Michael Sgroi, MD

View details for DOI 10.1016/j.jvs.2018.12.029

View details for Web of Science ID 000486615200031

Abstract

OBJECTIVE: The use of duplex ultrasound (DUS) examinations for surveillance after fenestrated endovascular aneurysm repair (FEVAR) is not well-studied. Our objective was to further characterize normal and abnormal duplex findings in renal branch grafts after FEVAR.METHODS: We retrospectively reviewed a single-center experience involving consecutive patients treated with Cook ZFEN devices between 2012 and 2017. Postoperative imaging consisted of a computed tomography (CT) scan at 1month, 6months, 1year, and annually thereafter. As experienced progressed, DUS examination with or without concurrent CT scans were obtained in a nonstandardized protocol, particularly for patients with decreased renal function. Renal patency loss was defined as occlusion or stenosis of greater than 50% evaluated on 3-day renal artery center-line imaging.RESULTS: A total of 116 patients were treated with FEVAR, of which 60 (51.7%) had concurrent CT and renal DUS images available for review. Six patients (10%) had limited ultrasound studies owing to bowel gas and were excluded. The study cohort therefore included 54 patients receiving of 94 renal fenestrated stents with a mean follow-up of 23months. Twelve cases of renal patency loss in 10 patients (9 stenoses, 3 occlusions) were found on CT scanning, 11 (91.6%) of which had concurrent abnormalities found on ultrasound examination. Stents with compression at the junction of the main body exhibited significantly elevated mean Peak systolic velocities (PSV) compared with nonstenosed stents (349.2cm/s vs 115.3cm/s; P= .003). Stenosis in the most proximal portion of the stent (ie, within the main body) showed no difference in proximal PSV (86.0cm/s vs 131.9cm/s; P= .257); however, dampened PSV showed significant differences in the mid (17.5cm/s vs 109.9cm/s; P= .027) and distal (19.0cm/s vs 78.3cm/s; P= .028) segments compared with nonstenosed stents. All occluded stents demonstrated no flow detection. Proximal PSV served as a strong classifier for junctional stenosis (area under the curve, 0.98). A combined criterion of proximal PSV of greater than 215cm/s or distal PSV of less than 25cm/s resulted in a sensitivity of 91.6% and specificity of 85.3% for detecting patency loss. All stents that were compromised underwent successful secondary reintervention and restoration of patency.CONCLUSIONS: DUS imaging is a clinically useful modality for surveillance of renal branch grafts after FEVAR. Patterns of segmental velocity elevation (proximal PSV, >215cm/s) and dampening in the distal renal indicate potential hemodynamic compromise and should prompt more aggressive workup or imaging and likely be considered for secondary intervention.

View details for DOI 10.1016/j.jvs.2018.12.050

View details for PubMedID 31327607

View details for DOI 10.1016/j.jvs.2018.08.190

View details for Web of Science ID 000469220300461

Abstract

OBJECTIVE: The number of patients with end-stage renal disease who require implantable cardiac devices is increasing. Rates of secondary interventions or fistula failure are not well studied in patients who have arteriovenous fistula (AVF) access placed on the ipsilateral side as a pacemaker. This study aimed to compare central vein-related interventions and failure rates of arteriovenous access in patients with pacemakers placed on the ipsilateral vs contralateral side.METHODS: A retrospective review of a prospectively collected database at a single high-volume dialysis institution was performed; all patients 18years or older who had both arteriovenous access and a pacemaker were included. Data points included the number of interventions such as thrombectomy, percutaneous transluminal angioplasty, and stent placement, as well as time to first intervention and failure of the fistula or graft. Patients with an implantable cardiac device who had contralateral AVF access were compared with AVF ipsilateral access using a t-test and Kaplan-Meier curves for primary patency. Outcomes evaluated included number of interventions and time to intervention from access creation.RESULTS: A total of 32 patients were identified; 20 had arteriovenous access on the contralateral side from the pacemaker and 12 had access on the ipsilateral side. In the contralateral group, there were a mean of 3.6 percutaneous transluminal angioplasties per patient (range, 1-12). In the ipsilateral group, there were an average of 2.8 percutaneous transluminal angioplasties per patient (range, 1-6). There was no difference in intervention rates between these cohorts; however, the time to intervention was increased in patients who had arteriovenous access on the contralateral side to their pacemaker (9.5 vs 19.5months; P< .05). Patency rates did not differ (P= .068).CONCLUSIONS: There was no difference in intervention rates between ipsilateral and contralateral patients; however, the time to intervention was increased in patients who had arteriovenous access on the contralateral side to their pacemaker (9.5months vs 19.5months). This study was limited by its lack of power. Patency rates did not differ (P= .068). Ipsilateral access placement should be considered rather than abandoning access in that extremity.

View details for PubMedID 30850286

Abstract

OBJECTIVE: Previous studies evaluating general anesthesia (GA) vs regional (epidural/spinal) anesthesia (RA) for infrainguinal bypass have produced conflicting results. The purpose of this study was to analyze the factors associated with contemporary use of RA and to determine whether it is associated with improved outcomes after infrainguinal bypass in patients with critical limb ischemia.METHODS: Using the Vascular Quality Initiative infrainguinal database, a retrospective review identified all critical limb ischemia patients who received an infrainguinal bypass from 2011 through 2016. Patients were then separated by GA or RA. Primary outcomes were perioperative mortality, complications, and length of stay. Predictive factors for RA and perioperative outcomes were analyzed using a mixed-effects model to adjust for center differences.RESULTS: There were 16,052 patients identified to have a lower extremity bypass during this time frame with 572 (3.5%) receiving RA. There was a wide variation in the use of RA, with 31% of participating centers not using it at all. Age (67.2 vs 70.3years; P< .001), chronic obstructive pulmonary disease (25.7% vs 30.9%; P< .001), and urgency of the operation (75.7% vs 80.4%; P= .01) were found to be independently associated with receiving a regional anesthetic. Univariate and multivariate analysis demonstrated that length of stay (6.8days vs 5.7days; P< .01), postoperative congestive heart failure (2.3% vs 1.1%; P= .040), and change in renal function (5.7% vs 2.9%; P= .005) were all significant outcomes in favor of RA. There was a trend toward lower mortality rates; however, this did not reach statistical significance. Rates of myocardial infarction, pulmonary complications, and stroke were not found to be statistically different. Coarsened exact matching continued to demonstrate a difference in length of stay and rates of new-onset congestive heart failure in favor of RA.CONCLUSIONS: RA is an infrequent but effective form of anesthesia for infrainguinal bypass surgery. Elderly patients and those with underlying respiratory problems may benefit from this form of anesthesia. Further evaluation within institutions should be performed to identify which patients would most benefit from RA or GA.

View details for PubMedID 30792062

Abstract

OBJECTIVE: Endovascular aneurysm repair (EVAR) has become the standard of care for infrarenal aneurysms. Endografts are commercially available in proximal diameters up to 36mm, allowing proximal seal in necks up to 32mm. We sought to further investigate clinical outcomes after standard EVAR in patients requiring large main body devices.METHODS: We performed a retrospective review of a prospectively maintained database for all patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms at a single institution from 2000 to 2016. Only endografts with the option of a 34- to 36-mm proximal diameter were included. Requisite patient demographics, anatomic and device-related variables, and relevant clinical outcomes and imaging were reviewed. The primary outcome in this study was proximal fixation failure, which was a composite of type IA endoleak and stent graft migration >10mm after EVAR. Outcomes were stratified by device diameter for the large-diameter device cohort (34-36mm) and the normal-diameter device cohort (<34mm).RESULTS: There were 500 patients treated with EVAR who met the inclusion criteria. A total of 108 (21.6%) patients received large-diameter devices. There was no difference between the large-diameter cohort and the normal-diameter cohort in terms of 30-day (0.9% vs 0.95%; P= .960) or 1-year mortality (9.0% vs 6.2%; P= .920). Proximal fixation failure occurred in 24 of 392 (6.1%) patients in the normal-diameter cohort and 26 of 108 (24%) patients in the large-diameter cohort (P<.001). There were 13 (3.3%) type IA endoleaks in the normal-diameter cohort and 16 (14.8%) in the large-diameter cohort (P< .001). Stent graft migration (>10mm) occurred in 15 (3.8%) in the normal-diameter cohort and 16 (14.8%) in the large-diameter cohort (P< .001). After multivariate analysis, only the use of Talent (Medtronic, Minneapolis, Minn) endografts (odds ratio [OR], 4.50; 95% confidence interval [CI], 1.18-17.21) and neck diameter 29mm (OR, 2.50; 95% CI, 1.12-5.08) remained significant independent risk factors for development of proximal fixation failure (OR, 3.99; 95% CI, 1.75-9.11).CONCLUSIONS: Standard EVAR in patients with large infrarenal necks 29mm requiring a 34- to 36-mm-diameter endograft is independently associated with an increased rate of proximal fixation failure. This group of patients should be considered for more proximal seal strategies with fenestrated or branched devices vs open repair. Also, this group likely needs more stringent radiographic follow-up.

View details for PubMedID 30686336

View details for DOI 10.1016/j.jvs.2018.02.054

View details for Web of Science ID 000456316700012

View details for DOI 10.1016/j.jvs.2018.04.064

View details for Web of Science ID 000456316700005

View details for DOI 10.1016/j.avsg.2018.10.003

View details for Web of Science ID 000452541600010

Abstract

The Heli-Fx Endoanchor system is a transmural aortic fixation device with Federal Drug Administration (FDA) approval for treatment of endoleaks, endograft migration, or high-risk seal zones. Published data is primarily from industry-sponsored registries highlighting safety and efficacy. Our objective is to evaluate real-world outcomes of Endoanchor usage after FDA approval across a variety of stent-grafts and indications at a single institution.We retrospectively reviewed our prospectively maintained aneurysm database for patients undergoing endovascular aortic repair with Heli-Fx Endoanchors (EAs). Technical success was defined as successful EA deployment, while procedural success was defined as absence of endoleak on completion aortogram. Cohorts were divided by indication and outcomes assessed via review of clinical and radiographic data.From 2016-2018, 37 patients underwent EA fixation. We divided the cohort by indication: Group A (Prior EVAR with endoleak), B (intraoperative type 1A endoleak), C (high-risk seal zone), and D (TEVAR). In Group A (n=11), all endoleaks were type 1A and a mean of 10 EAs were deployed with 100% technical and 45.4% procedural success. Two perioperative re-interventions were performed (translumbar coil embolization; proximal graft extension with bilateral renal artery stents). At a mean 10.6 months follow-up, 45.4% of patients had persistent endoleaks, with 100% aortic related survival. In Group B (n=10), a mean of 8.7 EAs were used with 100% technical and procedural success. One immediate adverse event occurred (right iliac dissection from wire manipulation, treated with a covered stent). At 13.6 month mean follow-up, there was significant sac regression (mean 9.75 mm) with no type 1A endoleaks. In Group C (n=10), a mean of 9.5 EAs were deployed with 100% technical and procedural success. At 11.2 month mean follow-up, there were no residual endoleaks and significant sac regression (mean 3.4 mm). Overall survival was 100%. In Group-D (n=6), a mean of 8.3 EAs were used with 83.3% technical and 66.6% procedural success. One immediate adverse event occurred, in which an EA embolized to the left renal artery. At 9.4 month mean follow-up, overall survival was 83.3% with a mean 2.2 mm increase in sac diameter.Early experience suggests EAs effectively treat intraoperative type-1A endoleaks and high-risk seal zones, with significant sac regression and no proximal endoleaks on follow-up. In patients treated for prior EVAR with postoperative type-1A endoleaks, fewer than half resolved after EA attempted repair. Further experience and longer-term followup will be necessary to determine which patients most benefit from postoperative EA fixation.

View details for DOI 10.1016/j.avsg.2019.05.006

View details for PubMedID 31201976

Abstract

BACKGROUND: Limited reports have documented the effect cardiac implantable electronic devices (CIEDs) have on arteriovenous (AV) access patency. Current recommendations suggest placing the access on the contralateral side of the CIEDs, as there is concern for increased central venous stenosis and access failure. The goal of this study is to review our single-center AV access patency rates for dialysis patients with an ipsilateral or contralateral side CIED.METHODS: A retrospective review was performed from 2008 to 2016 at a single institution identifying all patients who have received a CIED and the diagnosis of end-stage renal disease (ESRD). Medical records were queried to identify each patient's dialysis access and whether it was ipsilateral or contralateral to the CIED. Primary outcomes of study were primary and secondary patency rates.RESULTS: A total of 44 patients were identified to have ESRD and CIED. Of these patients, 28 patients with fistulas or grafts (13 ipsilateral and 15 contralateral) had follow-up with regards to their AV access. There were 3 primary failures in both groups. For patients who had the CIED placed after already starting the dialysis, patency was based on when the cardiac device was implanted. Primary patency for ipsilateral and contralateral access was 20.2 and 22.2months, respectively. With secondary interventions, ipsilateral and contralateral mean patency was 39 and 48.8months, respectively. Six-month and 1-year primary patency for arteriovenous fistula or arteriovenous graft on patients with ipsilateral access was 69.2% and 53.8%, respectively. Ipsilateral 1-year cumulative patency was 39months.CONCLUSIONS: CIED may lead to stenosis or occlusion to one's AV access; however, primary assisted and secondary patency rates are still acceptable at 6months and 1year compared to Kidney Disease Outcomes Quality Initiative guidelines. Despite a CIED, a surgeon's algorithm should not lead to the abandonment of an ipsilateral access if the central venous system is patent.

View details for PubMedID 30339901

View details for Web of Science ID 000439318700008

Abstract

OBJECTIVE: As our collective experience with complex endovascular aneurysm repair (EVAR) has grown, an increasing number of older patients are being offered endovascular repair of juxtarenal aneurysms. Outcomes after complex EVAR in this older subpopulation are not well-described. We sought to specifically evaluate clinical outcomes after complex EVAR compared with infrarenal EVAR in a cohort of octogenarians.METHODS: A single-center retrospective review was conducted using a database of consecutive patients treated with elective EVAR for abdominal aortic aneurysms (AAAs) between 2009 and 2015. Only patients 80years of age or older were included. Patients in the complex EVAR group were treated with either snorkel/chimney or fenestrated techniques, whereas infrarenal EVAR consisted of aneurysm repair without renal or visceral involvement. Relevant demographic, anatomic, and device variables, and clinical outcomes were collected.RESULTS: There were 103 patients (68 infrarenal, 35 complex) treated within the study period with a mean follow-up of 21months. A total of 75 branch grafts were placed (59 renal, 11 celiac, 5 superior mesenteric artery) in the complex group, with a target vessel patency of 98.2% at latest follow-up. Patients undergoing complex EVAR were more likely to be male (82.8% vs 60.2%; P= .02) and have a higher prevalence of renal insufficiency (71.4% vs 44.2%; P= .008). The 30-day mortality was significantly greater in patients treated with complex EVAR (8.6% vs 0%; P= .03). There were no differences in major adverse events (P= .795) or late reintervention (P= .232) between groups. Interestingly, sac growth of more than 10mm was noted to be more frequent with infrarenal EVAR (17.6% vs 2.8%; P= .039). However, both type IA (5.7% infrarenal; 4.9% complex) and type II endoleaks (32.3% infrarenal; 25.7% complex) were found to be equally common in both groups. Complex EVAR was not associated with increased all-cause mortality at latest follow-up (P= .322). Multivariable Cox modeling demonstrated that AAAs greater than 75mm in diameter (hazard ratio; 4.9; 95% confidence interval, 4.6-48.2) and renal insufficiency (hazard ratio, 3.71; 95% confidence interval, 1.17-11.6) were the only independent risk factors of late death.CONCLUSIONS: Complex EVAR is associated with greater perioperative mortality compared with infrarenal EVAR among octogenarians. However, late outcomes, including the need for reintervention and all-cause mortality, are not significantly different. Larger aneurysms and chronic kidney disease portends greater risk of late death after EVAR, regardless of AAA complexity. These patient-related factors should be considered when offering endovascular treatment to older patients.

View details for PubMedID 29970274

View details for Web of Science ID 000433036700148

View details for Web of Science ID 000412559500008

Abstract

Concern over perioperative and long-term durability of lower extremity revascularizations among active smokers is a frequent deterrent for vascular surgeons to perform elective lower extremity revascularization. In this study, we examined perioperative outcomes of lower extremity endovascular (LEE) revascularization and open lower extremity bypass (LEB) in active smokers with intermittent claudication (IC) and critical limb ischemia (CLI).Active smokers undergoing LEE or LEB from 2011 to 2014 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular data set. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between LEE and LEB procedures. Subgroup analysis was performed for patients undergoing revascularization for IC and CLI independently.From 2011 to 2014, 4706 lower extremity revascularizations were performed in active smokers (37% of all revascularizations). In this group, 1497 were LEE (55.6% for CLI, 13.4% for below-knee pathology) and 3209 were LEB (68.9% CLI, 34.7% below-knee). Patients undergoing LEE had higher rates of female gender, hypertension, end-stage renal disease, and diabetes (all P .02). LEE patients also had a higher frequency of prior percutaneous interventions (22.7% vs 17.2%; P< .01) and preoperative antiplatelet therapy (82.3% vs 78.7%; P= .02). On risk-adjusted multivariate analysis, LEE patients had higher need for reintervention on the treated arterial segment than LEB (5.1% vs 5.2%; odds ratio [OR], 1.52; 95% confidence interval [CI], 1.08-2.13; P= .02) but had lower wound complications (3.1% vs 13.2%; OR, 0.32; 95% CI, 0.23-0.45; P< .01) and no statistically significant difference in 30-day mortality (0.6% vs 0.9%), myocardial infarction or stroke (1.1% vs 2.6%), or major amputation (3.2% vs 2.1%) in the overall cohort of active smokers. In the IC subgroup, myocardial infarction or stroke was significantly higher in the LEB group (1.9% vs 0.6%; OR, 1.83; 95% CI, 1.17-1.97; P= .03), although no difference was found in the CLI subgroup (2.8% vs 1.4%; OR, 0.75; 95% CI, 0.37-1.52; P= .42,). Also in IC group, there was a trend for lower major amputation rates 30days in the LEE group, whereas in the CLI group, LEE had a trend toward higher risk of early amputation compared with LEB.In active smokers, LEB for IC and CLI requires fewer reinterventions but is associated with a higher rate of postoperative wound complications compared with LEE revascularization. However, the risk for limb amputation is higher in actively smoking patients when treated by LEE compared with LEB for CLI. Importantly, cardiovascular complications are significantly higher in actively smoking patients with IC undergoing LEB compared with LEE. This additional cardiovascular risk should be carefully weighed when proposing LEB for actively smoking patients with nonlimb-threatening IC.

View details for DOI 10.1016/j.jvs.2017.01.025

View details for PubMedID 28527930

Abstract

We attempted to create a surgical model to evaluate the retroperitoneal space for the ability to transfer solutes through the retroperitoneal membrane. Our dual objectives were to develop a technique to assess the feasibility of retroperitoneal dialysis (RPD) in a porcine model.We incorporated two 35-kg Yorkshire pigs for this pilot study. In the first animal, we clamped renal vessels laparoscopically. In the second animal, we embolized renal arteries. In both animals, we dilated the retroperitoneal space bilaterally and deployed dialysis catheters. We measured serum creatinine (Cr), urea, and electrolytes at baseline 6 hours before the dialysis and every 4 hours after.We successfully created retroperitoneal spaces bilaterally and deployed dialysis catheters in both animals. In the first animal, dialysate and plasma Cr ratio (D/P) on the left and right side were 0.43 and 0.3, respectively. Cr clearance by 40 minutes of dialysis treatment was 6.3 mL/min. The ratio of dialysate glucose at 4 hours dwell time to dialysate glucose at 0 dwell time (D/D0) for left/rights sides were 0.02 and 0.02, respectively. kt/Vurea was 0.43. In the second animal, D/P Cr for left/right sides were 0.34 and 0.33, respectively. kt/Vurea was 0.17. We euthanized the pigs due to fluid collection in the peritoneal space and rapid increase of serum Cr, urea, and electrolytes.We demonstrated the feasibility of creation of a functionally anephric porcine model with successful development of retroperitoneal spaces using balloon inflation. Notwithstanding minimal clearance and limited diffusion capacity in this experiment, additional studies are needed to examine potential use of retroperitoneal space for peritoneal dialysis.

View details for DOI 10.5414/CN108775

View details for Web of Science ID 000384940700003

View details for PubMedID 27345182

Abstract

Carotid endarterectomy (CEA) is the most commonly performed surgical procedure to reduce the risk of stroke. The operation may be performed under general anesthesia (GA) or regional anesthesia (RA). We used a national database to determine how postoperative outcomes were influenced by gender and type of anesthesia used.All patients who underwent CEA between 2005 and 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program database (N= 41,442). Incidence of stroke and myocardial infarction (MI) within 30days as well as other postoperative complications, operative time, and hospital length of stay were examined in groups separated by gender and anesthesia type. Multivariable logistic regression with effect modification was used to determine significant risk-adjusted differences between genders and type of anesthesia to assess outcomes after CEA.The male-to-female ratio among CEA cases performed was approximately 3:2. Most cases were performed under GA (85% male patients, 86% female patients). Adjusted multivariable analysis showed no statistical difference in rates of MI and stroke based on gender or type of anesthesia used. There were, however, higher 30-day postoperative local complications and MI (both P< .05) in those who had GA vs RA regardless of gender before adjustment. Total operative time was decreased (mean difference,-8.15minutes; 95% confidence interval,-10.09 to-6.21; P< .001) and length of stay was increased (mean difference, 0.34day; 95% confidence interval, 0.14-0.54; P< .02) in women, with statistical significance, whether RA or GA was used.On adjusted multivariate analysis, there is no statistically significant difference in postoperative incidence of MI or stroke between men and women undergoing CEA. Use of RA vs GA did not affect this finding. Furthermore, there was no correlation between gender and the type of anesthesia chosen. Women, however, experienced decreased operative times and increased length of stay regardless of anesthesia type.

View details for DOI 10.1016/j.jvs.2016.03.406

View details for PubMedID 27183853

Abstract

Postoperative ischemic colitis (IC) can be a serious complication following infrarenal abdominal aortic aneurysm (AAA) repair. We sought to identify risk factors and outcomes in patients developing IC after open AAA repair and endovascular aneurysm repair (EVAR).The American College of Surgeons National Surgical Quality Improvement Program database was used to examine clinical data of patients undergoing AAA repair from 2011 to 2012 who developed postoperative IC. Multivariate regression analysis was performed to identify risk factors and outcomes.We evaluated a cohort of 3486 patients who underwent AAA repair (11.6% open repair and 88.4% EVAR). The incidence of postoperative IC was 2.2% (5.2% for open repair and 1.8% for EVAR). Surgical treatment was needed in 49.3% of patients who developed IC. The mortality of patients with IC was higher than that of patients without IC (adjusted odds ratio [AOR], 4.23; 95% confidence interval [CI], 2.26-7.92; P< .01). The need for surgical treatment (AOR, 7.77; 95% CI, 2.08-28.98; P< .01) and age (AOR, 1.11; 95% CI, 1.01-1.22; P= .01) were mortality predictors of IC patients. Predictive factors of IC included need for intraoperative or postoperative transfusion (AOR, 6; 95% CI, 3.08-11.72; P< .01), rupture of the aneurysm before surgery (AOR, 4.07; 95% CI, 1.78-9.31; P< .01), renal failure requiring dialysis (AOR, 3.86; 95% CI, 1.18-12.62; P= .02), proximal extension of the aneurysm (AOR, 2.19; 95% CI, 1.04-4.59; P= .03), diabetes (AOR, 1.87; 95% CI, 1.01-3.46; P= .04), and female gender (AOR, 1.75; 95% CI, 1.01-3.02; P=.04). Although open AAA repair had three times higher rate of postoperative IC compared with endovascular repair, in multivariate analysis we did not find any statistically significant difference between open repair and EVAR in the development of IC (5.2% vs 1.8%; AOR, 1.25; 95% CI, 0.70-2.25; P= .43).Postoperative IC has a rate of 2.2% after AAA repair. However, it is associated with 38.7% mortality rate. Rupture of the aneurysm before surgery, need for transfusion, proximal extension of the aneurysm, renal failure requiring dialysis, diabetes, and female gender were significant predictors of postoperative IC. AAA patients who develop IC have four times higher mortality compared with those without IC. Surgical treatment is needed in nearly 50% of IC patients and is a predictor of higher mortality.

View details for DOI 10.1016/j.jvs.2015.10.064

View details for PubMedID 26747680

Abstract

Traditional treatment of infected polytetrafluoroethylene (PTFE) grafts consist of removal of the entire prosthesis. Closure of the native vessels may compromise vascular patency. We examined the outcomes for patients in whom a PTFE remnant of an infected graft was retained on the vessel.We reviewed the operating room log from 2000 to 2011 and identified all patients who had partial removal of an infected PTFE graft used for hemodialysis or peripheral bypass. These patients were examined for subsequent complications.Twenty-seven patients underwent 30 partial graft excisions with mean follow-up of 27 months. A total of 17% (5 of 30) of the partial graft resection procedures resulted in complications. Of 48 total remnants left behind at the arterial or venous anastomoses, reinfection occurred in 15%.Leaving a well-incorporated small 1-to 5-mm PTFE remnant at the arterial or venous anastomoses can be performed safely with a low risk of complications.

View details for DOI 10.1177/1538574415583849

View details for Web of Science ID 000356507400003

View details for PubMedID 25926296

Abstract

Median arcuate ligament syndrome (MALS) is a rare disorder defined by compression and narrowing of the celiac artery by the median arcuate ligament. The increased blood flow through the pancreaticoduodenal arcade can lead to the aneurysmal formation within the vessel. We report 3 cases of pancreaticoduodenal arterial aneurysms (PDAAs) in patients with MALS whose aneurysms were occluded, but celiac artery revascularization was not performed.Case 1: Asymptomatic 61-year-old female with no past medical history was referred to vascular surgery for evaluation of a PDAA incidentally found on computed tomography (CT) scan. The patient was taken for laparoscopic division of the median arcuate ligament; however, the release was incomplete. This was followed by endovascular coil embolization of the PDAA without celiac revascularization. The patient tolerated the procedure well with no complications and the 1-year follow-up shows no signs of aneurysm recurrence. Case 2: A 61-year-old male found to have an incidental PDAA on CT scan. The patient was taken for coil embolization without median arcuate ligament release. At the 1-year follow-up, the patient continues to be asymptomatic with no recurrence. Case 3: A 56-year-old male presented with a ruptured PDAA. He was taken immediately for coil embolization of the ruptured aneurysm. Postoperatively, the patient was identified to have MALS on CT scan. Because of his asymptomatic history and benign physical examination before the rupture, he was not taken for a ligament release or celiac revascularization. He continues to be asymptomatic at his follow-up.PDAAs secondary to MALS are very rare and most commonly diagnosed at the time of rupture, which has a mortality rate that reaches approximately 30%, making early identification and treatment necessary. Standard treatment would include exclusion of the aneurysm followed by celiac revascularization; however, these 3 cases identify an alternative approach to the standard treatment.Celiac revascularization may not be necessary in the asymptomatic patient with a PDAA who has close follow-up and serial imaging.

View details for DOI 10.1016/j.avsg.2014.05.020

View details for PubMedID 24930977

Abstract

Dynamic changes in anatomic geometry of the inferior vena cava from changes in intravascular volume may cause passive stresses on inferior vena cava filters. In this study, we aim to quantify variability in inferior vena cava dimensions and anatomic orientation to determine how intravascular volume changes may impact complications of inferior vena cava filter placement, such as migration, tilting, perforation, and thrombosis.Retrospective computed tomography measurements of major axis, minor axis, and horizontal diameters of the inferior vena cava at 1 and 5cm below the lowest renal vein in 58 adult trauma patients in pre-resuscitative (hypovolemic) and post-resuscitative (euvolemic) states were assessed in a blinded fashion by two independent readers. Inferior vena cava perimeter, area, and volume were calculated and correlated with caval orientation.Mean volumes of the inferior vena cava segment on pre- and post-resuscitation scans were 9.0cm(3) and 11.0cm(3), respectively, with mean percentage increase of 48.6% (P<0.001). At 1cm and 5cm below the lowest renal vein, the inferior vena cava expanded anisotropically, with the minor axis expanding by an average of 48.7% (P<0.001) and 30.0% (P=0.01), respectively, while the major axis changed by only 4.2% (P=0.11) and 6.6% (P=0.017), respectively. Cross-sectional area and perimeter at 1cm below the lowest renal vein expanded by 61.6% (P<0.001) and 10.7% (P<0.01), respectively. At 5cm below the lowest renal vein, the expansion of cross-sectional area and perimeter were 43.9% (P<0.01) and 10.7% (P=0.002), respectively. The major axis of the inferior vena cava was oriented in a left-anterior oblique position in all patients, averaging 20 from the horizontal plane. There was significant underestimation of inferior vena cava maximal diameter by horizontal measurement. In pre-resuscitation scans, at 1cm and 5cm below the lowest renal vein, the discrepancy between the horizontal and major axis diameter was 2.11.2mm (P<0.001) and 1.71.0mm (P<0.001), respectively, while post-resuscitation studies showed the same underestimation at 1cm and 5cm below the lowest renal vein to be 2.21.2mm (P<0.01) and 1.91.0mm (P<0.01), respectively.There is significant anisotropic variability of infrarenal inferior vena cava geometry with significantly greater expansive and compressive forces in the minor axis. There can be significant volumetric changes in the inferior vena cava with associated perimeter changes but the major axis left-anterior oblique caval configuration is always maintained. These significant dynamic forces may impact inferior vena cava filter stability after implantation. The consistent major axis left-anterior oblique obliquity may lead to underestimation of the inferior vena cava diameter used in standard anteroposterior venography, which may influence initial filter selection.

View details for DOI 10.1177/1708538114552665

View details for PubMedID 25298135

Abstract

The exponential rise in inferior vena cava (IVC) filter placement is associated with increased complications both during implantation and retrieval. In this report, a 64-year-old man was transferred from an outside hospital with cardiac tamponade secondary to a snare eroding into the right atrium. This complication occurred after attempted suprarenal IVC filter removal. The filter, entangled with the snare, was retrieved by a hybrid technique of mobilizing the liver to expose the suprarenal IVC, followed by using a snare and sheath to compress and extrude the filter. This is the first reported hybrid retrieval of a suprarenal IVC filter.

View details for DOI 10.1016/j.avsg.2014.07.040

View details for PubMedID 25304904

Abstract

Previous studies have proved the feasibility of performing a pancreaticoduodenectomy (Whipple operation) in patients with portal vein-superior mesenteric vein and hepatic artery invasion. We report our institutional experience with the use of a variety of vascular reconstructive methods during pancreatic resections for adenocarcinoma.A retrospective review was performed identifying all patients undergoing a Whipple operation or total pancreatectomy procedure from January 2003 to December 2013. All venous (portal vein-superior mesenteric vein) and arterial (superior mesenteric artery-hepatic artery) reconstructions were extracted and reviewed to determine survival and perioperative complications.During the 10-year study period, 270 Whipple and total pancreatectomy procedures were performed, of which 183 were for adenocarcinoma of the pancreas. Of the 183 operations, a total of 60 (32.8%) vascular reconstructions were found, 49 venous and 11 arterial. Venous reconstruction included 37 (61.7%) primary repairs, four (6.7%) reconstructions with CryoVein (CryoLife, Inc, Kennesaw, Ga), three (5.0%) repairs with autologous vein patch, three (5.0%) autologous saphenous reconstructions, and two (3.33%) portacaval shunts. In addition, there were 11 (18.3%) arterial reconstructions (seven hepatic artery and four superior mesenteric artery). The 1-year survival for all reconstructions was 71.1%, which is equivalent to T3 lesions that did not receive vascular reconstruction (70.11%), with a median survival time of 575.28 days and 12 patients still alive. Survival time was comparable with each type of venous reconstruction, averaging 528 days (11 of 49 patients still alive). There was a total thrombosis rate of seven of 60 (11.6%), all of which were portal vein thrombosis: three in the primary repair group and four delayed thromboses seen in primary repair, CryoVein repair, and vein patch repair. There was no thrombosis in any patients after arterial reconstruction.An aggressive approach for stage II pancreatic cancers with venous or arterial invasion can be performed with comparable results when it is executed by an experienced institution with skilled oncologic and vascular surgeons.

View details for DOI 10.1016/j.jvs.2014.09.003

View details for PubMedID 25441672

Abstract

The introduction of carotid stenting has led to a rapid rise in the number of vascular specialists performing this procedure. The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) has shown that carotid stenting can be performed with an equivalent major event rate compared with carotid endarterectomy. However, there is still controversy about the appropriate training and experience required to safely perform this procedure. This observational study examined the performance of carotid stenting with regard to specialty and case volume.From 2004 to 2011, inpatients diagnosed with carotid stenosis who had a carotid stenting procedure were extracted from the Nationwide Inpatient Sample database. The cohort was separated on the basis of the provider performing the procedure (surgeon vs interventionalist), hospital location, and volume. Surgeons were defined as providers who also performed either a carotid endarterectomy or femoral-popliteal bypass during the same time interval. Primary end points analyzed included stroke, myocardial infarction, and 30-day mortality. Length of stay and hospital costs were also analyzed as secondary outcomes.A total of 20,663 cases of carotid stenting were found; 15,305 (74%) cases were identified to be performed by a "surgeon," whereas 5358 (26%) were done by an "interventionalist." The majority of cases were done at hospitals in urban locations (96.51%) and designated teaching institutions (61.47%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% and 4.41%), myocardial infarction (2.10% and 2.13%), and mortality (0.84% and 1.03%) respectively. Qualitatively, volume per 10 cases was shown to decrease the risk of stroke. Adjusted multivariate analysis demonstrated no statistical significance between primary end point outcomes. However, length of stay (2.81 vs 3.08days) and total charges ($48,087.61 and $51,718.77) were lower for procedures performed by surgeons.Surgeons are performing the majority of carotid stent procedures in the United States. The volume of cases performed by a provider, rather than the provider's specialty, appears to be a stronger predictor of adverse outcomes for carotid stenting. There were, however, significant cost differences between surgeons and interventionalists, which needs to be further evaluated at an institutional level.

View details for DOI 10.1016/j.jvs.2014.11.066

View details for PubMedID 25600333

Abstract

To describe the salvage of a left axillary artery to right atrium hemodialysis graft using endovascular techniques.A 54-year-old man with multiple arteriovenous graft failures presented with a thrombosed left axillary artery to right atrium Gore-tex hemodialysis graft. The graft was salvaged using rheolytic catheter thrombectomy, mechanical thrombectomy, balloon angioplasty, and stenting.This single case report suggests that when axillary to right atrium grafts fail, various endovascular techniques can be employed to salvage the graft and maintain dialysis access.

View details for DOI 10.1016/j.clinimag.2014.06.007

View details for Web of Science ID 000344839400020

View details for PubMedID 25069753

Abstract

To discuss the rare finding of bronchial artery aneurysms and pseudoaneurysms as well as describing available endovascular treatment options.A 61-year-old male presented to the emergency department and was found to have a paraesophageal hematoma and 1cm bronchial artery pseudoaneurysm. The patient was taken for successful endovascular exclusion by embolization.Bronchial artery pseudoaneurysms are rare but have a chance of rupture. Percutaneous embolization is a reasonable treatment option for these patients.

View details for DOI 10.1016/j.clinimag.2014.01.010

View details for PubMedID 24637150

View details for Web of Science ID 000271831502680