[Results of hybrid loop endarterectomy from the superficial femoral artery with the MultiTASC]

The purpose of this study was to analyse the results of hybrid loop endarterectomy from the superficial femoral artery (SFA) in its occlusion, preformed in a total of forty-two patients. Of these, 27 patients had prior to the intervention been diagnosed with stage II B ischaemia and 15 patients had been diagnosed as having critical ischaemia. Technical success of the operation amounted to 88%, with the frequency of early thromboses equalling 2.7%. In the early postoperative period, one patient died of acute myocardial infarction. The 1-, 2- and 3-year remote cumulative primary patency rate amounted to 81, 74 and 74%, respectively. There were no amputations performed within the timeframe of the follow-up period. The technique of hybrid loop endarterectomy with the MultiTASC loop followed by stenting of the proximal portion of the popliteal artery in occlusion of the SFA and stenoses of the common femoral artery has proved to be a highly efficient intervention yielding good immediate and remote results.

[Use of the "Multitask" device while performing endarterectomy from iliac arteries]

AIM

The study was aimed at assessing efficacy of using the "MultiTASK" device manufactured by the Le Maitre Company while performing extended endarterectomy from iliac arteries in patients presenting with multilevel atherosclerotic lesions of the arterial bed and chronic ischaemia of lower extremities.

PATIENTS AND METHODS

We analysed the outcomes of surgical management of a total of 37 patients presenting with multilevel atherosclerotic lesions of the common and external iliac arteries and arteries below the inguinal ligament over the period from 2012 to 2015 at the Department of Emergency Vascular Surgery of the Scientific Research Institute of Emergency Ambulance Care named after N.V. Sklifosovsky. Twenty one (56.8%) patients presented with haemodynamically significant stenoses of the iliac artery. Eleven (29.7%) patients had occlusion of the external iliac artery and five (13.5%) patients presented with occlusion of the common iliac artery in the distal portion. In all cases there was a second block, i. e. occlusion of the superficial femoral artery.

RESULTS

The primary patency rate of the external iliac artery after endarterectomy amounted to 100%. Immediate complications directly associated with endarterectomy from the external iliac artery were encountered in one (2.7%) case - during back traction of the loop there occurred perforation of the wall of the external iliac artery by a calcified plaque, thus requiring external-iliac-common-femoral prosthetic repair. Amputation was performed in two (5.4%) patients (in both cases due to thrombosis and the development of ischaemic gangrene owing to poor condition of the distal arterial bed). One (2.7%) patient died of acute myocardial infarction.

CONCLUSION

Extended endarterectomy by means of the "MultiTASC" device turned out efficient, yielding good immediate outcomes in atherosclerotic lesions of femoral arteries both as an independent operation and when combined with reconstruction of arteries beneath the inguinal ligament.

Laser scoop desobliteration: a method for minimally invasive remote recanalization of chronically occluded superficial femoral arteries

Stenosis and occlusion of the superficial femoral artery (SFA) are most common in arterial occlusive disease. There are numerous interventional, surgical, and combined approaches to reconstitute maximum blood supply to the lower limb; however, despite intense clinical research, the long-term success rates are still poor. We present the first results with a catheter prototype for laser-based minimal invasive endarterectomy, called laser scoop desobliteration (LSD). The tip of a glass fiber containing a catheter was modified with a spatula head design and connected to an ultraviolet laser. It was tested in cadavers fixed with the Thiel embalming technique preserving tissue consistency, flexibility, and plasticity. After longitudinal arteriotomy of the SFA, a circular dissection between media and adventitia was performed. Then the LSD catheter was inserted and propagated with a progress of 1 mm∕s. Afterward, the atheroma core, which showed a plain surface without substantial attaching tissue debris, was removed. Histological examination of the vessel wall showed that the dissection was performed at the media/adventitia interface. In summary, the constructed LSD catheter allowed a rapid and easy way to perform an endarterectomy, thereby offering an innovative approach in the treatment of chronic occluded SFA.

Guided remote endarterectomy for superficial femoral artery occlusions: a technical note

The aim of this paper was to describe a new modification of the remote endarterectomy for the treatment of long superficial femoral artery (SFA) occlusions and to present our preliminary results. Through a subinguinal incision and arteriotomy over the SFA origin, a hydrophilic guidewire was introduced into the subintimal plane of the SFA and advanced distally until reentry into the distal patent popliteal artery. The hydrophilic guidewire is exchanged for an Ablatz wire to provide support for the advancement of the single endarterectomy ring. The MollRing Cutter was introduced in the SFA after the removal of the single endarterectomy ring and it was advanced until the re-entry point. The atherosclerotic core was removed and a nitinol self-expanding stent was placed at the peripheral end of the endarterectomy. Arteriotomy was closed with a patch. Guided subintimally-assisted remote endarterectomy seems to be a successful and safe modification of the traditional technique in the treatment of SFA occlusion, in patients with critical limb ischemia.

Remote superficial femoral artery endarterectomy

Remote superficial femoral artery endarterectomy (RSFAE) is an effective minimal invasive treatment modality of TransAtlantic Inter-Society Consensus (TASC) C and D atherosclerotic lesions of the superficial femoral artery (SFA) with at least equal patency rates as supragenicular synthetic bypass grafts. This procedure is performed through a single femoral arteriotomy and the intima core in the SFA is dissected using the Vollmar ring and the Mollring cutter devices, respectively. The intimal core distally of the transaction zone is secured by an expandable polytetrafluoroethylene-covered nitinol stent. By its minimal invasive character, RSFAE will lead to lower rate of postoperative complications and shorter hospital stay compared to supragenicular bypass graft surgery. Additional advantage in comparison with percutaneous procedures is the opportunity of open endarterectomy of the common femoral and/or profunda artery. Synthetic material will be avoided and vein will be preserved for possible future cardiovascular surgery. Reobstruction of the SFA tends to have, in contrast to bypass grafts, less severe symptoms due to preservation of collaterals and thereby lower amputation rate. Achilles heel of RSFAE is the relatively high percentage of first year restenosis due to neointimal hyperplasia. Strict follow-up at 3, 6 and 12 months is advised including duplex ultrasound. In case of symptomatic or asymptomatic hemodynamic restenosis (>50%) percutaneous transluminal angioplasty must be performed to improve long-term patency. The majority of reobstructions can be treated by endovascular means. New endovascular techniques, like balloon cryoplasty or drug eluting stents have to be studied in combination with RSFAE to optimize its technique and improve patency rates.

Ultrasonic endarterectomy for long superficial femoral artery atherosclerotic occlusive disease

OBJECTIVE

To report the long term results of ultrasonic superficial femoral artery endarterectomy (USFAE).

DESIGN

Retrospective study.

PATIENTS AND METHODS

From January 1998 to June 2004 218 USFAE were performed in 202 selected patients (178 males, 192 procedures) with a median age of 65 years (46-87 years). Indications for operation were disabling intermittent claudication in 137 procedures (68%), rest pain in 24 procedures (12%), and limb salvage in 41 procedures (20%). The new medical technology of ultrasonic endarterectomy is based on the application of the mechanical vibrations in the range of low frequency ultrasound. The ultrasonic device consists of the ultrasonic generator, acoustic unit and the flexible wave concentrators with special working tips in the shape of a ring. Follow up consisted of clinical evaluation, ankle-brachial index measurements and duplex scanning.

RESULTS

The mean follow-up time was 30.1 months. The mean length of the endarterectomised SFAs was 29 cm (range, 15-43 cm). The five year cumulative primary patency rate by means of life table analysis was 45.8 +/- 4.4% (SE). Percutaneous transluminal balloon angioplasty and surgical re-interventions were performed in thirty three and five patients respectively resulting in a primary assisted patency rate of 57.5 +/- 4.1%. The five year secondary patency rate was 65.6 +/- 3.8%. Limb salvage was achieved in 35 of the 41 patients with gangrene.

CONCLUSIONS

The long term results of ultrasonic SFA endarterectomy suggest this is an effective technique.

Multi Centre Study to Assess the Feasibility of a New Covered Stent and Delivery System in Combination with Remote Superficial Femoral Artery Endarterectomy (RSFAE)

OBJECTIVES

To evaluate the feasibility and efficacy of an innovative new covered stent and adjustable deployment system (aSpire Covered Stent, Vascular Architects Inc., San Jose, CA, USA) in combination with remote superficial femoral artery endarterectomy (RSFAE) for the treatment of long segment femoropopliteal occlusive disease.

DESIGN

Prospective multi-centre trial.

MATERIALS AND METHODS

Sixty-two limbs in 61 patients (41 men; median age 69 years, range 40-88) with severe disabling claudication (n=56) or critical limb ischaemia (n=6) were treated in five European centres with aSpire stenting after RSFAE for long segment occlusions (mean length 25 cm). Follow-up was by duplex scanning at 1-, 6-, 12- and 18-months. Primary, primary-assisted and secondary patency rates were analysed.

RESULTS

The median follow-up was 17 (range 2-34) months. A mean of 1.3 stents (range 1-3) were deployed with a median stent diameter of 7 mm (range 6-9). There were one early and 24 late failures. At 18-months the cumulative primary, primary-assisted and secondary patency rates were 60, 70 and 72%, respectively. There were no device related adverse events, such as kinking or fracturing and no stent migrations.

CONCLUSIONS

The aSpire stent and the delivery system are both safe and feasible in combination with RSFAE. The mid term follow-up appears favourable in view of the long segment occlusions treated. Further follow-up is required to compare the mid- and long-term outcomes with current stents and conventional femoropopliteal bypass.

The use of aortic connector as shunt during endarterectomy of innominate artery

The St. Jude aortic connector system (St. Jude Medical, Inc, St. Paul, MN) is being increasingly used for the construction of vein proximal anastomosis in coronary artery bypass grafting. We suggest a possible use of the connected vein as temporary shunt during open endarterectomy of the innominate artery and at the same time as graft for coronary artery bypass grafting.

[Pulmonary thromboendarterectomy for an elderly patient]

We describe a case of successful pulmonary thromboendarterectomy for an elderly patient. A 75-year-old female suffered from severe dyspnea in spite of administration of pulmonary vascular dilators and anticoagulants. Her pulmonary vascular resistance was 545 dyn x sec x cm(-5) and, her pulmonary angiogram and perfusion scan revealed that almost all branches of her right pulmonary artery were occluded. Pulmonary thromboendarterectomy was performed under cardiopulmonary bypass. A videoscope was employed to see inside of the pulmonary artery. Flexible aspirator chip was used to peed abnormal intima easily. A non-invasive intracranial oxygen saturation monitor was used for secure circulatory arrest. The duration of cardiopulmonary bypass was 101 minutes and minimum body temperature was 24.5 degrees C. Her symptoms improved markedly after operation, and she went back to the ordinary life. Pulmonary thromboendarterectomy was useful even for elderly patients under some modifications of the operative procedures.

Remote superficial femoral artery endarterectomy

The advent of minimally invasive procedures such as percutaneous transluminal angioplasty with or without stent, laser-assisted balloon angioplasty, and atherectomy, whose results have proven disappointing in the treatment of long-segment (> more than 15 cm) superficial femoral artery (SFA) occlusive disease, stimulated a reassessment of SFA endarterectomy. With the evolution of remote superficial femoral artery endarterectomy (RSFAE) a minimally invasive technique became available which could be performed through a single incision, allowed, debulking of the arterial plaque, and placement of an endovascular stent. We report results of RSFAE in an initial trial, results of RSFAE in concert with the aSpire Covered Stent which is a flexible ePTFE covered Nitinol stent with significant radial strength to withstand torsional stresses at the knee joint, and RSFAE and distal vein bypass for limb salvage.

Endoscopic approach for carotid artery surgery

BACKGROUND

Although recent advances in the treatment of carotid artery stenosis have included endovascular angioplasty and stent placement, carotid endarterectomy is still the approach of choice for carotid disease and is one of the most commonly performed operations today. Minimally invasive surgeries involving the neck have recently been performed for thyroid and parathyroid diseases. The purpose of this study was to evaluate the feasibility of an endoscopic approach for carotid artery surgery in a large animal model.

METHODS

Eight 25- to 30-kg pigs were used. Animals underwent endoscopic carotid dissection with carbon dioxide insufflation at 10 mmHg. A 1.5- to 2-cm arteriotomy was made in the common carotid artery. Four animals underwent direct arteriotomy closure, and four animals underwent synthetic patch graft placement using intracorporeal suturing techniques. Open examination of the operative site and carotid angiograms were performed at the end of the procedure. Operative time was recorded in the last four cases.

RESULTS

All animals tolerated the procedure well and carotid artery repair was successfully performed in all cases using a four-trocar technique. The entire extent of the cervical common and internal carotid arteries was exposed up to the cranial base. Cranial nerves and cervical structures were clearly visualized and preserved. No bleeding occurred at the end of the procedure. Carotid angiograms confirmed patent, nonstenotic vessels in all cases.

CONCLUSION

Endoscopic approach for carotid surgery is technically feasible in the porcine model. This approach may represent a valuable option for surgery of the carotid artery since it offers the advantages of minimally invasive techniques while maintaining the benefits of surgical arterial repair.

Carotid artery stenosis and endarterectomy

This article reviews the disease process of carotid artery stenosis, its symptomatology, and prognosis for progression to ischemic stroke. Indications for both medical and surgical treatment are reviewed as is criteria for surgical categorization as specified by the American Heart Association guidelines for carotid endarterectomy. Although diagnostic testing, medical treatment and alternative therapy options of angioplasty, stenting and thrombolysis are presented, a thorough overview of the surgical procedure of carotid endarterectomy is the major focus of discussion, as it remains the "gold standard" of treatment for severe carotid artery stenosis.

[Current aspects of cerebral protection in carotid surgery: update]

The goal of cerebral protection in carotid surgery is to reduce postoperative central neurological complications and thus reduce morbidity-mortality of carotid endarterectomy. With improving understanding of the mechanism leading to neurological complications, means of achieving cerebral protection have been developed. Preoperative evaluation of the ischemic risk is based on the neurological examination and on computed tomography and magnetic resonance imaging findings. The possibilities of arterial supply during carotid cross-clamping can be recognized with the help of arteriography, transcranial Doppler or angio-MRI. Selective or systematic use of an intraluminal shunt and preoperative heparin therapy are the main methods used for cerebral protection. The risk of early postoperative stroke can also be reduced by careful preoperative anatomic control to detect any technical failure. Discussion on the usefulness of monitoring cerebral function during the procedure is closely related to the experience of the surgical team. The only method currently accepted by all surgeons is the use of stents during carotid angioplasty to achieve cerebral protection.

Simultaneous aortic replacement and renal artery revascularization: the influence of preoperative renal function on early risk and late outcome

PURPOSE

We documented the postoperative complication rate and the late results of simultaneous infrarenal aortic replacement and renal artery (RA) revascularization at the Cleveland Clinic and correlated these findings with the preoperative serum creatinine level (S(Cr)) and other baseline risk factors.

METHODS

A retrospective review of hospital charts and outpatient records was supplemented with a telephone canvass and the invitation to return for a complimentary RA duplex scan, when a scan had not been done within the previous year. Data were collected for 73 consecutive patients (mean age, 69 years) who underwent aortic procedures that were combined with the repair of RA stenosis from 1989 to 1997 (mean follow-up, 44 months). The preoperative S(Cr) was 2 mg/dL or lower in 45 patients (group R1; median, 1.5 mg/dL) and was higher than 2 mg/dL in the remaining 28 patients (group R2; median, 2.6 mg/dL).

RESULTS

Forty-seven of the patients in this series had aortic aneurysms, 15 patients had aortoiliac occlusive disease, and 11 patients had both types of lesions. Bilateral RA revascularization was necessary for seven patients in group R1 (15%) and for eight patients in group R2 (29%). Group R2 contained more patients with medically resistant hypertension (57%) than group R1 (29%, P = .019). Although there was no statistically significant difference between the 30-day mortality rates (group R1, 2.2%; group R2, 11%), the related in-hospital mortality rate for 15 bilateral RA revascularizations (13%) was nearly twice that of 58 unilateral revascularizations (6.9%). Patients in group R2 were at a higher risk for postoperative dialysis than those in group R1 (36% vs 6.7%, P = .008), and patients in group R2 had longer lengths of stay in the hospital (median, 14 days vs 9 days; P = .004). By means of Kaplan-Meier analysis, the 5-year survival rate was lower for patients in group R2 (53%; 95% CI, 33%-73%) than for patients in group R1 (85%; 95% CI, 74%-96%; log rank P = .005). Despite all other liabilities in group R2 patients, however, their resistant hypertension was cured or improved in 88% of cases and their S(Cr) appeared to decline with time.

CONCLUSION

The early postoperative risk of simultaneous aortic/RA procedures appears to be highest in patients who have an elevated S(Cr), bilateral RA stenosis or occlusion, and a comparatively low long-term survival rate. In this particular group, the adjunctive use of endovascular techniques might conceivably reduce the magnitude of the planned surgical procedure and thus enhance the overall outcome.

A minimally invasive technique in occlusive disease of the superficial femoral artery: remote endarterectomy using the MollRing Cutter

Remote endarterectomy is a minimally invasive technique for revascularization that shortens hospital length of stay and reduces patient morbidity and mortality. With the use of the MollRing Cutter (Vascular Architects, Inc., San Jose, CA), a modification of the single ring stripper, the surgeon is able to cut the endoluminal atheroma core remotely from the site of entrance to the vessel. The surgical exposure for remote endarterectomy of the superficial femoral artery can thus be limited to a small, single groin incision.

Carotid endarterectomy with external shunt: a new device and indication for use: technical note

OBJECTIVE

We designed a new external shunt system and evaluated its indications and efficacy in patients undergoing carotid endarterectomy (CEA).

METHODS

In 8 of 332 CEA procedures, external shunts were placed between the common carotid artery and the internal carotid artery (ICA). This procedure was implemented for one of two indications: 1) a change in electroencephalographic and/or somatosensory evoked potential readings immediately after ICA occlusion, or 2) elongation of the ICA made safe insertion of an internal shunt impossible. In addition, a shunt was placed between the common carotid artery and the external carotid artery to establish collateral circulation from the external carotid artery to the intracranial circulation, which is essential during ICA occlusion.

RESULTS

All external shunts were functional, and electroencephalography and somatosensory evoked potentials demonstrated no significant abnormalities during the CEAs. All patients awoke from surgery without manifestation of new neurological deficits.

CONCLUSION

Our new external shunt device proved safe and efficacious in cases that did not permit the placement of an internal shunt.

Tourniquets in arterial bypass surgery

BACKGROUND

successful infra-popliteal bypass depends on precise, atraumatic technique in performing the distal anastomosis. The use of a tourniquet facilitates the distal anastomosis, reducing dissection, avoiding traumatising clamping of the vessels and providing an "uncluttered" operating field. Despite these advantages the technique is under-used.

OBJECTIVES

to review the use of tourniquets in arterial reconstruction, with particular reference to safety issues and complications. DESIGN, METHODS AND MATERIALS: a Medline search was performed (last search Feb. 2000), and keywords from relevant papers were used to perform subsequent searches. References were reviewed from each relevant paper.

RESULTS

no randomised controlled trials were found. The review details reported use of tourniquets in arterial reconstruction, including techniques, outcomes and potential complications.

CONCLUSION

the use of a tourniquet is a safe and effective technique to facilitate arterial reconstruction.

Which factors increase the risk of conversion to open surgery following endovascular abdominal aortic aneurysm repair? The EUROSTAR collaborators

OBJECTIVE

to identify factors that increase the risk of conversion to open surgery following endovascular repair of abdominal aortic aneurysms (AAAs) and to assess their outcome. Design analysis of 1871 patients enrolled in the EUROSTAR collaborators registry.

MATERIALS AND METHODS

patient characteristics, anatomic features of the aneurysm, type of endovascular device, institutional experience and the year in which the procedure was performed were related to risk of conversion.

RESULTS

forty-nine patients (2.6%) required conversion. In 38 patients conversion was performed during the first postoperative month (primary conversions) and in 11 patients during follow-up (secondary conversions). Primary conversion was mostly due to access problems and device migration. Secondary conversions were performed for rupture in six and for a persistent endoleak, with or without aneurysmal growth, in five patients. Patients who were converted were significantly older, had a lower body weight, and had a higher prevalence of chronic obstructive pulmonary disease. Conversion was associated with shorter, wider infrarenal necks and larger aneurysms. The conversion rate was lower when a team had performed more than 30 procedures, and in procedures performed during the last two years of the study period. The conversion rate was higher with EVT or Talent devices. Patients who required primary conversion had an 18% mortality rate, compared to 2.5% mortality in patients without conversion (p<0.01). Secondary conversion was associated with a perioperative mortality of 27%, and when performed for rupture 50%.

CONCLUSION

both primary conversion and secondary conversion for rupture carry a high operative mortality. Awareness of the risk factors may reduce conversion rate as well as early and medium term mortality.

Cervical carotid revascularization

The use of angioplasty and stent techniques for revascularization of the cervical carotid bifurcation has been limited. Carotid endarterectomy has been demonstrated to be safe and effective in two multicentered randomized trials. In patients who are considered at risk for excessive morbidity and mortality from open surgical revascularization, carotid endovascular revascularization provides a good alternative. This article outlines the indications, methods, complications and perioperative management of patients treated with balloon angioplasty and stent of the cervical carotid bifurcation.

The relative influence of lesion length and other stenosis morphologies on procedural success of coronary intervention

As coronary interventional technology improves, the influence of lesion length (LL) on procedural success and device selection may vary. Thus, the authors prospectively analyzed 957 consecutive coronary interventions (CI) in 1,404 stenoses to ascertain the influence of lesion length on CI outcome. Stenosis morphology was prospectively classified by the AHA/ACC criteria. LL was analyzed both as dichotomous (S: < 10 mm, L: > 10 mm) variables and by the three-tiered AHA/ACC criteria (I: < 10 mm, II: 10-20 mm, III: > 20 mm). There was a significant univariate relationship between CI success and S stenosis (S: 95.8% vs L: 91.8%, p = 0.002 and I: 96.0%, II: 91.7%, III: 89.3%). Numerous interrelationships involving the morphologic characteristics were noted: lesion morphologies associated with S lesions were concentric (p = 0.0001) and had smooth contour (p = 0.0001), ostial location (p = 0.05) and little calcification (p = 0.0007), while irregular contour (p=0.0001), calcification (p=0.0076), eccentric (p=0.0001), thrombus (p = 0.0001), recent (p = 0.0001) or chronic (p = 0.001) total occlusion were associated with L lesions. When these relationships were taken into account by multiple logistic regression analysis, lesion length was not predictive of procedural outcome (p = 0.099). One morphologic type was associated with increased CI success: irregular contour (p = 0.022); recent (p < 0.0001) or chronic (< 0.0001) occlusions were associated with decreased CI success. Another factor considered was device selection: S lesions were associated with greater balloon angioplasty usage (p = 0.002), whereas more coronary stents (p = 0.024) and rotoblator (p = 0.018) devices were used in L lesions. More balloon angioplasty was performed in concentric (p < 0.0001) lesions; interventional devices were employed more often in eccentric (p < 0.0001) and irregular lesions (p < 0.0001). More complications were noted in lesions with thrombus (p = 0.0002), but lesion length was not predictive (p = NS). Lesion length is not a significant predictor of procedural success when adjusted for other lesion morphologies in the modern interventional era. The availability of new devices has improved the results in longer lesions since the AHA/ACC criteria were originally proposed.