[show abstract][hide abstract] ABSTRACT: Repeat percutaneous endoluminal interventions for femoropopliteal occlusive disease are common, but the outcomes are poorly understood. We sought to determine the results of second-time femoropopliteal percutaneous transluminal angioplasty/stenting (SPTAS) and identify factors associated with success or failure of a continued endoluminal revascularization strategy.
A retrospective review of patients undergoing multiple percutaneous endoluminal lower extremity interventions at a single institution from 2002 and 2009 identified 70 SPTAS in 70 limbs. Patient comorbidities, anatomic severity of disease, and procedural characteristics were analyzed with respect to outcomes with descriptive statistics, Kaplan-Meier curves, and Cox proportional hazards modeling. Patency rates were determined from the time of SPTAS.
Patients included 37 men (63%) and 22 women (27%) at a mean age of 70 ± 10 years. Indications for SPTAS included claudication in 54 limbs (77%) and critical limb ischemia (CLI) in 16 (23%). Median time from the initial endoluminal intervention to SPTAS was 330 days. Lesion TransAtlantic InterSociety Consensus II (TASCII) classification was A in 18 (25.7%), B in 18 (25.7%), C in 25 (35.7%), and D in 9 (12.9%). Technical success was achieved in 68 (97%) with low rates of intraprocedural (10%) and postprocedural (4%) complications as well as initial clinical improvement in 61 (87%) patients. Over a median follow-up of 22.9 months following SPTAS, 2-year primary patency, secondary patency, limb salvage (in patients with CLI), and survival were 33% ± 7%, 63% ± 7%, 87% ± 9%, and 88% ± 5%, respectively. Cox proportional hazard modeling showed that SPTAS within 180 days of the initial endovascular intervention was the only significant predictor of failure of primary patency (hazard ratio, 2.65; 95% confidence interval, 1.4-5.2) and secondary patency (hazard ratio, 3.1; 95% confidence interval, 1.4-7.1) of SPTAS.
Second-time femoropopliteal angioplasty/stenting has excellent technical success but limited midterm primary and secondary patency. Early failure of the initial endovascular intervention strongly predicts poor outcome following SPTAS and in this cohort was more significant than comorbidities, anatomic factors, or procedural characteristics. These data suggest that after early endovascular failure, alternatives to a continued endoluminal strategy should be adopted.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2011; 53(3):651-7. · 3.52 Impact Factor
[show abstract][hide abstract] ABSTRACT: The optimal method of operative management of complex branch renal artery aneurysms (RAAs) remains unclear, with recent reports predominantly espousing endovascular and ex vivo repair. We sought to determine the long-term outcome of RAA repair performed with autogenous in situ techniques.
This was a cohort study of patients undergoing surgical repair of RAAs identified from our prospective vascular division registry (1984-2009).
Twenty-six RAAs were repaired in 24 patients (17 women, 7 men; mean age, 52 ± 16 years). Mean size was 2.3 ± 0.7 cm (range, 0.7-4.0 cm). Twenty RAAs were repaired based on size and six for hypertension alone. Multiple RAAs were present in 13 patients (54%). Associated conditions included hypertension in 24 (100%), fibromuscular dysplasia in 6 (25%), coexistent renal artery stenosis in 6 (25%), and aortic aneurysm in 3 (12.5%). Reconstruction of first- or second-order branches was required in 25 RAAs (96%). In situ techniques were used in 22 repairs and included resection combined with autogenous vein bypass and interposition in 11, primary anastomosis to conjoined outflow vessels in 3, and aortic reimplantation in 2. Aneurysmorrhaphy was combined with vein patch angioplasty in 6, exclusion in 2, tailored primary closure in 1, and autogenous bypass in 1. Four patients underwent ex vivo reconstruction. Perioperative mortality was 0% and morbidity was 11.5%, including one nephrectomy during ex vivo repair for immediate thrombosis. Renal function was preserved (preoperative creatinine, 0.94 ± 0.3 vs postoperative creatinine 1.06 ± 0.4 mg/dL; P = .11). Systolic (SBP) and diastolic blood pressure (DBP) control improved after operation: preoperative SBP 142 ± 18 vs postoperative SBP 130 ± 15 mm Hg (P = .007) and preoperative DBP 86 ± 14 vs postoperative DBP 78 ± 10 mm Hg (P = .01). Long-term patency was evaluated in 18 reconstructions (69%) by duplex imaging or contrast radiography at an average long-term follow-up of 99 months (range, 1-300 months) and was 94%. Five-year freedom from rupture and survival by the Kaplan-Meier method was 100%.
In situ techniques allow repair of complex RAAs involving branch vessels with minimal morbidity, improved blood pressure control, and maintenance of renal function. This operative approach further provides excellent long-term patency and survival in this relatively young patient population.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2011; 53(3):684-91. · 3.52 Impact Factor
[show abstract][hide abstract] ABSTRACT: Major amputation is often selected over infrainguinal bypass in patients with severe systemic comorbidities because it is assumed to have lower perioperative risks, yet this assumption is unproven and largely unexamined.
The 2005 to 2008 National Surgical Quality Improvement Project (NSQIP) database was used to identify all patients undergoing either infrainguinal bypass or major amputation using procedural codes. Patients with systemic or local infections were excluded. A subset of high-risk patients were then defined as American Society of Anesthesiologists (ASA) class 4 or 5, or ASA class 3 with renal failure, dyspnea at rest, ventilator dependence, recent congestive heart failure, or recent myocardial infarct. Propensity score matching was used to obtain two high-risk patient groups matched for preoperative characteristics.
No significant differences in demographic, preoperative, or anesthetic variables were found between the matched, high-risk amputation or bypass groups (792 and 780 patients, respectively). Bypass was associated with a lower 30-day postoperative mortality than amputation (6.54% vs 9.97%; P = .0147). Amputation was associated with higher rates of pulmonary embolism (0.9% vs 0% for amputation vs bypass groups, respectively; P = .009) and urinary tract infection (5.2% vs 2.7%; P = .01), while bypass was associated with higher rates of return to the operating room (14.1% vs 27.6%; P < .001) and a trend toward higher postoperative transfusion requirements (0.9% vs 2.1%; P = .054). The postoperative time to discharge did not differ between the two groups.
The decision to perform an infrainguinal bypass or amputation should depend on well-established predictors of graft patency and functional success rather than presumptions about different perioperative risks between the two procedures.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2011; 53(5):1251-1259.e1. · 3.52 Impact Factor
[show abstract][hide abstract] ABSTRACT: Thoracic aortic wall disruptions may occur secondary to trauma, surgical interventions, infection, or autoimmune or idiopathic inflammatory disorders. Such vessel wall disruption can lead to aortic dissections, aneurysm development, or more commonly, pseudoaneurysm (PSA) formation. Although aortic wall infections as an antecedent to mycotic aneurysms have been recognized since the 17th century, there has been a temporal evolution in the development of this disease. Prior to the antibiotic era they were commonly associated with endocarditis or syphilis. More recently, however, they are associated with infection of a damaged atherosclerotic area of the aorta and secondary hematogenous or contiguous seeding. We report the first case of the rapid development of a pseudoaneurysm in the descending thoracic aorta attributable to an infection of a contiguous esophageal duplication cyst by a diagnostic esophageal ultrasound (EUS) fine-needle aspiration. A literature review of mycotic thoracic aortic aneurysms and pseudoaneurysms is also presented.
Vascular and Endovascular Surgery 11/2010; 44(8):697-700. · 0.88 Impact Factor