Background Saccular aneurysms of the aortic arch are rare, and their surgical repair is challenging with potentially significant morbidity and mortality. Methods We examined our experience over a ...3-year period with nine consecutive patients that include nine hybrid repairs with initial extra-anatomic carotid and/or subclavian bypass and subsequent endovascular exclusion of the saccular arch aneurysm. Results Three patients presented with dysphagia from aberrant right subclavian arteries with aneurysm at the origin of the artery, two had asymptomatic aneurysms at the origin of the left subclavian, and four patients had isolated saccular aneurysms of the arch, three of whom presented with thoracic pain. A total of 16 extra-anatomic bypasses were done in the nine patients. Ten endografts and one nitinol plug were used for exclusion in the nine hybrid cases. There were no perioperative deaths, no strokes, or myocardial infarction events. During follow-up, two patients (22%) were found to have type II endoleaks, but no reinterventions were required. Symptoms resolved in six patients, whereas persistent dysphagia and pain occurred in one. Conclusions Repair of saccular aneurysms of the aortic arch by hybrid approach can be done with minimal morbidity and mortality and a reasonable rate of symptom resolution.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Hybrid visceral-renal debranching procedures with endovascular repair have recently been proposed as a less invasive alternative to conventional thoracoabdominal aortic aneurysm (TAAA) ...surgery. This study provides a concurrent assessment of hybrid and open TAAA repair. Methods One hundred two consecutive patients (mean age, 63.0 years) underwent open (73) or hybrid (29) Crawford type 1 (19), 2 (50), or 3 (33) TAAA repair from 2000 to 2009. Hybrid debranching procedures were selected for patients considered poor operative risk for standard TAAA repair (27) or for patient preference (2). The TAAAs were fusiform atherosclerotic (68), dissection (30), or pseudoaneurysm (4). Fifty-seven patients (55.9%) had previously undergone aortic repair. Outcomes were analyzed with 100% follow-up (mean, 30.5 months). Results Operative procedures were urgent or emergent in 16 (15.6%). Early mortality occurred in 13 (12.7%), and was independently predicted by use of hypothermic circulatory arrest ( p = 0.005). Early morbidity included permanent paraplegia (12), stroke (1), need for dialysis (22), or tracheostomy (7). Independent correlates of a composite outcome comprised of early mortality and these early morbidities included an urgent-emergent presentation ( p = 0.002) or open TAAA repair ( p = 0.021). Kaplan-Meier survival was similar between open and hybrid TAAA groups ( p = 0.88). Late mortality was independently predicted by the presence of diabetes ( p = 0.052) or the need for dialysis at the time of TAAA repair ( p < 0.001). Conclusions Hybrid debranching procedures may reduce early morbidity and yield similar late survival, even in a group considered high risk for open surgery. These data support the increasing utilization of a hybrid debranching and endovascular approach for patients requiring thoracoabdominal aneurysmectomy.
Objective Avoidance of nephrotoxic contrast agents during endovascular repair of abdominal aortic aneurysms (EVAR) may reduce the incidence of renal dysfunction following the procedure. Carbon ...dioxide (CO2 ) angiography is a safe alternative to iodinated contrast media vastly under-utilized by vascular surgeons. We herein describe our experience with a simple angiographic technique using CO2 for EVAR guidance that does not require a separate angiographic catheter. Methods Eighteen patients underwent EVAR using angiography with CO2 delivered through the endograft sheath. The renal and hypogastric arteries were localized for endograft deployment exclusively with CO2 in all patients. Completion angiography was done with CO2 in all patients and an additional angiogram with iodinated media was done in 13 cases. Results All endograft deployments were done successfully with CO2 angiography injected through the endograft delivery systems and femoral access sheaths. Additional iodinated media completion angiography did not modify the procedure in any case. All patients were discharged within two days after surgery. There were no ischemic or systemic complications related to CO2 administration. Follow-up CT-scan revealed well positioned endografts with the expected patent renal and hypogastric arteries in all patients, and no additional endoleaks. No significant deterioration in renal function occurred in any case. Conclusion Carbon dioxide angiography conducted through the endograft delivery sheath is reliable for endograft deployment, safe, non-toxic and inexpensive. In addition, it may expedite EVAR by eliminating a number of angiographic catheter placements and exchanges during the procedure. This favorable experience warrants further utilization of this technique.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective To evaluate our initial experience with hypogastric artery occlusion using a nitinol vascular plug during endovascular aortic aneurysm repair (EVAR). Methods We reviewed the records and ...images of 23 consecutive patients who underwent transluminal vessel occlusion of the hypogastric artery with a nitinol plug, as well as a cohort of 19 patients who underwent hypogastric artery embolization with coils in conjunction with EVAR. Results There were no demographic differences between the two groups of patients. Hypogastric artery occlusion was successful in all cases when a nitinol vascular plug was used. When coils were used, there was one unsuccessful embolization which required a second procedure. The number of embolic devices used in the coil group was 7.53 (range, three to 13) compared with 1.35 (range, one to six) in the plug group ( P < .05). Only one plug was used in 19 of 23 cases. The average cost to embolize per hypogastric artery was $1,496 compared with $470 when a nitinol plug was used. There were two instances of coil migration. No other intraoperative complications occurred. At one month follow up, seven patients (35%) in the coil group complained of buttock claudication compared with two patients (9%) in the nitinol plug group ( P = .027). Conclusion Our experience demonstrates the safety and effectiveness of the nitinol vascular plug for hypogastric artery occlusion during EVAR. When compared with coils for hypogastric embolization during EVAR, nitinol vascular plugs are less expensive, produce less technical complications, and are associated with a significantly lower incidence of gluteal claudication.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective This study evaluated the perioperative and 3-year follow-up results of 103 consecutive carotid artery stenting (CAS) procedures done with a transcervical approach using carotid flow ...reversal for cerebral protection that were performed over a 28-month period in 97 patients. Methods The mean age of these patients was 72 years, and 82 (80%) were men. Mean preoperative internal carotid artery (ICA) peak systolic velocity was 314 cm/s, 36% of treated hemispheres were symptomatic, and 42% of patients had neurologic symptoms for >6 months. Ten patients (10%) had contralateral ICA occlusion, six (6%) had recurrent carotid stenosis, and two (2%) had previous neck radiation. Local anesthesia was used in 72 (70%) cases and general in 31 (30%). Predilatation was used in 34 cases (33%), and closed-cell self-expanding stents were deployed and postdilated in all cases. Results Technical success was achieved in 100 cases (97%). No major strokes or deaths occurred. One ipsilateral transient ischemic attack (1%), one contralateral transient ischemic attack (1%), and two minor strokes (2%) occurred. There were two wound complications (2%) and one major arterial complication (1%). Mean operative time was 69 minutes, and mean carotid flow reversal time was 21 minutes. Three awake patients (4%) did not tolerate carotid flow reversal. Hypotension/bradycardia occurred in 24 cases (23%). No electrocardiographic myocardial infarctions were diagnosed. At 40 months of follow-up, the stent patency rate on an intention-to-treat basis was 95%, and the stroke-free survival was 91%. Conclusions Transcervical CAS with carotid flow reversal can be done with a high rate of technical success, a negligible rate of major adverse events, and an excellent 3-year stroke-free survival and stent patency rate. These results compare favorably with those of recently published prospective studies using distal filter protection during CAS.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Introduction Flow-limiting lesions or embolic phenomena can produce vertebrobasilar ischemia. This study aims to differentiate the pathophysiology of vertebral ischemia and examine contemporary ...outcomes after distal vertebral reconstruction. Methods Between February 2005 and November 2011, 41 consecutive distal vertebral artery (VA) reconstructions were performed in 34 patients, including bypass to the third portion of the VA (V3) at the C1-2 level (n = 24) or the C0-1 level (n = 7); transposition of the external carotid artery or its occipital branch onto V3 (n = 6); transposition of V3 onto the internal carotid artery (n = 3); and bypass from the ipsilateral subclavian artery to V3 (n = 1). Six patients required a concomitant carotid intervention, and nine patients required a partial resection of the C1 transverse process. Symptoms, present in 91% of patients, were attributed to a flow-limiting lesion in 16 (52%), to embolization in nine (29%), and to a mixed etiology in six (19%). Results Intraoperatively, five patients required graft revision or conversion of a transposition to a bypass, and two patients required vertebral ligation. Median blood loss was 260 mL. Median hospital length of stay was 1 day. Postoperatively, one patient (2%) required re-exploration for bleeding, a stroke occurred in one patient (2%), and cranial nerve injury occurred in three patients (7%). There were no perioperative deaths. Survival analysis showed that primary patency at 1, 2, and 5 years, respectively, was 74%, 74%, and 54%. Secondary patency was 80% at 1 year and remained so through the end of follow-up at 80 months. A statistically significant difference in patency was noted favoring arterial transposition over vertebral bypass of 100%, 100%, and 83% at 1, 2, and 5 years, respectively, vs 65%, 65%, and 39% ( P = .018). Considering successful redo bypass grafting for late failure, 97% of patients demonstrated preserved patency at their last follow-up. There were two late deaths of unknown etiology and no late strokes. Conclusions Distal VA reconstruction for flow-limiting or embolic lesions provides excellent stroke protection and symptomatic relief with acceptable perioperative risk in selected patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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