Open and endovascular repair of the nontraumatic isolated aortic arch aneurysm

ObjectiveRepair of isolated aortic arch aneurysms (nontraumatic) by either open (OAR) or endovascular (TEVAR) methods is associated with need for hypothermic circulatory arrest, complex debranching procedures, or use of marginal proximal landing zones. This study evaluates outcomes for treatment of this cohort.MethodsOf 2153 patients undergoing arch repair (1993-2013), 137 (mean age, 60 years) were treated with isolated arch resection for nontraumatic aneurysms. Treatment was by open (n = 93), hybrid (n = 11), or TEVAR (n = 33) methods, with the last two approaches reserved for poor OAR candidates. Treatment was predominantly for saccular (n = 53) or fusiform (n = 30) aneurysms or dissection (n = 15). Rupture was present in 15%. Prior aortic repair was performed in the ascending (n = 30), arch (n = 40), descending (n = 24), or abdominal (n = 9) aorta. Propensity score adjustment was performed for multivariable analysis to account for baseline differences in patient groups as well as treatment selection bias.ResultsEarly mortality was seen in nine patients (7%). Morbidity included stroke (n = 9), paraplegia (n = 1), and need for dialysis (n = 5) or tracheostomy (n = 10). A composite outcome of death and stroke was independently predicted by advancing age (P = .055) and performance of a hybrid procedure (P = .012). The 15-year survival was 59%, with late mortality predicted by increasing age, presence of peripheral vascular disease, and perioperative stroke (all P < .05). The 10-year freedom from aortic rupture or reintervention was 75% and was higher after OAR (2-year OAR, 94% vs TEVAR or hybrid, 78%; P = .018). After propensity-adjusted Cox regression analysis, both prior abdominal aortic aneurysmectomy (P = .017) and an endovascular or hybrid procedure (P = .001) independently predicted late aortic rupture or need for reintervention.ConclusionsIsolated arch repair remains a high-risk procedure occurring frequently in the reoperative setting. Despite being performed in a higher risk group, endovascular strategies yielded similar outcomes but with an increased risk for aorta-related complications. These data support ongoing efforts to develop branched endografts specifically tailored for arch disease to potentially reduce morbidity related to currently available approaches

Successful Angioplasty of a Superficial Femoral Artery StenosisCaused by a Suture-Mediated Closure Device

We report the successful angioplasty of an acutearterial narrowing after suture-mediated closure (SMC) of a femoralarterial puncture. A 75-year-old woman underwent a cerebral arteriogramvia a right common femoral artery puncture. The arteriotomy site wasclosed with a SMC device. Four days after placement the patientcomplained of pain in her right calf after walking. An arteriogram 7days after SMC showed a severe focal stenosis at the origin of thesuperficial femoral artery involving the presumed puncture site. Thelesion was successfully treated with balloon angioplasty. The patientat 6 months was asymptomatic.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41325/1/270_2003_Article_2649.pd

Gadolinium-enhanced magnetic resonance angiography of abdominal aortic aneurysms

AbstractPurpose: The objective of this study was to assess the usefulness of gadolinum-enhanced magnetic resonance angiography (MRA) for defining anatomic features relevant to performing aortic surgery for aneurysmal disease.Methods: Anatomic data defined by MRA, including abdominal aortic aneurysm (AAA) size and character, as well as the status of the celiac, mesenteric, renal, and iliac arteries, were correlated with angiography, ultrasonography, computed tomography, or operative data in 43 patients. Five MRA sequences were obtained in an hour-long examination optimized for aortoiliac, splanchnic, and renal artery imaging at 1.5 T in a body coil. Four of the sequences were performed during or after infusion of gadolinium to improve image quality.Results: MRA correctly defined the maximum aneurysm diameter, as well as its proximal and distal extent in all patients. MRA detected 33 of 35 significant stenoses among 153 splanchnic, renal, or iliac branches examined (sensitivity = 94% and specificity = 98%). MRA did not resolve the degree of aortic branch stenotic disease sufficiently to precisely grade its severity. MRA did not reliably define the status of the inferior mesenteric artery, lumbar arteries or internal iliac arteries. One ruptured AAA and one inflammatory AAA were correctly diagnosed by MRA. No patient had a contrast reaction or contrast-induced renal toxicity related to administration of gadolinium.Conclusion: Gadolinium-enhanced MRA of AAA provides appropriate, essential anatomic information for aortic reconstructive surgery in a 1-hour examination devoid of contrast-related renal toxicity or catheterization-related complications attending conventional arteriography. (J VASC SURG 1995;21:656-69.

A novel approach to the management of late-onset liver failure in biliary atresia

Purpose: Late-onset hyperbilirubinemia in patients who have undergone a successful portoenterostomy (PE) for biliary atresia (BA) is usually considered evidence of ongoing severe liver failure. The authors recently have treated 2 patients who had acute hyperbilirubinemia years and months after a successful PE and had dilated intrahepatic cysts. A combined operative and percutaneous approach reestablished drainage and a reduction in their bilirubin levels.Methods: Data from 2 cases of BA and late-onset hyperbilirubinemia from obstruction were reviewed and analyzed.Results: Two patients (15-year-old boy and a 2.5-year-old girl) presented with increasing serum bilirubin after a PE for BA in infancy. Both had extensive preoperative workup, which showed intrahepatic biliary dilatation in one and a large bile lake in the other. They underwent attempted percutaneous transhepatic cholangiography and stenting, followed by an intraoperative transhepatic approach in which the dilated ducts were connected to the PE. A rapid and sustained reduction in the serum bilirubin level was noted in these patients.Conclusions: When patients with BA after a successful PE present with sudden onset of hyperbilirubinemia, imaging for biliary obstruction should be carried out. If biliary dilatation is found, then a combined radiologic and operative approach may help improve the bile flow and delay the need for liver transplant