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Nicholas J Morrissey

Publications and source records attributed to Nicholas J Morrissey.

At least 19 recordsLinked to original sources
PubMed2006

Analysis of outcomes following failed endovascular treatment of chronic limb ischemia.

Despite recent studies highlighting the advantages of endoluminal intervention in the management of chronic limb ischemia (CLI), outcomes following failed peripheral angioplasty remain less well described. We present a retrospective analysis of failed transluminal infrainguinal percutaneous arterial angioplasty with or without stenting (PTA/S) in patients with CLI. A database of patients undergoing infrainguinal PTA/S between 2002 and 2005 was maintained. Patients underwent duplex scanning follow-up at 2 weeks, 3 months, and every 6 months after the intervention. Angiograms were reviewed in all cases to assess lesion characteristics. Results were standardized to current Transatlantic Inter-Society Consensus (TASC) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. In total, our analysis involved 246 patients who underwent treatment for CLI using PTA/S. Eighteen percent of procedures (n = 46) were considered an intervention failure secondary to restenosis by duplex ultrasound, returning clinical symptoms, a nonhealing foot lesion, or the absence of a prior palpable pulse. Indications for the original procedure in patients whose PTA/S failed were tissue loss in 44%, claudication in 44%, and rest pain in 12%, while TASC lesion grades were A (0%), B (18%), C (18%), and D (64%). Of patients failing PTA/S, 4% failed in the first 30 days, 78% failed between 1 and 18 months, while 18% failed following 18 months, with a mean time to failure of 8.7 months. Also, 82% of PTA/S failures were candidates for a second endovascular procedure, 11% were suitable for only traditional open bypass, and 4% demonstrated progression of disease necessitating amputation. Of patients undergoing a second endovascular procedure, limb salvage rates were 86% at 12-month follow-up and there was a single periprocedural mortality and complication rate of 6.6%. Of patients requiring open surgical bypass after failed PTA/S, 20% (n = 1) required a major amputation and there were no mortalities. Failure of endoluminal therapy for treatment of lower extremity arterial occlusive disease is amenable to subsequent endovascular intervention for limb salvage with limited morbidity and mortality.

Adult↗
PubMed2006

Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms.

INTRODUCTION: The successful application of endovascular techniques for the elective repair of abdominal aortic aneurysms (AAAs) has stimulated a strong interest in their possible use in dealing with a long-standing surgical challenge: the ruptured abdominal aortic aneurysm (RAAA). The use of a conventional open procedure to repair ruptured aneurysms is associated with a high operative mortality of 45% to 50%. In this study, we evaluated the current frequency of endovascular repair of RAAAs in four large states and the impact of this technique on patient outcome. METHODS: We examined discharge data sets from 2000 through 2003 from the four states of California, Florida, New Jersey, and New York, whose combined population represents almost a third of the United States population. Proportions and trends were analyzed by chi2 analysis and continuous variables by the Student's t test. RESULTS: We found that since the year 2000, endovascular repair has begun to emerge as a viable treatment option for RAAAs, accounting for the repair of 6.2% of cases in 2003. During the same period, the use of open procedures for RAAAs declined. The overall mortality rate for the 4-year period was significantly lower for endovascular vs open repair (39.3% vs. 47.7%, P = .005). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of pulmonary, renal, and bleeding complications. Survival after endovascular repair correlated with hospital experience, as assessed by the overall volume of elective and nonelective endovascular procedures. For endovascular repairs, mortality ranged from 45.9% for small volume hospitals to 26% for large volume hospitals (P = .0011). Volume was also a determinant of mortality for open repairs, albeit to a much lesser extent (51.5% for small volume hospitals, 44.3% for large volume hospitals; P < .0001). CONCLUSION: We observed a benefit to using endovascular procedures for RAAAs in institutions with significant endovascular experience; however, the analysis of administrative data cannot rule out selection bias as an explanation of better outcomes. These data strongly endorse the need for prospective studies to clarify to what extent the improved survival in RAAA patients is to be attributed to the endovascular approach rather than the selection of low-risk patients.

Aortic Aneurysm, Abdominal↗
PubMed2006

Analysis of parameters associated with hypotension requiring vasopressor support after carotid angioplasty and stenting.

INTRODUCTION: Systemic hypotension has been observed for up to 36 hours in response to stimulation of the carotid baroreceptor by carotid angioplasty and stenting (CAS). The aim of this study was to identify risk factors and cardiac outcomes for postprocedural hypotension requiring vasopressor support after CAS. METHODS: Between 2003 and 2005, 143 patients (87 men; mean age, 75 years) with high-grade carotid artery stenosis (mean, 87.3%) were treated with CAS and prospectively entered into a vascular registry. Data were retrospectively analyzed to determine factors predictive of hypotension requiring vasopressor support after CAS. Atropine and appropriate intravenous crystalloid solution were administered during CAS. For the first 30 patients, atropine was only used for symptomatic patients but then became routine and was used for all patients with primary carotid stenosis. Hypotension (systolic blood pressure <90 mm Hg or a mean arterial blood pressure <50 mm Hg) unresponsive to conservative measures was treated with vasopressors (phenylephrine or norepinephrine). Patients were stratified into three groups based on hypotension requiring vasopressors: (1) no vasopressors, (2) vasopressors for < or = 24 hours (short duration), and (3) vasopressors for >24 hours (prolonged duration). Risk factors for hypotension requiring vasopressors were analyzed by univariate and multivariate logistic regression analysis. RESULTS: Postprocedural hypotension requiring vasopressor treatment was seen in 16 (11%) of 143 of patients, with 6 (4%) requiring vasopressor support for >24 hours. Mean duration of vasopressor administration for all patients was 17 +/- 10 hours (range, 6 to 36 hours). By univariate analysis, a history of a previous myocardial infarction (P = .02) or use of the PercuSurge occlusion balloon (P = .05) were both associated with increased incidence of short duration (</=24 hours) use of vasopressors, and female sex (P = .03) and age >80 years old (P = .02) were associated with prolonged (>24 hours) vasopressor requirement. On multivariate analysis adjusted for age and sex, a history of myocardial infarction (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.0 to 16.4; P = .05) remained an independent predictor of short-duration vasopressors. On multivariate analysis, female sex (OR, 10.9; 95% CI, 1.2 to 100.4; P = .04) and age >80 years old (OR, 13.8, 95% CI, 1.5 to 127.2; P = .02) remained independent predictors of prolonged vasopressor use. The incidence of periprocedural myocardial infarctions, arrhythmias, or congestive heart failure did not differ between those patients who did not receive vasopressors (5/127) and those who received vasopressors for a short (< or = 24 hours) duration (1/10, P = NS) or prolonged (>24 hours) duration (0/6, P = NS). CONCLUSION: Prolonged hypotension requiring vasopressor support occurs in a minority of patients after CAS, with higher incidences in older women. In contrast, hypotension requiring a more limited duration of vasopressor use occurs more commonly in patients who had a prior myocardial infarction, independent of age or sex. In this cohort of patients, vasopressors required for hypotension were not associated with an increased incidence of periprocedural cardiac complications. Despite the increased incidence of prolonged hypotension in older women, this study demonstrates that CAS can be performed without an increase in cardiac morbidity in older women.

Aged↗
PubMed2006

Simulation improves resident performance in catheter-based intervention: results of a randomized, controlled study.

OBJECTIVES: Surgical simulation has been shown to enhance the training of general surgery residents. Since catheter-based techniques have become an important part of the vascular surgeon's armamentarium, we explored whether simulation might impact the acquisition of catheter skills by surgical residents. METHODS: Twenty general surgery residents received didactic training in the techniques of catheter intervention. Residents were then randomized with 10 receiving additional training with the Procedicus, computer-based, haptic simulator. All 20 residents then participated in 2 consecutive mentored catheter-based interventions for lower extremity occlusive disease in an OR/angiography suite. Resident performance was graded by attending surgeons blinded to the resident's training status, using 18 procedural steps as well as a global rating scale. RESULTS: There were no differences between the 2 resident groups with regard to demographics or scores on a visuospatial test administered at study outset. Overall, residents exposed to simulation scored higher than controls during the first angio/OR intervention: procedural steps (simulation/control) (50 +/- 6 vs. 33 +/- 9, P = 0.0015); global rating scale (30 +/- 7 vs. 19 +/- 5, P = 0.0052). The advantage provided by simulator training persisted with the second intervention (53 +/- 6 vs. 36 +/- 7, P = 0.0006); global rating scale (33 +/- 6 vs. 21 +/- 6, P = 0.0015). Moreover, simulation training, particularly for the second intervention, led to enhancement in almost all of the individual measures of performance. CONCLUSION: Simulation is a valid tool for instructing surgical residents and fellows in basic endovascular techniques and should be incorporated into surgical training programs. Moreover, simulators may also benefit the large number of vascular surgeons who seek retraining in catheter-based intervention.

Angiography↗
PubMed2006

Safety and efficacy of carotid angioplasty and stenting in high-risk patients.

Performance of carotid endarterectomy (CEA) may be associated with an increased risk in patients with significant comorbid medical conditions, neck irradiation, or previous CEA. This study compared the results of CEA with carotid angioplasty and stenting (CAS) in high-risk patients treated for carotid stenosis. Five hundred forty-five patients who underwent CEA and 148 patients who underwent CAS were evaluated. For patients undergoing CEA, general anesthesia was used in 91 per cent, electroencephalographic monitoring was used in 63 per cent, and shunting was performed in 19.8 per cent. Cerebral protection devices were used in 145/148 of CAS cases, and self-expanding stents were used in all cases. Evaluated end points included major cardiovascular events, and a composite of death, stroke, or myocardial infarction for the duration of the follow-up. Mean follow-up was 18 months for CAS and 23 months for CEA. Significant differences were present in patient age (CAS, 75 +/- 11.0 years vs CEA, 71 +/- 9 years, P = 0.012), however, there were no significant differences (P = NS) in gender or smoking history. The mean modified Goldman Score was significantly higher for CAS (21.1 +/- 14.8 [95% confidence interval = 18, 24]) than for CEA (6.3 +/- 6.8 [95% confidence interval = 5.7, 6.9]; P = 0.0001) patients. The incidence of periprocedural complications did not vary significantly between patients treated with CAS (CVA, 1.4%; myocardial infarction [MI], 1.4%; death, 0.7%; CVA/MI/death, 3.4%) compared with CEA (CVA, 1.8%; MI, 1.1%; death, 0.4%; CVA/MI/death, 4.0%). CAS is equivalent to CEA in safety and efficacy, even when performed in patients who may be at increased surgical risk.

Age Factors↗
PubMed2005

Percutaneous endovascular treatment for chronic limb ischemia.

Percutaneous transluminal methods of revascularization for chronic limb ischemia have traditionally been used as an adjunctive or secondary mode of treatment. This study examines the outcomes of patients treated via endovascular methods as the primary form of treatment. The records of 66 patients (average age, 71.3 years; range, 53 to 92) with chronic limb ischemia treated from November 2000 to January 2002 at a single institution with endovascular methods were retrospectively reviewed. Thirty-one patients had disabling claudication, 15 had rest pain, 17 had minor tissue loss, and 3 had major tissue loss. There were 94 lesions in the 66 limbs: 45 lesions in the superficial femoral artery, 28 lesions in the popliteal artery, and 21 lesions in tibial arteries. Occlusive lesions were treated by subintimal angioplasty. Stenoses were treated by percutaneous transluminal angioplasty (PTA). The median length of the lesions was 12 cm. Forty-six stents were placed in 32 patients; 34 patients did not receive stents. The approach was contralateral in 71% (47/66) and ipsilateral in 29% (19/66) of cases. Patients were followed up with physical exam, anklebrachial index (ABI), and duplex ultrasonography. Post-intervention medical treatment included aspirin and clopidogrel. Long-term patency was correlated with age, comorbidities, risk factors, and the use of stents in addition to angioplasty. Endovascular treatment was technically successful in 65 of 66 patients (98%). Residual stenosis (<30%) was found in three cases, two in patients with PTA alone and one patient with PTA and a stent. Mean length of follow-up was 6.3 months (range, 6 weeks to 15 months). Post-intervention ABI improved from a mean of 0.65 to a mean of 1.01 (p < 30.05). The perioperative complication rate was 9% and included three cases of hematoma and one case each of thrombosis, lymphocele, and rash reaction to medications. Outcome measures included primary patency (89%), assisted primary patency (96%), and limb salvage (97%) at 6 months. Restenosis of >50% occurred in four patients and occlusion occurred in two. At 6 months, patients with one or more stents had a patency rate of 84% (27/32), whereas those without a stent had a patency rate of 94% (32/34) (p = NS). Endovascular treatment is a safe, feasible, and effective method with a high short-term patency rate and may be used as an alternative to bypass for chronic limb ischemia.

Aged↗
PubMed2005

Multimodal percutaneous intervention for critical venous occlusive disease.

Critical deep venous thrombosis and occlusion constitutes a small percentage of patients with venous disease, who exhibit severe symptomatology. This study examined the results of multimodal percutaneous therapy for the treatment of complex critical venous thrombotic and occlusive disease. Twenty-five patients presented with critical venous thromboses or occlusions (11 with debilitating unilateral lower extremity edema causing ambulatory impairment, 2 with debilitating bilateral lower extremity edema, 3 with phlegmasia cerulea dolens, 2 with venous claudication, 2 with superior vena cava (SVS) syndrome with respiratory compromise, 4 with debilitating upper extremity edema, and 1 with renal insufficiency). Therapeutic modalities including thrombolysis, mechanical thrombectomy, percutaneous venoplasty and stent placement, temporary inferior vena cava filtration, and ultrasound guidance were used in all cases in conjunction with long-term systemic anticoagulation. The venous access site was determined by the anatomic location of the lesion and included popliteal, femoral, brachial, and lesser saphenous. Patients were followed with clinical exam and duplex surveillance. Resolution of symptoms was achieved in 18 of 25 patients (72%) and partial resolution occurred in 4 of 25 (16%). Failure of treatment identified as both lack of clinical response and evidence of continued venous thrombosis occurred 3 of 25 patients (12%). Restoration of arterial pulses and limb salvage was achieved in the three patients with phlegmasia cerulea dolens and acute limb-threatening ischemia. Both patients with SVC syndrome experienced resolution of respiratory compromise and facial edema. The mean length of follow-up was 11 +/- 2.7 months. Complications included transfusion requirement (2), hematuria (2), retroperitoneal hematoma (1), and cellulitis (1). Acute critical venous thrombotic and occlusive disease is responsive to multimodal percutaneous treatment. The relief of pain and resolution of acutely life and limb-threatening conditions in this most severely symptomatic subset of patients represents the immediate goal of treatment.

Algorithms↗
PubMed2005

Analysis of anatomic factors and age in patients undergoing carotid angioplasty and stenting.

Recent data suggest that patient age >80 years may be associated with increased risk of periprocedural complications from carotid angioplasty and stenting (CAS). In this study, we analyzed anatomic risk factors in patients undergoing CAS based on age >80 or <80 years. Our hypothesis was that patients >80 would have more challenging anatomy. Between February 2003 and August 2004, 82 patients underwent CAS. Images for 57 lesions were available for review. Eighteen patients were > or =80 years old and 39 were <80. Cerebral protection devices, including EPI Filterwire, Percusurge, Accunet, and Angioguard, were used in all but two cases; and self-expanding stents (Wallstent, NexStent, Acculink, Precise) were placed in all. Arterial anatomic characteristics were assigned a score based on complexity and associated procedural risk. Characteristics evaluated using angiographic images were aortic arch elongation classification, arch calcification, common carotid/innominate stenosis, common carotid tortuosity, internal carotid tortuosity, index lesion length, index lesion calcification, and index lesion stenosis. Statistical analysis was performed using Fisher's exact test. CAS was successfully completed in 98% of cases. The two patients in whom we could not perform CAS were 79 and 83 years old. The anatomic characteristics that were statistically significantly more complex/severe in patients > or =80 were arch calcification (p = 0.045), common carotid/innominate stenosis (p = 0.023), common carotid tortuosity (p = 0.049), and internal carotid tortuosity (p = 0.032). There was no statistically significant difference in arch elongation classification, lesion length, lesion calcification, or stenosis severity (p = nonsignificant). Overall, patients > or =80 years had an increased incidence of complex anatomic risk factors compared to younger patients (p < 0.001). Cerebrovascular accident without residual deficits occurred in two patients; both were >80 years old. Complex arterial anatomy is more often present in patients >80 years and may explain the increased complication rates associated with CAS. Pre- or intraoperative consideration of these characteristics may help provide better risk assessment in candidates for CAS.

Age Factors↗
PubMed2005

Comparison of results in endovascular interventions for infrainguinal lesions: claudication versus critical limb ischemia.

This study analyzed clinical success, patency, and limb salvage after endovascular repair in patients treated for chronic limb ischemia presenting with claudication versus critical limb ischemia. Between October 2001 and August 2004, 115 patients (mean age 71) underwent endovascular treatment for infrainguinal arterial disease. Techniques included subintimal angioplasty and transluminal angioplasty with or without stents. Lesions were classified according to Transatlantic InterSociety Consensus. Follow-up (mean 11 months) included physical exam, ankle-brachial index, and duplex ultrasound. Patency rates were determined using Kaplan-Meier and compared by log-rank analysis. One hundred ninety-nine lesions were treated in 121 limbs using percutaneous techniques. Comorbidities were similar except higher rates of diabetes mellitus (67% vs 41%, P < 0.001) and chronic renal insufficiency (22% vs 7%, P < 0.05) were found in critical limb ischemia patients. Primary patency for claudicants was 100 per cent, 98 per cent, and 85 per cent at 3, 6, and 12 months and 89 per cent, 80 per cent, and 72 per cent for critical limb ischemia, respectively (P = 0.06). Limb salvage was 91 per cent at 12 months for critical limb ischemia patients. Morbidity was similar between groups, and there was no perioperative mortality. Percutaneous intervention for both claudication and critical limb ischemia provides acceptable 12 month patency with limited morbidity.

Adult↗
PubMed2004

Endovascular aortic aneurysm repair in the octogenarian: is it worthwhile?

HYPOTHESIS: During the past decade, endovascular stent graft repair (EVSG) of abdominal aortic aneurysms has emerged as a less invasive and less morbid alternative to open surgical repair. We hypothesize that EVSG may become the treatment method of choice among patients older than 80 years. DESIGN: Retrospective case series. SETTING: Major academic medical center with extensive experience in endovascular and open aortic aneurysm surgery. PATIENTS AND METHODS: During a 5-year period, EVSG was performed in 595 patients at our institution. One hundred fifty (25.2%) of these patients were older than 80 years. Our prospectively acquired database was reviewed with respect to the demographic, intraoperative, and outcome data of this elderly population. MAIN OUTCOME MEASURES: Technical and clinical success, aneurysm-related events (aneurysm-related death, type I or type III endoleaks, aneurysm expansion, or aneurysm rupture), and secondary interventions. RESULTS: There were 119 men (79.3%) and 31 women (20.7%) (mean age, 84.6 years). Mean aneurysm diameter was 6.7 cm. Comorbidities including chronic obstructive pulmonary disease, coronary artery disease, chronic renal insufficiency, peripheral vascular disease, hypertension, and hypercholesterolemia were common in these patients, with an average of 2.9 comorbid conditions per patient. Mean follow-up was 16.9 months (range, 1.0-61.4 months). One hundred forty-six patients (97.3%) received only regional anesthesia, and the average intraoperative blood loss was 369 mL. Average hospital and intensive care unit stays were 2.5 days and 0.1 day, respectively. The procedure was performed emergently in 3 patients, and each recovered uneventfully. There were 5 aborted procedures (3.3%) for technical reasons and 4 conversions to open aortic repair (2.6%). In addition to these aborted procedures, there were 2 additional technical failures resulting in a technical success rate of 95.3%. Endoleaks were common and included 9 type I (6.90%), 35 type II (24.10%), and 1 type III (0.69%). The majority either resolved spontaneously (type IIs) or with minimally invasive secondary intervention, which was performed in 13 patients. Perioperative local/vascular and systemic complications occurred in 16 (10.7%) and 8 (5.3%) patients, respectively. There were 5 perioperative deaths (3.3%)(<30 days postoperatively). Forty late deaths (26.7%)(>30 days postoperatively) occurred, which were unrelated to the EVSG procedure. CONCLUSIONS: Endovascular repair of abdominal aortic aneurysms can be performed safely and successfully in the majority of octogenarians with relatively low complication rates. Improved EVSG devices and operator experience may make this procedure the treatment method of choice for patients in this age group who meet specific anatomical criteria.

Age Factors↗
PubMed2004

Endovascular treatment of an iatrogenic thoracic aortic injury after spinal instrumentation: case report.

Iatrogenic aortic injuries after spinal surgery have been described, but are rare. We describe a case of a 77-year-old woman who underwent surgical correction of a debilitating spinal deformity at an outside institution. Postoperative thoracic spine radiographs and computed tomography scans revealed a misplaced pedicle screw at T5, which was impinging on the descending thoracic aortic wall. The patient was brought to the operating room, where a thoracic stent graft was deployed under fluoroscopic guidance as the malpositioned screw was manually retracted. The patient had an uneventful postoperative course, and was discharged within 24 hours. This case represents a rare but potentially morbid vascular complication of spinal instrumentation surgery that was successfully treated without the need for thoracotomy.

Aged↗
PubMed2004

Computer simulation as a component of catheter-based training.

INTRODUCTION: Computer simulation has been used in a variety of training programs, ranging from airline piloting to general surgery. In this study we evaluate the use of simulation to train novice and advanced interventionalists in catheter-based techniques. METHODS: Twenty-one physicians underwent evaluation in a simulator training program that involved placement of a carotid stent. Five participants were highly experienced in catheter-based techniques (>300 percutaneous cases), including carotid angioplasty and stenting (CAS); the remaining 16 participants were interventional novices (<5 percutaneous cases). The Procedicus VIST simulator, composed of real-time vascular imaging simulation software and a tactile interface coupled to angiographic catheters and guide wires, was used. After didactic instruction regarding CAS and use of the simulator, each participant performed a simulated CAS procedure. The participant's performance was supervised and evaluated by an expert interventionalist on the basis of 50 specific procedural steps with a maximal score of 100. Specific techniques of guide wire and catheter manipulation were subjectively assessed on a scale of 0 to 5 points based on ability. After evaluation of the initial simulated CAS procedure, each participant received a minimum of 2 hours of individualized training by the expert interventionalist, with the VIST simulator. Each participant then performed a second simulated CAS procedure, which was graded with the same scale. After completion, participants assessed the training program and its utility via survey questionnaire. RESULTS: The average simulated score for novice participants after the training program improved significantly from 17.8 +/- 15.6 to 69.8 +/- 9.8 (P < .01), time to complete simulation decreased from 44 +/- 10 minutes to 30 +/- 8 minutes (P < .01), and fluoroscopy time decreased from 31 +/- 7 minutes to 23 +/- 7 minutes ( P < .01). No statistically significant difference in score, total time, or fluoroscopy time was noted for experienced interventionalists. Improvement was noted in guide wire and catheter manipulation skills in novices. Analysis of survey data from experienced interventionalists indicated that the simulated clinical scenarios were realistic and that the simulator could be a valuable tool if clinical and tactile feedback were improved. Novices also thought the simulated training was a valuable experience, and desired further training time. CONCLUSIONS: An endovascular training program using the Procedicus VIST haptic simulator resulted in significant improvement in trainee facility with catheter-based techniques in a simulated clinical setting. Novice participants derived the greatest benefit from simulator training in a mentored program, whereas experienced interventionalists did not seem to derive significant benefit.

Blood Vessel Prosthesis Implantation↗
PubMed2004

The role of surgical revascularization in the management of diabetic foot wounds.

Diabetic foot wounds affect an estimated 15% of all patients with diabetes. These wounds are typically multifactorial in origin. Neuropathy of the foot and impaired wound healing are frequently associated with peripheral arterial occlusive disease. These factors combine to contribute to the development of foot ulcers. Successful wound healing and limb salvage require prompt recognition and treatment. Assessment of arterial perfusion is imperative and may be accomplished by a combination of physical examination and noninvasive vascular laboratory studies. When associated with significant ischemia, diabetic foot ulcers require arterial revascularization to achieve wound healing.

Diabetic Foot↗
PubMed2004

Endovascular treatment of peripheral arterial aneurysms.

Aneurysmal degeneration of peripheral arteries occurs less frequently than aortic aneurysm. While rupture is the most common complication of aortic aneurysms, peripheral aneurysms frequently cause thrombosis or embolization of the involved vessels. It has generally been accepted that most peripheral aneurysms in good risk patients should be repaired to avoid the ischemic complications of thrombosis or embolization. Endovascular repair of abdominal aneurysms has revolutionized the treatment of aortic aneurysms. Endovascular techniques have been used to treat peripheral artery aneurysms with varying success. Thrombosis of stent grafts has been a significant problem which has limited the success of this treatment. At present, endovascular treatment of peripheral aneurysms must be reserved for selective instances in very high risk patients. Until devices are developed which resist kinking and thrombosis, open surgery will remain the treatment of choice.

Aneurysm↗
PubMed2003

Endovascular treatment of failed prior abdominal aortic aneurysm repair.

Failure of endovascular or conventional abdominal aortic aneurysm (AAA) repair may occur as a result of attachment site endoleak (type I) or paraanastomotic aneurysm and pseudoaneurysm formation. This study examined the results of the use of secondary endovascular grafts for the treatment of failed prior infrarenal AAA repair procedures. Forty-seven patients were treated with endovascular grafts. These included 14 patients with type I endoleaks (5 proximal, 8 distal, 1 proximal and distal) and 33 patients with paraanastomotic aneurysms after standard open surgical AAA repair (3 proximal aorta, 5 distal aorta, 21 iliac, 4 proximal and distal). The interval between the primary aortic procedure and the endovascular repair was significantly shorter for failed endovascular procedures (mean, 18.2 months; range, 1-42 months) than for failed conventional procedures (mean, 108.9 months; range, 12-216 months) (p <0.01). The endovascular devices used for correction of the failed AAA repairs were Talent (23), physician-made (19), AneuRx (2), Vanguard (2), and Excluder (1). Transrenal fixation was used for repair of all proximal anastomotic failures. Mean follow-up after reintervention was 12.2 months in patients with failed endovascular grafts and 10.6 months in patients with failed conventional grafts. Patient demographics were as follows: average age, 78 years; 36 male and 11 female; and 4.1 comorbid medical conditions per patient. The endovascular graft was successfully deployed in all 47 cases; 1 patient experienced a persistent proximal attachment site endoleak after endograft deployment. Endovascular grafts may be used to treat previously failed endovascular and conventional AAA repair procedures with good short- and intermediate-term results. Endovascular treatments in these cases may avoid the difficulties of aortic reoperation or AAA repair in the setting of prior endovascular aortic grafting.

Aged↗
PubMed2003

Endovascular stent graft repair of abdominal and thoracic aortic aneurysms: a ten-year experience with 817 patients.

OBJECTIVE: On November 23, 1992, the first endovascular stent graft (ESG) repair of an aortic aneurysm was performed in North America. Following the treatment of this patient, we have continued to evaluate ESG over the past 10 years in the treatment of 817 patients. SUMMARY AND BACKGROUND DATA: Abdominal (AAA) or thoracic (TAA) aortic aneurysms are a significant health concern traditionally treated by open surgical repair. ESG therapy may offer protection from aneurysm rupture with a reduction in procedure morbidity and mortality. METHODS: Over a 10-year period, 817 patients were treated with ESGs for AAA (723) or TAA (94). Patients received 1 of 12 different stent graft devices. Technical and clinical success of ESGs was reviewed, and the incidence of procedure-related complications was analyzed. RESULTS: The mean age was 74.3 years (range, 25-95 years); 678 patients (83%) were men; 86% had 2 or more comorbid medical illnesses, 67% of which included coronary artery disease. Technical success, on an intent-to-treat basis was achieved in 93.8% of patients. Primary clinical success, which included freedom from aneurysm-related death, type I or III endoleak, graft infection or thrombosis, rupture, or conversion to open repair was 65 +/- 6% at 8 years. Of great importance, freedom from aneurysm rupture after ESG insertion was 98 +/- 1% at 9 years. There was a 2.3% incidence of perioperative mortality. One hundred seventy five patients died of causes not related to their aneurysm during a mean follow-up of 15.4 months. CONCLUSIONS: Stent graft therapy for aortic aneurysms is a valuable alternative to open aortic repair, especially in older sicker patients with large aneurysms. Continued device improvements coupled with an enhanced understanding of the important role of aortic pathology in determining therapeutic success will eventually permit ESGs to be a more durable treatment of aortic aneurysms.

Adult↗
PubMed2003

Endovascular aortic biopsy in the diagnosis of takayasu arteritis.

PURPOSE: To use a minimally invasive approach to obtain biopsy specimens of the aorta to confirm the diagnosis of Takayasu arteritis and formulate a therapeutic plan. CASE REPORT: A 17-year-old woman with lower extremity claudication and a normal erythrocyte sedimentation rate had magnetic resonance angiography, which suggested stenotic lesions of the infrarenal aorta and left renal artery. An endovascular biopsy of the aortic lesion was performed under local anesthesia, retrieving sufficient tissue to make the diagnosis of Takayasu arteritis. The patient was discharged the same day. CONCLUSIONS: Endovascular aortic biopsy may be useful in diagnosing Takayasu arteritis and guiding the clinician toward the proper mode of treatment.

Adolescent↗