Artery Cutdown Research Articles

Femoral Artery Cutdowns: Tips & Tricks for Cardiac Surgeons

No abstract present.

Covered Endovascular Reconstruction of the Iliac Artery Bifurcation (CERIB).

The aim of this study was to present the covered endovascular reconstruction of the iliac artery bifurcation (CERIB) technique as a revascularization option for aorto-iliac occlusive disease (AIOD) involving the iliac artery bifurcation. This was a retrospective single-center study including all patients undergoing a CERIB procedure from January 2021 until December 2022. Covered endovascular reconstruction of the iliac artery bifurcation procedures were performed percutaneously with bilateral femoral access, excepting cases where simultaneous open femoral artery reconstruction was required due to the extension of peripheral arterial occlusive disease. Standard patient, procedural, and follow-up (FU) data including survival and arterial reinterventions were gathered and analyzed. A total of 13 patients were included (11/13 male, median age=70 [60-76] years). Additional open and/or endovascular procedures included endarterectomy of the femoral bifurcation (n=6), rotational atherectomy (n=2), and 1 axillary artery cutdown for upper limb access (n=1). Median operating time was 2.9 hours (1.5-4.9 hours); median radiation duration and dose were 28.4 (14.3-63.3 minutes) and 4090.6 (384.4-9430.1 cGray/cm2), respectively. The stent grafts used for CERIB were BeGraft peripheral n=31, BeGraft Aortic n=4 and BeGraft peripheral plus n=1 (Bentley InnoMed GmbH, Hechingen, Germany). In 2 patients with prior stenting of the common iliac artery (CIA), only the internal and external iliac arteries (IIA and EIA) were treated in this study, and in 2 cases, additional uncovered stents were required for relining. Technical success was 100%. During a midterm FU (median 18 [4-31] months), 2 patients died from cardiovascular reasons and 1 patient with prior iliac stenting required reinterventions for recurring occlusion. Covered endovascular reconstruction of the iliac artery bifurcation is a straightforward option for treating AIOD involving the iliac artery bifurcation that allows preservation of internal iliac artery perfusion and shows good early and midterm results. Prior iliac artery stenting may be a risk factor for early occlusion after CERIB. Aorto-iliac occlusive disease with involvement of the internal iliac artery is encountered regularly in vascular surgical practice, but the internal iliac artery is often not included in the revascularization strategy. The present article will increase the awareness for the relevance of including the internal iliac artery in revascularization strategies and presents CERIB as another method to be added to the armamentarium of (endo-)vascular surgeons and interventionalists.

Safety and Effectiveness of Brachial Artery Preclosure by Purse-String Suture Technique for Left Subclavian Artery Revascularization in Stanford B Aortic Dissection.

To assess the safety and efficacy of the combination of brachial artery (BA) cutdown with purse-string suture (PSS) for BA preclosure during fenestrated thoracic endovascular aortic repair (f-TEVAR). We reviewed the consecutive data in our center from January 2022 to May 2023. Clinical data were analyzed retrospectively, including the baseline characteristics, procedural details, complications, and outcomes. Dichotomous data were summarized as absolute values and percentages. Continuous variables were presented as median values and interquartile ranges (IQRs). All patients underwent arterial cutdown with the PSS technique for BA preclosure. The technique was considered successful when complete hemostasis was achieved and confirmed by ultrasonography 24h postoperatively. The patients were followed up 30days postoperatively for access-related complications. Forty-eight patients who underwent f-TEVAR with 48 BA access sites were included [36 males and 12 females; median age: 62 (IQR: 30-78) years]. The median body mass index was 27.3 (IQR: 21.2-32.7) kg/m2. The median access establishing and closing times were 7.8 (IQR: 6-9.3) min and 3.7 (IQR: 2.5-5) min, respectively. The median operative time and length of stay were 75 (IQR: 63-87) min and 7 (IQR: 5-9) days, respectively. Although the success rate was 100%, partial numbness in the median nerve distribution was noted in 1 patient in the forearm. This resolved spontaneously and no permanent neurological problem was seen. No other access-related complications were noted, and the total complication rate was 2.1% (1/48). BA preclosure with the PSS technique is safe and effective for left subclavian artery revascularization in Stanford B aortic dissection and can be another option for access closure during f-TEVAR.

Abstract 17923: Acute Limb Ischemia Due to Dissection and Thrombosis of Anomalous Right Subclavian Artery: A Rare Complication of Trans-Radial PCI

Introduction: Right subclavian artery (RSA) normally originates from brachiocephalic artery, but in 0.4-1.8% of the general population it may arise directly from the aortic arch distal to the left subclavian artery. We present a case of acute limb ischemia due to dissection and thrombosis of anomalous right subclavian artery (ARSA) following transradial PCI. Case: A 60-year-old female presented with anterior STEMI. Coronary angiogram was performed via right transradial approach. During the procedure the aortic arch was noted to be exceedingly tortuous and coronary artery catheterization was difficult. Post-procedure, patient reported right arm pain. Her right hand was cold with bluish discoloration, nonpalpable right radial, ulnar and brachial artery pulses which prompted a CTA of the chest and right upper extremity. Imaging revealed ARSA with dissection and thrombosis of the RSA extending to mid-brachial artery and absent opacification of radial/ulnar arteries. The patient underwent right brachial artery cutdown, axillary artery thrombectomy and stenting of ARSA dissection. Post procedure, her pulses were palpable with triphasic doppler signals in the radial and ulnar artery. Four months later, surveillance CTA of chest showed patent stent without additional evidence of dissection (Figure 1). Discussion: ARSA is a rare anatomical variation of the origin of the RSA but also the most common abnormality of the aortic arch. ARSA anomaly is often asymptomatic, but approximately 10% is associated with tracheo-esophageal symptoms; the most frequent among them is dysphagia. Only 60% of coronary procedures using transradial approach are successful in the presence of ARSA. This congenital variant makes it difficult to approach the ascending aorta by the right transradial route, as it requires the catheter to curve back to reach the aortic root. Prompt recognition of this anomaly during the procedure and alternate access routes can avoid these severe complications.

SP11.10 Assessment of Heart Rate Variability as A Marker of Stress and Cognitive Load During Vascular Surgery: Surgical Training

Abstract Introduction Decreased heart rate variability (HRV) correlates with subjective stress (STAI-6 score) and demonstrates increased stress at challenging steps during vascular surgery. This observational study aimed to examine HRV utility as an objective measure of stress and satisfaction during intra-operative vascular surgical training; hypothesising detrimental HRV change is associated with: (1) low training satisfaction, (2) operating compared to assisting, and (3) lower surgical experience. Methods Change from baseline (%) in HRV (SDNN - overall variability and LFHF - sympathetic tone) was calculated during arterial cutdown and arterial closure training points in 7 trainers and 10 trainees during 9 femoral vascular procedures. Pearson’s correlation coefficient was used to investigate association between training satisfaction and operative HRV in trainees, and overall operative experience and training point HRV. Mann-Whitney-U was used to investigate HRV difference in operating trainees with high versus average training satisfaction and operating versus assisting/supervising training points. Results Data (median (IQR)) included 13 cutdowns and 12 closures. Training satisfaction did not relate to STAI-6 or HRV. LFHF was significantly lower in trainers when operating (n=2) compared to supervising (n=10) cutdown (-18.96(-27.87--10.05) vs 36.96(10.83-147.2) p=0.0409*). No difference was seen during closure or in trainees. Operative LFHF non-significantly decreased with experience overall (r=-0.342, p=0.0944) and during cutdown (r=-0.498, p=0.0833), no association existed for assisting. Conclusion HRV may objectively measure stress during in-theatre training. This study suggests trainers may experience more stress when supervising rather than operating. Larger studies are required to demonstrate a more definitive relationship between training, stress and HRV.

How to Do It: Transbrachial Impella Placement to Facilitate Percutaneous Coronary Intervention.

A 64-year-old man with diffusely diseased iliofemoral vessels and an ejection fraction of 20% to 25% presented with a non-ST elevation myocardial infarction and proximal left anterior descending (LAD) and left circumflex (LCx) coronary artery disease, with a chronically occluded right coronary artery. The iliofemoral system was not suitable for Impella placement, and bilateral axillary arteries were heavily calcified. The proximal left brachial artery was chosen for placement of both an Impella CP (Abiomed, Danvers, MA, USA) and percutaneous coronary intervention (PCI) sheath through a graft sewn to the brachial artery in this single-access technique. A 6 mm graft was sewn to the brachial artery, through which the Impella CP was placed. The Impella CP sheath was then used to introduce a 7F sheath for PCI. Successful PCI with drug-eluting stents was carried out to the LAD and LCx arteries, the Impella was weaned and removed, and the graft was stapled. The patient was discharged without any access or PCI complications. This report demonstrates the feasibility of the single-access Impella technique through a brachial artery cutdown approach.

Direct Carotid Artery Cutdown and flow diversions for the bilateral Internal Carotid Artery Dissecting Pseudoaneurysms: A Case Report

Background: Surpass streamline flow diversion is performed by transfemoral, transradial or both approaches. Safety and feasibility of direct carotid artery cutdown and is not known. Objective is to report Surpass streamline flow diversion via direct carotid artery utdown for a patient with bilateral internal carotid artery dissecting pseudoaneurysm. Method: Case report. Outcome was measured using modified ranking scale (mRS). Results: Sixty-seven-year-old man with history of repaired aortic arch dissecting aneurysm using aortic stent, developed worsening headaches and dizziness and diagnosed with bilateral internal carotid artery dissecting pseudoaneurysm on a computed tomographic angiography; right internal carotid artery dissecting pseudoaneurysm measured 19x15x20 mm and left was 16x9x22 mm. Digital subtraction angiogram was attempted but failed. A direct carotid artery cutdown followed by surpass streamline flow diversion was performed in a staged fashion. A 6-french sheath was placed from right common carotid artery to right internal carotid artery by a vascular surgeon and was confined with digital subtraction angiography. An intermediate catheter was navigated to the internal carotid artery beyond the internal carotid artery dissecting pseudoaneurysm and surpass streamline flow diversion was achieved with 3 devices; 4x50 mm x2 and 5x40 mm. Carotid artery cutdown site was sutured by vascular surgeon. Patient was extubated and discharged home in 48 hours with NIHSS 0 and mRS1 at his baseline. The left internal carotid artery dissecting pseudoaneurysm was repaired after 3 month using similar technique as described above with two 5x50 mm flow diverters. For the second procedure, angioplasties were required for better appositions of flow diverters. Patient was discharged home in 24 hours. Patient’s symptoms resolved and resumed baseline activities. Prescribed to continued 325 mg aspirin and 75 mg clopidogrel for six months followed by 162 mg aspirin and 75 mg of clopidogrel. Patient maintained mRS 0 in follow-up visits but refused to have a computed tomographic angiography, which finally performed in 24 months, demonstrates complete obligations of the left internal carotid artery dissecting pseudoaneurysm but occlusion of right internal carotid artery with robust collaterals from left internal carotid artery through collaterals. Patient admits premature discontinuation of antiplatelets when he learned about his computed tomographic angiography results. Conclusion: This is the first report of treatment of bilateral internal carotid artery dissecting pseudoaneurysm repaired by direct carotid artery cutdown approach. This is also the first report of a patient with an aortic arch stent, who developed bilateral internal carotid artery dissecting pseudoaneurysm and direct carotid artery cutdown required for treatment. Additionally, antiplatelets must be continued to prevent device occlusion.

Hybrid Revascularization of Infrarenal Aortic Occlusion due to Thrombophilia: A Case Report

Background: Infrarenal abdominal aortic occlusive disease has traditionally been treated with aortic endarterectomy, aortobifemoral bypass grafting, or both; however, it has also been associated with up to a 3.3% to 4.6% perioperative mortality rate and an 8.3% to 13.1% major early complication rate. European Guidelines on Peripheral Artery Diseases published in 2017 support a hybrid approach. Thrombophilia is a commonly overlooked cause of peripheral arterial disease (PAD) in younger patients. Thrombophilia is reported to lead to an increased incidence of graft failure and multiple revascularization procedures. This presented a rare case highlighting the surgical approach to complex aortoiliac occlusion due to thrombophilia with subsequent lower limb ischemia and the multi-disciplinary input needed in this vulnerable patient cohort. Case presentation: Herein, we present a case of an acute distal aortic occlusion and failed revascularization with a history of thrombophilia and previous left leg below-knee-amputation (BKA) due to acute limb ischemia. He had a background of recently withholding warfarin for a ureteric stent insertion for renal calculus. The diagnosis of our case depended on CT and angiography, where they confirmed an occluded infrarenal aorta with bilaterally occluded common and external iliac arteries. Our case underwent hybrid revascularisation under bivalirudin cover. An open thrombectomy of the right common femoral artery (CFA) and PFA was performed. A left brachial artery cutdown was performed, and a catheter was placed in the suprarenal abdominal aorta. The right iliac artery occlusion was crossed from the left brachial access with a Command 0.018 wire supported by a Van Schie II catheter with a through-and-through wire able to be retrieved from the open right CFA. The proximal IMA was stented with a 6 x 80mm Absolute Pro-self-expanding stent, deployed in a kissing-stent fashion with a 10 x 100mm Absolute Pro stent in the distal aorta. Overlapping self-expanding stents were deployed from the distal aorta to the right external iliac. Six weeks after the procedures, computed tomography/angiography confirmed the excellent radiologic results. Conclusion: This rare case highlights the catastrophic outcomes that can happen when anticoagulation is withheld in thrombophilic patients. It exhibits the Role of a hybrid open and endovascular approach in complex occlusive aortoiliac disease and the critical importance of early multi-disciplinary involvement in critically unwell patients.

Cerebral Aneurysms Repair Using Direct Carotid Artery Cutdown: A Case Series

Background: Cerebral Aneurysms (CA) including dissecting pseudoaneurysms are treated endovascularly through a trans-radial or trans-femoral approach. When these options are not available, a trans-carotid approach via Direct Carotid Artery Cutdown (DCAC) may be used as the last option. However, the safety and feasibility of DCAC is not well studied or defined in these contexts. Our objective is to present our four unique patients who were treated by the DCAC approach for their cerebral aneurysm and/or internal carotid artery dissecting pseudoaneurysm using flow diversion. Method: This is a report of a case series and retrospective review. Results: Patient 1; A 75-year-old woman with known left internal carotid artery (ICA) petrocavernous aneurysm that enlarged from 6 mm to 10 mm resulting in double vision and headaches. Trans-femoral approach failed due to the tortuosity in the common carotid artery (CCA). A multidisciplinary team was formed; A vascular surgeon began the surgery followed by FD by a neuroendovascular surgeon. A 6 French sheath was placed on the right common carotid artery via DCAC then brought to right ICA by vascular surgeon, and a neuroendovascular surgeon confirmed the placement with digital subtraction angiography (DSA). The DSA confirmed a large 10 x 8 x 5mm broad-based aneurysm. Flow diversion was performed with pipeline flex measuring 5 x 30mm. Patient was discharged home and achieved baseline modified Rankin Scale (mRS )1 which sustained in 5 years with aneurysm obliteration. Patient 2; A 65- year-old woman with multiple symptomatic left ICA-Para-ophthalmic artery aneurysm measuring 9 mm. Both femoral and radial arteries were occluded and underwent DCAC and flow diversion with pipeline flex of 4x30 mm using the similar technique described above. Patient discharged home in 48 hours with National Institute of Health Stroke Scale (NIHSS) of 0 and achieved her baseline mRS. However, this patient refused to have any further follow-up studies done. Patient 3; A 67-year-old man with aortic arch endograph with stent graft after previous aortic dissection and diagnosed with bilateral internal carotid artery dissecting pseudoaneurysm (ICADP) by computed topographic angiography (CTA). The right ICADP measured 19 x 15 x 20 mm, was multilevel, extending from skull base to the internal carotid artery (ICA) origin. The left ICADP was 16 x 9 x 22 mm with inflow-zone stenosis. The DSA was attempted but failed due to the aortic stent. The right ICADPA was repaired first using Surpass streamline (Stryker Neurovascular, Irving, CA) device measuring 4 x 50 mm x2 and 5 x 40 mm covering the entire dissecting artery. Patient was discharged home in 48 hours. Three months after the first procedure, using similar technique the left ICADPA was treated with a 5 x 50 mm Surpass evolve flow diverter. Patient achieved mRS 0. In 24-months follow up CTA demonstrated complete resolution of left ICDAP, but occlusion of the right ICA without impairing his mRS 0. Patient 4; a 76-year-old-woman with tinnitus, headaches and dizziness; DSA demonstrated RICA dissecting large 16 x 8 mm pseudoaneurysm. Trans-femoral approach failed and underwent DCAC, and flow diversion with a single surpass evolve flow diverter 4.5 x3 0 mm. Patient was discharged with NIHSS 0 and achieved her baseline mRs 0.

Ankle-Brachial Index evaluation in totally percutaneous approach vs. femoral artery cutdown for endovascular aortic repair of abdominal aortic aneurysms

article: Ankle-Brachial Index evaluation in totally percutaneous approach vs. femoral artery cutdown for endovascular aortic repair of abdominal aortic aneurysms - Chirurgia 2022 December;35(6):349-54 - Minerva Medica - Journals

Safety and efficacy of aortic coarctation stenting in children and adolescents

Percutaneous aortic coarctation treatment with primary stent implantation is the first choice in adult patients. However, current guidelines do not suggest a lower weight limit to perform this procedure safely.The aim of this study was to retrospectively analyze the safety and the mid-term outcome of aortic coarctation stenting in pediatric age at different patients’ weights.We enrolled 47 patients, 8 of them weighting lower than 25 kg, 10 with a weight between 25 and 30 kg and 29 patients with a weight >30 kg.Covered CP stent was used in 32 patients (68.1%), bare CP stent in 6 (12.8%), Andrastent XL in 8 (17.0%) and Palmaz Genesis in one case (2.1%). The balloon mean diameter was 13.8 ± 2.4 mm, range 10–18 mm. The procedure was effective in all patients. The aortic gradient dropped from 28.0 ± 7.8 mmHg to 2.2 ± 2.0 mmHg (p < 0.0001). Hemostasis was achieved by a surgical cut-down in 20 (42.5%) patients, manual compression in 2 (4.3%) or by vascular closure devices (VCDs) in 25 (53.2%) patients. There was no difference in terms of efficacy, safety and complication rate among the three weight-based groups. We found a trend toward higher incidence of vascular complications following hemostasis with VCDs (4/24, 16.7%) vs surgical cut-down (1/21; 4.8%)In conclusion, aortic coarctation stenting is a safe procedure in patients weighing less than 30 kg. Surgical arterial cut-down can minimize the risk of vascular injury by reducing the stress on the arterial wall in smaller patients, or in case, a large sheath is needed.

Abstract 1122‐000076: Direct Carotid Artery Cutdown and Flow Diversions for the Bilateral Dissecting Pseudo‐Aneurysms

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

Perioperative neurologic outcomes of right versus left upper extremity access for fenestrated-branched endovascular aortic aneurysm repair

ObjectiveUpper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right- vs left-side UE access. MethodsDuring an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications. ResultsUE access was used in 361 (80%) patients. The right side was used in 232 (64%) and the left side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal, and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which three were ischemic and two were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated with permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P = .99). Arm access-related complications occurred in 15 (5%) patients, 11 (4.8%) on the right side and 4 (6%) on the left side (P = .74). ConclusionsRight UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.

Preclosure technique versus arterial cutdown after percutaneous cannulation for venoarterial extracorporeal membrane oxygenation.

BackgroundArteriotomy repair through the preclosure technique during elective arterial access procedures is well documented. Outcomes associated with application of this technique to the removal of arterial access cannulas in patients undergoing urgent venoarterial extracorporeal membrane oxygenation (VA-ECMO) have not previously been reported.MethodsWe reviewed the records of consecutive patients who required VA-ECMO for cardiogenic shock. Patients were compared by use of the preclosure device (Perclose ProGlide Suture-Mediated Closure System; Abbott Vascular, Abbott Park, Ill) at time of VA-ECMO cannulation. The rate of limb complications (composite of limb ischemia, infection, and site necrosis) and secondary end points of bleeding events, pseudoaneurysm, distal part embolization, and intensive care unit length of stay after decannulation were compared between the groups.ResultsNinety-nine consecutive patients managed with VA-ECMO were identified and the preclosure device was utilized in 51 of these patients. Preclosure device failure occurred in 5 instances (9.8%) and was successfully managed with surgical repair in 4 cases and endovascular intervention in another. Use of the preclosure device was associated with both fewer limb complications (odds ratio, 0.19; 95% confidence interval, 0.03-0.78) and bleeding events (odds ratio, 0.21; 95% confidence interval, 0.04-0.89). Pseudoaneurysm (n = 0) and distal part embolization (n = 1) were infrequently encountered in the cohort and no difference in intensive care unit length of stay after decannulation was noted between the groups.ConclusionsIn this cohort, use of the preclosure technique in weaning from VA-ECMO was technically feasible, safe, and associated with an approximate 80% lower likelihood of limb complications and bleeding events compared with surgical removal.

Perioperative Neurologic Outcomes of Right Versus Left Upper Extremity Access for Fenestrated-Branched Endovascular Aortic Repair

Upper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right versus left-side UE access. During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right versus left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications. UE access was used in 355 (88%) patients. The right-side was used in 232 (65%) and the left-side in 123 (35%) patients for the treatment of 84 (24%) juxtarenal, 135 (38%) suprarenal and 148 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 348 patients (98%). In-patient or 30-day mortality was 3%. Five (1.4%) perioperative strokes occurred in patients undergoing right UE access, of which two were ischemic and three were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated to permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .17). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5 [1.4%]) and femoral access only (1 [1%]). Arm access related complications occurred in 15 (5%) patients, 11 (3.8%) on the right-side and 4 (6%) on the left-side (P = .5). Right UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.

The “two-cut monorail” technique, for the over-the-wire removal of the Impella CP device

The Impella is a percutaneously placed intra-arterial flow pump positioned across the aortic valve for circulatory support. A limitation of the Impella is that it lacks a central wire channel, to maintain intra-arterial wire access when removing the device. Open surgical arterial cutdown is needed for the removal of the Impella CP placed emergently, without the use of preclose sutures. This case review describes an alternative removal method for the aforementioned occasions.

Perioperative and Long-term Results of Zenith Fenestrated Aortic Repair in Women

Inferior perioperative outcomes for women receiving major vascular surgery are well established in the literature in multiple arterial distributions. Therefore, this study was completed to determine the perioperative and durability results associated with women undergoing complex aortic reconstruction using the Zenith Fenestrated platform (ZFEN; Cook Medical, Bloomington, IN). A retrospective review of a fenestrated endovascular aortic repair (FEVAR) database capturing all ZFENs performed at our institution between October 2012 and March 2019 was completed. Preoperative, intraoperative, perioperative, and follow-up outcomes were tabulated for females and compared with their male counterparts. Within our study period, 136 total ZFEN procedures were performed; of which, 20 devices (14.7%) were implanted in women. Intraoperatively, we observed a higher rate of estimated blood loss (660.0mL vs. 311.6mL, P<0.01) and resultant need for transfusion (1.4 vs. 0.3 units, P<0.01) in women despite a similar frequency of brachial (5.0% vs. 7.8%, P>0.99) and femoral artery cutdowns (55.0% vs. 49.1%, P=0.81). Operative (295.7min vs. 215.7mins, P<0.01) and fluoroscopy (84.3 vs. 58.7min, P<0.01) times were also significantly higher in females than those in their male counterparts. In the perioperative (30-day) period, we observed significantly longer length of stay (5.6days vs. 3.3days, P=0.03) and continued need for transfusion (50% vs. 9.5%, P<0.01) in women. Statistical trends favoring men were also noted with respect to all-cause mortality, reintervention, visceral stent thrombosis, renal failure, acute kidney injury, and respiratory failure. After a mean follow-up of nearly 2 years, we found no differences in late all-cause or aneurysm-related mortality, major adverse cardiovascular events, or need for reinterventions. The implantation of ZFEN in females is significantly more difficult than that in their male counterparts and may result in increased perioperative, but not necessarily long-term, complications.

Dual-layer everted saphenous vein patch for pediatric femoral artery repair following ECMO decannulation

Decannulation from pediatric veno-arterial extracorporeal membrane oxygenation (VA-ECMO) involves the removal of large arterial perfusion cannulas from relatively small lower extremity arteries. While these challenging repairs are frequently performed by general pediatric surgeons, there is little standardization with regard to vascular techniques within the pediatric surgery training paradigm, resulting in variability in the repair of these arteriotomies and potential future consequences for lower extremity perfusion and growth. Herein we present a technique for repair of large common femoral arteriotomies following removal of ECMO perfusion cannulas utilizing a dual-layer patch of ipsilateral saphenous vein harvested via the arterial cutdown incision. This vein segment is everted to maximize endothelial surface area of the patch and dual layered to provide additional support against aneurysmal degeneration. The described technique is an effective repair of arteriotomy following VA-ECMO decannulation, which minimizes vascular complications and is an accessible technique to those without advanced vascular surgical training. Level of EvidenceLevel IV; operative technique description with small case series.

Pulse Oximetry Screening Has Not Changed Timing of Diagnosis or Mortality of Critical Congenital Heart Disease.

This study evaluates the effectiveness of mandatory pulse oximetry screening. The objective is to evaluate whether mandatory pulse oximetry testing had decreased the late critical congenital heart disease (CCHD) diagnosis rate and reduced mortality in neonatal subjects. This was a single center, retrospective cohort study comparing the timing of diagnosis of CCHD between neonates undergoing cardiac surgery in 2009-2010, prior to mandatory pulse oximetry screening, and neonates in 2015-2016, after mandatory pulse oximetry screening was instituted. Follow-up was for 1year. We defined CCHD as lesions requiring surgical correction within 30days of life. Exclusions included: pacemaker insertions, vascular ring divisions, closure of patent ductus arteriosus, arterial cutdown, or extracorporeal membrane oxygenation cannulation without structural heart disease as the sole procedure, or if subjects were born at home. Infants diagnosed prior to discharge from birth hospital were defined as early postnatal; late postnatal subjects were diagnosed after birth hospital discharge. In-hospital mortality and 1-year mortality were measured. A total of 527 neonates were included; 251 (47.6%) comprised the pre-mandatory pulse oximetry screening cohort (2009-2010). Only 3.6% of the 2009-2010 cohort and 4.3% of the 2015-2016 cohort were diagnosed late (p = 0.66). One-year mortality decreased during the study period (17.2% in 2009-2010 vs 10.5% in 2015-2016, p = 0.03). There were no deaths in the late CCHD diagnosis groups. Mandatory pulse oximetry screening legislation has not changed the late postnatal diagnosis rate at our institution. Mortality for neonatal CCHD has declined, but this decline is not attributable to mandatory pulse oximetry screening.

Utility of Intravascular Ultrasound During Carotid Angioplasty and Stenting with Proximal Protection.

Carotid artery stenting (CAS) is an established treatment for patients at high-risk for endarterectomy. Patients who undergo CAS have been shown to have periprocedural microembolic events on transcranial Doppler ultrasonography. Flow reversal is often applied in these situations to prevent distal emboli and concurrently allow blood to flush into the common carotid artery. Patients who demonstrate soft plaque morphology that may embolize distally during CAS benefit from flow reversal. Even so, the all-stroke risk in these patients is nearly 1.4%. High-risk patients typically have more difficult plaque morphology; flow reversal decreases the rate of distal emboli but does not offer the intraprocedural visualization seen with intravascular ultrasound (IVUS). In this paper, we illustrate potential periprocedural outcomes associated with stenting of the stenotic carotid bifurcation under flow reversal and how IVUS influenced endovascular management. Three high-risk patients who underwent CAS with direct common carotid artery cutdown approaches due to common carotid ostia disease with flow-reversal proximal embolic protection also had intraprocedural IVUS performed to evaluate plaque morphology and stability before the protection system was removed. Case 1 illustrates no intraluminal thrombus on IVUS, requiring no further intervention after stent placement. Case 2 demonstrates intraluminal thrombus on IVUS requiring a second stent to stabilize plaque. Case 3 shows the inadequate resolution of thrombus after a second stent, which was addressed with balloon angioplasty. In our experience, using IVUS as an adjunct to CAS under proximal embolic protection helped demonstrate plaque morphology and plaque fragmentation after stent placement. These cases illustrate the potential benefit of allowing stabilization of the plaque before flow reversal is stopped.