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Objective: Despite current guidelines recommending the use of distal embolic protection during transfemoral carotid artery stenting (tfCAS) to prevent periprocedural stroke, there remains significant variation in the routine use of distal filters. We sought to assess in-hospital outcomes in patients undergoing tfCAS with and without embolic protection using a distal filter., Methods: We identified all patients undergoing tfCAS in the Vascular Quality Initiative from March 2005 to December 2021 and excluded those who received proximal embolic balloon protection. We created propensity score-matched cohorts of patients who underwent tfCAS with and without attempted placement of a distal filter. Subgroup analyses of patients with failed vs successful filter placement and failed vs no attempt at filter placement were performed. In-hospital outcomes were assessed using log binomial regression, adjusted for protamine use. Outcomes of interest were composite stroke/death, stroke, death, myocardial infarction (MI), transient ischemic attack (TIA), and hyperperfusion syndrome., Results: Among 29,853 patients who underwent tfCAS, 28,213 (95%) had a filter attempted for distal embolic protection and 1640 (5%) did not. After matching, 6859 patients were identified. No attempted filter was associated with significantly higher risk of in-hospital stroke/death (6.4% vs 3.8%; adjusted relative risk [aRR], 1.72; 95% confidence interval [CI], 1.32-2.23; P < .001), stroke (3.7% vs 2.5%; aRR, 1.49; 95% CI, 1.06-2.08; P = .022), and mortality (3.5% vs 1.7%; aRR, 2.07; 95% CI, 1.42-3.020; P < .001). In a secondary analysis of patients who had failed attempt at filter placement vs successful filter placement, failed filter placement was associated with worse outcomes (stroke/death: 5.8% vs 2.7%; aRR, 2.10; 95% CI, 1.38-3.21; P = .001 and stroke: 5.3% vs 1.8%; aRR, 2.87; 95% CI, 1.78-4.61; P < .001). However, there were no differences in outcomes in patients with failed vs no attempted filter placement (stroke/death: 5.4% vs 6.2%; aRR, 0.99; 95% CI, 0.61-1.63; P = .99; stroke: 4.7% vs 3.7%; aRR, 1.40; 95% CI, 0.79-2.48; P = .20; death: 0.9% vs 3.4%; aRR, 0.35; 95% CI, 0.12-1.01; P = .052)., Conclusions: tfCAS performed without attempted distal embolic protection was associated with a significantly higher risk of in-hospital stroke and death. Patients undergoing tfCAS after failed attempt at filter placement have equivalent stroke/death to patients in whom no filter was attempted, but more than a two-fold higher risk of stroke/death compared with those with successfully placed filters. These findings support current Society for Vascular Surgery guidelines recommending routine use of distal embolic protection during tfCAS. If a filter cannot be placed safely, an alternative approach to carotid revascularization should be considered., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The objective of the present study was to categorize the presentation and treatment of acute limb ischemia (ALI) in young patients and compare the adverse outcomes after revascularization compared with that of older patients., Methods: All the patients who had presented to a multi-institution healthcare system with ALI from 2016 to 2020 were identified. The presenting features, operative details, and outcomes were included in the present analysis. Patients with existing peripheral arterial disease (acute on chronic) were analyzed separately from those without (de novo thrombosis or embolus). Within these groups, younger patients (age, ≤50 years) were compared with older patients (age, >50 years). The 3-month major adverse limb event-free survival was the primary outcome., Results: A total of 232 patients (age, 60 ± 16 years; 44% female sex, 87% white race) were included in the analysis. Of the 232 patients, 119 were in the acute on chronic cohort and 113 were in the de novo thrombosis/embolism cohort. Age did not affect the overall outcomes (P = .45) or the outcomes for the acute on chronic group (P = .17). However, in the de novo thrombosis/embolism cohort, patients aged ≤50 years had worse major adverse limb event-free survival compared with patients aged >50 years (hazard ratio, 2.47; 95% confidence interval, 1.08-5.68; P = .03) after adjustment for Rutherford class, interval from presentation to the operating room, and smoking status. In the de novo thrombosis/embolism group, the operative approach was similar across the age groups (endovascular, 12% vs 14%; open, 48% vs 41%; hybrid, 41% vs 45%; P = .78). In the younger patients, embolism was more likely from a proximal arterial source (71%). In contrast, in the older patients, the source of embolism was more often a cardiac source (86%). The rates of hypercoagulable disease were equal across the age groups (10% vs 10%; P = .95). The In-hospital mortality was 3% overall (acute on chronic, 5%; de novo, 3%)., Conclusions: Despite advances in interventional options, for patients with ALI due to de novo thrombosis or embolus, younger age was associated with worse short-term limb-related outcomes., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Recent data have shown that transcarotid artery revascularization (TCAR) with flow reversal provides a superior method of embolic protection compared with transfemoral carotid artery stenting (tfCAS) with distal embolic protection. Flow reversal or flow arrest systems with proximal endovascular balloon occlusion can also be used through the transfemoral approach; however, their outcomes compared with TCAR with flow reversal and tfCAS with distal embolic protection are poorly described., Methods: We performed a retrospective review of all patients undergoing tfCAS with proximal balloon occlusion, tfCAS with distal embolic protection, and TCAR with flow reversal in the Society for Vascular Surgery Vascular Quality Initiative from March 2005 to May 2019. We assessed in-hospital outcomes in propensity score-matched cohorts of patients using tfCAS with proximal balloon occlusion as the comparison cohort. The primary outcome was stroke or death. Secondary end points included the individual outcomes of stroke, death, transient ischemic attack (TIA), and myocardial infarction., Results: Of the 24,232 patients undergoing carotid artery stenting, 561 (2.3%) procedures were performed through tfCAS with proximal balloon occlusion, 18,126 (74%) through tfCAS with distal embolic protection, and 5545 (22.9%) through TCAR with flow reversal. After matching, 463 pairs of patients undergoing tfCAS with proximal balloon occlusion and tfCAS with distal embolic protection were identified. There were no differences in stroke or death (proximal balloon, 3.2%; distal embolic protection, 3.7%; relative risk [RR], 0.88; 95% confidence interval [CI], 0.45-1.73; P = .73), stroke (2.4% vs 2.6%; RR, 0.92; 95% CI, 0.42-2.00; P = .83), death (1.1% vs 1.5%; RR, 0.71; 95% CI, 0.41-3.15; P = .80), TIA (1.7% vs 1.5%; RR, 1.14; 95% CI, 0.41-3.15; P = .80), or myocardial infarction (0.4% vs 0.6%; RR, 0.67; 95% CI, 0.11-3.99; P = .65). However, after matching 357 pairs of patients undergoing tfCAS with proximal balloon occlusion and TCAR with flow reversal, tfCAS with proximal balloon occlusion was associated with higher rates of stroke or death (3.1% vs 0.8%; RR, 3.67; 95% CI, 1.02-13.14; P = .03) and a trend toward higher rates of stroke (2.5% vs 0.8%; RR, 3.00; 95% CI, 0.81-11.08; P = .08) and death (0.8% vs 0.0%; P = .08), but no statistically significant differences in TIA (0.8% vs 0.8%; P > .99) or myocardial infarction (0.6% vs 0.3%; RR, 2.00; 95% CI, 0.18-22.06; P = .56)., Conclusions: Compared with tfCAS with distal embolic protection, tfCAS with proximal balloon occlusion has similar major outcomes. However, tfCAS with proximal balloon occlusion does not offer the same degree of embolic protection compared with TCAR with flow reversal, given the significantly higher risk of perioperative stroke or death., (Copyright © 2020. Published by Elsevier Inc.)

Background: Intravascular ballistic embolization is a rare complication of missile injury. Because of its rarity, much remains to be known about its presentation, pathophysiology, complications, and management. In this study, we analyze case reports of ballistic embolization in the last 30 years and available cases from our institution to determine the likely patient, the nature of the embolization, the possible complications, and a general management strategy., Methods: A PubMed search was performed in search of missile embolization cases from 1988 to 2018 in the English language, including only cases of intravascular emboli. Cases resulting from combat and explosive devices were excluded. In addition, five cases from our institution were included in the analysis., Results: A total of 261 cases were analyzed. The most common presentation was that of a young man (reflecting the demographics of those sustaining gunshot wound injuries) with injury to the anterior torso from a single gunshot wound. Venous entry was most common, most often through large-caliber vessels. There was roughly equal involvement of the right and left circulation. Left circulation emboli were frequently symptomatic, with ischemia being the most frequent sequela. In contrast, a right circulation embolus was rarely associated with significant complications., Conclusions: Despite its rarity, ballistic embolization should be considered in gunshot injury with known large-vessel injury when an exit wound is not identified. In particular, signs of ischemia distant from the injury site warrant timely investigation to maximize tissue salvageability. We present a management strategy model for consideration., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of the study was to report the feasibility and results of superior mesenteric artery (SMA) stenting using embolic protection devices (EPDs) to treat acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI)., Methods: A retrospective review was conducted of consecutive patients who underwent SMA stenting with EPDs from 2007 to 2016. EPDs were used selectively in patients with occlusions, severe calcification, or acute thrombus. A two-wire technique with SpiderFX 0.014-inch filter wire (Medtronic, Minneapolis, Minn) combined with a 0.018-inch wire was used to provide support and to facilitate stenting and EPD retrieval. Presence of macroscopic debris in the EPD was recorded and graded as minor (minimal debris) or major (large thrombus or plaque). End points were technical success, presence of EPD debris, embolization, early morbidity, and mortality., Results: SMA stenting was performed in 179 patients, of whom 65 (36%) had EPDs. The mean age was 73 ± 11 years, and 49 were female (75%). Clinical presentation was CMI in 48 patients (74%) and AMI or acute-on-CMI in 17 (26%). Indications for EPD were severe calcification in 22 patients (34%), acute thrombus in 18 (28%), and total occlusion in 16 (25%). Bare-metal stents were used in 33 patients, covered stents in 26, and both types in 6. Adjunctive therapy included thrombolysis in seven patients, thrombectomy in four, and atherectomy in three. Technical success was 100%. There were no instances of filter retention or arterial trauma due to filter manipulation. Distal embolization was noted in four patients (6%), of whom two had AMI. All large emboli were retrieved using catheter aspiration devices, but one small distal embolus was left untreated with no clinical consequences. Two patients had vessel spasm treated by nitroglycerin. Macroscopic debris was noted in 43 patients (66%) and was major in 21 (49%) or minor in 22 (51%). Of the patients with AMI, five (29%) required exploratory laparotomy and four (23%) had bowel resection. Eight additional patients (12%) had early complications (five CMI, three AMI), including cardiac complications, brachial hematoma, acute cholecystitis, and acute respiratory distress syndrome in two patients each. There were no deaths among CMI patients and two early deaths (12%) among those who had AMI., Conclusions: Use of EPDs during SMA stenting is safe and feasible with a two-wire technique. Large macroscopic debris was noted in one-third of the patients when the filter was applied selectively in patients with acute symptoms, occlusions, or severely calcified lesions. Despite the use of EPD, distal embolization occurred in 6% of patients and was successfully treated using catheter aspiration devices., (Copyright © 2018. Published by Elsevier Inc.)

Objective: The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) and present a new classification system for assessment of AWT burden., Methods: The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F-BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal-mesenteric (C). Volumetric measurements (cm 3 ) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30-day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease [RIFLE]), and solid organ infarction., Results: The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016)., Conclusions: AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F-BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic aortic mural thrombus (TAMT) of the descending aorta is rare but can result in dramatic embolic events. Early treatment is therefore crucial; however, there is not a consensus on ideal initial treatment., Methods: A review of the literature using PubMed was conducted, and all relevant publications describing descending TAMT of the past 15 years were reviewed. Variables included for this analysis were presentation, initial treatment strategy employed, outcome measures of thrombus resolution or regression, recurrence of symptomatic emboli, and mortality., Results: Seventy-four patients were included in this analysis. Women were significantly more likely to be described with descending TAMT. The majority (82.4%) of cases reported were diagnosed after an embolic event. Patients were equally likely to receive medical, open surgical, or endovascular therapy as the initial treatment modality. However, there is a trend within the past 5 years to report cases describing successful thoracic endovascular aortic repair for initial management. Of patients who initially underwent medical management, nine patients (34.6%) had persistent thrombus. Of the patients who initially underwent open surgical repair, six patients (31.6%) had persistent thrombus; of these patients, four underwent endovascular repair. Twenty-nine patients (39.2%) with descending TAMT initially underwent thoracic endovascular aortic repair. Twenty-seven (93.1%) had fully excluded thrombus at the time of the procedure, with no recurrence or evidence of repeated embolic phenomena at follow-up., Conclusions: Whereas mural thrombus of the thoracic aorta is uncommon, it must be considered in the differential diagnosis of embolic events. Although endovascular therapy may be a useful first-line option for TAMT with reports of positive outcomes in select literature, further study of this treatment option is required., (Copyright © 2017. Published by Elsevier Inc.)

Objective: Conventional catheter manipulation in the arch and supra-aortic trunks carries a risk of cerebral embolization. This study proposes a platform for detailed quantitative analysis of contact forces (CF) exerted on the vasculature, in order to investigate the potential advantages of robotic navigation., Methods: An anthropomorphic phantom representing a type I bovine arch was mounted and coupled onto a force/torque sensor. Three-axis force readings provided an average root-mean-square modulus, indicating the total forces exerted on the phantom. Each of the left subclavian, left common carotid, and right common carotid arteries was cannulated within a simulated endovascular suite with conventional (n = 42) vs robotic techniques (n = 30) by two operator groups: experts and novices. The procedure path was divided into three phases, and performance metrics corresponding to mean and maximum forces, force impact over time, standard deviation of forces, and number of significant catheter contacts with the arterial wall were extracted., Results: Overall, median CF were reduced from 1.20 N (interquartile range [IQR], 0.98-1.56 N) to 0.31 N (IQR, 0.26-0.40 N; P < .001) for the right common carotid artery; 1.59 N (IQR, 1.11-1.85 N) to 0.33 N (IQR, 0.29-0.43 N; P < .001) for the left common carotid artery; and 0.84 N (IQR, 0.47-1.08 N) to 0.10 N (IQR, 0.07-0.17 N; P < .001) for the left subclavian artery. Robotic navigation resulted in significant reductions for the mean and maximum forces for each procedural phase. Significant improvements were also seen in other metrics, particularly at the target vessel ostium and for the more anatomically challenging procedural phases. Force reductions using robotic technology were evident for both novice and expert groups., Conclusions: Robotic navigation can potentially reduce CF and catheter-tissue contact points in an in vitro model, by enhancing catheter stability and control during endovascular manipulation., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Lack of a reliable outcome measure often leads to excessive or insufficient interventions for critical limb ischemia (CLI). SPY technology (Novadaq Technologies Inc, Bonita Springs, Fla), widely adapted by plastic and general surgeons, uses laser-assisted fluorescence angiography (LAFA) to assess tissue perfusion. We sought to determine the role of SPY as an alternative, perhaps more reliable outcome measure for vascular interventions., Methods: All patients undergoing elective or urgent revascularization for claudication and CLI were prospectively recruited from June 2012 to August 2014. LAFA using SPY technology was performed before and after revascularization procedures under a standard Institutional Review Board-approved protocol. Quantitative measures of perfusion at plantar surfaces were analyzed and compared with ankle-brachial index., Results: A total of 93 patients with claudication or CLI underwent LAFA before and after a revascularization procedure in the study period. The mean preoperative ankle-brachial index increased from 0.60 to 0.84 (P < .001) after a revascularization procedure. Plantar perfusion as measured by LAFA also improved significantly after intervention. Ingress, defined as the rate at which fluorescence intensity increases on the plantar surface during LAFA, increased from 7.1 to 12.4 units/s (P < .001). Peak perfusion, defined as the difference between the baseline and the peak of fluorescence intensity, increased from 97.1 and 143.9 units (P < .001). Egress, defined as the rate at which intensity diminishes after reaching peak perfusion, increased from 1.0 to 1.9 units/s (P = .035). Procedure-related digital embolization was also observed in several patients despite lack of an angiographic finding., Conclusions: This is the largest prospective study evaluating SPY technology in peripheral vascular interventions. Our study shows that SPY is a valuable tool in visualizing real-time procedural outcomes and providing additionally useful information on regional tissue perfusion. Further investigation is warranted to standardize outpatient use and to determine threshold values that predict wound healing., (Published by Elsevier Inc.)

Endovascular procedures carry an intrinsic risk of distal embolization. A large embolus may occlude major vessels with serious consequences. Endovascular procedures in the thoracic aorta may expose the entire visceral and lower limb circulation to this risk. We describe a method of using an endovascular filter to trap large emboli during thoracic aortic stenting using the Wallstent and describe its use in a case of primary aortic mural thrombus., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Neck radiation therapy (XRT) can induce carotid artery stenosis and may increase the technical difficulty of endarterectomy. It is considered a relative indication for carotid angioplasty and carotid artery stenting (CAS). This study sought to evaluate differences in CAS embolic potential and restenosis performed on XRT and non-XRT patients., Methods: At three institutions, 366 CAS procedures were performed on 321 patients (XRT, n = 43; non-XRT, n = 323). Mean follow-up was 410 days (median, 282 days; range, 7-1920 days). Patients were observed with duplex ultrasound to assess for restenosis. Additional end points included target lesion revascularization (TLR), myocardial and cerebrovascular events, and perioperative complications. Captured particulate from embolic protection filters was analyzed with photomicroscopy and image analysis software for 27 XRT and 214 non-XRT filters., Results: XRT patients were more likely to be male and had lower rates of hypertension, coronary artery disease, and diabetes mellitus, although the mean age at procedure did not differ. There was no increase in severe internal carotid tortuosity among XRT patients (XRT: 50% vs non-XRT: 34.7%; P = .06). Indication for CAS did not differ between the two groups, including the number of CAS procedures performed for symptomatic carotid stenosis (XRT: 39.7% vs non-XRT: 39.0%; P = NS). Perioperative outcomes, including the composite 30-day stroke, myocardial infarction, and mortality, were not significantly different (XRT: 2.6% vs non-XRT: 3.9%; P = NS.) There were no significant differences in restenosis rate at the 50% (XRT: 9.4% vs non-XRT: 8.6%; P = NS) or 70% (XRT: 3.5% vs non-XRT: 8.6%; P = NS) threshold. Filter particle analysis revealed that filters from XRT patients had more numerous large particles per filter (1.4 vs 0.7; P < .05) and larger mean particle size (464.1 μm vs 320.0 μm; P < .05). TLR did not differ significantly between the groups., Conclusions: In contrast to earlier studies, this analysis reveals that there are significant differences in XRT and non-XRT patients undergoing CAS in terms of medical comorbidities and embolic material captured in embolic protection filters. The decreased incidence of atherosclerotic risk factors was observed in XRT patients probably because XRT was the primary factor responsible for carotid stenosis. Despite increased embolic particle size, CAS can be performed safely with no increased morbidity, TLR, or restenosis in XRT patients., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Primary aortic mural thrombus (PAMT) is an uncommon condition but an important source of noncardiogenic emboli with a difficult diagnosis and a high rate of complications, including high mortality. We report our experience of thromboembolic disease from PAMT and review its contemporary management., Methods: Retrospective analysis of prospectively collected data of all patients who presented with acute occlusion of a limb or visceral vessels between January 2011 and September 2013 was performed., Results: A total of 88 patients presented with acute occlusion of the extremities or visceral arteries. All underwent extensive evaluation for the possible source of the embolism. Of these 88 patients, 19 patients (mean age, 41.2 years; male:female ratio, 1:2.1) were found to have aortic mural thrombus as the source of distal embolism. Thrombus was located in the thoracic aorta in 10 patients, in the perivisceral aorta in three patients, and in the infrarenal aorta in six patients. Thrombus in the thoracic aorta was treated with stent grafts in four patients, bare metal stents in three patients, and anticoagulation alone in two patients. In the suprarenal abdominal aorta, all three patients underwent trapdoor aortic thrombectomy. Infrarenal aortic thrombus was managed by aortobifemoral embolectomy in two patients, aortic stenting in two patients, surgical thrombectomy in one patient, and anticoagulation alone in one patient. Successful treatment, defined as freedom from further embolic events or recurrence of thrombus, was achieved in 14 of 19 patients (76.4%) with a mean follow-up period of 16.2 months (range, 2-28 months). There were four (21%) thrombus-related deaths, all due to primary thromboembolic insults. One patient needed a below-knee amputation because of a recurrent thrombotic episode., Conclusions: Symptomatic PAMT is an uncommon but important source of noncardiogenic embolus. It appears to occur more frequently in young women. Endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with either stent grafts or closed-cell metal stents. When thrombus is located adjacent to visceral vessels, it should be managed with an open trapdoor thromboembolectomy., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Aortic sources of peripheral and visceral embolization remain challenging to treat. The safety of stent graft coverage continues to be debated. This study reports the outcomes of stent coverage of these complex lesions., Methods: Hospital records were retrospectively reviewed for patients undergoing aortic stenting between 2006 and 2013 for visceral and peripheral embolic disease. Renal function, method of coverage, and mortality after stent grafting were reviewed., Results: Twenty-five cases of embolizing aortic lesions treated with an endovascular approach were identified. The mean age was 65 ± 13 years (range, 45-87 years), and 64% were female. Sixteen (64%) patients presented with peripheral embolic events, six with concomitant renal embolization. Five patients presented with abdominal or flank pain, and two were discovered incidentally. Three patients had undergone an endovascular procedure for other indications within the preceding 6 months of presentation. Nineteen patients had existing chronic kidney disease (stage II or higher), but only three had stage IV disease. Of the eight patients tested, four had a diagnosed hypercoagulable state. Eight of the patients had lesions identified in multiple aortic segments, and aortic aneurysm disease was present in 24%. Coverage of both abdominal and thoracic sources occurred in eight patients, whereas 17 had only one segment covered. Minimal intraluminal catheter and wire manipulation was paired with the use of intravascular ultrasound in an effort to reduce embolization and contrast use. Intravascular ultrasound was used in the majority of cases and transesophageal echo in 28% of patients. Two patients with stage IV kidney disease became dialysis-dependent within 3 months of the procedure. No other patients had an increase in their postoperative or predischarge serum creatinine levels. No embolic events were precipitated during the procedure, nor were there any recurrent embolic events detected on follow-up. The 1-year mortality rate was 25%., Conclusions: Endovascular coverage of atheroembolic sources in the aorta is feasible and is safe and effective in properly selected patients. It does not appear to worsen renal function when performed with the use of specific technical strategies., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Stent fracture after fenestrated endovascular aneurysm repair is a recognized complication. In this report, we record the occurrence of superior mesenteric artery stent fractures in our series and describe the management of embolized stent fragments during secondary intervention., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Contrast angiography with carbon dioxide (CO2) is frequently used in patients with renal dysfunction or iodinated contrast allergies, as CO2 is nonallergenic, nontoxic, and rapidly absorbed in the blood. However, when delivered intra-arterially, there is a possibility that CO2 may create a vapor lock with resultant transient ischemia. We describe a case of suspected CO2 embolus to the iliolumbar artery after iliac artery stenting resulting in immediate loss of bilateral lower extremity motor and sensory function. After placement of a spinal drain and elevation of mean arterial blood pressure, the patient had complete return of sensation with improvement in motor function., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

In an era of increasing emphasis on minimally invasive surgery, distal embolization remains a concern in the absence of distal flow control. We present a case using an endovascular flow control technique that can be used for reducing distal embolic events during endovascular recanalization of aortoiliac occlusive disease. This technique has been used in four patients so far (two with native anatomy and two with aorto-bi-iliac grafts) with no evidence of angiographic or clinical embolic complications., (Published by Mosby, Inc.)

Percutaneous vertebroplasty (PVP) with polymethylmethacrylate (PMMA) is a minimally invasive procedure that provides significant pain relief in a high percentage of patients with osteoporotic fractures. The complication rate of PVP is reported to be below 6%. This case illustrates, for the first time, an arterial PMMA embolus to the aorta and its branches as a complication of PVP., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

A 57-year-old man with premature coronary artery disease presented to the emergency department with left facial pain, numbness, and tongue swelling. The patient was found to have significant tongue necrosis, and subsequent arteriography demonstrated carotid bifurcation stenosis with embolization to the left lingual artery. The patient was successfully treated with debridement of his tongue and left carotid endarterectomy., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Conventional catheter instability and embolization risk limits the adoption of endovascular therapy in patients with challenging arch anatomy. This study investigated whether arch vessel cannulation can be enhanced by a remotely steerable robotic catheter system., Methods: Seventeen clinicians with varying endovascular experience cannulated all arch vessels within two computed tomography-reconstructed pulsatile flow phantoms (bovine type I and type III aortic arches), under fluoroscopic guidance, using conventional and robotic techniques. Quantitative (catheterization times, catheter tip movements, vessel wall hits, catheter deflection) and qualitative metrics (Imperial College Complex Endovascular Cannulation Scoring Tool [IC3ST]) performance scores were compared., Results: Robotic catheterization techniques resulted in a significant reduction in median carotid artery cannulation times and the median number of catheter tip movements for all vessels. Vessel wall contact with the aortic arch wall was reduced to a median of zero with robotic catheters. During stiff guidewire exchanges, robotic catheters maintained stability with zero deflection, independent of the distance the catheter was introduced into the carotid vessels. Overall IC3ST performance scores (interquartile range) were significantly improved using the robotic system: Type I arch score was 26/35 (20-30.8) vs 33/35 (31-34; P = .001), and type III arch score was 20.5/35 (16.5-28.5) vs 26.5/35 (23.5-28.8; P = .001). Low- and medium-volume interventionalists demonstrated an improvement in performance with robotic cannulation techniques. The high-volume intervention group did not show statistically significant improvement, but cannulation times, movements, and vessel wall hits were significantly reduced., Conclusion: Robotic technology has the potential to reduce the time, risk of embolization and catheter dislodgement, radiation exposure, and the manual skill required for carotid and arch vessel cannulation, while improving overall performance scores., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: To describe the spectrum of axillary artery pathology seen in high-performance overhead athletes and the outcomes of current treatment., Methods: A retrospective review of patients that had undergone management of axillary artery lesions in a specialized center for thoracic outlet syndrome (TOS). Treatment outcomes were assessed with respect to arterial pathology and operative management., Results: Nine male athletes were referred for arterial insufficiency in the dominant arm between January 2000 and August 2010, representing 1.6% of 572 patients treated for TOS (19% of 47 patients treated for arterial TOS). Seven were elite baseball pitchers (six professional, one collegiate), and two were professional baseball coaches with practice pitching responsibilities, with a mean age of 30.9 ± 2.9 years. Presenting symptoms included arm fatigue (five), finger numbness (four), cold hypersensitivity/Raynaud's (two), rest pain (one), and cutaneous fingertip embolism (one). Three patients underwent transcatheter thrombolysis prior to referral, including one with angioplasty and stenting. At angiography and surgical exploration 2.5 ± 0.8 weeks after symptom presentation (range, 1-8 weeks), six patients had occlusion of the distal axillary artery opposite the humeral head either at rest (three) or with arm elevation (three), one had axillary artery dissection with positional occlusion, and two had thrombosis of circumflex humeral artery aneurysms. Five patients had embolic arterial occlusions distal to the elbow. Treatment included segmental axillary artery repair with saphenous vein (n = 7; five interposition bypass grafts and two patch angioplasties), ligation/excision of circumflex humeral artery aneurysms (n = 2), and distal artery thrombectomy/thrombolysis (n = 2). Mean postoperative hospital stay was 3.8 ± 0.5 days, and the time until resumption of unrestricted overhead throwing was 10.8 ± 2.7 weeks. At a median follow-up of 15 months (range, 3-123 months), primary-assisted patency was 89%, and secondary patency was 100%. All nine patients had continued careers in professional baseball, although one retired during long-term follow-up., Conclusions: Repetitive positional compression of the axillary artery can cause a spectrum of pathology in the overhead athlete, including focal intimal hyperplasia, aneurysm formation, segmental dissection, and branch vessel aneurysms. Prompt recognition of these rare lesions is crucial given their propensity toward thrombosis and distal embolism, with positional arteriography necessary for diagnosis. Full functional recovery can usually be anticipated within several months of surgical treatment, consisting of mobilization and segmental reconstruction of the diseased axillary artery or ligation/excision of branch aneurysms, as well as concomitant management of distal thromboembolism., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Venous bullet embolism is a rare and complicated occurrence reported in approximately 0.3% of penetrating trauma. The management of bullet emboli is decided on a case-by-case basis, balancing the risk of the embolus itself against those associated with extraction. We report a case of a 19-year-old man who sustained a gunshot wound to the anterior chest, which migrated to the left internal iliac vein in a retrograde fashion. We were able to successfully retrieve the missile using an endovascular approach, thereby minimizing the morbidity associated with an open procedure., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

We report a case of a thrombotic common iliac lesion with concern for elevated risk of downstream embolization during intervention. In this case, a transradial approach enabled the novel, simultaneous deployment of two embolic protection devices, one in the internal iliac artery and the other in the common femoral artery, for complete downstream protection during intervention. An endovascular stent, which accommodates a 0.035-inch wire lumen, was able to be delivered over both 0.014-inch protection device wires simultaneously and was successfully deployed with evidence of captured embolic material., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Distal embolization (DE) during percutaneous lower extremity revascularization (LER) may cause severe clinical sequelae. To better define DE, we investigated which lesion types and treatment modalities increase the risk for embolization., Methods: A prospective registry of LER from 2004 to 2009 was reviewed. All cases with runoff evaluated before and after intervention were included. Angiograms and operative reports were reviewed for evidence of DE. Interventions included percutaneous transluminal angioplasty (PTA), with or without stent placement, and atherectomy with four different devices. Chi-square analysis and Fisher's exact test were used to assess significance. Patency rates were calculated using Kaplan-Meier analysis and compared using log-rank analysis., Results: There were 2137 lesions treated in 1029 patients. The embolization rate was 1.6% (34 events). Jetstream (Pathway, Kirkland, Wash) and DiamondBack 360 (Cardiovascular Systems Inc, St Paul Minn) devices had a combined embolization rate of 22% (8 of 36), 4 of 18 (22%) in each group, which was significantly higher than with PTA alone (5 of 570, 0.9%), PTA and stent (5 of 740, 0.7%), SilverHawk (ev3, Plymouth, Minn) atherectomy (14 of 736, 1.9%), and laser atherectomy (2 of 55, 3.6%; P < .001). There was a significantly higher rate of embolization for in-stent restenosis (6 of 188, 3.2%) and chronic total occlusions (15 of 615, 2.4%) compared with stenotic lesions (13 of 1334, 0.9%; P = .01). The embolization rate was significantly higher in Transatlantic Inter-Society Consensus (TASC) II C and D lesions compared with TASC A and B lesions (P = .018). DE rates were not affected by preoperative runoff status (P = .152). Patency was restored at the completion of the procedure in 32 of 34 cases of DE. The 24-month primary patency, assisted primary patency, and secondary patency in the DE group was 54.0% ± 11.9%, 70.0% ± 10.3%, and 73.2% ± 10.3%, respectively, and was 44.4% ± 1.7%, 61.5% ± 1.7%, and 68.2% ± 1.6%, respectively, when embolization did not occur (P > .05). Limb salvage was 72.6% ± 3.1% in lesions in which no DE occurred vs 83.3% ± 15.2% in lesions in which DE occurred (P = .699)., Conclusions: DE is a rare event that occurs more often with the Jetstream and DiamondBack 360 devices. In-stent and complex native lesions are at higher risk for DE. DE is typically reversible with endovascular techniques and has no effect on patency rates and limb salvage., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

A 34-year-old [corrected] woman was diagnosed with Loeys-Dietz syndrome. Five months later, the patient presented with a symptomatic 2.6-cm subclavian pseudoaneurysm. Staged endovascular treatment was initiated with left vertebral artery embolization, followed by sac ablation and stent graft exclusion. The pseudoaneurysm cavity was filled with n-butylcyanoacrylate ("glue") via a microcatheter. Despite balloon occlusion of the pseudoaneurysm orifice, a small amount of glue debris embolized to the brachial artery, necessitating a vein bypass. In this case, distal embolization of glue may have been avoided by leaving a microcatheter in the aneurysm sac for glue injection after first deploying the stent graft., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Introduction: Extracranial carotid stenoses exhibit significant variance in embolic potential, with restenotic lesions having a particularly low propensity for embolization. This study sought to identify characteristics associated with increased generation of embolic debris during carotid angioplasty and stenting (CAS)., Methods: Captured particulate was available for analysis in 56 consecutive patients. Demographics were mean age, 74 years (range, 60-94 years); mean stenosis, 88% (range, 70%-99%); symptomatic, 27%; prior carotid endarterectomy (CEA), 27%; prior radiotherapy, 7%. Plaque echogenicity, heterogenicity, ulceration, and irregularity were assessed with B-mode duplex ultrasound analysis. Gray scale median (GSM) was calculated from normalized B-mode VHS video recordings. Calcification and degree of stenosis were determined angiographically. Captured particulate debris was evaluated for total number; number >200 microm, >500 microm, >1000 microm; mean and median size. Hematoxylin and eosin, trichrome, and von Kossa stains were used for histologic analysis of captured material., Results: Restenotic carotid stenoses after prior CEA generated minimal embolic debris compared with primary stenoses. Four of 15 patients (27%) with restenotic lesions demonstrated embolic particles; all debris was <500 microm. All 41 patients with primary stenoses had some embolic debris; particulate size was >200 microm in 91%, >500 microm in 72%, and >1000 microm in 43%. In primary lesions, the number and size of captured particulate correlated with GSM and with the combined ultrasound findings of echogenicity, heterogenicity, and luminal irregularity/ulceration (P < .02, 95% confidence interval, 4.5-27.6). None of these ultrasound factors correlated independently with embolic particulate (P = NS). Patients aged >70 years exhibited more total particles (8.1 vs 2.3, P = .008) and increased mean particle size (370 vs 157 mum, P = .02). No significant correlation was observed between the number and size of captured embolic particulate and any other variable (stenosis percentage, prior radiotherapy, preprocedural symptoms, periprocedural symptoms, and calcification). Histologically, the embolic debris consisted of extensive amorphous, acellular proteinaceous material. Calcium debris in the embolic particulate was associated with heavily and moderately calcified lesions., Conclusions: Considerable variation exists in the number and size of embolic particles generated during CAS. Embolic potential is positively correlated with lesion GSM and the combination of lesion echogenicity, heterogenicity, and irregularity. Restenosis after prior CEA is associated with minimal embolic particulate generation, suggesting that embolic protection may not be necessary for CAS of restenotic lesions., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

We report the case of a 51-year-old woman who underwent kyphoplasty with polymethylmethacrylate for painful compression fracture of the third lumbar vertebra. Infiltration of cement into the inferior vena cava, noted intraoperatively, was confirmed with postoperative CT scan. A Greenfield filter was placed to prevent cardiopulmonary embolization of the fragment. On follow-up x-rays, the cement fragment was found to have detached and embolized into the vena cava filter. Endovascular technique was used to retrieve it to the common femoral vein with subsequent successful removal of the crescent-like fragment with operative exploration. Patient was asymptomatic at four-week follow-up visit., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Fragment embolization is a rare phenomenon in trauma patients. Although surgical and endovascular management of vascular injuries have evolved significantly, the detection and management of fragment emboli remain a formidable challenge. We reviewed our experience with this entity from December 2001 to March 2008. During this time period, four (1.1%) of 346 US soldiers evacuated to Walter Reed with arterial or venous injuries were discovered to have suffered missile emboli. Venous emboli were treated with anticoagulation and arterial emboli were treated with standard embolectomy techniques with good result. The presentation, diagnosis, and surgical management of these cases are described., (Published by Mosby, Inc.)

Introduction: Prior neck irradiation may induce atherosclerosis in the carotid artery and is considered an indication for carotid angioplasty and stenting (CAS). This study sought to evaluate the effect of neck radiation therapy (XRT) on the rate of restenosis and embolic potential in patients undergoing CAS., Methods: Two hundred ten CAS procedures were performed on 193 patients (XRT [N = 28], non-XRT [N = 182]). Mean follow-up was 347 +/- 339 days (median, 305 days; range, 16-1354 days). Duplex velocity criteria for restenosis after CAS were: >50% restenosis (peak systolic velocity [PSV] > 125 cm/sec, end diastolic velocity [EDV] 40-99 cm/sec, and internal carotid artery to common carotid artery systolic ratio [ICA/CCA] > 2.0); >70% restenosis (PSV>230 cm/sec, EDV>100 cm/sec, and ICA/CCA ratio >4.0). Restenosis >70% was confirmed by digital subtraction angiography. Additional endpoints included groin hematoma, groin pseudoaneurysm, myocardial infarction, stroke, mortality, and the combined myocardial infarction/stroke/mortality rate. Captured particulate data was obtained from microporous filters used during CAS. Nineteen XRT and 128 non-XRT consecutive filters were analyzed. Photomicroscopy was performed along three axes for each filter, and the quantity and size of the captured particles were analyzed using video image analysis software., Results: There were more men (XRT: 85.7% vs. non-XRT: 52.8%, P < .001) and prior surgical neck dissections in the XRT patients (XRT: 82.1% vs. non-XRT: 4.7%, P < .001). Pre-procedural stenosis did not differ significantly betweeen the two groups (XRT: 86.5% +/- 8.9% [range, 70%-99%] vs. non-XRT: 85.5% +/- 8.7% [range 70%-99%], P = NS). Perioperative outcomes, including the composite 30 day stroke/myocardial infarction/mortality rate did not differ significantly between the two groups (XRT: 0% vs. non-XRT: 3.2%, P = NS). Twelve-month freedom from restenosis rates did not differ significantly at the 50% threshold (XRT: 95.5% vs. non-XRT: 90.3%, P = NS) or at the 70% threshold (XRT: 95.5% vs. non-XRT: 96.5%, P = NS). Target lesion revascularization did not differ significantly (XRT: 0% vs. non-XRT: 0.5%, P = NS). Photomicroscopy demonstrated a trend towards increased particle number and size in the XRT filters, however the results did not achieve statistical significance: particle number (XRT: 9.8 +/- 8.4 vs. non-XRT: 9.6 +/- 11.7, P = NS), %patients with particle size >1000 microm (XRT: 47.4% vs. non-XRT: 30.5%, P = NS)., Conclusions: This study suggests that the durability of CAS and the characteristics of captured embolic particles are not altered by a history of neck XRT. This supports the safety and efficacy of CAS for the treatment of patients with a history of neck XRT. Prior neck XRT may predispose the patient to the de novo development of stenoses at locations that were not previously treated.

Thoracoabdominal aortic aneurysms (TAAA) are associated with high rupture rates and poor outcome in patients who do not have surgical repair. Endovascular and hybrid techniques have gained increasing acceptance for the treatment of TAAA in patients with multiple comorbidities and an increased anesthetic risk. One of the complications of endovascular repair in TAAA is procedurally related embolism to visceral vessels. Visceral embolism causes bowel ischemia and is a potentially lethal complication. This report illustrates the intermittent use of catheters with balloon-inflatable tips as visceral embolus protection systems. These catheters are easy to apply and demonstrated perfect prevention of visceral embolization. To date, 10 patients have undergone operations at our clinic using this protection system, and no embolic complications were observed at the visceral vessels. Therefore, catheters with balloon-inflatable tips for visceral embolous protection should be considered in patients undergoing a two-stage hybrid TAAA repair to avoid embolus-associated morbidity and mortality.

Objective: We have previously demonstrated a 70% incidence of microemboli on diffusion weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS). The purpose of this study is to compare the incidence of microemboli in two distinct time periods when procedural modifications were implemented into a CAS program., Methods: Following a retrospective quality review of our CAS cohort (n = 27) from November 2004 through April 2006 (period 1), we enrolled patients (n = 20) from May 2006 through February 2008 (period 2) undergoing CAS into a prospective cohort that included obtaining pre- and postprocedure DW-MRI exams. Procedural modifications during period 2 included the preferential use of closed-cell systems (60% vs 0% in period 1), early heparinization at the initiation of arterial access, and elimination of an arch angiogram. The hospital records of these 47 patients were reviewed; symptoms, comorbidities, lesion characteristics, periprocedural information, and postoperative outcomes were collected. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs., Results: Twenty (74%) CAS patients from period 1 and seven (35%) patients from period 2 demonstrated acute microemboli on postprocedural DW-MRI (P = .02). The mean number of microemboli in period 1 was 4.1 +/- 5.3 vs 1.5 +/- 2.7 during period 2 (P = .04). Two of the 27 patients (7.4%) during period 1 experienced temporary neurologic changes that resolved within 36 hours. None of the patients during period 2 exhibited any neurologic changes. Patient demographics, comorbidities, and presenting symptoms were similar between the two groups except for smoking prevalence, female presence, and obesity (BMI > 30). Period 2 patients when compared with period 1 had more technically challenging anatomy with more calcified lesions (68% vs 27%), longer lesions (15.9 mm vs 8.2 mm), and higher incidence of ulceration (55% vs 27%) (all P < .04)., Conclusion: Despite successful performance of 47 consecutive CAS procedures without permanent neurologic sequelae, significant reductions in periprocedural embolic events as identified via DW-MRI lesions may be achieved through implementation of quality improvement measures identified through continuous outcome analysis. The long-term neurologic benefits associated with reduced subclinical neurologic events remains to be determined.

Objective: Carotid artery stenting (CAS) is emerging as an acceptable treatment alternative to surgery for patients with carotid artery stenosis. The major risk of CAS is cerebral embolization of plaque and thrombus causing stroke or asymptomatic brain infarction. Use of embolic protection devices (EPD) to trap emboli before they reach the brain is now standard practice in CAS. The pore size of the currently available filters is >100 microns and emboli smaller than the EPD pores can still reach the brain. While the use of EPD is widespread, little evidence exists of their in vivo efficacy in preventing distal embolization. Our aim was to quantify the number of emboli reaching the brain with the device in place. Therefore, the expected value of this report is in its description of a novel application of transcranial Doppler (TCD). Due to the limited number of cases, it is not intended to support the use of one EPD over another., Methods: Six patients were monitored with ipsilateral simultaneous dual probe TCD during CAS. Two types of cerebral protection systems were evaluated: FilterWire EZ System (FW; Boston Scientific, Santa Clara, Calif) and GORE Neuro Protection System (NPS; W.L. Gore and Associates, Flagstaff, Ariz). By placing TCD probes both proximal and distal to the filterwire EPD, we quantified the microembolic signals before the EPD as well as those, which reached the intracranial circulation after the EPD. One probe was placed submandibularly to monitor the ICA (SICA), while another was placed transtemporally to monitor the middle and anterior cerebral artery (MCA + ACA). We compare the number of extracranial emboli prior to the EPD with the number of intracranial emboli after the EPD., Results: Dual probe monitoring was successful during the five stages of the CAS: lesion crossing (LC), predilatation (PreD), stent placement (SP), postdilatation (PostD), and filter/device removal (FR/DR). Using FW during LC by probe 1 (SICA)/probe 2 (MCA + ACA): (18 [range, 15-22]/15 [range, 11-20]), PreD (111 [range, 101-121]/101 [range, 90-111]), SP (68 [range, 60-76]/42 [range, 30-53]), PostD (27 [range, 25-30]/24 [range, 22-27]), FR (0.3 [range, 0-1]/0.7 [range, 0-1]) average number of microembolic signals were detected. Using NPS during LC (1.7 [range, 0-3]/1 [range, 0-2]), PreD (0/1.7 [range, 0-4]), SP (0/0), PostD (0/0), DR (18 [range, 0-18]/6.7 [range, 1-13]) average number of microembolic signals were detected., Conclusion: EPD significantly reduces but does not eliminate the number of microemboli reaching the brain during carotid artery angioplasty and stenting. We propose monitoring of CAS with submandibular and transtemporal TCD probes to further evaluate the practice of distal embolization protection. Although our study is not powered to make any recommendations about EPDs, we believe that sequential dual probe TCD monitoring is a worthy tool with the potential to give vital information to assess the various devices and the techniques of utilization.

Purpose: Aneurysms involving the supra-aortic vessels are rare but carry serious risk of embolization, thrombosis, and rupture. We describe our experience with the diagnosis, treatment strategies, and outcomes in patients with extended follow-up., Methods: Data during a 17-year period (January 1990 to December 2007) was analyzed. We assessed age, gender, presenting symptoms, localization, pathologic diagnosis, type of procedures, complications, and survival., Results: A total of 74 patients were treated for supra-aortic aneurysms. Of all aneurysms treated, 63% were degenerative, 24% iatrogenic, 8% traumatic, 3% genetic, and 1% mycotic. The subclavian artery was most commonly affected (50%, 2/3 in the right side), followed by the common carotid (36%), internal carotid (10%), innominate (3%), and vertebral (1%). At the time of diagnosis, 52 patients (70%) were asymptomatic, but of those symptomatic 68% had an embolic event as a presenting symptom. Embolic episodes were more common in patients with smaller aneurysms (P < .006). Open surgery was performed in 77% of all cases, and the use of endovascular techniques became the predominant treatment modality over the last 4 years. Survival at 30 days was 100%. Five- and 10-year survival rates were 87% and 43%, respectively., Conclusion: Most cases of supra-aortic aneurysm are asymptomatic and embolization as opposed to rupture represents the greatest risk to the patient. Most cases can be detected prior to symptoms. Endovascular repair is an emerging alternative of treatment and, with the current development of appropriate devices, will likely form the mainstay of therapy in the near future.

Objectives: Lower extremity embolization occurs during aortoiliac aneurysm repair and may require major amputation when distal arteries are occluded. Because nonoperative treatments are often ineffective, we evaluated an aggressive operative approach., Methods: In the past 11 years, we performed 328 endovascular and 350 open aortoiliac aneurysm repairs. Excluding cases of embolization to iliac, femoral, popliteal, and more proximal tibial vessels, which were treated in a standard fashion, foot ischemia severe enough to produce cadaveric, pregangrenous, or gangrenous skin changes occurred from more distal embolization after seven endovascular and three open aortoiliac aneurysm repairs. Six of these 10 patients underwent thromboembolectomies of both their dorsalis pedis and perimalleolar posterior tibial arteries < or =4 hours of their original operation. In the other four patients, treatment was delayed 7 to 10 days. Because of progressive foot ischemia, arteriography was performed. From these results, four bypasses (3 autologous vein, 1 polytetrafluoroethylene graft) were performed to the transverse metatarsal arch, dorsalis pedis, perimalleolar peroneal artery, or perimalleolar anterior tibial artery., Results: Patency and limb-salvage rates for both thromboembolectomy and bypass procedures were 100% at a mean follow-up of 3.0 years (range, 5 months-8 years)., Conclusions: Perimalleolar and foot artery thromboembolectomy and bypasses to arteries as distal as the metatarsal arch can be effective treatment for distal embolization from aortoiliac aneurysm repair. Even when cadaveric, pregangrenous, or gangrenous lesions are present, distal arteriography and operative treatment (thromboembolectomy or bypass) may be indicated to successfully salvage the foot.

Mobile thrombus of the thoracic aorta is an uncommon pathology with potentially catastrophic complications. Recurrent spontaneous distal embolization may also occur from an ulcerated thrombus of the abdominal aorta. The simultaneous presence of a mobile thrombus in the thoracic aorta and ulcerated thrombus of the abdominal aorta is extremely rare and poses a significant treatment dilemma. Although various approaches have been reported, there is no standard treatment. Direct replacement of the thoracoabdominal aorta is extremely morbid, while continued embolization despite anticoagulation mandate intervention. We herein present the first case report of successful treatment of symptomatic mobile/ulcerated thrombi of the thoracic and abdominal aorta using staged endovascular stent graft repair. Successful treatment of the thoracic component with a thoracic aortic graft (TAG, Gore-Tex, W. L. Gore & Assoc., Flagstaff, Ariz.) was followed one week later by exclusion of the infrarenal aortic lesion with a bifurcated stent graft. Endovascular stent graft exclusion of mobile/ulcerated thoracic and abdominal aortic thrombi is a minimal invasive operation. It can be employed as an alternative procedure in treatment of aortic thrombus with embolization in high risk patients. Long-term follow-up will be necessary to assess the durability of this technique.

Objective: Distal embolization of plaque or thrombus may cause organ ischemia following percutaneous peripheral interventions. The purpose of this study was to evaluate the incidence and clinical significance of particulate embolization during percutaneous superficial femoral artery (SFA) intervention by monitoring with continuous Doppler ultrasound. The rate and timing of embolization at various phases of intervention such as guidewire crossing, balloon angioplasty, stent deployment, and directional atherectomy were analyzed and compared., Methods: Sixty patients underwent SFA intervention. Of these 60 patients, 10 patients underwent percutaneous transluminal angioplasty (PTA) alone, 40 patients underwent PTA with stenting, and 10 patients underwent plaque excision with the SilverHawk atherectomy device (8) or Spectranetics excimer laser (2) with or without additional PTA or stent placement. A 4-MHz Doppler probe was used for continuous monitoring in the ipsilateral popliteal artery. Distal embolization was registered as embolic signals (ES). ES were quantitatively assessed during critical portions of the procedure including guidewire crossing, balloon angioplasty, stent deployment and/or atherectomy. ES during different phases of intervention were compared using analysis of variance (ANOVA)., Results: ES was noted in every patient during wire crossing, angioplasty, stent deployment and atherectomy. The average number of ES noted during guidewire crossing was 8, PTA was 12, stent deployment was 28, SiverHawk atherectomy was 49, and Spectranetics excimer laser was 51. The frequency of ES was statistically higher during stent deployment vs wire crossing or balloon angioplasty but equivalent to that generated by plaque excision. ES was observed more frequent during balloon angioplasty than during wire crossing. In one patient who was treated with the excimer laser, a single runoff vessel was occluded with embolic debris but patency was restored angiographically after thrombolysis. The patient went on to require below knee amputation. During follow-up, all patients with claudication reported improved symptoms and those with ulcers or gangrene demonstrated healing. The average increase in ankle-brachial index following intervention was 0.31., Conclusion: While ES were recorded at each step of SFA intervention, the frequency was greatest during stent deployment. Despite the frequency of these events, only one patient developed angiographically and clinically significant embolization. Thus, our findings do not support the routine use of protection devices during percutaneous SFA intervention.

Although the causes of digital ischemia and necrosis are diverse in women, the most common etiology is connective tissue disease. We describe a patient with scleroderma who presented with arm ischemia secondary to arterial embolization from thoracic outlet syndrome. Her sublavian artery was compressed by the anterior scalene muscle and a cervical rib, leading to a stenosis with poststenotic dilation of the artery. Within the aneurysmal formation was a thrombus, which was probably the source of the distal embolization. The patient underwent surgical resection of the cervical and first rib. The abnormal portion of the subclavian artery was resected and replaced with an interposition graft.

Objectives: The reported rate of subclinical brain injury after carotid artery stenting (CAS) seen on diffusion-weighted magnetic resonance imaging (DWI) varies from 10% to >40%. Data from transcranial Doppler after CAS indicate that embolization may continue for several days, suggesting that that at least some lesions seen on DWI occur postprocedure. Because DWI lesions appear or=60 microm., Results: There were two periprocedural strokes and one transient ischemic attack (TIA), but no strokes or TIAs occurred during follow-up. In the 23 patients imaged 1 hour postprocedure, new lesions were found in two (9%), and 18 (78%) had new lesions at 48 hours (P < .001). For the entire study group, the incidence of new lesions at 48 hours was 67% (36/54). The median number of DWI lesions was four (range, 1 to 17). Every protection device examined had atherosclerotic debris, with a mean of 135 +/- 73 fragments (range, 18 to 310) sized >60 microm and a mean of eight fragments (range, 2 to 21) sized >500 microm. Findings on postprocedure DWI did not correlate with the degree of stenosis, size of angioplasty balloon, or number of inflations, nor with the number or size of fragments retrieved from the protection device., Conclusions: CAS can be performed with a very low incidence of clinically evident neurologic events; however, it is associated with embolization during and after the procedure. Protection devices effectively prevent clinical and subclinical events during the procedure. Significant embolization continues for at least 48 hours postprocedure, causing lesions on DWI when there is no mechanism for cerebral protection. These data correlate with transcranial Doppler reports of continued embolization after CAS and indicate that DWI should be done as late as possible to accurately assess the rate of subclinical brain injury with CAS procedures.

Objectives: Carotid artery angioplasty and stenting (CAS) is now routinely performed with embolic protection devices, yet little is known about the compositional characteristics of the captured embolic debris and whether the type or quantity of debris correlates with patient, lesion, or operator characteristics. This study examined the embolic debris generated during CAS using electron microscopy and energy dispersive spectroscopy (EDS) for symptomatic and asymptomatic patients., Methods: Between 2003 and 2005, CAS for carotid stenosis was performed in 175 patients. Cerebral protection devices were used in all but three cases. Sixty-four consecutive unselected microporous filters from procedures performed by a single vascular surgeon were obtained for analysis. Captured particulate debris within the protection devices was quantified (number and mean size of particles) by light microscopy for all filters. Twenty protection devices (9 symptomatic, 11 asymptomatic patients) were processed for electron microscopy and EDS to assess morphology, cellular composition, and calcium content of debris., Results: Captured particulate matter was present in 49 filters (77%) and included particles measuring 200 to 500 mum in 72%, 500 to 1000 mum in 53%, and >1000 mum in 33%. The mean number of captured particles was 6.9, and mean size was 248 +/- 150 mum. Univariate analysis revealed that sequential patient cohort and filter type were correlated with the number (but not size) of captured particles. The number of particles significantly decreased after the first cohort of 20 patients (11.5 particles) compared with the second (5.0 particles, P = .023) and third (5.2 particles, P = .029) cohorts. The type of captured debris ranged from sheets of damaged red blood cells without other components to clumps of recently activated platelets with early fibrin crosslinking to plaque debris coated with well-organized coalescing areas of platelet thrombus. Platelet activation was more common in symptomatic patients (78%) than asymptomatic patients (27%; P < .05). Despite the presence of calcified lesions in six patients whose filters were analyzed by EDS, <1% of energy emission on EDS of scanned particulate debris fell within the emission range of calcium, indicating the presence of minimal calcium in the embolic particles., Conclusions: Particulate embolic debris is released in most patients during CAS and can measure >1000 mum in one third of patients. The number of particles may decrease with increasing operator experience with CAS. Debris captured during CAS with embolic protection exhibits a range of cellular and acellular components on electron microscopy, with a higher prevalence of platelet activation evident in symptomatic patients.

A 65-year-old woman was evaluated for acute right lower-extremity ischemia secondary to embolization from atrial fibrillation and subtherapeutic anticoagulation. Her symptoms quickly evolved in a dynamic fashion to involve multiple vascular beds, including a transient ischemic attack, abdominal pain secondary to mesenteric ischemia, and contralateral lower-extremity ischemia. Synchronous emboli were treated by using mechanical and pharmacologic thrombolysis via an endovascular approach under local anesthesia. This intervention allows prompt evaluation of multiple vascular beds with good short-term outcomes and minimal morbidity.

This Clinical Update summarizes the results of larger case series, industry-sponsored registries, and randomized trials of carotid artery stenting (CAS). In >20 case series that studied >24,000 patients undergoing CAS, 51% of patients were symptomatic, most procedures (97%) resulted in successful stent deployment, and 30-day stroke rates varied from 1% to 8%, with a trend toward lower rates as experience and embolic protection device (EPD) use increased. In 12 industry-sponsored registries (none were published in peer-reviewed journals), 30-day stroke rates varied from 2% to 7%, and 30-day combined adverse events, including stroke, death, and myocardial infarction, were 3% to 9%. More than 12 randomized trials comparing CAS and carotid endarterectomy (CEA) have been initiated since 1998. Results have varied over time, depending on the population studied and the technology used. However, the largest and most recent results of the completed SAPPHIRE trial in high-risk patients undergoing CAS with the use of EPDs demonstrated that CAS is at least not inferior to CEA, with a 1-year combined adverse event rate of 12% for CAS and 20% for CEA (P = .05). Other ongoing trials will address not only whether CAS could be superior to CEA in high-risk patients but also, more importantly, whether CAS is beneficial in other subgroups, such as low-risk and asymptomatic patients.

We present 2 cases in which a surgical adhesive embolized to the extremities. In the first case an adhesive was successfully used in the repair of a DeBakey type I aortic dissection. The patient was seen 2 months postoperatively with acute lower extremity ischemia, and a large piece of adhesive was extracted from the iliac and femoral arteries at embolectomy. In the second case the adhesive was used to seal a pericardial patch during repair of a ventricular septal defect. This patient was seen 1 day postoperatively with acute arm ischemia, and the adhesive particle was extracted from the brachial artery during embolectomy.

Objective: Upper extremity embolic complications of occluded axillofemoral bypass grafts are infrequent. However, traditional management of dissection of axillary anastomosis for removal of the stump can be challenging. We report two patients with critical upper extremity ischemia secondary to stump syndrome and its successful management with endovascular techniques., Methods: One hundred fifty-two patients underwent axillofemoral bypass grafting over 10 years from 1991-2001. Two patients from this series had acute ischemia involving the ipsilateral upper extremity of occluded axillofemoral bypass graft. Duplex ultrasound scans revealed occlusion of the axillofemoral bypass graft and acute occlusion of ipsilateral upper extremity arteries. Both patients underwent brachial artery exploration and embolectomy. Completion angiograms revealed persistent axillofemoral bypass graft stump as the source of embolus. The stump was obliterated with a 10-mm/40-mm Wallgraft introduced through the same arteriotomy made for brachial embolectomy. Transesophageal echocardiography and magnetic resonance angiography of the arch and great vessels were performed to exclude other sources of origin for the embolus., Results: Both patients remained symptom-free and with patent stent grafts, as seen on duplex scans at 3, 6, and 9 months of follow-up., Conclusions: Upper extremity embolism is a rare complication after occlusion of axillofemoral bypass grafts. The endovascular approach to obliterate the stump of occluded axillofemoral bypass grafts is minimally invasive and an effective alternative treatment of this rare condition.

Paraplegia or paraparesis secondary to spinal cord ischemia is an extremely rare complication after elective repair of abdominal aortic aneurysm. We report delayed paraparesis after endovascular abdominal aortic aneurysm repair in which one hypogastric artery was unintentionally occluded due to atheroembolism. A spinal catheter was immediately inserted after onset of paraplegia to promote cerebrospinal fluid drainage, which partially reversed the neurologic deficit. Our case underscores both the importance of the critical spinal collateral supply from the hypogastric artery and the role of spinal fluid drainage to maximize spinal cord perfusion in the setting of spinal cord ischemia.

Spontaneous embolization resulting in peripheral arterial occlusion remains a significant cause of morbidity and limb loss. Accurate localization and correction of the embolic source is paramount for the prevention of further episodes and for the preservation of long-term patency and limb salvage. Common well-recognized embolic sources include intracardiac thrombus or myxoma, and thrombus within arterial aneurysms or complex atherosclerotic plaques. Less common is thrombus arising de novo in an otherwise normal aorta, possibly as a result of prior trauma, occult arteriopathy, and/or hypercoagulability. Reported herein are three cases of peripheral or mesenteric embolization arising from large thrombi within the visceral aortic segment, with minimal evidence for atherosclerosis or other aortic pathology. Each patient was treated with visceral aortic thrombectomy using a direct surgical approach.

The use of percutaneous angioplasty with subsequent intravascular metallic stent placement has gained increasing acceptance over the past decade. Infections of these stents appear to be uncommon; however, the rarity of this complication may in part be the result of a lack of availability of long-term follow-up data. A number of examples of infected cardiac and peripheral vascular stents have been reported, often with fatal consequences. Herein, we report a 74-year-old woman who underwent subclavian and brachiocephalic artery angioplasty and stent placement for symptomatic stenoses. Six months after the initial intervention, the patient returned with restenosis of the stents and underwent repeat angioplasty to restore full patency. Two weeks later, the patient was readmitted with generalized malaise and multiple erythematous, macular lesions on the right forearm and hand. Blood cultures grew Staphylococcus aureus, and a computed tomographic scan of the chest showed a large brachiocephalic artery pseudoaneurysm with surrounding hematoma. Despite prompt surgical intervention, this complication proved ultimately fatal. Infections of metallic endovascular stents are potentially life-threatening complications and must be addressed urgently, including possible surgical intervention.