Coverage of the left subclavian artery during thoracic endovascular aortic repair

BackgroundThoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions.MethodsBetween October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone 1 deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia.ResultsMean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subclavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subclavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type IA and type III) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures.ConclusionIntentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions

Treatment of superficial and perforator venous incompetence without deep venous insufficiency: is routine perforator ligation necessary?

Abstract Purpose We investigated whether routine ligation of incompetent perforator veins is necessary in treatment of symptomatic chronic venous insufficiency (CVI) due to combined superficial and perforator vein incompetence, without deep venous insufficiency. Methods This was a retrospective review of prospectively collected data. Twenty-four limbs with both superficial and perforator venous incompetence but no deep venous insufficiency were identified at venous duplex scanning. Air plethysmography (APG) was performed preoperatively, to obtain venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) of the affected limb. Saphenous vein stripping from the groin to knee and powered transilluminated phlebectomy for varicosity ablation were performed in all patients. Postoperatively, all patients underwent duplex scanning and APG to determine the status of the perforator veins and hemodynamic improvement from surgery. Results Average patient age was 55.8 years; 62% of patients were women. CVI was class 3 in 4 limbs, class 4 in 12 limbs, and class 5 and class 6 in 4 limbs each. Postoperative duplex scans demonstrated that 71% of previously incompetent perforator vessels were now competent or absent. Significant improvement in all APG values was documented after superficial surgery. VFI improved from 6.0 ± 2.9 preoperatively to 2.2 ± 1.3 after surgery (P < .001); EF improved from 56.3 ± 18 to 62 ± 21 (P = .02); and RVF improved from 40.1 ± 19 to 28.3 ± 18 (P = .009). Mean preoperative symptom score (5.3 ± 1.9) was significantly improved at mean follow-up of 18.3 months (1.4 ± 1.2; P < .001). Conclusion Patients with superficial and perforator vein incompetence and a normal deep venous system experienced significant improvement in APG-measured hemodynamic parameters and clinical symptom score after superficial ablative surgery alone. This suggests that ligation of the perforator veins can be reserved for patients with persistent incompetent perforator vessels, with abnormal hemodynamic parameters or continued symptoms after superficial ablative surgery

Management and outcome of chronic atherosclerotic infrarenal aortic occlusion

Abstract Purpose: To evaluate the management and outcome of chronic atherosclerotic infrarenal aortic occlusion (IRAO), a review of 48 patients who were treated for angiographically documented IRAO between January 1980 and December 1994 was undertaken. Mean follow-up was 45 months. Mean age was 57 years (range, 33 to 88 years). Forty-seven patients were heavy smokers. Symptoms included claudication in 81%, rest pain in 25%, and tissue loss in 15%. Impotence was documented in 73% of men. Associated arterial disease included inferior mesenteric artery occlusion in 31 patients, renal artery stenosis or occlusion in 12, superior mesenteric artery stenosis in two, and celiac artery stenosis in one.Methods: Forty inflow procedures were performed, including 17 thoracobifemoral bypass (TBF) procedures, 15 aortobifemoral/iliac bypass (ABFI) procedures, and eight axillo-bifemoral bypass (AXBF) procedures. Eight patients were managed without surgery. The thoracic aorta was chosen as the inflow source in 17 patients because of previous abdominal aortic surgery in eight, poor status of the abdominal aorta in eight, and horseshoe kidney in one. Results: The overall operative mortality rate was 5%, and the perioperative morbidity rate was 18%. There was no statistical difference in perioperative mortality and morbidity rates among the operative groups. The five-year survival rate (life-table) for all IRAO patients was 67%. TBF and ABFI revascularization procedures yielded 5-year patency rates of 71% and 79%, respectively ( p 2.0 mg/dl were documented in three operative patients and in one nonoperative patient, and none required dialysis.Conclusions: In patients who have IRAO, aorta-based inflow procedures are superior to AXBF both in hemodynamic outcome and in patency rates. Treatment of IRAO with TBF or ABFI yields similar long-term results; the descending thoracic aorta represents an excellent inflow alternative to the abdominal aorta. Clinically significant renal impairment is rarely associated with IRAO. Nonoperative management of IRAO is associated with an increased mortality rate and a high rate of limb loss. (J Vasc Surg 1996;24:394-405.

The importance of deep venous reflux velocity as a determinant of outcome in patients with combined superficial and deep venous reflux treated with endovenous saphenous ablation

INTRODUCTION: Twenty to thirty percent of patients with symptomatic chronic venous insufficiency (CVI) are found to have combined superficial and deep venous reflux on duplex testing. It is currently unclear whether endovenous ablation (EVA) of the saphenous vein will result in correction of CVI without addressing the deep venous reflux. In this study, we examined deep venous reflux velocities to determine whether these would predict outcome after endovenous ablation. METHODS: Patients with symptomatic CVI and both saphenous and deep venous reflux were identified using duplex ultrasonography. Reflux times and maximal reflux velocity (MRV) in each examined vein segment were determined. In each limb, the venous filling index (VFI) and the venous clinical severity score (VCSS) were obtained both before and after laser ablation of the great and/or small saphenous veins. Preoperative venous reflux velocities were correlated with improvement in VFI and VCSS after ablation. RESULTS: 75 limbs with both deep and superficial venous reflux were identified. Seventy-five percent of limbs were CEAP clinical class 3 or 4 and the other 25% were class 5 or 6. Forty limbs demonstrated deep venous reflux in the femoral and/or popliteal vein. After EVA, significant improvements in VFI and VCSS were seen, but this depended on MRV in the deep vein. When MRV in the popliteal or femoral vein was 10 cm/sec as measured by both VFI (P = .01) and VCSS (P = .03). In 35 limbs, deep venous reflux was identified only in the CFV. In this group, the average pre-procedure VFI (6.54 +/- 3.9 cc/sec) decreased significantly to 2.2 +/- 1.9 cc/sec (P < .001) and the VCSS improved markedly from 7.0 +/- 2.8 to 1.3 +/- 1.4 (P < .001). CONCLUSIONS: EVA of the saphenous veins can be performed in patients with concomitant deep venous insufficiency with hemodynamic and clinical improvement in most cases. Patients with popliteal or femoral reflux velocities lower than 10 cm/sec usually experience marked improvement in both the VFI and the VCSS. Patients with femoral or popliteal reflux velocities greater than 10 cm/sec have a high incidence of persistent symptoms after EVA

Descending thoracic aorta to iliofemoral artery bypass grafting: A role for primary revascularization for aortoiliac occlusive disease?

AbstractPurpose: Bypass grafts that originate from the descending thoracic aorta to the iliac or femoral arteries are well described but are not commonly used as primary procedures, and the long-term results remain unknown. A 15-year experience with 50 descending thoracic aorta to iliofemoral artery bypass grafts for aortoiliac occlusive disease is the basis of this report. Methods: From January 1983 to December 1997, patients who underwent bypass grafting procedures from the descending thoracic aorta to the iliac or femoral arteries were identified. Surgical indications, morbidity and mortality rates, primary and secondary patency rates, limb salvage rates, and survival rates were determined. Results: Fifty descending thoracic aorta to iliofemoral artery bypass grafting procedures were performed—24 (48%) for severe claudication, 22 (44%) for rest pain, and 4 (8%) for ischemic ulceration. A primary procedure was performed in 31 patients (62%) for complete occlusion (21 patients) and severe atherosclerotic disease (10 patients) of the infrarenal aorta. The indications for 19 secondary revascularizations (38%) were prior aortic or extra-anatomic graft failure in 17 cases and aortic graft infection in 2 cases. The follow-up periods ranged from 1 to 150 months (mean, 39 months). The cumulative life-table 5-year primary patency, secondary patency, limb salvage, and survival rates were 79%, 84%, 93%, and 67%, respectively. An improved patency trend was observed for patients who underwent operation for severe claudication as compared with limb-threatening ischemia (92% and 69%; P = .07). However, there was no difference between primary and secondary operations in primary patency rates (81% and 79%; P = NS) or survival rates (72% and 62%; P = NS). Conclusion: Descending thoracic aorta to iliofemoral artery bypass grafting has excellent overall long-term results. These results support its more liberal use for primary revascularization, especially for patients with severe atherosclerotic disease or complete occlusion of the infrarenal aorta. (J Vasc Surg 1999;29:249-58.

Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts

Abstract Purpose: Salvage of thrombosed prosthetic dialysis shunts can be performed using surgical or endovascular techniques. A prospective randomized trial was designed to compare the efficacy of these two methods in restoring dialysis access function. Methods: One hundred fifteen patients with thrombosed dialysis shunts were randomized prospectively to surgical (n = 56) or endovascular (n = 59) therapy. In the surgical group, salvage was attempted with thrombectomy alone in 22% and with thrombectomy plus graft revision in 78%. In the endovascular group, graft function was restored with mechanical (82%) or thrombolytic (18%) graft thrombectomy followed by percutaneous angioplasty. Results: Stenosis limited to the venous anastomotic area was the cause of shunt thrombosis in 55% of patients, and long-segment venous outflow stenosis or occlusion was the cause in 30%. In 83% of the surgical group and in 72% of the endovascular group, graft function was immediately restored ( p = NS). The postoperative graft function rate was significantly better in the surgical group ( p < 0.05). Thirty-six percent of grafts managed surgically remained functional at 6 months and 25% at 12 months. In the endovascular group, 11% were functional at 6 months and 9% by 12 months. Patients with long-segment venous outflow stenosis or occlusion had a significantly worse patency rate than those with venous anastomotic stenosis ( p < 0.05). Conclusions: Neither surgical nor endovascular management resulted in long-term function for the majority of shunts after thrombosis. However, surgical management resulted in significantly longer primary patency in this patient population, supporting its use as the primary method of management in most patients in whom shunt thrombosis develops

Descending thoracic aorta to iliofemoral artery bypass grafting: A role for primary revascularization for aortoiliac occlusive disease?

AbstractPurpose: Bypass grafts that originate from the descending thoracic aorta to the iliac or femoral arteries are well described but are not commonly used as primary procedures, and the long-term results remain unknown. A 15-year experience with 50 descending thoracic aorta to iliofemoral artery bypass grafts for aortoiliac occlusive disease is the basis of this report. Methods: From January 1983 to December 1997, patients who underwent bypass grafting procedures from the descending thoracic aorta to the iliac or femoral arteries were identified. Surgical indications, morbidity and mortality rates, primary and secondary patency rates, limb salvage rates, and survival rates were determined. Results: Fifty descending thoracic aorta to iliofemoral artery bypass grafting procedures were performed—24 (48%) for severe claudication, 22 (44%) for rest pain, and 4 (8%) for ischemic ulceration. A primary procedure was performed in 31 patients (62%) for complete occlusion (21 patients) and severe atherosclerotic disease (10 patients) of the infrarenal aorta. The indications for 19 secondary revascularizations (38%) were prior aortic or extra-anatomic graft failure in 17 cases and aortic graft infection in 2 cases. The follow-up periods ranged from 1 to 150 months (mean, 39 months). The cumulative life-table 5-year primary patency, secondary patency, limb salvage, and survival rates were 79%, 84%, 93%, and 67%, respectively. An improved patency trend was observed for patients who underwent operation for severe claudication as compared with limb-threatening ischemia (92% and 69%; P = .07). However, there was no difference between primary and secondary operations in primary patency rates (81% and 79%; P = NS) or survival rates (72% and 62%; P = NS). Conclusion: Descending thoracic aorta to iliofemoral artery bypass grafting has excellent overall long-term results. These results support its more liberal use for primary revascularization, especially for patients with severe atherosclerotic disease or complete occlusion of the infrarenal aorta. (J Vasc Surg 1999;29:249-58.

The role of air plethysmography in the diagnosis of chronic venous insufficiency

AbstractPurpose: The role of air plethysmography (APG) in the diagnosis of venous disease is not well defined. We conducted this study to investigate the value of APG in the diagnosis of chronic venous insufficiency and to determine its correlation with the clinical severity of disease and the anatomic distribution of reflux. Methods: We studied 186 lower extremities with duplex scanning and venography and measured the venous volume, venous filling index (VFI), ejection fraction, and residual volume fraction with APG. Limbs were categorized according to the Society for Vascular Surgery and International Society for Cardiovascular Surgery classification of clinical severity of disease and according to the anatomic distribution of valvular incompetence. Results: Sixty-one limbs had no evidence of disease (class 0), 60 limbs had mild disease (classes 1, 2, and 3), and 65 limbs had severe disease (classes 4, 5, and 6). According to the results of duplex scanning and venography, there was no evidence of reflux in 56 limbs. Isolated superficial venous reflux occurred in 52 limbs, and perforator reflux, alone or in conjunction with superficial reflux, occurred in 30. Deep reflux, with or without superficial reflux, was found in 25 limbs. Deep and perforator reflux, with or without superficial reflux, was found in 19 limbs. The VFI had a sensitivity of 80% and 99% positive predictive value for any type of reflux. The VFI was significantly different between groups of limbs with different clinical severities of disease or different types of reflux. The incidence of deep or perforator reflux in limbs with a normal VFI value was 7%, and it was 82% in limbs with a VFI of more than 5. Among 86 limbs with VFI values not corrected with use of a thigh tourniquet, 28% did not have evidence of deep or perforator reflux, and among 15 limbs with VFI values corrected with the use of a tourniquet, 33% had perforator reflux, deep reflux, or both. All APG parameters had low positive predictive values for severe disease or ulceration. The ejection fraction and residual volume fraction did not influence the clinical severity of disease, did not discriminate between types of reflux, and in combination with the VFI did not improve the predictive value of APG. Conclusions: The VFI measured by APG is an excellent predictor of venous reflux, provides an estimate of the clinical severity of disease, and at high levels predicts deep reflux, perforator reflux, or both. Correction of an abnormal VFI with a thigh tourniquet is an unreliable predictor of the absence of deep or perforator incompetence. The predictive value of APG for severe disease or ulceration is poor. The ejection fraction and residual volume fraction, individually or in combination with the VFI, add little to the diagnostic value of APG, and their routine performance may not be clinically justified. (J Vasc Surg 1998;27:660-70.

Beidler SK, Douillet CD, Berndt DF et al.Inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy. J Vasc Surg 49:1013-1020

Elevated inflammatory cytokine levels have been implicated in the pathogenesis of non-healing chronic venous insufficiency (CVI) ulcers. The goal of this study was to determine the protein levels of a wide range of inflammatory cytokines in untreated CVI ulcer tissue before and after 4 weeks of high-strength compression therapy. These levels were compared to cytokines present in healthy tissue. Thirty limbs with untreated CVI and leg ulceration received therapy for 4 weeks with sustained high-compression bandaging at an ambulatory wound center. Biopsies were obtained from healthy and ulcerated tissue before and after therapy. A multiplexed protein assay was used to measure multiple cytokines in a single sample. Patients were designated as rapid or delayed healers based on ulcer surface area change. The majority of pro-inflammatory cytokine protein levels were elevated in ulcer tissue compared to healthy tissue, and compression therapy significantly reduced these cytokines. TGF-beta1 was upregulated in ulcer tissue following compression therapy. Rapid healing ulcers had significantly higher levels of IL-1alpha, IL-1beta, IFN-gamma, IL-12p40, and granulocyte macrophage colony stimulating factor (GM-CSF) before compression therapy, and IL-1 Ra after therapy. IFN-gamma levels significantly decreased following therapy in the rapidly healing patients. CVI ulcer healing is associated with a pro-inflammatory environment prior to treatment that reflects metabolically active peri-wound tissue that has the potential to heal. Treatment with compression therapy results in healing that is coupled with reduced pro-inflammatory cytokine levels and higher levels of the anti-inflammatory cytokine IL-1 Ra

Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization

OBJECTIVES: The natural history of limbs affected by ischemic ulceration is poorly understood. In this report, we describe the outcome of limbs with stable chronic leg ulcers and arterial insufficiency that were treated with wound-healing techniques in patients who were not candidates for revascularization. METHODS: A prospectively maintained database of limb ulcers treated at a comprehensive wound center was used to identify patients with arterial insufficiency, defined as an ankle-brachial index (ABI) 2.5 mg/dL), severity of ischemia measured by ABI or toe pressure, wound grade, wound size, and wound location. RESULTS: Between January 1999 and March 2005, 142 patients with 169 limbs having arterial insufficiency and full-thickness ulceration were treated without revascularization. Mean patient age was 70.8 +/- 4.5. Diabetes mellitus was present in 70.4% of limbs and chronic renal insufficiency in 27.8%. Toe amputations or other foot-sparing procedures were performed in 28% of limbs. Overall, limb loss occurred in 37 patients. By life-table analysis, 19% of limbs required amputation 0.5 (P = .01). The only risk factor associated with wound closure was initial wound size (P < .005). CONCLUSIONS: Limb salvage can be achieved in most patients with arterial insufficiency and uncomplicated chronic nonhealing limb ulcers using a program of wound management without revascularization. Healing proceeds slowly, however, requiring more than a year in many cases. Patients with an ABI <0.5 are more likely to require amputation. Interventions designed to improve outcomes in critical limb ischemia should stratify outcomes based on hemodynamic data and should include a comparative control group given the natural history of ischemic ulcers treated in a dedicated wound program