cases were converted intraprocedurally owing to difficult iliac access (early group) and a severely angulated proximal neck (late group). There was a tendency toward more frequent use of intraoperative proximal extender cuffs in the early group (12% versus 4% in the late group, p50.13). Femoral reconstructions were more frequent in the early group (36% versus 19%, p,0.025). While total contrast volume was similar (111 6 56 versus 105 6 45 mL, p5NS), total fluoroscopy time was significantly reduced (p,0.05) between the early and late groups. Conclusions: With attention to detail and careful patient selection, successful endovascular AAA repair can be achieved with very few conversions and low perioperative mortality even during the center’s early experience. Evidence indicates, however, that a learning curve definitely exists, as shown by fewer access site problems, more accurate device deployments, and decreased fluoroscopy times as proficiency is attained. J Endovasc Ther 2002;9:269–276

Purpose: To determine whether increasing experience with endovascular abdominal aortic aneurysm (AAA) repair in a single institution will result in improved outcome. Methods: A retrospective review was undertaken of 150 consecutive cases of endovascular AAA repairs performed using the AneuRx device between October 1996 and April 2000 in a university-based medical center. The population was divided into early and late groups of 75 patients each. Endpoints included technical success; complications; early (≤30-day) morbidity, mortality and rupture; endoleak at discharge and at 1 month; early secondary intervention; proximal neck and iliac tortuosity; extender cuff placement; femoral reconstructions beyond primary repair; total fluoroscopy time; and contrast load. Results: Baseline patient and aneurysm characteristics were similar between the 2 groups. Technical success was 98.7%; 2 cases were converted intraprocedurally owing to difficult iliac access (early group) and a severely angulated proximal neck (late group). There was a tendency toward more frequent use of intraoperative proximal extender cuffs in the early group (12% versus 4% in the late group, p=0.13). Femoral reconstructions were more frequent in the early group (36% versus 19%, p<0.025). While total contrast volume was similar (111 ± 56 versus 105 ± 45 mL, p=NS), total fluoroscopy time was significantly reduced (p<0.05) between the early and late groups. Conclusions: With attention to detail and careful patient selection, successful endovascular AAA repair can be achieved with very few conversions and low perioperative mortality even during the center's early experience. Evidence indicates, however, that a learning curve definitely exists, as shown by fewer access site problems, more accurate device deployments, and decreased fluoroscopy times as proficiency is attained.

High-velocity gunshot and shrapnel-blast vascular injuries pose a great challenge and need to be approached in a systematic, multidisciplinary fashion. Early revascularization with temporary shunts, the use of autologous tissue, major venous reconstruction, a low threshold for fasciotomy, and reliable tissue coverage are the mainstays of management.

Background Perioperative myocardial ischemia is conventionally monitored using five electrocardiographic leads, with only one precordial lead placed at V5. This is based on studies from more than a decade ago. The authors reassessed this convention by analyzing data obtained from continuous on-line 12-lead electrocardiographic monitoring. Methods One hundred eighty-five consecutive patients undergoing vascular surgery were monitored by continuous 12-lead ST-trend analysis during and for 48-72 h after surgery. Cardiac troponin I was measured in the first 3 postoperative days, and cardiac outcome was prospectively recorded. Ischemia was defined as ST deviation, relative to the reference preanesthesia electrocardiogram, of 0.2 mV or more in one lead or 0.1 mV or more in two contiguous leads, lasting more than 10 min. Results During 11,132 patient-hours of monitoring, 38 patients (20.5%) had 66 transient ischemic events, with all but one denoted by ST-segment depression. Twelve patients (6.5%) sustained postoperative infarction (cardiac troponin I > 3.1 ng/ml). Among the 38 patients with ischemia, lead V3 most frequently (86.8%) demonstrated ischemia, followed by V4 (78.9%) and V5 (65.8%). Among the 12 patients with infarction, V4 was most sensitive to ischemia (83.3%), followed by V3 and V5 (75% each). Combining two precordial leads increased the sensitivity for detecting ischemia (97.4% for V3 + V5 and 92.1% for either V4 + V5 or V3 + V4) and infarction (100% for V4 + V5 or V3 + V5 and 83.3% for V3 + V4). On average, baseline preanesthesia ST was above isoelectric in V1 through V3 and below isoelectric in V5 through V6. Lead V4 was closest to the isoelectric level on the baseline electrocardiogram, rendering it most suitable for ischemia monitoring. Conclusions As a single lead, V4 is more sensitive and appropriate than V5 for detecting prolonged postoperative ischemia and infarction. Two precordial leads or more are necessary so as to approach a sensitivity of greater than 95% for detection of perioperative ischemia and infarction.