Intraoperative Completion Angiography Research Articles

Intraoperative angiography in carotid artery reconstruction-Pathological findings, reliability and importance of the procedure

ZielDer Wert der intraoperativen Angiographie und deren Ad-hoc-Beurteilung im Hinblick auf operationstechnische Unzulänglichkeiten soll geprüft werden.MethodeInsgesamt 523 konsekutive A.-cartotis-Thrombendarteriektomie(TEA)-Patienten mit intraoperativer Kontrollangiographie, postoperativer Duplexsonographie und retrospektiver Zweitbeurteilung der Angiographie wurden in die Auswertung einbezogen.ErgebnisseIn der retrospektiven Zweitbeurteilung der Angiographie wurden 23 (4,4%) Verschlüsse oder hochgradige Stenosen der Arteria carotis communis (ACC) oder Arteria carotis interna (ACI) im Operationsbereich (12/2,3%) bzw. in der Abstrombahn (distale extrakranielle und intrakranielle ACI, A. cerebri media [ACM]) detektiert (11/2,1%), wohingegen bei der intraoperativen Ad-hoc-Beurteilung nur 13 (2,5%) derartige Pathologien beschrieben worden waren (7/1,3% im Operationsbereich, 6/1,1% in der Abstrombahn; p=0,002). Duplexsonographisch wurden postoperativ bei 50 von 505 untersuchten Patienten (10,1%) operationstechnische Unzulänglichkeiten lokal detektiert, was signifikant mehr war als in der Angiographie (p<0,001). In den meisten Fällen handelte es sich um nicht okkludierende/nicht hochgradig stenosierende Intima-Media-Ablösungen (19), Nahteinziehungen (13) und Kinkings/Kalibersprünge am distalen Patchende (14). Nahteinziehungen und Kinkings/Kalibersprünge waren mit einer linksseitigen TEA (adjustierte OR: 2,4; 95%-KI: 1,1‑5,1), einer Operation ohne Patch (adjustierte OR: 16,6; 95%-KI: 1,3–215,0) und der Verwendung eines Dacron- vs. Polytetrafluorethylen-Patch (adjustierte OR: 3,0; 95%-KI: 1,4–6,6) assoziiert.SchlussfolgerungBei der Ad-hoc-Beurteilung der intraoperativen Kontrollangiographie kann eine nicht unerhebliche Zahl auch okkludierender und hochgradig stenosierender Pathologien übersehen werden (zur Detektion nicht okkludierender und nicht hochgradig stenosierender operativer Unzulänglichkeiten methodisch nicht geeignet – Ausweich: postoperative Duplexsonographie).

The Assessment of Carbon Dioxide Automated Angiography in the Type II Endoleaks Detection: Comparison with Contrast-Enhanced Ultrasound

Introduction - The presence of type II endoleak (ELII) after endovascular aortic repair (EVAR) can be investigated with different methods. Since intraoperative completion angiography (ICA) may underestimate their presence, particularly if they are at low flow, contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard during EVAR follow-up. Intra-procedural carbon dioxide (CO2) angiography has been shown to be useful in this setting, however no comparative studies including these three techniques are currently available. Aim of our study is to investigate the accuracy of a new automated CO2 angiographic (CO2A) system in the detection of ELII, by comparing it with ICA and CEUS. Methods - A series of consecutive patients undergoing EVAR for Abdominal Aortic Aneurysm (AAA) were enrolled and submitted to ICA and CO2A during the procedure. The iodinate contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta, with constant flow velocity and volume injection. The CO2 was delivered through a recently available automatic injector connected to a 10F, 11mm long sheet positioned in the external iliac artery, with constant CO2 injection in terms of flow velocity and volume rate. All patients were blindly evaluated by CEUS on postoperative day1. The presence of ELII was defined as contrast enhancement into the residual sac appearing with a ≥ 5 seconds delay from contrast injection. The ICA and CO2A ability to detect ELII was compared with that of CEUS through the Cohen's concordance Index (K).s Results - Twenty-one patients with a mean AAA size of 56±8mm, were entered in the study. There were no intra or peri-operative complications related to ICA or CO2A. No type I-III endoleak were detected by ICA or CO2A, as confirmed also by CEUS. One (5%), 7(33%) and 4(19%) ELII, were detected by ICA, CO2A and CEUS, respectively. The only ELII detected by ICA was also detected by CO2A and CEUS. Three cases of ELII detected by CO2A were not detected by CEUS. No cases of ELII undetected by CO2A were visualized by CEUS. A perfect agreement between CEUS and both ICA and CO2A was observed for type I/III endoleak (Cohen's K:1). CEUS and ICA showed a poor agreement for ELII detection (Cohen's K:0.35). A substantial agreement was observed between CEUS and CO2A for ELII (Cohen's K:0.65). Conclusion - CO2A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICA.

Management of Renal Artery Dissection Post Endovascular Graft Repair of Salmonella Aortitis

Introduction - Salmonella aortitis is a rare and rapidly progressive pathology that requires early surgical intervention. In recent years, endovascular grafts have increasingly been utilised for this purpose with promising outcomes but a new set of complications. We describe a case of salmonella aortitis managed with early endovascular grafting complicated by Stanford Type B aortic dissection involving the left renal artery. Methods - Case Report Results - An 83 year old male presented with a 2-day history of fevers and back pain. He had a history of rheumatoid arthritis not being treated with steroids or immunosuppressive agents, hypertension and hypercholesterolaemia. He was diagnosed with salmonella enteritidis infrarenal aortitis on blood culture and CT scan, and was commenced on intravenous antibiotics. However, progression demonstrated on CT of a penetrating aortic ulcer the following day prompted urgent treatment with an endovascular graft. Intraoperative completion angiography demonstrated satisfactory graft positioning immediately inferior to the left renal artery origin and exclusion of the ulcer. However, a progress CT scan 7 days later showed a retrograde aortic dissection from the origin of the left renal artery extending proximally to the left subclavian artery origin. The left renal artery was perfused via both the true and false lumens; the left kidney appeared adequately perfused and the patient had a normal serum creatinine. The patient developed left renal corticol infarcts seen on CT 2 weeks later but continued to have normal serum creatinine and stable renal artery dissection. The patient followed up routinely at 3 months when his serum creatinine had more than doubled; a MAG3 perfusion scan showed markedly reduced left renal perfusion as well as function. This prompted endovascular treatment with a left renal artery stent with restoration of true lumen flow to the left kidney. However, although his creatinine had mildly improved, his follow up MAG3 scan showed no resultant improvement in perfusion or function of the left kidney. Conclusion - This case demonstrates that renal artery dissection can lead to significant subclinical malperfusion and malfunction of the kidney. Dedicated renal perfusion and function studies such as a MAG3 scan should be considered early in these cases to determine the need for intervention before irreversible consequences occur.

Endovascular Aneurysm Sealing and Chimney Endovascular Aneurysm Sealing in the Treatment of Type Ia and Type III Endoleaks After Endovascular Aneurysm Repair

The aim of this study was to report the treatment of type Ia and type III endoleaks after endovascular aneurysm repair (EVAR) or chimney EVAR using endovascular aneurysm sealing (EVAS) and chimney EVAS. Ten consecutive patients who underwent the EVAS procedure to treat endoleaks after EVAR were retrospectively included between July 2015 and July 2017. Technical success of EVAS was defined as a successful sealing of the Nellix endograft with visceral vessel patency on intraoperative completion angiography. The median time between EVAR and EVAS procedure was 41.5months (29-81.8). Eight patients had an elective procedure, whereas 2 were treated in emergency. Chimney endografts were placed during the EVAS procedure in 4 patients, whereas classic EVAS was performed for the other 6 patients. The median procedural time was 222.5min (138.8-418.8). The technical success was achieved for all patients. The median length of stay after EVAS was 7days (6.8-14). No death related to abdominal aortic aneurysms or vascular complications were reported for a median follow-up duration of 13.5months (6.3-25.5). A reintervention was required for 2 patients who developed persistent type II and type Ia endoleaks, which were successfully treated using an embolization procedure. EVAS and chimney EVAS in the treatment of type Ia and type III endoleaks after EVAR and chimney EVAR are technically feasible. Short-term follow-up suggests that the procedure is a safe and efficient therapeutic alternative to manage disabled EVAR.

Conservative management of type 1A endoleaks at completion angiogram in endovascular repair of infra-renal abdominal aortic aneurysms with current generation stent grafts.

Proximal type 1A endoleaks on completion intra-operative angiography are not infrequently seen following endovascular abdominal aneurysm repair (EVAR). The natural course of these leaks is not well established. We sought to determine the rate of spontaneous resolution and a conservative treatment approach to these endoleaks. All cases involving endovascular repairs of infra-renal abdominal aortic aneurysms resulting in proximal type 1A endoleak on final intra-operative completion angiography were retrospectively reviewed from 1 April 2010 and 30 March 2015. Demographic, pre and post-procedural imaging, and clinical outcomes were reviewed. Summarizing descriptive statistics are reported. Of the 337 patients who underwent an EVAR, 24 patients (7.1%) had a proximal type 1A endoleak on final intra-operative angiography. Twenty-two of 24 patients (92%) with proximal type 1A endoleaks had spontaneous resolution on follow-up imaging without any intervention, while two (8%) patients had a persistent endoleak. One of these patients required intervention. The median follow-up for patients with resolved endoleaks was 2.5 years vs. 4 and 6 years, respectively, for patients that did not resolve spontaneously. A conservative approach may be used in the management of patients with proximal type 1A endoleaks on completion angiography once maximum proximal seal was achieved intra-operatively as the vast majority of these leaks spontaneously seal.

Feasibility Study of a Novel Thoraco-abdominal Aortic Hybrid Device (SPIDER-graft) in a Translational Pig Model

The hybrid SPIDER-graft consists of a proximal descending aortic stent graft and a conventional six branched Dacron graft for open abdominal aortic repair. Technical feasibility with regard to avoiding thoracotomy and extracorporeal circulation (ECC) during thoraco-abdominal aortic hybrid repair and peri-procedural safety of this novel device are unknown. This was a feasibility and safety study in domestic pigs (75-85kg). The abdominal aorta including iliac bifurcation, left renal artery, and visceral arteries were exposed via retroperitoneal access. The right iliac branch was first temporarily anastomosed end to side to the distal aorta via partial clamping. During inflow reduction and infra-coeliac cross-clamping, the coeliac trunk (CT) was divided and the proximal stent graft portion of the SPIDER-graft was deployed into the descending aorta via the CT ostium. Retrograde visceral and antegrade aorto-iliac blood flow was maintained via the iliac side branch. The visceral, renal, and iliac arteries were sequentially anastomosed, finally replacing the first iliac end to side anastomosis. Technical success, blood flow, periods of ischaemia, and peri-procedural complications were evaluated after intra-operative completion angiography and post-operative computed tomography angiography. Six animals underwent successful thoracic stent graft deployment and distal open reconstruction without peri-operative death. The median thoracic graft implantation time was 4.5min, and the median ischaemia times before reperfusion were 10min for the CT, 8min for the superior mesenteric artery, 13min for the right renal artery, and 22min for the left renal artery. Angiography demonstrated appropriate graft implantation and blood flow measurements confirmed sufficient blood flow through all side branches. In this translational pig model, thoraco-abdominal hybrid repair using the novel SPIDER-graft was successful in avoiding thoracotomy and ECC. Technical feasibility and safety appear promising, but need to be reassessed in humans.

PC042 Concordance of Contrast-Enhanced Ultrasound and Carbon Dioxide Automated Angiography in the Detection of Type II Endoleaks

The presence of type II endoleak (ELII) after endovascular aortic repair (EVAR) can be investigated with different methods. Since intraoperative completion angiography (ICA) may underestimate their presence, particularly if they are at low flow, contrast-enhanced ultrasound (CEUS) imaging has been proposed as the gold standard during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however, no comparative studies including these three techniques are currently available. Aim of our study was to investigate the accuracy of a new automated CO2 angiographic (CO2A) system in the detection of ELII by comparing it with ICA and CEUS imaging. A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and underwent to ICA and CO2A during the procedure. The iodinate contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta, with constant flow velocity and volume injection. The CO2 was delivered through a recently available automatic injector connected to a 10F, 11-mm-long sheath positioned in the external iliac artery, with constant CO2 injection in terms of flow velocity and volume rate. All patients were blindly evaluated by CEUS imaging on postoperative day1. The presence of ELII was defined as contrast enhancement into the residual sac appearing with a ≥5-second delay from contrast injection. The ICA and CO2A ability to detect ELII was compared with that of CEUS imaging through the Cohen concordance index (κ). Twenty-one patients with a mean AAA size of 56 ± 8 mm were entered in the study. There were no intraoperative or perioperative complications related to ICA or CO2A. No type I to III endoleak were detected by ICA or CO2A, as confirmed also by CEUS imaging. One (5%), 7 (33%), and 4 (19%) ELII were detected by ICA, CO2A, and CEUS imaging, respectively. The only ELII detected by ICA was also detected by CO2A and CEUS imaging. Three ELII detected by CO2A were not detected by CEUS imaging. No cases of ELII undetected by CO2A were visualized by CEUS imaging. A perfect agreement between CEUS imaging and both ICA and CO2A was observed for type I/III endoleak (Cohen κ = 1). CEUS imaging and ICA showed a poor agreement for ELII detection (Cohen κ = 0.35). A substantial agreement was observed between CEUS imaging and CO2A for ELII (Cohen κ = 0.65). CO2A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICA.

A Single-Center Experience of Aortic and Iliac Artery Aneurysm Treated with Multilayer Flow Modulator

The aim of this study was to analyze our series of endovascular treatments using a multilayer flow modulator (MFM) and to show the midterm results. At our institution, 8 patients were treated with an MFM. Four patients presented with an aortic aneurysm (2 type II thoracoabdominal aortic aneurysms [TAAAs], 1 type IV TAAA, and 1 juxtarenal abdominal aortic aneurysm) and 4 with an aneurysm involving the common iliac artery. Mortality, rupture and secondary intervention, major complications, patency of collateral vessels, and volume analysis were evaluated. Treated patients were followed up with computed tomography angiography at 1, 3, 6, and 12 months. Results showed no 30-day mortality or major complications; technical success was achieved in 87.5% of patients, patency of collateral vessels was reached in all cases at intraoperative completion angiography. Mean follow-up was 22.1 months (range, 18-30), survival rate was 87.5%, and one case of death unrelated to MFM treatment was reported. During follow-up, MFM and collateral vessel patency were observed in all cases. Secondary endovascular or open surgical procedures were not needed during follow-up. Volume analysis showed a slight increase in patients with aortic aneurysm, and an overall trend to increase in thrombosis was observed in all cases. Endovascular treatment of aneurysms with MFM seems to have encouraging midterm results. Should our results be confirmed by larger series and longer follow-up studies, MFM may become a viable alternative to other endovascular approaches.

Early clinical and angiographic outcomes after robotic-assisted coronary artery bypass surgery

Robotic-assisted coronary artery bypass grafting has emerged as an alternative to traditional coronary artery bypass grafting or percutaneous intervention for patients with coronary artery disease. However,the safety and efficacy of this minimally invasive procedure have not been established in large series. From October 2009 to September 2012, 307 consecutive robotic-assisted coronary artery bypass grafting procedures were performed at a single US institution by 2 surgeons. Isolated, off-pump, left internalthoracic artery to left anterior descending coronary artery grafting was planned via a 3- to 4-cm non-rib-spreading minithoracotomy after robotic left internal thoracic artery harvest in all patients. Hybrid coronary revascularization was planned in 159 patients (51.8%). Of the 199 angiograms (64.8%) performed before discharge, 63 were performed as completion angiograms in a hybrid suite immediately after left internal thoracic artery-left anterior descending artery grafting. Thirty-day mortality occurred in 4 patients (1.3%), conversion to sternotomy occurred in 16 patients (5.2%), postoperative myocardial infarction occurred in 5 patients (1.6%), and reexploration for bleeding occurred in 7 patients (2.3%). There was 1 (0.3%) postoperative stroke. For the 199 patients with follow-up angiography before discharge, the left internal thoracic artery was confirmed to be patent (<50% stenosis) in 189 patients (95.0%). Among the 10 patients with significant (≥50% stenosis) defects, 5 had graft occlusion or distal left anterior descending occlusion, 2 had poor flow distal to the anastomosis, and 3 had anastomotic lesions (≥50% stenosis). Among the 63 patients with intraoperative completion angiography, 5 patients underwent surgical graft revision, 3 patients underwent minithoracotomy, and 2 patients underwent conversion to sternotomy. Robotic-assisted coronary artery bypass grafting is an effective alternative to traditional coronary artery bypass grafting for patients with single or multivessel coronary artery disease, with comparable short-term clinical and angiographic results.

Early Follow-Up After Endovascular Aneurysm Repair: Is the First Postoperative Computed Tomographic Angiography Scan Necessary?

To examine whether initial postoperative computed tomographic angiography (CTA) is needed in all patients undergoing endovascular aneurysm repair (EVAR). A total of 105 consecutive patients underwent EVAR with standard infrarenal devices in our department between November 2009 and May 2011. Five patients were excluded due to severe renal insufficiency, leaving 100 (85 men; median age 73 years, range 46-91) eligible for prospective enrollment in a triple-modality early postoperative follow-up protocol [intraoperative completion angiography, postoperative duplex ultrasonography (DUS), and plain abdominal radiography). Findings were compared for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) against the first postoperative CTA results for the detection of endoleaks or other signs of EVAR failure. There were 10 inconclusive DUS examinations. In the remaining 90 patients, DUS had 75.0% sensitivity, 95.4% specificity, 85.7% PPV, and 91.5% NPV for the detection of endoleaks. The intraoperative angiogram, DUS, and abdominal radiograph combined resulted in 87.5% sensitivity and 95.4% specificity, with a 65.6% PPV and 94.8% NPV for the detection of endoleaks. In 2 patients who required a reintervention for endoleak in the early postoperative period, both endoleaks were correctly detected by the triple-modality early postoperative follow-up protocol. An early follow-up protocol consisting of an intraoperative completion angiogram, DUS, and abdominal radiograph shows a high sensitivity and NPV for the detection of endoleaks and should detect early migration or kinking of the stent-graft. An initial postoperative CTA is not necessary for most patients undergoing EVAR and should be reserved for those individuals in whom the aforementioned modalities are inconclusive or show signs of endoleak or other EVAR failure.

Aortic Aneurysm Pressure Sensors Can be of Value in the Acute Postoperative Setting

To report on a case that demonstrates the use and current limits of abdominal aortic pressure sensor devices. An 83-year-old, high-risk patient underwent endovascular aortic repair (EVAR) of an infrarenal aortic aneurysm (maximum aneurysm diameter: 6.5 cm) with implantation of a pressure sensor device. At the end of the procedure and on the first postoperative day, the sensor detected persistent high pressures in the aneurysm sac, indicating an endoleak that could not be visualized on the intraoperative completion angiography but was confirmed on duplex ultrasound. During repeated angiography (postoperative day 6), again no endoleak could be detected, this time corresponding with the sensor reading that was unfortunately not interrogated again before the reintervention. Pressure sensor devices provide a useful, additional diagnostic tool in detecting and following endoleaks after EVAR and can help guide decisions regarding reinterventions.

Endovascular repair of extent I thoracoabdominal aneurysms with landing zone extension into the aortic arch and mesenteric portion of the abdominal aorta

Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative for patients at prohibitive risk for open thoracic or thoracoabdominal surgery, decreasing perioperative morbidity and mortality. Aneurysms that involve both the left subclavian artery (LSA) proximally and the celiac artery (CA) distally present a unique challenge to the use of TEVAR. We report a series of six high-risk patients presenting with extent I thoracoabdominal aortic aneurysms who were successfully treated with TEVAR including coverage of the LSA and the CA.

Pre-Discharge Duplex Ultrasound Scans Detect Endoleaks Not Seen on Completion Angiography After Endovascular Aneurysm Repair

To determine whether a pre-discharge duplex ultrasound scan detects early endoleaks that would not otherwise have been identified. A retrospective review was conducted of all patients undergoing elective infrarenal endovascular aneurysm repair (EVAR) at our center. These patients underwent intraoperative completion angiography, had a duplex ultrasound scan prior to hospital discharge, and were followed at 1, 3, and 6 months and at 6-month intervals thereafter. The outcome of any patients found to have an endoleak on a pre-discharge scan was studied. There were 52 EVAR patients (50 men; mean age 76 years, range 61-87) with endoleak on the pre-discharge duplex: 17 (2.8%) type I, 28 (4.6%) type II, and 8 (1.3%) type III. Of these, only 7 of the type I and 2 of the type II leaks had been detected on completion angiography. Among the patients with type I endoleaks, 5 had resolution of the leak, 10 required further endovascular interventions, and 2 had open repair (1 died of aneurysm rupture). Two patients with failed endovascular repairs of the leak also had open repair. Fifteen of the 28 type II endoleaks resolved, 4 were treated with endovascular procedures, 1 had open repair, 7 are being observed, and 1 was lost to follow-up. Six of the 8 type III leaks resolved, 1 required open repair for an enlarging sac, and 1 is being observed. Despite routine completion angiography, new endoleaks may be identified postoperatively, which suggests that more rigorous imaging at the point of completion angiography is required.

Intracranial dissection during carotid endarterectomy treated by carotid stenting

Intracranial dissection of the internal carotid artery after carotid endarterectomy (CEA) is a serious complication with a potentially fatal outcome. We report on a 67 male with a symptomatic high grad stenosis of the internal carotid artery. Intraoperative completion angiography showed a thrombotic occlusion and the internal carotid artery (ICA) was resected with interposition of a Dacron graft. Completion angiography then revealed a dissection of the petreous ICA, which was corrected by insertion of a coronary artery stent.Stenting of the ICA is a useful tool to restore cerebral perfusion without time delay and completion imaging is extremely helpful for early detection of dissection during CEA.

Routine Intraoperative Completion Angiography After Coronary Artery Bypass Grafting and 1-Stop Hybrid Revascularization: Results From a Fully Integrated Hybrid Catheterization Laboratory/Operating Room

This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room. The value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved. Between April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n = 112) or without (n = 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings. Among the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n = 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n = 48, 6%) or with traditional surgical revision (n = 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients. Routine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.

Doppler ultrasound of the saphenous vein as a bypass. Detection of arteriovenous fistulae

In 13 patients who underwent a femorodistal revascularisation with an in situ saphena vein graft and who had been operated on by angioscopic technique, intraoperative angiography and postoperative colour-coded Doppler sonography and i.v./i.a. digital subtraction angiography (DSA) were performed to detect arteriovenous fistulas (AV fistulas). In intraoperative completion angiography no AV fistulas were seen. Colour-coded Doppler sonography and DSA studies performed three to five days postoperatively revealed AV fistulas in 8 patients. The fistulas could be exactly located by sonography, and, if confirmed haemodynamically significantly by i.v./i.a. DSA, they were marked on the skin and ligated. In the detection of AV fistulas in in situ saphenous vein grafts operated by angioscopic technique colour-coded doppler sonography and i.v./i.a. DSA showed equivalent results. In the detection of connections of AV fistulas to the deep draining veins the i.v./i.a. DSA was superior.

Endoluminal versus open treatment of descending thoracic aortic aneurysms

This report describes the authors' initial experience with the Excluder thoracic endoprosthesis (W. L. Gore and Associates, Inc, Flagstaff, Ariz) and the thoracic Talent endoprosthesis (Medtronic AVE, Sunrise, Fla) and their safety and efficacy in the primary endovascular repair of descending thoracic aortic aneurysms (TAAs). In addition, comparison with a historic nonrandomized cohort of patients that had undergone open repair of descending TAAs is reported. Repair of TAA (mean diameter, 68 +/- 22 mm) was attempted in 19 patients with the Excluder (n = 14) and the Talent (n = 5) endoprostheses between March 1999 and January 2000. This group was compared with a historic nonrandomized cohort of 10 patients that had undergone open repair of anatomically similar descending TAA (mean diameter, 74 +/- 22 mm) between January 1996 and January 1998. The mean age in the endovascular group was 70.6 +/- 5.3 years versus 70.1 +/- 4.5 years in the historic open group. All the procedures were performed in a standard operating room with angiographic capabilities. In the historic open group, each standard tube graft repair of descending TAA was performed by one of three staff surgeons. Endograft deployment was successful in 18 patients (95%). The procedure was aborted in one patient (Excluder) because of small iliac arteries and access difficulty. The average operative time was 155 +/- 62 minutes, with a mean blood loss of 325 +/- 353 mL (versus 256 +/- 102 minutes and 1205 +/- 1493 mL, respectively, in the open group). Eight patients needed the planned use of more than one component for enhanced sealing or additional length in the endovascular group. No type I endoleaks were identified on the intraoperative completion angiography. One perioperative mortality occurred in the endovascular group and the open group. In the endovascular group, other complications included retroperitoneal hematoma and external iliac artery dissection (n = 1), lymphocele (n = 1), and common femoral artery pseudoaneurysm (n = 1). In the open group, other complications included ischemic colitis (n = 1), severe renal insufficiency (n = 2), wound infection (n = 1), and stroke (n = 1). In the endovascular group, the length of stay was 6.2 +/- 3.3 days (range, 1 to 13 days), with only nine patients needing intensive care, whereas in the open group, the length of stay was 16.3 +/- 6.7 days, with all patients needing intensive care. Endoleaks, graft migrations, or ruptures were not seen on the 1-month, 6-month, and 12-month follow-up computed tomographic scans in the endovascular group. On the average, aneurysm size decreased from 68 +/- 22 mm to 58 +/- 13 mm, to 51 +/- 14 mm, and to 49 +/- 12 mm at 1, 6, and 12 months after endovascular repair, respectively. No spinal cord ischemia was seen in either group. The endoluminal repair was effective in exclusion of descending TAAs from the systemic circulation in this selected group of patients. In this short-term follow-up, compared with the nonrandomized historic cohort of open descending TAA repair, the endovascular group had significantly shorter operating times and hospital and intensive care unit stays and lower operative blood loss. Further follow-up and continued assessment of the long-term durability of these devices in elective and emergency circumstances are warranted.

Endograft limb occlusion and stenosis after ANCURE endovascular abdominal aneurysm repair

Objective: The purpose of this study was to define the incidence and treatment of endograft limb stenosis or occlusion (endograft limb dysfunction [ELD]) in a single center with the ANCURE unsupported bifurcated or aortouniiliac endograft by using intraoperative completion angiography and postoperative color duplex ultrasound scanning (CDU). Methods: Sixty-seven endografts (58 bifurcated, 9 uniiliac) were implanted between February 1996 and July 2000. Intraoperative completion aortography was performed in every patient. Postoperative assessment of the endograft consisted of CDU and computed tomography scanning and kidney, ureter and bladder radiographs within 7 days of implantation, at 3 and 6 months after the operation, and every 6 months thereafter. Results: At the time of endograft implantation, widely patent normal-appearing endograft limbs were revealed by means of the initial completion angiogram in 58 of 67 patients (group 1). ELD subsequently developed in seven of these 58 patients (13.4%). The results of the completion angiogram were not normal in the remaining nine patients (group 2), leading to the deployment of a self-expanding stent within the endograft limbs. The results of subsequent angiography were normal. No ELD has occurred in any patient in group 2 to date. The primary assisted patency rate at 30 months was 88% ± 5.2% for group 1 versus 100% ± 0% for group 2 (P = not significant, Log-rank test). Postoperative ELD occurred in seven patients (10.4%). Endovascular graft thrombosis occurred in three patients (3 endograft limbs). In each case, an endovascular approach was attempted; however, the guidewire would not traverse the occluded endovascular graft limb. Revascularization was accomplished by means of femorofemoral bypass grafting. Endovascular graft stenosis occurred in four patients (4 endograft limbs). Three patients with bifurcated endografts and limb stenosis who had no symptoms diagnosed by means of CDU were successfully treated by means of balloon angioplasty with self-expanding stent implantation, and the endograft limbs remained patent at 3, 5, and 26 months follow-up. The remaining patient who had an aortouniiliac endograft with recurrent severe stenoses underwent endograft explantation and aortobifemoral bypass grafting. The overall incidence of ELD during or after endovascular abdominal aortic aneurysm repair was 23.8% (16 of 67 patients). Conclusion: Unsupported endografts are at risk for developing ELD. The use of stents for limb support at the time of the initial endograft implantation may prevent subsequent ELD and bears further study. Endograft limb occlusion usually presents with acute severe ischemic symptoms, and the failure of operative thrombectomy necessitates femorofemoral artery bypass grafting. Endograft limb stenosis is identified by means of CDU surveillance in the postoperative period. Prompt treatment with percutaneous transluminal angioplasty/stent yields satisfactory primary assisted patency. Intraoperative intravenous ultrasound scanning, oblique angiograms, pressure gradients, and completion angiography may be necessary to detect and treat ELD. (J Vasc Surg 2002;35:686-90.)

Early experience with the bifurcated Excluder endoprosthesis for treatment of the abdominal aortic aneurysm

Purpose: This report describes our initial experience with the modular, bifurcated Excluder endoprosthesis and its safety and efficacy in the primary endovascular repair of infrarenal abdominal aortic aneurysms (AAAs). Methods: AAAs (mean diameter, 58.2 ± 14.3 mm) were repaired in 19 patients with this device between March 1999 and January 2000. The mean age of patients was 71.8 ± 8.4 years (range, 57-86 years). This modular device was inserted through an 18F introducer sheath placed in one femoral artery, and the contralateral artery was cannulated with a 12F introducer sheath. All procedures were performed in a standard operating room with angiographic capabilities. Results: Endograft deployment was successful in all patients. The average surgical time was 135 ± 37 minutes, with a mean blood loss of 229 ± 138 mL. In eight patients, the use of either aortic or iliac extenders was required for enhanced sealing or additional length. An external iliac artery dissection occurring at the time of endograft insertion was successfully treated with a Wallstent. Type II leaks initially found to be present by means of intraoperative completion angiography had spontaneously thrombosed by the 1-month follow-up computed tomography scan. There was one perioperative death (5.3%). Complications included superficial wound infections (n = 3) and a nonfatal myocardial infarction (n = 1). The mean length of hospital stay was 2.9 ± 1.2 days, and only six patients required intensive care. Endoleaks were seen in four patients (21%) by means of the 30-day computed tomography scan; three of these endoleaks had spontaneously sealed at the time of the 6-month follow-up examination (5.5% 6-month endoleak rate). Aneurysm size did not increase in the patients with leaks. Conclusion: The Excluder endoprosthesis was an effective means of excluding an infrarenal AAA from the systemic circulation in this selected group of patients. The smaller sheath sizes may increase the pool of potential candidates. Further study of this device is warranted, and continued assessment of the long-term durability of the device will be necessary. (J Vasc Surg 2001;33:497-502.)

Venous bypass: gold standard with excellent results

Since 1974 we have performed 1104 in situ vein bypasses for the reconstruction of femoropopliteal or femorotibial occlusions. The venous valves were made incompetent by using our Insitucut. An intraoperative completion angiography is mandatory. The primary cumulative patency rate is 93.5% at one year and 64.9% at five years. The permeability is depending on the quality of the outflow tract. The patency of femoropopliteal in situ bypasses with a three vessel runoff is 82.2% at five years, whereas bypasses with a single vessel runoff show a patency of 56%. The own results are comparable with the results of reversed and non-reversed vein bypasses given in the literature.