Search

The outcomes of endovascular repair for small abdominal aortic aneurysm (4.0-4.9 cm) is reported. All patients undergoing endovascular abdominal aortic aneurysm repair between 2000 and 2006 with maximal diameter 4.0 to 4.9 cm form the small aneurysm study cohort. Data were analyzed retrospectively and life-table methods were used. Of 743 endovascular repairs, 132 (17.8%) were performed for small abdominal aortic aneurysm. Perioperative complication rate was 9.1%. Freedom from aneurysm expansion was 96% at 1 year, 86% at 3 years, and 77% at 5 years. Overall survival was 98%, 93%, and 84% at 1, 3, and 5 years, respectively. Perioperative 30-day mortality was 0.8% with an aneurysm-related mortality of 1.5% at 5 years. There were no deaths from delayed aneurysm rupture. Endovascular repair of small abdominal aortic aneurysm is associated with low perioperative morbidity and mortality compared with published results for open repair, and treatment threshold can be reduced to 4 cm in selected patients.

Objective: To evaluate the impact of creating a new specialty vein clinic within an academic-based vascular practice on clinical volume, physician workload and financial parameters. Methods: All patients evaluated and treated for varicose vein related problems within an academic vascular surgery practice were identified from institutional billing databases. Data were stratified according to the time period prior to establishing a vein clinic (PRE-VC) (1999–2001) and after creation of a vein clinic (POST-VC) (2002–2004). Clinical volume, physician workload and financial parameters were evaluated. Comparisons were made between vein (VEIN) and overall vascular (VASC) practice trends. Results: Comparison of clinical volume, physician workload and financial parameters in both the clinic and operative settings showed larger and more rapid expansion of the VEIN practice than VASC practice between PRE-VC and POST-VC time periods (VEIN vs. VASC growth, respectively: new patient clinic volume +162 vs. +18%; clinic relative value units (RVUs) +131 vs. +1%, clinic revenue +201 vs. +44%; procedure volume +348 vs. +19%; procedure RVUs +129 vs. +11%; procedure revenue +93 vs. +10%). Comparing the beginning of PRE-VC to the end of POST-VC time periods, an increasing trend was also present for the percentage of VEIN practice accounting for the total VASC practice (%VEIN PRE-VC to POST-VC, respectively: new patient clinic volume 11.6–30.2%; clinic RVUs 3.2–48.2%; clinic revenue 17.6–31.2%; procedure volume 3.1–14.3%; procedure RVUs 2.8–9.8%; procedure revenue 3.3–11.7%). Conclusion: Establishing a specialty vein clinic within an academic vascular practice can lead to a rapid expansion of clinical volume with associated increase in physician workload and reimbursement at a rate greater than that for the overall vascular practice.

This study was undertaken to evaluate the evolution of operative vein approaches from combined “open” saphenous stripping-stab avulsion phlebectomy to combined “minimally invasive” endovenous ablation-transilluminated powered phlebectomy with a focus on comparing clinical outcomes. All patients undergoing a combined operative approach for concomitant saphenous vein insufficiency and associated varicose tributary veins between January 1, 1998 and December 31, 2005 were identified. Patients were stratified by operative approach into 3 groups: combined saphenous vein stripping-stab avulsion phlebectomy (STRIP-PHLEB); combined saphenous vein stripping-transilluminated phlebectomy (STRIP-TPP); and combined endovenous ablation-transilluminated phlebectomy (EVAB-TPP). Clinical volume, indications, technical details, and complications were retrospectively reviewed. Over the 8-year period, there were 72 limbs in 59 patients treated with STRIP-PHLEB, 92 limbs in 81 patients with STRIP-TPP, and 99 limbs in 76 patients with EVAB-TPP, with a time-dependent transition in operative techniques noted. There was no difference in distribution of CEAP clinical classification between groups, overall with most limbs in the C2-C4 categories (93.1%) and fewer in the C5-C6 categories (6.9%). There was no difference in overall complication rates between STRIP-PHLEB and EVAB-TPP, although the distribution of complications did shift with a trend toward more wound problems noted in procedures involving saphenous stripping (STRIP-PHLEB 5.6%, STRIP-TPP 6.5%, EVAB-TPP 2.0%; P = NS), and more hematomas in procedures involving transilluminated powered phlebectomy (STRIP-PHLEB 5.6%, STRIP-TPP 16.3%, EVAB-TPP 6.9%; P < .05; see Table 2). Complications associated with the endovenous ablation portion were low including technical inability to cannulate 1.6%, saphenous re-cannulation 2.4%, hematoma 2.4%, severe phlebitis 3.1%, venous thromboembolism 0.8%, and no wound or thermal injury problems. With the shift of combined operative vein approaches for concomitant saphenous vein insufficiency and varicose tributary veins towards “minimally invasive” techniques the overall complication rate has remained unchanged. While combined endovenous ablation-transilluminated phlebectomy offers some advantage of “less” invasiveness, this perceived benefit should be balanced against unchanged overall risk over traditional operative approaches.

Purpose: To demonstrate a direct operative approach to vascular lesions of the internal carotid artery (1CA) at the level of the skull base. Methods: Between January 1993 and October 1999, five patients underwent lateral skull base resection with cervical-to-petrous carotid artery saphenous vein bypass for repair of distal 1CA lesions. This report describes operative methods, morbidity, graft patency, and long-term outcome with this experience. Results: Of the five patients with skull base ICA lesions, all had aneurysmal disease. Three were atherosclerotic and two were dysplastic. Preoperative neurologic symptoms including transient ischemic attacks (2) and Horner's syndrome with vascular headaches (1) were completely resolved after operation. Preoperative dysphagia (2) was resolved in one patient and clinically improved in the other. Postoperative complications included transient paresis in the cranial nerve (CN) VII distribution, as well as permanent loss of the eustachian tube and chorda tympani nerve in all five patients. One patient had lasting paresis in the CN XI distribution as well as a mild stroke resulting in arm weakness. No residual arm weakness was detected at one year. There were no graft occlusions by duplex ultrasound at 45.8 months mean objective follow-up, and no ipsilateral stroke or mortality at 51.2 months mean clinical follow-up. Conclusions: Saphenous vein bypass from the cervical-to-petrous ICA is technically feasible and provides a valuable reconstruction option for patients with skull base ICA lesions.

Abdominal aortic coarctation (AAC) is an uncommon vascular lesion with serious sequelae related to uncontrolled hypertension. Balloon-expandable stents have recently been utilized in the treatment of AAC as an alternative to surgical intervention. A 17-year-old female presented with hypertension uncontrolled by beta blockade. She underwent angiography, which revealed an isolated supraceliac aortic coarctation without visceral or renal artery involvement. Balloon angioplasty with stent placement was performed. At 2-year follow-up, a restenosis was identified and was treated with repeat balloon-expandable stent placement. Implantation of balloon-expandable stents is a safe and technically feasible treatment modality for abdominal aortic coarctation not involving the renal and mesenteric arteries. However, it is currently unknown whether the long-term durability of this approach may limit its effectiveness when compared to traditional surgical interventions.

Although distal anastomotic vein patch and cuff techniques have been advocated to improve the patency of lower extremity bypass grafts with polytetrafluoroethylene (PTFE), use of this approach in the infrapopliteal position remains unproven. The purpose of this study is to evaluate the results of infrapopliteal bypass grafting using PTFE and Taylor vein patch for critical lower extremity ischemia. All patients undergoing infrapopliteal bypass grafting with PTFE and Taylor vein patch for ischemic rest pain or tissue loss were identified from the vascular surgery registry. This report describes results for surgical morbidity and mortality, patency, limb salvage, and survival for procedures performed from 1993 through 1998. Forty-two infrapopliteal bypass grafts with PTFE and Taylor vein patch were placed for critical lower extremity ischemia during the 6-year period. Surgical indications were rest pain in 25 (60%) patients and ischemic tissue loss in 17 (40%). Distal arterial anastomosis included 17 (40%) anterior tibial, 10 (24%) peroneal, eight (19%) posterior tibial, and seven (17%) tibioperoneal arteries. Follow-up ranged from 1 to 52 months (mean 17 months). Life-table primary patency, secondary patency, limb salvage, and survival at 3 years were 25%, 31%, 44%, and 66%, respectively. Infrapopliteal bypass with PTFE and Taylor vein patch for critical lower extremity ischemia has poor long-term results that are comparable to those reported for PTFE without Taylor vein patch.

This case illustrates the feasibility and effectiveness of percutaneous balloon fenestration and endovascular renal artery stenting for Type B acute aortic dissection with associated renal ischemia. Percutaneous balloon fenestration and endovascular stent placement should be considered as an alternative to traditional surgical approaches to restore blood flow to arteries compromised by acute aortic dissection.