[Show abstract][Hide abstract] ABSTRACT: Recent randomized controlled trials have shown that age significantly affects the outcome of carotid revascularization procedures. This study used data from the Society for Vascular Surgery Vascular Registry (VR) to report the influence of age on the comparative effectiveness of carotid endarterectomy (CEA) and carotid artery stenting (CAS).
VR collects provider-reported data on patients using a Web-based database. Patients were stratified by age and symptoms. The primary end point was the composite outcome of death, stroke, or myocardial infarction (MI) at 30 days.
As of December 7, 2010, there were 1347 CEA and 861 CAS patients aged < 65 years and 4169 CEA and 2536 CAS patients aged ≥ 65 years. CAS patients in both age groups were more likely to have a disease etiology of radiation or restenosis, be symptomatic, and have more cardiac comorbidities. In patients aged <65 years, the primary end point (5.23% CAS vs 3.56% CEA; P = .065) did not reach statistical significance. Subgroup analyses showed that CAS had a higher combined death/stroke/MI rate (4.44% vs 2.10%; P < .031) in asymptomatic patients but there was no difference in the symptomatic (6.00% vs 5.47%; P = .79) group. In patients aged ≥ 65 years, CEA had lower rates of death (0.91% vs 1.97%; P < .01), stroke (2.52% vs 4.89%; P < .01), and composite death/stroke/MI (4.27% vs 7.14%; P < .01). CEA in patients aged ≥ 65 years was associated with lower rates of the primary end point in symptomatic (5.27% vs 9.52%; P < .01) and asymptomatic (3.31% vs 5.27%; P < .01) subgroups. After risk adjustment, CAS patients aged ≥ 65 years were more likely to reach the primary end point.
Compared with CEA, CAS resulted in inferior 30-day outcomes in symptomatic and asymptomatic patients aged ≥ 65 years. These findings do not support the widespread use of CAS in patients aged ≥ 65 years.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2012; 55(5):1313-20; discussion 1321. · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The goal of rehabilitation following lower extremity amputation is to restore the highest level of independent function. As much as possible, this includes the functional use of a prosthetic device fitted to the residual limb. Early prosthetic fit depends, in turn, on rapid healing of the amputation site.
We hypothesized that compliance with a novel custom-designed amputation protection and compression system (CAPCS) to the residual limb can accelerate and improve the likelihood of successful prosthesis use. We conducted a retrospective study of all patients who were offered CAPCS by certified prosthetists (Hanger Prosthetics and Orthotics, Bethesda, MD) during the period between April 2004 and November 2009. Variables included age, sex, indication for amputation, and compliance with CAPCS. Compliance was defined as consistent observed wearing of the CAPCS as directed. The primary end point was the fitting of a prosthetic device to the amputated limb, with time to prosthetic fit being the secondary outcome.
Out of 100 patients who were offered CAPCS (n = 100) during the study period, 76% were considered compliant (n = 76). Sixty five patients (65%) were ultimately fitted with prosthetic limbs. In multivariate analysis, we found that patients who had compliant use of CAPCS were significantly more likely to be successfully fit with prosthesis (72 vs. 42%, p = 0.005). At 100 days post amputation, the cumulative incidence of prosthesis fitting was significantly higher in CAPCS compliant patients (69.7 vs. 22.2%, p = 0.012).
Compliant use of a CAPCS following amputation is associated with earlier and more frequent use of a prosthetic. Based on this limited data set, a conclusion can be drawn that the potential exists to significantly improve functional outcomes after amputation, but well-designed prospective studies are needed to confirm this association.
Annals of Vascular Surgery 11/2011; 26(2):242-9. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fond
Le traitement ouvert traditionnel des anévrysmes aortiques de l'arche distal exige une procédure en deux temps associée à une morbidité et à une mortalité significative. L'introduction du traitement endovasculaire des anévrysmes thoraciques représente une option moins invasive pour accomplir le second temps du traitement après création proximale de la trompe d'éléphant. Cette étude présente une série de patients traités par technique hybride proximale ouverte et distale endovasculaire des anévrysmes aortiques de l'arche distal.
Une revue rétrospective a été réalisée dans un centre médical universitaire. Tous les patients traités par technique hybride étaient identifiés. Les patients étaient évalués selon leurs données démographiques, l'imagerie préopératoire, le succès technique, les complications postopératoires, la longueur du séjour hospitalier, le recours à une intervention secondaire, et la survie globale.
Un total de 10 patients (3 hommes, âge moyen : 67,5 ans) a été identifié au cours d'une période de quatre ans entre août 2005 et juillet 2009. Tous les patients étaient traités de façon élective et le diamètre maximum moyen de l'anévrysme était de 70,8 mm. Sur les 10 patients, quatre avaient subi une thoracotomie précédente (trois traitements aortiques, une résection pulmonaire pour lésion maligne) et tous étaient considérés à risque élevé pour la chirurgie ouverte du deuxième temps. Les trois premiers patients ont été traités avec une intervention endovasculaire secondaire par accès artériel rétrograde. Les sept patients plus récents ont subi un traitement en un seul temps avec pose de l'endoprothèse par un accès aortique ascendant antérograde. Le succès technique a été obtenu dans tous les cas. Aucune paraplégie ou accident vasculaire cérébral periopératoire n'a été rapporté. Un patient a été traité avec succès de façon endovasculaire d'une endofuite de type IB à 38 mois. Un autre a présenté un élargissement de son anévrysme thoraco-abdominal entrainant une endofuite de type IB qui a été détecté à 43 mois. Il y avait un décès dans les 30 jours postopératoires. Les neuf autres patients sont tous vivants, avec une survie moyenne de 35,1 mois (extrêmes: 8-53) après la chirurgie.
L'approche hybride du traitement des anévrysmes aortiques de l'arche distal est sûre et représente une d'alternative à la chirurgie ouverte conventionnelle. Son caractère moins invasif techniquement, le fait d'éviter un deuxième temps chirurgical et d'éliminer le risque de perte de suivi, ou de mortalité dans l'intervalle, nous ont menés à préférer le traitement en une seule étape en utilisant un abord antérograde.
Annales de Chirurgie Vasculaire. 07/2011; 25(5):641–647.
[Show abstract][Hide abstract] ABSTRACT: The Society for Vascular Surgery (SVS) Vascular Registry (VR) collects data on outcomes of carotid endarterectomy and carotid artery stenting (CAS). The purpose of this study was to evaluate the impact of open vs closed cell stent design on the in-hospital and 30-day outcome of CAS.
The VR collects provider-reported data on patients using a Web-based database. Data were analyzed both in-hospital and at 30 days postprocedure. The primary outcome is combined death/stroke/myocardial infarction (MI).
As of October 14, 2009, there were 4337 CAS with discharge data and 2397 with 30-day data. Open cell stents (OPEN) were used in 3451 patients (79.6%), and closed cell stents (CLOSED) were used in 866 patients (20.4%). Baseline demographics showed no differences in age, gender, race, and ethnicity. However, the OPEN group had more patients with atherosclerosis (74.5% vs 67.4%; P = .0003) as the etiology of carotid artery disease. The OPEN group also had a higher prevalence of preprocedural stroke (25.8% vs 21.4%; P = .0079), chronic obstructive pulmonary disease (COPD; 21.0% vs 17.6%; P = .0277), cardiac arrhythmia (14.7% vs 11.4%; P = .0108), valvular heart disease (7.4% vs 3.7%; P < .0001), peripheral vascular disease (PVD; 40.0% vs 35.3%; P = .0109), and smoking history (59.0% vs 54.1%; P = .0085). There are no statistically significant differences in the in-hospital or 30-day outcomes between the OPEN and CLOSED patients. Further subgroup analyses demonstrated symptomatic patients had a higher event rate than the asymptomatic cohort in both the OPEN and CLOSED groups. Among symptomatic patients, the OPEN patients had a lower (0.43% vs 1.41%; P = .0349) rate of in-hospital mortality with no difference in stroke or transient ischemic attack (TIA). There were no differences in 30-day event rates. In asymptomatic patients, there were also no statistically significant differences between the OPEN and CLOSED groups. After risk adjustment, there remained no statistically significant differences between groups of the primary endpoint (death/stroke/MI) during in-hospital or 30 days.
In-hospital and 30-day outcomes after CAS were not significantly influenced by stent cell design. Symptomatic patients had higher adverse event rates compared to the asymptomatic cohort. As there is no current evidence of differential outcome between the use of open and closed cell stents, physicians should continue to use approved stent platforms based on criteria other than stent cell design.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2011; 54(1):71-9. · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute atherothrombotic occlusion in heart attack and stroke implies disruption of the vascular endothelial barrier that exposes a highly procoagulant intimal milieu. However, the evolution, severity, and pathophysiological consequences of vascular barrier damage in atherosclerotic plaque remain unknown, in part because quantifiable methods and experimental models are lacking for its in vivo assessment.
To develop quantitative nondestructive methodologies and models for detecting vascular barrier disruption in advanced plaques.
Sustained hypercholesterolemia in New Zealand White (NZW) rabbits for >7-14 months engendered endothelial barrier disruption that was evident from massive and rapid passive penetration and intimal trapping of perfluorocarbon-core nanoparticles (PFC-NP: ∼250 nm diameter) after in vivo circulation for as little as 1 hour. Only older plaques (>7 mo), but not younger plaques (<3 mo) demonstrated the marked enhancement of endothelial permeability to these particles. Electron microscopy revealed a complex of subintimal spongiform channels associated with endothelial apoptosis, superficial erosions, and surface-penetrating cholesterol crystals. Fluorine ((19)F) magnetic resonance imaging and spectroscopy (MRI/MRS) enabled absolute quantification (in nanoMolar) of the passive permeation of PFC-NP into the disrupted vascular lesions by sensing the unique spectral signatures from the fluorine core of plaque-bound PFC-NP.
The application of semipermeant nanoparticles reveals the presence of profound barrier disruption in later stage plaques and focuses attention on the disrupted endothelium as a potential contributor to plaque vulnerability. The response to sustained high cholesterol levels yields a progressive deterioration of the vascular barrier that can be quantified with fluorine MRI/MRS of passively permeable nanostructures. The possibility of plaque classification based on the metric of endothelial permeability to nanoparticles is suggested.
PLoS ONE 01/2011; 6(10):e26385. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Traditional open repair of distal arch aortic aneurysms requires a two-stage procedure associated with significant morbidity and mortality. The introduction of thoracic endovascular aneurysm repair has created a less invasive option to complete the second stage of the repair after proximal elephant trunk creation. The present study reports a series of patients treated with a combined open proximal and endovascular distal repair of distal arch aortic aneurysms.
A retrospective review was undertaken at a university medical center. All patients treated with the hybrid approach were identified. The patients were evaluated for demographics, preoperative imaging, technical success, postoperative complications, length of hospital stay, need for secondary intervention, and overall survival.
A total of 10 patients (3 men, mean age: 67.5 years) were identified during a 4-year period between August 2005 and July 2009. All patients were treated electively and the mean maximum aneurysm diameter was 70.8 mm. Of the 10 patients, four had undergone previous thoracotomy (three aortic repair, one pulmonary resection for malignancy) and all were deemed at prohibitive risk for open second-stage surgery. The first three patients had staged reconstruction with delayed endovascular intervention through retrograde arterial access. The more recent seven patients underwent single-stage repair with endograft delivery through an antegrade ascending aortic access. Technical success was achieved in all cases. No perioperative paraplegias or strokes were reported. One patient had successful endovascular treatment of a type IB endoleak at 38 months. Another had an enlarging thoracoabdominal aneurysm resulting in a type IB endoleak which was detected at 43 months. There was one death within 30 days after the procedure. The remaining nine patients are all alive, with a mean survival of 35.1 months (range: 8-53) after surgery.
The hybrid approach to treatment of distal arch aortic aneurysms is safe and serves as a viable alternative to conventional open repair. Less technically challenging, avoidance of a second surgery as well as elimination of the possibility of becoming lost to follow-up, or interval mortality have led us to consider a single-stage repair using an antegrade approach as the preferred option.
Annals of Vascular Surgery 12/2010; 25(5):598-604. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although endovascular aneurysm repair has been shown to be an effective way to treat abdominal aortic aneurysm (AAA), certain anatomic characteristics such as a short aortic neck, limit its applicability. Initially, commercially available devices were approved only for the treatment of AAA with an aortic neck length ≥ 15 mm. The purpose of this study was to evaluate the outcomes of the recently approved Talent endograft for AAAs with a short aortic neck length (10-15 mm).
Data were obtained from the prospective, nonrandomized, multicenter Talent enhanced Low Profile Stent Graft System trial which enrolled patients between February 2002 and April 2003. A total of 154 patients with adequate preoperative imaging were identified for this study. Subgroup analyses were performed for AAA with 10-15 mm aortic neck and those with >15 mm neck. Safety and effectiveness endpoints were evaluated at 30 days, 1 year, and 5 years postprocedure.
Patients treated with aortic neck lengths of 10-15 mm (n = 35) and those with >15 mm (n = 102) had similar age, gender, and risk factor profile. Both groups had similar preoperative aneurysm morphology in terms of maximum aneurysm size, degree of neck angulation, or proximal neck diameter. There were no statistically significant differences in freedom from major adverse events and mortality rates at 30 and 365 days. Similarly, there was no difference in the effectiveness endpoints at 12 months. At 5 years, there was no difference in migration rate, endoleaks, or change in aneurysm diameter from baseline. In addition, there is no difference in freedom from aneurysm-related mortality (94% vs. 99%).
AAAs with short aortic necks (10-15 mm) and otherwise suitable anatomy for endovascular repair can be safely and effectively treated with the Talent endograft with excellent 1 and 5 year outcomes.
Annals of Vascular Surgery 10/2010; 24(7):851-8. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Popliteal artery aneurysms have traditionally been repaired with an open surgical approach. However, endovascular popliteal artery repair (EVPAR) has been used in selected patients because of its less invasive nature. In this report, we present our long-term outcomes for EVPAR.
Retrospective review of all patients who underwent EVPAR at a single academic institution between September 2002 and March 2006. These patients were evaluated for patency, need for secondary intervention, amputation-free survival, and overall survival.
A total of 15 limbs in 13 patients were treated with EVPAR during the study period. All EVPAR were performed using the Viabahn(®) endoprostheses, with an average of 1.67 stents per limb. The mean age of the patients was 74.6 years (range, 66-84). Technical success was achieved in 100% and all limbs had initial postoperative ankle-arm indices of ≥ 1.0. Mean duration of follow-up was 54 months (range, 42-70). Two patients died of unrelated causes at 3 and 38 months with intact limbs, and one patient was lost to follow-up. Two limbs developed type I or III endoleaks, and were successfully treated with additional endovascular stent placement, resulting in a primary patency rate of 84.6% and secondary patency rate of 100%. There were no instances of limb loss during the follow-up period, yielding both amputation-free survival and overall survival rates of 85.7%.
Long-term follow-up of this cohort of EVPAR patients suggests that in selected patients, this is a durable technique, capable of achieving excellent patency rates and limb preservation. Further large-scale clinical trials are warranted to help define optimal candidates for this technique.
Annals of Vascular Surgery 10/2010; 24(7):871-5. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Endovascular repair of thoracic aortic disease continues to evolve since FDA approval of the first thoracic endograft in the United States in March 2005. Certain anatomic characteristics, including adequacy of arterial access, remain a significant limiting factor in thoracic endovascular repair. In clinical trials evaluating thoracic endografts, vascular access complications occurred in >20% of cases. The purpose of this study is to evaluate the arterial access and the selective use of the ascending aorta for thoracic endograft placement.
A retrospective review was performed for patients who underwent thoracic endograft placement between May 2005 and April 2009 (4 years since FDA approval of the first thoracic endograft). Patient records were reviewed for the indication for the procedure, type of arterial access, technical success, and access-related complications.
Seventy-nine thoracic endografts were placed during the study period. The indications for endograft placement included 53 aneurysms, 10 traumatic lesions, 6 endoleaks, 4 dissections, 3 penetrating ulcers, 2 bleeding aortic fistulas, and 1 thoracic diverticulum. Retrograde access was used in 70 cases (89%): 60 femoral (76%) and 10 aortoiliac (13%). Antegrade access through a 10-mm polyester graft anastomosed to the ascending aorta was used in nine cases (11%). These procedures included endograft placement with proximal elephant trunk creation in six cases, endograft-alone in two cases, and combination with proximal arch reconstruction/debranching in one case. There was 100% technical success for all cases. The overall access-related complication rate was 6%. There were no complications with antegrade access through the ascending aorta or with aortoiliac access. There were five complications in the femoral access group (three iliac artery dissection, one iliac artery injury, and one femoral artery injury).
Access selection is an important part of the preoperative planning of endovascular procedures. Choosing the most appropriate access for a patient will decrease the access-associated complication rate. In addition, selected patients with poor aortoiliac access and those that require debranching or elephant trunk procedures may benefit from antegrade access.
Annals of Vascular Surgery 07/2010; 24(5):640-5. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Proximal attachment failure, often leading to graft migration, is a severe complication of endovascular aneurysm repair (EVAR). Aortic cuffs have been used to treat proximal attachment failure with mixed results. The Zenith Renu AAA Ancillary Graft (Cook Inc, Bloomington, Ind) is available in two configurations: converter and main body extension. Both provide proximal extension with active fixation for the treatment of pre-existing endovascular grafts with failed or failing proximal fixation or seal in patients who are not surgical candidates. We prospectively compared the outcomes of patient treatment with these two device configurations.
From September 2005 to May 2008, a prospective, nonrandomized, postmarket registry was conducted to collect data from 151 patients treated at 95 institutions for proximal aortic endovascular graft failure using the Renu graft. Treatment indications included inadequate proximal fixation or seal, for example, migration, and type I and III endoleak. A total of 136 patients (90%) had migration, 111 (74%) had endoleak, and 94 (62%) had endoleaks and graft migration. AneuRx grafts were present in 126 patients (83%), of which 89 (59%) were treated with a converter and 62 (41%) with a main body extension. Outcomes using converters vs main body extensions for endoleak rates, changes in aneurysm size, and ruptures were compared.
Preprocedural demographics between the two groups did not differ significantly. Procedural success rates were 98% for the converter group and 100% for the main body extension group. At a mean follow-up of 12.8 +/- 7.5 months, no type III endoleaks (0%)were identified in the converter group, and five (8%) were identified in the main body extension group. There were no aneurysm ruptures in patients treated with converters (0%) and three ruptures (5%) in patients treated with main body extensions. Each patient with aneurysm rupture had been treated with a Renu main body extension, developed a type III endoleak, and underwent surgical conversion. Two of the three patients died postoperatively.
Proximal attachment failure and graft migration are potentially lethal complications of EVAR. Proximal graft extension using an aortic cuff is the easiest technique for salvaging an endovascular graft. Unfortunately, it has a predictable failure mode (development of a type III endoleak due to component separation) and is associated with a significantly higher failure rate than with the use of a converter. EVAR salvage with a converter and a femorofemoral bypass is a more complex but superior option for endovascular graft salvage.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 06/2010; 51(6):1373-80. · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report the outcomes of a single-center experience with endovascular aneurysm repair (EVAR) in nonagenarians.
Via a retrospective medical records review, we identified all patients > or = 90 years old who underwent EVAR at a single university teaching hospital during a 5-year period (January 2004 to December 2008). Patients were evaluated for surgical risk factor profile, preoperative imaging, technical success, postoperative complications, length of hospital stay, and need for secondary intervention. In addition, mortality rates were evaluated at 30 days, 365 days, and 2 years.
There were 18 nonagenarians (12 male, 67%) with a mean age of 91.2 years (range 90-95). Each patient averaged 3.5 risk factors, and the mean preoperative maximal aneurysm size was 68.3mm (range 50-105). Sixteen (89%) patients were treated on an elective basis, and two patients were emergently treated for aneurysm rupture, with one undergoing aortouni-iliac stenting with femoral-femoral bypass. All other patients in the study had bifurcated stent grafts. There was 100% technical success with no need for open conversion. The mean length of hospital stay was 4.3 days with a mean intensive care unit stay of 0.6 days. Systemic complications occurred in three patients (17%) including one death within 30 days. Secondary interventions were required in two patients (11%). One had endovascular treatment of a type I endoleak at 4 months, and a second patient underwent femoral-femoral bypass at 25 months for severe flow-limiting limb angulation. Mortality rates were 5.6% at 30 days, 41.2% at 365 days, and 58.3% at 2 years. Mean survival of the 11 patients who expired beyond the first 30 days was 17.5 months (range 4-50). Of these, mean survival of the nine patients treated electively was 20.2 months (range 7-50). Mean survival of the six patients still alive is 25.6 months (range 8-65).
EVAR is safe in nonagenarians despite their advanced age and significant surgical risk factor profile. The procedure can be performed with excellent technical success and a low rate of perioperative complications. However, mortality rates after 30 days are significant. The substantial long-term mortality raises the question of possible treatment futility in this unique population. While age should not be a contraindication for EVAR, recommendations for the procedure should be based on individual patient selection.
Annals of Vascular Surgery 05/2010; 24(4):441-6. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Vascular Registry (VR) on carotid procedures collects long-term outcomes on carotid artery stenting (CAS) and carotid endarterectomy (CEA) patients. The purpose of this report is to describe in-hospital and 30-day CAS outcomes in patients with atherosclerotic carotid artery disease (CAD; atherosclerosis [ATH]) compared to recurrent carotid stenosis (RES) and radiation-induced stenosis (RAD).
The VR collects provider-reported data on CAS using a Web-based data management system. For this report, data were analyzed at the preprocedure, procedure, predischarge, and 30-day intervals.
As of November 20, 2008, there were 4017 patients with CAS with discharge data, of which 72% were due to ATH. A total of 2321 patients were available for 30-day outcomes analysis (1623 ATH, 529 restenosis, 119 radiation, 17 dissection, 3 trauma, and 30 other). Baseline demographics showed that ATH occurred in older patients (72-years-old), had the greatest history of coronary artery disease (CAD; 62%), myocardial infarction (MI; 24%), valvular heart disease (8%), arrhythmia (16%), congestive heart failure (CHF; 16%), diabetes mellitus (DM; 35%), and chronic obstructive pulmonary disease (COPD; 20%). RES had a higher degree of baseline stenosis (87.0 vs 85.8 ATH; P = .010), were less likely to be symptomatic (35.5% vs 46.3% ATH; P < .001), but had a greater history of hypertension, peripheral vascular disease (PVD), and smoking. RAD was seen in younger patients (66.6 vs 71.7 ATH; P < .001), were more likely to be male (78.2% vs 60.9% ATH; P < .001), and had less comorbidities overall, with the exception of amaurosis fugax, smoking, and cancer. The only statistically significant difference in perioperative rates was in transient ischemic attack (TIA; 2.7% ATH vs 0.9% RES; P = .02). There were no statistically significant differences in in-hospital death/stroke/MI (ATH 5.4%, RES 3.8%, RAD 4.2%) or at 30 days (ATH 7.1%, RES 5.1%, RAD 5.0%). Even after adjusting for age, gender, symptomatology, CHF, and renal failure, the only statistically significant difference at 30 days was amaurosis fugax between ATH and RAD (odds ratio [OR] 0.13; P = .01).
Although patients with ATH have statistically significant comorbidities, they did not have statistically significant increased rates of death/stroke/MI during hospitalization or within 30 days after discharge when compared to RES or RAD. The CAS event rates for ATH vs RES and RAD are similar, despite prior published reports. Symptomatic ATH have statistically significant higher rates of death/stroke/MI compared to asymptomatic cohort. Finally, consistent and accurate entry of long-term data beyond initial hospitalization is essential to fully assess CAS outcomes since a significant number of adverse events occur in the interval from hospital discharge to 30 days.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2010; 51(5):1116-23. · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Carotid endarterectomy (CEA) has long been considered the "gold standard" in the treatment of patients with symptomatic or asymptomatic carotid stenosis. However, the utility of this treatment modality in medical or surgical "high-risk" patients remains in question. Numerous clinical trials have demonstrated that carotid angioplasty and stenting (CAS) is not inferior to CEA. Furthermore, there are also increasing data that show that best medical therapy is becoming more effective in preventing strokes and in a more cost-effective manner than carotid interventions. With this in mind, there is now ample evidence to suggest that in a certain subgroup of patients, CEA may not be indicated, and in fact, CAS or observation with best medical therapy is preferred.
Perspectives in Vascular Surgery 03/2010; 22(1):40-6.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2010; 51(3):799-800. · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectifs
Les anévrysmes de l’artère poplitée ont traditionnellement été réparés par voie chirurgicale ouverte. Cependant, la réparation endovasculaire de l’artère poplitée (REVAP) a été employée chez des malades choisis en raison de sa nature moins invasive. Dans ce travail, nous présentons nos résultats à long terme pour REVAP.
Une revue rétrospective de tous les malades qui ont eu une REVAP dans une seule institution académique de septembre 2002 à mars 2006. Ces malades ont été évalués pour la perméabilité, le besoin d’une intervention secondaire, la survie sans amputation, et la survie globale.
Un total de 15 membres chez 13 malades ont été traités par REVAP au cours de la période d’étude. Toutes les REVAP ont été faites avec des endoprothèses Viabahn®, avec une moyenne de 1,67 stents par membre. L’âge moyen des patients était de 74,6 ans (extrêmes, 66-84). Le succès technique a été obtenu dans 100% des cas et tous les membres avaient des index cheville-bras postopératoires initiaux ≥1,0. La durée moyenne du suivi était de 54 mois (extrêmes, 42-70). Deux malades sont morts de causes indépendantes à 3 et 38 mois avec des membres intacts, et un malade a été perdu de vue. Deux membres ont présenté des endofuites de types I ou III, et ont été traités avec succès par la mise en place endovasculaire d’un stent additionnel, ayant pour résultat un taux de perméabilité primaire de 84,6% et un taux de perméabilité secondaire de 100%. Il n’y avait aucune perte de membre au cours de la période de suivi, avec des taux de survie sans amputation et de survie globale de 85,7%.
Le suivi à long terme de cette cohorte de malades REVAP suggère que chez des malades choisis, il s’agit d’une technique durable, capable d’obtenir d’excellents taux de perméabilité et de sauvetage de membre. D’autres études cliniques à plus grande échelle sont justifiées pour aider à définir les candidats optimaux pour cette technique.
Annales De Chirurgie Vasculaire. 01/2010; 24(7):949-953.
[Show abstract][Hide abstract] ABSTRACT: Introduction
Le traitement endovasculaire des pathologies de l’aorte thoracique continue d’évoluer depuis l’agrément FDA donné à la première endoprothèse thoracique aux Etats-Unis en Mars 2005. Certaines caractéristiques anatomiques, dont l’existence d’un accès artériel adéquat, demeurent des facteurs limitants significatifs lors de la chirurgie endovasculaire de l’aorte thoracique. Dans les études cliniques évaluant les endoprothèses aortiques, des complications liées aux accès vasculaire survenaient dans >20% des cas. Le but de cette étude est d’évaluer l’accès artériel et l’utilisation sélective de l’aorte ascendante dans la mise en place des endoprothèses thoraciques.
Une revue rétrospective était réalisée concernant les patients ayant eu la mise en place d’une endoprothèse thoracique entre Mai 2005 et Avril 2009 (4 ans depuis l’agrément FDA de la première endoprothèse thoracique). Les dossiers des patients étaient revus concernant l’indication de la procédure, le type d’accès artériel utilisé, le succès technique, et les complications liées aux accès vasculaires.
Soixante-dix-neuf endoprothèses thoraciques étaient mises en place au cours de la période étudiée. Les indications de pose incluaient 53 anévrysmes, 10 lésions traumatiques, 6 endofuites, 4 dissections, 3 ulcères pénétrants, 2 fistules aortiques hémorragiques, et 1 diverticule thoracique. Un accès rétrograde était utilisé dans 70 cas (89%): 60 accès fémoraux (76%) et 10 accès aorto-iliaques (13%). Un accès antérograde via une prothèse polyester 10-mm anastomosée à l’aorte ascendante était utilisé dans neuf cas (11%). Ces procédures incluaient la mise en place d’une endoprothèse avec création d’une trompe d’éléphant proximale dans six cas, une endoprothèse seule dans deux cas, et une procédure combinée à une reconstruction proximale de l’arche aortique/déroutage dans un cas. Le taux de succès technique était de 100%. Le taux global de complications liées à l’accès était de 6%. Aucune complication n’était notée lors de l’utilisation d’accès antérogrades via l’aorte ascendante ainsi qu’avec les accès aorto-iliaques. Il y avait cinq complications dans le groupe de patients opérés via un accès fémoral (trois dissections de l’artère iliaque, une lésion de l’artère iliaque, et une lésion de l’artère fémorale).
La sélection de l’accès vasculaire constitue une part importante du plan préopératoire des procédures endovasculaires. Le choix de l’accès vasculaire le plus approprié chez chaque patient diminuera le taux de complications liées à l’accès vasculaire. De plus, les patients sélectionnés ayant un axe aorto-iliaque de mauvaise qualité ou ceux nécessitant un procédure de déroutage ou une trompe d’éléphant pourraient bénéficier d’un accès antérograde.
Annales De Chirurgie Vasculaire. 01/2010; 24(5):699-705.