[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.

Endarterectomy of the superficial femoral artery

Semiclosed endarterectomy of the SFA belongs in the armamentarium of the vascular surgeon. New technology offers the possibility of performing this less invasive operation so that only a single incision is needed to obtain access to the artery and perform remote disobliteration. Strong indications show that the anticipated restenosis of long, segmental, closed endarterectomies can be reduced remarkably by expanded PTFE endolining.

Development and application of modern devices in vascular surgery including comment on modern antithrombotic and lytic drug therapy

Since modern vascular surgery started with the discovery of heparin and the development of modern vascular grafts including autogenous saphenous vein, the speciality has been technologically driven. At the outset, vascular surgery depended almost entirely on the development of specialized clamps, instruments, and tools to permit decisive attack on the problems of occlusion. No less important was the development of insight into the basis of atherosclerosis, the discovery that atherogenesis with thrombosis is electrochemically identical to corrosion in pipes and therefore subject to chemical forces, which have not yet been delineated, as well as mechanical forces which have been delineated and permit one to attack the atheroma directly. Thus, classic replumbing techniques including bypass and endarterectomy have long been a part of the fundamental firmament of vascular surgery. Most recently, modern techniques in cleaning out blood vessels, removing occlusive processes, and modern thrombus-dissolving enzymes have all come to the forefront. Frequently multiple techniques are used simultaneously. This article is an attempt to summarize various aspects of this activity and describe several of the patents which have been seminal in the ultimate application of the techniques in both experimental animals and man. This should be the first of a series of efforts to summarize this area. The process of change has never been more kinetic than now.

Long-term clinical follow-up of patients treated with the coronary rotablator: a single-center experience

The acute angiographic and long-term clinical outcomes of a consecutive series of patients treated with the coronary rotablator at a single center are described. The patient population was a high-risk population, with significant instances of unstable angina or acute myocardial infarctions (MI) on presentation (75.5%), three-vessel coronary artery disease (27.5%), congestive heart failure (23.8%), and diabetes (39%). The coronary anatomy was also complex, with 79.3% of lesions treated being National Heart Lung and Blood Institute (NHLBI) class B or C. The maximum burr:artery ratio averaged 0.79+/-0.11. The maximum balloon:artery ratio averaged 1.19+/-0.17. Acute procedural success was 90%. The reference vessel diameter was 2.72 mm +/-0.54 mm. The average minimum luminal diameter (MLD) preprocedure was 0.87+/-0.31 mm. The average MLD postprocedure was 2.01+/-0.54 mm. The acute gain averaged 1.14+/-0.51 mm. Urgent coronary artery bypass grafting was required in 1% of patients. Subendocardial infarctions occurred in 8.5% of patients, and abrupt closure postprocedure while in hospital occurred in 1% of patients. Reinterventions or coronary artery bypass grafting (CABG) in hospital occurred in only 3.5% of patients; 96% of patients were available for a long-term clinical follow-up. Repeat coronary interventions for target lesion revascularizations were required in 17.4% of patients, coronary artery bypass grafting for target lesion revascularization was necessary in 9.5% of patients, and the combined target lesion revascularization rate was 25.3% at 1 year. Subsequent Q-wave myocardial infarctions or cardiac death occurred in 5.7% of patients at 1 year. Event-free survival was 75.1% at 6 months and 69.9% at 1 year. The strongest predictor of subsequent target lesion revascularization was lesion length (P=0.034) and not the postprocedure MLD (P=0.41). Most major adverse clinical events occurred within the first 4 months and greater than 90% of all major adverse clinical events occurred within the first 6 months. The coronary rotablator was able to achieve a high degree of clinical success in a high-risk patient population with complex anatomy. Most major adverse clinical events occurred early (<6 months) and were comprised principally of target lesion revascularizations. The overall target lesion revascularization rates and combined major adverse clinical event rates are favorable, given the complex anatomy and the high proportion of diabetics, females, and multivessel disease patients treated in this series.

[Simultaneous or stepwise procedure in combined minimal invasive and conventional operation methods in vascular surgery]

Long-term results of femoral angioplasty and stenting are not as successful as open surgical procedures. Transfemoral retrograde recanalisation of the iliac vessel by semiclosed endarterectomy is a low-invasive procedure. Certainly the outcome is characterised by a number of early occlusions caused by dissections or remaining intimal flaps. Recent advances in endovascular management of occlusive disease have changed the situation. Intraoperative control of lumen by angioscopy and removal of occlusive material via TV-monitored endoscopic manipulation has induced better results of endarterectomy. In addition to this more effective recanalisation, the proximal intimal step, mostly at the level of the iliac bifurcation, is managed by intraoperative balloon dilatation and stenting. This combined approach has reduced the necessity of reoperation by about 15%. The cumulative 5-year patency rate for this combined procedure is 88%.

Complete thromboendarterectomy of the calcified ascending aorta and aortic arch

BACKGROUND

Arteriosclerotic plaques of the ascending aorta and transverse arch increase the operative risk of cardiac operations and are strong predictors for late cerebrovascular events.

METHODS

Twenty-two patients, mean age 68 +/- 6 years (range, 55 to 77 years), with grade IV + V plaques of the ascending aorta and transverse arch underwent coronary artery bypass grafting (n = 21) and aortic valve replacement (n = 8). Cerebrovascular emboli from unknown sources were found preoperatively in 8 patients (36%). All were in sinus rhythm. Complete thromboendarterectomy of the ascending aorta and transverse arch was performed during hypothermic circulatory arrest. After 21 +/- 12 months (range, 4 to 44 months), magnetic resonance imaging and transthoracic echocardiography of endarterectomized vessels was performed.

RESULTS

There was one perioperative death (4.5%), one early (4.5%), and one late (4.7%) adverse neurologic event. Follow-up examinations revealed normal diameters of the endarterectomized aorta.

CONCLUSIONS

For patients with grade IV + V plaques, thromboendarterectomy of the ascending aorta and transverse arch can be performed with an acceptable surgical risk and a low recurrence rate for cerebrovascular events. Dilatation of the endarterectomized aorta was not observed.

Remote endarterectomy in SFA occlusive disease

The authors present a new modified endarterectomy technique for the treatment of artherosclerotic occlusive disease of the superficial femoral artery (SFA). The SFA remote endarterectomy procedure can be performed through a single groin incision using a ring strip cutter and stenting the distal endpoint. Complete disobliteration of lengthy occlusions was accomplished in more than 100 cases with a cumulative 2-year primary and assisted primary patency rate of 71 and 86%. The mean length of the removed intima core was 33 (10-45) cm. The endovascular remote endarterectomy technique is explained and depicted in detail and some important questions and controversies are discussed.

Minimally invasive superficial femoral artery endarterectomy: early experience with a modified technique

OBJECTIVES

To describe our experience of a modified technique for carrying out remote endarterectomy for superficial femoral artery occlusive disease.

METHODS

A 4-French arterial dilator is inserted using a Smart needle into the popliteal artery below the occlusion. A remote endarterectomy is carried out through an arteriotomy in the proximal superficial femoral artery. The atheroma is cut distal to the lower extent of disease using a Moll ring cutter. The lower flap of atheroma is secured with an intraluminal stent inserted from the arteriotomy in the superficial femoral artery. The arteriotomy is extended into the common femoral artery and closed with a vein patch.

RESULTS

The procedure was completed in 21 of 26 limbs. In 18 cases the superficial femoral artery remained patent at 30 days. Of the 21 cases all but four stayed in hospital for one night. A successful femoropopliteal bypass was carried out in the five patients in whom the procedure was not completed.

CONCLUSION

Insertion of the dilator into the popliteal artery distal to the occlusion before carrying out the remote endarterectomy has two advantages. Firstly, the stent insertion is carried out in the correct plane and prevents dissection of the distal cut atheroma when attempting to pass the guidewire from above. Secondly, the procedure can be carried out under simple image intensification without sophisticated radiological equipment. The early results are encouraging and further evaluation of the technique is justifiable.

[Pulmonary thromboendarterectomy with video-angioscopy and circulatory arrest: an alternative to cardiopulmonary transplantation and post-embolism pulmonary artery hypertension]

The best predictor of poor or suboptimum outcome from pulmonary thromboendarterectomy (PTE) is insufficient relief of obstruction, especially in the lower lobes. The aim of this study is to emphasize that the use of video-assisted angioscopy may increase the quality of PTE and thus improve outcome. PTE included a median sternotomy, intrapericardial dissection limited to the superior vena cava, institution of cardiopulmonary bypass, deep hypothermia and sequential circulatory arrest periods. PTE was always bilateral and performed through two separate arteriotomies of both main intrapericardial pulmonary arteries. A rigid 5 mm angioscope connected to a video camera was introduced through the arteriotomy into the lumen to increase the visibility and perform the video-assisted endarterectomies of all obstructed segmental branches, including normally inaccessible anterior segmental branches. Between January 1996 and December 1997, 48 patients with severe postembolic pulmonary hypertension had PTE. Patients were in New York Heart Association (NYHA) class II (n = 2), III (n = 28) or IV (n = 18) with the following hemodynamics: mean pulmonary arterial pressure (PAP) 53 +/- 13 mmHg, cardiac index 2.16 +/- 0.5 L/min/m2, pulmonary vascular resistances (PVR): 1,152 +/- 414 dyne.s-1.cm-5. Six patients died from alveolar hemorrhage (n = 1), high residual pulmonary pressure and rethrombosis (n = 4) and hypoxic cardiac arrest (n = 1). The functional outcome in surviving patients was as follows: (NYHA) class I (n = 24), II (n = 16) or III (n = 2) with improved hemodynamics: mean pulmonary arterial pressure: 30 +/- 9 mmHg, cardiac index: 2.78 +/- 0.5 L/min/m2, pulmonary vascular resistances (PVR): 484 +/- 159 dynes.s-1.cm-5. Video-assisted angioscopy allows much improved quality and degree of pulmonary endarterectomy. This expands the indications to include patients with previously inaccessible distal disease and candidates for heart-lung transplantation.

Closed superficial femoral artery endarterectomy: a 2-year follow-up

Closed superficial femoral artery endarterectomy is a minimal invasive technique. Through a single groin incision the occluded intima is remotely removed by a newly modified ring stripper. This device has a double ring which acts like remote scissors and enables the surgeon to recanalize long segmental femoral popliteal occlusive disease. The device was used in 103 limbs in 90 patients. The cumulative assisted primary and secondary patency was 86%. This technique is an alternative to bypass grafting when vein is not available.

[Mechanical endarterectomy: review of the literature and description of an original device]

The Authors, after a Literature review on endovascular invasive procedures used for inferior limbs obstructive arteriopathy, describe the use of a new device for mechanical endarterectomy. Through the latest acquired experience the importance of dissecting progressively the single layers of the atheroma plaque without arriving to a complete denudation of the arterial wall, so avoiding the risk of myointimal hyperplasia reactions, is outlined. The possibility of using endoarterial stents in case of more indaginous recanalization is also stressed.

Boundary layer infusion of nitric oxide reduces early smooth muscle cell proliferation in the endarterectomized canine artery

To evaluate the direct effect of nitric oxide (NO) on vascular smooth muscle cell (SMC) proliferation in vivo, we used an expanded polytetrafluoroethylene (ePTFE)-based local infusion device to deliver an NO donor, proline/NO (PROLI/NO), to the luminal boundary layer of endarterectomized artery and the distal anastomosis of the graft in a canine model. Once delivered to the blood, PROLI/NO releases NO by a mechanism involving pH-dependent decomposition. Six dogs underwent bilateral femoral artery endarterectomies. ePTFE infusion devices, blindly primed with PROLI/NO to one artery or proline to the contralateral vessel, were anastomosed proximal to the injured segments so that each animal served as its own control. PROLI/NO or proline was continuously delivered for 7 days from an osmotic reservoir, through the wall of the graft infusion device. Euthanasia was carried out at 7 days, and the processed specimens were blindly analyzed for SMC proliferation at both graft anastomoses and endarterectomized segments by a bromodeoxyuridine index assay. All dogs survived with no clinical side effects. In comparing the treated and control vessels, NO released from PROLI/NO significantly reduced SMC proliferation by 43% (13.24 +/- 1.24% versus 23.24 +/- 1.01%, P = 0.004) at the distal anastomoses and by 68% (10.58 +/- 1.63% versus 25.17 +/- 3.39%, P = 0.007) at endarterectomized segments. However, there was no significant difference in blood flow measurements between treated and control arteries (56.25 +/- 6.50 ml/min versus 46.50 +/- 3.20 ml/min, P = 0.094). These data demonstrate that local boundary layer infusion of NO released from PROLI/NO significantly reduces SMC proliferation in injured arteries with no effect on regional blood flow. This study suggests a new strategy to inhibit early SMC proliferation in injured arteries and probably to control intimal hyperplastic lesion formation in the manipulated vessels.

Endovascular remote endarterectomy in femoropopliteal occlusive disease: one-year clinical experience with the ring strip cutter device

OBJECTIVES

One-year clinical outcome of a new endovascular treatment for long segmental arterial occlusive disease using a ring strip cutter (RSC) to minimise surgical exposure.

DESIGN

Prospective, open study.

MATERIALS

Thirty-eight consecutive RSC procedures in 36 consecutive patients with lengthy occlusive (34) or multiple stenotic (4) femoropopliteal lesions were performed. Indications for operation were disabling claudication in 25 (66%), rest pain in 3 (8%), and gangrene in 10 (26%) patients.

METHODS

A newly developed endovascular ring strip cutter device was used to perform a remote endarterectomy through a single groin incision. Clinical data were analysed based on intention-to-treat.

RESULTS

Initial angiographic, clinical and haemodynamic success was achieved in all 38 (100%) limbs. Mean ankle-brachial index increased significantly from 0.62 +/- 0.14 to 1.02 +/- 0.14 postoperatively (p = 0.01). Four failures have occurred during follow-up. After one-year experience the cumulative (assisted) primary and secondary patency rates are 80% and 85% respectively. Duplex surveillance has detected progressive recurrent stenoses in 10 cases.

CONCLUSIONS

Remote endarterectomy of long segmental femoropopliteal occlusive disease through a single groin incision with the Ring Strip Cutter device is a safe and effective procedure. The early patency rates are good. Further long-term results are needed to evaluate this technique.

Current status of atherectomy for peripheral arterial occlusive disease

Atherectomy physically removes plaque by cutting, pulverizing, or shaving it in atherosclerotic arteries using a mechanical, catheter-deliverable endarterectomy device. Theoretically, atherectomy offers the following advantages over percutaneous transluminal angioplasty (PTA): It shows a greater immediate success rate with less dissection and acute occlusion, treats complex lesions, and reduces the restenosis rate. This article presents the unique features of four atherectomy devices designed to meet the above challenges: Simpson AtheroCath, Transluminal Extraction Catheter (TEC), Trac-Wright Catheter, and Auth Rotablator. The results, complications, and limitations reported by clinical investigators are discussed critically and realistically. A new device, the OmniCath, under investigative trial, is presented briefly. Clinical studies evaluating the Simpson AtheroCath have reported impressively high initial success rates (ranging from 82% to 100%) but disparate intermediate patency results (ranging from 35% to 84%). Complications associated with the device include hematoma, pseudoaneurysm, and distal embolization. Clinical studies show that the device is relatively ineffective for treating diffusely diseased and long-occluded lesions. Restenosis has also been a primary constraint of the Simpson device, with reported restenosis rates ranging from 11% to 55% at 6 months. The initial technical and clinical success rates reported with the TEC atherectomy device have been promising at 79% to 92%; however, short- and mid-term follow-up results have been either lacking or disappointing, with a reported patency of 67% at 6 months and 51% at 12 months. Furthermore, the problems of restenosis and reocclusion have limited its short-term benefits. The Trac-Wright catheter has demonstrated widely disparate technical success rates (from 58% to 100%) and clinical success rates (from 33% to 80%). Patency rates reported have been suboptimal, ranging from 25% to 68% at 6 months and 25% to 45% at 12 months. Furthermore, severe complications associated with the device include perforation, dissection, and embolization. Reocclusion also limits the applicability of the device. The reported immediate success rates of 72% to 94% using the Auth Rotablator are similar to those reported for other atherectomy devices. Patencies reported at 1 and 2 years are dismal, ranging from 31% to 61% and from 12% to 18%, respectively. Significant complications are associated with the device, including thrombosis, arterial spasm, hemoglobinuria, hematoma, and embolization. Contrary to previous studies and expectations, perforations and dissections have been encountered by some investigators. Late restenosis and reocclusion are also significant limiting factors of the Auth Rotablator. Atherectomy currently has limited applications for treatment of peripheral arterial occlusive disease. The intermediate- and long-term results obtained with the atherectomy devices are worse than those reported for PTA. Furthermore, all of the atherectomy devices have failed to reduce the restenosis and reocclusion rates from those reported for PTA. The problem of restenosis, reocclusion, and other complications must be solved before atherectomy can be used generally as an alternative to vascular reconstruction procedures such as PTA.

[Angioscopy as intraoperative outcome control after reconstructive surgery of the renal arteries: presentation of a new method]

Main reasons for obstruction of renal arteries are atherosclerosis and fibromuscular dysplasia. In our clinic transaortic renal endarterectomy and interposition of a vein segment are preferred for arterial reconstruction. The surveillance of the distal intimal ridge after blind transaortic endarterectomy is still an unsolved problem, and the distal anastomosis of a vein graft must be checked, as it is performed under difficult conditions, if the suture is done in situ. We introduce angioscopy as a means of intraoperative surveillance.

Aortofemoral graft occlusion: strategy and timing of reoperation

The authors' experience with 46 patients treated over 8.5 years was reviewed to determine the optimal secondary revascularization procedure after occlusion of a unilateral aortobifemoral graft limb. A total of 64 procedures was performed on these patients to restore and maintain graft patency. Repetitive operations for reocclusion were needed in 14 patients (30%). Transcatheter thrombolytic therapy was used in 14 patients, four as sole therapy and 10 in conjunction with operation. The mean time from aortofemoral grafting to presentation with graft limb occlusion was 59.4 months. Rest pain or severe ischemia was present in 85%, and severe claudication in the remainder. Some 78% had urgent operation after diagnostic angiography and catheter-directed thrombolytic therapy was attempted in 22%. The etiology of graft thrombosis was outflow obstruction in 78.2% of cases. Inflow was obtained by surgical thrombectomy in 35 and by lytic therapy in 13. Extra-anatomic inflow was used in 11 and intra-abdominal thrombectomy or redo aortofemoral grafting in five. Outflow procedures, mainly profundaplasty, were performed in all but five cases (four urokinase and one surgical). Infrainguinal bypass was needed in 10 cases in addition to the groin reconstruction. Catheter-directed thrombolysis was successful in 13 of 14 instances; however, in nine of these residual stenosis was disclosed in the outflow requiring surgical repair. Ultimately, 12 of 14 cases treated with thrombolysis required surgical intervention. Cumulative patency for all procedures was 68%. Complications were seen in 14% of cases. Operative mortality was 5%, and limb salvage was obtained in 85%.(ABSTRACT TRUNCATED AT 250 WORDS)

Infrainguinal atherectomy using the transluminal endarterectomy catheter: patency rates and clinical success for 144 procedures

PURPOSE

To determine if atherectomy using the transluminal endarterectomy catheter (TEC) is an effective endoluminal therapy for infrainguinal occlusive disease.

METHODS

Three surgeons used the TEC for 144 infrainguinal atherectomy procedures in 133 patients. The indications were severe claudication in 83, critical ischemia in 56, and graft stenosis in 5 limbs. The pathology was stenosis in 36 and occlusion in 105 limbs. Balloon dilation was also performed in 109 and stenting in 17 limbs.

RESULTS

There was initial technical and anatomic success in 124 (86%) procedures. There were 67 technically successful procedures at mean follow-up of 19 months, although 3 of these limbs with gangrene and extensive distal disease required major amputation. There were 26 failures due to stenosis leading to further intervention and 51 due to occlusion. Twenty of these cases were managed conservatively, 21 were treated with repeat endovascular intervention, 31 with bypass grafting, and 5 with amputation. Repeat intervention in 52 limbs resulted in 36 with patent arteries, 10 that are occluded, and 6 that required amputation. Thirteen of the 14 amputations were for limbs with critical ischemia, but 1 was in a patient with claudication. Life-table analysis showed that the primary patency rate was 51%, the assisted primary patency rate was 61%, and the secondary patency rate was 75% at 15 months. The clinical success rate was 49%, and the salvage rate for limbs with critical ischemia was 78% at 12 months. Univariate log-rank testing showing no significant differences according to the clinical presentation of pathology, but results were worse for lesions > 5 cm long due to more frequent immediate failures. However, multivariate Cox regression analysis showed that results were significantly worse for critical ischemia than for claudication, stenosis compared to occlusions, for limbs with poor runoff, for operations performed by percutaneous rather than an open approach, and for those performed more recently.

CONCLUSIONS

TEC atherectomy may have a place in selected patients, but the optimal circumstances for its use and long-term efficacy require further study.

How to do it. A modified battery-powered toothbrush for coronary artery endarterectomy

A modified battery-powered toothbrush for performing coronary artery endarterectomy is described. The device facilitates the dissection of the atheromatous core, is safe and inexpensive.

Endarterectomy with arterial dilators: surgical technique

A simplified technique of semi-closed endarterectomy with arterial dilators that insures complete removal of intimal fragments was used by the authors. Complications, such as arterial wall penetration and residual intimal fragments, are reduced. This technique has proven useful in aortoiliac and short-segment femoral artery endarterectomy. It is also helpful for proximal anastomosis of femoral/popliteal/tibial in situ bypass where termination of saphenous vein cannot reach femoral artery.

[A new intraluminal endarterectomy instrument]

In 40 human cadaver arteries endarterectomy was performed using a new intravascular device. The system and technique are described. According to our preliminary laboratory experiences the new device proofed to be save and effective. It will allow us to approach more complex lesions not ideal for balloon angioplasty. Clinical investigations will be performed in the near future.