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Biomedical subjects

Frank J Veith

Publications and source records attributed to Frank J Veith.

At least 19 recordsLinked to original sources
PubMed2004

Discontinuous, staccato growth of abdominal aortic aneurysms.

BACKGROUND: To evaluate whether abdominal aortic aneurysm (AAA) growth in individual patients can be characterized as continuous or discontinuous (staccato). STUDY DESIGN: From 1996 to 2002, 609 patients presented with unruptured AAAs. Of these, 278 underwent prompt repair and 331 were observed. In this study, we included 52 patients (16% of the latter group) who had at least four CT scans and were observed for 18 months or longer without any intervention. AAA growth was defined as any increase in diameter of >/= 3 mm over any observation period(s). AAA nongrowth was defined as absence of growth for at least 6 months. Staccato growth was defined as at least one period of nongrowth combined with at least one period of growth. RESULTS: The 52 patients had a mean age of 75 +/- 8 (SD) years. The mean observation period was 42 +/- 20 months and the mean AAA diameter growth rate was 3.6 +/- 2.4 mm/y. Only 12 of these 52 patients (23%) demonstrated continuous growth. Staccato growth occurred in 34 patients (65%). Six patients (12%) showed no growth at all over 18 to 57 months (mean 30 months). No correlation was observed between initial diameter of AAAs and a patient's individual growth rate during the whole observation period (R = 0.04, p = 0.46). CONCLUSIONS: Individual AAA behavior is usually characterized by periods of nongrowth alternating with periods of growth, ie, staccato growth. Some aneurysms may have long periods of nongrowth. Accordingly, management decisions cannot be based on the presumption that observed growth rates of AAAs can be extrapolated to predict future growth rates.

Aged↗
PubMed2004

System to decrease length of stay for vascular surgery.

OBJECTIVES: Reduction of length of stay (LOS) is critical for optimal use of hospital resources. We developed and evaluated a system to aggressively reduce LOS for vascular surgery. METHOD: Key to this system, which we introduced on January 1, 2001, was appointment of a LOS officer, who communicated daily during hospitalization with patients and families about discharge planning, organized outpatient services for wound care and rehabilitation to transition patients quickly to nonhospital care, and had biweekly meetings with relevant paramedical services. LOS for 509 patients operated on in 2000 (standard group) was compared with LOS for 474 operated on in 2001 and 595 patients operated on in 2002 (LOS reduction groups). Data for all patients with aortic aneurysm, carotid artery stenosis, lower extremity critical ischemia or amputation, and foot debridement were included. RESULTS: LOS in 2000 averaged 8.5 days, compared with 5.9 days in 2001 and 5.6 days in 2002. All decreases in LOS for each diagnostic category in 2001 and 2002 were statistically significant (P = <.001-.03). There was no significant increase in readmission rate (2.2% vs 1.9% and 2.0%, respectively), mortality rate (0.8% vs 0.6% and 0.7%, respectively), or percent of patients who received endovascular treatment (18% vs 16% and 14%, respectively). These decreases in LOS saved the hospital more than US dollars 616200 in 2001, and US dollars 847550 in 2002 (US dollars 500/patient-day). CONCLUSIONS: A committed LOS officer with major specific daily responsibilities for decreasing LOS and discharging patients resulted in a 31% to 33% decrease in LOS, with important cost savings to the hospital and no negative effect on patient care.

Aged↗
PubMed2004

Variability of maximal aortic aneurysm diameter measurements on CT scan: significance and methods to minimize.

OBJECTIVES: We noted substantial differences when measuring repeatedly the same abdominal aortic aneurysm (AAA) on the same computed tomography (CT) scan. This study quantitated this variability, and methods to minimize it were developed. METHODS: The CT maximal diameter of 25 AAAs was measured by eight experienced observers, including six vascular surgeons and two radiologists, using two methods: an unstandardized protocol, and a standardized protocol using fine calipers to carefully measure the largest diameter perpendicular to the estimated aneurysm centerline, from outer aneurysm wall to outer wall. The average measurement difference between observers was calculated for each method. The average difference between each observer's measurement and the official radiology report value was also calculated. Agreement between the two measurement methods was assessed with Bland-Altman plots. RESULTS: The difference in maximal diameter measurements between each observer averaged 4.0 +/- 5.1 mm (range, 0.0-35.0 mm) with the unstandardized method. The mean measurement difference with the standardized protocol was significantly lower, and averaged 2.8 +/- 4.4 mm (range, 0.0-26.0 mm; P<.05). Measurements taken from the official radiology report differed from each of the observer's standardized measurement by an average of 5.0 +/- 6.3 mm (range, 0.0-28.0 mm). This difference was similar for both the unstandardized and standardized methods. Bland-Altman plots confirmed the wide variation of the maximal diameter measurements when the unstandardized method was compared with the standardized method (95% confidence interval, -9-9 mm). CONCLUSIONS: Routine CT maximal diameter measurement of AAAs can have substantial interobserver variability. Standardized measurement protocols can decrease, but not eliminate, this measurement variability. Thus apparent size changes based on CT measurements may represent measurement artifact rather than actual aneurysm growth or shrinkage, particularly when a standardized system is not used.

Aortic Aneurysm, Abdominal↗
PubMed2004

Predicting aneurysm enlargement in patients with persistent type II endoleaks.

OBJECTIVE: The clinical significance of type II endoleaks is not well understood. Some evidence, however, indicates that some type II endoleaks might result in aneurysm enlargement and rupture. To identify factors that might contribute to aneurysm expansion, we analyzed the influence of several variables on aneurysm growth in patients with persistent type II endoleaks after endovascular aortic aneurysm repair (EVAR). METHODS: In a series of 348 EVARs performed during a 10-year period, 32 patients (9.2%) developed type II endoleaks that persisted for more than 6 months. Variables analyzed included those defined by the reporting standards for EVAR (SVS/AAVS) as well as other endoleak characteristics. Univariate, receiver operating characteristic curve, and Cox regression analyses were used to determine the association between variables and aneurysm enlargement. RESULTS: The median follow-up period was 26.5 months (range, 6-88 months). Thirteen patients (41%) had aneurysm enlargement by 5 mm or more (median increase in diameter, 10 mm), whereas 19 (59%) had stable or shrinking aneurysm diameter. Univariate and Cox regression analyses identified the maximum diameter of the endoleak cavity, ie, the size of the nidus as defined on contrast computed tomography scan, as a significant predictor for aneurysm enlargement (relative risk, 1.12; 95% confidence interval, 1.04-1.19; P =.001). The median size of the nidus was 23 mm (range, 13-40 mm) in patients with aneurysm enlargement and 8 mm (range, 5-25 mm) in those without expansion (Mann-Whitney U test, P <.001). Moreover, receiver operating characteristic curve and Cox regression analyses showed that a maximum nidus diameter greater than 15 mm was particularly associated with an increased risk of aneurysm enlargement (relative risk, 11.1; 95% confidence interval, 1.4-85.8; P =.02). Other risk factors including gender, smoking history, hypertension, need of anticoagulation, aneurysm diameter, type of endograft used, and number or type of collateral vessels were not significant predictors of aneurysm enlargement. CONCLUSIONS: In patients with persistent type II endoleaks after EVAR, the maximum diameter of the endoleak cavity or nidus is an important predictor of aneurysm growth and might indicate the need for more aggressive surveillance as well as earlier treatment.

Aged↗
PubMed2004

A new approach to carotid angioplasty and stenting with transcervical occlusion and protective shunting: Why it may be a better carotid artery intervention.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness and demonstrate the advantages of a new technique for carotid angioplasty and stenting (CAS) with proximal cerebral protection through a direct transcervical approach, as compared with a percutaneous transfemoral approach. METHODS: CAS procedures were carried out in 25 consecutive patients, 4 with the femoral approach and 21 through a 2-cm incision at the base of the neck, with the patient under local anesthesia. For transcervical occlusion and protective shunting (TOPS), a short 9F sheath was inserted directly into the common carotid artery and connected to a 6F sheath placed percutaneously in the ipsilateral internal jugular vein. After clamping the common carotid artery proximal to the 9F sheath, internal carotid artery blood flow reversal was confirmed or an occluding external carotid balloon was placed. A filter interposed between the arterial and venous sheaths collected embolic debris from transcarotid manipulations. The arterial puncture was directly repaired with suture. Neurologic status was assessed with the National Institutes of Health stroke scale by an independent neurology consultant before and after the procedure. RESULTS: One of the four percutaneous femoral approaches that failed because of tortuous anatomy was successfully treated with TOPS. Angiographic confirmation demonstrating resolution of asymptomatic (>80%; n = 12) stenosis or symptomatic (>60%; n = 12) stenosis was achieved in all patients with stents. A 0% technical failure rate and 0% combined 30-day stroke or mortality rate were achieved in all CAS attempted with TOPS. There were no hematomas in the cervical group, despite pretreatment with clopidogrel bisulfate and heparin, and one hematoma in the femoral group after failure of a Perclose arterial closure device. In one of the patients in the femoral group bilateral cholesterol emboli to the toes developed. CONCLUSION: TOPS solves problems of access, embolization into the cerebral and peripheral circulation, and specialized cerebral protection devices, and enables secure closure of the access vessel in patients given anticoagulation therapy. TOPS may provide a safer, more effective, economical means for performing CAS.

Aged↗
PubMed2004

Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair.

PURPOSE: Hypogastric artery interruption is sometimes required during aortoiliac aneurysm repair. We have not experienced some of the life-threatening complications of pelvic ischemia reported by others. Therefore we analyzed our experience to identify factors that help minimize pelvic ischemia with unilateral and bilateral hypogastric artery interruption. METHODS: From 1995 to 2003, 48 patients with aortoiliac aneurysm required interruption of both hypogastric arteries as part of endovascular (n = 32) or open surgical (n = 16) repair. During endovascular aneurysm repair coils were placed at the origin of the hypogastric arteries, and bilateral hypogastric artery interruptions were staged at 1 to 2 weeks when possible. Open surgery necessitated oversewing or excluding the origins of the hypogastric arteries and extending the prosthetic graft to the external iliac or femoral artery. Collateral branches from the external iliac and femoral arteries were preserved, and patients received systemic heparinization (50 units/kg). RESULTS: There was no buttock necrosis, ischemic colitis requiring colon resection, or death with the bilateral hypogastric artery interruption. Initially buttock claudication developed in 20 patients (42%), but persisted in only 7 patients (15%) at 1 year. New onset of impotence occurred in 4 of 28 patients (14%), and there were no neurologic deficits. CONCLUSIONS: Bilateral hypogastric artery interruptions can be accomplished with limited morbidity. When hypogastric artery interruption is needed during endovascular aneurysm repair, certain principles help minimize pelvic ischemia. These include hypogastric artery interruption at its origin to preserve the pelvic collateral vessels, staging bilateral hypogastric artery interruptions when possible, preserving collateral branches from the femoral and external iliac arteries, and providing adequate heparinization of the patient during these procedures.

Aged↗
PubMed2004

Is elevated creatinine level a contraindication to endovascular aneurysm repair?

PURPOSE: It is widely believed that chronic renal insufficiency (CRI) greatly increases the risk associated with endovascular abdominal aortic aneurysm repair (EVAR) and is a relative contraindication to the procedure and to the use of intra-arterial contrast agents (IACA). We reviewed a 5-year EVAR experience to determine whether the procedure and use of IACA have an important deleterious effect on renal function in patients with and without pre-existing CRI. METHODS: Endovascular aneurysm repair (EVAR) was performed in 200 patients with a variety of endografts, with intra-arterial contrast agents. The patients were retrospectively assigned to three groups on the basis of preoperative serum creatinine concentration (Cr): group 1 (n = 108), Cr less than 1.5 mg/dL (normal range); group 2 (n = 65), Cr 1.5 to 2.0 mg/dL; group 3 (n = 27), Cr 2.1 to 3.5 mg/dL. No patients had undergone hemodialysis. In groups 2 and 3, patients received hydration perioperatively, and received mannitol intraoperatively; no nephrotoxic drugs were administered during the procedure, other than nonionic contrast agent (Omnipaque 350). RESULTS: The incidence of postoperative complications between the three study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in three patients (2.7%), two of whom (1.9%) required temporary hemodialysis and one (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in two patients (3.1%); both patients (3.1%) required temporary hemodialysis, and one patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in two patients (7.4%); one patient (3.7%) required temporary hemodialysis, and one patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (P <.05), and larger contrast volume was associated with an increase in serum Cr (P <.05) during the postoperative period. CONCLUSIONS: EVAR with intra-arterial contrast agents can be accomplished in patients with chronic renal insufficiency who do not require dialysis, with limited and acceptable morbidity and mortality, similar to that observed with open aneurysm repair. Contrary to other reports in which perioperative precautions were not used, our study shows that with EVAR the risk for worsening renal failure, dialysis, and death is only slightly, and not significantly, greater in patients with preoperative chronic renal insufficiency compared with patients with normal renal function. Perioperative hypotension and increased contrast volume are significant risk factors for postoperative increase in serum Cr and death. With appropriate precautions such as averting perioperative hypotension and limiting the volume of nonionic contrast agents, elevated Cr need not be a contraindication to EVAR with intra-arterial contrast agents.

Aged↗
PubMed2004

American board of vascular surgery: the first 7 years.

The American Board of Vascular Surgery (ABVS) was incorporated in 1996 with a vision of improved training standards and certification of vascular surgeons. At that time, 91% of those holding American Board of Surgery Certificates of Added Qualifications in Vascular Surgery supported the formation of the ABVS. Subsequent events have led to a clear definition of specific educational issues important to the vascular surgery community. Unresolved issues relate to the need to complete a general surgery residency before beginning a vascular surgery fellowship, the continued inclusion of vascular surgery as a primary component of general surgery training, and the absence of a designated Residency Review Committee for Vascular Surgery. These issues have persisted since the inception of the ABVS. An application for the ABVS to become an American Board of Medical Specialties (ABMS) primary board was submitted in 2002 with a preliminary hearing before a liaison committee composed of American Medical Association and ABMS members. The American Board of Surgery (ABS) and a minority of the vascular surgery community vigorously opposed the application. The perceived divisiveness created by their actions contributed to the application's initial rejection and the necessity for an appeal. Certain ABS directors have recently stated that they would consider approving multiple track-type training that could allow single certification in vascular surgery, following 5 to 6 years of postgraduate training after medical school. The ABVS cautiously supports this action, recognizing that this radical change for the ABS may not be feasible given the broad-ranging interests of general surgery and restrictive ABMS guidelines for certifying medical specialists. The impact of not resolving the critical issues facing vascular surgery in a timely manner is that there will be inadequate numbers of competent vascular surgeons to provide for society's needs. An independent ABMS-approved ABVS provides a clear opportunity to resolve the recognized failings of the status quo.

Education, Medical, Graduate↗
PubMed2004

Fate of collateral vessels following subintimal angioplasty.

PURPOSE: To evaluate the fate of collateral vessels adjacent to and within the target lesion following subintimal angioplasty (SIA). METHODS: Pre and postprocedural angiograms were reviewed for 29 patients undergoing SIA of the lower extremity arteries over a 3-year period. The number of patent collateral vessels </=5 cm proximal to the occlusion (proximal segment) and </=5 cm distal to the occlusion (distal segment) were recorded pre and postprocedurally and compared. In addition, the number of collateral vessels that were re-opened within the recanalized segment following SIA was counted. RESULTS: The mean number of patent collaterals in the proximal segment was 1.9 (range 0-4) preprocedurally and 1.4 (range 0-4) postprocedurally (p<0.002). The mean number of patent collaterals in the distal segment was 1.9 (range 0-4) pre-procedurally and 1.0 (range 0-4) postprocedurally (p<0.0001). Previously absent collaterals within the recanalized segment were observed in 4 (14%) of 29 patients post-SIA. The mean number of collateral vessels within all 3 segments (proximal, treated, and distal) was 3.9 collaterals preprocedurally and 2.9 collaterals postprocedurally. CONCLUSIONS: Some collateral vessels are sacrificed during SIA, but the majority are preserved. In addition, SIA has the potential to open new collaterals within the occluded segment. These collaterals may play an important role should restenosis develop within the target segment.

Aged↗
PubMed2003

Vascular surgery won a battle but is losing the war: a call to arms for every vascular surgeon.

This paper describes the present status of the initiative to obtain American Board of Medical Specialties (ABMS) approval of an independent American Board of Vascular Surgery (ABVS). The need for such a board arises from the evolution of vascular surgery into a distinct, well-defined specialty that deals with all aspects of vascular disease, including knowledge of its natural history, all methods of noninvasive and invasive diagnosis, conservative and medical treatment, open operative treatment, endovascular treatment, and periprocedural care. Because of the greater skill requirements and increased complexity of vascular surgery, its paradigms of training must be changed. Longer periods of vascular training are required with a reciprocal 2- to 3-year shortening of training in general surgery. This cannot be done without an independent ABVS. The effort to obtain ABVS approval has elicited opposition from the American Board of Surgery (ABS) and from some vascular surgery leaders associated with it, making the ABVS a contentious issue. A successful effort was made to reach consensus within vascular surgery, and the ABVS application was submitted to the ABMS. As a result of an ABS campaign that combined pressure and dire warnings, this application encountered intense opposition within the ABMS and its Liaison Committee for Specialty Boards (LCSB). Institutional and professional self-interest, rather than quality of patient care, appeared to be the overriding considerations in the ABS argument. Measures to overcome this ABS opposition and obstructionism are proposed. They require unity, action, and tangible support from all vascular surgeons. If this call to arms goes unheeded, vascular surgery will not continue to be the self-sufficient specialty it has become and, most importantly, patient care will suffer.

General Surgery↗
PubMed2003

Detection of endoleaks after endovascular repair of abdominal aortic aneurysm: value of unenhanced and delayed helical CT acquisitions.

PURPOSE: To assess unenhanced and delayed phase computed tomographic (CT) images combined with arterial phase images for detecting endoleaks after endovascular treatment for abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: CT scans were retrospectively evaluated for the presence of endoleaks after endovascular treatment of AAAs in 33 patients with endoleak (positive group) and 40 patients without evidence of endoleak or aneurysm enlargement (negative group). All patients underwent unenhanced and biphasic contrast material-enhanced CT. The CT scans were reviewed in the following combinations: (a) arterial phase and unenhanced scans (uniphasic/unenhanced set), (b) arterial and delayed phase scans only (biphasic set), and (c) arterial and delayed phase scans with unenhanced scans (complete set). Each set was reviewed by two radiologists blinded to the diagnosis of endoleak. Findings were recorded as positive, negative, or indeterminate for endoleak. RESULTS: Within the positive group, endoleaks were diagnosed with the uniphasic/unenhanced, biphasic, and complete image sets in 30 (91%), 32 (97%), and 33 (100%) patients, respectively. With the uniphasic/unenhanced set, three (9%) endoleaks (seen only on delayed phase images) were missed. With the biphasic set, one (3%) endoleak was interpreted as indeterminate. Within the negative group, uniphasic/unenhanced, biphasic, and complete image sets were negative for endoleaks in 100%, 80%, and 100% of patients, respectively. With the biphasic set, results were indeterminate in 20% of cases. CONCLUSION: A delayed CT acquisition enables detection of additional endoleaks, while an unenhanced acquisition helps eliminate indeterminate results. Thus, both acquisitions contribute to accurate diagnosis of endoleaks when combined with an arterial phase acquisition.

Aged↗
PubMed2003

Delayed open conversion following endovascular aortoiliac aneurysm repair: partial (or complete) endograft preservation as a useful adjunct.

OBJECTIVES: The purpose of this study was to review our experience with delayed open conversion (>30 days) following endovascular aortoiliac aneurysm repair (EVAR) and to introduce the concept and advantages of endograft retention in this setting. METHODS: From January 1992 to January 2003, a total of 386 EVARs using a variety of endografts were successfully deployed. Eleven (2.8%) patients required delayed conversion to open repair at an average of 30 months (range, 10-64). Data from all patients undergoing both EVAR and open conversion were prospectively collected. RESULTS: EVARs were performed using grafts made by Talent (4), Vanguard (2,) AneuRx (1), and Surgeon (4). Conversion to open repair (9 transabdominal, 1 retroperitoneal, 1 transabdominal plus thoracotomy) was performed for aneurysm rupture in 7 patients (4 type 1 endoleak, 2 type 2 endoleak, 1 aortoenteric fistula) and aneurysm enlargement in 4 patients (1 type 1 endoleak, 1 type 2 endoleak, 1 type 3 endoleak, 1 endotension). Patients with aneurysm rupture were treated on an emergent basis. Complete removal of the endograft with supraceliac cross-clamping was performed in two cases. One patient (rupture) did not survive the operation, and one patient (aortoenteric fistula) died 2 weeks postoperatively. In the remaining nine cases, the endograft was either completely (1) or partially (6) removed, or left in situ (2). Supraceliac balloon control (2), supraceliac clamping (1), suprarenal clamping (1), or infrarenal clamping (5) was used in these cases. All nine of these patients survived the operation. In one procedure in which the endograft was left intact (endotension), repair was accomplished by exposing the endograft and by placing a standard tube graft over it as a sleeve. In the second procedure in which the graft was left in situ (rupture), the graft was well incorporated, and bleeding lumbar arteries were oversewn and the sac was closed tightly over the endograft. In the remaining 7 cases, the endograft was transected and the proximal portion only (6) or the proximal and distal portions (1) were excised. All surviving patients continue to do well and remain without complications associated with the endograft remnant at a mean follow-up of 22 months (range, 3-56) from the time of open conversion and 46 months (range, 10-73) from the time of original EVAR. CONCLUSIONS: Open repair in the setting of a long-standing endograft offers several unique technical challenges but can be successfully accomplished in most patients. Preservation of all or part of the endograft is possible in many patients. This technique simplifies the operative approach and is preferred over complete endograft removal if possible.

Aged↗
PubMed2003

Open aneurysm repair at an endovascular center: value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms.

OBJECTIVE: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. METHODS: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15%-30%) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55% in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P =.04-.001) in the retroperitoneal group. All factors were correlated with outcome. RESULTS: Despite these risk factors, overall 30-day mortality was 3.5% (retroperitoneal group, 3.8%), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P >.2). CONCLUSION: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.

Academic Medical Centers↗
PubMed2003

Iliac artery stenting in patients with poor distal runoff: Influence of concomitant infrainguinal arterial reconstruction.

OBJECTIVE: Inadequate infrainguinal runoff is considered an important risk factor for iliac stent failure. However, the influence of concomitant infrainguinal arterial reconstruction (CIAR) on iliac stent patency is unknown. This study evaluated the influence of CIAR on outcome of iliac angioplasty and stenting (IAS) in patients with poor distal runoff. METHODS: Over 5 years (1996 to 2001), 68 IAS procedures (78 stents) were performed in 62 patients with poor distal runoff (angiographic runoff score >or=5). The SVS/AAVS reporting standards were followed to define outcome variables and risk factors. Data were analyzed with both univariate analysis (Kaplan-Meier method [K-M]) and regression analysis (Cox proportional hazards model). RESULTS: Indications for iliac artery stenting were disabling claudication (59%) and limb salvage (41%). Of the 68 procedures, IAS with CIAR was performed in 31 patients (46%), and IAS alone was performed in 37 patients (54%). Patients undergoing IAS with CIAR were older (P =.03) and had more extensive and multifocal iliac artery occlusive disease, with more TASC (TransAtlantic Inter-Society Consensus) type C lesions (P =.03), compared with patients undergoing IAS alone. No other significant differences in risk factors were noted. Runoff scores between patients undergoing IAS with CIAR and those undergoing IAS alone were not significantly different (median runoff scores, 6 [range, 5-8] and 7 [range, 5-9], respectively; P =.77). Primary stent patency rate at 1, 3, and 5 years was 87%, 54%, and 42%, respectively, for patients undergoing IAS with CIAR, and was 76%, 66%, and 55%, respectively, for patients undergoing IAS. Univariate analysis revealed that primary stent patency rate was not significantly different between the 2 groups (K-M, log-rank test, P =.81). Primary graft patency rate for CIAR was 81%, 52%, and 46% at 1, 3, and 5 years, respectively. Performing CIAR did not affect primary iliac stent patency (relative risk, 1.1; 95% confidence interval, 0.49-2.47; P =.81). Overall, there was a trend toward improved limb salvage in patients undergoing IAS with CIAR, compared with those undergoing IAS alone (K-M, log rank test, P =.07). CONCLUSION: In patients undergoing IAS with poor distal runoff, CIAR does not improve iliac artery stent patency. Infrainguinal bypass procedures should therefore be reserved for patients who do not demonstrate clinical improvement and possibly for those with limb-threatening ischemia.

Adult↗
PubMed2003

Does transrenal fixation of aortic endografts impair renal function?

OBJECTIVES: Transrenal fixation (TFX) of aortic endografts is thought to increase the risk for renal infarction and impaired renal function. We studied the late effects of TFX on renal function and perfusion. METHODS: Of 189 patients with commercial aortic endografts, which we inserted between 1995 and 2002, we reviewed data for 130 patients (112 men, 18 women) with available creatinine (Cr) concentration and contrast enhanced computed tomography (CT) scans preoperatively and 1 to 97 months after the procedure. Of the 130 patients, 69 patients had TFX and 61 patients had infrarenal fixation (IFX). Both groups were physiologically comparable. Average age was 76 +/- 8 years for patients with TFX and 75 +/- 8 years for patients with IFX. Presence of renal infarct or renal artery occlusion was determined by nephrograms on serial contrast-enhanced CT scans. RESULTS: Mean follow-up was 17 +/- 16 months (range, 1-54 months) for TFX and 21 +/- 21 months (range, 1-97 months) for IFX. Mean serum Cr concentration increased significantly during long-term follow-up in both groups (TFX, 1.3 +/- 0.5 mg/dL to 1.5 +/- 0.8 mg/dL, P <.01; IFX, 1.3 +/- 0.7 mg/dL to 1.4 +/- 0.8 mg/dL, P <.03). Creatinine clearance (CrCl) similarly decreased over long-term follow-up in both groups (TFX, 53.3 +/- 17.7 mL/min/1.73 m(2) to 47.9 +/- 16.2 mL/min/1.73 m(2), P <.01; IFX, 58.1 +/- 22.7 mL/min/1.73 m(2) to 53.1 +/- 23.4 mL/min/1.73 m(2), P <.02). There were no significant differences in the increase in Cr concentration (P =.19) or decrease in CrCl (P =.68) between TFX and IFX groups. Small renal infarcts were noted in four patients (5.8%) in the TFX group and one patient (1.6%) in the IFX group. No increase in Cr concentration or decrease in CrCl was noted in any patient with a renal infarct. Postoperative renal dysfunction developed in 7 of 69 patients (10.1%) in the TFX group and 7 of 61 patients (11.5%) in the IFX group. There were no statistically significant differences between groups with respect to number of patients with new renal infarcts (P =.37) or postoperative renal dysfunction (P =.81). CONCLUSION: There is a slight increase in serum Cr concentration and decrease in CrCl after aortic endografting. However, there was no significant difference in these changes between patients with TFX and IFX. Although TFX may produce a higher incidence of small renal infarcts, these do not impair renal function. Thus our midterm results suggest that TFX can be performed safely, with no greater change in renal function than observed after IFX.

Aged↗
PubMed2003

Endovascular abdominal aortic aneurysm repair to prevent rupture in a patient requiring lithotripsy.

Extracorporeal shock wave lithotripsy (ESWL) for urolithiasis may result in rupture of a coexistent abdominal aortic aneurysm (AAA). We report a patient who required ESWL and who had an AAA. Open surgery was precluded by morbid obesity and persisting incisional hernias after mesh repair. Endovascular AAA repair (EVAR) with bifurcated grafts was precluded by an 11-mm distal aorta. EVAR with stacked tubular AneuRx components was performed, followed by ESWL. The AAA was excluded, and the integrity and position of the endografts were not altered by ESWL.

Aged↗
PubMed2003

Intra-abdominal aortic graft infection: complete or partial graft preservation in patients at very high risk.

BACKGROUND: Total graft excision with in situ or extra-anatomic revascularization is considered mandatory to treat infection involving the body of aortic grafts. We present a series of nine patients with this complication and such severe comorbid medical illnesses or markedly hostile abdomens that traditional treatments were precluded. In these patients selective complete or partial graft preservation was used. METHODS: Over the past 20 years we have treated nine infected infrarenal aortic prosthetic grafts with complete or partial graft preservation, because excision of the graft body was not feasible. In all nine patients infection of the main body of the aortic graft was documented at computed tomography or surgery. Essential adjuncts included percutaneous or operative drain placement into retroperitoneal abscess cavities and along the graft, with instillation of antibiotics three times daily, repeated debridement of infected groin wounds, and intravenous antibiotic therapy for at least 6 weeks. RESULTS: One patient with purulent groin drainage treated with complete graft preservation died of sepsis. One patient with groin infection treated with complete graft preservation initially did well, but ultimately required total graft excision 5 months later, after clinical improvement. In four patients complete graft preservation was successful; two patients required excision of an occluded infected limb of the graft; and one patient underwent subtotal graft excision, leaving a graft remnant on the aorta, and axillopopliteal bypass. In summary, seven of nine patients survived hospitalization after complete or partial graft preservation; amputation was avoided in all but one patient; and no recurrent infection developed over mean follow-up of 7.6 years (range, 2-15 years). CONCLUSIONS: Although contrary to conventional concepts, partial or complete graft preservation combined with aggressive drainage and groin wound debridement is an acceptable option for treatment of infection involving an entire aortic graft in selected patients with prohibitive risks for total graft excision. This treatment may be compatible with long-term survival and protracted absence of signs or symptoms of infection.

Aged↗