Adjunctive primary stenting of Zenith endograft limbs during endovascular abdominal aortic aneurysm repair: Implications for limb patency

ObjectiveEndograft limb occlusion is an infrequent but serious complication of endovascular abdominal aortic aneurysm (AAA) repair. The insertion of additional stents within the endograft limb may prevent future occlusion. This study evaluates limb patency with and without adjunctive stenting of endograft limbs at the time of endovascular AAA repair.MethodsWe performed a retrospective review of 248 patients who underwent endovascular abdominal aortic aneurysm repair with the Zenith AAA endovascular graft between 1999 and 2004. Among these patients, two groups were identified: 64 patients with adjunctive stents placed in 85 limbs and 184 patients without additional bare stent placement in endograft limbs at the time of endovascular AAA repair.ResultsWomen comprised 23% of stented and 11% of unstented patients (P = .02). The mean length of follow-up in the stented and unstented groups was 2.0 years. There were 13 instances of limb thrombosis in 13 patients (5.2% of patients, 2.7% of limbs), all in the unstented group. No limb occlusions occurred in the presence of adjunctive bare metal stents. Seventy-three percent of the occlusions occurred ≤6 months of endovascular AAA repair. Two patients (15%) had no symptoms of lower-extremity ischemia despite graft limb occlusion and did not undergo intervention. The others underwent thrombectomy (n = 2), thrombectomy with bare stent placement (n = 3), femoral-femoral bypass (n = 4), thrombolysis (n = 1), and thrombolysis with bare stent placement (n = 1). Of the seven who underwent thrombectomy or thrombolysis, three had no additional stents placed at the secondary procedure, and two of these three went on to rethrombose. By life-table analysis, primary patency at 3 years in the stented and nonstented limbs was 100% ± 0% and 94% ± 3%, respectively (P = .05).ConclusionsThe intraoperative insertion of additional bare metal stents appeared to eliminate the risk of thrombosis and was without complication. Of the 85 stented limbs in this series, not one occluded. The overall rate of limb thrombosis was low, with most limb occlusions occurring ≤6 months of stent-graft insertion, and would probably have been even lower had we been able to identify all high-risk cases for prophylactic adjunctive stenting. Limb occlusion denotes an underlying problem with the graft, which if left untreated after thrombectomy or thrombolysis will lead to rethrombosis. Postoperative imaging was of little value in detecting impending limb occlusion. Based on these findings, we believe one should identify and stent any limbs that appear to be at risk for thrombosis, but this study lacks the data to predict which limbs need stenting

Inequalities in physical comorbidity:a longitudinal comparative cohort study of people with severe mental illness in the UK

OBJECTIVES: Little is known about the prevalence of comorbidity rates in people with severe mental illness (SMI) in UK primary care. We calculated the prevalence of SMI by UK country, English region and deprivation quintile, antipsychotic and antidepressant medication prescription rates for people with SMI, and prevalence rates of common comorbidities in people with SMI compared with people without SMI. DESIGN: Retrospective cohort study from 2000 to 2012. SETTING: 627 general practices contributing to the Clinical Practice Research Datalink, a UK primary care database. PARTICIPANTS: Each identified case (346 551) was matched for age, sex and general practice with 5 randomly selected control cases (1 732 755) with no diagnosis of SMI in each yearly time point. OUTCOME MEASURES: Prevalence rates were calculated for 16 conditions. RESULTS: SMI rates were highest in Scotland and in more deprived areas. Rates increased in England, Wales and Northern Ireland over time, with the largest increase in Northern Ireland (0.48% in 2000/2001 to 0.69% in 2011/2012). Annual prevalence rates of all conditions were higher in people with SMI compared with those without SMI. The discrepancy between the prevalence of those with and without SMI increased over time for most conditions. A greater increase in the mean number of additional conditions was observed in the SMI population over the study period (0.6 in 2000/2001 to 1.0 in 2011/2012) compared with those without SMI (0.5 in 2000/2001 to 0.6 in 2011/2012). For both groups, most conditions were more prevalent in more deprived areas, whereas for the SMI group conditions such as hypothyroidism, chronic kidney disease and cancer were more prevalent in more affluent areas. CONCLUSIONS: Our findings highlight the health inequalities faced by people with SMI. The provision of appropriate timely health prevention, promotion and monitoring activities to reduce these health inequalities are needed, especially in deprived areas

Primary care consultation rates among people with and without severe mental illness:a UK cohort study using the Clinical Practice Research Datalink

OBJECTIVES: Little is known about service utilisation by patients with severe mental illness (SMI) in UK primary care. We examined their consultation rate patterns and whether they were impacted by the introduction of the Quality and Outcomes Framework (QOF), in 2004. DESIGN: Retrospective cohort study using individual patient data collected from 2000 to 2012. SETTING: 627 general practices contributing to the Clinical Practice Research Datalink, a large UK primary care database. PARTICIPANTS: SMI cases (346 551) matched to 5 individuals without SMI (1 732 755) on age, gender and general practice. OUTCOME MEASURES: Consultation rates were calculated for both groups, across 3 types: face-to-face (primary outcome), telephone and other (not only consultations but including administrative tasks). Poisson regression analyses were used to identify predictors of consultation rates and calculate adjusted consultation rates. Interrupted time-series analysis was used to quantify the effect of the QOF. RESULTS: Over the study period, face-to-face consultations in primary care remained relatively stable in the matched control group (between 4.5 and 4.9 per annum) but increased for people with SMI (8.8-10.9). Women and older patients consulted more frequently in the SMI and the matched control groups, across all 3 consultation types. Following the introduction of the QOF, there was an increase in the annual trend of face-to-face consultation for people with SMI (average increase of 0.19 consultations per patient per year, 95% CI 0.02 to 0.36), which was not observed for the control group (estimates across groups statistically different, p=0.022). CONCLUSIONS: The introduction of the QOF was associated with increases in the frequency of monitoring and in the average number of reported comorbidities for patients with SMI. This suggests that the QOF scheme successfully incentivised practices to improve their monitoring of the mental and physical health of this group of patients

Endovascular treatment of thoracoabdominal aortic aneurysms

ObjectiveThis study assessed the role of multibranched stent grafts for thoracoabdominal aortic aneurysm (TAAA) repair.MethodsSelf-expanding covered stents were used to connect the caudally directed cuffs of an aortic stent graft with the visceral branches of a TAAA in 22 patients (16 men, 6 women) with a mean age of 76 ± 7 years. All patients were unfit for open repair, and nine had undergone prior aortic surgery. Customized aortic stent grafts were inserted through surgically exposed femoral (n = 16) or iliac (n = 6) arteries. Covered stents were inserted through surgically exposed brachial arteries. Spinal catheters were used for cerebrospinal fluid pressure drainage in 22 patients and for and spinal anesthesia in 11.ResultsAll 22 stent grafts and all 81 branches were deployed successfully. Aortic coverage as a percentage of subclavian-to-bifurcation distance was 69% ± 20%. Mean contrast volume was 203 mL, mean blood loss was 714 mL, and mean hospital stay was 10.9 days. Two patients (9.1%) died perioperatively: one from guidewire injury to a renal arterial branch and the other from a medication error. Serious or potentially serious complications occurred in 9 of 22 patients (41%). There was no paraplegia, renal failure, stroke, or myocardial infarction among the 20 surviving patients. Two patients (9.1%) underwent successful reintervention: one for localized intimal disruption and the other for aortic dissection, type I endoleak, and stenosis of the superior mesenteric artery. One patient has a type II endoleak. Follow-up is >1 month in 19 patients, >6 months in 12, and >12 months in 8. One branch (renal artery) occluded for a 98.75% branch patency rate at 1 month. The other 80 branches remain patent. There are no signs of stent graft migration, component separation, or fracture.ConclusionsMultibranched stent graft implantation eliminates aneurysm flow, preserves visceral perfusion, and avoids many of the physiologic stresses associated with other forms of repair. The results support an expanded role for this technique in the treatment of TAAA

Assessment of carotid artery stenosis by ultrasonography, conventional angiography, and magnetic resonance angiography: Correlation with ex vivo measurement of plaque stenosis

AbstractPurpose: Several studies have investigated the correlation between Doppler ultrasonography (DUS), angiography (CA), and magnetic resonance angiography (MRA) in the evaluation of stenosis of the carotid bifurcation. However, these studies suffer from the lack of a true control—the lesion itself—and therefore conclusions about the diagnostic accuracy of each method remain relative. To determine the absolute accuracy of these modalities, we have prospectively studied lesion size with DUS, MRA, and CA in 28 patients undergoing 31 elective carotid endarterectomies and compared the percent of carotid stenosis determined by each technique to the carotid atheroma resected en bloc.Methods: All patients were evaluated by each modality within 1 month before the thromboendarterectomy. With DUS, stenosis size was determined by standard flow criteria. For angiography and MRA, stenosis was defined as residual lumenal diameter/estimated normal arterial diameter (European Carotid Surgery Trial criteria). At surgery the carotid atheroma was removed en bloc in all patients. Patients in whom the lesion could not be removed successfully without damage were excluded from the study. Stenosis of the atheroma was determined ex vivo with high-resolution (0.03 mm3) magnetic resonance and confirmed by acrylic injection of the specimen under pressure and measurement of the atheroma wall and lumen.Results: The measurements of the ex vivo stenosis by high-resolution magnetic resonance imaging correlated closely with the size of stenosis determined by the acrylic specimen casts ( r = 0.92). By ex vivo measurement, the lesions were placed in the following size categories: 40% to 59% stenosis ( n = 2), 60% to 79% stenosis ( n = 6), 80% to 89% stenosis ( n = 7), and 90% to 99% stenosis ( n = 16).Conclusions: In general, the correlation of measurements of ex vivo stenosis with all modalities was good in these severely diseased arteries, although it was better for DUS ( r = 0.80; p < 0.001) and MRA ( r = 0.76; p < 0.001) than for CA ( r = 0.56; p < 0.05). (J VASC SURG 1995;21:82-9.

Systemic inflammation, coagulopathy, and acute renal insufficiency following endovascular thoracoabdominal aortic aneurysm repair

ObjectiveTo characterize the inflammatory and coagulopathic response after endovascular thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the effect of the response on postoperative renal function.MethodsFrom July 2005 to June 2008, 42 patients underwent elective endovascular repair of a TAAA using custom designed multi-branched stent-grafts at a single academic institution. Four patients were excluded from the analysis. White blood cell count (WBC), platelet count, prothrombin time (PT), and creatinine were measured in all patients. In the last nine patients, interleukin-6 (IL-6), protein C, Factor V, d-dimers, cystatin C, and neutrophil gelatinase-associated lipocalin (NGAL) levels were also measured. Change in lab values were expressed as a percentage of baseline values.ResultsThe 30-day mortality rate was 5% (2/38). All patients (n = 38) had a higher WBC (mean ± SD: 139 ± 80%, P < .0001), lower platelet count (56 ± 15%, P < .0001), and higher PT (median: 17%, Interquartile range (IQR) 12%-22%, P < .0001) after stent-graft insertion. Twelve of 38 patients (32%) developed postoperative acute renal insufficiency (>50% rise in creatinine). Patients with renal insufficiency had significantly larger changes in WBC (178 ± 100% vs 121 ± 64%, P = .04) and platelet count (64 ± 17% vs 52 ± 12%, P = .02) compared with those without renal insufficiency. All patients (n = 9) had significant increases in NGAL (182 ± 115%, P = .008) after stent-graft insertion. Six of nine patients (67%) had increased cystatin C (35 ± 43%, P = .04) after stent-graft insertion, with a greater rise in those with postoperative renal insufficiency (87 ± 32% vs 8 ± 13%, P = .02). IL-6 levels were markedly increased in all patients (n = 9) after repair (9840 ± 6160%, P = .008). Protein C (35 ± 10%, P = .008) and Factor V levels (28 ± 20%, P = .008) were uniformly decreased, while d-dimers were elevated after repair in all patients (310 ± 213%, P = .008).ConclusionsLeukocytosis and thrombocytopenia were uniform following endovascular TAAA repair, and the severity of the response correlated with post-operative renal dysfunction. Elevation of a sensitive marker of renal injury (NGAL) suggests that renal injury may occur in all patients after stent-graft insertion

SS25. Cryopreserved Venous Allograft: An Alternative Conduit for Reconstruction of Infected Prosthetic Aortic Grafts

Olivé Milián, ArmandPla general picat del mosaic format per tres cercles: el central, amb un sol de color ocre sobre un cel blau. El sol, somrient, està encarat cap al sud. Aquest està envoltat d'un primer anell dentat i un segon on s'hi representen les fases d

Abdominal aortic aneurysm repair with the Zenith stent graft: Short to midterm results

AbstractPurpose: The purpose of this study was to assess the short-term and mid-term results of endovascular aneurysm repair with the Zenith stent graft in a single-center prospective study. Method: Between October 1998 and July 2001, we used the Zenith stent graft for elective endovascular aneurysm repair in 116 patients, six of whom were women. The mean age was 75 years, and the mean aneurysm diameter was 60.3 ± 8.8 mm. Stent grafts were oversized 10% to 20% relative to computed tomographic (CT) scan-based diameter measurements. All repairs were performed in the operating room through surgically exposed femoral arteries. The results were assessed before discharge with three-phase, contrast-enhanced CT scan and plain abdominal radiograph. These studies were repeated at 1, 6, 12, and 24 months after operation. Follow-up periods ranged from 1 to 34 months. Results: No failed insertions and no conversions to open surgery occurred. The diameter of the main body of the stent graft was 28 mm or more in 73 patients (63%). Additional stents were inserted during surgery to treat kinking in eight patients (6.9%) and renal artery encroachment in two patients (1.7%). Mean fluoroscopy time was 35.1 ± 18.3 minutes, contrast load was 146 ± 53 mL (350 mg/mL), and estimated blood loss was 249 ± 407 mL. The major complication rate was 9.5%, and the minor complication rate was 10.3%. The perioperative complications were myocardial infarction in four patients, arrythmia in four patients, and pulmonary embolism, renal failure, stroke, small bowel obstruction, femoral stenosis, digital embolism, and graft limb thrombosis in one patient each. All 116 patients went home from the hospital, but one patient died 2 weeks later of a combination of pulmonary embolism and myocardial infarction. Endoleak was seen on the first CT scan in 16 patients (15%); 15 were type II, and one was type III. No endoleaks of type I or IV were seen. Additional interventions were performed for each of the following conditions: type II endoleak (n = 4), type III endoleak (n = 1), femoral clamp injury (n = 1), renal artery stenosis (n = 1), and graft limb occlusion (n = 1). One patient had acute aneurysm dilatation and rupture caused by a type II endoleak through the inferior mesenteric artery 6 months after stent graft implantation. No cases were seen of late graft occlusion, stent graft migration, stent fracture, barb fracture, or secondary endoleak. Conclusion: The Zenith device is safe, versatile, and effective in the short to medium term. Most patients need wide stent grafts (≥28 mm proximally and ≥16 mm distally) to achieve 10% to 20% oversizing to prevent type I endoleak. (J Vasc Surg 2002;36:217-25.

Endoleak after endovascular repair of abdominal aortic aneurysm

AbstractPurpose: We sought to assess the role of endovascular techniques in the management of perigraft flow (endoleak) after endovascular repair of an abdominal aortic aneurysm. Method: We performed endovascular repair of abdominal aortic aneurysm in 114 patients, using a variety of Gianturco Z-stent–based prostheses. Results were evaluated with contrast-enhanced computed tomography (CT) at 3 days, 3 months, 6 months, 12 months, and every year after the operation. An endoleak that occurred 3 days after operation led to repeat CT scanning at 2 weeks, followed by angiography and attempted endovascular treatment. Results: Endoleak was seen on the first postoperative CT scan in 21 (18%) patients and was still present at 2 weeks in 14 (12%). On the basis of angiographic localization of the inflow, the endoleak was pure type I in 3 cases, pure type II in 9, and mixed-pattern in 2. Of the 5 type I endoleaks, 3 were proximal and 2 were distal. All five resolved after endovascular implantation of additional stent-grafts, stents, and embolization coils. Although inferior mesenteric artery embolization was successful in 6 of 7 cases and lumbar embolization was successful in 4 of 7, only 1 of 11 primary type II endoleaks was shown to be resolved on CT scanning. There were no type III or type IV endoleaks (through the stent-graft). Endoleak was associated with aneurysm dilation two cases. In both cases, the aneurysm diameter stabilized after coil embolization of the inferior mesenteric artery. There were two secondary (delayed) endoleaks; one type I and one type II. The secondary type I endoleak and the associated aneurysm rupture were treated by use of an additional stent-graft. The secondary type II endoleak was not treated. Conclusions: Type I endoleaks represent a persistent risk of aneurysm rupture and should be treated promptly by endovascular means. Type II leaks are less dangerous and more difficult to treat, but coil embolization of feeding arteries may be warranted when leakage is associated with aneurysm enlargement. (J Vasc Surg 2001;34:98-105.