Success Rate of Embolization for Type II Endoleaks at a Major Tertiary Referral Center

Objective: The rise of endovascular aneurysm repair (EVAR) as the preferred treatment for abdominal aortic aneurysm (AAA) has introduced endoleaks as a major complication following AAA repair. The objective of this study is to assess the outcomes associated with endovascular embolization of type II endoleaks after EVAR. Methods: The institutional Radiology database at our tertiary referral hospital was queried for type II endoleak during the period 2006-2018. A retrospective chart review was then carried out. Only patients who underwent intervention for isolated type 2 endoleaks were analyzed. The primary outcome was success of the endoleak repair as determined by cessation of growth (i.e., ≤5mm change in diameter over follow-up period) of the native aneurysm sac. Patient outcomes for each failure of the above criterion were also collected. Other data pertaining to the location of endoleak, type of occlusion performed, type of embolic agent used, type of endograft used for EVAR, and incidence of aneurysm rupture were collected as secondary outcomes.Results:During this period 41 patients were treated for type II endoleaks. Demographics are shown in table 1. Cessation of growth was achieved in 28/41 (68.3%) of the patients after one embolization procedure. In 13/41 (31.7%) of patients, growth of the native aneurysm sac continued. Of the patients whose aneurysms continued to grow, 61.5% (8/13) did not undergo a second embolization. The remaining 38.5% (5/13) underwent a second embolization.Patient outcomes for both of these groups are presented in table II. None of the patients were found to have ruptured their aneurysm sac during follow-up after embolization. None of gender, race, the embolization site, or method of embolization were associated with embolization failure. Conclusions: Embolization of type II endoleaks is associated with a cessation of growth in the majority of cases and seems to be protective regarding the risk of aneurysm sac rupture. Future studies and additional follow-up will be important to elucidate the most significant risk factors for expansion and/or rupture of the endovascularly repaired abdominal aneurysm.Table I: Demographics for patients with type II endoleaks who underwent endovascular embolizationVariableValue Age (years +/- sd)75.66 +/- yearsAverage follow-up (months)62.65 monthsSex (%)71.7% male28.3% femaleRace (%)77.7% white17.8% black4.4% otherInflow vessel (%)43.2% lumbar only36.4% IMA only20.5% mixEmbolization site (%)40.5% vessel only14.3% cavity only20.5% mixEmbolization type (%)66.7% coil9.5% glue23.8% mixTable II: Outcomes for patients with continued growth after embolizationThose that did no undergo further embolizationThose that underwent a second embolization 3 were found to have type III endoleak and were successfully repaired with lining of the graft.2 whose aneurysm sac ceased growing. 2 who declined further treatment. 2 whose aneurysm sac continued to grow with persistent evidence of endoleak.1 who died from non-vascular complications. 1 who was lost to follow-up. 1 who is scheduled future surgical repair. 1 who was lost to follow-up.https://scholarlycommons.henryford.com/merf2019clinres/1026/thumbnail.jp

Compression of endograft limb after translumbar embolization of a type II endoleak using n-butyl cyanoacrylate

Cyanoacrylate glue has been used in a variety of surgical disciplines. In vascular surgery, it has been used to seal type II endoleaks after endovascular aneurysm repair. In this case, we report a rare complication after translumbar injection of n-butyl cyanoacrylate to occlude a persistent type II endoleak. The cyanoacrylate resulted in significant compression of the right iliac graft limb with reduced distal perfusion

Men present with higher clinical class of chronic venous disease before endovenous catheter ablation

BACKGROUND: Risk factors for chronic venous disease (CVD) have been widely reported in population health management. However, predisposing factors associated with patients treated for advanced stages of CVD have yet to be established. We examined the demographics and risk factors associated with advanced clinical presentation of CVD for patients referred for vein ablation. METHODS: Retrospective analysis of our institutional Vascular Quality Initiative Varicose Vein Registry included endovenous laser treatment and radiofrequency ablation procedures at our tertiary institution, community hospital, and outpatient vein clinic between January 2015 and December 2016. All incompetent truncal veins were divided into two groups based on the Clinical, Etiology, Anatomy, and Pathophysiology clinical class of CVD: mild-moderate (C1-C3) and severe (C4-C6). The two groups were compared in terms of their demographics and medical comorbidities using univariate and multivariate analysis. Data analysis was conducted on SPSS 22.0 (IBM Corp, Armonk, NY). RESULTS: During the study period, a total of 650 incompetent truncal veins were ablated. The mean age of patients was 58 years, and 73% were female. Severe CVD composed 21% of the cohort. Male sex was a risk for advanced CVD (odds ratio, 2.6; P \u3c .001). Older age was also associated with severe CVD; the average age was 63 years for patients with advanced stage CVD vs 56 years for mild to moderate CVD (P \u3c .001). Race, diabetes, body mass index, number of pregnancies, congestive heart failure, history of venous thromboembolism, current anticoagulation, and history of smoking or current smoking status did not affect the severity of CVD. CONCLUSIONS: Among patients treated with vein ablation for superficial venous insufficiency, older age and male sex were associated with increased severity of advanced CVD. Despite the higher incidence of varicose veins among women, men are more likely to have clinically advanced CVD when they present for truncal vein ablation

Progressive stenosis of a popliteal artery stent graft by laminated thrombus

We present a case of failed popliteal artery aneurysm repair using a Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) due to laminated thrombus formation. A 75-year-old man presented with a symptomatic popliteal artery aneurysm. He was treated with a Viabahn stent graft. On follow-up, the patient complained of lower extremity claudication, and duplex ultrasound examination showed a focal intrastent stenosis. A computed tomography scan showed a significant stenosis within the stent graft, at the level of the knee joint creases. The patient underwent superficial femoral artery to distal popliteal surgery. This case report aims to expand on the mechanism of stent graft failure in popliteal aneurysms

Early clinical experience using telemedicine for the management of patients with varicose vein disease

INTRODUCTION: The use of telemedicine services may be effective in the perioperative management of patients with varicose veins. METHODS: Over a seven-month period, patients with varicose veins were evaluated in the virtual clinic via two-way secure videoconferencing or the traditional clinic by the same physician provider. Data sources included institutional Vascular Quality Initiative registry and patient satisfaction surveys. RESULTS: Among a total of 121 patients with varicose veins who underwent endovenous catheter ablation of the saphenous vein, 20 patients (16.5%) chose the telemedicine clinic (Group A) and 101 patients (83.5%) chose the traditional clinic (Group B) for their perioperative management. Comparing Group A and Group B, the mean age was 59.2 ± 12.1 versus 59.6 ± 13.0, respectively ( p = 0.944); women were 75% versus 73.3%, respectively ( p = 0.872); African Americans comprised 5% versus 22.8%, while Caucasians comprised 95% versus 63%, respectively ( p = 0.049). Half of the telemedicine patients had multiple virtual visits for a total of 31 virtual encounters. Among telemedicine patients using SurveyMonkey®, 29 telemedicine encounters (93.5%) reported that their virtual visit is Yes, definitely or Yes, somewhat more convenient over traditional methods. All patients answered that they were able to communicate clearly with the provider, able to have their questions answered, and able to clearly hear and see the provider via telemedicine methods. DISCUSSION: Telemedicine services enable another means to deliver high-quality care for patients with venous disease in a safe and coordinated manner. Patients with varicose veins are highly satisfied with the use of telehealth services over the traditional healthcare delivery model

Post-anastomotic venous stenosis after Optiflow deployment: An unexpected outcome

Arteriovenous fistula failure represents a major cause of hospitalization and a significant economic burden for end-stage renal disease patients on hemodialysis. The Optiflow (Bioconnect Systems Inc., Ambler, PA) is a new device developed to improve arteriovenous fistula outcomes and decrease failure rates by reducing the risk of stenosis and improving maturation rates. This case report describes a 50-year-old male with hypertensive nephropathy on dialysis who had multiple arteriovenous fistula failures in the past. He was scheduled to undergo brachiocephalic fistula construction using the Optiflow device. After 8 months of use, the new fistula developed a peri-anastomotic venous stenosis, just distal to the Optiflow device. To our knowledge, this is the first time such a complication has been reported

Core versus specialty rotations do not affect students\u27 surgical development

BACKGROUND: Research is scarce on how the diversity of surgical rotations affects students. We sought to assess the effect of core rotations compared to specialty rotations on students\u27 development. METHODS: Students were given a suturing workshop at the beginning of their surgical clerkship along with a questionnaire. They performed both a simple and a complex suturing task at the beginning and end of the 2-month clerkship. The students were divided into 2 groups based on their surgical rotations. Technical skill and exam scores were compared. RESULTS: Thirty-eight students were included in the study. Objective scores increased for the simple task (14.2, standard deviation 4.5 vs 16.4, standard deviation 4.2, P = .04) and the complex task (12.9, standard deviation 5.3 vs 16.5, standard deviation 4.1, P \u3c .01). Times decreased for the simple task (5.1, standard deviation 1.8 vs 4.1, standard deviation 1.3, min, P \u3c .01) and the complex task (7.9, standard deviation 2.7 vs 6.3, standard deviation 1.5, min, P \u3c .01). Using multivariate analysis, we found that reported hours in the operating room per week and previous hands-on experience affected proficiency of the simple suturing task only. Sixteen students had predominantly core surgical rotations. When compared to the 22 students with more specialty rotations, the only difference was gender (87.5% male vs 50.0% male, P = 0.02). There was no significant difference in the completion times (P = .96, .82), the objective scores (P = .06, .120), the written exam scores (P = .57), or the oral exam scores (P = .89). CONCLUSION: In this small study, it was found that the type of students\u27 rotations does not affect surgical skill or knowledge acquisition

Compression of endograft limb after translumbar embolization of a type II endoleak using n-butyl cyanoacrylate

Cyanoacrylate “glue” has been used in a variety of surgical disciplines. In vascular surgery, it has been used to seal type II endoleaks after endovascular aneurysm repair. In this case, we report a rare complication after translumbar injection of n-butyl cyanoacrylate to occlude a persistent type II endoleak. The cyanoacrylate resulted in significant compression of the right iliac graft limb with reduced distal perfusion. Keywords: EVAR, Type II endoleak, Glue embolizatio

Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms

Objectives: It is not clear whether endovascular repair of abdominal aortic aneurysms (EVAR) Results in more decline in renal function over the long-term when compared to open repair (OR). We reviewed our experience with abdominal aortic aneurysm (AAA) repair to determine whether there was a significant difference in immediate postoperative and long-term renal outcomes between OR and EVAR. Methods: A retrospective cohort study was conducted on all patients who underwent AAA repair between January 1993 and July 2013 at a tertiary referral hospital. Demographics, comorbidities, preoperative and postoperative laboratory values, morbidity, and mortality were collected. Patients with ruptured AAAs, preoperative hemodialysis, juxtarenal or suprarenal aneurysm origin, and no follow-up laboratory values were excluded. Preoperative, postoperative, 6-month, and yearly serum creatinine values were collected. Glomerular filtration rate (GFR) was calculated based on the Chronic Kidney Disease Epidemiology Collaboration equation. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes guidelines. Δ GFR was defined as preoperative GFR minus the GFR at each follow-up interval. Comparison was made between EVAR and OR groups using multivariate logistics for categoric data and linear regression for continuous variables. Results: During the study period, 769 infrarenal AAA repairs were performed at our institution; 675 repairs fit the inclusion criteria (315 OR and 360 EVARs). Mean age was 73.9 years, 79% were males, 78% were hypertensive, 18% were diabetic, and 31% had preoperative renal dysfunction defined as a GFR \u3c60 mL/min. A multivariate logistic model to control for all variables found that OR had a 1.6-times greater chance of developing immediate postoperative AKI compared with EVAR (P =.038). Hypertension and aneurysm size were also independent risk factors for developing AKI (P =.012 and P =.022, respectively). Using a linear regression model, we found a greater decline in GFR postoperatively in the EVAR group. This was significant starting at postoperative year 4 (Fig). AKI and preoperative renal dysfunction were other independent risk factors for long-term decline in renal function. Conclusions: Despite the deleterious effect of OR on immediate postoperative renal function, patients undergoing OR experience a slower decline in GFR over time compared to EVAR patients. The basis for this greater decline in renal function in EVAR patients is undefined but could relate to the need for postoperative EVAR surveillance. Studies comparing EVAR and OR may need longer follow-up to detect clinically significant differences in renal function

Kidney transplant increases the risk of ipsilateral critical limb ischemia

Objectives: End-stage renal disease is a known risk factor for peripheral arterial disease (PAD). Hypertension, hyperlipidemia, and diabetes, which are highly prevalent in renal transplant candidates, are independent risk factors for atherosclerosis and PAD. Renal transplantation is an invasive arterial procedure that may have effects on ipsilateral limb perfusion and/or progression of atherosclerotic disease. We hypothesized that the lower extremity ipsilateral to the side of the kidney transplant may be at increased risk for PAD complications. Methods: Our transplant database was retrospectively queried for all kidney transplant patients who underwent subsequent lower extremity revascularization or amputation procedures. Patients with concomitant pancreatic transplants or bilateral renal transplants were excluded. Patient demographics, comorbidities, and discharge medications were collected, and data analysis was conducted on SPSS 22.0 software (IBM Corp, Armonk, NY). Results: Between January 2004 and August 2016, 1214 patients received a renal transplant at our tertiary referral center. Of these, 25 patients (2%) had subsequent arterial revascularizations or amputations on either lower extremity. Average age was 55 years; 76% were male, 65% were African American, 92% had diabetes, 92% had hypertension, 44% had a history of coronary artery disease, and 72% were on aspirin or another antiplatelet agent. Eighteen patients had lower extremity vascular interventions (13 amputations and 5 revascularizations) ipsilateral to the transplanted kidney, and seven patients had contralateral vascular interventions (all amputations; P =.043). The average interval between transplantation and subsequent vascular intervention was 27 months for the ipsilateral interventions and 39 months for the contralateral interventions (P =.37). Conclusions: Kidney transplantation is associated with an increased risk of ipsilateral lower extremity PAD requiring surgical intervention. Further studies are necessary to determine whether this represents a “steal” phenomenon vs progression of atherosclerosis distal to the transplanted kidney. Renal transplant patients should be monitored closely for the development of ischemic symptoms in the lower extremity ipsilateral to the transplanted kidney