Annals of vascular surgery
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We assessed the technical success and early outcome of thoracic endovascular aortic repair (TEVAR) for complicated acute type B thoracic aortic dissection treated at a single institution using a commercially available device. All patients with symptomatic complicated acute type B thoracic aortic dissection treated with TEVAR since Food and Drug Administration approval of the Gore (Flagstaff, AZ) TAG endoprosthesis were identified from a prospectively maintained vascular registry. Clinical indications, operative technique, perioperative complications, follow-up imaging, and mortality were analyzed. ⋯ Major perioperative complications included paraplegia (13.3%), renal failure requiring hemodialysis (13.3%), and stroke (6.7%). Perioperative mortality was 13.3%, occurring in one patient presenting with rupture and one with profound heart failure on admission. For complicated acute type B thoracic aortic dissection, TEVAR using commercially available stent grafts showed high technical success, excellent results at resolving malperfusion, and acceptably low complications and perioperative mortality.
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The prostaglandin I(2) (PGI(2)) analogue iloprost, a potent vasodilator and inhibitor of platelet activation, has traditionally been utilized in pulmonary hypertension and off-label use for revascularization of chronic critical lower limb ischemia. This study was designed to assess the effect of 72 hr iloprost infusion on systemic ischemia post-open elective abdominal aortic aneurysm (EAAA) surgery. Between January 2000 and 2007, 104 patients undergoing open EAAA were identified: 36 had juxtarenal, 15 had suprarenal, and 53 had infrarenal aneurysms, with a mean maximal diameter of 6.9 cm. ⋯ Survival rates were significantly better with iloprost than without in both 30-day (p=0.009) and 5-year cumulative (p=0.0187) survival. Iloprost infusion for 72 hr after open AAA repair was associated with improved systemic perfusion and decreased systemic ischemia. Patients had a significant survival benefit at 30 days and 5 years and significantly improved renal, cardiac, and respiratory function.
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Thoracic endovascular aortic repair (TEVAR) may involve either planned or inadvertent coverage of aortic branch vessels when stent grafts are implanted into the aortic arch. Vital branch vessels may be preserved by surgical debranching techniques or by placement of additional stents to maintain vessel patency. We report our experience with a double-barrel stent technique used to maintain aortic arch branch vessel patency during TEVAR. ⋯ The double-barrel stent technique maintains aortic branch patency and provides additional stent-graft fixation length during TEVAR to treat aneurysms involving the aortic arch. Moreover, the technique uses commercially available devices and permits complete aortic arch coverage (zone 0) without a sternotomy. Although initial outcomes are encouraging, long-term durability remains unknown.
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The National Kidney Foundation Dialysis Outcomes and Quality Initiative (DOQI) recommends autogenous fistulae as the preferred access for new dialysis procedures. Unfortunately, despite superior patency rates compared to prosthetic grafts, even autogenous access durability is often undermined by venous stenosis due to intimal hyperplasia at the outflow vein or by central venous stenosis due to long-standing central venous catheters. Salvage interventions, in the form of endovascular treatments such as percutaneous transluminal angioplasty (PTA) and/or stenting, are increasingly utilized for access salvage and maintenance. ⋯ Central venous and venous outflow interventions extended overall access patency by 38.5 and 33 months, respectively (p < 0.0001). Endovascular interventions are the mainstay of treatment for the malfunctioning dialysis access. Despite the need for multiple reinterventions and close surveillance, catheter-based interventions positively contribute to dialysis access durability in accordance with DOQI guidelines.
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Randomized Controlled Trial Comparative Study
The effect of beta-blocker dosing strategy on regulation of perioperative heart rate and clinical outcomes in patients undergoing vascular surgery: a randomized comparison.
The optimal dosing strategy for perioperative beta-blockers to safely achieve recommended target heart rates (HRs) by current guidelines is not well defined. An HR-titrated perioperative beta-blocker dosing regimen versus a fixed-dose regimen was assessed by clinical outcomes, postoperative heart rate, and beta-blocker-related complications. Patients (n = 64) scheduled to undergo moderate- to high-risk vascular surgery and without contraindications to beta-blockade were randomized to either a fixed-dose or HR-titrated beta-blocker dosing schedule. ⋯ There were no significant differences in the occurrence of asymptomatic hypotension between the two study arms, and no beta-blocker-related adverse events occurred in either study arm. An aggressive, HR-titrated perioperative beta-blocker dosing strategy was associated with more consistent maintenance of postoperative HRs within the range recommended by current guidelines and did not result in increased drug-related adverse events. The question of what is the best perioperative beta-blocker dosing regimen warrants further evaluation in a large-scale clinical trial.