Journal of vascular surgery
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True and false lumen changes and patient outcomes following thoracic endovascular aortic repair (TEVAR) for patients with stable type B dissection have been described by the The Investigation of Stent Grafts in Aortic Dissection (INSTEAD) trial. However, these changes have not been described in TEVAR patients treated for complications of chronic dissection. ⋯ TEVAR is a potential treatment option for patients experiencing complications of chronic type B dissection. During follow-up, there is a predictable expansion of the thoracic true lumen and regression of the thoracic false lumen. These findings correlate with those of the INSTEAD trial, which demonstrated false lumen regression and true lumen expansion in a cohort of patients with stable type B dissection. However, many patients with extension of thoracic dissection into the infrarenal aorta demonstrate continued aortic dilation and, on occasion, the need for secondary intervention for persistent distal perfusion. Further analysis is needed in this subgroup of patients so as to better determine potential predictors and the clinical significance of post-TEVAR infrarenal expansion. Moreover, further investigations may support a role for secondary endovascular intervention in remedying persistent infrarenal aortic expansion after TEVAR for chronic dissection.
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Multicenter Study Comparative Study
Regional use of combined carotid endarterectomy/coronary artery bypass graft and the effect of patient risk.
Although carotid artery stenosis and coronary artery disease often coexist, many debate which patients are best served by combined concurrent revascularization (carotid endarterectomy [CEA]/coronary artery bypass graft [CABG]). We studied the use of CEA/CABG in New England and compared indications and outcomes, including stratification by risk, symptoms, and performing center. ⋯ Although practice patterns in the use of CEA/CABG vary across our region, the risk of complications with CEA/CABG remains significantly higher than in isolated CEA. Future work to improve patient selection in CEA/CABG is needed to improve perioperative results with combined coronary and carotid revascularization.
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Anatomic factors may limit the application of stent grafts for the treatment of arterial aneurysms. Flow- diverting stents (FDSs) are specially designed to reduce flow velocity in the aneurysm sac and promote thrombosis while maintaining flow in the main artery and branch vessels. FDSs include the Pipeline Embolization Device (ev3, Plymouth, Minn), the SILK Arterial Reconstruction Device (Balt Extrusion, Montmorency, France), and the Cardiatis Multilayer Stent (Cardiatis, Isnes, Belgium). The first two have been mainly used for the treatment of intracranial aneurysms. The aim of this study was to review the current role of FDSs in the treatment of extracranial arterial aneurysms. ⋯ Initial clinical experience with the use of FDSs in the treatment of visceral and peripheral aneurysms yielded satisfactory results in technical success, aneurysm thrombosis and shrinkage, and in patency of branch vessels. The results in aortic aneurysms are still under investigation. No aneurysm rupture has yet been described. There is a significant incidence of FDS thrombosis. Volume reduction of the aneurysm is a clearer evidence of the clinical success after treatment with FDSs than aneurysm thrombosis.
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Comparative Study
Predictors of emergency department death for patients presenting with ruptured abdominal aortic aneurysms.
Ruptured abdominal aortic aneurysm (rAAA) is a critically time-sensitive condition with outcomes dependent on rapid diagnosis and definitive treatment. Emergency department (ED) death reflects the hemodynamic stability of the patient upon arrival and the ability to mobilize resources before hemodynamic stability is lost. The goals of this study were to determine the incidence and predictors of ED death for patients presenting to EDs with rAAAs. ⋯ ED death remains a significant cause for mortality for rAAAs and varies by hospital type, rural/urban location, and geographic region. Both delays in ED arrival and delays in providing definitive care may contribute to increased ED death rates, suggesting that improved regional systems of care may improve survival after rAAA.
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Comparative Study
Superior outcomes for rural patients after abdominal aortic aneurysm repair supports a systematic regional approach to abdominal aortic aneurysm care.
The impact of geographic isolation on abdominal aortic aneurysm (AAA) care in the United States is unknown. It has been postulated but not proven that rural patients have less access to endovascular aneurysm repair (EVAR), vascular surgeons, and high-volume treatment centers than their urban counterparts, resulting in inferior AAA care. The purpose of this study was to compare the national experience for treatment of intact AAA for patients living in rural areas or towns with those living in urban areas. ⋯ Despite geographic isolation, patients in rural areas needing treatment for intact AAAs have equivalent access to EVAR and vascular surgeons, increased referral to high-volume hospitals, and improved outcomes after repair. This suggests that urban patients may be disadvantaged even with nearby access to high-quality centers. This study supports the need for criteria that define centers of excellence to extend the benefit of regionalization to all patients.