Low Reintervention Rates Research Articles

Open surgery for descending thoracic aorta in an endovascular era

BackgroundThoracic endovascular aortic repair has become the preferred treatment for a variety of descending thoracic aortic pathologies. However, there are unresolved issues such as morphologic appearance of chronic dissection, persistent false lumen perfusion, and adequacy of landing zone. Enthusiasm for improving the technique of open aortic repair and perioperative management is fading. In this study, we would like to demonstrate how we improve our surgical outcomes by establishing a dedicated aortic multidisciplinary team at the Kawasaki Aortic Center. MethodWe performed a single-center retrospective study from January 2015 to December 2016. All patients with open descending thoracic aortic replacement were recruited. Preoperative patient demographic data, bypass strategies, operative details, and postoperative outcomes were reviewed. ResultFrom January 2015 to December 2016, we treated 168 cases of descending thoracic aortic repair using a left thoracotomy. Median age was 69.0 ± 21.8 years old, and 63.1% were aortic dissection (acute, 4.8%; chronic, 58.3%); 81.3% patients underwent elective operations. Left heart bypass, deep hypothermic circulatory arrest, and partial cardiopulmonary bypass were performed in 88.6%, 9.0%, and 2.4% of patients, respectively. Mean operative time was 312 ± 94 minutes. In-hospital mortality in total was 0.6%. The rate of transient spinal cord injury was 4.7%. ConclusionsUnder a dedicated aortic multidisciplinary team, we demonstrated that open descending thoracic aorta replacement can be performed with excellent early outcomes with low reintervention rates, regardless of the nature of the aortic pathologies.

Long-Term Outcomes of Coarctation Repair Through Left Thoracotomy

Optimal surgical approach for repair of coarctation of the aorta (CoA) remains controversial. This study aimed to evaluate reintervention rates and its predictors by using a strategy of resection with extended end-to-end anastomosis (REEEA) through left thoracotomy. A retrospective analysis was performed for all patients who underwent isolated CoA repair or simultaneous repair of CoA and ventricular septal defect repair by REEEA between January 2000 and December 2015 at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. Patients with complex congenital heart disease were excluded. Transverse arch hypoplasia was defined as echocardiographic z-score lower than-2 or by documentation in medical or operative reports. Reintervention was defined as the need for balloon angioplasty or reoperation. Hypertension was defined as antihypertensive medication use or blood pressure greater than or equal to the 95th percentile. A total of 251 patients with median age at repair of 14.6 days met inclusion criteria. Repair was by left thoracotomy in 226 (90%). Follow-up data were available for 186 of 251 patients, with median follow-up time of 5.4 years (range, 0.2 to 15.3 years); 169 (91%) of these patients underwent thoracotomy. There were no early deaths or early reoperations. A proximal transverse arch z-score lower than-4.1 or a distal transverse arch z-score of less than-2.8 was predictive of repair through sternotomy. Only 4 (2%) patients required reintervention (2 patients had balloon angioplasties, 2 had reoperations). Transverse arch hypoplasia was a risk factor for reintervention (p= 0.048), but surgical approach was not (p= 0.35). Late hypertension was identified in only 33 of 186 (18%) patients. Repair of CoA, even with associated transverse arch hypoplasia, by REEEA through left thoracotomy has a low mortality, low reintervention rate, and low incidence of late hypertension.

Acute Type A Aortic Dissection: Managing More Than Just the Entry-Tear

As emergency repair for acute type A aortic dissection is improving, the reintervention rate increases. Over 10% of cases require an aortic reintervention, which should ideally be performed in an early stage to allow for positive aortic remodeling and to prevent limitations by the stiffened aortic flap. These reinterventions remain a surgical challenge and may come with complications. We provide a comprehensive overview of different management strategies and their success in treating aortic adverse remodelling, based on current evidence of the literature. Two meta-analyses and an additional literature search yielded comparable mortality rates between limited repair and extensive repair. Cardiopulmonary bypass time, cross clamping time and cardiac arrest time were significantly shorter in limited repairs. Reintervention rate was generally lower in extensive repair, although not always significant. In conclusion, the early aggressive approach may be useful to lower reintervention rates. However, it has not yet been proven to be more beneficial. It will be imperative to develop a patient-specific early stage prediction model for residual aortic reintervention.

Laparoscopic gastrojejunostomy for gastric outlet obstruction: personal serie

Traditionally, benign diseases were responsible for most of the causes of gastric outlet obstruction (GOO), but in recent years, 50-80% could be attributable to malignancy. Malignancy includes distal gastric cancer and hepatobiliary-pancreatic (HBP) neoplasms. In metastatic/unresectable HPB tumors, GOO decrease quality of life and treatment should be necessary. Options are duodenal stent or gastrojejunostomy (GJ), but there is no consensus. In benign diseases, 1-5% of patients with chronic pancreatitis (PC) would develop GOO. We retrospectively review all consecutive patients who underwent laparoscopic GJ for GOO due to CP or advanced HBP cancer at University Hospital of Guadalajara, Spain. We studied 10 patients with laparoscopic GJ. HBP neoplasms: Age: 78,01±6,8 years. Albumin: 28,36 ±2,7. No patient received prior chemo. Tabled 1EP02F-021 TableAge/SexGOOSSClinical successTime to initiate intakeLOS (days)Duration of food intake77/F0Yes412402 (until death)76/M3Yes312228(until death)91/F0Yes15278 (until death)78/F0Yes3107868/M0YesND128276/M0YesND13220 (until death)76/F0YesND5ND Open table in a new tab CP: 3 males. Age: 56,2±3,4. Median albumin: 37,7±6,6. Clinical success: 100%. Median LOS: 6,33±0,6. Previous literature on GOO treatment mixes different causes with different prognosis, so level of evidence is low. In benign diseases, such as CP, data are limited and patients typically requires surgical GJ. In malignancy, literature on GJ showed better long-term relief and lower reintervention rates. In other hand, stents are associated with lower hospital stay, faster initial relief and shorter time to intake, with more recurrent symptoms. Survival is essential for the choice of treatment. In HBP neoplasms, chemotherapy has increased survival. Stent is usually preferred in patients with poor general condition or life expectancy of less than 90 days but more studies are needed to standardize treatment. Laparoscopic GJ is a feasible, safe and efficient technical option.

Outcomes of Planned Two-Stage Hybrid Aortic Repair With Dacron-Replaced Proximal Landing Zone

Results of hybrid arch repair (HAR) using the native zone 0 proximal landing zone (PLZ) have been unsatisfactory in many series, especially in the setting of ascending aortic dilation (>4.0 cm). This study reports early and late outcomes of planned two-stage HAR with open first-stage proximal aortic replacement, followed by second-stage thoracic endovascular aortic repair (TEVAR) with PLZ within the Dacron-replaced zone 0. Between January 2006 and August 2017, 34 patients underwent planned two-stage HAR. The first-stage proximal aortic replacement included ascending aorta (with or without valve, with or without root) and total arch replacement, which was performed with creation of an elephant trunk in 22 patients (65%) and without an elephant trunk in 12 (35%). Primary outcomes included 30-day/in-hospital results and Kaplan-Meier estimates of overall/aorta-specific survival and freedom from reintervention. Mean age was 59 ± 12 years. Both stages of repair were completed in a single hospitalization in 53% of patients, including operations done since January 2012. The 30-day/in-hospital rates of mortality, stroke, permanent paraparesis/plegia, and new dialysis were 6%, 3%, 0%, and 0%, respectively. Kaplan-Meier overall and aorta-specific survivals at 5 years were 63% and 94%, respectively, with 5-year freedom from reintervention of 78%. Planned two-stage HAR with open first-stage proximal aortic replacement, followed by second-stage TEVAR with Dacron-replaced PLZ yields excellent short-term and long-term results, including low rates of reintervention likely due to the long-segment PLZ within the Dacron-replaced aorta. The technique should be considered in patients with even mild (>4.0 cm) ascending aortic dilation in whom HAR is otherwise the preferred treatment option.

Autologous Saphenous Vein Panel Graft for Vascular Reconstruction

This study aims to present early and midterm results of vascular reconstruction with saphenous vein panel graft. Between August 2014 and August 2017, 11 saphenous vein panel grafts were used for vascular reconstruction in 10 patients. Patient data including age, gender, etiology of the vascular pathology, concomitant injury, site of injury, surgical procedure, additional surgical procedure, and hemodynamic status were retrospectively collected and analyzed. The Kaplan-Meier method was used to calculate the reintervention and patency rates. Mean duration of follow-up was 16.5±13.2months (ranged, 2-39months). The freedom from reintervention for any reason was 82% at 1 and 2years. There was no evidence of arterial claudication or venous insufficiency in all patients. The primary patency rates were 82% at 1 and 2years. There was no mortality, deep venous thrombosis, pulmonary embolism, graft thrombosis, anastomotic stenosis, diameter discrepancy, and aneurysm formation during late follow-up. The autologous saphenous panel vein graft enables the surgeon to prepare suitable conduits easily with an appropriate diameter and length for vascular reconstruction. Although long-term results are unknown, this technique provides high patency rates in midterm follow-up, resistance to infection, and low reintervention rates. In conclusion, autologous saphenous vein panel grafts may well be preferred in various vascular disorders that require surgical reconstruction.

A Review of the Current Status of Percutaneous Endovascular Arteriovenous Fistula Creation for Haemodialysis Access.

Surgical fistulas were first described over 50years ago and have revolutionized the outlook for millions of dialysis-dependent patients. Despite many developments, results remain sub-optimal with high rates of primary failure and re-intervention to maintain patency. Surgical fistulas are known to fail in part due to intimal hyperplasia leading to stenosis, and vessel manipulation during anastomosis creation can be contributory. New technology is emerging that allows the endovascular creation of fistulas with minimal vessel trauma and the initial results demonstrate encouraging outcomes with high technical success rates, low re-intervention, and failure rates and good usability for hemodialysis. Two such device systems are currently available, and here, we provide an overview of the current global status of endoAVF, patient selection criteria, trial results, technical aspects, re-interventions, and outlook for the future.

Pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals: collateral vessel disease burden and unifocalisation strategies.

Median follow-up was 4.8 compared with 5.7 years for Groups 1 and 2, respectively, p = 0.65. Median number of major aortopulmonary collaterals/patient was 3, ranging from 1 to 8, in Group 1 compared with 4, ranging from 1 to 8, in Group 2, p = 0.09. Group 2 had a higher number of lobar/segmental stenoses within collateral vessels (p = 0.02). Group 1 had fewer catheter-based branch pulmonary artery reinterventions, with 5 (inter-quartile range from 1 to 7) per patient, compared with 9 (inter-quartile range from 4 to 14) in Group 2, p = 0.009. Among patients who achieved ventricular septal defect closure, median right ventricle/left ventricle pressure was 0.48 in Group 1 compared with 0.78 in Group 2, p = 0.03. Overall mortality was 6 (17%) in Group 1 compared with 9 (21%) in Group 2.DiscussionSingle-stage unifocalisation is a promising repair strategy in select patients, achieving low rates of reintervention for branch pulmonary artery restenosis and excellent mid-term haemodynamic outcomes. However, specific anatomic substrates of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals may be better suited to multi-stage repair. Preoperative evaluation of collateral vessel calibre and function may help inform more patient-specific surgical management.

Incomplete revascularization: what the surgeon needs to know.

For many years, the concept of "complete revascularization" (CR) was considered an absolute truth in coronary surgery with improved long-term survival and a lower rate of reintervention. This was derived from early publications which showed a survival benefit for patients undergoing coronary artery bypass grafting (CABG) who received CR. Many advances in the field of coronary revascularization have been made in the years that passed since those publications, including more frequent use of percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD). This has led some to question the importance of CR and raise the option of "reasonable incomplete revascularization" (IR) for selected patients. The definition of CR is variable in the literature with the two most common definitions being an anatomical (revascularization of all coronary segments with stenosis and larger than a predefined size) and a functional definition (where revascularization is considered complete if all ischemic and viable territories are reperfused). No randomized control trials have been conducted to compare complete versus IR, and a significant proportion of data is based on post hoc analysis of data from randomized control trials and registries. Multiple studies have proven that CR is achieved more frequently with CABG then with PCI. A review of the available data from the past three to four decades shows a trend toward improved results with CR, regardless of the reperfusion strategy chosen. This should impact the heart team discussion when choosing a revascularization strategy and impact the surgical decision making while preforming CABG. IR can be part of a hybrid revascularization strategy or be reserved for rare cases where the cost of achieving CR much outweighs the benefit.

Early and Late Outcomes of Endovascular Aortic Aneurysm Repair versus Open Surgical Repair of an Abdominal Aortic Aneurysm: A Single-Center Study

The objective of the study was to compare the treatment outcomes and cost of endovascular aortic aneurysm repair (EVAR) and open surgical repair (OSR) in patients with an abdominal aortic aneurysm (AAA) at a single center. Patients treated for an AAA at a single center between January 2007 and December 2012 were retrospectively identified and classified based on the treatment they received (EVAR or OSR). Patient demographics and in-hospital costs were recorded. Long-term survival was calculated using the Kaplan-Meier method. During the study period, 401 patients with AAA were treated at Asan Medical Center. Among these cases, 226 were treated with EVAR (56%) and 175 received OSR (44%). The mean age of the EVAR group was higher than that of the OSR group (71.25±7.026 vs. 61.26±8.175, P<0.001). The need for intraoperative transfusion and total length of in-hospital stay were significantly lower in the EVAR group (P<0.001). The OSR group showed significantly reduced rates of overall mortality (P=0.003), overall reintervention (P=0.001), and long-term survival (63.98±1.86 vs. 99.54±3.17, P<0.001). The OSR group was charged significantly less than the EVAR group ($12,879.21 USD vs. $18,057.78 USD, P<0.001). EVAR has advantages over OSR in terms of short-term mortality, in-hospital length of stay, and rates of perioperative transfusion. However, OSR is associated with better long-term survival, lower reintervention rates, and lower costs.

Ultrasound-Guided Breast-Conservative Surgery Decreases the Rate of Reoperations for Palpable Breast Cancer

The purpose of this study is to verify whether the performance of ultrasound-guided quadrantectomy (USGQ) versus palpation-guided quadrantectomy (PGQ) can reduce the incidence of positive margins and if it can change the attitude of the surgeon. A retrospective study was conducted on 842 patients underwent quadrantectomy for breast cancer, 332 of them underwent USGQ, whereas 550 underwent PGQ. The histological type of the tumors and the margin status obtained with the histological examination were compared. The histological examination of the surgical specimen showed involvement of the margins in 24/842 patients (2.85%), 22 (2.61%) of them belonged to the PGQ group, and two to the USGQ group (P = 0.0011). The highest rate of microscopically positive margins was, statistically significant, for carcinoma in situ, when compared with patients with invasive carcinoma (0.0001). USGQ technique showed several advantages compared with PGQ. In fact, the former notes a lower positive margin rate and, consequently, a lower rate of reintervention. In addition, it may change the surgeon's attitude by causing him to remove another slice of margin to ensure more histological negativity. It should be the gold standard technique for breast-conservative surgery of palpable tumors.

IP223. Endovascular First Treatment Is Associated With Improved Amputation-Free Survival in Patients With Critical Limb Ischemia

Critical limb ischemia remains a difficult disease to treat, with limited level 1 data. The Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial is attempting to answer whether initial treatment with surgical bypass or endovascular therapy improves outcomes. Although still in the enrollment phase, this study aims to compare amputation-free survival (AFS) and reintervention in patients treated with initial open surgical bypass or endovascular intervention for ischemic ulcers of the lower extremities. By use of statewide data, all patients were identified with lower extremity ulcers and a diagnosis of peripheral arterial disease who underwent a revascularization procedure from 2005 to 2013. Propensity scores were formulated from baseline characteristics of the patients. Inverse probability weighting was used within Kaplan-Meier analysis to determine AFS and time to reintervention for open vs endovascular treatment. Cox proportional hazards modeling was used to adjust for access to care and hospital revascularization experience. A total of 16,800 patients were identified. Open surgical bypass was the initial treatment of 5970 (36%) patients, whereas 10,830 (64%) underwent endovascular interventions. Patients in the endovascular group were slightly younger compared with the open group (70 vs 72 years; standard deviation, 12 years; P < .001). Endovascular patients were more likely to have renal failure (36% vs 24%) and coronary artery disease (34% vs 32%), whereas patients in the open bypass group were more likely to have diabetes mellitus (30% vs 44%; all P values < .05). After propensity weighting, open first treatment was associated with lower rates of reintervention (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.83-0.91); however, surgery first was associated with a lower AFS (HR, 1.16; 95% CI, 1.12-1.2; Fig). Initial treatment at a high-volume center was associated with improved AFS compared with medium-volume (HR, 1.3; CI, 1.21-1.36) or low-volume (HR, 1.2; CI, 1.1-1.3) centers. Patients with critical limb ischemia have multiple comorbidities, and initial surgical bypass is associated with poorer quality of AFS compared with an endovascular first approach. Treatment in high-volume centers improves AFS. This may be due to improved resources at high-volume centers.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature.

The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

Custom-Made Endograft for Endovascular Repair of Thoraco-Abdominal Aneurysm and Type B Dissection: Single-Centre Experience.

To report a series of patients treated with the Jotec custom-made endograft for thoraco-abdominal aneurysms and dissections and identify predictive factors for re-intervention. We retrospectively analysed 49 patients unsuitable for surgery, treated between 2011 and 2017 (71.3 ± 9.5years; 15 females). Indications included Crawford type 4 aneurysm in 25 patients, type 3 in 13, type 2 in 4, type 1 in 2 and chronic aneurysmal dilatation of the false lumen following dissection in 5 cases. Mean aneurysm diameter was 58.7 ± 8.4mm. The study aims were to assess procedural success, complications rate, mortality and long-term follow-up. We also analysed factors that predicted the need for re-intervention. The endograft was successfully deployed in all patients, catheterization of the fenestration and/or branches was achieved in 152/156 (97.4%) vessels. Early complications occurred in 10 patients (3 paraplegia, 3 haemorrhages, pancreatitis, aortic rupture, iliac artery rupture, 2 strokes). Thirty-day mortality was 10.2% and 180-day mortality 14.3%; two non procedure related deaths occurred. Mean follow-up was 23.6 ± 29.9months [range 1-80]. No patients needed surgical explantation or developed significant renal impairment. Endoleak rate was 34.6% and re-intervention rate 9.7%. The aneurysm sac reduced or was stable in 36/49, and enlarged in 9/49 patients prompting re-intervention. Primary, primary-assisted and secondary patency of fenestrations/branches at 80months was 90, 96 and 100%. Re-intervention was required more frequently in braches than in fenestrations, most commonly the external type branches. The results of the Jotec endograft are comparable to other devices, with acceptable complication and re-intervention rates. Fenestration and inner-branch should be preferred due to lower re-intervention rates.

Hybrid three-stage repair of mega-aortic syndrome with the Lupiae technique: 10-year results.

Mega-aortic syndrome (MAS) is a rare disease carrying a poor prognosis if treated conservatively. Open repairs of these aneurysms are invasive, while totally endovascular repairs are associated with higher rates of late reintervention due to endoleaks, compromising long-term prognosis. We describe the 10-year results of a hybrid three-stage approach to MAS using the Lupiae technique. Between 2006 and 2016, 27 patients with MAS extending from the ascending aorta to the iliac arteries (MAS type III) underwent: (I) a surgical aortic arch debranching, using the Vascutek Lupiae™ multibranched graft to create a proximal Dacron landing zone; (II) an abdominal aorta debranching to create a distal Dacron landing zone and (III) the implantation of multiple endovascular stents to exclude any residual aneurysm between the two landing zones. One patient died following the first stage, and another following the second stage of the repair (overall mortality 7.4%). The interval between the first and the second stage was 58.3±16.1 days. The interval between the second and the third stage was 47.7±13.1 days. Four-year survival was 88.6%±6.2% while 10-year survival was 51.7%±17.9%. One patient had a type III endoleak after the third stage that self-resolved within 6 months without intervention. No patient had type I or II endoleaks and none underwent redo procedures. Mean follow-up was 5.9±3.6 years and completeness was 100%. Three-stage hybrid repairs using the Lupiae technique can be safely performed in MAS type III patients. Short intervals between the stages should mitigate the risk of rupture during the waiting periods and may enhance patient compliance, but to achieve this, the burden and the complexity of the first stage must be carefully weighted. Our strategy improves the long-term survival of these patients compared to their natural history and is less invasive than an open repair. The adoption of Dacron landing zones appears to be associated with very low rates of reintervention due to endoleaks.

Abstract 132: Endovascular First Treatment is Associated With Improved Amputation Free Survival in Patients With Critical Limb Ischemia

Objective: Critical Limb Ischemia (CLI) remains a difficult disease to treat with limited level-1 data. The BEST-CLI trial is attempting to answer whether initial treatment with surgical bypass or endovascular therapy improves outcomes. Although still in the enrollment phase, this study aims to compare amputation free survival (AFS) and reintervention in patients treated with initial open surgical bypass or endovascular intervention for ischemic ulcers of the lower extremities. Methods: Using statewide data, all patients were identified with lower extremity ulcers and a diagnosis of peripheral arterial disease that underwent a revascularization procedure from 2005- 2013. Propensity scores were formulated from baseline patient characteristics. Inverse probability weighting was used within Kaplan Meier analysis to determine AFS and time to reintervention for open vs. endovascular treatment. Cox proportional hazards modeling was used to adjust for access to care and hospital revascularization experience. Results: A total of 16,800 patients were identified. Open surgical bypass was the initial treatment in 5,970 (36%) patients while 10,830 (64%) underwent endovascular interventions. Patients in the endovascular group were slightly younger compared to the open group (70 vs. 72 years, sd = 12 years, p&lt;0.001). Endovascular patients were more likely to have renal failure (36 % vs. 24%) and coronary artery disease (34 % vs. 32%), while patients in the open bypass group were more likely to have diabetes mellitus (30% vs. 44%, all p values &lt;0.05). After propensity weighting, open first treatment was associated with lower rates of reintervention (hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.83 to 0.91); however, surgery first was associated with a lower AFS (HR; 1.16, 95% CI: 1.12- 1.2). (Image) Initial treatment at a high-volume center was associated with improved amputation free survival compared to medium (HR 1.3, CI: 1.21-1.36) or low (1.2, CI: 1.1-1.3) volume centers. Conclusions: Patients with CLI have multiple comorbidities, and initial surgical bypass is associated with poorer quality of amputation free survival compared to an endovascular first approach. Treatment in high volume centers improves amputation free survival. This may be due to improved resources at high volume centers.

Endoscopic versus percutaneous management for symptomatic pancreatic fluid collections: a systematic review and meta-analysis.

Background Symptomatic pancreatic fluid collections (PFCs) are managed by surgical, percutaneous, or endoscopic drainage. Due to morbidity associated with surgical drainage, percutaneous and/or endoscopic options have increasingly been used as initial management. Aims We conducted a systematic review and meta-analysis comparing the efficacy and safety of endoscopic versus percutaneous drainage for management of PFCs. Methods We searched several databases from inception through 31 August 2017 to identify comparative studies using endoscopic or percutaneous drainage for PFCs. Our primary outcome was clinical success. Secondary outcomes were technical success, adverse events (AE), rates of recurrence, requirement for subsequent procedures, and length of stay in hospital. Pooled risk ratios (RR) and mean difference (MD) were calculated for categorical and continuous outcomes, respectively. Results Seven studies with 490 patients were included in the final analysis. Pooled RR for clinical success was 0.40 (0.26, 0.61), I 2 = 42 % in favor of endoscopic management. On sensitivity analysis, after excluding one study on patients with walled-off necrosis (WON), the clinical success was 0.43 (0.28, 0.66) with no heterogeneity. Pooled RR for technical success was 1.50 (0.52, 4.37) with no heterogeneity. Pooled RR for AE and rate of recurrence were 0.77 (0.46, 1.28) and 0.60 (0.29, 1.24), respectively. Pooled MD for length of stay in hospital and rate of re-intervention were – 8.97 (– 12.88, – 5.07) and – 0.66 (– 0.93, – 0.38), respectively, in favor of endoscopic drainage. Conclusions Endoscopic drainage should be the preferred therapeutic modality for PFCs compared to percutaneous drainage as it is associated with significantly better clinical success, a lower re-intervention rate, and a shorter hospital length of stay.

Full Drug-Eluting Stent Jacket: Two-Year Results of a Single-Center Experience With Zilver PTX Stenting for Long Lesions in the Femoropopliteal Arteries

Purpose: To evaluate the 1- and 2-year patency and reintervention rates with the Zilver PTX drug-eluting stent (DES) in long complex femoropopliteal disease. Methods: A retrospective review was conducted of 89 consecutive patients (mean age 68.7±9.8 years; 86 men) with femoropopliteal occlusive disease (Rutherford category 2–6) treated with the Zilver PTX between December 2012 and December 2013. Mean lesion length for the entire cohort was 24.2±11.3 cm (median 24.0, range 4–48). The patient population was dichotomized into a short lesion (≤20 cm) group (n=41; mean lesion length 13.3±5.6 cm) and the full DES jacket (>20 cm) group (n=48; mean lesion length 33.0±6.5 cm). Primary endpoints were duplex-derived restenosis (peak systolic velocity ratio >2.5), clinically driven reintervention, and major amputation. Results: The incidence of restenosis was lower in the short lesion group at 1 year (19% vs 40% for the longer lesions, p=0.050) and 2 years (39% vs 54%, respectively; p=0.331). The short lesion group had significantly lower rates of reintervention at both 1 year (2% vs 21% in long lesions, p=0.009) and 2 years (12% vs 33%, p=0.019). Conclusion: Treatment of femoropopliteal lesions >20 cm with the Zilver PTX appears to be a clinically effective therapy for patients with symptomatic peripheral artery disease. However, there is an increase in restenosis and a need for reintervention that continues to progress up to 2 years.

Caval Thrombus Management: The Data, Where We Are, and How It Is Done

Thromboses of the superior and inferior vena cava, either isolated or associated with distal deep venous thrombosis, are uncommon, but confer potentially serious morbidity and mortality. Incidence is increasing, especially with the prominence of intravascular devices. The range of treatment options is also expanding to include medical management, surgery, and endovascular techniques which are now frequently considered first line therapy due to lower reintervention rates and decreased periprocedural morbidity. Currently, there are no official guidelines for screening or treatment. This article reviews the etiology, diagnosis, and management of caval thromboses, including equipment, procedural steps, outcomes, and complications, particularly with regard to endovascular techniques, such as catheter-directed thrombolysis, pharmacomechanical catheter-directed thrombolysis, angioplasty, and stenting.

Use of the Gore Tigris Vascular Stent in Advanced Femoropopliteal Peripheral Arterial Disease

PurposeTo prospectively evaluate the safety and efficacy of using the Tigris vascular stent (Gore, Flagstaff, Arizona) alone or in combination with the Viabahn stent (Gore) for revascularizing femoropopliteal Trans-Atlantic Intersociety Consensus (TASC) type B–D lesions with varying degrees of calcification. Materials and MethodsPatients with Rutherford stage ≥ 3 and TASC type ≥ B were included in the study. From January 2015 to April 2017, 31 segments in 31 patients (21 men, ovarall mean age 73.3 ± 9.2 years) were treated. The breakdown by TASC type and Rutherford stage were TASC B (n = 12), C (n = 6), and D (n = 13), and Rutherford 3 (n = 28) and 4 (n = 3). The lesions were located in the common femoral artery (n = 1), superficial femoral artery (SFA; n = 20), distal SFA to P1 (n = 3), popliteal P1 (n = 1), popliteal P1–3 (n = 3), popliteal P2–3 (n = 2), and 1 femoropopliteal bypass. There were 18 occlusions (58.1%) and 13 stenoses (41.9%). The mean diseased segment length was 15.5 ± 9.9 cm with 80.6% of moderate/severe calcification. The follow-up consisted of color Doppler ultrasound and clinical assessment at 1, 3, 6, 9, 12, and 15 months. ResultsTechnical success was 100%. There were no periprocedural or postprocedural complications. The mean stented lesion length was 17.2 ± 10.5 cm with a mean follow-up of 13.1 ± 6.9 months. Primary patency rates at 6, 9, 12, and 15 months were, respectively, 100% (24/31 patients), 90.5% (21/31 patients), 88.9% (20/31 patients), and 80% (15/31 patients). The median postprocedural Rutherford stage was 1. Three occlusions occurred at 7, 9, and 14 months, leading to a target lesion revascularization of 9.7% and a secondary patency of 100% at 15 months. Logistic analysis results demonstrated that lesion length (P = .003) was associated with reocclusion. Amputation-free survival at 15 months was 100%. Intrastent restenosis was observed in four cases (12.9%) but none were associated with worsening of symptoms. No stent fractures were observed. ConclusionsThe Tigris stent used alone or in combination with a Viabahn stent for femoropopliteal TASC B–D lesions demonstrated acceptable 12-month primary patency with a low reintervention rate.