Journal of Vascular Surgery

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Transcaval Repositioning of Renal Snorkel Stent and Gutter Leak Coil Embolization

September 1, 2018 - 00:00
The patient is a 74-year-old man who initially had undergone endovascular aneurysm repair for a 6.4-cm infrarenal abdominal aortic aneurysm with a Cook Zenith Flex endograft (Cook Medical, Bloomington, Ind), now presenting 3 years later with a progressively enlarging 7.9-cm aneurysm, a malpositioned renal snorkel stent, and an adjacent type IA gutter endoleak. The patient previously had an attempted repair of a type IA endoleak by relining of the previous graft with a Gore Excluder device (W. L.

Right-Sided Axillary and Brachial Access Is Efficacious and Safe for Chimney and Snorkel Grafts

September 1, 2018 - 00:00
As life expectancy extends and aortic disease becomes more complex, we are faced with the challenge of treating increasingly complicated pathologic processes in an increasingly frail population. We are also challenged with treating the sequelae of prior aortic treatments. Chimney endovascular aneurysm repair (ChEVAR), although off-label, is valuable for these patients. We favor the right axillary approach because of the relative ease of access to the visceral branches and the ability of the team to work on the same side of the patient while avoiding the left-sided image intensifier.

John L. Ochsner, 1927-2018

September 1, 2018 - 00:00
Dr John Lockwood Ochsner will be remembered as a charismatic physician, a dedicated teacher, a loving father, and a role model for the hundreds of surgeons he trained. He was revered as an innovative, energetic, and talented surgeon, performing over 12,000 operations, including the first cardiac transplant in the Gulf South. He always said he was happiest in the operating room and loved teaching young resident surgeons. He believed that “surgery is an art as much as a science. You have to improvise almost every case – no two cases are the same – and that's where the fun of surgery comes in, making something new that particular moment that you've never seen before … It's like opening up a package; it's always a little different.”—Dr Larry H.

Invited commentary

September 1, 2018 - 00:00
The authors report their experience with the treatment of complex splenic artery aneurysms complete with a new classification scheme: type I, rupture or impending rupture; type II, at the origin of the splenic artery; and type III, aberrant splenic artery originating from the splenomesenteric or celiacomesenteric trunk. They used a variety of techniques, including combinations of occluding the inflow artery, the inflow collaterals, the aneurysm itself, and the outflow artery using either embolic coils or a covered stent.

Invited commentary

September 1, 2018 - 00:00
In light of the current enthusiasm for the expanded use of branched and fenestrated endovascular aneurysm repair (F/B-EVAR) of complex aortic aneurysms, we are fortunate that Dr Schanzer and his colleagues have given us some insight into the high reintervention rate of patients after F/B-EVAR. The 26% need for at least one re intervention is probably understated in this study, given the inclusion of a small number of iliac branched devices and the significant number of commercially available Cook Zenith fenestrated renal branch devices (arguably the low-hanging fruit of F/B-EVAR grafts).

Management of isolated femoropopliteal in-stent restenosis

September 1, 2018 - 00:00
The optimal catheter-directed therapy for femoropopliteal in-stent restenosis (ISR) remains controversial with limited durability. The natural history of untreated ISR is not well characterized. We evaluated the midterm outcomes of patients with asymptomatic isolated femoropopliteal ISR who were observed under a surveillance program.

Invited commentary

September 1, 2018 - 00:00
Nullius in verba is the 1660 motto of the Royal Society and essentially means “take nobody's word for it.” This advice is pertinent to the findings of the paper by Clouse et al, who challenge currently accepted practices regarding the management of patients with tandem aortic arch branch inflow and bifurcation carotid disease. When the European Society for Vascular Surgery was preparing its 2018 carotid guidelines,1 the available evidence was considered sufficient to support a class IIa, level C recommendation that “most proximal common carotid artery and innominate artery lesions should be considered for treatment via open retrograde angioplasty and stenting.” This recommendation was supported by data from a large single-center series of primary stenting for 145 aortic side branch origin lesions in 114 patients published in 2015,2 in which there were no strokes or deaths within 30 days.

Invited commentary

September 1, 2018 - 00:00
The diagnosis of chronic intestinal ischemia can be problematic and is most often based on a combination of clinical symptoms and imaging studies demonstrating high-grade stenosis or occlusion of the celiac and superior mesenteric arteries. In general, functional tests demonstrating physiologic abnormalities correlating with intestinal malperfusion are not used as they are not widely known or available. For many years, investigators in The Netherlands have, however, advocated use of a combination of clinical symptoms, arterial imaging studies, and functional tests of mucosal perfusion to potentially improve diagnostic accuracy of chronic intestinal ischemia.

Invited commentary

September 1, 2018 - 00:00
Regarding aortic dissection, all those treating the condition understand the serious inherent risks of the problem and the value of medical therapy in reducing progression and complications from this disorder. Martin et al, in the accompanying article, have pointed out the risks for clinicians in simply assuming medication compliance in this high-risk group of patients. In just fewer than 50 patients cared for in an aortic dissection specialty clinic, the authors used a validated, self-reported method to assess medication adherence among the population.

Invited commentary

September 1, 2018 - 00:00
A federal court ordered the tobacco industry to publish information that all cigarettes cause cancer, lung disease, heart attacks, and premature death. Unfortunately, there was no legislation to inform the lay public about the perils of smoking on their vascular system.

Invited commentary

September 1, 2018 - 00:00
The diagnosis of chronic intestinal ischemia can be problematic and is most often based on a combination of clinical symptoms and imaging studies demonstrating high-grade stenosis or occlusion of the celiac and superior mesenteric arteries. In general, functional tests demonstrating physiologic abnormalities correlating with intestinal malperfusion are not used as they are not widely known or available. For many years, investigators in The Netherlands have, however, advocated use of a combination of clinical symptoms, arterial imaging studies, and functional tests of mucosal perfusion to potentially improve diagnostic accuracy of chronic intestinal ischemia.

Abdominal aortic pseudoaneurysm eroding lumbar vertebra

September 1, 2018 - 00:00
A 68-year-old woman presented to the emergency department with a 15-day history of back pain. This nonsmoking patient denied any recent history of fever or symptomatic infection or foreign travel. She also denied hypertension and diabetes. The patient had no family history of aneurysm. Physical examination was unremarkable. Results of laboratory testing, including white blood cell count and erythrocyte sedimentation rate, were within normal limits. Computed tomography aortography of the abdomen showed L1-2 lumbar compression fracture, and two-thirds of the L1 and L2 vertebral bodies were eroded by aortic pseudoaneurysm (A/Cover).

Invited commentary

September 1, 2018 - 00:00
Autophagy is a tightly regulated, multistep intracellular process by which cytoplasmic components are packed in double-membrane vesicles, delivered to the lysosome, and ultimately degraded for energy production and nutrient recycling to maintain cell survival in unfavorable emergent conditions. Whereas autophagy is critically important for cardiovascular homeostasis, dysregulated autophagy is involved in cardiovascular pathologic processes such as atherosclerosis. Although increased autophagy has been reported in experimental and clinical abdominal aortic aneurysms (AAAs),1,2 the role that autophagy plays in AAAs remains unknown.

Invited commentary

September 1, 2018 - 00:00
A major limitation in developing molecular therapies for critical limb ischemia has been the lack of a clinically relevant model to test efficacy. The existing animal models primarily depend on acute limb ischemia generated by femoral artery ligation or excision. These models have provided insights into cellular and molecular mechanisms that underlie collateral artery growth, primarily because young rodents collateralize quickly in response to ischemia. This trait is less helpful when trying to test potential treatments that will be effective in older, atherosclerotic, diabetic human patients.

Invited commentary

September 1, 2018 - 00:00
Cellular senescence is an important contributor to the development of atherosclerosis. The mechanisms by which senescence promotes atherosclerosis, however, remain poorly understood. This important study by Lv et al demonstrates the causal association between reduced expression of peptidyl-prolyl cis/trans isomerase (Pin 1), increased vascular smooth muscle cell (VSMC) senescence, increased cellular senescence molecules p21 and p53, and reduced cell cycle-related cyclin-dependent kinases based on gain- and loss-of-function studies performed in vitro.

Toronto PowerWire fenestration technique to access false lumen branches in fenestrated endovascular aneurysm repair for chronic type B dissection

August 31, 2018 - 00:00
Chronic type B aortic dissection with aneurysmal degeneration requiring intervention presents significant therapeutic challenges. Thoracic endovascular aortic repair with a fenestrated endograft is a feasible option, but false lumen branches without an adjacent re-entry or perforation in the septum can pose a significant challenge. We present two cases of fenestrated endovascular aneurysm repair for chronic type B aortic dissection in which a renal artery from the false lumen was cannulated by creating a “neofenestration” through the dissection flap using a radiofrequency PowerWire (Baylis Medical Inc, Montreal, Quebec, Canada) technique (Toronto PowerWire fenestration technique).

Impact of aortic wall thrombus on late changes in renal function among patients treated by fenestrated-branched endografts

August 25, 2018 - 00:00
Renal function deterioration is an important determinant of mortality in patients treated for complex aortic aneurysms. We have previously determined that catheter and guidewire manipulation in diseased aortas during fenestrated-branched endovascular aneurysm repair (F-BEVAR) is associated with risk of renal function deterioration. The aim of this study was to describe the impact of atherothrombotic aortic wall thrombus (AWT) on renal function deterioration among patients treated by F-BEVAR for pararenal and extent IV thoracoabdominal aortic aneurysms.

Splenic artery pseudoaneurysm with hemosuccus pancreaticus requiring multimodal treatment

August 25, 2018 - 00:00
Termed hemosuccus pancreaticus by Sandblom in 1970, hemorrhage from the pancreatic duct into the gastrointestinal tract represents a rare and challenging problem. Patients present with repeated upper gastrointestinal bleeding that is intermittent but often self-limited. In most cases, this pathophysiologic process is secondary to pancreatitis, chronic inflammation, and subsequent splenic artery pseudoaneurysm bleeding. Previously treated with open splenectomy and distal pancreatectomy, hemosuccus pancreaticus is now often managed with minimally invasive endovascular means.

Molecular identity of arteries, veins, and lymphatics

August 25, 2018 - 00:00
Arteries, veins, and lymphatic vessels are distinguished by structural differences that correspond to their different functions. Each of these vessels is also defined by specific molecular markers that persist throughout adult life; these markers are some of the molecular determinants that control the differentiation of embryonic undifferentiated cells into arteries, veins, or lymphatics.

Outcomes associated with hyperglycemia after abdominal aortic aneurysm repair

August 25, 2018 - 00:00
We evaluated the association between postoperative hyperglycemia and outcomes after abdominal aortic aneurysm (AAA) repair.