bluuebunny/crossref_metadata_2025 huggingface dataset:
Infrainguinal Atherectomy Using the Transluminal Endarterectomy Catheter: Patency Rates and Clinical Success for 144 Procedures
Authors: Myers Kenneth A. , Denton Michael J. , Devine Terence J.
Published: March 2015

Purpose:

To determine if atherectomy using the transluminal endarterectomy catheter (TEC) is an effective endoluminal therapy for infrainguinal occlusive disease.

Methods:

Three surgeons used the TEC for 144 infrainguinal atherectomy procedures in 133 patients. The indications were severe claudication in 83, critical ischemia in 56, and graft stenosis in 5 limbs. The pathology was stenosis in 36 and occlusion in 105 limbs. Balloon dilation was also performed in 109 and stenting in 17 limbs.

Results:

There was initial technical and anatomic success in 124 (86%) procedures. There were 67 technically successful procedures at mean follow-up of 19 months, although 3 of these limbs with gangrene and extensive distal disease required major amputation. There were 26 failures due to stenosis leading to further intervention and 51 due to occlusion. Twenty of these cases were managed conservatively, 21 were treated with repeat endovascular intervention, 31 with bypass grafting, and 5 with amputation. Repeat intervention in 52 limbs resulted in 36 with patent arteries, 10that are occluded, and 6that required amputation. Thirteen of the 14 amputations were for limbs with critical ischemia, but 1 was in a patient with claudication. Life-table analysis showed that the primary patency rate was 51%, the assisted primary patency rate was 61%, and the secondary patency rate was 75% at 15 months. The clinical success rate was 49%, and the salvage rate for limbs with critical ischemia was 78% at 12 months. Univariate log-rank testing showed no significant differences according to the clinical presentation or pathology, but results were worse for lesions > 5 cm long due to more frequent immediate failures. However, multivariate Cox regression analysis showed that results were significantly worse for critical ischemia than for claudication, stenosis compared to occlusions, for limbs with poor runoff, for operations performed by percutaneous rather than an open approach, and for those performed more recently.

Conclusions:

TEC atherectomy may have a place in selected patients, but the optimal circumstances for its use and long-term efficacy require further study.
Intravascular Ultrasound Guidance for Peripheral Vascular Interventions
Authors: Scoccianti Marco , Verbin Christopher S. , Kopchok George E. , Back Martin R. , Donayre Carlos E. , Sinow Robert M. , White Rodney A.
Published: March 2015

Intravascular ultrasound (IVUS) imaging during peripheral endovascular interventions adds important information regarding the distribution of disease by providing controlled measurements of the cross-sectional area of the vessel lumen and wall prior to and following procedures. IVUS is useful in determining the mechanism and efficacy of balloon angioplasty, in guiding atherectomy devices, and in assuring appropriate placement of intravascular stents. The incorporation of an IVUS element into catheter-based interventional devices may improve the immediate and long-term results of endovascular interventions by decreasing complications from dissection and perforation of the arterial wall. Combined IVUS-stent prototype catheters are being developed to enable imaging and deployment simultaneously. Similar devices are being explored to enhance expedient, precise delivery of endoluminal grafts. Future studies of endovascular techniques should include IVUS, when possible, to accurately quantitate the initial efficacy of devices and to determine the nature and distribution of recurrent lesions.
Wound Healing: An Endpoint for Complex Peripheral Angioplasty
Authors: Crew John R. , Thuener Marilyn
Published: March 2015

Purpose:

The standard endpoint for lower limb revascularization is long-term patency; however, in high-risk patients with end-stage ischemia, healing of chronic ulcerations has been proposed as an acceptable endpoint. To evaluate if today's minimally invasive interventions, in combination with comprehensive wound healing procedures, can resolve nonhealing wounds, we performed a retrospective review of chronic ulceration patients treated at the San Francisco Wound Care Center.

Methods:

Eight-five patients with 96 limbs at risk due to nonhealing ulcers were treated with a variety of endovacular procedures: 7 patients (group 1) received PalmazR stents for unilateral iliac occlusions; 42 limbs (group II) in 39 patients were treated with balloon angioplasty for superficial femoral and popliteal lesions; and 47 extremities in 39 patients (group III) underwent rotational atherectomy for tibioperoneal lesions. Comprehensive wound management techniques, including the application of growth factors, were used.

Results:

All group I wounds healed, although 6 of 7 patients required additional procedures to address outflow lesions. In groups II and III, primary patencies were similar (64% and 70%, respectively), and nine treated sites reoccluded in each group. Restenotic lesions were retreated in both groups (three in group II and four in group III); secondary patencies were 71% and 78%, respectively. There were more amputations in group III patients (five) compared to group II (one). In both groups after 5 months, 90% of wounds had healed in group II and 72% in group III.

Conclusion:

The use of endovascular procedures appears to play an important role in the healing of chronic lower extremity ulcerations in high-risk patients with end-stage ischemia.
Endovascular Surgery in Daily Practice: A Re-Appraisal
Authors: Criado Frank J. , Queral Luis A. , Patten Peggy
Published: March 2015

For more than 10 years, endoluminal therapy has been marked by an explosion in the number and variety of devices designed to enhance or supplant its first and still most commonly used technique, balloon angioplasty. Among all these innovative catheter-based technologies, only stents have emerged as a truly effective device capable of achieving results comparable or superior to balloon angioplasty. In combination with thrombolysis and balloon dilation, they form the triadic foundation of endovascular surgery today. The prudent and judicious use of these tools, and a few other “niche” devices, such as atherectomy, in conjunction with classical vascular surgical techniques is the special and unique purview of the vascular surgeon. His development of a therapeutic plan, whose components include patient selection, lesion assessment, device decisions, procedure monitoring, completion evaluation, and follow-up, is incumbent upon an appreciation of the capabilities of each available intraluminal device in the various arterial segments and lesion pathologies.

The strategies that facilitate optimum matching of endoluminal tools and techniques to each patient situation form the basis of this report. They offer today's vascular surgeon a guide to the use of intraluminal therapies in daily practice. On the horizon is the new and exciting technique of endoluminal grafting, which, if it proves efficacious, will bring about profound changes in our specialty.
Endovascular Surgical Approach to Intracranial Vascular Diseases
Authors: Higashida Randall T. , Halbach Van V. , Dowd Christopher F. , Hieshima Grant B.
Published: March 2015

Purpose:

The endovascular surgical approach to complex disorders of the central nervous system has made rapid and significant advancements over the past decade. Patients with intracranial arterial aneurysms, traumatic carotid and vertebral artery lesions, including fistulas and pseudoaneurysms, hemodynamically significant atherosclerotic lesions, vasospasm, and acute stroke are now being approached and treated by newer and less invasive techniques, including cerebral angioplasty and thrombolytic therapy.

Methods:

All procedures are usually performed from a transfemoral approach utilizing a variety of occlusion devices, including detachable silicone balloons, microcoils, electrolytic detachable coils, liquid tissue adhesives, and particulate emboli for vessel occlusion. For dilatation and reperfusion of vessels, balloon angioplasty catheters, stents, and thrombolytic drugs are being used.

Results:

For the treatment of traumatic vascular injuries, such as carotid cavernous sinus fistulas and vertebral arteriovenous fistulas and pseudoaneurysms, endovascular therapy has become the treatment of choice. The endovascular approach for intracranial aneurysms is emerging as a therapeutic option in selected cases. For occlusive disorders in patients presenting with acute cerebral ischemia, extracranial angioplasty and cerebral thrombolysis techniques are currently under investigation.

Conclusions:

As these techniques continue to evolve, the field of interventional neuroradiology will expand the therapeutic options for managing complex cerebrovascular disorders and improve patient outcome in acute stroke therapy.
Complications Associated with Extracranial Carotid Artery Interventions
Authors: Dorros Gerald
Published: March 2015

Efforts to ameliorate the tremendous personal and financial ramifications of stroke in this country have focused on the recently validated stroke reduction potential of carotid endarterectomy. During the years in which numerous randomized trials compiled their evidence in favor of surgical treatment, the evolution of minimally invasive therapeutic alternatives to surgery spread to encompass nearly every vascular bed in the body. Only the fragile cerebrovascular system remains as the final challenge for interventionists.

Any revascularization alternative to carotid endarterectomy should achieve the same initial and long-term outcomes as the surgical gold standard, with comparable morbidity and mortality. After years of cautious, circumspect application, carotid angioplasty is now a contender for this role. Assisted by the newer stent technology, minimally invasive carotid interventions are entering clinical trials. While it is premature to discuss the stroke reduction potential of these catheter-based techniques, it is imperative that we recognize and prepare to treat the myriad, sometimes catastrophic, complications of these therapeutic approaches to carotid obliterative disease.
Percutaneous Transluminal Angioplasty of Supra-aortic Vessels
Authors: Motarjeme Amir
Published: March 2015

Purpose:

To retrospectively review the techniques and results of percutaneous transluminal angioplasty (PTA) in the supra-aortic vessels.

Methods:

Over a 5-year period, 112 patients underwent percutaneous treatment of 151 lesions in the innominate, subclavian, carotid, and vertebral arteries. The percutaneous technique included standard retrograde femoral artery access in the majority of patients with balloon dilation of the lesion site. In the more recently treated patients, stents were deployed for suboptimal PTA; primary stent deployment was used rarely. Symptom resolution and > 50% increase in flow were criteria necessary for a successful procedure.

Results:

In this population, 141 (93%) of 151 lesions were successfully treated. PTA achieved 100% success in stenotic lesions in the internal (n = 9) and external (n = 2) carotid; common carotid (n = 8); subclavian (n = 67); and innominate (n = 13) arteries. Ninety-two percent (36/39) of vertebral artery stenoses were successfully treated. In 13 cases of subclavian occlusion, however, only 6 (46%) were recanalized. There were 3 periprocedural complications, but only 1 was major; a focal stroke manifesting as right arm weakness occurred in a patient with left common carotid PTA and stenting. Five cases of reocclusion have been seen in 5 years of follow-up. All occurred in the subclavian artery, and 3 of the 5 were in arteries originally occluded.

Conclusions:

Brachiocephalic PTA can achieve excellent immediate and long-term results in proximal stenoses. Subclavian occlusions do not respond well to PTA, and those successfully recanalized have a high restenosis rate (50%). PTA of the arch vessel branches, particularly the vertebral artery, should be attempted only by experienced interventionists. Atherosclerotic lesions in the internal carotid arteries are best treated with endarterectomy at present, but fibromuscular dysplasia in the carotid arteries is an appropriate indication for PTA therapy.
Percutaneous Techniques for Endoluminal Carotid Interventions
Authors: Diethrich Edward B. , Marx Peter , Wrasper Robert , Reid Donald B.
Published: March 2015

Purpose:

To describe the evolving techniques for stent implantation in the proximal and cervical carotid arteries.

Methods and Results:

Percutaneous access to proximal and cervical carotid lesions is either via direct puncture of the common carotid artery or through the more familiar retrograde common femoral (RCF) artery approach. Both techniques and their variations are described in detail, along with their benefits, disadvantages, and possible complications. Dual lesions at the arch and higher up the neck can be treated either from the RCF route or, if the cervical lesion requires endarterectomy, with open exposure at the bifurcation and stenting of the proximal lesion.

Conclusions:

While the RCF route is more familiar to the majority of interventionists and provides adequate access in most situations, traversing the arch and negotiating acute angles at the ostia of the great vessels may render this method infeasible. The direct puncture technique is a useful alternative; however, it requires more expertise to prevent potentially disastrous access-site complications. One further caveat must be stated: regardless of the access approach selected, the opportunity for serious, debilitating—and lethal—complications is always present in cerebrovascular interventions. At this earliest phase in our experience with carotid stenting, cautious investigative methodologies must prevail.
Intravascular Ultrasound Assessment in Carotid Interventions
Authors: Reid Donald B. , Diethrich Edward B. , Marx Peter , Wrasper Robert
Published: March 2015

Purpose:

To demonstrate the clinical value of intravascular ultrasound (IVUS) imaging in monitoring stent deployment in the cervical carotid arteries.

Methods and Results:

Two-dimensional (2D) and three-dimensional (3D) IVUS imaging has been used routinely in more than 100 patients following carotid stenting and the completion angiogram to detect evidence of inaccurate stent deployment. Axial 2D views were used to measure diameters and cross-sectional areas and provide the basis for 3D reconstruction. These composited images produced single-frame views of entire vascular segments, with definition of vessel wall morphology, stent placement, and angioplasty-induced defects. This information was used in the decision to apply further treatment to the area in order to maximize luminal diameter and/or correct defects.

Conclusions:

IVUS imaging is an important component of carotid artery stent procedures. It more accurately visualizes stent placement and vessel wall morphology than arteriography, information critical to the intraprocedural assessment process.
Anesthesia for Carotid Stent Procedures
Authors: Kharrazi M. Reza
Published: March 2015

Purpose:

To present the techniques of anesthesia management used during percutaneous carotid interventions involving balloon dilation and stent deployment.

Methods and Results:

Two access routes may be used for carotid angioplasty, and the anesthesia techniques for each are different. In the conventional common femoral artery approach, the patient is sedated, heparinized, and ventilated by mask with 100% oxygen; the groin site is anesthetized locally with lidocaine. When the procedure reaches the point of balloon inflation, the patient is awakened, and atropine is administered to block the baroreceptor response. The heparin is not reversed after the procedure. General anesthesia with short-acting nonopioid intravenous anesthetics is preferred for patients undergoing direct puncture of the common carotid artery. The patient is intubated and ventilated with 100% oxygen. Here the patient is awakened after completion of the procedure, at which time protamine sulfate is used if needed to restore coagulation time to normal prior to sheath removal. The anesthesiologist must be vigilant in monitoring hemodynamic and neurological status throughout these carotid interventions, particularly during balloon inflations and after the sheath removal for the cervical approach.

Conclusions:

Anesthesia for percutaneous carotid interventions differs from that used for carotid surgery. Protection of the brain from ischemic insult is paramount, and scrupulous attention to physiological factors influencing cerebral blood flow is mandatory. The anesthesiologist plays a crucial role in maintaining hemodynamic stability, adjusting anticoagulation, and monitoring neurological status.
Carotid Angioplasty and Stenting: Will Periprocedural Transcranial Doppler Monitoring Be Important?
Authors: Benichou Hubert , Bergeron Patrice
Published: March 2015

Purpose:

To explore the value of transcranial Doppler (TCD) ultrasonography in the periprocedural monitoring of patients undergoing angioplasty procedures for stenosis of the internal carotid artery.

Methods:

Thirty-two patients were included in the study between April 1991 and September 1995 (6 females, 26 males; average age 66 years). All patients were interrogated before and after angioplasty by a standard TCD examination protocol. Intraprocedurally, TCD was used continuously to monitor cerebral blood flow and supply evidence of embolic particulates. Nineteen patients were treated by percutaneous transluminal angioplasty (PTA) alone; the other 13 underwent primary stent (PS) implantation.

Results:

High-intensity transient signals indicative of emboli appeared to be more frequent in the PTA group than in the PS cohort. Preoperative TCD identified 3 (9%) high-risk patients with incompetent collateral pathways through the circle of Willis. Intraoperatively, TCD detected two postdilation carotid occlusions, a sylvian embolism, and one case of arterial spasm. The preprocedural TCD in a patient with contralateral carotid occlusion showed good collateral circulation, providing reassurance during conversion to endarterectomy when an undeployed stent obstructed blood flow. Postoperatively, TCD confirmed restored intracerebral circulation and identified one hyperperfusion syndrome.

Conclusions:

TCD is a simple, relatively inexpensive examination that can preprocedurally identify carotid stenosis patients at high risk for intraoperative cerebral ischemia in whom PTA might be preferable to surgery. During the procedure, TCD can document the benefits of endovascular treatment and offer early detection of ischemic complications.
Patient Preparation and Monitoring for Carotid Stenting: The Operating Room Nurse's Perspective
Authors: Plat Sylvie , Hilaire Isabelle , Vuillemin Elisabeth , Lafaye Maryse
Published: March 2015

Endovascular procedures should be performed by a trained surgical staff in a surgical suite equipped with a high-resolution fluoroscopic unit. The operating room nurse must be skilled in the handling and preparation of specialized instruments and equipment necessary for carotid angioplasty procedures. Patient preparation and postprocedural wound care techniques are particular to the cervical approach for carotid angioplasty; the operating room nurse should be well trained in these areas in order to provide optimum assistance during the procedure.
Deployment Technique and Histopathological Evaluation of an Endoluminal Vascular Prosthesis Used to Repair an Iliac Artery Aneurysm
Authors: White Rodney A. , Donayre Carlos E. , deVirgilio Christian , Weinstein Eric , Tio Fermin , Kopchok George
Published: March 2015

Purpose:

To describe the deployment technique, function, and gross healing of an endoluminal vascular prosthesis deployed in a high-risk patient for treatment of a common iliac artery (CIA) aneurysm.

Methods:

An 82-year-old, high-risk male with a 4-cm-diameter CIA aneurysm approximately 4.5 to 5 cm long was treated with endoluminal exclusion of the lesion using a 6-cm-long, 14-mm-internal diameter Dacron vascular prosthesis with Palmaz 308 stents sutured to either end of the graft. Intravascular ultrasound (IVUS) imaging facilitated sizing of the endograft and its accurate positioning so as to occlude both the aneurysm and the hypogastric artery, which was a potential source of retrograde flow to the aneurysm. Exclusion of the lesion and occlusion of the hypogastric artery were demonstrated on delayed angiographic images and contrast computed tomography scans obtained at 16 days postprocedure. Unfortunately, the patient died 67 days following implantation from a nonprocedure-related gastrointestinal complication.

Results:

At autopsy, the aortoiliac segment was excised and examined grossly and histologically; the evaluation confirmed complete isolation of the aneurysm by the fully expanded endoluminal prosthesis. The surface of the vascular graft was covered by a glistening, thin, fibrinous membrane. The graft material was filled with hypocellular compact fibrinous material with no evidence of endothelialization. These observations confirm preliminary sealing and isolation of the iliac artery aneurysm as healing of the endograft progressed.

Conclusions:

The data acquired from the analysis of this specimen provide information regarding the utility and early healing of an endograft used for iliac artery aneurysm exclusion. This case also exemplifies the utility of IVUS in endograft deployment.
Adenosine-Induced Transient Cardiac Asystole Enhances Precise Deployment of Stent-Grafts in the Thoracic or Abdominal Aorta
Authors: Dorros Gerald , Conn Joel M.
Published: March 2015

Purpose:

To present a cardiac asystole technique that assists in the accurate deployment of stent-grafts during endovascular repair of thoracic or abdominal aortic aneurysms.

Technique:

In the anesthetized patient, trial doses of intravenous adenosine are delivered until a ≥ 20-second period of asystole is recorded. The endograft procedure then proceeds until the device is ready for deployment. The predetermined dose of adenosine is administered, and the device is deployed during asystole. Adenosine-induced transient asystole has been utilized in 16 patients undergoing balloon-expandable endograft exclusion of 6 thoracic aortic and 10 abdominal aortic aneurysms. Asystole lasted for 20 to 30 seconds, during which time the devices were accurately deployed without interference from the aortic flow. There were no clinical sequelae of this technique in any patient.

Conclusions:

Pharmacologically induced transient asystole appears to be a safe maneuver to preclude endograft movement by systolic blood flow. The technique permits precise placement of balloon-expandable stent-grafts and is applicable to self-expanding devices as well. Interventionists may wish to incorporate adenosine-induced asystole into their aortic aneurysm exclusion procedures.
Polymeric Surface Modifications of Tantalum Stents
Authors: Fontaine Arthur B. , Koelling Kurt , Passos Susan Dos , Cearlock Jody , Hoffman Randy , Spigos Dimitrios G.
Published: March 2015

Purpose:

To compare two kinds of polymer-coated tantalum stents with bare tantalum stents (control) to determine if the coatings can improve thromboresistance.

Methods:

Twenty-seven Fontaine-Dake stents were balloon expanded in three 8-mm × 80-cm.polytetrafluoroethylene (PTFE) grafts; 9 stents were bare tantalum (T); 9 were coated with polyetherurethane (PL); and 9 were coated with parylene (PA). There were 9 stents placed in each graft as follows: 3 tantalum, 3 polyetherurethane, and 3 parylene. In swine whose platelets had been radiolabeled with indium 111, the ends of each stented graft were connected to 14F femoral and venous sheaths to create an ex vivo fistula. Each graft was exposed to blood for 30, 60, and 120 minutes. At the end of each test period, the stented grafts were disconnected from the sheaths, flushed with saline until clear, and then flushed with formalin. The stents were removed from the grafts, and a radionuclide well counter recorded radionuclide counts from each stent type at each period of blood contact. These values were converted to platelet density per 1000 mUm2. Stents were then photographed and scanned with electron microscopy (EM) for qualitative analysis. Possible significant differences in platelet adhesion with the three types of stents (both between stent groups and within stent groups) were examined using a two-tailed Student's f-test.

Results:

There were significantly fewer platelets adsorbed on PA versus T at all time periods (p < 0.005); on PL versus T at 60 and 120 minutes (p < 0.005); and on PA versus PL at 30 and 120 minutes (p < 0.0005). There was no significant difference in platelet density within each stent group (p = 0.1). Mean platelet density (number of platelets per 1000 mUm2 ± SD) was as follows: at 30 minutes: T = 1891 ± 965; PL = 373 ± 193; and PA = 27 ± 3; at 60 minutes: T = 6226 ± 1621; PL = 1573 ± 793; and PA = 1185 ± 710; at 120 minutes: T = 5307 ± 591; PL = 3164 ± 318; and PA = 180 ± 100. Gross inspection of the 120-minute groups demonstrated focal areas of thrombus on T, less on PL, and none on PA. Scanning EM demonstrated extensive platelet accumulation covering T at all time periods, less on PL, and even less on PA.

Conclusions:

Polymeric surface modification of tantalum stents with parylene and/or polyetherurethane can improve the acute thromboresistance of these devices; parylene appears to be the more thromboresistant of the two coatings.
Femoropopliteal Venous Bypass Studied with Intravascular Ultrasound: A Case Report
Authors: van der Lugt Aad , Gussenhoven Elma J. , Tai Jo-Ann , van Sambeek Mar R.H.M. , Pieterman Herman , van Urk Hero
Published: March 2015

Purpose:

To describe the ability of intravascular ultrasound (IVUS) to document the status of the greater saphenous vein during bypass surgery, the long-term changes in the bypass, and the effects of balloon angioplasty on vein graft stenoses.

Methods:

An 80-year-old female underwent in situ femoropopliteal venous bypass grafting. Vein graft stenosis developed 6 months later, necessitating balloon angioplasty. The angioplasty failed, and a polytetrafluoroethylene (e-PTFE) interposition graft was placed. Ten months after bypass surgery, balloon angioplasty was performed for new stenoses. This procedure also failed, and the venous bypass and interposition graft were removed and replaced by an e-PTFE graft. IVUS images obtained during the first surgery were compared with those obtained 10 months later. Histologic sections were used to confirm the IVUS findings.

Results:

IVUS detected a distinct narrowed venous segment, pre-existent intimal thickening, and disrupted valves. Over the follow-up period, both the pre-existent intimal thickening and the narrowed segment evolved into stenoses, necessitating treatment. Luminal gain after balloon angioplasty of graft stenosis was associated with vascular damage.

Conclusions:

This report shows that IVUS has the ability to document long-term venous bypass alterations and to demonstrate the effect of balloon angioplasty on venous bypass stenoses.
Clinical Experience with a New Nitinol Self-Expanding Stent in Peripheral Arteries
Authors: Henry Michel , Amor Max , Beyar Rafael , Henry Isabelle , Porte Jean-Marc , Mentre Bernard , Tricoche Olivier , Ethevenot Gérard
Published: March 2015

Purpose:

To evaluate a new self-expanding nitinol coil stent in stenotic or occluded peripheral arteries.

Methods:

Seventy-three symptomatic patients (58 men; mean age 67 years) were treated with nitinol stents for lesions in the iliac artery (9 stenoses); superficial femoral artery (SFA) (39 stenoses, 6 occlusions); popliteal artery and tibioperoneal trunk (9 stenoses, 7 occlusions); and 3 bypass grafts. Mean diameter stenosis was 84.4% ± 9.9% (range 75% to 100%), and mean lesion length was 45 ± 23 mm (range 20 to 120 mm).

Results:

Eighty-eight 40-mm-long stents with diameters between 5 and 8 mm were implanted percutaneously for suboptimal dilation (n = 45); dissection (n = 21); and restenosis (n = 7). All stents but one were implanted successfully; the malpositioned stent was removed, and another stent was successfully deployed. There were 3 (4.1%) failures due to thrombosis at 24 hours. During the mean 16-month follow-up (range to 44 months), 4 restenoses (3 femoral, 1 popliteal) have occurred; 2 were treated with repeat dilation and 2 underwent bypass. Primary and secondary patency rates at 18 months were 87% and 90%, respectively, for all lesions (iliac: 100% for both; femoral: 85% and 88%; popliteal: 87% and 100%).

Conclusions:

This new nitinol stent seems to be safe and effective with favorable long-term results, even in distal SFA lesions and popliteal arteries. Its flexibility and resistance to external compression allow its placement in tortuous arteries and near joints.
Proximal Stent Deployment without Contrast during Endovascular Aneurysm Repair: An Improved Technique
Authors: Boyle Jonathan R. , Thompson Matthew M. , Nasim Akhtar , Sayers Robert D. , Fishwick Guy , Bell Peter R.F.
Published: March 2015

Purpose:

To describe a technique to enhance stent visibility on the fluoroscopic monitor during aortic endograft deployment.

Technique:

To assist in accurate positioning and deployment of the proximal stent in a Parodi-type aortic endograft, the stent is affixed to the balloon so that the radiopaque marker sits at the stent's distal end. When the device is in position and the sheath is retracted, the stent and the radiopaque balloon markers are clearly seen on the fluoroscopic image. Using normal saline only to inflate the balloon allows the stent to remain visible throughout deployment.

Conclusions:

The use of saline rather than contrast medium for balloon inflation provides continuous visualization of the stent during expansion, thus facilitating accurate deployment and early recognition of balloon migration within the stent.
Endovascular Graft Repair of Penetrating Subclavian Artery Injuries
Authors: Patel Amit V. , Marin Michael L. , Veith Frank J. , Kerr Andrew , Sanchez Luis A.
Published: March 2015

Purpose:

Penetrating subclavian arterial injuries are often difficult to treat. Standard surgical techniques require wide exposure and dissection in traumatized areas, which is often challenging. This report summarizes the early results of endovascularly placed stented grafts for the treatment of penetrating subclavian arterial trauma.

Methods:

Six patients with penetrating injuries of the subclavian artery had stented grafts inserted to repair five pseudoaneurysms and one arteriovenous fistula. The stented grafts consisted of a polytetrafluoroethylene graft sutured over a balloon-expandable Palmaz stent. The devices were inserted from an ipsilateral brachial arteriotomy and deployed using fluoroscopic guidance in the operating room.

Results:

Immediate success was obtained in all procedures (100%). All patients continue to have patent grafts with a follow-up ranging from 7 to 30 months (mean 19 months). The only procedure-related complication was the need for a brachial artery patch angioplasty at the site of device insertion in the first patient. There was one other patient who developed a stent fracture at 8 months; a second stent was inserted. Duplex studies up to 24 months later show no recurrence in this patient.

Conclusions:

Endovascular stented grafts offer an effective, less invasive alternative to standard techniques in treating traumatic arterial lesions. Early results are encouraging, but long-term follow-up will be necessary to fully delineate the effectiveness of this technique.
Endovascular Management of Unusual Aneurysms of the Axillary and Subclavian Arteries
Authors: Sullivan Timothy M. , Bacharach J. Michael , Perl John , Gray Bruce
Published: March 2015

Purpose:

Aneurysms of the upper extremity arteries are uncommon and may be difficult to manage with standard surgical techniques. We report the exclusion of three axillary-subclavian aneurysms with covered stents.

Methods and Results:

Palmaz stents were covered with either polytetrafluoroethylene (2 cases) or brachial vein and deployed to exclude pseudoaneurysms in 1 axillary (ruptured) and 2 left subclavian arteries. Two of the patients had advanced cancer and died within 52 days and 3 months of treatment, but their aneurysms were occluded at the time of their death. The repair in the third patient is patent at 9 months.

Conclusions:

Endovascular exclusion of axillary and subclavian aneurysms with covered stents may offer a useful alternative to operative repair, particularly in patients with significant comorbidities.
Will it Be Feasible to Insert Endoprostheses under Interventional MRI?
Authors: Stroman Patrick W. , Roby Patrice , Alikacem Nadir , Martin Louisette , Mayanloo Mahmood , Formichi Maxime , Guidoin Robert G.
Published: March 2015

Purpose:

Recent advances in magnetic resonance imaging (MRI) technology may provide a safer and more sensitive monitoring modality than X-ray imaging for endovascular surgical procedures. The purpose of this study was to investigate the feasibility of using MRI to monitor the insertion of endoprostheses.

Methods:

The endoprostheses we studied were composed of a nitinol stent encased in a polyester sheath. These were characterized with four different MRI techniques: the fast spin-echo; spin-echo; gradient-recalled echo; and the spoiled gradient-recalled echo. The deployment of the endoprosthesis into an artery was simulated in an in vitro model and viewed using a fast spin-echo MRI technique.

Results:

Image artifacts produced by the nitinol framework in these endoprostheses were minimal when fast spin-echo or spin-echo imaging techniques were used, improving the visibility of the device. In in vitro tests, the catheters and endoprostheses were visualized by MRI with sufficient clarity to guide the placement of a device in the model artery.

Conclusions:

Insertion of this type of endoprosthesis under interventional MRI guidance is feasible. The convenience and improved safety provided by interventional MR systems and “real-time” imaging capabilities are expected to make this technology an attractive alternative to X-ray imaging techniques.
Endoscopic Technique for Subfascial Perforating Vein Interruption
Authors: Tawes Roy L. , Wetter L. Albert , Hermann George D. , Fogarty Thomas J.
Published: March 2015

Surgical treatment of incompetent perforating veins of the lower leg performed openly carries considerable morbidity associated with wound healing. Newer minimally invasive techniques offer an effective treatment alternative that avoids the lengthy incisions of the classical subfascial ligation techniques. The authors report a simple and quick two-port endoscopic method for clipping incompetent perforating veins of the lower leg using commonly available endoscopic instrumentation. The technique is unique in its use of a balloon dissector to rapidly establish the subfascial working space.
Temporary Subclavian Steal to Reduce Intraprocedural Embolic Risk during Detachable Balloon Occlusion of Vertebrobasilar Aneurysms: Technical Note with Two Case Reports
Authors: Eckard Donald A. , O'Boynick Paul L. , Han Patrick P.
Published: March 2015

Purpose:

Unintentional intracerebral embolization is a serious, ever present threat during neurointerventional procedures. We have devised a method to reduce this intraprocedural risk in vertebral artery interventions by creating a temporary subclavian steal.

Methods and Results:

For this technique, a temporary balloon occlusion catheter is advanced into the proximal subclavian artery via a femoral artery approach, while a second introducer catheter is passed into the target vertebral artery via an axillary artery access. The temporary occluding balloon is then inflated within the proximal subclavian artery, establishing a subclavian steal that diverts blood flow into the arm. Permanent balloon occlusion of the vertebral artery can then be accomplished without fear of intracerebral embolization. Two patients with vertebrobasilar junction aneurysms were successfully treated with detachable balloon embolization using this cerebral protection technique. The permanent occlusion balloons were easily passed through the introducer catheter without difficulty despite reversed vertebral artery flow. No complications were encountered, and the aneurysms were successfully occluded in both patients.

Conclusions:

Temporary subclavian steal can be easily created to reduce the risk of cerebral embolic complications when performing interventional neuroradiological procedures in the vertebral artery.
Intravenous Intravascular Ultrasound for Arterial Visualization: A Feasibility Study
Authors: Kriegel Andrew V. , Salles-Cunha Sergio , Pigott John P. , Beebe Hugh G.
Published: March 2015

Purpose:

The advent of endovascular grafting has created detailed imaging requirements for which intravascular ultrasound (IVUS) may be useful. Since intra-arterial IVUS imaging uses space within endovascular graft delivery systems and risks embolism, we investigated the use of intravenous IVUS imaging of arterial vasculature and endovascular grafts, a technique that appears not to have been previously described.

Methods:

IVUS catheters with 12.5- and 20-MHz transducers were inserted through the common femoral artery and vein of mature sheep. Transcutaneous images were also obtained with a 5-MHz linear transducer. B-mode images of the aortoiliac arterial segments and diameter measurements were recorded from both access vessels using anatomic landmarks for site localization. To assess device visualization from the intravenous image source, studies were done in vessels containing previously placed endovascular stent-grafts.

Results:

In this feasibility study, comparison among intravenous IVUS, arterial IVUS, and external ultrasound indicated equal diameter precision and ability to recognize arterial structures. Comparison of arterial diameter, whether obtained from an arterial, venous, or transcutaneous source, showed similar values.

Conclusions:

We conclude that it is probable for such techniques to be usefully applied to human aortoiliac arterial segments and that further investigation of arterial visualization from adjacent venous structures is warranted.
Influence of Angioscopic Vein Graft Preparation on Development of Neointimal Hyperplasia in an Organ Culture Model of Human Saphenous Vein
Authors: Wilson Yvonne G. , Davies Alun H. , Southgate Kay , Currie Ian C. , Knight David , Patton David , Baird Roger N. , Lamont Peter M. , Angelini Gianni D.
Published: March 2015

Purpose:

Angioscopy for in situ vein graft preparation has been criticized on the basis that the trauma of instrumentation may predispose to accelerated intimal hyperplasia, jeopardizing patency rates following infrainguinal revascularization. The aim of this study was to assess the effects of angioscopic preparation on endothelial integrity and smooth muscle cell (SMC) behavior in an established organ culture model of human saphenous vein (HSV).

Methods:

HSV was harvested from 12 patients during bypass surgery before and after angioscopic preparation. Endothelial integrity was evaluated by immunohistochemical staining with JC-70 and scanning electron microscopy (SEM); remaining segments of pre-and postangioscopy vein were maintained in culture for 14 days in medium supplemented with 30% fetal calf serum. Viability was confirmed by measurement of tissue adenosine triphosphate on day 14 and thickness of the neointima was measured by computerized image analysis of histologic sections. Monoclonal antibodies to proliferating cell nuclear antigen (PCNA) were used as an immunohistochemical marker for proliferating SMCs.

Results:

There was a significant reduction in the percentage staining by JC-70 (71.3% versus 20.4%) in pre- versus postangioscopy vein (p = 0.002 by Wilcoxon's rank test; n = 12). This was supported by SEM images. Despite this, there were no significant differences between the pre- and postangioscopy HSVs after 14 days of culture with respect to neointimal thickness (61 versus 56 μm) and staining with PCNA (4.80 versus 4.08 nuclei per 10 (μm), all according to Wilcoxon's rank test.

Conclusions:

Angioscopic vein graft preparation is associated with endothelial cell loss but does not induce additional neointimal hyperplasia in HSV in vitro. These results suggest that angioscopic manipulation does not alter SMC behavior.
European Experience with a System for Bifurcated Stent-Graft Insertion
Authors: Chuter Timothy A.M. , Wendt George , Hopkinson Brian R. , Scott R. Alan P. , Risberg Bo , Kieffer Edouard , Raithel Dieter , vanBockel Johan H.
Published: March 2015

Purpose:

To test an endovascular aneurysm exclusion system in the presence of a wide range of challenging anatomic features.

Methods:

Bifurcated endovascular stent-grafts were inserted in 52 patients and followed with serial computed tomography for up to 3 years. The device underwent several modifications during this time, the most significant of which represent the difference between the homemade (n = 42) and industry-made (n = 10) versions.

Results:

The initial procedural success rate was 92% in the homemade group and 100% in the industry-made group. In the 3 years of follow-up, the long-term success rate was 64% in the homemade group and 90% in the industry-made group. The primary reasons for failure in the homemade group were graft thrombosis due to kinking early in the series and proximal stent migration later in our experience. All cases of migration occurred when the neck was < 15 mm in length, the neck was lined with thrombus, or the stent was implanted > 15 mm from the renal arteries. Kinking was subsequently overcome by implanting Wallstents throughout the graft limbs. The sole failure in the industry-made group was a case in which collateral perfusion reached the aneurysm through patent lumbar arteries.

Conclusions:

The fruits of this experience are a better technique, a better device, and, most importantly, a better understanding of the system's limits, as reflected in the current selection criteria.
Ultrasound-Based Quantification of Emboli during Conventional and Endovascular Aneurysm Repair
Authors: Thompson Matthew M. , Smith Julie , Naylor A. Ross , Nasim Ahktar , Sayers Robert D. , Boyle Jonathan R. , Tinkler Kerry , Goodall Steve , Evans David , Bell Peter R.F.
Published: March 2015

Purpose:

To differentiate and quantify the type and number of lower limb emboli occurring during endovascular aneurysm repair, as compared to conventional surgery.

Methods:

Thirty-eight patients underwent elective infrarenal aneurysm repair using a conventional surgical approach in 18 and an endovascular procedure in 20. Emboli were detected using a Doppler ultrasound system with a 2-MHz transducer interrogating the mid superficial femoral artery. Lower limb emboli were differentiated as particulate or gaseous based on the physical distance traversed by the embolic signal.

Results:

Significantly more particulate (median 108 versus 59, p = 0.015) and gaseous (134 versus 46, p = 0.008) emboli were detected during endovascular aneurysm repair as compared to conventional surgery. Clinically, no case of massive microembolization occurred in either group, but one patient in the conventional group required a femoral embolectomy, and three patients undergoing endovascular repair developed self-limiting trash feet postoperatively. In patients undergoing endovascular aortomonoiliac aneurysm repair, there was only a poor correlation between the number of particulate emboli and either procedural duration or operator experience.

Conclusions:

The apparent lack of a relationship between particulate embolization and operative time or technical experience suggests that manipulation of endoluminal devices within the aneurysm sac may not be the sole determinant of intraprocedural embolization. Other as yet undetermined factors may predict patients at high risk for massive embolization.
Morphometry and Classification in Abdominal Aortic Aneurysms: Patient Selection for Endovascular and Open Surgery
Authors: Schumacher Hardy , Eckstein Hans H. , Kallinowski Friedrich , Allenberg Jens Rainer
Published: March 2015

Purpose:

To evaluate the anatomic morphology of abdominal aortic aneurysms (AAAs) and compose a classification system to facilitate patient selection for endovascular graft (EVG) repair.

Methods:

Data on 242 consecutive AAA patients evaluated on a nonemergent basis in a 3.5-year period to July 1996 were prospectively entered into a registry. Patients were examined using sequential intravenous spiral computed tomographic angiography and intraarterial digital subtraction angiography. The data collected and analyzed included: diameters of the supra- and infrarenal aorta, aneurysm, aortoiliac bifurcation, and iliac arteries; lengths of the proximal neck, distal cuff, and aneurysm; degrees of iliac artery tortuosity; and occlusion of the visceral, renal, or iliac arteries.

Results:

The 242 aneurysms could be easily grouped into three distinctive categories related to the extent of the aneurysmal disease. Type I AAAs (11.2%) had nondilated, thrombus-free infrarenal (15 mm) necks and distal (10 mm) cuffs appropriate for EVG anchoring. In type II and its subgroups (72.3%), a sufficient proximal neck was present, but the aneurysm extended into the iliac arteries; 56% of these were eligible for a bifurcated endograft. In type III (16.5%), a sufficient proximal neck was missing, independent of distal involvement. In all, 51.7% were good EVG candidates based on AAA morphology. Taking into consideration relevant concomitant vascular diseases, proximal iliac kinking, and iliac, renal, or visceral occlusive disease, only 30.2% of the population were potential candidates for an efficient and secure EVG repair using the devices currently available.

Conclusions:

In contrast to classical open repair, detailed preoperative measurements are recommended for EVG planning. The use of liberal EVG indications may lead to a higher incidence of complications, whereas restrictive morphology-based selection criteria may offer excellent results.
Regional Anesthesia for Endovascular Treatment of Abdominal Aortic Aneurysms
Authors: Aadahl Petter , Lundbom Jan , Hatlinghus Staal , Myhre Hans O.
Published: March 2015

Purpose:

To investigate the feasibility of regional anesthesia for endovascular repair of abdominal aortic aneurysms (AAAs).

Methods:

Since February 1995, 21 patients (17 men and 4 women; median age 67 years, range 49 to 80) have been treated with endovascular technique for true infrarenal AAA using Mialhe Stentor bifurcated grafts. A single dose of spinal anesthesia combined with epidural anesthesia was used in all procedures. Electrocardiography and arterial blood pressure were monitored.

Results:

No cases of emboli, hematoma, or graft migration were seen, and there were no reoperations or conversions to open operation. Arterial blood pressure was stable at a satisfactory level from induction of anesthesia throughout the procedure, and there was no period of clinically significant hypotension during any implantation. One patient died on the second postoperative day from cardiac and renal insufficiency. Three endoleaks were observed during the procedure; one healed spontaneously within 5 weeks, and the other two were repaired by endovascular techniques after 1 and 4 months, respectively. During follow-up, one patient died at 6 months from pancreatic carcinoma.

Conclusions:

The application of regional anesthesia is feasible for endovascular treatment of AAA. The arterial blood pressure remained stable throughout the procedure, and all patients, with two exceptions, were mobilized on the first day and placed on a regular diet. Based on these early results, it appears that regional anesthesia is feasible, effective, and safe for endovascular AAA repair.