Neal S. Cayne, M.D.

Increasing ablation distance peripheral to the saphenofemoral junction may result in a diminished rate of ehits
Sadek M.; Kabnick L.S.; Berland T.; Giammaria L.E.; Zhou D.; Mussa F.; Cayne N.S.; Maldonado T.; Rockman C.B.; Jacobowitz G.R.; Lamparello P.J.; Adelman M.A.
2012 ;55(1):298-298, Journal of vascular surgery
Background: The treatment of venous insufficiency using endovenous laser ablation or radiofrequency ablation may result in endothermal heat induced thrombosis (EHIT), a form of deep venous thrombosis. This study sought to assess the effect of ablation distance peripheral to the deep venous system on the incidence of EHIT. Methods: This study was a retrospective review of a prospectively maintained database from 4/2007 to 7/2011. Consecutive patients undergoing great saphenous vein (GSV) or small saphenous vein (SSV) ablation were evaluated. Previous to 2/2011, all venous ablations were performed 2cm peripheral to the saphenofemoral or saphenopopliteal junctions (Group I). Subsequent to 2/2011, ablations were performed 2.5cm peripheral to the respective deep system junctions (Group II). The primary outcome was the development of EHIT II or greater, i.e. thrombus protruding into the deep venous system. Secondary outcomes included procedure-site complications such as hematomas and saphenous nerve injury. Chi-square tests were performed for all discrete variables, and unpaired Students t-tests were performed for all continuous variables. P<.05 was considered statistically significant. Results: A total of 3,526 procedures were performed, Group I (N=2672) and Group II (N=854). General demographics and CEAP classification did not differ significantly between the two groups. EHIT demonstrated a trend towards diminished frequency in Group II (Group I: 2.8% vs Group II: 1.6%, P=.077). There were no reported cases of EHIT III or IV in this patient cohort. Patients in Group I were treated using anticoagulation 56% of the time, and patients in Group II were treated using anticoagulation 100% of the time. The frequency of procedure site complications was low and did not differ significantly between the two groups. Conclusions: This study suggests that changing the treatment distance from 2cm to 2.5cm peripheral to the deep venous junction may result in a diminished incidence of EHIT. Ongoing evaluation is required to validate these results and to reaffirm the durability of the technique
— id: 149973, year: 2012, vol: 55, page: 298, stat: Journal Article,

Cystic adventitial disease of the popliteal artery: is there a consensus in management?
Baxter, Andrew R; Garg, Karan; Lamparello, Patrick J; Mussa, Firas F; Cayne, Neal S; Berland, Todd
2011 May-Jun;19(3):163-166, Vascular
Cystic adventitial disease (CAD) is a well described disease entity that commonly affects the popliteal artery, presenting as a rare cause of non-atherosclerotic claudication. The traditional surgical approaches are cyst resection and bypass, or cyst evacuation or aspiration. We report the case of a 58-year-old female with CAD of the popliteal artery treated successfully with cyst resection and bypass using an autologous graft. We reviewed the literature over the last 25 years on management and outcomes of CAD of the popliteal artery. We identified a total of 123 cases; most cases were treated using a traditional repair, while 3 cases used an endovascular approach. The overall success rate using bypass was 93.3%, compared to 85% in the evacuation/aspiration cohort. All cases treated endovascularly resulted in failure. While no consensus exists regarding the preferred modality to treat CAD, we believe that resection of the cyst and bypass affords the best outcomes
— id: 134316, year: 2011, vol: 19, page: 163, stat: Journal Article,

Symptomatic carotid artery stenosis is best treated by carotid endarterectomy
Berland, Todd L; Cayne, Neal S; Veith, Frank J
2011 Oct-Dec;7(4):41-43, Methodist DeBakey cardiovascular journal
INTRODUCTION: Ask a dysphasic patient who has received a carotid artery stent if he or she would instead have rather had a troponin enzyme leak or minor myocardial infarction (MI). Although the answer is clear to most of us, there are many interventionalists and clinicians who have inappropriately interpreted recent data from the CREST trial to conclude that carotid artery stenting (CAS) is equivalent to carotid endarterectomy (CEA)
— id: 150012, year: 2011, vol: 7, page: 41, stat: Journal Article,

Mechanical and pharmacologic catheter-directed thrombolysis treatment of severe, symptomatic, bilateral deep vein thrombosis with congenital absence of the inferior vena cava
Garg, Karan; Cayne, Neal; Jacobowitz, Glenn
2011 Jun;53(6):1707-1710, Journal of vascular surgery
We report the use of mechanical and pharmacologic catheter-directed thrombolysis in treating deep vein thrombosis with congenital absence of the inferior vena cava The patient presented with disabling bilateral lower extremity swelling and pain and was found to have extensive bilateral iliofemoral deep vein thromboses. Genetic testing revealed a factor V Leiden mutation. The patient underwent thrombolysis using a Possis (MEDRAD Inc, Warrendale, Pa) catheter and overnight infusion of tissue plasminogen activator. The patient tolerated the procedure well, with prompt return to daily activities. He remains free of symptoms at 3 years on oral anticoagulation, with a patent venous architecture
— id: 132889, year: 2011, vol: 53, page: 1707, stat: Journal Article,

Endovascular repair of the thoracic aorta: preoperative and postoperative evaluation with multidetector computed tomography
Godoy, Myrna C B; Cayne, Neal S; Ko, Jane P
2011 Feb;26(1):63-73, Journal of thoracic imaging
Endovascular techniques have emerged as a minimally invasive alternative for the repair of the descending thoracic aorta, especially in high-risk patients. Multidetector computed tomography has a pivotal role, specifically in determining the candidacy or exclusion of patients for thoracic endovascular aortic repair and preoperative planning. In addition, multidetector computed tomography is used for follow-up assessment of the postsurgical aorta, so that potentially fatal complications can be correctly diagnosed and treated in a timely manner. In this pictorial review, we focus on the preoperative assessment of the pathologic aorta and evaluation after thoracic endovascular aortic repair
— id: 138216, year: 2011, vol: 26, page: 63, stat: Journal Article,

Endovascular solutions to arterial injury due to posterior spinal surgery
Loh SA; Maldonado TS; Rockman CB; Lamparello PJ; Adelman MA; Kalhorn SP; Frempong-Boadu A; Veith FJ; Cayne NS
2011 Jan 5;:?-? #, Journal of vascular surgery
INTRODUCTION:: Iatrogenic arterial injury is an uncommon but recognized complication of posterior spinal surgery. The spectrum of injuries includes vessel perforation leading to hemorrhage, delayed pseudoaneurysm formation, and threatened perforation by screw impingement on arterial vessels. Repair of these injuries traditionally involved open direct vessel repair or graft placement, which can be associated with significant morbidity. METHODS:: We identified five cases of iatrogenic arterial injury during or after posterior spinal surgery between July 2004 and August 2009 and describe the endovascular treatment of these five patients. RESULTS:: In two patients, intraoperative arterial bleeding was encountered during posterior spinal surgery. The posterior wounds were packed, temporarily closed, and the patients were placed supine. Angiography in both patients demonstrated arterial injury necessitating repair. Covered stent grafts were deployed through femoral cutdowns to exclude the areas of injury. In three additional patients, postoperative computed tomography imaging demonstrated pedicle screws abutting or penetrating the thoracic or abdominal aorta. In all three patients, angiography or intravascular ultrasound (IVUS), or both, confirmed indention or perforation of the aorta by the screw. Aortic stent graft cuffs were deployed through femoral cutdowns to cover the area of aortic contact before hardware removal. All five patients did well and were discharged home in good condition. CONCLUSIONS:: Endovascular repair of arterial injuries occurring during posterior spine procedures is feasible and can offer a safe and less invasive alternative to open repair
— id: 120626, year: 2011, vol: , page: ?, stat: Journal Article,

Existing trauma and critical care scoring systems underestimate mortality among vascular trauma patients
Loh, Shang A; Rockman, Caron B; Chung, Christine; Maldonado, Thomas S; Adelman, Mark A; Cayne, Neal S; Pachter, H Leon; Mussa, Firas F
2011 Feb;53(2):359-366, Journal of vascular surgery
BACKGROUND: The impact of vascular injuries on patient mortality has not been well evaluated in multi-trauma patients. This study seeks to determine (1) whether the presence of vascular trauma negatively affects outcome compared with nonvascular trauma (NVT) and (2) the utility of existing severity scoring systems in predicting mortality among vascular trauma (VT) patients. METHODS: A retrospective review of our trauma database from January 2005 to December 2007 was conducted. Demographics, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Trauma Score-Injury Severity Scores (TRISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and mortality rates were compared. Control patients were selected from a matching cohort based on ISS. Comparisons were made between groups based on the above scoring systems. Statistical analysis used chi(2) analysis and Student t-tests. RESULTS: Fifty VT and 50 NVT patients were identified with no significant differences in age, gender, mechanism of injury, ISS, RTS, or TRISS. The mean APACHE II score was higher in VT compared with NVT (12.3 vs 8.8, P < .05). Overall mortality was higher in VT compared with NVT but did not reach statistical significance (24% vs 11.8%, P = .108). VT patients with RTS score >5 had a higher mortality rate (26% vs 2.2%, P = .007). VT patients with an ISS score >24 had a higher mortality compared with NVT patients (61% vs 28.6%, P = .04). VT patients with an APACHE II score <14 also had a higher mortality rate (18.2% vs 0%, P = .007). Finally, VT patients with a TRISS probability of survival of >80% had a higher mortality rate (13.9% vs 0%, P = .05). CONCLUSIONS: In multi-trauma patients, the presence of vascular injury was associated with increased mortality in less severely injured patients based on the RTS, TRISS, and APACHE II scores. These scoring systems underestimated mortality in patients with vascular trauma. Level of care and future trauma algorithms should be adjusted in the presence of vascular trauma
— id: 138264, year: 2011, vol: 53, page: 359, stat: Journal Article,

Outcome of carotid artery interventions among female patients, 2004 to 2005
Rockman, Caron B; Garg, Karan; Jacobowitz, Glenn R; Berger, Jeffrey S; Mussa, Firas F; Cayne, Neal S; Adelman, Mark A; Maldonado, Thomas S
2011 Jun;53(6):1457-1464, Journal of vascular surgery
BACKGROUND: The benefit of carotid endarterectomy (CEA) in female patients has been questioned by various randomized, prospective trials, particularly in asymptomatic cases; several have noted an increase in perioperative stroke among women after CEA. The outcome of carotid angioplasty and stenting (CAS) has not been extensively examined in women. This study examined the outcome of CEA and CAS in women vs men by using a national database. METHODS: Outcomes of CEA and CAS were stratified by sex using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. The NIS was used to identify patient discharges that occurred during 2004 and 2005. Appropriate International Classification of Diseases, 9th Revision (ICD-9) procedure and diagnosis codes were used to identify CEA and CAS cases. Outcome measures included in-hospital perioperative stroke and death. Comparisons of demographics, procedures, and outcome were performed between men and women. Additional analysis was performed among women alone to attempt to identify whether improved outcome was noted with either procedure. RESULTS: Of 54,658 procedures, 94.2% were CEA and 5.8% were CAS. Women comprised 42.3% of the analyzed cases. Women and men were equally likely to be symptomatic (5.3% vs 5.3%, P = .8). Women were significantly less likely to undergo CAS than men (5.4% vs 6.1%, P < .001). Women and men had equivalent rates of perioperative stroke when undergoing CEA (1.0% vs 1.0%, P = .9) and CAS (2.7% vs 2.0%, P = .2). Symptomatic women had a significantly higher rate of perioperative stroke overall than did symptomatic men (3.8% vs 2.3%, P = .03). Asymptomatic women had a significantly lower perioperative stroke rate after CEA than after CAS (0.9% vs 2.1%, P < .001). Rates of perioperative showed a trend favoring CEA vs CAS among symptomatic women (3.4% vs 6.2%, P = .1). CONCLUSIONS: The concern regarding an increased perioperative stroke rate after CEA among asymptomatic women appears to be unfounded. The perioperative stroke rate among symptomatic women was higher than that of symptomatic men, but still well within the acceptable range for symptomatic patients undergoing a cerebrovascular intervention. Nationally, women underwent CAS significantly less frequently than did men. Outcome among women for perioperative stroke favored CEA over CAS, particularly in asymptomatic patients. CEA may be the preferred treatment in women seeking intervention for cerebrovascular disease, unless compelling reasons exist to perform CAS
— id: 132879, year: 2011, vol: 53, page: 1457, stat: Journal Article,

Update on Endovenous Laser Ablation: 2011
Sadek M; Kabnick LS; Berland T; Cayne NS; Mussa F; Maldonado T; Rockman CB; Jacobowitz GR; Lamparello PJ; Adelman MA
2011 Nov 29;:?-?, Perspectives in vascular surgery & endovascular therapy
In 2001, the use of endovenous laser ablation (EVLA) was introduced to the United States to treat superficial venous insufficiency. EVLA has subsequently undergone a rapid rise in popularity and usage with a concomitant decrease in traditional operative saphenectomy. Since its inception, the use of EVLA to treat superficial venous insufficiency has advanced significantly. The efficacy of treatment has been validated using both hemoglobin-specific laser wavelength and water-specific laser wavelength lasers. Currently, laser optimization is focusing on reducing postprocedural sequelae. The clinical parameters that correlate best with improved postoperative recovery use lower power/energy settings, water-specific laser wavelength lasers, and jacket or radial-emitting tips. Future study is still required to assess the durability of treatment at lower power and energy settings coupled with jacket or radial-emitting tip fibers. Long-term follow-up using duplex imaging is recommended to ensure persistent treatment success
— id: 150013, year: 2011, vol: , page: ?, stat: Journal Article,

Endovenous Laser Ablation Using Higher Wavelength Lasers Results in Diminished Post-Procedural Symptoms
Sadek, Mikel; Kabnick, Lowell S.; Berland, Todd; Chasin, Cara; Cayne, Neal S.; Maldonado, Thomas S.; Rockman, Caron B.; Jacobowitz, Glenn R.; Lamparello, Patrick J.; Adelman, Mark A.
2011 JUN ;53(6):67S-68S, Journal of vascular surgery
— id: 134491, year: 2011, vol: 53, page: 67S, stat: Journal Article,

Laser saphenous ablations in more than 1,000 limbs with long-term duplex examination follow-up
Spreafico, Giorgio; Kabnick, Lowell; Berland, Todd L; Cayne, Neal S; Maldonado, Tom S; Jacobowitz, Glenn S; Rockman, Caron R; Lamparello, Pat J; Baccaglini, Ugo; Rudarakanchana, Nung; Adelman, Mark A
2011 Jan;25(1):71-78, Annals of vascular surgery
BACKGROUND: The goal of this study was to evaluate the duplex results of endovenous laser ablation in the treatment of incompetent great saphenous veins (GSV) and small saphenous veins (SSV) with at least 1-year follow-up. METHODS: A retrospective registry was entered by 11 centers from Europe and America, organized by the International Endovenous Laser Working Group. Data concerning 1,020 limbs in patients with incompetence of the GSV and/or SSV, treated with the Endovenous Laser Ablation (EVLA) procedure, were collected. EVLA failures were defined on duplex imaging as reflux confined to the saphenofemoral or saphenopopliteal junction, reflux confined to the main saphenous trunk, or reflux of both junction and main trunk (totally patent saphenous vein) were analyzed at one or more years postoperatively. RESULTS: The mean age of patients was 54 +/- 5 years (range: 18-91 years). The average body mass index was 25. There was a paucity of severe complications: One case of third-degree skin burn, six patients with postsurgical deep vein thrombosis (0.6%), and 27 cases of sensory nerve damage (2.7%). At 1-year, the rate of complete occlusion of the saphenous trunk was 93.1%. There were 79 cases of treatment failures as evidenced by duplex: 22 isolated junction failures (2.2%), 44 isolated trunk failures (4.4%), and 13 totally patent veins (1.3%). Two-year duplex results were reported for 329 limbs with the identification of 19 new cases of failure. No new cases of failure were reported at 3-year follow-up of 130 limbs. Cumulative failure rates estimated by Kaplan-Meier analysis were 7.7% at 1-year and 13.1% at 2- and 3-year follow-up. CONCLUSIONS: On the basis of a duplex scan performed at least 1-year post-treatment, this multicenter registry confirms the safety and efficacy of the EVLA procedure in the treatment of GSV and SSV reflux. Considering the continued failure rate documented in the present study, an annual follow-up by duplex is recommended to 2 years after EVLA
— id: 120627, year: 2011, vol: 25, page: 71, stat: Journal Article,

New developments in the preoperative evaluation and perioperative management of coronary artery disease in patients undergoing vascular surgery
Bauer, Stephen M; Cayne, Neal S; Veith, Frank J
2010 Jan;51(1):242-251, Journal of vascular surgery
BACKGROUND: Preoperative evaluation and perioperative management of cardiac disease in patients undergoing vascular surgery (VS) is important for patients and vascular surgeons. Recent evidence has emerged that has allowed us to develop contemporary paradigms for evaluating and managing coronary artery disease in VS patients perioperatively. METHODS: The utility of stress testing, the role of preoperative coronary revascularization, the optimal use of beta-blockers and statins, and the role of antiplatelet therapy in VS patients were reviewed in the literature. RESULTS: The revised Lee cardiac risk index, based on the number of risk factors (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, renal failure, hypertension, and age >75) quantitates cardiac risk. Stress testing is not predictive of myocardial ischemia/infarction (MI) or death and is only recommended in patients with unstable angina or an active arrhythmia. Stress testing for patients with 0 to 2 risk factors delays VS up to 3 weeks. In high-risk patients (>or=3 risk factors), it helps to identify patients who may develop myocardial ischemia and would benefit from a 30-day period to optimize medical therapy before VS. Stress testing and coronary catheterization do not predict which coronary artery to revascularize to prevent MI or death. Revascularization does not decrease MI or death rates at 1 month or 6 years. Although beta-blocker treatment decreases cardiac risk with VS, timing and dosage (titration) influence outcomes, improper usage may increase stroke and death rate, and not all VS patients should be taking these drugs. Patients with >or=1 risk factor should be considered to begin a low dose beta-blocker 1 month before VS. Preoperative statin use sharply decreases MI, stroke, and death perioperatively and long-term postoperatively. CONCLUSION: Routine stress testing should not be performed before VS. The Lee index should be used to stratify risk in patients undergoing VS. Patients with >or=3 risk factors or active cardiac conditions should undergo stress testing, if VS can be delayed. All VS patients, except those with 0 risk factors, should be considered for a beta-blocker (bisoprolol, 2.5-5 mg/d started 1 month before VS, titrated to a pulse <70 beats/min and a systolic blood pressure >or=120 mm Hg). Intermediate risk factors may not require aggressive heart rate control but simply maintenance on a low-dose beta-blocker. Statins should be started (ideally 30 days) before all VS using long-acting formulations such as fluvastatin (80 mg/d) for patients unable to take oral medication
— id: 114562, year: 2010, vol: 51, page: 242, stat: Journal Article,

Access complications during endovascular aortic repair
Berland, T L; Cayne, N S; Veith, F J
2010 Jan;51(1):43-52, Journal of cardiovascular surgery
Endovascular repair is becoming the mainstay of treatment for aneurysmal disease of the abdominal and thoracic aorta. Access related issues comprise a major reason for failure or conversion to open repair and can contribute to a significant amount of morbidity and mortality. This article will discuss a multitude of access related complications and their treatment. Preoperative imaging is paramount to the success of endovascular procedures. Intraoperative adjuncts, such as iliac artery angioplasty/stenting, the 'pull-down' technique, and aorto mono iliac/femoral systems will be discussed. Occasionally, challenging iliac or femoral anatomy may preclude access through these vessels and the endovascular specialist may need to gain direct access through the aorta or via the carotid artery. In addition, the advantages and disadvantages of an entirely percutaneous technique will be discussed. Finally, peri-operative complications such as rupture, dissection, pseudoaneurysm and infection will be discussed and various treatment modalities reviewed. As stent graft technology and our own skill sets and experience continue to improve, fewer patients will be refused an endovascular repair based on access issues alone
— id: 106281, year: 2010, vol: 51, page: 43, stat: Journal Article,

Experience and Technique for the Endovascular Management of Iatrogenic Subclavian Artery Injury
Cayne, N S; Berland, T L; Rockman, C B; Maldonado, T S; Adelman, M A; Jacobowitz, G R; Lamparello, P J; Mussa, F; Bauer, S; Saltzberg, S S; Veith, F J
2010 Jan;24(1):44-47, Annals of vascular surgery
OBJECTIVES: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries. METHODS: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. RESULTS: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. DISCUSSION: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair
— id: 106166, year: 2010, vol: 24, page: 44, stat: Journal Article,

Ruptured abdominal aortic aneurysms: role of endovascular therapy
Cayne, Neal S; Veith, Frank J
2010 May;77(3):250-255, Mount Sinai journal of medicine
Ruptured abdominal aortic aneurysms historically have high mortality rates. Despite improvements in many open surgical techniques and perioperative care, these mortality rates have not significantly changed. Some of the reasons for the high mortality rates include the excessive blood loss and hypothermia that occur during open operative repair. The blood loss and hypothermia, combined with resuscitative dilutional coagulopathy, can lead to an irreversible spiraling coagulopathy that ultimately ends in the patient's demise. The availability of endovascular approaches to treat abdominal aortic aneurysms in the early 1990s offered an opportunity to substantially alter the treatment outcomes of ruptured abdominal aortic aneurysms. Endovascular repair offers many advantages, including rapid aortic control under local anesthesia, as well as an opportunity to limit the hypothermia and blood loss that occur with an open abdomen. This article will review the endovascular management of ruptured abdominal aortic aneurysms and describe the endovascular techniques for safe and effective treatment. Mt Sinai J Med 77:250-255, 2010. (c) 2010 Mount Sinai School of Medicine
— id: 109813, year: 2010, vol: 77, page: 250, stat: Journal Article,

Improved hemodynamic outcomes with glycopyrrolate over atropine in carotid angioplasty and stenting
Chung, Christine; Cayne, Neal S; Adelman, Mark A; Riles, Thomas S; Lamparello, Patrick; Han, Daniel; Marin, Michael L; Faries, Peter L
2010 Sep;22(3):164-170, Perspectives in vascular surgery & endovascular therapy
OBJECTIVE: Prophylactic atropine traditionally has been used to prevent CAS-associated hemodynamic depression. Glycopyrrolate may serve as an alternative with decreased cardiac effects. This study aims to compare the efficacy of prophylactic glycopyrrolate to atropine in preventing CAS-induced hemodynamic instability and cardiac complications. METHODS: 115 consecutive CAS patients from 2004-2010 were evaluated. Primary endpoints were stroke, MI, bradycardia (HR<60 beats/min), and hypotension (systolic BP <90 mm Hg). Additional outcomes included tachycardia (HR >100 beats/min), hypertension (systolic BP >160 mm Hg), pre- and postoperative systolic BP difference, vasopressor use, arrhythmias, cardiac enzyme elevations, and access site complications. RESULTS: Of 115 patients, 65 (56.5%) patients who received atropine or glycopyrrolate prior to CAS were analyzed [40 (61.5%) patients received glycopyrrolate, 25 (38.5%) received atropine]. Mean age was 70.0 +/- 8.5 years (range, 48-86 years). Mean stenosis was 86.2 +/- 7.4% (range, 70-99%). No MI, major stroke, or death was observed in the 30-day postoperative period. Baseline systolic BP and HR were equivalent between groups. Postoperative bradycardia and hypotension were significantly lower in glycopyrrolate patients compared with atropine patients (30% vs 72%, P = .002; 2.5% vs 36%, P < .001, respectively). Postoperative hypertension was also significantly lower in the glycopyrrolate cohort (2.5% vs 16%, P = .047), whereas tachycardia, pressure changes, vasopressor use, and cardiac complications did not differ significantly. No significant differences in neurologic and access site complications were observed. CONCLUSIONS: Prophylactic glycopyrrolate, compared with atropine, reduces hemodynamic instability during CAS. The authors recommend glycopyrrolate use to prevent CAS-induced bradycardia and hypotension
— id: 133478, year: 2010, vol: 22, page: 164, stat: Journal Article,

Intermediate-term EVAR outcomes in octogenarians
Fonseca, Rodrigo; Rockman, Caron; Pitti, Abhishek; Cayne, Neal; Maldonado, Tom S; Lamparello, Patrick J; Riles, Thomas; Adelman, Mark
2010 Sep;52(3):556-560, Journal of vascular surgery
OBJECTIVE: The utilization of endovascular abdominal aortic aneurysm repair (EVAR) in suitable patients has resulted in decreased perioperative morbidity and mortality. Octogenarians as a subgroup have been more readily offered EVAR, as it is less invasive, and therefore presumably better tolerated than conventional open aortic repair. The purpose of this study is to investigate periprocedural and late EVAR outcomes in octogenarians compared with patients less than 80 years of age. METHODS: From January 2003 to May 2008, 322 patients underwent EVAR. A total of 117 octogenarians were compared with 205 patients less than 80 years of age. A retrospective review of the demographic data, aneurysm details, perioperative morbidity, mortality, and late outcomes were analyzed. RESULTS: Octogenarians were significantly more likely to have a history of diabetes mellitus (51% vs 23%; P < .001), coronary artery disease (45% vs 32%; P = .0165), chronic obstructive pulmonary disease (44% vs 30%; P = .0113), and renal insufficiency (57% vs 31%; P < .0001). There were no significant differences in the rates of perioperative myocardial infarction, stroke, death, intestinal, or arterial ischemic complications between the two groups. Octogenarians had a significant higher rate of pulmonary complications (5.1% vs 1%; P < .03) and access-site hematomas (12% vs 2.4%; P = .001) than younger patients. When all significant perioperative morbidity was combined, octogenarians were twice as likely to develop complications following EVAR than younger patients (27.4% vs 11.7%; P = .001). At 5-year follow-up, younger patients were twice as likely to develop type II endoleaks. CONCLUSIONS: EVAR can be performed safely and effectively in octogenarians, and the incidence of major complications including myocardial infarction, stroke, and death is unchanged compared with younger patients. However, there is a significantly increased rate of access-site hematomas, pulmonary, and perioperative complications in octogenarians as a whole. Our findings suggest EVAR remains a suitable form of therapy in the elderly group provided there is an appropriate preoperative evaluation and perioperative monitoring following repair
— id: 136563, year: 2010, vol: 52, page: 556, stat: Journal Article,

Comparison of Endovascular and Open Popliteal Artery Aneurysm Repair
Kim, BJ; Garg, K; Rockman, C; Jacobowitz, GR; Maldonado, T; Lamparello, P; Riles, T; Adelman, MA; Veith, FJ; Cayne, NS
2010 JUN ;51(9739):60S-61S, Journal of vascular surgery
— id: 111900, year: 2010, vol: 51, page: 60S, stat: Journal Article,

Endovascular Solutions to Arterial Complications Resulting from Posterior Spine Surgery
Loh, S; Maldonado, T; Berland, T; Rockman, C; Veith, FJ; Cayne, NS
2010 JUN ;51(9739):86S-87S, Journal of vascular surgery
— id: 111901, year: 2010, vol: 51, page: 86S, stat: Journal Article,

Female Patients Undergoing TEVAR May Have an Increased Risk of Postoperative Spinal Cord Ischemia
Shah, Tejas R; Maldonado, Thomas; Bauer, Stephen; Cayne, Neal S; Schwartz, Charles F; Mussa, Firas; Adelman, Mark A; Rockman, Caron
2010 Jul;44(5):350-355, Vascular & endovascular surgery
Background: There is a paucity of literature regarding thoracic endovascular aneurysm repair (TEVAR) in women. We report our institutional experience with TEVAR. Methods: Retrospective chart review was performed from 2004 to 2008. TEVAR was performed in 59 patients; 29 (49%) were female. Results: Mean age was 73.5 years. Mean thoracic aortic aneurysm (TAA) diameter was larger for women (5.9 cm vs 4.7 cm). A trend toward an increase in paraplegia was noted in women, 10.3% vs 4.8%. This may be related to increase in length of aortic coverage in women, 18.2 cm vs 15.2 cm (P < .05). Conclusion: TEVAR in women is safe and effective. The length of aortic coverage is greater in women, which may be related to larger aneurysms and more diffuse disease. This may be associated with a concerning increase in postoperative paraplegia. Women undergoing TEVAR should be considered for prophylactic maneuvers to prevent spinal cord ischemia (SCI), including minimizing length of coverage
— id: 110870, year: 2010, vol: 44, page: 350, stat: Journal Article,

The coronary technique for complex carotid artery stenting in the setting of complex aortic arch anatomy
Solomon, B; Berland, T; Cayne, N; Rockman, C; Veith, Fj; Maldonado, T
2010 Oct;44(7):572-575, Vascular & endovascular surgery
Carotid artery stenting (CAS) remains a viable option for treating carotid artery lesions in high surgical risk patients. We retrospectively reviewed our experience in performing CAS in patients with complex aortic arch anatomy. The ''coronary technique'' uses an AL1 guiding catheter to engage the origin of the common carotid artery permitting delivery of protection device and stent. In total, 12 patients had complex arch anatomy which precluded access using the standard technique as determined on preoperative imaging. A total of 8 patients with such anatomy underwent femoral artery catheterization with placement of an Amplatz AL1 guide catheter into the common carotid artery. All were able to be successfully treated, with no dissection, neurovascular deficit, or other major complication. Based on this case series, we describe the coronary technique as a safe and viable method for CAS in the setting of complex anatomy which might otherwise preclude CAS
— id: 112430, year: 2010, vol: 44, page: 572, stat: Journal Article,

Current status of investigational devices for EVAR: similarities and differences
Cayne, Neal S; Adelman, Mark A; Veith, Frank J
2009 Sep;22(3):127-131, Seminars in vascular surgery
Improvements in the design of endovascular grafts are based on lessons learned from difficulties encountered with prior-generation devices. The most common difficulties in device design relate to how the device is delivered and how it can safely and durably fix the aneurysm. This concept is especially true in patients with difficult anatomy. Difficult anatomy, such as small, calcified, tortuous access vessels and short angulated sealing zones, continue to challenge engineers. Currently, the US Food and Drug Administration has approved eight endovascular devices for the treatment of aortic aneurysms: five for abdominal aortic aneurysms and three for thoracic aortic aneurysms. Compared to the first-generation devices approved in 1999, current devices have smaller and more flexible delivery systems. The devices themselves are more flexible and have better fixation than prior-generation devices. This article will focus on the next generation of devices that are not yet approved, but currently under investigation in the United States
— id: 102501, year: 2009, vol: 22, page: 127, stat: Journal Article,

Outcome of carotid endarterectomy for acute neurological deficit
Mussa, Firas F; Aaronson, Nicole; Lamparello, Patrick J; Maldonado, Thomas S; Cayne, Neal S; Adelman, Mark A; Riles, Thomas S; Rockman, Caron B
2009 Aug-Sep;43(4):364-369, Vascular & endovascular surgery
We reviewed our experience with urgent carotid intervention in the setting of acute neurological deficits. Between June 1992 and August 2008, a total of 3145 carotid endarterectomies (CEA) were performed. Twenty-seven patients (<1.0%) were categorized as urgent. The mean age was 74.1 years (range 56-93 years) with 16 (60%) men, and 11 (40%) women, Symptoms included extremity weakness or paralysis (n = 13), amaurosis fugax (n = 6), speech difficulty (n = 2), and syncope, (n = 3). Three patients exhibited a combination of these symptoms. Three open thrombectomy were performed. Regional anesthesia was used in 13 patients (52%). Seventeen patients (67%), required shunt placement. At 30-days, 2 patient (7%) suffered a stroke, and 1 (4%) died. Urgent CEA can be performed safely. A stroke rate of 7% is acceptable in those who may otherwise suffer a dismal outcome without intervention
— id: 101891, year: 2009, vol: 43, page: 364, stat: Journal Article,

Safety and efficacy of carotid angioplasty and stenting for radiation-associated carotid artery stenosis
Sadek, Mikel; Cayne, Neal S; Shin, Hyun J; Turnbull, Irene C; Marin, Michael L; Faries, Peter L
2009 Dec;50(6):1308-1313, Journal of vascular surgery
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
— id: 105644, year: 2009, vol: 50, page: 1308, stat: Journal Article,

Endovascular repair for ruptured abdominal aortic aneurysms: Why the results vary
Veith F.J.; Cayne N.
2009 ;6(6):165-170, Vascular Disease Management
— id: 106197, year: 2009, vol: 6, page: 165, stat: Journal Article,

Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms
Veith, Frank J; Lachat, Mario; Mayer, Dieter; Malina, Martin; Holst, Jan; Mehta, Manish; Verhoeven, Eric L G; Larzon, Thomas; Gennai, Stefano; Coppi, Gioacchino; Lipsitz, Evan C; Gargiulo, Nicholas J; van der Vliet, J Adam; Blankensteijn, Jan; Buth, Jacob; Lee, W Anthony; Biasi, Giorgio; Deleo, Gaetano; Kasirajan, Karthikeshwar; Moore, Randy; Soong, Chee V; Cayne, Neal S; Farber, Mark A; Raithel, Dieter; Greenberg, Roy K; van Sambeek, Marc R H M; Brunkwall, Jan S; Rockman, Caron B; Hinchliffe, Robert J
2009 Nov;250(5):818-824, Annals of surgery
BACKGROUND: Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial. OBJECTIVE: To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers. METHODS: Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR). RESULTS: Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients. CONCLUSION: These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed
— id: 114564, year: 2009, vol: 250, page: 818, stat: Journal Article,

Hemodynamic changes associated with carotid artery interventions
Cayne, Neal S; Rockman, Caron B; Maldonado, Thomas S; Adelman, Mark A; Lamparello, Patrick J; Veith, Frank J
2008 Sep;20(3):293-296, Perspectives in vascular surgery & endovascular therapy
Carotid artery interventions can be associated with adverse hemodynamic changes, including bradycardia and hypotension. These hemodynamic changes are believed to be caused by direct stimulation of the carotid sinus baroreceptors, mimicking normal physiological response to rises in blood pressure. During open carotid surgery, these hemodynamic changes can be controlled by direct injection of medications that block fast voltage gated sodium channels in the neuron cell membrane, thus preventing depolarization of the presynaptic neuron in the carotid sinus. This form of control is difficult or impossible during percutaneous carotid interventions because direct access to the carotid artery and carotid sinus is not available. This discussion focuses on the cause, effects, and possible treatments for the hemodynamic changes associated with carotid artery stenting procedures
— id: 94023, year: 2008, vol: 20, page: 293, stat: Journal Article,

Early results for below-knee bypasses using Distaflo
Gulkarov, Iosif; Malik, Rajesh; Yakubov, Rakhsim; Gagne, Paul; Muhs, Bart E; Rockman, Caron; Cayne, Neal S; Jacobowitz, Glenn R; Lamparello, Patrick J; Adelman, Mark A; Maldonado, Thomas S
2008 Dec-2009 Jan;42(6):561-566, Vascular & endovascular surgery
In patients who require lower extremity revascularization, prosthetic graft is a reasonable alternative in the absence of a suitable autologous vein conduit. However, prosthetic bypass grafts have limited patency, especially for infrageniculate reconstruction. Polytetrafluoroethylene grafts were geometrically modified at the distal end to increase their patency. The authors reviewed their experience with the Distaflo graft in patients who required lower extremity below-knee popliteal and tibial bypasses when no suitable autologous vein conduit was available. Chart review was conducted of the 57 patients who underwent 60 lower extremity bypasses over a 3-year period between June 2003 and April 2006. Twenty-four revascularizations were constructed to the tibial outflow sites, whereas the remaining grafts were placed to the below-knee (28) and above-knee (8) popliteal artery, respectively. Study endpoints were primary, assisted primary, secondary patency, and limb salvage at the time of follow-up. Distaflo bypass was performed at the infrageniculate level in 86.7% of cases (28 below-knee popliteal, 24 tibial). Mean follow-up time was 12 months (range, 0.5-37.5 months). At 1 year, primary, assisted primary, and secondary patencies and limb salvage rates for below-knee popliteal bypasses were 83.5%, 89.5%, 94.7%, and 94.4%, respectively. Primary, assisted primary, and secondary patencies and limb salvage rates for tibial bypasses were 44.4%, 44.4%, 63.2%, and 74.9%, respectively. Distaflo precuffed graft is a good alternative conduit for below-knee popliteal and tibial lower extremity reconstructions in the absence of an autologous vein and appears to have promising early patency and limb salvage rates even when used for tibial bypasses
— id: 92678, year: 2008, vol: 42, page: 561, stat: Journal Article,

Endovenous procedures in varicose veins What is the best choice today?
Kabnick, LS; Cayne, N; Jacobowitz, G; Lamparello, P; Maldonado, I; Rockman, C; Adelman, M
2008 NOV ;37(5):229-236, Phlebologie
Over the post ten years endoveous treatment options for varicose veins have evovled considerably,offering clinicians a multitude of options to meet the needs of their patients. The endothermal oblation procedures have moved to the forefront as the choice modality for treating truncal reflux. Both radiofrequency ablation and endovenous loser ablation are widely accepted and interchangeable, showing comparable efficacy and safety. Although numerous endovenous loser wavelengths exist, the data indicates that the differences do not affect the efficacy or postoperative recovery of the procedure. The endovenous laser innovation that has shown early evidence of improved patient outcome is the jacket-tip fiber. The versatility of sclefotheropy makes it a critical component in the endovenous treatment of varicosities. Although not approved by the Food and Drug Administration (USA), the use of a foamed sclerosing agent is the fastest growing segment of sclerotherapy and an important treatment modality in the future of varicose vein treatment. Cutaneous losers and intense pulse light devices contribute a crucial element, enabling clinicians to treat minute veins that may be impossible to treat with other therapies
— id: 91326, year: 2008, vol: 37, page: 229, stat: Journal Article,

Incidence and outcome of filter occlusion during carotid artery stent procedure
Maldonado, Thomas S; Loh, Shang; Fonseco, Rodrigo; Poblete, Honesto; Adelman, Mark A; Cayne, Neal S; Mussa, Firas; Rockman, Caron B; Sadik, Michael; Ellozy, Sharif; Faries, Peter
2008 Nov;22(6):756-761, Annals of vascular surgery
Recent reviews of device-specific complications using neuroprotection have addressed technical difficulties during delivery as well as adverse outcomes, intraoperative and 30-day. Little has been written, however, regarding the relevance of filter occlusion during the carotid stent procedure. A retrospective review was conducted of patients undergoing carotid artery stent procedures using a variety of neuroprotection devices from 2003 to 2007. Prospective databases from two institutions were examined for incidence and management of filter occlusions during procedures as well as adverse neurological events (intraoperative and 30-day) associated with filter occlusion. There were 283 carotid artery stent procedures performed on 256 patients (163 male, 93 female): 177 (62.5%) arteries were asymptomatic and 106 were symptomatic. Neurological adverse events occurred in six patients (2.1%); three of these resolved completely at 72 hr. Neuroprotection was used in 95% of all patients, and filters were used in 221 stent procedures: Boston Scientific Filter Wire (n = 81), Guidant Accunet (n = 100), Angioguard (n = 17), and Abbot Emboshield (n = 23). Filter occlusion occurred in 11 patients (4.9%) in whom this form of neuroprotection was employed: Angioguard (n = 5), Accunet (n = 2), Emboshield (n = 2), and EPI Filter wire (n = 2). Two of the 11 patients with filter occlusions suffered a neurological event. There was no correlation between filter occlusion and gender, symptoms, stent, or filter type (p > 0.05). Filter occlusion was managed with export catheter-directed aspiration in seven patients and with prompt filter retrieval in five patients. Filter occlusion is an infrequent event that does not appear to be filter-specific and can be managed successfully by catheter-directed aspiration or filter retrieval. The majority of patients with filter occlusion do not suffer from atheroemboli as a result of this occlusion
— id: 91485, year: 2008, vol: 22, page: 756, stat: Journal Article,

Total Viabahn endoprosthesis collapse
Ranson, Mark E; Adelman, Mark A; Cayne, Neal S; Maldonado, Thomas S; Muhs, Bart E
2008 Feb;47(2):454-456, Journal of vascular surgery
We present a case of Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) collapse during popliteal artery aneurysm treatment. An elderly man with severe comorbidities presented with a 34-mm popliteal artery aneurysm. Proximal and distal landing sites of 11 and 9 mm, respectively, demonstrated by preoperative computed tomography angiography were confirmed by intraoperative angiography. After Viabahn deployment, angiography revealed a filling defect in the distal popliteal graft with poor flow. Balloon dilatation failed. A femoropopliteal bypass with aneurysm ligation was performed. Transection of the distal popliteal vessel demonstrated complete infolding. Our choice of grafts represented 15% to 18% proximal and distal oversizing. Focal areas of relative vessel narrowing may lead to incomplete graft unfolding and graft failure
— id: 76343, year: 2008, vol: 47, page: 454, stat: Journal Article,

"Unpredictable" late rupture of an abdominal aortic aneurysm after bifurcated Ancure endograft repair
Rosen, Noah A; Cayne, Neal S; Macari, Michael; Jacobowitz, Glenn R
2008 Feb-Mar;42(1):69-73, Vascular & endovascular surgery
The goal of endovascular repair of an abdominal aortic aneurysm is to exclude the aneurysm from systemic arterial pressure, thereby preventing rupture. However, the long-term durability of endovascular repair continues to be in question, as aneurysm rupture after endovascular repair continues to be reported. We report the case of an 89-year-old patient who underwent endovascular repair of a 7.1-cm abdominal aortic aneurysm with an Ancure endograft 5 years earlier. Despite close follow-up and a shrinking aneurysm sac on annual contrast-enhanced computed tomography, he presented with aneurysm rupture and a new proximal type I endoleak. The endoleak and rupture were successfully repaired with endovascular placement of a main body extension
— id: 78735, year: 2008, vol: 42, page: 69, stat: Journal Article,

Use of a retrievable suprarenal inferior vena cava filter as a primary intervention for postpartum ovarian vein thrombosis: a case report
Sinha, Sara; Roman, Ashley S; Cayne, Neal S; Saltzberg, Stephanie; Rebarber, Andrei
2008 Feb;53(2):135-137, Journal of reproductive medicine
BACKGROUND: Postpartum ovarian vein thrombosis is a rare diagnosis with a significant associated risk of pulmonary embolism. The mainstay of therapy consists of intravenous antibiotics and anticoagulation. CASE: A 30-year-old woman presented with fever and abdominal pain 3 days after cesarean section and was found to have an ovarian vein thrombosis on computed tomography. Given her history of cerebral arteriovenous malformation and the attendant risk for cerebral hemorrhage with the use of anticoagulation, she was successfully treated with a removable suprarenal inferior vena cava (IVC) filter and intravenous antibiotics. CONCLUSION: For patients who fail to respond to anticoagulation alone or in whom anticoagulation is contraindicated, placement of a retrievable suprarenal IVC filter is a viable treatment option in the setting of postpartum ovarian vein thrombosis
— id: 76856, year: 2008, vol: 53, page: 135, stat: Journal Article,

Multidimensional characterization of carotid artery stenosis using CT imaging: a comparison with ultrasound grading and peak flow measurement
van Prehn, J; Muhs, B E; Pramanik, B; Ollenschleger, M; Rockman, C B; Cayne, N S; Adelman, M A; Jacobowitz, G R; Maldonado, T S
2008 Sep;36(3):267-272, European journal of vascular & endovascular surgery
PURPOSE: Clinical decision making for carotid surgery depends largely upon stenosis grade. While digital subtraction angiography remains the gold standard for stenosis grading, many physicians use less invasive modalities. The purpose of this study was to compare the results of multidimensional Computed tomography (CTA) with ultrasound (US) grading and peak flow velocity (PSV). METHODS: 37 stenosed carotid arteries were studied retrospectively in 36 consecutive patients. US grading and PSV were compared to multidimensional CTA analysis (diameter, area and volumetric measurements), performed by a medical software company. Calculations of stenosis percentage on CTA were made using the NASCET and ECST methodology. Diameter measurements were also performed by a neuroradiologist. RESULTS: All CTA diameter, area and volume measurements had only modest correlation with PSV (r<0.5) and ultrasound grading (p<0.5). There was concordant classification of stenosis grades in only 40-60% of cases. CTA diameter, area and volume measurements had good correlation (0.69<r<0.87) with one another using ECST methodology. Using NASCET methodology on CTA, correlation between diameter and area was insignificant (r=0.32). CTA volumetric analysis with the NASCET method yielded 27 negative stenosis grades. Repeatability coefficient for selecting the normal distal ICA 20 mm more distally was 20% for diameter and 43% for area. CTA diameter interobserver repeatability coefficients were 22.9% (NASCET) and 17.8% (ECST) and 0.7 mm (lumen) and 1.9 mm (vessel). CONCLUSIONS: All CTA measurements showed moderate correlation with both ultrasound grading and PSV. Selection of the level of the normal distal ICA influences the NASCET calculations and can produce discrepant stenosis grades. Multidimensional CTA analysis seems to have no additional value for stenosis grading, but provides other useful anatomic information
— id: 106167, year: 2008, vol: 36, page: 267, stat: Journal Article,

Regional nerve block allows for optimization of planning in the creation of arteriovenous access for hemodialysis by improving superficial venous dilatation
Laskowski, I A; Muhs, B; Rockman, C R; Adelman, M A; Ranson, M; Cayne, N S; Leivent, J A; Maldonado, T S
2007 Nov;21(6):730-733, Annals of vascular surgery
Durable vascular access for hemodialysis remains a critical issue in end-stage renal disease patients. Creation of an autogenous arteriovenous (AV) fistula in the most distal location of the nondominant extremity is the preferred technique and provides superior patency over an AV graft. Others have shown that regional anesthesia in the form of axillary block results in the dilatation of the native veins and allows for their increased utilization in creating AV fistulae. We report on 26 patients undergoing creation of a vascular access for hemodialysis. Regional anesthesia consisting of axillary nerve block was used in all cases. All surgical plans with regard to the site and type of access were made based on the physical exam and ultrasound vein measurements taken prior to surgery. On the day of surgery patients were reevaluated with venous ultrasound using tourniquet before and after administration of the regional block. The previously determined operative plan either remained unchanged or was modified depending on the venous dilatation noted after administration of regional block. Among 26 patients, average vein diameter increased from 0.29 +/- 0.12 cm to 0.34 +/- 0.11 cm (P = 0.008). Twenty-one of 26 patients had no modification in operative plan (group 1). Five had some modification of the original operative plan (group 2): AV graft to a brachial vein transposition (n = 2), AV graft to a Cimino fistula (n = 2), and brachiocephalic to a Cimino (n = 1). The average follow-up for all patients was 82.6 +/- 75.6 days and did not differ between the groups. There was one failure in a patient from group 1, and there was no significant difference in the patency rate between study groups (P = 0.29). Following regional nerve block, operative plans in patients undergoing AV access surgery were modified in 29.4% of patients undergoing creation of an AV access for hemodialysis; either from graft to fistula creation or from the proximal to more distal fistula site. The routine use of regional anesthesia as well as intraoperative ultrasound during AV access surgery can lead to improved site selection and increased opportunity for AV fistula creation
— id: 75652, year: 2007, vol: 21, page: 730, stat: Journal Article,

Decreased ischemic complications after endovascular aortic aneurysm repair with newer devices
Maldonado, Thomas S; Ranson, Mark E; Rockman, Caron B; Pua, Brad; Cayne, Neal S; Jacobowitz, Glenn R; Adelman, Mark A
2007 Jun-Jul;41(3):192-199, Vascular & endovascular surgery
Ischemic complications after endovascular abdominal aortic aneurysm repair (EVAR) are well-recognized and have been reported to be as high as 9%. The goal of our study was to examine the incidence, management, and outcome of ischemic complications at our institution after EVAR and to compare complications according to graft type and time period. This is a retrospective review of all EVARs performed at our institution from 1993 through 2005 (n = 430). EVAR was performed in asymptomatic patients in most cases. Follow-up consisted of a computed tomography scan and office visit at 1, 6, and 12 months and yearly thereafter. Ischemic complications after EVAR have decreased significantly with the advent of lower-profile devices with easier delivery systems and supported limbs. Simultaneous coil embolization of internal iliac artery at the time of EVAR implant does not appear to increase the risk of pelvic or lower-extremity ischemia, can be done safely, and does not need to be staged
— id: 73863, year: 2007, vol: 41, page: 192, stat: Journal Article,

Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes
Rockman, Caron B; Maldonado, Thomas S; Jacobowitz, Glenn R; Cayne, Neal S; Gagne, Paul J; Riles, Thomas S
2006 Sep;44(3):480-487, Journal of vascular surgery
OBJECTIVE: The optimal timing of carotid endarterectomy (CEA) after ipsilateral hemispheric stroke is controversial. Although early studies suggested that an interval of about 6 weeks after a completed stroke was preferred, more recent data have suggested that delaying CEA for this period of time is not necessary. With these issues in mind, we reviewed our experience to examine perioperative outcome with respect to the timing of CEA in previously symptomatic patients. METHODS: A retrospective review of a prospectively maintained database of all CEAs performed at our institution from 1992 to 2003 showed that 2537 CEA were performed, of which 1,158 (45.6%) were in symptomatic patients. Patients who were operated on emergently <or=48 hours of symptoms for crescendo transient ischemic attacks (TIAs) or stroke-in-evolution were excluded from analysis (n = 25). CEA was considered 'early' if performed <or=4 weeks of symptoms, and 'delayed' if performed after a minimum of a 4-week interval following the most recent symptom. RESULTS: Of nonurgent CEAs in symptomatic patients, in 87 instances the exact time interval from symptoms to surgery could not be precisely determined secondary to the remoteness of the symptoms (>18 months), and these were excluded from further analysis. Of the remaining 1,046 cases, 62.7% had TIAs and 37.3% had completed strokes as their indication for surgery. Among the entire cohort, patients who underwent early CEA were significantly more likely to experience a perioperative stroke than patients who underwent delayed CEA (5.1% vs 1.6%, P = .002). Patients with TIAs alone were more likely to be operated on early rather than in a delayed fashion (64.3% vs 46.7%, P < .0001), likely reflecting institutional bias in selecting delayed CEA for stroke patients. However, even when examined as two separate groups, both TIA patients (n = 656) and CVA patients (n = 390) were significantly more likely to experience a perioperative stroke when operated upon early rather than in a delayed fashion (TIA patients, 3.3% vs 0.9%, P = .05; CVA patients, 9.4% vs 2.4%, P = .003). There were no significant differences in demographics or other meaningful variables between patients who underwent early CEA and those who underwent delayed CEA. CONCLUSIONS: In a large institutional experience, patients who underwent CEA <or=4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke compared with patients who underwent CEA in a more delayed fashion. This was true for both TIA and stroke patients, although the results were more impressive among stroke patients. On the basis of these results, we continue to recommend that waiting period of 4 weeks be considered in stroke patients who are candidates for CEA
— id: 68644, year: 2006, vol: 44, page: 480, stat: Journal Article,

Cardiac Catheterization and Percutaneous Interventions
Cayne N
2005 Mar 4;19(2):292-292, Annals of vascular surgery
— id: 48699, year: 2005, vol: 19, page: 292, stat: Journal Article,

Carotid angioplasty and stent-induced bradycardia and hypotension: Impact of prophylactic atropine administration and prior carotid endarterectomy
Cayne, Neal S; Faries, Peter L; Trocciola, Susan M; Saltzberg, Stephanie S; Dayal, Rajeev D; Clair, Daniel; Rockman, Caron B; Jacobowitz, Glenn R; Maldonado, Thomas; Adelman, Mark A; Lamperello, Patrick; Riles, Thomas S; Kent, K Craig
2005 Jun;41(6):956-961, Journal of vascular surgery
Objective We compared the physiologic effect of selective atropine administration for bradycardia with routine prophylactic administration, before balloon inflation, during carotid angioplasty and stenting (CAS). We also compared the incidence of procedural bradycardia and hypotension for CAS in patients with primary stenosis vs those with prior ipsilateral carotid endarterectomy (CEA). Methods A total of 86 patients were treated with CAS at 3 institutions. Complete periprocedural information was available for 75 of these patients. The median degree of stenosis was 90% (range, 60%-99%). Indications for CAS were severe comorbidities (n = 49), prior CEA (n = 21), and prior neck radiation (n = 5). Twenty patients with primary lesions were treated selectively with atropine only if symptomatic bradycardia occurred (nonprophylactic group). Thirty-four patients with primary lesions received routine prophylactic atropine administration before balloon inflation or stent deployment (prophylactic group). The 21 patients with prior CEA received selective atropine treatment only if symptomatic bradycardia occurred (prior CEA group) and were analyzed separately. Mean age and cardiac comorbidities did not vary significantly either between the prophylactic and nonprophylactic atropine groups or between the primary and prior CEA patient groups. Outcome measures included bradycardia (decrease in heart rate >50% or absolute heart rate <40 bpm), hypotension (systolic blood pressure <90 mm Hg or mean blood pressure <50 mm Hg), requirement for vasopressors, and cardiac morbidity (myocardial infarction or congestive heart failure). Results The overall incidence of hypotension and bradycardia in patients treated with CAS was 25 (33%) of 75. A decreased incidence of intraoperative bradycardia (9% vs 50%; P < .001) and perioperative cardiac morbidity (0% vs 15%; P < .05) was observed in patients with primary stenosis who received prophylactic atropine as compared with patients who did not receive prophylactic atropine. CAS after prior CEA was associated with a significantly lower incidence of perioperative bradycardia (10% vs 33%; P < .05), hypotension (5% vs 32%; P < .05), and vasopressor requirement (5% vs 30%; P < .05), with a trend toward a lower incidence of cardiac morbidity (0% vs 6%; not significant) as compared with patients treated with CAS for primary carotid lesions. There were no significant predictive demographic factors for bradycardia and hypotension after CAS. Conclusions The administration of prophylactic atropine before balloon inflation during CAS decreases the incidence of intraoperative bradycardia and cardiac morbidity in primary CAS patients. Periprocedural bradycardia, hypotension, and the need for vasopressors occur more frequently with primary CAS than with redo CAS procedures. On the basis of our data, we recommend that prophylactic atropine administration be considered in patients with primary carotid lesions undergoing CAS
— id: 55781, year: 2005, vol: 41, page: 956, stat: Journal Article,

Gadolinium-enhanced versus time-of-flight magnetic resonance angiography: what is the benefit of contrast enhancement in evaluating carotid stenosis?
Muhs, Bart E; Gagne, Paul; Wagener, Jael; Baker, Jessica; Ortega, Marta Ramirez; Adelman, Mark A; Cayne, Neal S; Rockman, Caron B; Maldonado, Thomas
2005 Nov;19(6):823-828, Annals of vascular surgery
Accurate patient selection based on preoperative imaging is imperative to good risk reduction in patients undergoing carotid endarterectomy (CEA). The goal of this study was to assess the accuracy of gadolinium-enhanced magnetic resonance angiography (GE MRA) versus time-of-flight (TOF) MRA in the work-up of patients undergoing CEA. Patients undergoing CEA between 1999 and 2001 were identified from a prospectively maintained institutional database. GE or TOF MRA was obtained on extracranial carotid arteries (n = 319) in patients undergoing CEA. Stenosis on MRA images was graded as moderate (n = 76) or severe (n = 243) by an attending radiologist who was blind to duplex results. Duplex imaging was performed in an Intersocietal Commission for the Accreditation of Vascular Labs (ICAVL) accredited lab, and stenosis was stratified as moderate (50-79%, n = 76) or high (80-99%, n = 243) grade using University of Washington criteria. For each patient, the degree of stenosis as determined by MRA (GE versus TOF) was compared to percent stenosis on duplex. For moderate-grade lesions, GE MRA concurred with duplex in 11.1% (4/36), underestimated in 2.8% (1/36), and overestimated in 86.1% (31/36) of carotid arteries imaged. TOF MRA concurred with duplex in 35% (14/40), underestimated in 0% (0/40), and overestimated in 65% (26/40) of carotid arteries. High-grade lesions demonstrated improved concordance between MRA and duplex. For these lesions, GE MRA concurred with duplex in 95.6% (130/136) of carotid arteries imaged, never overestimated stenosis (0/136), and underestimated in 4.4% (6/136). TOF MRA concurred with duplex 96.3% (103/107), overestimated stenosis as an occlusion in 0.9% (1/107), and underestimated in 2.8% (3/107). In addition to neck visualization, the GE technique allowed simultaneous aortic arch imaging. This was accomplished in 79.1% (136/172) of all GE MRAs. Simultaneous aortic arch imaging was not technically feasible with TOF MRA. For moderate-grade lesions, both MR techniques are inaccurate predictors of degree of carotid stenosis and result in a significant overestimation of stenosis. Each technique demonstrates improved concordance with duplex ultrasound in the setting of severe carotid artery stenoses. The ability of GE MRA to simultaneously image the aortic arch and the neck may allow for detection of occult tandem lesions and other anatomic variations, which may be particularly important in preoperative planning for carotid artery stenting
— id: 61845, year: 2005, vol: 19, page: 823, stat: Journal Article,

Erratum: Interval gangrene complicating superficial femoral artery stent placement (Journal of Vascular Surgery (2005) 42 (564-566))
Pua BB; Muhs BE; Parikh MS; Cayne N; Lamparello PJ
2005 ;42(6):1285-1285, Journal of vascular surgery
— id: 61430, year: 2005, vol: 42, page: 1285, stat: Journal Article,

Bilateral gluteal compartment syndrome after elective unilateral hypogastric artery ligation and revascularization of the contralateral hypogastric artery during open abdominal aortic aneurysm repair
Pua, Bradley B; Muhs, Bart E; Cayne, Neal S; Dobryansky, Michael; Jacobowitz, Glenn R
2005 Feb;41(2):337-339, Journal of vascular surgery
Gluteal compartment syndrome is an uncommon entity that has been described in the literature after drug overdose and orthopedic procedures. We describe the first case of bilateral gluteal compartment syndrome that followed pelvic revascularization after the repair of an abdominal aortic aneurysm with bilateral common and internal iliac aneurysms. The patient was treated with aggressive fluid hydration and bilateral gluteal fasciotomies with resolution. The bilateral gluteal compartment syndrome was likely caused by increased pressure on the gluteal muscles, secondary to increased patient weight combined with a period of local ischemia to the watershed areas during iliac cross-clamp
— id: 48993, year: 2005, vol: 41, page: 337, stat: Journal Article,

The safety of carotid endarterectomy in diabetic patients: clinical predictors of adverse outcome
Rockman, Caron B; Saltzberg, Stephanie S; Maldonado, Thomas S; Adelman, Mark A; Cayne, Neal S; Lamparello, Patrick J; Riles, Thomas S
2005 Nov;42(5):878-883, Journal of vascular surgery
OBJECTIVES: Patients with diabetes mellitus have been shown to have an increased incidence of complications after elective major vascular surgery. The objective of this study was to evaluate a large series of diabetic patients undergoing carotid endarterectomy (CEA) to determine if outcome differed from nondiabetic patients and to examine predisposing factors of poor outcome among diabetic patients. METHODS: A retrospective review of a prospectively compiled database was performed. From 1992 through 2000, 2151 CEAs were performed at our institution. Of these, 507 were in diabetic patients (23.6%), and the remaining 1644 procedures were in nondiabetic patients (76.4%). RESULTS: Diabetic patients were significantly more likely than nondiabetic patients to have hypertension (70.8% vs 64.5%, P = .01) and cardiac disease (54.6% vs 49.1%, P = .03). They were more likely than nondiabetic patients to be symptomatic before surgery (52.5% vs 47.1%, P = .04) and to have sustained a preoperative stroke (21.3% vs 17.7%, P = .07). No differences were noted in other recorded demographic factors or in intraoperative factors between diabetic and nondiabetic patients. Despite these differences, diabetic patients had similar perioperative outcomes compared with nondiabetic patients, including perioperative myocardial infarction (0.6% vs 0.4%, P = NS), perioperative death (0.8% vs 0.5%, P = NS), and perioperative neurologic events such as transient ischemic attack and stroke (3.2% vs 2.4%, P = NS). Among diabetic patients alone, cigarette smoking, general anesthesia, the use of a shunt, and the lack of clamp tolerance while under regional anesthesia predicted adverse perioperative neurologic outcome, and contralateral occlusion was associated with increased perioperative mortality. CONCLUSIONS: Despite an increased prevalence of cardiac disease and preoperative neurologic symptoms among diabetic patients undergoing CEA, the rates of perioperative cardiac morbidity, mortality, and stroke were equal to nondiabetic patients. In contrast to nondiabetic patients, current cigarette smoking appeared to predict increased adverse neurologic outcomes among diabetic patients, and the presence of contralateral occlusion among diabetic patients appeared to predispose them towards increased perioperative mortality. The use of a general anesthetic appeared to increased perioperative neurologic risk among diabetic patients; however, this may be related to surgeon bias in the selection of anesthetic technique. Although diabetic patients may have an increase in complications after other major vascular surgical procedures, the presence of diabetes mellitus does not appear to significantly increase risk
— id: 68645, year: 2005, vol: 42, page: 878, stat: Journal Article,

Is Endovascular Therapy the Preferred Treatment for All Visceral Artery Aneurysms?
Saltzberg, Stephanie S; Maldonado, Thomas S; Lamparello, Patrick J; Cayne, Neal S; Nalbandian, Matthew M; Rosen, Robert J; Jacobowitz, Glenn R; Adelman, Mark A; Gagne, Paul J; Riles, Thomas S; Rockman, Caron B
2005 Jul;19(4):507-515, Annals of vascular surgery
Endovascular intervention can provide an alternative method of treatment for visceral artery aneurysms. We conducted a retrospective review of all patients with visceral artery aneurysms at a single university medical center from 1990 to 2003, focusing on the outcome of endovascular therapy. Sixty-five patients with visceral artery aneurysms were identified: 39 splenic (SAA), 13 renal, seven celiac, three superior mesenteric (SMA), and three hepatic. Eleven patients (16.9%) had symptoms attributable to their aneurysms, which included a total of four ruptures (6.2%): three splenic and one hepatic. Management consisted of 18 (27.7%) endovascular interventions, nine (13.9%) open surgical repairs, and 38 (58.5%) observations. Mean aneurysm diameter for patients treated expectantly was significantly less than for those who underwent intervention (p = 0.001). Endovascular interventions included 15 (83.3%) embolizations (11 SAA, three renal, one hepatic) and three (16.7%) stent grafts (two SMA, one renal). The initial technical success rate of the endovascular procedures was 94.4% (17/18). However, there were four patients (22.2%) with major endovascular procedure-related complications: one late recurrence requiring open surgical repair, two large symptomatic splenic infarcts, and one episode of severe pancreatitis. These four patients had distal splenic artery aneurysms at or adjacent to the splenic hilum. There were no endovascular procedure-related deaths. Reasons for performing open surgical repair included three SAA ruptures diagnosed at laparotomy and complex anatomy not amenable to endovascular intervention (six patients). One surgical patient had a postoperative small bowel obstruction treated nonoperatively; and there was one perioperative death in a patient operated on emergently for rupture. Endovascular management of visceral artery aneurysms is a reasonable alternative to open surgical repair in carefully selected patients. Individual anatomic considerations play an important role in determining the best treatment strategy if intervention is warranted. However, four of 11 (36.4%) patients with distal splenic artery aneurysms treated with endovascular embolization developed major complications. Based on our experience, traditional surgical treatment of SAA with repair or ligation and concomitant splenectomy when necessary may be preferred in these cases
— id: 56278, year: 2005, vol: 19, page: 507, stat: Journal Article,

Variability of maximal aortic aneurysm diameter measurements on CT scan: significance and methods to minimize
Cayne, Neal S; Veith, Frank J; Lipsitz, Evan C; Ohki, Takao; Mehta, Manish; Gargiulo, Nick; Suggs, William D; Rozenblit, Alla; Ricci, Zina; Timaran, Carlos H
2004 Apr;39(4):811-815, Journal of vascular surgery
OBJECTIVES: We noted substantial differences when measuring repeatedly the same abdominal aortic aneurysm (AAA) on the same computed tomography (CT) scan. This study quantitated this variability, and methods to minimize it were developed. METHODS: The CT maximal diameter of 25 AAAs was measured by eight experienced observers, including six vascular surgeons and two radiologists, using two methods: an unstandardized protocol, and a standardized protocol using fine calipers to carefully measure the largest diameter perpendicular to the estimated aneurysm centerline, from outer aneurysm wall to outer wall. The average measurement difference between observers was calculated for each method. The average difference between each observer's measurement and the official radiology report value was also calculated. Agreement between the two measurement methods was assessed with Bland-Altman plots. RESULTS: The difference in maximal diameter measurements between each observer averaged 4.0 +/- 5.1 mm (range, 0.0-35.0 mm) with the unstandardized method. The mean measurement difference with the standardized protocol was significantly lower, and averaged 2.8 +/- 4.4 mm (range, 0.0-26.0 mm; P <.05). Measurements taken from the official radiology report differed from each of the observer's standardized measurement by an average of 5.0 +/- 6.3 mm (range, 0.0-28.0 mm). This difference was similar for both the unstandardized and standardized methods. Bland-Altman plots confirmed the wide variation of the maximal diameter measurements when the unstandardized method was compared with the standardized method (95% confidence interval, -9-9 mm). CONCLUSIONS: Routine CT maximal diameter measurement of AAAs can have substantial interobserver variability. Standardized measurement protocols can decrease, but not eliminate, this measurement variability. Thus apparent size changes based on CT measurements may represent measurement artifact rather than actual aneurysm growth or shrinkage, particularly when a standardized system is not used
— id: 42274, year: 2004, vol: 39, page: 811, stat: Journal Article,

Discontinuous, staccato growth of abdominal aortic aneurysms
Kurvers, Harrie; Veith, Frank J; Lipsitz, Evan C; Ohki, Takao; Gargiulo, Nicholas J; Cayne, Neal S; Suggs, William D; Timaran, Carlos H; Kwon, Grace Y; Rhee, Soo J; Santiago, Christian
2004 Nov;199(5):709-715, Journal of the American College of Surgeons
BACKGROUND: To evaluate whether abdominal aortic aneurysm (AAA) growth in individual patients can be characterized as continuous or discontinuous (staccato). STUDY DESIGN: From 1996 to 2002, 609 patients presented with unruptured AAAs. Of these, 278 underwent prompt repair and 331 were observed. In this study, we included 52 patients (16% of the latter group) who had at least four CT scans and were observed for 18 months or longer without any intervention. AAA growth was defined as any increase in diameter of >/= 3 mm over any observation period(s). AAA nongrowth was defined as absence of growth for at least 6 months. Staccato growth was defined as at least one period of nongrowth combined with at least one period of growth. RESULTS: The 52 patients had a mean age of 75 +/- 8 (SD) years. The mean observation period was 42 +/- 20 months and the mean AAA diameter growth rate was 3.6 +/- 2.4 mm/y. Only 12 of these 52 patients (23%) demonstrated continuous growth. Staccato growth occurred in 34 patients (65%). Six patients (12%) showed no growth at all over 18 to 57 months (mean 30 months). No correlation was observed between initial diameter of AAAs and a patient's individual growth rate during the whole observation period (R = 0.04, p = 0.46). CONCLUSIONS: Individual AAA behavior is usually characterized by periods of nongrowth alternating with periods of growth, ie, staccato growth. Some aneurysms may have long periods of nongrowth. Accordingly, management decisions cannot be based on the presumption that observed growth rates of AAAs can be extrapolated to predict future growth rates
— id: 45469, year: 2004, vol: 199, page: 709, stat: Journal Article,

Ischemic complications after endovascular abdominal aortic aneurysm repair
Maldonado, Thomas S; Rockman, Caron B; Riles, Eric; Douglas, Diah; Adelman, Mark A; Jacobowitz, Glenn R; Gagne, Paul J; Nalbandian, Matthew N; Cayne, Neal S; Lamparello, Patrick J; Salzberg, Stephanie S; Riles, Thomas S
2004 Oct;40(4):703-710, Journal of vascular surgery
Objectives Limb and pelvic ischemia are known complications after endovascular abdominal aortic aneurysm repair (EVAR). The objective of this paper is to present our experience with the incidence, presentation, and management of such complications. Methods Over 9 years 311 patients with aortic aneurysms underwent EVAR. A retrospective review identified 28 patients (9.0%) with ischemic complications. Results Among 28 patients with ischemic complications, 21 had lower extremity ischemia and 7 had pelvic ischemia: colon (n = 4), buttock (n = 2), and spinal cord (n = 2). Of the 21 patients with lower extremity ischemia, 15 had limb occlusions (71.4%), 3 due to embolization (14.7%) and 3 the result of common femoral artery thromboses (14.7%). Limb occlusions were manifested as severe acute arterial ischemia (n = 6), rest pain (n = 3), intermittent claudication (n = 5), and decreased femoral pulse (n = 1). Limb occlusions were managed with thrombectomy and stent placement (n = 4), femorofemoral bypass (n = 7), eventual explantation because of persistent endoleak (n = 1), and expectant management (n = 3). The 3 patients with occlusions managed expectantly all had intermittent claudication, which has subsequently improved. In the 6 patients with lower extremity ischemia due to embolization or common femoral artery injury presentation was acute, and embolectomy was performed, followed by femoral artery endarterectomy and patch angioplasty or placement of an interposition graft. One patient who had a prolonged postoperative course including cardiac arrest subsequently required distal bypass and ultimately above- knee amputation. Among the 7 patients with pelvic ischemia, 2 patients had unilateral hypogastric artery embolization before the original surgery. Among the patients with colonic ischemia, 3 were seen immediately postoperatively, and required colectomy and colostomy. Two patients who required urgent colectomy subsequently had multiple organ failure, and died in the perioperative period. One patient had abdominal pain 1 week after surgery, which was managed with bowel rest, with subsequent improvement. In 2 patients spinal cord ischemia developed immediately after surgery, w hich resulted in persistent paraplegia. Buttock ischemia developed in 2 patients, 1 of whom required fasciotomy because of gluteal compartment syndrome, and had transient renal failure. Conclusions Ischemic complications are not uncommon after EVAR, and may exceed the incidence with open surgical repair. Limb ischemia is most often a result of limb occlusion, and can be successfully managed with standard interventions. Pelvic ischemia often results from atheroembolization despite preservation of hypogastric arterial circulation. Colonic and spinal ischemia are associated with the highest morbidity and mortality
— id: 45296, year: 2004, vol: 40, page: 703, stat: Journal Article,

Relationship of proximal fixation to renal dysfunction in patients undergoing endovascular aneurysm repair
Mehta, M; Cayne, N; Veith, F J; Darling, R C 3rd; Roddy, S P; Paty, P S K; Ozsvath, K J; Kreienberg, P B; Chang, B B; Shah, D M
2004 Aug;45(4):367-374, Journal of cardiovascular surgery
Technological advancements have lead to dramatic improvements in stentgraft device design resulting in more trackable delivery systems and transrenal uncovered stents and barbs for better fixation. Transrenal bare-stents may limit stentgraft migration, particularly in patients with short or flared proximal aortic necks. However, potential disadvantages might be in worsening renal function, particularly in patients with preexisting renal insufficiency. We retrospectively analyzed our recent 7 year experience of patients undergoing endovascular aneurysm repair (EVAR) using a variety of stentgrafts with and without transrenal bare-stent fixation. Patients were divided into 2 groups; infrarenal fixation (IRF) vs transrenal fixation (TRF), or patients with preoperative serum Cr values that were normal (=/<1.5 mg/dl) vs slightly elevated (1.6-2 mg/dl), vs markedly elevated (2.1- 3.5 mg/dl). The exclusion criteria included patients with chronic renal insufficiency (CRI) on hemodialysis, and preoperative high-grade renal artery stenoses requiring angioplasty and stenting. Of 705 patients that underwent EVAR, 496 (IRF: 385 [78%], and TRF: 111 [22%]) were available with routine evaluations of serum Cr and CT scans. Preexisting comorbidities, mean procedure contrast volume, and postprocedure follow-up were similar in both groups. In the immediate postoperative period, mean serum Cr did not change significantly in either the IRF group (1.3+/-0.7 mg/dl to 1.2+/-0.9 mg/dl) or the TRF group (1.3+/-0.5 mg/dl to 1.3+/-0.6 mg/dl). Mean serum Cr did, however, significantly increase over longer follow-up in both groups: 1.4+/-0.8 mg/dl for IRF (P<0.03), and 1.5 +/- 0.8 mg/dl for TRF (P<0.01). Cr clearance was similarly unchanged in the immediate postoperative period (58+/-23 to 61+/-25 ml/min/1.73 m(2) for IRF group, 53+/-17 to 55+/-17 ml/min/1.73 m(2) for TRF group), but was significantly decreased in longer follow-up (53+/-23 ml/min/1.73 m(2) for IRF, p<0.02: and 48+/-16 ml/min/1.73 m(2) for TRF, P<0.01). There were no significant differences in serum Cr increase (p=0.19) or Cr clearance decrease (p=0.68) between the IRF and TRF groups. Small renal infarcts were noted in 6 patients (1.6%) in the IRF group, and in 8 patients (7%) in the TRF group (p=0.37). Of patients with normal preoperative renal function, renal dysfunction developed in 7.7% of IRF group and 6.1% of TRF group (p=0.76). In patients with preexisting CRI, renal dysfunction developed in 18.2% of IRF group, and 17.1% of TRF group (p=0.95). Eight patients with postoperative renal dysfunction, 5 (1.3%) from IRF group and 3 (2.7%) from TRF group subsequently required hemodialysis, and this difference was not statistically significant (p=0.91). We also analyzed 200 consecutive patients undergoing EVAR with intra-arterial contrast agents with and without preexisting CRI not on dialysis. The groups were identified on the basis of preprocedure serum Cr: group 1 (n=108), Cr less than 1.5 mg/dL (normal range); group 2 (n=65), Cr 1.5 to 2.0 mg/dL; group 3 (n=27), Cr 2.1 to 3.5 mg/dL. Routine precautions in patients with CRI included preoperative intravenous hydration with 2 L of normal saline solution, discontinuation of all nephrotoxic drugs, intraoperative administration of mannitol (0.5 g/kg intravenously), and use of nonionic, low osmolar intra-arterial contrast agent (Omnipaque 350). One-hundred and eight patients had normal renal function (group 1), and 92 patients had preexisting CRI with baseline Cr 1.5 to 2.0 mg/dL (group 2, n=65) or 2.1 to 3.5 mg/dL (group 3, n=27). Comorbid conditions included coronary artery disease (group 1, 51%; group 2, 49%; group 3, 59%), hypertension (group 1, 39%; group 2, 46%; group 3, 52%), and diabetes mellitus (group 1, 25%; group 2, 35%; group 3, 48%). In groups 1, 2, and 3, the mean volume of low osmolar contrast agent used was 210 cc, 160 cc, 130 cc, respectively; hemodynamic instability developed in 3, 1, and 1 patient, respectively. The incidence of postoperative complications between the 3 study groups was not statistically different. In grications between the 3 study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in 3 patients (2.7%), 2 of whom (1.9%) required temporary hemodialysis and 1 (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in 2 patients (3.1%); both patients (3.1%) required temporary hemodialysis, and 1 patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in 2 patients (7.4%); 1 patient (3.7%) required temporary hemodialysis, and 1 patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (p<0.05), and larger contrast volume was associated with an increase in serum Cr (p<0.05) during the postoperative period. Following EVAR renal function declines slightly with both IRF and TRF. Our data show no overall difference between patients with IRF and TRF with respect to infarcts, decline in renal function, or onset of dialysis. There were a slightly greater number of renal infarcts in the TRF group, but these infarcts were clinically inconsequential. In patients with CRI, EVAR with intra-arterial radiographic contrast agents is believed to impair renal function, and CRI is considered a relative contraindication to the procedure. Results of our investigation indicate that risk for worsening renal insufficiency, dialysis, and death is only slightly and not significantly greater in patients with CRI compared with patients with normal renal function. With appropriate precautions of avoiding perioperative hypotension and limiting the volume of nonionic contrast agents, CRI need not be a contraindication for EVAR with intra-arterial contrast agents
— id: 45023, year: 2004, vol: 45, page: 367, stat: Journal Article,

Is elevated creatinine level a contraindication to endovascular aneurysm repair?
Mehta, Manish; Veith, Frank J; Lipsitz, Evan C; Ohki, Takao; Russwurm, George; Cayne, Neal S; Suggs, William D; Feustel, Paul J
2004 Jan;39(1):118-123, Journal of vascular surgery
PURPOSE: It is widely believed that chronic renal insufficiency (CRI) greatly increases the risk associated with endovascular abdominal aortic aneurysm repair (EVAR) and is a relative contraindication to the procedure and to the use of intra-arterial contrast agents (IACA). We reviewed a 5-year EVAR experience to determine whether the procedure and use of IACA have an important deleterious effect on renal function in patients with and without pre-existing CRI. METHODS: Endovascular aneurysm repair (EVAR) was performed in 200 patients with a variety of endografts, with intra-arterial contrast agents. The patients were retrospectively assigned to three groups on the basis of preoperative serum creatinine concentration (Cr): group 1 (n = 108), Cr less than 1.5 mg/dL (normal range); group 2 (n = 65), Cr 1.5 to 2.0 mg/dL; group 3 (n = 27), Cr 2.1 to 3.5 mg/dL. No patients had undergone hemodialysis. In groups 2 and 3, patients received hydration perioperatively, and received mannitol intraoperatively; no nephrotoxic drugs were administered during the procedure, other than nonionic contrast agent (Omnipaque 350). RESULTS: The incidence of postoperative complications between the three study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in three patients (2.7%), two of whom (1.9%) required temporary hemodialysis and one (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in two patients (3.1%); both patients (3.1%) required temporary hemodialysis, and one patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in two patients (7.4%); one patient (3.7%) required temporary hemodialysis, and one patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (P <.05), and larger contrast volume was associated with an increase in serum Cr (P <.05) during the postoperative period. CONCLUSIONS: EVAR with intra-arterial contrast agents can be accomplished in patients with chronic renal insufficiency who do not require dialysis, with limited and acceptable morbidity and mortality, similar to that observed with open aneurysm repair. Contrary to other reports in which perioperative precautions were not used, our study shows that with EVAR the risk for worsening renal failure, dialysis, and death is only slightly, and not significantly, greater in patients with preoperative chronic renal insufficiency compared with patients with normal renal function. Perioperative hypotension and increased contrast volume are significant risk factors for postoperative increase in serum Cr and death. With appropriate precautions such as averting perioperative hypotension and limiting the volume of nonionic contrast agents, elevated Cr need not be a contraindication to EVAR with intra-arterial contrast agents
— id: 41867, year: 2004, vol: 39, page: 118, stat: Journal Article,

Does transrenal fixation of aortic endografts impair renal function?
Cayne, Neal S; Rhee, Soo J; Veith, Frank J; Lipsitz, Evan C; Ohki, Takao; Gargiulo, Nicholas J 3rd; Mehta, Manish; Suggs, William D; Wain, Reese A; Rosenblit, Alla; Timaran, Carlos
2003 Oct;38(4):639-644, Journal of vascular surgery
OBJECTIVES: Transrenal fixation (TFX) of aortic endografts is thought to increase the risk for renal infarction and impaired renal function. We studied the late effects of TFX on renal function and perfusion. METHODS: Of 189 patients with commercial aortic endografts, which we inserted between 1995 and 2002, we reviewed data for 130 patients (112 men, 18 women) with available creatinine (Cr) concentration and contrast enhanced computed tomography (CT) scans preoperatively and 1 to 97 months after the procedure. Of the 130 patients, 69 patients had TFX and 61 patients had infrarenal fixation (IFX). Both groups were physiologically comparable. Average age was 76 +/- 8 years for patients with TFX and 75 +/- 8 years for patients with IFX. Presence of renal infarct or renal artery occlusion was determined by nephrograms on serial contrast-enhanced CT scans. RESULTS: Mean follow-up was 17 +/- 16 months (range, 1-54 months) for TFX and 21 +/- 21 months (range, 1-97 months) for IFX. Mean serum Cr concentration increased significantly during long-term follow-up in both groups (TFX, 1.3 +/- 0.5 mg/dL to 1.5 +/- 0.8 mg/dL, P <.01; IFX, 1.3 +/- 0.7 mg/dL to 1.4 +/- 0.8 mg/dL, P <.03). Creatinine clearance (CrCl) similarly decreased over long-term follow-up in both groups (TFX, 53.3 +/- 17.7 mL/min/1.73 m(2) to 47.9 +/- 16.2 mL/min/1.73 m(2), P <.01; IFX, 58.1 +/- 22.7 mL/min/1.73 m(2) to 53.1 +/- 23.4 mL/min/1.73 m(2), P <.02). There were no significant differences in the increase in Cr concentration (P =.19) or decrease in CrCl (P =.68) between TFX and IFX groups. Small renal infarcts were noted in four patients (5.8%) in the TFX group and one patient (1.6%) in the IFX group. No increase in Cr concentration or decrease in CrCl was noted in any patient with a renal infarct. Postoperative renal dysfunction developed in 7 of 69 patients (10.1%) in the TFX group and 7 of 61 patients (11.5%) in the IFX group. There were no statistically significant differences between groups with respect to number of patients with new renal infarcts (P =.37) or postoperative renal dysfunction (P =.81). CONCLUSION: There is a slight increase in serum Cr concentration and decrease in CrCl after aortic endografting. However, there was no significant difference in these changes between patients with TFX and IFX. Although TFX may produce a higher incidence of small renal infarcts, these do not impair renal function. Thus our midterm results suggest that TFX can be performed safely, with no greater change in renal function than observed after IFX
— id: 38326, year: 2003, vol: 38, page: 639, stat: Journal Article,

Use of cine magnetic resonance angiography in quantifying aneurysm pulsatility associated with endoleak
Faries, Peter L; Agarwal, Gautam; Lookstein, Robert; Bernheim, Joshua W; Cayne, Neal S; Cadot, Hadley; Goldman, Jeffery; Kent, K Craig; Hollier, Larry H; Marin, Michael L
2003 Oct;38(4):652-656, Journal of vascular surgery
OBJECTIVE: Persistent aneurysm perfusion or endoleak is associated with pulsatility of abdominal aortic aneurysm (AAA) after endovascular repair. However, the resultant pulsatile change in aneurysm diameter may be difficult to quantify, and therefore its significance is unknown. In this study cine magnetic resonance angiography (MRA) was used to quantify aneurysm wall motion during the cardiac cycle and to correlate it with the presence and type of endoleak. METHODS: Cine MRA was performed in 16 patients undergoing endovascular repair of AAA. A 1.5 T magnet and post-processing with GEMS 4.0 Fiesta computerized video image analysis software were used to calculate maximum aortic diameter during systole and diastole. Changes in aortic diameter were determined from these measurements. Cine MRA was performed on aneurysms before treatment and in patients with and without endoleak after endovascular repair. Type of endoleak was confirmed at angiography in all cases. Four patients had antegrade (type I) endoleak, and eight patients had retrograde (type II) endoleak; no endoleak was present in four patients. Endovascular grafts with stent support throughout the entire length of the graft (Talent) were used in all cases (14 bifurcated grafts, 2 tube grafts). RESULTS: Cine MRA demonstrated significantly greater wall motion and resultant change in aneurysm diameter in patients with type I endoleak compared with patients without endoleak (type I, 2.14 +/- 1.28 mm vs no endoleak, 0.12 +/- 0.09 mm, P =.001). Change in aneurysm diameter in patients with type II endoleak was not significantly greater than in patients with no endoleak (type II, 0.26 +/- 0.21 mm vs no endoleak, 0.12 +/- 0.09 mm, P = NS). Untreated aneurysms demonstrated the greatest change in diameter during the cardiac cycle (3.51 +/- 0.79 mm). CONCLUSION: Cine MRA may be used to accurately quantify AAA wall motion before and after endovascular stent-graft treatment. The extent of change in diameter corresponds to the type of endoleak, with antegrade (type I) endoleak generating greater pulsatile change in diameter than retrograde-collateral (type II) endoleak or no endoleak. Cine MRA may provide a noninvasive means of assessing the success of endovascular treatment of AAA. Further studies will be necessary to confirm the utility and efficacy of cine MRA in postoperative assessment of endovascular aneurysm repair
— id: 38325, year: 2003, vol: 38, page: 652, stat: Journal Article,

Does subintimal angioplasty have a role in the treatment of severe lower extremity ischemia?
Lipsitz, Evan C; Ohki, Takao; Veith, Frank J; Suggs, William D; Wain, Reese A; Cynamon, Jacob; Mehta, Manish; Cayne, Neal; Gargiulo, Nicholas
2003 Feb;37(2):386-391, Journal of vascular surgery
OBJECTIVE: Subintimal angioplasty (SIA) has been advocated to treat long segment lower extremity arterial occlusions, but many question its value. We evaluated the role of SIA in a group of patients with severe lower extremity arterial occlusive disease. METHODS: During a 2.5-year period, 39 patients with arterial occlusions (median length, 8 cm; range, 2 to 31 cm) were treated on an intention-to-treat basis with SIA. Twenty-five patients had gangrene, five had rest pain, and nine had disabling (<one block) claudication. There were 24 superficial femoral, two superficial-femoral-popliteal, four popliteal, two popliteal-tibial, five tibial, and two external iliac artery lesions. With fluoroscopic guidance, via a prograde common femoral artery puncture (n = 29) or a contralateral common femoral artery puncture (n = 9), a subintimal dissection plane was created across the occlusion with a standard guidewire and catheter. The arterial lumen was reentered distal to the occlusion, and the recanalized segment balloon was dilated. All patients were followed prospectively with arterial duplex scan. RESULTS: SIA was technically successful in 34 of 39 patients (87%). All five failures were from an inability to reenter the patent lumen distally. These five patients underwent successful bypasses that in no case were more distal than would have been required before SIA. In the 34 technically successful SIAs, pain completely resolved (14/14) and areas of gangrene (21/25) healed. The cumulative patency rate in patients who underwent successful SIA was 74% +/- 10% at 12 months. The mean increase in ankle-brachial index after SIA was 0.34 (range, 0.1 to 0.69). There were two distal embolic events, successfully treated surgically (n = 1) or with catheter-directed techniques (n = 1). Three patients underwent subsequent bypass, and the remaining five patients remain asymptomatic. CONCLUSION: SIA is feasible and can be effective in some patients with lower extremity arterial occlusions and threatened limbs. These results, plus SIA's many advantages, support an increasing role for it in the treatment of lower extremity arterial occlusive disease
— id: 33619, year: 2003, vol: 37, page: 386, stat: Journal Article,

Significance of endotension, endoleak, and aneurysm pulsatility after endovascular repair
Mehta, Manish; Veith, Frank J; Ohki, Takao; Lipsitz, Evan C; Cayne, Neal S; Darling, R Clement 3rd
2003 Apr;37(4):842-846, Journal of vascular surgery
OBJECTIVE: The lack of aneurysm pulsatility after endovascular aneurysm repair (EVAR) is deemed by some an important guide to the effectiveness of exclusion. However, factors that contribute to aneurysm pulsatility after EVAR have not been elucidated. This study quantitatively analyzed the effects of systemic pressure, aneurysm sac pressure, endoleak, branch outflow from aneurysm sac, and intra-sac thrombus on aneurysm pulsatility after EVAR. METHODS: In an ex vivo model, an artificial aneurysm sac was incorporated within a mock circulation comprised of rubber tubing and a pulsatile pump. The aneurysm sac was then completely excluded from the circulatory circuit with two types of stent-grafts, ie, supported and unsupported, and heparinized canine blood was circulated. Systemic circulation and aneurysm sac pressure was recorded in the absence and presence of endoleaks, and simulated open and closed lumbar branch outflow from the aneurysm sac. The aneurysm sac was then filled with organized human thrombus, and all pressure measurements were repeated. Two observers blinded to the above-mentioned variables independently evaluated aneurysm sac pulsatility with palpation in five separate experiments. Analysis of variance was performed, with significance accepted at P =.05. RESULTS: Systemic pressure was simulated in the artificial circulation to range from 100/60 to 180/60 mm Hg. Regardless of the simulated lumbar branch outflow from the aneurysm, sac pressure was directly related to the presence of endoleak (P <.001). Aneurysm sac pulsatility was present only when the lumbar branch outflow was patent and not dependent on sac pressures. Aneurysm sac thrombosis or type of stent-graft did not influence sac pressure and pulsatility. CONCLUSIONS: In this model, after EVAR pulsatility depends on aneurysm sac outflow, regardless of endoleak, sac thrombosis, sac pressure, or stent-graft. Furthermore, persistent pulsatility does not predict systemic intra-sac pressure, nor does lack of pulsatility reflect freedom of the aneurysm sac from systemic pressurization. This ex vivo model suggests that aneurysm pulsatility is an unreliable guide for predicting aneurysm sac pressurization after EVAR. Other diagnostic methods must be used to assess successful aneurysm exclusion
— id: 34103, year: 2003, vol: 37, page: 842, stat: Journal Article,

Spontaneous recanalization of arterial occlusions: an unusual mechanism for symptomatic improvement
Gargiulo, Nicholas J 3rd; Veith, Frank J; Lipsitz, Evan C; Ohki, Takao; Suggs, William D; Cayne, Neal S; Dadian, Nishan; Wain, Reese A
2002 Dec;36(6):1161-1166, Journal of vascular surgery
OBJECTIVE: Patients with infrainguinal occlusive disease may experience spontaneous symptomatic improvement. This is generally thought to be from augmented collateral circulation. This study reports another mechanism. METHODS: Over a 20-year period, 4123 patients underwent lower extremity arteriography for limb ischemia. For a variety of reasons, 451 patients had repeat arteriography. RESULTS: Five patients were identified as having conclusive arteriographic evidence of spontaneous recanalization of occluded arterial segments without having undergone any surgical or thrombolytic interventions. Repeat contrast arteriography was performed on these patients for failing grafts (n = 2) or contralateral lower extremity ischemia (n = 3). Three other patients had magnetic resonance arteriographic or duplex arteriographic evidence of spontaneous arterial recanalization. Spontaneous recanalizaton occurred in ileofemoral (n = 2), superficial femoral (n = 2), popliteal (n = 3), and peroneal (n = 1) arterial segments. The average time interval of occlusion to recanalization was 21 weeks (2 weeks to 2 years). Two of the eight patients had failed revascularization procedures before spontaneous recanalization. All eight patients had restoration of pulses distal to the recanalized segments and significant symptomatic improvement as defined with the Society for Vascular Surgery/American Association for Vascular Surgery categories for limb ischemia. CONCLUSION: Spontaneous recanalization of arterial segments can occur and must be considered when evaluating other proposed treatments of critical limb ischemia, including cilostazol, lytic agents, and angiogenic agents, such as vascular endothelial growth factor. Although its true incidence is unknown, this represents another mechanism for spontaneous symptomatic improvement without treatment in patients with severe limb ischemia
— id: 33122, year: 2002, vol: 36, page: 1161, stat: Journal Article,

Nonoperative management with selective delayed surgery for large abdominal aortic aneurysms in patients at high risk
Tanquilut, Eugene M; Veith, Frank J; Ohki, Takao; Lipsitz, Evan C; Shaw, Palma M; Suggs, William D; Wain, Reese A; Mehta, Manish; Cayne, Neal S; McKay, Jamie
2002 Jul;36(1):41-46, Journal of vascular surgery
OBJECTIVE: An accepted fact is that abdominal aortic aneurysms (AAAs) larger than 5.5 cm should undergo elective repair. However, subsets of these patients have serious comorbid conditions, which greatly increase operative risk. This study evaluated the outcomes of periods of protracted nonoperative observational management with selective delayed surgery in patients at high risk with large infrarenal and pararenal AAAs. METHODS: Among 226 patients with AAAs more than 5.5 cm, we selected 72 with AAAs from 5.6 to 12.0 cm (mean, 7.0 cm) for periods of nonoperative management because of their prohibitive surgical risks. Comorbid factors included a low ejection fraction of 15% to 34% (mean, 22%) in 18 patients, 1 second forced expiratory volume less than 50% (mean, 38%) in 25, prior laparotomy in 10, and morbid obesity in 22. Follow-up examination was complete in the 72 patients for the 6 to 76 months (mean, 23 months) that they underwent nonoperative treatment. Fifty-three patients ultimately underwent operation because of AAA enlargement or onset of symptoms after 6 to 72 months (mean, 19 months) of nonoperative treatment. RESULTS: Of the 72 selected patients, 54 (75%) are living and 18 (25%) are dead. Seven patients who underwent only nonoperative treatment presently survive after 28 to 76 months (mean, 48 months). Of the 18 deaths, AAA rupture occurred in only three patients (4%) who were observed for 12, 31, and 72 months before rupture. Nine other deaths (13%) occurred after 6 to 72 months from comorbidities unrelated to the AAA. Six of the 53 patients who underwent delayed operation died within 30 days of operation (11% mortality rate). The mortality rate for the 154 good-risk patients with an AAA who underwent prompt open or endovascular repair was 2.2%. CONCLUSION: These data indicate that some patients with large AAAs and serious comorbidities are acceptably managed for long periods (6 to 76 months) with nonoperative means. Substantial delays of 12 to 76 months resulted in an AAA rupture rate of only 4%, and 13% of these patients (nine of 72) died of comorbidities unrelated to AAA rupture or surgery. Mortality rate in this group of patients, when operated, was 11% (six of 53). These findings support the selective use of nonoperative management in some patients with large AAAs and serious comorbidities
— id: 32573, year: 2002, vol: 36, page: 41, stat: Journal Article,

Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience
Ohki T; Veith FJ; Shaw P; Lipsitz E; Suggs WD; Wain RA; Bade M; Mehta M; Cayne N; Cynamon J; Valldares J; McKay J
2001 Sep;234(3):323-334, Annals of surgery
OBJECTIVE: To analyze the late complications after endovascular graft repair of elective abdominal aortic aneurysms (AAAs) at the authors' institution since November 1992. SUMMARY BACKGROUND DATA: Recently, the use of endovascular grafts for the treatment of AAAs has increased dramatically. However, there is little midterm or long-term proof of their efficacy. METHODS: During the past 9 years, 239 endovascular graft repairs were performed for nonruptured AAAs, many (86%) in high-risk patients or in those with complex anatomy. The grafts used were Montefiore (n = 97), Ancure/EVT (n = 14), Vanguard (n = 16), Talent (n = 47), Excluder (n = 20), AneuRx (n = 29), and Zenith (n = 16). All but the AneuRx and Ancure repairs were performed as part of a U.S. phase 1 or phase 2 clinical trial under a Food and Drug Administration investigational device exemption. Procedural outcomes and follow-up results were prospectively recorded. RESULTS: The major complication and death rates within 30 days of endovascular graft repair were 17.6% and 8.5%, respectively. The technical success rate with complete AAA exclusion was 88.7%. During follow-up to 75 months (mean +/- standard deviation, 15.7 +/- 6.3 months), 53 patients (22%) died of unrelated causes. Two AAAs treated with endovascular grafts ruptured and were surgically repaired, with one death. Other late complications included type 1 endoleak (n = 7), aortoduodenal fistula (n = 2), graft thrombosis/stenosis (n = 7), limb separation or fabric tear with a subsequent type 3 endoleak (n = 1), and a persistent type 2 endoleak (n = 13). Secondary intervention or surgery was required in 23 patients (10%). These included deployment of a second graft (n = 4), open AAA repair (n = 5), coil embolization (n = 6), extraanatomic bypass (n = 4), and stent placement (n = 3). CONCLUSION: With longer follow-up, complications occurred with increasing frequency. Although most could be managed with some form of endovascular reintervention, some complications resulted in a high death rate. Although endovascular graft repair is less invasive and sometimes effective in the long term, it is often not a definitive procedure. These findings mandate long-term surveillance and prospective studies to prove the effectiveness of endovascular graft repair
— id: 33123, year: 2001, vol: 234, page: 323, stat: Journal Article,