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Mark Fillinger

Publications and source records attributed to Mark Fillinger.

8 recordsLinked to original sources
PubMed2006

Are type II endoleaks after endovascular aneurysm repair endograft dependent?

PURPOSE: Most clinical end points after endovascular aneurysm repair (EVAR) are endograft-specific, but type II endoleaks have been assumed to be an unavoidable consequence of the repair method and independent of the type of endograft used. Some recent data have suggested that the rate of type II endoleaks may also be graft-dependent. We reviewed a large clinical experience with six endografts to determine the behavior of type II endoleaks and whether they are graft-specific. METHODS: All elective EVAR cases from five university institutions from 1996 to 2003 were retrospectively analyzed. Endografts used in <50 patients were excluded. Endoleaks were diagnosed and classified from contrast-enhanced computed tomography (CT) scans by the treating surgeons. Results of angiography and interventions for endoleaks were tracked. The rate of type II endoleaks was compared among endografts at 1, 6, and 12 months, and yearly thereafter. Statistical significance was defined as P < .05. RESULTS: During the study period, 1909 patients underwent elective EVAR and had an adequate imaging follow-up at one of the specified time points. At 1 month, the overall rate of type II endoleak was 14.0% (range, 9.8% to 25.2%.) The Excluder had a significantly higher incidence of type II endoleaks at 1 month but was similar to most other grafts during longer follow-up. At 6 months, the overall rate of type II endoleak was 16.3% (range, 8.3% to 16.8%). The Talent and Lifepath had an apparent lower initial rate of type II leaks, but this was only significant for the Talent at 6 months compared with Excluder, Zenith, and Ancure, and at 1 year compared with Excluder and Zenith. No graft had a long-term statistically significant difference in the rate of type II endoleak formation. Intervention rates varied by institution and graft type but in general were quite low. Of 25 successful interventions (Ancure, 12; AneuRx, 8; Excluder, 2; Lifepath, 2; Zenith, 1; Talent, 0), 21 were performed during the first year. Interim spontaneous resolution, defined as a negative CT scan after a CT positive for endoleak, was high, especially in the first year. Resolution of type II endoleaks occurred in 54 (33%) of 164 between 1 and 6 months, in 37 (33%) of 112 between 6 and 12 months, in 20 (35%) of 57 from 12 to 24 months, and in 5 (20%) of 25 between 24 and 36 months. The various grafts had a nearly identical pattern, but the rates were highest for the Talent. Late appearing endoleaks, defined as a positive CT after a negative CT, were frequent. At 6 months, 44 (30%) of 147 type II endoleaks were newly diagnosed. The rates were 37 (35%) of 107 at 12 months, 15 (27%) of 56 at 2 years and 5 (25%) of 20 at 3 years. No conversions to open repair for type II endoleaks were noted in the first 4 years. The thrombus burden could not be determined in this analysis. CONCLUSIONS: Type II endoleaks occur in nearly 15% of patients treated by EVAR. The early incidence varies only slightly with graft type. The long-term prevalence and clinical significance are masked by different treatment patterns, spontaneous resolution, newly evident endoleaks, and aneurysm size at initial treatment.

Adult↗
PubMed2006

Three-dimensional analysis of enlarging aneurysms after endovascular abdominal aortic aneurysm repair in the Gore Excluder Pivotal clinical trial.

OBJECTIVE: Recent reports have raised concern about the percentage of enlarging abdominal aortic aneurysms (AAAs) after endovascular repair with the Gore Excluder device. As part of the investigation into this issue, a morphologic analysis was performed on enlarging aneurysms in the Excluder Pivotal clinical trial. METHODS: Computed tomographic scans were evaluated on all patients identified with enlarging aneurysms (5-mm increase by Core laboratory or site) and at least 4 years of follow-up in the Excluder Pivotal clinical trial. Three-dimensional reconstruction, a set of 24 standard morphologic measurements, and analysis of potential enlargement mechanisms were performed. RESULTS: Of 112 trial patients with 4 years of follow-up, 38 AAAs (34%) were identified as enlarging. Data were obtained from 196 computed tomographic scans (the mean interval was 47 months from first to last scan). Of the 158 scans with a prior scan for comparison, 41% demonstrated growth relative to the initial scan by diameter criteria, but 79% demonstrated growth relative to the initial scan by 3-dimensional volume criteria (P < .0001 vs diameter; chi2 analysis). This difference was most evident at early time points: at 1 year, diameter criteria indicated that 8% of these AAAs were enlarging, but 56% were already enlarging by volume criteria. On average, enlargement was detected by volume 18 months before it was detected by diameter (P < .0001), and at a smaller diameter (55 +/- 1 mm vs 60 +/- 1 mm; P < .0001). Only 19% of scans (39% of patients) had apparent endoleaks. Scans with apparent endoleaks demonstrated a greater interval rate of growth as compared with those without apparent endoleak (3.6 +/- 0.8 mm vs 1.9 +/- 0.3 mm [P < .02] by diameter; 23 +/- 4 cm3 vs 11 +/- 1 cm3 [P < .001] by volume). Although the etiology of enlargement may be endotension or device permeability in up to 74% of patients, other potential causes of aneurysm enlargement included neck apposition length less than 15 mm (15 patients; 39%), large aortic diameter relative to device (18%), large iliac diameter (5%), and iliac apposition length less than 15 mm (20%). Multiple potential etiologies of enlargement were present in 53% of AAAs. CONCLUSIONS: The etiology of aneurysm enlargement in the Excluder Pivotal trial is likely multifactorial, including endoleak, inadequate attachment site length, and endotension or device permeability. Even by conservative criteria, a substantial percentage of aneurysm growth with the original device is likely due to material permeability. Three-dimensional volume criteria detected aneurysm enlargement more frequently, at a smaller diameter, and on average 18 months sooner than standard diameter criteria, thus suggesting a role in further investigation of this issue.

Angioplasty↗
PubMed2006

Comparison of embolization protection device-specific technical difficulties during carotid artery stenting.

BACKGROUND: Embolic protection devices (EPDs) consisting of an internal carotid artery (ICA) filter or balloon occlusion are typically used during carotid artery stenting (CAS). This study compares the technical difficulties encountered using these two types of EPD. METHODS: A retrospective review was conducted of patients undergoing CAS using a balloon occlusion EPD (balloon group: PercuSurge GuardWire) or filter EPD (filter group: Accunet, AngioGuard, or FilterWire). Complications were defined as minor stroke, National Institutes of Health (NIH) stroke scale <3; major stroke, NIH stroke scale > or =3; transient ischemic attack (TIA), reversible focal neurologic impairment; technical, reversible neurologic compromise during EPD deployment, inability to cross lesion, ICA spasm requiring treatment, EPD-related factors that prolonged CAS. RESULTS: CAS (n = 141) was performed in 133 patients (82% men) with a mean age of 72 of years. Comorbidities included diabetes, 35%; coronary artery disease, 75%; hypertension, 82%; and renal insufficiency, 15%. Indication was previous cerebrovascular accident in 10%, TIA in 29%, and asymptomatic >80% stenosis in 61%. Primary lesions were treated in 83% vs restenosis in 17%. The 30-day event rate was 1.4% major stroke, 2.1% minor stoke, 1.4% myocardial infarction, and 0.7% death. The overall combined 30-day stroke, death, and myocardial infarction rate was 5.6%. The 30-day stroke and death rate was 4.0% in the balloon group (n = 99) and 4.6% in the filter group (n = 42, P = .51). EPD-related technical difficulties occurred in 15% of the balloon group and 31% of the filter group (P < .05). Technical difficulties included a 10% incidence of reversible neurologic compromise during balloon deployment compared with 0% in the filter group (P = .002) and 12% incidence of inability to cross the lesion before predilation in the filter group compared with 0% in the balloon group (P = .001). CONCLUSIONS: During CAS, both balloon occlusion and filter devices provide acceptable results and appear complimentary. Filters can be used preferentially to avoid a 10% incidence of reversible neurologic compromise associated with balloon occlusion, except in critically narrowed or tortuous lesions when balloon occlusion may be preferred because of a 12% need for unprotected predilatation with filters.

Aged↗
PubMed2006

The long-term relationship of wall stress to the natural history of abdominal aortic aneurysms (finite element analysis and other methods).

For the past four decades, abdominal aortic aneurysm (AAA) rupture risk has been estimated using maximum aneurysm diameter. Although this works relatively well in general, clinicians know that some aneurysms rupture at an unusually small size, while others grow to exceptionally large sizes without rupture. We have demonstrated that finite element analysis (FEA) of AAA wall stress using three-dimensional computed tomography (CT) reconstructions is better than diameter for differentiating AAAs near the time of rupture, and that wall stress is superior to AAA diameter for predicting rupture risk in patients under observation. This article summarizes our current work, future areas of investigation, and issues related to "translational" research for FEA of aortic aneurysms.

Aortic Aneurysm, Abdominal↗
PubMed2004

Early results of carotid stent placement for treatment of extracranial carotid bifurcation occlusive disease.

OBJECTIVE: The purpose of this study was to review the initial results of carotid artery angioplasty with stenting (CAS) performed by vascular surgeons to treat bifurcation occlusive disease. Most patients were selected for CAS if they had indications for endarterectomy (CEA) but were considered at high risk for surgery. METHODS: Since December 2000, 74 carotid arteries in 69 patients underwent CAS, with distal balloon embolization protection in 96%. Mean patient age was 72 years; 82% of patients were men. Indications for CAS included asymptomatic disease (62%), transient ischemic attack (TIA; 23%), and cerebrovascular accident (15%). Mean internal carotid artery diameter stenosis was 82%. CAS was chosen over CEA because of cardiac (49%) or pulmonary (4%) comorbid conditions, hostile neck (25%), distal extent of disease (6%), and contralateral cranial nerve injury (1%). CAS was performed in 15% patients who were good surgical candidates, because of patient preference. Pathologic conditions were primary atherosclerosis (81%), recurrent carotid stenosis (18%), and dissection (1%). Procedures were transfemoral in 95% of cases and transcarotid in 5%. In 30% of cases the contralateral carotid artery had 80% or greater stenosis or was completely occluded. RESULTS: Technical success was achieved in 96% of cases. There were no deaths, no major strokes, one minor stroke (National Institutes of Health Stroke Scale, 3), and one TIA (neurologic event rate, 2.6%). The single minor stroke resolved completely by 1 month. One patient (1.3%) had a perioperative myocardial infarction. Transient neurologic changes occurred in 8% of patients during the protection balloon inflation, and all resolved with deflation. Bradyarrhythmia requiring pharmacologic treatment occurred in 14% of patients. At mean follow-up of 6 months there have been two instances of recurrent stenosis greater than 50% as noted at duplex scanning. During the same period, 266 carotid CEAs were performed, with a neurologic event rate of 0.8% (major stroke, 0.4%; no minor strokes; TIA, 0.4%) and a myocardial infarction rate of 3%. Combined stroke and death rate was 1.3% in patients who underwent CAS and 0.5% in patients who underwent CEA. CONCLUSION: CAS with cerebral protection can be performed safely in patients at high surgical risk, with low perioperative morbidity and mortality. The durability of the procedure must be determined with longer follow-up.

Aged↗