Regression of perianeurysmal fibrosis and ureteral dilation following endovascular repair of inflammatory abdominal aortic aneurysm

An inflammatory component to abdominal aortic aneurysms (AAA) is thought to occur in approximately 5% of cases. Accompanying ureteral entrapment may be involved in 20% of these. Transabdominal repair of inflammatory AAA with ureterolysis may result in increased complications. Many authorities have recommended a retroperitoneal approach to decrease dissection. Similarly, an endovascular approach has been utilized. We report here the results of a patient with an inflammatory AAA with bilateral ureteral obstruction successfully treated with endovascular stent graft repair and bilateral ureteral stents with exclusion of the aneurysm and resolution of hydronephrosis.

Endovascular stent-graft in abdominal aortic aneurysms: the relationship between patent vessels that arise from the aneurysmal sac and early endoleak

PURPOSE

To determine the association of patent sac branch vessels (lumbar and inferior mesenteric arteries [IMAs]) with early endoleak rate after stent-graft repair of abdominal aortic aneurysm (AAA).

MATERIALS AND METHODS

Pre- and postoperative computed tomographic (CT) angiograms in 158 patients who underwent stent-graft AAA repair were retrospectively reviewed to determine the preoperative patency of IMAs and other sac branch vessels (feeders) and presence or absence of immediate postoperative endoleak. Relationships of early endoleak rate with total branch vessel, IMA, and lumbar artery patency and graft type were evaluated.

RESULTS

There was a significant association between patency of sac feeders and rate of early endoleak, especially type 2. As total patent feeders increased from zero to three to four to six, total endoleak rate increased from 6% (one of 17) to 35% (30 of 86); type 2 endoleak rate, from 0% to 25%. IMA patency was significantly associated with total early endoleak rate. Increasing lumbar artery patency also was associated with significantly higher total and type 2 endoleak rates: With zero to three lumbar arteries, the total endoleak rate was 17% and type 2 endoleak rate was 13%, as compared with 60% and 50%, respectively, with more than six patent lumbar arteries.

CONCLUSION

Sac branch vessel patency is associated with significantly higher early total and type 2 endoleak rates after stent-graft repair of AAAs; thus, patent sac branches play an important role in the pathogenesis of endoleaks.

Inferior vena caval filters: review of a 26-year single-center clinical experience

PURPOSE

To review a 26-year single-center clinical experience with inferior vena caval filters.

MATERIALS AND METHODS

During 1973-1998, 1,765 filters were implanted in 1,731 patients. Hospital files were reviewed, and data were collected about the indications, safety, effectiveness, numbers, and types of caval filters. Fatal post-filter pulmonary embolism (PE) was considered the primary outcome. Morbidity and mortality were determined as secondary outcomes. Survival and morbidity-free survival curves were calculated.

RESULTS

The prevalence of observed post-filter PE was 5.6%. It was fatal in 3.7% of patients. In most patients, fatal PE occurred soon after filter insertion (median, 4.0 days; 95% CI: 2.2, 5.8 days). Major complications occurred in 0.3% of procedures. The prevalence of observed post-filter caval thrombosis was 2.7%. The 30-day mortality rate was 17.0% overall, higher among patients with neoplasms (19.5%) as compared with those without neoplasms (14.3%; P =.004). Filter efficacy and associated morbidity were not different in 46 patients with suprarenal filters. The rate of filters placed for prophylaxis was 4.7% overall and increased to 16.4% in 1998. From 1980 to 1996, there was a fivefold increase in the number of caval filter implants. In recent years, more filters were implanted in younger patients.

CONCLUSION

Inferior vena caval filters provide protection from life-threatening PE, with minimal morbidity.

Utility and reliability of endovascular aortouniiliac with femorofemoral crossover graft for aortoiliac aneurysmal disease

OBJECTIVE

The purpose of this study was to determine the early efficacy of endovascular aortouniiliac stent grafts with femorofemoral bypass graft in the treatment of aortoiliac aneurysmal disease.

METHODS

We analyzed 51 consecutive patients from January 1997 to March 1999 with a mean follow-up of 15.8 months. Patients ranged in age from 44 to 93 years (mean, 75 years) with a mean aortic aneurysm diameter of 6.2 cm. Technical success was achieved in 50 patients; one patient required conversion to open repair intraoperatively. We placed 28 custom-made and 22 commercial devices. The mean operative time was 223 minutes. The endograft was extended to the external iliac artery in 42% of cases. The contralateral common iliac artery was occluded using either a closed covered stent or intraluminal coils.

RESULTS

The median hospital stay was 4 days with an average intensive care unit stay of 0.25 days. There were no operative mortalities. Two patients died during follow-up from unrelated conditions. Endoleaks occurred in 11 patients (22%); seven patients (14%) required intervention (four catheter based, three operative). Other complications occurred in 38% of patients but were largely remote or wound related. One femorofemoral bypass graft occluded immediately postoperatively as a result of an intraprocedural external iliac dissection yielding a 98% primary patency and 100% secondary patency. Clinical success was achieved in 88% of patients.

CONCLUSIONS

These data suggest that this strategy represents a reliable method of repair of aortoiliac aneurysmal disease and extends the capability of an endoluminal approach to patients with complex iliac anatomy.

Clinical outcome of internal iliac artery occlusions during endovascular treatment of aortoiliac aneurysmal diseases

PURPOSE

To determine the clinical outcome of hypogastric artery occlusion in patients who underwent endovascular treatment of aortoiliac aneurysmal disease.

MATERIAL AND METHODS

From January 1994 to March 1998, 94 patients underwent endovascular treatment of aneurysmal diseases involving the infra-abdominal aorta or iliac arteries. Preoperative and intraoperative radiologic data were reviewed. Discharge summaries, clinic visits, and phone calls formed the basis for clinical follow-up, with a mean follow-up period of 7.3 months (range, 1-24 months).

RESULTS

Because of the anatomy of the aneurysms, 28 patients required occlusion of one or more hypogastric arteries. One of the 28 patients died of unrelated causes before follow-up. Seven (26%) of the remaining 27 patients developed symptoms attributable to the hypogastric artery occlusions. Five patients developed new buttock or thigh claudication; of these five patients, three with initially mild symptoms noted complete or near complete resolution of symptoms upon follow-up. One patient with originally significant claudication at 2-year follow-up noted near resolution of symptoms. The other patient with severe pain did not improve significantly on final 1-year follow-up before his death (of unrelated causes). Other clinical complications were worsening sexual function in one patient and a nonhealing sacral decubitus ulcer that developed in a debilitated patient in the postoperative setting, which required surgery. No bowel ischemia was observed.

CONCLUSION

When treating aortoiliac aneurysmal disease through an endovascular approach, the occlusion of internal iliac artery is often necessary but carries with it a small but finite chance of morbidity.

Custom bifurcated stent-graft for abdominal aortic aneurysms: initial experience

PURPOSE

To describe a custom bifurcated stent-graft for possible treatment of abdominal aortic aneurysm (AAA).

MATERIALS AND METHODS

Five male patients (mean age, 76 +/- 6 years), who had AAA (mean diameter, 4.7 +/- 0.4 cm) and who were considered to be at high risk for conventional surgery, were treated with a custom modular bifurcated stent-graft constructed with bifurcated 24-mm x 12-mm (upper body diameter x iliac limb diameter) Cooley Veri-Soft Woven polyester grafts and Gianturco-Rösch Z stents. The stent-graft body was delivered through 20-22-F sheaths, and the contralateral iliac limb was delivered through a 16-F sheath by means of surgical exposure of the common femoral arteries. A flared distal limb extender (12 mm to 14 mm) was created for one patient to accommodate a large common iliac artery.

RESULTS

Stent-grafts were successfully deployed without complications in all five patients. There were no proximal or distal leaks. A lumbar-to-inferior mesenteric artery leak was seen in one patient at 24 hours. At 6-month follow-up, all devices were intact, with complete exclusion and shrinkage of the aneurysm in four of five patients. Aneurysm size remained stable in the one patient with a lumbar-to-inferior mesenteric artery leak.

CONCLUSION

A custom, bifurcated stent-graft was utilized for endovascular treatment of AAA. Long-term follow-up is necessary for the device.

Gadolinium-based contrast agents as an alternative at vena cavography in patients with renal insufficiency--early experience

The authors reviewed results of digital subtraction vena cavography with a gadolinium-based contrast agent in 14 patients with serum creatinine levels greater than or equal to 1.5 mg/dL (133 mumol/L). All cavograms were diagnostic. In 11 patients, there was no impairment of renal function. In three patients, a rise in serum creatinine level of greater than or equal to 0.5 mg/dL (44 mumol/L) was attributable to concurrent medical problems. Gadolinium-based contrast agents may be suitable for digital subtraction vena cavography in patients with renal insufficiency.

Cost comparison of radiologic versus surgical placement of long-term hemodialysis catheters

OBJECTIVE

The purpose of this study was to compare the cost of radiologic versus surgical placement of long-term hemodialysis catheters.

MATERIALS AND METHODS

Our cost analysis was based on 47 long-term hemodialysis catheters radiologically placed in 45 patients and 25 catheters surgically placed in 25 patients from October 1996 through March 1997. Variable and total costs were calculated using data from the hospital administrative computer system that records the actual costs incurred by the hospital in caring for patients.

RESULTS

The average total hospital cost was $926 for each radiologic placement and $1849 for each surgical placement of long-term hemodialysis catheters. The total cost saving for radiologic placement was $923 for each catheter.

CONCLUSION

Radiologic placement of long-term hemodialysis catheters resulted in substantial savings over surgical placement.

Gadopentetate dimeglumine: a possible alternative contrast agent for CT angiography of the aorta

We report the use of a gadolinium chelate for limited CT angiography of the aorta in a patient in whom iodinated contrast agent was contraindicated and who had undergone nondiagnostic MRI.

Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair

PURPOSE

To determine the safety, effectiveness, and problems encountered with endovascular repair of abdominal aortic aneurysm (AAA). Initial experience with endoluminal stent grafts was examined and compared with outcome for a matched concurrent control group undergoing conventional operative repair of AAA.

METHODS

Over a 3-year period, 30 patients underwent attempts at endovascular repair of infrarenal AAA. Of the 28 (93%) successfully implanted endografts, 8 were tube endografts, 8 bifurcated grafts, and 12 aortouniiliac grafts combined with femorofemoral bypass. Most of the procedures were performed in the past year because the availability of bifurcated and aortoiliac endografts markedly expanded the percentage of patients with AAA who might be treated with endoluminal methods. The follow-up period ranged from 1 to 44 months, with a mean value of 11 months.

RESULTS

Endovascular procedures demonstrated significant advantages with respect to reduced blood loss (408 versus 1287 ml), use of an intensive care unit (0.1 versus 1.75 days), length of hospitalization (3.9 versus 10.3 days), and quicker recovery (11 versus 47 days). Although the total number of postoperative complications was identical for the two groups, the nature of the complications differed considerably. Local and vascular complications characteristic of endovascular repair could frequently be corrected at the time of the procedure and tended to be less severe than systemic or remote complications, which predominated among the open surgical repair group. On an intent-to-treat basis, 23 (77%) of the 30 AAAs were successfully managed with endoluminal repair. The seven (23%) failures were attributable to two immediate conversions caused by access problems, three persistent endoleaks, one late conversion caused by AAA expansion, and one late rupture.

CONCLUSIONS

Although less definitive than those for conventional operations, these early results suggest that endovascular AAA repair offers considerable benefits for appropriate patients. The results justify continued application of this method of AAA repair, particularly in the treatment of older persons at high risk.

Evaluation of renal artery stenosis with dynamic gadolinium-enhanced MR angiography

OBJECTIVE

The purpose of this study was to compare dynamic gadolinium-enhanced three-dimensional spoiled gradient-recalled MR angiography with conventional arteriography in the evaluation of proximal renal artery stenosis (RAS).

MATERIALS AND METHODS

MR angiography and conventional arteriographic examinations of 30 patients evaluated for RAS were analyzed retrospectively. Three-dimensional MR angiography was performed with an RF spoiled gradient-recalled imaging sequence acquired during the dynamic i.v. injection of gadolinium (0.2-0.3 mmol/kg), MR data and conventional arteriograms were independently evaluated for the number and location of renal arteries and the degree and location of stenoses. The patients had a mean age of 70 years old and a mean serum creatinine level of 2.9 mg/dl, reflecting a population in whom atherosclerotic RAS was the primary concern.

RESULTS

Gadolinium-enhanced MR angiography revealed 100% of main renal arteries. For RAS of 50% or greater occlusion, the technique was 100% sensitive and 71% specific; the negative predictive value was 100%. The technique was 100% sensitive and 71% specific for RAS of 75% or greater occlusion.

CONCLUSION

Dynamic gadolinium-enhanced three-dimensional spoiled gradient-recalled MR angiography has a high sensitivity for revealing proximal RAS and is a quick and reliable technique for obtaining helpful anatomic information.

Migration of central venous catheters: implications for initial catheter tip positioning

PURPOSE

To evaluate the change in position of chest wall central venous access catheters (CVACs) after placement. Complication rates associated with catheter tip position were reviewed.

PATIENTS AND METHODS

Fifty patients (36 women, 14 men) with chest wall CVACs placed in the angiography suite were studied. Catheter migration was calculated as the difference between the carina-catheter tip measurements on immediate supine and upright postprocedure (within 24 hours) chest radiographs. Catheter-related complication data were gathered via telephone interview and review of the medical records.

RESULTS

Peripheral catheter migration occurred in 49 of 50 patients (average, 3.2 cm +/- 1.8); central catheter migration occurred in one of 50 patients (3.9 cm). Catheter type was the only significant factor that affected the amount of migration; side of insertion or the patient's gender were not significant. Catheter malfunction and symptomatic upper extremity venous thrombosis rates tended to be lower in patients with right atrial versus superior vena cava catheters (18% vs 34%), but differences were not significant (P = .202).

CONCLUSION

Catheter migration after chest wall CVAC placement is a common event. The catheter tip should be initially positioned approximately 3-4 cm more centrally than the desired final position. Further study is necessary of catheter-related complication rates relative to the final position of the catheter tip.

Long-term outcomes of radiologically placed arm ports

PURPOSE

To evaluate long-term outcomes of an initial experience with radiologic placement of arm ports.

MATERIALS AND METHODS

The follow-up of 46 consecutive arm port placements (44 patients) was reviewed by means of chart review (hospital, office, and clinic) in 41 patients, telephone interview in 20, physical, examination in 15, and venous ultrasound in 14. Data on port complications and function were recorded. Statistical methods were the Fisher Exact Test and Cochran-Mantel-Haenszel Test.

RESULTS

Technical success for placement was 100%. Follow-up was obtained in 41 (93%) of the 44 patients (43 ports); mean days of catheter use was 344 days (total, 14,797 days; range, 10-1,104 days; median, 278 days). Rate (per 100 catheter days) of symptomatic central venous thrombosis was 0.054; arm phlebitis, 0.007; confirmed infection, 0.034; and catheter dysfunction, 0.095. Prophylactic anti-coagulants did not affect symptomatic central venous thrombosis (P > .05, Fisher Exact Test). Catheter tip high in the right atrium was marginally associated with better catheter function (P = .041, Fischer Exact Test).

CONCLUSION

Good long-term results can be anticipated with radiologic placement of arm ports.

Embolization of pulmonary catheter-induced pulmonary artery pseudoaneurysms

STUDY OBJECTIVES

To determine the outcome of patients with pulmonary catheter-induced pulmonary artery pseudoansurysms (PSAs) treated with embolization.

DESIGN

Retrospective outcomes review.

SETTING

Large urban tertiary-care hospital.

PATIENTS

All patients who presented to diagnostic angiography for ruptured pulmonary artery PSA caused by pulmonary artery catheters (PACs) from November 1990 to September 1995. A total of six patients were examined.

INTERVENTIONS

Transcatheter embolotherapy with coils, absorbable gelatin sponges (Gelfoam), and suture material.

RESULTS

These procedures were technically successful in all patients, and none had recurrent hemoptysis. Four of the six patients were discharged from the hospital.

CONCLUSION

Embolotherapy is a useful alternative to surgery for some patients with PAC-induced pulmonary PSA.

MR angiography of tibial runoff vessels: imaging with the head coil compared with conventional arteriography

OBJECTIVE

We compared peripheral vascular MR angiography done with a standard transmit-receive head coil with conventional arteriography for identifying and evaluating runoff vessels below the knee.

MATERIALS AND METHODS

We examined 55 legs in 31 symptomatic patients with both conventional contrast angiography and gradient-echo two-dimensional time-of-flight MR angiography. Both legs of patients were placed in a standard transmit-receive head coil for MR angiography and were imaged simultaneously. For evaluation of stenoses, images of vessels were divided into 10 segments, and each segment was graded on a four-point scale.

RESULTS

In the 393 native vascular segments evaluated, the sensitivity of MR angiography in identifying normal vessels was 95% and the specificity was 98%. In detecting segmental occlusion, MR angiography was 98% sensitive and 97% specific. Sensitivity and specificity for stenoses greater than 75% were 98% and 96%, respectively, and for stenoses greater than 50%, they were 98% and 95%, respectively. Interpretative discrepancies were found in 35 vessel segments in 18 legs; none was of clinical relevance. Of all vessel segments shown as occluded by conventional angiography, 1% appeared patent on MR angiograms. No vessel segments shown as normal on MR angiograms were found to be occluded on conventional angiograms.

CONCLUSION

When performed simultaneously on both legs of symptomatic patients, 2D time-of-flight MR angiography with a standard transmit-receive head coil provides a time-efficient and highly sensitive and specific means of evaluating below-knee runoff.