Totally percutaneous endovascular renal allograft salvage for common iliac artery pseudoaneurysm

Delayed presentation of recipient artery pseudoaneurysms following kidney transplantation is a rare, yet critical, complication. Although the precise etiology remains unclear, factors such as chronic steroid use, iatrogenic injuries (including vascular clamp damage during index surgery), or infections could contribute. Timely surgical intervention is imperative to prevent arterial rupture and life-threatening bleeding. Open repair, although commonly used, is associated with notable mortality rates and graft loss. Endovascular repair for delayed presentations of native iliac artery pseudoaneurysms has seen limited documentation in the literature. We present a case involving salvage of a kidney graft through innovative application of an endovascular technique using a modified stent graft with fenestration for the transplanted renal artery. The pseudoaneurysm, discovered 4 years after transplantation, was situated in proximity to the anastomosis site of the kidney graft's renal artery to recipient common iliac artery. Traditional open repair posed significant risks of graft loss due to its location near the kidney allograft. Our approach successfully resolved the issue, preserving graft function and resulting in a short length of hospital stay. This case contributes to the limited body of knowledge on delayed presentation of pseudoaneurysms after kidney transplantation. Successful application of an endovascular approach underscores its potential as a safe and effective alternative to open repair, offering favorable outcomes in terms of patient morbidity, mortality, and graft salvage.

Medulla and cervical cord contrast-induced encephalopathy detected by neuromonitoring during coil embolization of posterior circulation aneurysms

Understanding the risks of contrast-induced encephalopathy (CIE), a serious complication of contrast agents, is crucial in endovascular treatment. We present the case of a 73-year-old woman who developed CIE in the medulla and cervical cord during coil embolization for unruptured left basilar-superior cerebellar artery and basilar artery tip aneurysms. The CIE was identified via neuromonitoring. In this case, spinal cord ischemia might have occurred due to reduced perfusion pressure after inserting the distal access catheter (DAC) in the vertebral artery. Multiple injections of contrast medium via the DAC during coil embolization likely contributed to an unusual form of CIE. Extreme caution is warranted during endovascular treatments involving the posterior circulation, due to the relatively high incidence of contrast-mediated encephalopathy, which can lead to severe consequences such as perforator infarction. Neuromonitoring is very useful for the early detection of neurological changes, particularly because intraoperative angiography may not reveal all irregularities.

Intraoperative neuromonitoring as real-time diagnostic for cerebral ischemia in endovascular treatment of ruptured brain aneurysms

OBJECTIVE

To evaluate the diagnostic accuracy of intraoperative neurophysiological monitoring (IONM) during endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA).

METHODS

IONM and clinical data from 323 patients who underwent EVT for rIA from 2014-2019 were retrospectively reviewed. Significant IONM changes and outcomes were evaluated based on visual review of data and clinical documentation.

RESULTS

Of the 323 patients undergoing EVT, significant IONM changes were noted in 30 patients (9.29%) and 46 (14.24%) experienced postprocedural neurological deficits (PPND). 22 out of 30 (73.33%) patients who had significant IONM changes experienced PPND. Univariable analysis showed changes in somatosensory evoked potential (SSEP) and electroencephalogram (EEG) were associated with PPND (p-values: <0.001 and <0.001, retrospectively). Multivariable analysis showed that IONM changes were significantly associated with PPND (Odd ratio (OR) 20.18 (95%CI:7.40-55.03, p-value: <0.001)). Simultaneous changes in both IONM modalities had specificity of 98.9% (95% CI: 97.1%-99.7%). While sensitivity when either modality had a change was 47.8% (95% CI: 33.9%-62.0%) to predict PPND.

CONCLUSIONS

Significant IONM changes during EVT for rIA are associated with an increased risk of PPND.

SIGNIFICANCE

IONM can be used confidently as a real time neurophysiological diagnostic guide for impending neurological deficits during EVT treatment of rIA.

"TCAR or nothing": the only options for some complex carotid stenosis

Transcervical carotid artery revascularization has emerged as an alternative to carotid endarterectomy and transfemoral carotid artery stenting. We present four cases for which we believe transcervical carotid artery revascularization was the only option to treat the lesions. Each case presented with specific technical challenges that were overcome by intraoperative planning that allowed for safe deployment of the Enroute stent (Silk Road Medical) with resolution of each patient's stenosis.

Unruptured Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis of Mortality and Morbidity in Aruba-Eligible Studies

BACKGROUND

Treating unruptured brain arteriovenous malformations (bAVMs) represent significant challenges, with numerous uncertainties still in debate. The ARUBA trial induced further investigation into optimal management strategies for these lesions. Here, we present a systematic-review and meta-analysis focusing on ARUBA-eligible studies, aiming to correlate patient data with outcomes and discuss key aspects of these studies.

METHODS

Following PRISMA guidelines, we conducted a systematic-review. Variables analyzed included bAVM Spetzler-Martin (SM) grade, treatment modalities, and outcomes such as mortality and neurological deficits. We compared studies with a minimum of 50% cases classified as SM 1-2 lesions and those with less than 50% in this category. Similarly, a comparison between studies with at least 50% microsurgery-cases and those with less than 50% was performed. We examined correlations between mortality incidence, SM distribution, and treatment modalities.

RESULTS

Our analysis included 16 studies with 2.417 patients. The frequency of bAVMs SM-grade 1-2 ranged from 44% to 76%, SM-grade 3 from 19% to 48%, and SM 4-5 from 5 to 23%. Notably, studies with more than 50% cases presenting lesions SM-grade 1-2 presented significantly lower mortality rates than those with less than 50% cases of SM 1-2 lesions (P < 0.001). No significant difference in mortality rates or neurological deficits was identified between studies with more than 50% of microsurgery-cases and those with less than 50%.

CONCLUSIONS

The analysis revealed that studies with a higher proportion of bAVMs presenting SM 1-2 lesions were associated with lower mortality rates. Mortality did not show a significant association with treatment modalities.

Market competition influences practice patterns in management of patients with intermittent claudication in the vascular quality initiative

OBJECTIVE

The Society for Vascular Surgery (SVS) clinical practice guidelines recommend best medical therapy (BMT) as first-line therapy before offering revascularization to patients with intermittent claudication (IC). Notably, atherectomy and tibial-level interventions are generally discouraged for management of IC; however, high regional market competition may incentivize physicians to treat patients outside the scope of guideline-directed therapy. Therefore, we sought to determine the association between regional market competition and endovascular treatment of patients with IC.

METHODS

We examined patients with IC undergoing index endovascular peripheral vascular interventions (PVI) in the SVS Vascular Quality Initiative from 2010 to 2022. We assigned the Herfindahl-Hirschman Index as a measure of regional market competition and stratified centers into very high competition (VHC), high competition, moderate competition, and low competition cohorts. We defined BMT as preoperative documentation of being on antiplatelet medication, statin, nonsmoking status, and a recorded ankle-brachial index. We used logistic regression to evaluate the association of market competition with patient and procedural characteristics. A sensitivity analysis was performed in patients with isolated femoropopliteal disease matched by the TransAtlantic InterSociety classification of disease severity.

RESULTS

There were 24,669 PVIs that met the inclusion criteria. Patients with IC undergoing PVI were more likely to be on BMT when treated in higher market competition centers (odds ratio [OR], 1.07 per increase in competition quartile; 95% confidence interval [CI], 1.04-1.11; P < .0001). The probability of undergoing aortoiliac interventions decreased with increasing competition (OR, 0.84; 95% CI, 0.81-0.87; P < .0001), but there were higher odds of receiving tibial (OR, 1.40; 95% CI, 1.30-1.50; P < .0001) and multilevel interventions in VHC vs low competition centers (femoral + tibial OR, 1.10; 95% CI, 1.03-1.14; P = .001). Stenting decreased as competition increased (OR, 0.89; 95% CI, 0.87-0.92; P < .0001), whereas exposure to atherectomy increased with higher market competition (OR, 1.15; 95% CI, 1.11-1.19; P < .0001). When assessing patients undergoing single-artery femoropopliteal intervention for TransAtlantic InterSociety A or B lesions to account for disease severity, the odds of undergoing either balloon angioplasty (OR, 0.72; 95% CI, 0.625-0.840; P < .0001) or stenting only (OR, 0.84; 95% CI, 0.727-0.966; P < .0001) were lower in VHC centers. Similarly, the likelihood of receiving atherectomy remained significantly higher in VHC centers (OR, 1.6; 95% CI, 1.36-1.84; P < .0001).

CONCLUSIONS

High market competition was associated with more procedures among patients with claudication that are not consistent with guideline-directed therapy per the SVS clinical practice guidelines, including atherectomy and tibial-level interventions. This analysis demonstrates the susceptibility of care delivery to regional market competition and signifies a novel and undefined driver of PVI variation among patients with claudication.

Modified bare-back micro-retrograde tibial arterial access to facilitate peripheral endovascular therapy

Patients with critical limb threatening ischemia often present with complex segmental peripheral arterial chronic total occlusions, which might not be amenable to traditional antegrade revascularization techniques. For these patients, alternative retrograde revascularization techniques could be necessary. In the present report, we describe a novel modified retrograde cannulation technique using a bare back technique that eliminates the need for conventional tibial access sheath placement and, instead, facilitates distal arterial blood sampling, blood pressure monitoring, retrograde administration of contrast agents and vasoactive substances, and a rapid-exchange strategy. This cannulation strategy can serve as part of the armamentarium in the treatment of patients with complex peripheral arterial occlusions.

Parent artery occlusion for cerebral infarction after spontaneous recanalization in traumatic vertebral artery: A case report

Background

There is no established treatment strategy for traumatic vertebral artery occlusion that does not require cervical spine repair surgery.

Case Description

A 49-year-old man was brought to our hospital with traffic trauma. Fractures were observed in the left lateral mass and transverse process of Atlas and the left vertebral artery was occluded at the level of the foramen transversum of Atlas. No acute cerebral infarction was observed. Because the cervical spinal cord was not compressed by the fracture, no repair surgery was performed. Continuous intravenous heparin and oral aspirin were started for traumatic vertebral artery occlusion. Thereafter, the left vertebral artery spontaneously recanalized, but no cerebral infarction was observed. The patient was discharged home on day 16 of injury. Four days later, however, he was brought to our hospital with nausea and lightheadedness. Acute cerebral infarction was observed in the left posterior inferior cerebellar artery territory and a thrombus in the left vertebral artery V4 segment. Parent artery occlusion was performed to prevent further cerebral infarction due to distal embolization of the thrombus. No further cerebral infarction occurred after the operation and the patient was discharged home with a modified Rankin scale score of 1.

Conclusion

In cases of traumatic vertebral artery occlusion without an occlusive mechanism, parent artery occlusion may be considered in terms of recanalization risk, regardless of the need for repair surgery.

Diagnostic Accuracy of Somatosensory Evoked Potentials and EEG during Endovascular Treatment of Unruptured Cerebral Aneurysms

OBJECTIVE

Endovascular treatment (EVT) of unruptured cerebral aneurysms (UCA) offers a safer alternative to clipping. However, it is still associated with an increased risk for Post Procedural Neurological Deficits (PPND). Prompt recognition using intraoperative neurophysiologic monitoring (IONM) and intervention can reduce the incidence and impact of new post-operative neurological complications. We aim to evaluate the diagnostic accuracy of IONM in predicting PPND after EVT of UCA.

METHODS

We included 414 patients who underwent EVT for UCA from 2014 to 2019. The sensitivities, specificities, and diagnostic odds ratio of SSEP and EEG monitoring methods were calculated. We also determined their diagnostic accuracy using receiver operating characteristic (ROC) plots.

RESULTS

The highest sensitivity of 67.7% (95% CI, 34.9-90.1%) was obtained when either modality had a change. Simultaneous changes in both modalities have the highest specificity of 97.8% (95% CI, 95.8-99.0%). The area under the ROC curve was 0.795 (95% CI, 0.655-0.935) for changes in either modality.

CONCLUSIONS

IONM with SSEP alone or in combination with EEG has high diagnostic accuracy in detecting periprocedural complications and resultant PPND during EVT of UCA.

SIGNIFICANCE

IONM allows for confident and early intervention when obvious complications may not be evident to the endovascular professional.

The role of multimodal imaging in emergency vascular conditions: The journey from diagnosis to hybrid operating rooms

Multimodal imaging is the incorporation of two or more imaging modalities during the same examination, and it has both diagnostic and treatment applications. The use of image fusion for intraoperative guidance in endovascular interventions is being extended increasingly to the field of vascular surgery, especially in the context of hybrid operating rooms. The aim of this work was to perform a review and narrative synthesis of the available literature in order to report on current applications of multimodal imaging in diagnosis and treatment of emergent vascular conditions. Of 311 records selected in the initial search, 10 articles were included in the present review: 4 cohort studies and 6 case reports. The authors have presented their experience in treating ruptured abdominal aortic aneurysms; aortic dissections; traumas; standard endovascular aortic aneurysm repair, with or without deterioration of renal function; and complex endovascular aortic aneurysm repair, and reported on the long-term clinical results. Although the current literature about multimodal imaging application in emergency vascular conditions is limited, this review highlights the potential of image fusion in hybrid angio-surgical suites, especially for diagnosing and performing treatment in the same operating room, avoiding patient transfer, and allowing procedures with zero or low-dose contrast mean.

Remote training and evaluation of a simulator-based training course for complex endovascular procedures

Background

Intimate knowledge of the materials used in endovascular aortic interventions is essential for trainees and supporting staff taking part in an endovascular intervention. Training courses can help to familiarize trainees with the equipment. However, the pandemic has changed the landscape of hands-on training courses significantly. Therefore, we developed a training course including an educational recording of the procedure to transfer knowledge about the materials used during endovascular interventions and radiation exposure reduction.

Methods

We produced a video depicting cannulation of the left renal artery in a silicon cast of an aorta and its major side branches under C‑arm fluoroscopy. A presentation using the video was given to the trainees. The trainees were randomized into a control and an intervention group. Their performance was filmed and rated on a standardized five-point scale in the style of the OSATS global rating scale. The intervention group was remeasured after additional training time.

Results

In total, 23 trainees participated in the training and agreed to have their performance recorded. The control and intervention groups showed no difference in the assessed performance metrics during their initial attempt. However, after receiving additional training, the intervention group significantly improved in all evaluated metrics.

Conclusion

Our data add to the growing evidence that simulator-based training can help to increase trainees' understanding and performance of relevant skills. A standardized and evidence-based validation process for simulators could improve their acceptance in the medical field.

Remodeling of venous drainage after the treatment of dural sinus malformation with arteriovenous shunts in a neonate: a case report and literature review

Dural sinus malformations (DSMs) are rare congenital vascular diseases characterized by a giant venous pouch with or without arteriovenous shunts. We present a neonatal case of DSM that was diagnosed prenatally and treated via endovascular intervention in the early postnatal period. The patient presented with a large DSM involving the torcular Herophilion prenatal magnetic resonance imaging (MRI). Enlargement of the head circumference and respiratory failure rapidly progressed after birth. On the 5th day after birth, the neonate underwent endovascular occlusion via the umbilical artery. The arteriovenous shunt was occluded, and the reflux from the enlarged venous pouch to the dural sinus was decreased. No additional procedure other than ventriculoperitoneal shunting was required. The neonate's development slowly caught up to normal parameters. Follow-up MRI demonstrated the successful development of the venous drainage system. DSMs are characterized by an abnormally dilated dural sinus, which can block the venous return and ultimately increase intracranial pressure and cerebral ischemia. Long-term follow-up indicates that an abnormally developed dural sinus can be reconstructed by appropriate and timely treatment.

Factors related to high bifurcation level of common femoral artery

BACKGROUND

Common femoral artery (CFA) puncture is performed for endovascular treatment. However, we sometimes experience branch punctures when the CFA bifurcation level is high. In this study, we examined the frequency of high CFA bifurcation level and related factors.

METHODS

The CFA bifurcation level was identified in 100 patients, who underwent cerebral angiography or endovascular treatment by femoral artery (FA) puncture, on 191 sides. The height of the CFA bifurcation level was classified into three groups: normal, high, and very high. Age, gender, left-right difference, height, weight, body mass index, and comorbidities, including hypertension, dyslipidemia, and diabetes, were examined to determine the factors associated with high CFA bifurcation level.

RESULTS

The normal, high, and very high groups were on 142, 35, and 14 sides, respectively. The high and very high groups, which were defined as high CFA bifurcation levels, accounted for 25% of all patients. Multivariate analysis revealed that the proportion of patients with high CFA bifurcation levels was higher in the elderly (p = 0.009) and those with a history of diabetes (p = 0.042).

CONCLUSIONS

Approximately one-fourth of all patients undergoing cerebral angiography or endovascular treatment by FA puncture had high CFA bifurcation levels, which had a significant association with old age and history of diabetes. For urgent treatment, FA puncture might be performed at a higher level below the inguinal ligament if patients are elderly of those with a history of diabetes.

Applications of Vascular Imaging and Interventional Radiology Modalities in the Upper Extremity: A Review

Hand and upper extremity (HUE) vascular disorders are encountered frequently by hand surgeons in clinical practice. A wide array of imaging and vascular interventional radiology modalities exists for the diagnosis and treatment of HUE vascular disorders, some of which may not be familiar to the HUE surgeons. In this review article, we summarize the vascular imaging and vascular interventional radiology modalities and their relative advantages, disadvantages, and indications with respect to HUE pathology. We aim to familiarize HUE surgeons with the available types of diagnostic and therapeutic options for HUE vascular pathologies and aid interdisciplinary communication with vascular interventional radiology specialists during the clinical decision-making process.

Practice patterns surrounding the use of tibial interventions for claudication in the Medicare population

OBJECTIVE

At present, no data are available to support the use of tibial interventions in the treatment of claudication. We characterized the practice patterns surrounding tibial peripheral vascular interventions (PVIs) for patients with claudication in the United States.

METHODS

Using 100% Medicare fee-for-service claims from 2017 to 2019, we conducted a retrospective analysis of all patients who underwent an index PVI for claudication. Patients with any previous PVI, acute limb ischemia, or chronic limb-threatening ischemia in the preceding 12 months were excluded. The primary outcome was the receipt or delivery of tibial revascularization during an index PVI for claudication, defined as tibial PVI with or without concomitant femoropopliteal PVI. Univariable comparisons and multivariable hierarchical logistic regression were used to assess the patient and physician characteristics associated with the use of tibial PVI for claudication.

RESULTS

Of 59,930 Medicare patients who underwent an index PVI for claudication between 2017 and 2019, 16,594 (27.7%) underwent a tibial PVI (isolated tibial PVI, 38.5%; tibial PVI with concomitant femoropopliteal PVI, 61.5%). Of the 1542 physicians included in our analysis, the median physician-level tibial PVI rate was 20.0% (interquartile range, 9.1%-37.5%). Hierarchical logistic regression suggested that patient-level characteristics associated with tibial PVI for claudication included male sex (adjusted odds ratio [aOR], 1.23), increasing age (aOR, 1.30-1.96), Black race (aOR, 1.47), Hispanic ethnicity (aOR, 1.86), diabetes (aOR, 1.36), no history of hypertension (aOR, 1.12), and never-smoking status (aOR, 1.64; P < .05 for all). Physician-level characteristics associated with tibial PVI for claudication included early-career status (aOR, 2.97), practice location in the West (aOR, 1.75), high-volume PVI practice (aOR, 1.87), majority of practice in an ambulatory surgery center or office-based laboratory setting (aOR, 2.37), and physician specialty. The odds of vascular surgeons performing tibial PVI were significantly lower compared with radiologists (aOR, 2.98) and cardiologists (aOR, 1.67; P < .05 for all). The average Medicare reimbursement per patient was dramatically higher for physicians performing high rates of tibial PVI (quartile 4 vs quartile 1-3, $12,023.96 vs $692.31 per patient; P < .001).

CONCLUSIONS

Tibial PVI for claudication was performed more often by nonvascular surgeons in high-volume practices and high-reimbursement settings. Thus, a critical need exists to reevaluate the indications, education, and reimbursement policies surrounding these procedures.

Possible Contribution of the Aspiration Catheter in Preventing Post-stent Retriever Thrombectomy Subarachnoid Hemorrhage

PURPOSE

This study aimed to identify factors related to the incidence of post-thrombectomy subarachnoid hemorrhage (PTSAH).

METHODS

This retrospective, observational cohort study enrolled consecutive patients with acute ischemic stroke (AIS) due to the internal carotid artery (IC) top or middle cerebral artery (MCA) M1 or M2 segment occlusion who underwent single-pass stent retriever (SR) treatment between January 2015 and May 2022 at two acute care hospitals.

RESULTS

Of the 54 included patients, 10 were in the PTSAH group (18.5%). The occlusion sites were IC top (31.5%), M1 segment (48.1%), and M2 segment (20.4%). Aspiration catheters (ACs) were used in 32 (59.3%) patients; however, the combined technique (AC advancement at least to the most proximal marker of SR) was actually used in 26 (48.1%) patients because a ledge effect at the ophthalmic artery origin from the IC interfered with distal navigation of the ACs. The baseline patient characteristics did not differ between the groups. M2 segment occlusion in the PTSAH and non-PTSAH groups were 40.0% and 15.9%, respectively (p = 0.19). More ACs were used in the non-PTSAH group (65.9% vs. 30.0%, p = 0.07). Significantly fewer combined techniques were performed in the PTSAH group (10.0% vs. 56.8%, p = 0.01). In multivariate analysis adjusted by variables with M2 segment occlusion and the combined technique, the combined technique (odds ratio 0.098; 95% confidence interval, 0.011-0.887; p = 0.039) was identified as a significantly associated factor for PTSAH. There was one PTSAH case (1.9%) with symptom worsening.

CONCLUSION

The combined technique significantly influenced PTSAH occurrence as a preventive factor.

Three-year follow-up of aortic arch endovascular stent grafting with the Nexus device: results from a prospective multicentre study

OBJECTIVES

Endovascular aortic arch stent grafting with branched devices has shown initial promising results. The aim of this prospective, multicentre study was to evaluate 3-year outcomes of aortic arch stent grafting with NEXUS® Aortic Arch Stent Graft System (Nexus), a single-branch, bi-modular, off-the-shelf aortic arch stent graft system in high-risk patients.

METHODS

Patients treated with Nexus, either under the feasibility clinical study or as compassionate use procedures in 5 centres, were included in this study. The primary end point was overall survival. The secondary end points included the incidence of procedure-related unplanned intervention, stroke, paraplegia and endoleak. Clinical and radiologic follow-up was performed at each study site at 30 days, 6 months and on a yearly basis thereafter up to 3 years postoperatively.

RESULTS

We analysed data from a total of 28 patients. The overall median follow-up was 1132 (interquartile range: 809-1537). There were no device or procedure-related deaths between 1 and 3 years. Overall survival at 1 and 3 years was 89% and 71%, respectively. The cumulative incidence of unplanned reintervention at 1 and 3 years was 11% and 29%, respectively. There were no reports of stroke, paraplegia, aneurysm rupture, myocardial infarction or new aortic valve insufficiency. In this study's 1-3 year follow-up period, 1 type Ib (4%), 1 type II (4%) and 2 type III (8%; between Nexus' distal end and Thoracic endovascular aortic repair (TEVAR) extensions) endoleak were detected.

CONCLUSIONS

Endovascular aortic arch exclusion with the single-branch, off-the-shelf Nexus system provides promising clinical and radiologic results at 3-year follow-up in a high-risk patient cohort.

Association Between Type of Anaesthesia and Clinical Outcome in Patients Undergoing Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms by Fenestrated and Branched Endografts

OBJECTIVE

Although endovascular repair of thoraco-abdominal aortic aneurysm (TAAA) is the treatment of choice in the high risk population that is ineligible for an open surgical approach, little is known about the association between the type of anaesthesia and complications. This study compared the short term clinical outcomes of patients undergoing the visceral step of TAAA with fenestrated endograft aortic repair (FEVAR) and branched endograft aortic repair (BEVAR) under general anaesthesia (GA) with sedation with monitored care anaesthesia (MAC).

METHODS

This single centre, retrospective, observational study recruited 124 consecutive patients undergoing elective F/BEVAR from 2014 - 2021. The primary endpoint was the short term complication rate according to the type of anaesthesia. Secondary endpoints included: need for inotropes or vasopressors for hypotension, time spent in the operating room, and admission to the intensive care unit. Propensity score matching was generated to account for the between group imbalance in the pre-operative covariables.

RESULTS

After propensity score matching, 42 patients under GA were matched with 42 under MAC. The two groups showed no difference in cardiac and non-cardiac complications. Among the secondary outcomes, a higher number of patients in the GA group required inotropes or vasopressors compared with MAC (33% vs. 9%; p = .031). Although GA and MAC showed the same 30 day technical success (81% vs. 83%; p = .078), non-significant lower rates of major adverse events (10% vs. 12%; p = .72), one year re-intervention (14% vs. 21%; p = .39), and one year target vessel instability (10% vs. 21%; p = .39) were observed in the GA group. Overall, the in hospital mortality rate was 4%, with no difference between GA and MAC (2% vs. 5%; p = 1.0).

CONCLUSION

The type of anaesthesia seemed to have no effect on procedure success, peri-operative morbidity, or mortality in patients undergoing F/BEVAR.

Protected and Unprotected Radiation Exposure to the Eye Lens During Endovascular Procedures in Hybrid Operating Rooms

OBJECTIVE

Radiation cataract has been observed at lower doses than previously thought, therefore the annual limit for equivalent dose to the eye lens has been reduced from 150 to 20 mSv. This study evaluated radiation exposure to the eye lens of operators working in a hybrid operating room before and after implementation of a dose reduction program.

METHODS

From April to October 2019, radiation exposure to the first operator was measured during all consecutive endovascular procedures performed in the hybrid operating room using BeOSL H_p(3) eye lens dosimeters placed both outside and behind the lead glasses (0.75 mm lead equivalent). Measured values were compared with data from a historic control group from the same hospital before implementation of the dose reduction program.

RESULTS

A total of 181 consecutive patients underwent an endovascular procedure in the hybrid operating room. The median unprotected eye lens dose (outside lead glasses) of the main operator was 0.049 mSv for endovascular aortic repair (EVAR) (n = 30), 0.042 mSv for thoracic endovascular aortic repair (TEVAR) (n = 23), 0.175 mSv for complex aortic fenestrated or branched endovascular procedures (F/BEVAR; n = 15), and 0.042 mSv for peripheral interventions (n = 80). Compared with the control period, EVAR had 75% lower, TEVAR 79% lower, and F/BEVAR 55% lower radiation exposure to the unprotected eye lens of the first operator. The lead glasses led to a median reduction in the exposure to the eye lens by a factor of 3.4.

CONCLUSION

The implementation of a dose reduction program led to a relevant reduction in radiation exposure to the head and eye lens of the first operator in endovascular procedures. With optimum radiation protection measures, including a ceiling mounted shield and lead glasses, more than 440 EVARs, 280 TEVARs, or 128 FEVARs could be performed per year before the dose limit for the eye lens of 20 mSv was reached.

Treatment of Dissecting Vertebral Pseudoaneurysms: A Single-Center Experience

Background

Dissecting vertebral artery pseudoaneurysms represent a unique clinical challenge with careful appreciation for location of the posterior inferior cerebellar artery. Limited data is available in terms of outcomes regarding the various treatment modalities.

Methods

11 patients with dissecting pseudoaneurysms were identified from 2013-2021. Pseudoaneurysm size and morphology, clinical presentation, and treatment approach was collected. Success of treatment was recorded based on post-operative imaging as well as documented overall patient outcomes. Three primary treatment modalities emerged: coil embolization, stent assisted coiling, and flow diversion.

Results

Of the 11 patients, 5 were female and 6 were male with an age from 36 to 69.7. 7 had ruptured pseudoaneurysms at time of treatment. Size of pseudoaneurysm ranged from 3 to 6 mm. 8 were on the right and 3 were on the left vertebral artery. 8 were proximal to PICA and 3 were distal. Co-dominance of vertebral filling was seen in 5 patients, 5 with dominance through right vertebral artery, and 1 with dominance through left vertebral artery. Variability existed in treatment approaches with 4 patients undergoing coil occlusion, 5 patients undergoing flow diversion stenting, and 2 patients undergoing flow diversion stenting with jailed coiling. 1 patient had enlargement of pseudoaneurysm while inpatient and required a second flow diversion device. 1 patient had two flow diversion devices placed initially at time of treatment due to morphology of PA. 6 patients had repeat angiograms between 6 to 9 months with complete occlusion. 3 had CTA or MRA with complete occlusion for those that had flow diversion, they were transitioned from aspirin and clopidogrel to aspirin monotherapy after first repeat angiogram. 6 patients required shunt placement for hydrocephalus. 1 patient died prior to discharge due to sepsis. 2 patients died post discharge: 1 with myocardial infarction and the 2nd due to urosepsis.Dissecting vertebral pseudoaneurysm has high morbidity and mortality if rupture occurs. Location of PICA origin influences treatment approach. Patients with poor Hunt/Hess scores upon arrival had increased risk for systemic infection and mortality.

A Systematic Review of Simulation-Based Training in Vascular Surgery

Introduction

Recent advancements in surgical technology, reduced working hours, and training opportunities exacerbated by the COVID-19 pandemic have led to an increase in simulation-based training. Furthermore, a rise in endovascular procedures has led to a requirement for high-fidelity simulators that offer comprehensive feedback. This review aims to identify vascular surgery simulation models and assess their validity and levels of effectiveness (LoE) for each model in order to successfully implement them into current training curricula.

Methods

PubMed and EMBASE were searched on January 1, 2021, for full-text English studies on vascular surgery simulators. Eligible articles were given validity ratings based on Messick’s modern concept of validity alongside an LoE score according to McGaghie’s translational outcomes.

Results

Overall 76 eligible articles validated 34 vascular surgery simulators and training courses for open and endovascular procedures. High validity ratings were achieved across studies for: content (35), response processes (12), the internal structure (5), relations to other variables (57), and consequences (2). Only seven studies achieved an LoE greater than 3/5. Overall, ANGIO Mentor was the most highly validated and effective simulator and was the only simulator to achieve an LoE of 5/5.

Conclusions

Simulation-based training in vascular surgery is a continuously developing field with exciting future prospects, demonstrated by the vast number of models and training courses. To effectively integrate simulation models into current vascular surgery curricula and assessments, there is a need for studies to look at trainee skill retention over a longer period of time. A more detailed discussion on cost-effectiveness is also needed.

Characteristics and Management of Dilated Mastoid Emissary Veins: A Case Report and Literature Review

INTRODUCTION

The mastoid emissary vein (MEV) describes a transosseous connection between the sigmoid dural venous sinus and the suboccipital venous plexus. In cases of outflow stenosis or malformation, the MEV may become dilated and a source of pulsatile tinnitus (PT) amenable to treatment. We describe a case of PT secondary to MEV treated successfully via endovascular coil embolization and conduct a systematic review of the literature.

METHODS

We performed a systematic review without meta-analysis of studies involving management of dilated MEV on January 14, 2022, and describe a case of PT secondary to an enlarged MEV treated via coil embolization.

RESULTS

A total of 13 studies were selected for full review. Reports identified MEV presenting as PT in 60% (12 of 20) of cases, intraoperative hemorrhage in mastoid surgery in 15% (3 of 20), a compressive scalp mass in 10% (2 of 20), and thrombophlebitis, facial swelling, or an incidental finding in 5% (1 of 20) each. Forty-five percent (9 of 20) underwent treatment, with all experiencing symptom resolution or improvement. Surgery included transvenous coil embolization in 33.3% (3 of 9), flap reconstruction in 22.2% (2 of 9), and surgical packing, ligation, and thrombectomy in 11.1% (1 of 9) each. Dilated MEV was reported concurrently with impeded drainage pathways in 35% (7 of 20) of reports.

CONCLUSIONS

Dilated MEV has been reported as an etiology of pulsatile tinnitus and appears amenable to treatment via open and endovascular means. Endovascular coil embolization appears to offer effective symptom resolution, however, available literature exists only in case reports and small series. Further investigation is highly warranted.

Occupational Radiation Exposure Among General Surgery Residents: Should We Be Concerned?

BACKGROUND

Low-dose ionizing radiation exposure is associated with development of solid organ tumors as well as increased risk of cataract formation in a linear-dose response. While occupational radiation exposure has been studied across subspecialties with regular fluoroscopy exposure such as interventional radiology and urology, the contribution of increasing endovascular case volume to occupational radiation exposure among general surgery residents remains largely unreported. In this study, we sought to determine typical occupational radiation exposure among a pool of general surgery residents as part of a formal radiation safety curriculum.

METHODS

A radiation safety program was introduced to a group of 28 general surgery residents who rotate on a vascular surgery service with a high endovascular volume in a hybrid room setting. All residents received training in proper use of a radiation dosimeter and minimizing exposure during fluoroscopy times in the operating room. Data was collected from radiation film dosimetry badges distributed to general surgery residents on a bimonthly basis throughout the year, and radiation exposure in mRem was compared between residents rotating on vascular and nonvascular surgical services during 4-week rotations.

RESULTS

A total of 14 months of data were collected. Resident compliance was 84% with regular use and return of dosimeters at the end of each bimonthly cycle. The radiation exposure among residents rotating on vascular surgery was significantly higher compared to those on nonvascular rotations (mean = 71 mRem vs 3.13 mRem, p = 0.02). Exposure among senior residents was not statistically different than that of attending vascular surgeons (mean = 212 mRem vs 164 mRem, p = 0.20). All exposures were significantly lower than institutional ALARA dose limits for radiation exposure (5000 mRem/year).

CONCLUSION

General surgery residents are routinely exposed to measurable occupational radiation levels, especially while participating in endovascular procedures during their training. However, data from our study suggests that these levels are below ALARA dose limits and senior surgical residents are not at greater risk than vascular surgery attending surgeons while on their vascular rotation. The results of this study will be used to help guide resident education on radiation safety and identify institution-specific practices which can minimize exposure and improve radiation safety adherence.

Endovascular Treatment for Anterior Communicating Artery Aneurysms

Previously, anterior communicating artery aneurysms were considered unsuitable for endovascular treatment. In recent years, however, endovascular treatment has been increasingly performed due to the fact that it is less likely to cause high dysfunction compared to surgery and the treatment has been improved. The International Subarachnoid Aneurysm Trial reported anterior communicating artery aneurysms comprise 45.4% of cerebral aneurysms on which both endovascular treatment and surgery are suitable. The use of the endovascular treatment for anterior communicating artery aneurysms is expected to increase in the future. In this paper, we present cases from our institution based on the characteristics of anterior and distal communicating artery aneurysms, treatment strategies, and treatment indications.

Radiation-free Thoracic Endovascular Aneurysm Repair with Fiberoptic and Electromagnetic Guidance:A Phantom Study

PURPOSE

The purpose of this study was to evaluate the feasibility and accuracy of a radiation-free implantation of a thoracic aortic stent-graft employing fiberoptic and electromagnetic tracking in an anthropomorphic phantom.

MATERIALS AND METHODS

An anthropomorphic phantom was manufactured based on computed tomography angiography (CTA) data from a patient. An aortic stent-graft application system was equipped with a fiber Bragg gratings fiber and three electromagnetic sensors. The stent-graft was navigated in the phantom by three interventionalists using the tracking data generated by both technologies. One implantation procedure was performed. The technical success of the procedure was evaluated using digital subtraction angiography and pre- and post-interventional CTA. Tracking accuracy was determined at various anatomical landmarks based on separately acquired fluoroscopic images. The mean/maximum errors were measured for the stent-graft application system and the tip/end of the stent-graft.

RESULTS

The procedure resulted in technical success with a mean error below 3 mm for the entire application system and <2 mm for the position of the tip of the stent-graft. Navigation/implantation and handling of the device were rated sufficiently accurate and on a par with comparable, routinely used stent-graft application systems.

CONCLUSION

Our study demonstrates successful stent-graft implantation during a thoracic endovascular aortic repair procedure employing advanced guidance techniques and avoiding fluoroscopic imaging. This is an essential step in facilitating the implantation of stent-grafts and reducing the health risks associated with ionizing radiation during endovascular procedures.

A patient-specific proof of concept with a three-dimensionally printed model before performing an endovascular Bentall procedure

Three-dimensionally (3D) printed models have been increasingly used in medicine. Few reports have focused on prototype experiments, especially in aortic surgery. Although endovascular repairs are routinely performed for thoracoabdominal aortic aneurysms and lesions involving the aortic arch, endovascular treatment of the ascending aorta is still at an early stage of development. Using a 3D model, based on patient computed tomography scans and manufactured by Biomodex (Paris, France), we performed a patient-specific rehearsal of an endovascular Bentall repair to treat an ascending aorta aneurysm involving the aortic root. We achieved a patient-specific proof of concept of a new technique using an in vitro 3D model.

Clinical features and significance of leukopenia occurring immediately after endovascular surgery

PURPOSE

Inflammation after stent graft surgery is known as postimplantation syndrome (PIS) and it causes leukocytosis. However, we have experienced leukopenia in the very early postoperative phase of endovascular surgery at our institution. We investigated leukopenia, an under-recognized phenomenon that occurred after transcatheter aortic valve implantation (TAVI), endovascular aortic repair (EVAR), and thoracic endovascular aortic repair (TEVAR).

METHODS

Records of patients who underwent TAVI, EVAR, and TEVAR between March 2018 and February 2019 were retrospectively reviewed. Primary outcomes were the decline rate of white blood cell count (DR-WBC) in the immediate postoperative period and its differences among surgical procedures. The secondary endpoint was the relationship between DR-WBC and infectious complications. Furthermore, the incidence of PIS and its differences among the procedures and associations with DR-WBC were evaluated.

RESULTS

A total of 108 patients (TAVI 41, EVAR 37, TEVAR 30) were included. DR-WBC immediately after surgery was higher in the TAVI group when compared with other groups (TAVI, 43.1 ± 22.6%; EVAR, 27.6 ± 17.3%; TEVAR, 25.4 ± 27.4%; P < 0.01). DR-WBC was not significantly different regardless of postoperative infection (P = 0.45) or PIS (P = 0.62). The incidence rate of PIS was higher in the EVAR group compared with the TAVI group, and was not associated with DR-WBC.

CONCLUSIONS

Leukopenia was a common phenomenon immediately after endovascular surgery, especially TAVI. It resolved a day after surgery and was not associated with PIS or infectious complications. Therefore, it seems to be a transient abnormal hematological finding and a self-limiting condition.

Endovascular management of a complex high-flow lower limb arteriovenous malformation: Case report and literature review

INTRODUCTION

Lower limb high-flow arteriovenous malformations (AVM) are a rare pathology with a chronic and progressive evolution. Development in imaging and treatment has helped to improve outcome.

OBJECTIVE

We report a case treated with multi-session endovascular embolization therapy with favorable results.

CASE REPORT

A 44-year-old man referred with a complex high-flow lower limb AVM, previously treated with covered stents and a bypass. Six endovascular interventions were performed, combining different embolization methods.

CONCLUSION

Endovascular treatment is a safe and effective option for high-flow AVMs. Embolization should be done carefully to prevent complications that could threaten the patient's limb or life.

Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature

Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.

Closure device use for common femoral artery antegrade access is higher risk than retrograde access

OBJECTIVE

Although the use of closure devices (CD) for femoral artery antegrade access (AA) is not in the instructions for use (IFU) for many devices, AA has been reported to be associated with a lower incidence of access site complications compared to manual compression alone. We hypothesized that CD use for AA would not be associated with a clinically significant increased odds of access site complications compared to CD use for retrograde access (RA).

METHODS

This was a retrospective review of the Vascular Quality Initiative from 2010 to 2019 for infrainguinal peripheral vascular interventions with common femoral artery access closed with a CD. Patients who had a cutdown or multiple access sites were excluded. Cases were then stratified into whether access was antegrade or retrograde. Hierarchical multivariable logistic regressions controlling for hospital level variation were used to examine the independent association between AA and access site complications. The primary outcomes were access site hematoma, stenosis, or occlusion as defined in the VQI. The secondary outcome was the development of an access site hematoma requiring an intervention, which was defined as transfusion, thrombin injection, or surgery. Sensitivity analyses after coarsened exact matching were performed to reduce residual bias.

RESULTS

Overall, 72,463 cases were identified and 6,070 (8.4%) had AA. Patients with AA were less likely to be smokers (27.2% vs 33.0%) or obese (31.5% vs 35.6%; all P<0.05). Patients with AA were more likely to be on dialysis (12.8% vs 10.1%) and have ultrasound-guided access (76.4% vs 66.2%; P<0.05 for all). Compared to RA, patients with AA were more likely to develop any access site hematoma (2.5% vs 1.8%; P<0.01) and a hematoma requiring intervention (0.7% vs 0.5%; P=0.03), but had no difference in access site stenosis or occlusion (0.3% vs 0.2%; P=0.21). On multivariable analyses, AA had increased odds of developing any access site hematoma (OR=1.46; 95% CI=1.22-1.76) and a hematoma requiring intervention (OR=1.48; 95% CI=1.10-1.98). Sensitivity analyses after coarsened exact matching confirmed these findings.

CONCLUSION

In this nationally representative sample, the use of CDs for femoral access was associated with an overall low rate of access site complications. However, there was an increased odds of access site hematomas with AA. Patient selection for AA remains important and ultrasound guided access should be the standard of care for this approach.

Impact of radiation to the eye of operators during endo-cardiovascular surgery and the importance of protection

OBJECTIVE

To verify the amount of radiation exposure to the eye of operators during endocardiovascular surgery (ECVS) in hybrid operating room (HOR), which increases the risk of cataracts in surgeons.

METHODS

Fifty cases of ECVS (including 36 transcatheter aortic valve implantation and 14 thoracic endovascular repair) using the transfemoral approach performed from February 2020 to July 2020 were included. A measurement device was attached to the left side of the head of the operators and their assistants to measure the cumulative dose (CD) of intraoperative radiation exposure. The subjects were divided into the control group (Group C, n = 26), received conventional protection using the protective curtain in HOR and the protected group (Group R, n = 24), received conventional protection and protection sheet. The normalized CD by dose area product (CD/DAP) was evaluated.

RESULTS

The CD/DAP of the surgeons was significantly decreased in Group R, averaging at 5.97 μSV/Gy cm² in Group C group and 4.40 μSV/Gy cm² in Group R (p < 0.01). Moreover, CD/DAP of the assistant was significantly reduced in the Group R, with an average of 1.87 μSV/Gy cm² in the Group C and 1.01 μSV/Gy cm² in Group R (p < 0.01).

CONCLUSIONS

The radiation exposure to the surgeon's eye could be significantly reduced by protection sheet.

Surgeon-modified fenestrated endovascular aortic repair for ruptured anastomotic aneurysm after open thoracoabdominal repair

We report the case of a 60-year-old female patient with a contained rupture of a proximal anastomotic pseudoaneurysm after previous open repair of a type IV thoracoabdominal aneurysm. A repeat open repair was considered to be too risky. We performed an urgent endovascular repair with a thoracic stent-graft and a surgeon-modified fenestrated aortic cuff with two fenestrations. The final angiogram and postoperative imaging studies showed complete aneurysm exclusion without any endoleak. Surgeon-modified fenestrated endovascular aortic repair is a feasible treatment option for emergency cases for which repeat open repair or custom-made complex endovascular repair is not an option.

Impact of Physician Volume and Specialty on In-Hospital Mortality of Ischemic and Hemorrhagic Stroke

BACKGROUND

The degree of association between mortality and case volume/physician volume is well known for many surgical procedures and medical conditions. However, the link between physician volume and death rate in patients hospitalized for stroke remains unclear. This study analyzed the correlation between in-hospital stroke mortality and physician volume per hospital, considering board certification status.Methods and Results:For this retrospective registry-based cohort study, data were obtained from the Japanese nationwide registry on patients hospitalized for ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) between 2010 and 2016. The number of stroke care physicians and relevant board-certified physicians was also obtained. Odd ratios (ORs) of 30-day in-hospital mortality were estimated after adjusting for institutional and patient differences using generalized mixed logistic regression. From 295,150 (ischemic stroke), 98,657 (ICH), and 36,174 (SAH) patients, 30-day in-hospital mortality rates were 4.4%, 16.0%, and 26.6%, respectively. There was a correlation between case volume and physician volume. A higher number of stroke care physicians was associated with a reduction in 30-day mortality after adjusting for stroke case volume and comorbidities for all stroke types (all P for trend<0.05).

CONCLUSIONS

An increased number of stroke care physicians was associated with reduced in-hospital mortality for all types of stroke. The volume threshold of board-certified physicians depends on the specialty and stroke type.

Ruptured Aneurysm of the Common Iliac Artery Caused by Brucella melitensis: A Case Report

Introduction

Brucella is a genus of aerobic Gram negative bacteria that causes the disease brucellosis. It is considered a zoonotic infection transmitted to humans by ingestion of unpasteurised dairy products. Although aortic involvement is rarely seen, it can be a life threatening complication of this disease. This case report describes a ruptured aneurysm of the common iliac artery (CIA) due to secondary infection by Brucella melitensis.

Report

A 79 year old man with a known isolated aneurysm of the CIA presented with acute abdominal pain. Contrast enhanced computed tomography (CT) revealed rupture of the aneurysm. The patient underwent prompt endovascular repair. Several weeks after an uneventful recovery, the patient presented with spiking fever and abdominal discomfort. CT revealed an abscess anterior to the CIA. Blood and pus cultures grew B. melitensis. In recurrent re-admissions, conservative antibiotic therapy proved to be insufficient. Eventually, neo-aorto-iliac system (NAIS) reconstruction using bilateral femoral veins was performed to provide definitive treatment four months after initial presentation.

Conclusion

Although Brucella infected aneurysms are rare, they are associated with life threatening disease. Diagnosing this type of brucellar infection can be challenging owing to the long incubation time needed for blood and tissue cultures. Definitive treatment of these aneurysms often needs open surgery and antibiotics for complete treatment. Vigilant surveillance is required to monitor for post-operative complications such as graft infection, recurrent (false) aneurysm, and abscess formation.

•

Brucella species are a genus of aerobic Gram negative bacteria.

•

Infected aneurysms caused by Brucella species are rare.

•

Although rare, this clinical condition is associated with life threatening disease.

•

Treatment consists of open surgery combined with antibiotic therapy.

•

Endovascular procedures can be used as bridge to surgery or as palliative therapy.

Retinal emboli after cervicopetrous junction internal carotid artery pseudoaneurysm stenting

Purpose

To describe acute and chronic retinal ischemic changes following an internal carotid artery pseudoaneurysm stenting procedure, and to review current evidence for risk factors and management of post-procedural retinal ischemic events.

Observation

A 50-year-old man presented with a 3-month history of pulsatile tinnitus, headache, and intermittent blurry vision. A CT angiogram of head and neck showed bilateral cervicopetrous internal carotid artery (ICA) pseudoaneurysms. The patient underwent successful repair with angioplasty and stenting of the flow-limiting high-grade (>95%) stenosis of his left high cervical ICA. On post-operative day 1, the patient reported monocular vision loss with a large central scotoma. He was found to have a central macular area of retinal whitening and multiple areas of perivascular retinal whitening on exam, concerning for retinal artery occlusions secondary to peri-procedural emboli. Dual antiplatelet therapy was started and a stroke evaluation was performed. Two months later, his visual acuity in the affected eye was counting fingers and his left eye fundus examination was notable for multiple areas of scattered hemorrhages, microaneurysms, and retinal exudates in the distribution of prior retinal ischemia. OCT imaging revealed atrophic changes in the left macula. Subsequently, the patient completed stage-2 repair of the left ICA pseudoaneurysm followed by uncomplicated repair of the right ICA. Four months later, his left eye visual acuity and retinal findings remained stable.

Conclusions and Importance

Post-procedure retinal emboli and ischemia are important, vision threatening possible ocular complications for patients undergoing carotid vascular and endovascular procedures.

Outcomes after clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage among dual-eligible beneficiaries

Dual-eligible beneficiaries, individuals with both Medicare and Medicaid coverage, represent a high-cost and vulnerable population; however, literature regarding outcomes is sparse. We characterized outcomes in dual-eligible beneficiaries treated for aneurysmal subarachnoid hemorrhage (aSAH) compared to Medicare only, Medicaid only, private insurance, and self-pay. A 10-year cross-sectional study of the National Inpatient Sample was conducted. Adult aSAH emergency admissions treated by neurosurgical clipping or endovascular coiling were included. Multivariable regression was used to adjust for confounders. A total of 57,666 patients met inclusion criteria. Dual-eligibles comprised 2.8% of admissions and were on average younger (62.4 years) than Medicare (70.0 years), older than all other groups, and had higher mean National Inpatient Sample-Subarachnoid Hemorrhage Severity Scores than all other groups (p ≤ 0.001). Among patients treated by clipping, dual-eligibles were less often discharged to home compared to Medicare (adjusted odds ratio (aOR) = 0.51, 95% CI = 0.30-0.87, p < 0.05) and all other insurance groups, p < 0.01. Likewise, those who received coiling were less often discharged to home compared to Medicaid (aOR = 0.41, 95% CI = 0.23-0.73), private (aOR = 0.42, 95% CI = 0.23-0.76) and self-pay patients (aOR = 0.24, 95% CI = 0.12-0.46). They also had increased odds of poor National Inpatient Sample-Subarachnoid Hemorrhage Outcome Measures compared to Medicaid, private, and self-pay patients, all p < 0.05. There were no differences in inpatient mortality or total complications. In conclusion, dual-eligible patients had higher aSAH severity scores, less often discharged home, and among patients who received coiling, dual-eligibles had increased odds of poor outcome. Dual-eligible patients with aSAH represent a vulnerable population that may benefit from targeted clinical and public policy initiatives.

Intraoperative posture and workload assessment in vascular surgery

Quantifying the workload and postural demand on vascular surgeons provides valuable information on the physical and cognitive factors that predispose vascular surgeons to musculoskeletal pain and disorders. The aim of this study was to quantify the postural demand, workload, and discomfort experienced by vascular surgeons and to identify procedural factors that influence surgical workload. Both objective (wearable posture sensors) and subjective (surveys) assessment tools were used to evaluate intraoperative workload during 47 vascular surgery procedures. Results demonstrate unfavorable neck and low back postures as well as high pain scores for those body segments. Additionally, workload from subjective surveys increased significantly as a function of operative duration, and mental workload was high across all procedure types. Neck postural risk exposure and physical demand were among the variables that increased with surgical duration, procedure type, and loupes used by the surgeons. Correlations among postural angles and pain scores showed consistency between the objective assessment and the subjective surveys for neck and trunk. The authors believe that the results of this study highlight the need for developing mitigating measures such as ergonomic interventions for vascular surgery.

Impact of network performance on remote robotic-assisted endovascular interventions in porcine model

Remote robotic-assisted endovascular interventions require real-time control of the robotic system to conduct precise device navigation. The delay (latency) between the input command and the catheter response can be affected by factors such as network speed and distance. This study evaluated the effect of network latency on robotic-assisted endovascular navigation in three vascular beds using in-vivo experimental model. Three operators performed femoral, carotid, and coronary endovascular robotic navigation blinded from the hybrid room with the prototype remote-enabled CorPath GRX system in a porcine model. Navigation was performed to different targets with randomly assigned network latencies from 0 to 1000 ms. Outcome measurements included navigation success, navigation time, perceived lag (1 = imperceptible, 5 = too long), and procedural impact scored by the operators (1 = no impact, 5 = unacceptable). Robotic-assisted remote endovascular navigation was successful in all 65 cases (9 femoral, 38 external carotid, 18 coronary). Guidewire times were not significantly different across the simulated network latency times. Compared to 0 ms added latency, both the procedural impact and perceived lag scores were significantly higher when the added latency was 400 ms or greater (< 0.01). Remote endovascular intervention was feasible in all studied anatomic regions. Network latency of 400 ms or above is perceptible, although acceptable to operators, which suggests that remote robotic-assisted femoral, carotid or coronary arterial interventions should be performed with network latency below 400 ms to provide seamless remote device control.

Endovascular and surgical approaches of iatrogenic vertebrovertebral arteriovenous fistula

Vertebrovertebral arteriovenous fistula is an uncommon vascular disease with no clear management guidelines. It is most commonly caused by iatrogenic injury. We have presented the details of two iatrogenic cases and a review to discuss strategies for endovascular and surgical approaches. From the digital subtraction angiography findings, the vertebrovertebral arteriovenous fistulas were occluded by endovascular coil positioning (patient 1) and surgical ligation of the fistulas (patient 2). Although endovascular approaches are increasing in popularity and considered well-tolerated treatments, open surgical treatment is still reserved for the most complex cases and those not feasible for endovascular treatment.

A systematic review of the effect of surgeon and hospital volume on survival in aortic, thoracic and fenestrated endovascular aneurysm repair

BACKGROUND

Endovascular aneurysm repair (EVAR) is becoming a mainstay in vascular surgery, both in metropolitan and regional hospitals. This review aims to assess the impact of hospital and surgeon volume on perioperative mortality specific to this surgery type to support the use of this treatment modality extensively.

METHODS

A literature search was performed on multiple dedicated medical databases using a detailed search strategy with terms focusing on hospital volume and EVARs. Inclusion and exclusion criteria were used to screen and evaluate suitable sources, focusing on operators and hospitals performing EVARs and the morbidity/mortality as outcomes. The results were then appraised using a PRISMA framework.

RESULTS

We reviewed 45 articles. Twelve articles met inclusion criteria for complete review. There was no level 1 evidence, and only a single systematic review and meta-analysis. EVAR and thoracic EVAR perioperative mortality had no correlation with hospital volume. Limited evidence was presented for fenestrated EVAR, where a mortality risk based on hospital volume remains unanswered. Open procedures for aneurysm repair had perioperative mortality outcomes that grossly correlated with hospital volume, supporting their use in high-volume centers.

CONCLUSIONS

With open aneurysm repairs having an increased mortality risk in low-volume centers, and endovascular treatment options gaining momentum, there is considerable support for the use of EVAR and thoracic EVAR in smaller regional centers safely and effectively. There is very limited evidence in the use of fenestrated EVAR, which remains unanswered, but presents a significant opportunity for research.

The experience of surgery and endovascular procedure of cerebrovascular disease in the hybrid operating room; Multi-axis robotic C-arm DSA system

Objective

To report on combined surgical and/or endovascular procedures for cerebrovascular disease in a hybrid operating room (OR).

Methods

Between October 2016 and June 2020, 1832 neurosurgical procedures were performed in a hybrid OR. Our institution’s hybrid OR consists of a multi-axis robotic C-arm monoplane digital subtraction angiography (DSA) system with an operating table, 3D-rotational DSA, cone-beam computed tomography (dyna CT), and real-time navigation software. Procedures were categorized into six categories according to purpose: (1) simple diagnosis and follow-up, (2) simple endovascular procedure, (3) combination of surgery and endovascular procedures, (4) rescue surgery after endovascular procedures, (5) frameless stereotactic procedure, and (6) other surgeries requiring C-arm.

Results

Of 1832 neurosurgical procedures in the hybrid OR, 1430 were simple diagnosis and follow-up cases, 330 simple endovascular procedures, 8 combination of surgery and endovascular procedures, 15 rescue after endovascular procedure, 40 frameless stereotactic procedures, and 9 other surgeries. Eight cases of combination of surgery and endovascular procedures, safely performed without wasting time on patient transfer, were performed in seven bypass end endovascular procedures and one case of bow-hunter syndrome in complex cerebrovascular disease. After embolization, craniotomy (or craniectomy) and intracerebral hemorrhage removal were performed in eight patients in-situ. Of the 40 frameless stereotactic procedure, 37 were extraventricular drainage before/after coil embolization in subarachnoid hemorrhage patients. They all mounted conduits in their planned locations.

Conclusions

A hybrid OR for combined endovascular and surgical procedures represents a safe and useful strategy for cerebrovascular disease. In hybrid ORs various neurosurgical procedures can be safely and conveniently performed. Hybrid OR will pioneer a new era in neurosurgical procedures.

First in Human Clinical Feasibility Study of Endovascular Navigation with Fiber Optic RealShape (FORS) Technology

OBJECTIVE

Endovascular procedures are conventionally conducted using two dimensional fluoroscopy. A new technology platform, Fiber Optic RealShape (FORS), has recently been introduced allowing real time, three dimensional visualisation of endovascular devices using fiberoptic technology. It functions as an add on to conventional fluoroscopy and may facilitate endovascular procedures. This first in human study assessed the feasibility of FORS in clinical practice.

METHODS

A prospective cohort feasibility study was performed between July and December 2018. Patients undergoing (regular or complex) endovascular aortic repair (EVAR) or endovascular peripheral lesion repair (EVPLR) were recruited. FORS guidance was used exclusively during navigational tasks such as target vessel catheterisation or crossing of stenotic lesions. Three types of FORS enabled devices were available: a flexible guidewire, a Cobra-2 catheter, and a Berenstein catheter. Devices were chosen at the physician's discretion and could comprise any combination of FORS and non-FORS devices. The primary study endpoint was technical success of the navigational tasks using FORS enabled devices. Secondary study endpoints were user experience and fluoroscopy time.

RESULTS

The study enrolled 22 patients: 14 EVAR and eight EVPLR patients. Owing to a technical issue during start up, the FORS system could not be used in one EVAR. The remaining 21 procedures proceeded without device or technology related complications and involved 66 navigational tasks. In 60 tasks (90.9%), technical success was achieved using at least one FORS enabled device. Users rated FORS based image guidance "better than standard guidance" in 16 of 21 and "equal to standard guidance" in five of 21 procedures. Fluoroscopy time ranged from 0.0 to 52.2 min. Several tasks were completed without or with only minimal X-ray use.

CONCLUSION

Real time navigation using FORS technology is safe and feasible in abdominal and peripheral endovascular procedures. FORS has the potential to improve intra-operative image guidance. Comparative studies are needed to assess these benefits and potential radiation reduction.

Endovascular surgery in the field of ophthalmology

In this article, we provide an overview of the current perspectives on endovascular surgery in ophthalmology, including a description of the various approaches, recent clinical results and future prospects. Experimental studies of endovascular surgery in ophthalmology started in the 1980s; since then, a considerable amount of research has been done to develop the procedure for clinical use. During the past two decades endovascular surgery has been performed on eyes with retinal vascular disorders, including central retinal vein occlusion and central retinal artery occlusion. The first endovascular surgery on human eyes was performed in 1998 on a patient with central retinal vein occlusion (CRVO). The most recent techniques used in retinal endovascular surgery involve manual injection of liquid agents such as tissue plasminogen activator into major retinal vessels using a 47 or 48-gauge micro-needle. New technology using a bimanual procedure and digitally assisted vitrectomy systems enables surgeons to perform this delicate procedure more effectively. Recent results reported from a number of researchers corroborate the effectiveness of the procedure. Endovascular surgery is one of the latest techniques in the field of ophthalmology and has garnered significant interest from vitreoretinal surgeons. However, it is also at the limit of what surgeons are able to accomplish with manual precision. There is still much to learn and improve to maximize the potential of this approach. The combination of skills as a surgeon, sound science, objective clinical evidence and cutting edge technology will lead to improvements in this field.

Microsurgical or endovascular strategy for complete obliteration of spinal arteriovenous shunts in a single-institute 10-year retrospective study

The objective of this retrospective study is to more fully understand the optimal strategy to manage spinal arteriovenous (AV) shunts. This study included a cohort of 35 patients with a diagnosis of spinal AV shunts who were treated over the past 10 years at a single institute. Angiographic diagnosis of intramedullary AV malformations (IM-AVM), perimedullary AV fistulas (PM-AVF), dural AV fistulas (D-AVF), or epidural AV fistulas (ED-AVF) was carefully made, and the microsurgical or endovascular strategy for them was determined at the interdisciplinary meeting consisting of neurospinal surgeons and endovascular specialists. Endovascular surgery was first considered whenever safely possible. Microscopic direct surgery using intraoperative image guidance was considered for cases in which endovascular access was challenging or not safely possible. Combined treatment was another option. The clinical condition was assessed using the modified Rankin scale (mRS). Seventeen of 35 cases were treated with microscopic direct surgery, 13 cases with endovascular surgery, and the remaining five cases with the combination. Complete angiographic obliteration was achieved in 30 of 35 cases (85.7%). Although residual AV shunts was recognized in 3 cases of IM-AVM, 1 case of PM-AVF and 1 case of ED-AVF, no angiographic recurrence was present with an average postoperative follow-up period of 44 months. The average mRS before surgery was 2.37 and significantly improved to 1.94 at the most recent follow-up. Interdisciplinary collaboration between neurospinal surgeons and endovascular specialists should be standard to achieve safe and successful outcomes in treating such rare and difficult spinal disorders.

A retrospective comparison of thrombectomy followed by stenting and thrombectomy alone for the management of deep vein thrombosis with May-Thurner syndrome

OBJECTIVE

To summarize the clinical results of thrombectomy with stenting (TBS) in patients with deep venous thrombosis (DVT) secondary to May-Thurner syndrome (MTS) compared with the outcomes in patients treated with thrombectomy alone (TB).

METHODS

A retrospective observation of patients with proximal DVT secondary to MTS was conducted in our institution. Patients accepted treatment including either catheter-directed TBS or TB. The complications and stent patency rates were recorded after treatments. The clinical results were assessed in both groups. The independent predictors for in-stent restenosis were further calculated in this study.

RESULTS

We included 372 patients with DVT secondary to MTS. Two hundred twenty-one patients received treatment with thrombectomy with TBS and 151 with TB. A longer mean procedure time (65.1 ± 13.9 minutes vs 49.5 ± 15.7 minutes; P < .001) and higher venous perforation rate (23 patients vs 5 patients; P = .011) were observed in the TBS group than in the TB group. The median follow-up time was 34 months. The patency rates in the TBS group at 36 months were as follows: primary patency rate of 74.0% and secondary patency rate of 92.1%. Independent predictors for restenosis included visible remaining collateral vessels (hazard ratio [HR], 1.12-3.29; P = .02), residual thrombus (HR, 1.40-4.38; P = .002), and tapered iliac vein (HR, 1.26-4.06; P = .006). Clinical results, including Venous Clinical Severity Scores (TBS, 8.0 ± 3.0; TB, 11.4 ± 3.2), Chronic Venous Insufficiency Questionnaire score (TBS, 76.4 ± 4.0; TB, 83.1 ± 4.6), Villalta scores (TBS, 3.8 ± 1.7; TB, 6.6 ± 3.2), and edema scores (TBS, 0.7 ± 0.7; TB, 1.6 ± 0.6), improved significantly in the TBS group.

CONCLUSIONS

TBS is effective and feasible for patients with proximal DVT secondary to MTS. Furthermore, compared with TB, additional stenting might be effective in improving the venous clinical results at follow-up observations.

[Occlusion of the abdominal aorta in patients infected with the human immunodeficiency virus: Clinical case and review of the literature]

HIV infection has now become a chronic disease with a good life expectancy thanks to antiretrovirals. The mortality currently is attributed to other pathologies in particular cardiovascular because of the inflammation and the side effects of the drugs. All arteries can be damaged in HIV, especially the aorta, with several types of lesions which can be occlusive, aneurysmal, dissecting, even with the cases of arteriovenous fistula which have been described. HIV occlusive arterial disease is different from atheromatous disease in HIV-free patients and this is confirmed by pathology and ultrasound studies, which makes it more difficult to manage HIV-related occlusions. The open surgical treatment especially in the acute forms is disappointing with complications of rethrombosis and infectious and of sepsis of prosthesis considering the immunosuppression, the endovascular treatment begins to become the treatment of choice in the aneurysmal pathology and probably it would be in the future for occlusive disease.

Management of unruptured intracranial aneurysms: correlation of UIATS, ELAPSS, and PHASES with referral center practice

Concordance between the Unruptured Intracranial Aneurysm Treatment Score (UIATS), Earlier Subarachnoid Hemorrhage, Location, Age, Population, Size, Shape (ELAPSS) score, and Population, Hypertension, Age, Size, Earlier Subarachnoid Hemorrhage, Site (PHASES) score with real-world management decisions in unruptured intracranial aneurysms (UIAs) remains unclear, especially in current practice. This study aimed to investigate this concordance, while developing an optimal model predictive of recent decision practices at a quaternary referral center. A prospective database of patients presenting with UIAs to our institution from January 1 to December 31, 2018, was used. Concordance between the scores and real-world management decisions on every UIA was assessed. Complications and length of stay (LOS) were compared between aneurysms in the UIATS-recommended treatment and observation groups. A subgroup analysis of concordance was also conducted among junior and senior surgeons. An optimal logistic regression model predictive of real-world decisions was also derived. The cohort consisted of 198 patients with 271 UIAs, of which 42% were treated. The UIATS demonstrated good concordance with an AUC of 0.765. Of the aneurysms in the UIATS-recommended "observation" group, 22% were discordantly treated. The ELAPSS score demonstrated good discrimination (AUC = 0.793), unlike the PHASES score (AUC = 0.579). Endovascular treatment rates, complications, and LOS were similar between aneurysms in the UIATS-recommended treatment and observation groups. Similar concordance was obtained among junior and senior surgeons. The optimal predictive model consisted of several significantly associated variables and had an AUC of 0.942. Cerebrovascular specialists may be treating aneurysms slightly more than these scores would recommend, independently of years in practice. Wide variation still exists in management practices of UIAs.

Risk of fatal sinus arrest induced by low-grade subarachnoid hemorrhage: A case of a young patient with obstructive sleep apnea

Background

Sleep apnea syndrome (SAS) and subarachnoid hemorrhage (SAH) are both considered possible causes of secondary arrhythmias. However, there are limited reports on the increased risk of bradyarrhythmia for arrhythmia-free SAS patients with SAH.

Case Description

A 31-year-old woman with SAS developed low-grade SAH and underwent coil embolization on postbleed day 1. Following a coiling procedure, she experienced worsening episodes of sinus arrest lasting up to 12 s and required a temporary pacemaker. Frequent episodes of sinus arrest were detected for the next 4 days. Thereafter, all types of arrhythmias gradually decreased, and she eventually recovered to be arrhythmia free.

Conclusion

Acceleration of sympathetic nervous activity caused by acute SAH may predispose patients to bradyarrhythmia with SAS and elicit asystole. The coexistence of SAS and SAH should be recognized as a cause of life-threatening sinus arrest, even if the severity of SAH is low grade.

Amputation-free survival in patients with diabetic foot ulcer and peripheral arterial disease: Endovascular versus open surgery in a propensity score adjusted analysis

AIMS

The aim of the present study was to compare outcomes of endovascular surgery versus open vascular surgery in patients with diabetic foot ulcer (DFU) and peripheral arterial disease (PAD).

METHODS

Between 1984 and 2006, 1151 patients with DFU were admitted to the diabetic foot care team. Three hundred seventy-six patients with 408 limbs were consecutively included at a multidisciplinary foot center, 289 limbs were treated with endovascular surgery and 119 limbs with open vascular surgery first strategy. A propensity score adjusted analysis was performed to compare outcomes for type of revascularization.

RESULTS

Major amputation rates at 3 years were 17.0% and 16.8% (p = 0.97) and mortality at 3 years were 43.1% and 46.5% (p = 0.55) after endovascular surgery and open vascular surgery, respectively. In the propensity score adjusted analysis, patients undergoing endovascular surgery first had similar outcomes in terms of major amputation, mortality, combined major amputation/mortality compared to those undergoing open vascular surgery. Longer time to intervention (p = 0.003) was associated with increased major amputation rate in the multivariable Cox regression analysis.

CONCLUSION

The endovascular surgery first and open vascular surgery first strategies were associated with similar long-term results in a large cohort of patients with DFU and PAD undergoing revascularization. Rapid revascularization reduces the risk of amputation.

Successful endovascular treatment of an ascending aortic pseudoaneurysm using an Amplatzer Vascular Plug II

Pseudoaneurysms are a rare complication of cardiovascular surgery, caused by disruption of the aortic structure (adventitia, media, and intima). Some reports have observed an extremely high mortality rate associated with the open surgical repair of pseudoaneurysms. In elderly or highly frail patients, the use of less invasive procedures is preferable. In this article, we report a case of an octogenarian who had a symptomatic ascending aortic pseudoaneurysm and a history of two sternotomies and present the successful treatment strategy. We treated the patient via an endovascular procedure using an Amplatzer Vascular Plug II (AVP II). After the intervention, the symptoms of the patient resolved. A computed tomography scan performed 1 year after the procedure confirmed the exclusion of the pseudoaneurysm.