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Background Carotid artery stenting (CAS) for high-risk individuals is accepted practice. An impaired fasting hyperglycemia (IFG) is often associated with poor procedural outcomes after other percutaneous procedures. The clinical outcomes of CAS for patients with elevated fasting blood sugar (FBS) are not well defined. Methods A database of patients undergoing CAS was sampled from 2000 to 2009. An IFG was defined as plasma glucose >110 mg/dL. Life table analyses were performed to assess time-dependent outcome differences between those patients with and without IFG. The outcomes of freedom from restenosis, occlusion, death, recurrent symptoms, and neurologic event were calculated. Cox proportional hazard analysis or Fisher's exact test was performed to identify factors associated with outcomes. Results During the study period 322 patients underwent 345 CAS procedures. The mean follow-up was 4.6 years. A total of 196 patients (61%) were male. The indications for CAS were neurologic symptoms in high-risk patients in 23% and asymptomatic high-risk in the remainder. Fifty-nine percent had an IFG but only 30% had a history of diabetes mellitus (DM). Patients with an IFG were more likely to suffer a major adverse event (MAE; death, myocardial infarction, stroke; 12% vs. 26%, ≤110 vs. >110, respectively, at 5 years, P = 0.021 by chi-squared analysis) in the 90-day perioperative period. By life table analysis, there were no differences between normal and IFG patients with regards to freedom from occlusion or target vessel revascularization. The long-term MAE rate was significantly worse in patients with an IFG, driven by decreased survival and stroke rates. Patients carrying the diagnosis of DM had equivalent outcomes to non-DM patients (67 ± 5% vs. 62 ± 7%, ≤110 vs. >110, respectively, at 5 years, P = 0.84). The presence of metabolic syndrome and/or the combination of diabetes and metabolic syndrome in the IFG group were drivers of increasing poor MAE rates. Conclusions Patients with IFG undergoing CAS are at a greater risk for periprocedural morbidity and worse MAE in both the short and long term. The diagnosis of DM does not have a similar impact on outcomes. A current IFG, as opposed to a history of DM, should be considered an important risk factor when determining the suitability for CAS.

Superior vena cava (SVC) syndrome, characterized by facial and arm swelling, is most frequently caused by intrathoracic malignancies. Decompression may be achieved with endovenous stent placement. Polytetrafluoroethylene-covered stents have shown to have higher long-term cumulative patency rates compared with uncovered stents for the treatment of malignant SVC syndrome. Unfortunately, polytetrafluoroethylene-covered stents are not readily available worldwide. Moreover, the existing armamentarium, including balloon-expandable iCAST stents (maximum diameter 10 mm) and heparin-coated Viabahn stent-graft endoprostheses (maximum diameter 13 mm), is too small to adequately treat malignant obstruction of the SVC. This report describes a patient with SVC syndrome and SVC tumor thrombus secondary to recurrent nonseminomatous germ cell carcinoma of the mediastinum treated with a Gianturco Z-stent–fixed modified EXCLUDER abdominal aortic aneurysm iliac limb endoprosthesis.

Percutaneous renal artery revascularization for hypertension and renal dysfunction is now common, and there is an increasing realization that renal artery intervention can be associated with parenchymal injury. The frequency, cause, and outcomes of acute functional injury associated with renal intervention are poorly delineated. Our aim was to determine the frequency of acute functional renal injury 30 days after renal artery intervention, to identify factors associated with functional renal injury and determine whether functional renal injury related to renal intervention is associated with late adverse clinical events. A retrospective analysis of patients undergoing renal artery interventions for atherosclerotic renal artery disease between 1990 and 2007 was performed. No distal embolic protection devices were used. Acute functional parenchymal renal injury was defined as a persistent increase in serum creatinine of > or =0.5 mg/dL at 1 month after the procedure. Freedom from kidney-related morbidity (increase in persistent creatinine >20% of baseline, progression to hemodialysis, death from kidney-related causes) and patient survival were measured. There were 418 patients who underwent 581 renal artery interventions: 57% for hypertension, 23% for hypertension associated with chronic renal insufficiency, and 12% for renal insufficiency. Acute functional renal injury occurred in 20% of the patients. The occurrence of a functional injury was associated with a significant decrement in freedom from kidney-related morbidity (mean +/- SEM 80 +/- 2% vs. 55 +/- 10%, no injury vs. injury, p < 0.01) and markedly decreased survival at 5-year follow-up (71 +/- 4% vs. 41 +/- 10%, p < 0.01). At 5-year follow-up, three times as many patients with functional injury progressed to hemodialysis compared to those without injury (19% vs. 7%, p < 0.01). By multivariate analysis, the presence of an unrepaired abdominal aortic aneurysm (AAA), low estimated glomerular filtration rate, non-insulin-dependent diabetes mellitus, contralateral renal artery disease, and a solitary kidney were significantly associated with functional injury and poor long-term clinical benefit. Hypertension, hyperlipidemia, and contrast volume were determined to be not significant. Acute functional renal injury occurs in approximately 20% of patients undergoing percutaneous renal artery intervention and is more likely in the presence of an unrepaired AAA, non-insulin-dependent diabetes mellitus, and preexisting renal disease. Acute functional renal injury is a negative predictor of survival and is associated with subsequent renal failure, need for dialysis, and death. While this data set does not establish a causal relationship, patients who are predisposed to acute functional injury may have underlying factors that also lead to decreased long-term renal function and decreased survival.

Therapy for atherosclerotic occlusive subclavian arterial disease is undergoing a paradigm shift from open to endoluminal therapy. The aim of this study was to review the changing patterns of presentation and clinical outcomes based on presenting symptoms of subclavian artery revascularization. We performed a retrospective analysis of consecutive patients treated for symptomatic atherosclerotic occlusive subclavian arterial disease from 1992 through 2006. Mean follow-up was 4 years. One hundred fourteen patients with a mean age of 63 years (range 33-89, 61% female) underwent 137 procedures. Of these, 89% had hypertension, 32% were diabetic, 69% had hyperlipidemia, and 13% had chronic renal insufficiency. Sixty-seven primary stent attempts (five technical failures) and 70 open (64 carotid-subclavian bypasses, six subclavian-carotid transpositions) were performed. No deaths occurred within the 30-day perioperative period. Fifty-seven percent of the patients presented with symptoms of arm ischemia: exertional pain (84%), rest pain (12%), and ulceration (4%). The assisted primary patency was 81 +/- 7% and 80 +/- 10% at 5 and 10 years, respectively. Symptoms resolved in all patients, and none required major or minor amputations. Freedom from recurrent arm symptoms was 71 +/- 8% and 71 +/- 10% at 5 and 10 years, respectively. Twenty-five percent of the patients presented with a cardiac indication: preparation for a left internal mammary artery (IMA) bypass in 61% and recurrent cardiac ischemia in the remainder. The assisted primary patency was 97 +/- 6% at 5 years. No IMAs were abandoned in this group, and the freedom from recurrent cardiac symptoms related to IMA distribution was 79 +/- 10% at 5 years. Eighteen percent of patients presented with posterior circulation symptoms secondary to vertebrobasilar disease. The assisted primary patency was 100 +/- 0% and 100 +/- 0% at 5 and 10 years, respectively. Freedom from recurrent vertebrobasilar symptoms was 95 +/- 6% and 95 +/- 10% at 5 and 10 years, respectively. Subclavian artery revascularization is safe and effective, but long-term outcomes are determined by the presenting symptomatology.

The role of endovascular therapy for thrombosed dialysis access has grown despite the paucity of data on its viability. The purpose of this study was to characterize the outcomes of a universal endovascular dialysis declot policy at a tertiary medical center. A database of patients undergoing endovascular treatment of thrombosed dialysis access between 1997 and 2003 was maintained. A two-puncture, combined percutaneous mechanical and pharmacologic thrombectomy technique was used. Data were collected on the success rate, complication rate, long-term patency, and presence and location of stenosis. Fistulograms were reviewed in all cases to assess lesion characteristics and pre- and postprocedure results. Results were standardized to current Society of International Radiology and Society for Vascular Surgery criteria. Failure was considered as either an anatomic defect requiring therapy or loss of functionality of the fistula. Life-table analyses were performed to assess time-dependent outcomes. Cox's proportional hazard analyses were performed to identify factors associated with outcomes. Values are the mean +/- standard error of the mean. There were 114 patients (50% male; average age 58 years, range 21-78) who presented with 174 thrombosed grafts. Therapy was performed for 237 thrombotic events (median 2, range 1-5 thrombotic events per hemodialysis access). After successful declot, anastomotic venous stenoses were encountered in 72% and central venous stenoses in 18% of cases; no cause was found in 10%. All stenoses were treated with balloon angioplasty. The technical failure rate was 4.6%. The 30-day all-cause mortality rate was 1.7%, and major morbidity rate was 2.4%. There were 413 interventions (236 percutaneous transluminal angioplasty and/or 183 declot) performed to maintain patency, which amounted to 2.3 interventions per patient. Average primary functional dialysis life span was 6.7 months up to the primary thrombotic event. Aggressive endoluminal therapy added a further average of 12 months of functionality (defined as continued dialysis access). A universal policy of endovascular therapy for occluded dialysis access results in reestablishment of function in the majority of patients and will triple functional longevity. Furthermore, while this approach remains procedure-intensive, it carries low morbidity and mortality and preserves future sites of access.

In the setting of portal hypertension, the body responds by creating portosystemic venous shunts, which may lead to the development of varices. Endoscopic treatment of these varices is often warranted to prevent catastrophic bleeding. During the course of variceal treatment, 1 or more portosystemic shunts may be sacrificed, which may acutely exacerbate portal hypertension and reduce systemic venous return. This report describes percutaneous creation of a mesocaval shunt and balloon-occluded retrograde transvenous obliteration (BRTO) in a patient with cavernous transformation of the portal vein. The patient had previously undergone an unsuccessful attempt at transjugular intrahepatic portosystemic shunt (TIPS) creation with postoperative bleeding requiring splenectomy. As TIPS was not feasible, creation of a percutaneous mesocaval shunt provided an alternate pathway for portosystemic decompression, facilitating safe treatment of gastric varices with BRTO via a gastrorenal shunt. These procedures were performed simultaneously to reduce the risk of variceal bleeding from acute changes in portal venous pressures and redirect blood flow through the shunt to maintain patency. This is the first reported case of combined mesocaval shunt placement and BRTO in a single session.

Type II Abernethy malformations, characterized by side-to-side portosystemic shunting with preserved intrahepatic portal venous system, have been treated with shunt closure surgically and endovascularly. Three-dimensional printing has been used to develop highly accurate patient-specific representations for surgical and endovascular planning and intervention. This innovation describes 3-dimensional printing to successfully close a flush-oriented type II Abernethy malformation with discrepant dimensions on computed tomography, conventional venography, and intravascular ultrasound, using a 12-mm Amplatzer atrial septal occluder device.

While aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of chronic kidney disease (CKD) on long-term outcomes in this population are unclear. We examined the consequences of endovascular treatment of the SFA in patients with and without varying stages of CKD. A database of patients undergoing endovascular treatment of the SFA between 1986 and 2007 was queried, and two groups were defined: estimated glomerular filtration rate (eGFR)or=60 and60 mL/min/1.73 cm(2). Intention-to-treat analysis was performed. Results were standardized to TransAtlantic Inter-Society Consensus (TASC-II) and Society for Vascular Surgery criteria. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- standard deviation where appropriate. There were 525 limbs in 535 patients (68% male, average age 66 +/- 14 years) that underwent endovascular treatment for claudication or chronic critical limb ischemia (51%). Patients with eGFRor=60 were older and had significantly more coronary artery disease, congestive heart failure, diabetes mellitus, and hyperlipidemia. TASC-II lesion distribution was equivalent (37% for TASC-II C and D), but tibial runoff was significantly worse in the eGFRor=60 group. In addition, there were more inflow and outflow interventions in the eGFRor=60 group. In patients with claudication, there was no difference in patency or limb salvage between those with eGFRor=60 and60. In patients with critical limb ischemia, there was no difference in patency between those with eGFRor=60 and60. Limb salvage was worse in patients with eGFRor=60 compared to eGFR60. With respect to limb salvage, six factors were significantly associated with a reduction in rates: presence of tissue loss at presentation (relative risk [RR] = 6.45, p = 0.003), 0 or 1 vessel tibial runoff (RR = 2.56, p0.01), progression of distal disease noted in follow-up (RR = 4.62, p0.01), embolization at the initial intervention (RR = 2.70, p0.05), diabetes mellitus (RR = 3.71, p0.01), and a history of congestive heart disease (RR = 2.42, p0.01). Notable factors that were not significantly associated included lesion calcification (p = 0.64), TASC C or D lesion categorization (p = 0.99), acute occlusion at initial intervention (p = 0.40), and adjuvant stenting (p = 0.67). CKD does not impact the patency of SFA interventions. Limb salvage in patients with critical ischemia is significantly worse when the eGFR isor=60 mL/min/1.73 cm(2).

Percutaneous interventions for symptomatic chronic mesenteric arterial atherosclerosis are rapidly gaining popularity. This study evaluates the long-term anatomic and functional outcomes of endovascular therapy for chronic atherosclerotic occlusive mesenteric arterial disease at a tertiary referral academic medical center. A retrospective analysis of records from patients who underwent endovascular mesenteric arterial interventions between 1984 and 2006 for chronic mesenteric ischemia was performed. Cases of acute ischemia or cases with associated bowel resection were excluded. Results were standardized to current Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using either a multivariate model for fixed variables or a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- SEM. Thirty-one patients (84% female, average age 70, range 43-90, years) with 41 visceral vessel interventions were identified. Indications for intervention included weight loss >10 kg (61%) and/or postprandial pain (94%). The median SVS comorbidity score was 15 (range 10-24). All had three-vessel athero-occlusive mesenteric disease with a median of two vessels occluded on angiography. The median number of vessels revascularized was two. In all cases stenosis, and not occlusion, was treated. The 90-day mortality was 20% and the major morbidity was 6%. While primary and assisted patency rates for the interventions at 7 years were 69 +/- 8% and 72 +/- 9%, respectively (mean +/- SE, n > or = 10), cumulative freedom from recurrent symptoms was only 56 +/- 10%. Twenty percent of the vessels developed restenosis at a median interval of 0.29 years (range 0.3-2.8), with a freedom from restenosis of 79 +/- 8% at 5 years. Fifty percent of these, all with recurrent symptoms, were reintervened successfully with balloon angioplasty and resolution of their symptoms. There was no significant difference between the celiac and superior mesenteric artery outcomes. The correlation of recurrent symptoms and restenosis was significant (p < 0.001). Endoluminal therapy for chronic mesenteric ischemia carries a low morbidity and mortality in a high-risk population. While anatomic patency remains high, long-term therapeutic benefit is not achieved. In its present iteration, endovascular therapy for mesenteric ischemia should be limited to those patients without an open surgical option.

While aggressive endoluminal therapy for occlusive disease of the major branches of the arch of the aorta (brachiocephalic [BCA], left common carotid [LCCA], and left subclavian [LSCA] arteries) is commonplace, long-term outcomes in this population are unclear. We examined the long-term outcomes of endoluminal therapy for ostial aortic arch disease at a single tertiary referral academic medical center. A prospective database of patients undergoing endovascular treatment of aortic arch vessel atherosclerotic occlusive disease between 1990 and 2004 was maintained and retrospectively analyzed. Patients with stenotic ostial lesions of the major thoracic aorta branches were selected. Angiograms were reviewed in all cases to assess lesion characteristics. Patency was assessed by routine clinical and, in the LCCA and LSCA, duplex ultrasound follow-up at 1, 6, and 12 months postintervention and every 12 months thereafter. Results were standardized to current Trans-Atlantic Inter-Society Consensus and Society for Vascular Surgery criteria. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- SEM. Forty-four patients (average age 64 +/- 2 years, 59% male) underwent 26 LSCA, 11 LCCA, and eight BCA interventions for primary indications of arm ischemia (29%), prevention or treatment of coronary steal syndrome (29%), or cerebrovascular signs/symptoms (42%). The technical success rate was 98%, with a 90-day mortality rate of 0% and a major adverse event rate of 2%. There were no strokes and no upper extremity embolic events. Cumulative patency was 88 +/- 8% at 3 years, with a reintervention rate of 7%. The overall symptom recurrence rate was 4%. No local or systemic factors were associated with poor outcomes. Endoluminal stenting for ostial disease of the branches of the aortic arch provides excellent and long-term patency rates with low morbidity, mortality, and secondary intervention rates. With an overall technical success of 98%, our results parallel those for lesions located more distally in the arch branches and support the continued use of percutaneous therapy for atherosclerotic disease throughout the arch branches.

"Spontaneous" subclavian vein ("effort") thrombosis is usually related to extrinsic compression of the vein at the costoclavicular junction. Our experience with this entity over the past decade was reviewed with specific focus on the role of thrombolysis and our selection algorithm. All patients treated for this problem at the University of Rochester over the past decade were identified and records retrospectively reviewed. From 1996 to June 2006, a total of 34 patients with spontaneous complete occlusion of the subclavian vein documented by venography were treated, half with a history of an antecedent exertional factor. Catheter-directed thrombolysis prior to planned immediate thoracic outlet decompression (TOD) was performed in 26 patients, while TOD alone was performed in eight. Time since onset of symptoms was the major factor influencing the decision, being a mean of 5.5 days in the 26 referred for lysis but 1 month to many years in the group who underwent surgery alone. In patients undergoing lysis, flow was restored in 16 (62%), of whom nine had a residual lesion. All but two of the 26 who received thrombolysis then underwent TOD with or without angioplasty, and 13 underwent venous reconstruction as well (eight of the 16 in whom patency had been restored and five of eight in whom it had not). Patients not undergoing lysis were managed by TOD, with five (62%) undergoing decompression alone and three (38%) undergoing formal venous reconstruction. Thrombolysis was not attempted (eight) or unsuccessful (four) in all 12 patients whose symptoms had been present for more than 14 days at presentation. At mean follow-up of 33 months, symptom resolution was almost universal. Primary patency at 5 years was 84% in the thrombolysis group and 83% in the TOD-only group. In conclusion, the primary factor influencing treatment choice at our institution has been time since onset of symptoms. Patients presenting soon after symptom onset underwent thrombolysis followed by TOD, while patients presenting with chronic symptoms underwent TOD alone; in both cases venous reconstruction was based on residual findings after lysis. We have not had successful thrombolysis in a patient presenting with 14 days or more of symptoms. While optimal therapy cannot be defined based on this retrospective review, our algorithm resulted in excellent overall long-term patency and symptom relief.