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Northwestern University: Annual Northwestern Vascular Symposium
Keep mesenteric ischemia on your radar in young patients
CHICAGO – Early recognition of mesenteric ischemia in young adults and children is essential to prevent bowel loss and other serious consequences associated with this rare condition, Dr. Michael Dalsing said at a vascular surgery symposium.
Mesenteric ischemia is generally seen in the elderly as the result of atherosclerotic and embolic occlusive diseases. Because young adults and children typically don’t have any of the telltale associated comorbidities such as cardiac arrhythmia or coronary artery disease to point physicians in this direction, the diagnosis of mesenteric ischemia is often delayed or misinterpreted as appendicitis, cholecystitis, or intra-abdominal abscess, he said.
Among 26 young adults under age 40 years who presented with acute mesenteric ischemia, only 6 were properly diagnosed preoperatively (Wien. Med. Wochenschr. 2012;162:349-53). The postoperative complication and mortality rates reached 61.5% and 27%, which is typical in this population, despite their otherwise good health, said Dr. Dalsing, director of vascular surgery at Indiana University, Indianapolis.
The hallmarks of acute mesenteric ischemia are standard in both young and old patients and include abdominal pain out of proportion to the physical exam, nausea, vomiting, and/or diarrhea. Acidosis, acute renal failure, and septic shock/sepsis can develop in roughly half of patients with more extensive liver or bowel ischemia or necrosis. The signs and symptoms of chronic ischemia are weight loss, food fear, and postprandial abdominal pain.
"For chronic mesenteric ischemia, what’s the important message? Consider the diagnosis," Dr. Dalsing said. "Do the imaging, find out what you have, and then you can worry about ancillary testing because, in general, these aren’t going to be your typical etiologies. In fact, they’re not standard fare at all."
The broad and atypical list of etiologies to consider in those under age 40 years include congenital aortic anomalies, hypercoagulable states, inflammatory conditions, collagen vascular disorders, and environmental agents such as cocaine use, smoking, or trauma. While MI is often suspected in those using cocaine, the vasoconstrictive effects of the drug can also cause vasospasm of the smaller branches of the mesenteric vessels, leading to nonocclusive mesenteric ischemia, he explained.
Once a diagnosis of chronic mesenteric ischemia is made in a young patient, management consists of fluid resuscitation, broad spectrum antibiotics, bowel rest, and imaging, often with a CT angiogram. The need for additional work-up, including hypercoagulable and inflammatory marker panels, varies based on initial clinical symptoms.
If vascular compromise is identified, the overall management goals should be to remove frankly necrotic bowel, reperfuse ischemic bowel, limit the resection length when possible to prevent short-gut syndrome, and treat the underlying etiology, Dr. Dalsing advised. Anticoagulation is also integral to prevent thrombus propagation.
Just six cases of mesenteric ischemia have been diagnosed at Indiana University in young adults over the last 16 years, with Takayasu’s arteritis the most common etiology, he noted. This includes a 20-year-old woman with a 5-year history of Takayasu’s, who presented with worsening abdominal pain despite remission of her Takayasu’s, as indicated by a normal sedimentation rate.
Repeat CT imaging revealed more than 70% celiac artery stenosis and more than 50% stenosis of the superior mesenteric artery (SMA). A median arcuate ligament division and celiac and SMA bypass graft, both with reverse saphenous vein originating from bilateral iliac arteries, was performed. "She’s had dramatic improvement" in her symptoms and remains on clopidogrel (Plavix) and low-dose steroids, Dr. Dalsing said.
A second patient with Takayasu’s presented with a 4-month history of abdominal pain, a 50-pound weight loss, stenosis of all major mesenteric arteries, and bowel pneumatosis. Despite this, her sedimentation rate was only slightly elevated at 33 mm/hour, and all other coagulation and inflammatory tests were normal. She remains symptom free at 2 years on daily aspirin after undergoing an emergent right common iliac-to-SMA bypass graft with reversed saphenous vein and bowel resection.
In cases in which bypass grafting is necessary, the internal iliac artery is the preferred conduit in children since the saphenous vein is very thin walled and thus, more prone to aneurysmal degeneration, Dr. Dalsing observed. In grown patients, the saphenous vein may be the best conduit in terms of ease of harvest and adequate length for even bifurcated grafts or C-loop alignment.
During postoperative follow-up, special effort should be taken because of the young age of these patients to reduce the detrimental effects of radiation from recurrent CT angiograms, he said. Patients with symptomatic improvement are followed at 1 month postoperatively with a physical exam that includes their weight and a mesenteric duplex to evaluate graft or stent patency. This is repeated every 6 months for 1-2 years, and decreased to yearly visits, if no disease progression is detected. More aggressive imaging with CT angiography is reserved for patients with recurrent symptoms or if duplex ultrasound is insufficient or shows progressive disease, he said at the meeting, sponsored by Northwestern University.
Dr. Dalsing reported having no financial disclosures.
No longer is gastrointestinal ischemia a disease that only gerontologists need know about. Ischemic diseases present in a very wide disease spectrum that may be acute, subacute, or chronic; may involve the mesenteric veins, venules, arterioles, or arteries; small and or large intestine; short segments of bowel or long areas. Moreover, even in young adults, the list of predisposing factors is immense and includes inflammatory diseases, vasculitides, thrombophilic states, surgery, colonoscopy, and medications such as triptans , estrogens, and those that cause constipation; as well as recreational activities such as long-distance running and illicit cocaine use.
To complicate diagnostic matters, the GI tract can evidence disease only in a limited number of ways and so, regardless of etiology, manifestations can mimic those of more common diseases, including abdominal pain, diarrhea, rectal bleeding, and abdominal distention, among others. The CT scan has become a prominent substitute for complete history and physical examination today, but a CT scan does not allow appreciation of the fearful look on a patient's face when a physical exam reveals little and the patient still has severe pain. It is this discrepancy that is still fundamental in recognizing acute mesenteric ischemia early on when the injury is still reversible and the injured bowel can be salvaged by the combined use of intra-arterial papaverine and prompt surgery. Early findings on CT, however, are nonspecific, and findings that are specific - for example, gangrene of the bowel, pneumatosis linearis, and portal mesenteric venous gas - occur too late in the game to help save bowel.
For chronic mesenteric ischemia or intestinal angina, it is important to recognize the classic history of food-associated abdominal pain that tends over time to occur earlier in the meal; lasts longer after the meal; and ultimately, preinfarction, become persistent. Fear of eating, avoidance of meals, and weight loss are characteristic. In such circumstances, splanchnic vascular imaging usually shows two of the three mesenteric vessels to be occluded. Such occlusion does not make the diagnosis, however, as angiography merely shows anatomy that supports or refutes the clinician's diagnosis. A typical clinical history and supportive anatomy prompts either percutaneous or surgical revascularization - probably the latter in a young patient - an otherwise good operative risk.
This was once sure death but can now be treated if diagnosed in time.
Dr. Lawrence J. Brandt, MACG, AGA-F, FASGE, professor of medicine and surgery at Albert Einstein College of Medicine, N.Y., emeritus chief of gastroenterology at Montefiore Medical Center, N.Y. He has no disclosures.
No longer is gastrointestinal ischemia a disease that only gerontologists need know about. Ischemic diseases present in a very wide disease spectrum that may be acute, subacute, or chronic; may involve the mesenteric veins, venules, arterioles, or arteries; small and or large intestine; short segments of bowel or long areas. Moreover, even in young adults, the list of predisposing factors is immense and includes inflammatory diseases, vasculitides, thrombophilic states, surgery, colonoscopy, and medications such as triptans , estrogens, and those that cause constipation; as well as recreational activities such as long-distance running and illicit cocaine use.
To complicate diagnostic matters, the GI tract can evidence disease only in a limited number of ways and so, regardless of etiology, manifestations can mimic those of more common diseases, including abdominal pain, diarrhea, rectal bleeding, and abdominal distention, among others. The CT scan has become a prominent substitute for complete history and physical examination today, but a CT scan does not allow appreciation of the fearful look on a patient's face when a physical exam reveals little and the patient still has severe pain. It is this discrepancy that is still fundamental in recognizing acute mesenteric ischemia early on when the injury is still reversible and the injured bowel can be salvaged by the combined use of intra-arterial papaverine and prompt surgery. Early findings on CT, however, are nonspecific, and findings that are specific - for example, gangrene of the bowel, pneumatosis linearis, and portal mesenteric venous gas - occur too late in the game to help save bowel.
For chronic mesenteric ischemia or intestinal angina, it is important to recognize the classic history of food-associated abdominal pain that tends over time to occur earlier in the meal; lasts longer after the meal; and ultimately, preinfarction, become persistent. Fear of eating, avoidance of meals, and weight loss are characteristic. In such circumstances, splanchnic vascular imaging usually shows two of the three mesenteric vessels to be occluded. Such occlusion does not make the diagnosis, however, as angiography merely shows anatomy that supports or refutes the clinician's diagnosis. A typical clinical history and supportive anatomy prompts either percutaneous or surgical revascularization - probably the latter in a young patient - an otherwise good operative risk.
This was once sure death but can now be treated if diagnosed in time.
Dr. Lawrence J. Brandt, MACG, AGA-F, FASGE, professor of medicine and surgery at Albert Einstein College of Medicine, N.Y., emeritus chief of gastroenterology at Montefiore Medical Center, N.Y. He has no disclosures.
No longer is gastrointestinal ischemia a disease that only gerontologists need know about. Ischemic diseases present in a very wide disease spectrum that may be acute, subacute, or chronic; may involve the mesenteric veins, venules, arterioles, or arteries; small and or large intestine; short segments of bowel or long areas. Moreover, even in young adults, the list of predisposing factors is immense and includes inflammatory diseases, vasculitides, thrombophilic states, surgery, colonoscopy, and medications such as triptans , estrogens, and those that cause constipation; as well as recreational activities such as long-distance running and illicit cocaine use.
To complicate diagnostic matters, the GI tract can evidence disease only in a limited number of ways and so, regardless of etiology, manifestations can mimic those of more common diseases, including abdominal pain, diarrhea, rectal bleeding, and abdominal distention, among others. The CT scan has become a prominent substitute for complete history and physical examination today, but a CT scan does not allow appreciation of the fearful look on a patient's face when a physical exam reveals little and the patient still has severe pain. It is this discrepancy that is still fundamental in recognizing acute mesenteric ischemia early on when the injury is still reversible and the injured bowel can be salvaged by the combined use of intra-arterial papaverine and prompt surgery. Early findings on CT, however, are nonspecific, and findings that are specific - for example, gangrene of the bowel, pneumatosis linearis, and portal mesenteric venous gas - occur too late in the game to help save bowel.
For chronic mesenteric ischemia or intestinal angina, it is important to recognize the classic history of food-associated abdominal pain that tends over time to occur earlier in the meal; lasts longer after the meal; and ultimately, preinfarction, become persistent. Fear of eating, avoidance of meals, and weight loss are characteristic. In such circumstances, splanchnic vascular imaging usually shows two of the three mesenteric vessels to be occluded. Such occlusion does not make the diagnosis, however, as angiography merely shows anatomy that supports or refutes the clinician's diagnosis. A typical clinical history and supportive anatomy prompts either percutaneous or surgical revascularization - probably the latter in a young patient - an otherwise good operative risk.
This was once sure death but can now be treated if diagnosed in time.
Dr. Lawrence J. Brandt, MACG, AGA-F, FASGE, professor of medicine and surgery at Albert Einstein College of Medicine, N.Y., emeritus chief of gastroenterology at Montefiore Medical Center, N.Y. He has no disclosures.
CHICAGO – Early recognition of mesenteric ischemia in young adults and children is essential to prevent bowel loss and other serious consequences associated with this rare condition, Dr. Michael Dalsing said at a vascular surgery symposium.
Mesenteric ischemia is generally seen in the elderly as the result of atherosclerotic and embolic occlusive diseases. Because young adults and children typically don’t have any of the telltale associated comorbidities such as cardiac arrhythmia or coronary artery disease to point physicians in this direction, the diagnosis of mesenteric ischemia is often delayed or misinterpreted as appendicitis, cholecystitis, or intra-abdominal abscess, he said.
Among 26 young adults under age 40 years who presented with acute mesenteric ischemia, only 6 were properly diagnosed preoperatively (Wien. Med. Wochenschr. 2012;162:349-53). The postoperative complication and mortality rates reached 61.5% and 27%, which is typical in this population, despite their otherwise good health, said Dr. Dalsing, director of vascular surgery at Indiana University, Indianapolis.
The hallmarks of acute mesenteric ischemia are standard in both young and old patients and include abdominal pain out of proportion to the physical exam, nausea, vomiting, and/or diarrhea. Acidosis, acute renal failure, and septic shock/sepsis can develop in roughly half of patients with more extensive liver or bowel ischemia or necrosis. The signs and symptoms of chronic ischemia are weight loss, food fear, and postprandial abdominal pain.
"For chronic mesenteric ischemia, what’s the important message? Consider the diagnosis," Dr. Dalsing said. "Do the imaging, find out what you have, and then you can worry about ancillary testing because, in general, these aren’t going to be your typical etiologies. In fact, they’re not standard fare at all."
The broad and atypical list of etiologies to consider in those under age 40 years include congenital aortic anomalies, hypercoagulable states, inflammatory conditions, collagen vascular disorders, and environmental agents such as cocaine use, smoking, or trauma. While MI is often suspected in those using cocaine, the vasoconstrictive effects of the drug can also cause vasospasm of the smaller branches of the mesenteric vessels, leading to nonocclusive mesenteric ischemia, he explained.
Once a diagnosis of chronic mesenteric ischemia is made in a young patient, management consists of fluid resuscitation, broad spectrum antibiotics, bowel rest, and imaging, often with a CT angiogram. The need for additional work-up, including hypercoagulable and inflammatory marker panels, varies based on initial clinical symptoms.
If vascular compromise is identified, the overall management goals should be to remove frankly necrotic bowel, reperfuse ischemic bowel, limit the resection length when possible to prevent short-gut syndrome, and treat the underlying etiology, Dr. Dalsing advised. Anticoagulation is also integral to prevent thrombus propagation.
Just six cases of mesenteric ischemia have been diagnosed at Indiana University in young adults over the last 16 years, with Takayasu’s arteritis the most common etiology, he noted. This includes a 20-year-old woman with a 5-year history of Takayasu’s, who presented with worsening abdominal pain despite remission of her Takayasu’s, as indicated by a normal sedimentation rate.
Repeat CT imaging revealed more than 70% celiac artery stenosis and more than 50% stenosis of the superior mesenteric artery (SMA). A median arcuate ligament division and celiac and SMA bypass graft, both with reverse saphenous vein originating from bilateral iliac arteries, was performed. "She’s had dramatic improvement" in her symptoms and remains on clopidogrel (Plavix) and low-dose steroids, Dr. Dalsing said.
A second patient with Takayasu’s presented with a 4-month history of abdominal pain, a 50-pound weight loss, stenosis of all major mesenteric arteries, and bowel pneumatosis. Despite this, her sedimentation rate was only slightly elevated at 33 mm/hour, and all other coagulation and inflammatory tests were normal. She remains symptom free at 2 years on daily aspirin after undergoing an emergent right common iliac-to-SMA bypass graft with reversed saphenous vein and bowel resection.
In cases in which bypass grafting is necessary, the internal iliac artery is the preferred conduit in children since the saphenous vein is very thin walled and thus, more prone to aneurysmal degeneration, Dr. Dalsing observed. In grown patients, the saphenous vein may be the best conduit in terms of ease of harvest and adequate length for even bifurcated grafts or C-loop alignment.
During postoperative follow-up, special effort should be taken because of the young age of these patients to reduce the detrimental effects of radiation from recurrent CT angiograms, he said. Patients with symptomatic improvement are followed at 1 month postoperatively with a physical exam that includes their weight and a mesenteric duplex to evaluate graft or stent patency. This is repeated every 6 months for 1-2 years, and decreased to yearly visits, if no disease progression is detected. More aggressive imaging with CT angiography is reserved for patients with recurrent symptoms or if duplex ultrasound is insufficient or shows progressive disease, he said at the meeting, sponsored by Northwestern University.
Dr. Dalsing reported having no financial disclosures.
CHICAGO – Early recognition of mesenteric ischemia in young adults and children is essential to prevent bowel loss and other serious consequences associated with this rare condition, Dr. Michael Dalsing said at a vascular surgery symposium.
Mesenteric ischemia is generally seen in the elderly as the result of atherosclerotic and embolic occlusive diseases. Because young adults and children typically don’t have any of the telltale associated comorbidities such as cardiac arrhythmia or coronary artery disease to point physicians in this direction, the diagnosis of mesenteric ischemia is often delayed or misinterpreted as appendicitis, cholecystitis, or intra-abdominal abscess, he said.
Among 26 young adults under age 40 years who presented with acute mesenteric ischemia, only 6 were properly diagnosed preoperatively (Wien. Med. Wochenschr. 2012;162:349-53). The postoperative complication and mortality rates reached 61.5% and 27%, which is typical in this population, despite their otherwise good health, said Dr. Dalsing, director of vascular surgery at Indiana University, Indianapolis.
The hallmarks of acute mesenteric ischemia are standard in both young and old patients and include abdominal pain out of proportion to the physical exam, nausea, vomiting, and/or diarrhea. Acidosis, acute renal failure, and septic shock/sepsis can develop in roughly half of patients with more extensive liver or bowel ischemia or necrosis. The signs and symptoms of chronic ischemia are weight loss, food fear, and postprandial abdominal pain.
"For chronic mesenteric ischemia, what’s the important message? Consider the diagnosis," Dr. Dalsing said. "Do the imaging, find out what you have, and then you can worry about ancillary testing because, in general, these aren’t going to be your typical etiologies. In fact, they’re not standard fare at all."
The broad and atypical list of etiologies to consider in those under age 40 years include congenital aortic anomalies, hypercoagulable states, inflammatory conditions, collagen vascular disorders, and environmental agents such as cocaine use, smoking, or trauma. While MI is often suspected in those using cocaine, the vasoconstrictive effects of the drug can also cause vasospasm of the smaller branches of the mesenteric vessels, leading to nonocclusive mesenteric ischemia, he explained.
Once a diagnosis of chronic mesenteric ischemia is made in a young patient, management consists of fluid resuscitation, broad spectrum antibiotics, bowel rest, and imaging, often with a CT angiogram. The need for additional work-up, including hypercoagulable and inflammatory marker panels, varies based on initial clinical symptoms.
If vascular compromise is identified, the overall management goals should be to remove frankly necrotic bowel, reperfuse ischemic bowel, limit the resection length when possible to prevent short-gut syndrome, and treat the underlying etiology, Dr. Dalsing advised. Anticoagulation is also integral to prevent thrombus propagation.
Just six cases of mesenteric ischemia have been diagnosed at Indiana University in young adults over the last 16 years, with Takayasu’s arteritis the most common etiology, he noted. This includes a 20-year-old woman with a 5-year history of Takayasu’s, who presented with worsening abdominal pain despite remission of her Takayasu’s, as indicated by a normal sedimentation rate.
Repeat CT imaging revealed more than 70% celiac artery stenosis and more than 50% stenosis of the superior mesenteric artery (SMA). A median arcuate ligament division and celiac and SMA bypass graft, both with reverse saphenous vein originating from bilateral iliac arteries, was performed. "She’s had dramatic improvement" in her symptoms and remains on clopidogrel (Plavix) and low-dose steroids, Dr. Dalsing said.
A second patient with Takayasu’s presented with a 4-month history of abdominal pain, a 50-pound weight loss, stenosis of all major mesenteric arteries, and bowel pneumatosis. Despite this, her sedimentation rate was only slightly elevated at 33 mm/hour, and all other coagulation and inflammatory tests were normal. She remains symptom free at 2 years on daily aspirin after undergoing an emergent right common iliac-to-SMA bypass graft with reversed saphenous vein and bowel resection.
In cases in which bypass grafting is necessary, the internal iliac artery is the preferred conduit in children since the saphenous vein is very thin walled and thus, more prone to aneurysmal degeneration, Dr. Dalsing observed. In grown patients, the saphenous vein may be the best conduit in terms of ease of harvest and adequate length for even bifurcated grafts or C-loop alignment.
During postoperative follow-up, special effort should be taken because of the young age of these patients to reduce the detrimental effects of radiation from recurrent CT angiograms, he said. Patients with symptomatic improvement are followed at 1 month postoperatively with a physical exam that includes their weight and a mesenteric duplex to evaluate graft or stent patency. This is repeated every 6 months for 1-2 years, and decreased to yearly visits, if no disease progression is detected. More aggressive imaging with CT angiography is reserved for patients with recurrent symptoms or if duplex ultrasound is insufficient or shows progressive disease, he said at the meeting, sponsored by Northwestern University.
Dr. Dalsing reported having no financial disclosures.
AT A VASCULAR SURGERY SYMPOSIUM
Anatomy dictates endovascular repair of popliteal artery aneurysms
CHICAGO – Endovascular repair of popliteal artery aneurysms is a relatively safe and viable off-label alternative to open repair, but appropriate anatomy is essential. This includes a landing zone of at least 2 cm above and below the aneurysm, minimal discrepancy in size between the proximal and distal landing zones, and lack of extensive vessel tortuosity due to potential kinking of the endograft, Dr. Neal S. Cayne said at a symposium on vascular surgery sponsored by Northwestern University.
The risk of kinking and graft thrombosis also excludes patients who frequently flex their knee more than 90 degrees, such as carpenters and gardeners.
Patients with a contraindication to antiplatelet medication are also off limits, as clopidogrel (Plavix) has been shown to be a predictor of success, said Dr. Cayne, director of endovascular surgery at New York University Langone Medical Center.
In 2012, his team reported technical success in 25 of 26 endovascular popliteal artery aneurysm (PAA) repairs performed in 21 consecutive patients between January 2004 and January 2011, with the one technical failure due to stent graft infolding (J. Vasc. Surg. 2012;55:1647-53).
Primary and secondary patency rates were both 91.2% at 1 year, and were 85.5% and 91.2%, respectively, at 2 years. All patients were maintained on aspirin or clopidogrel.
No limb loss was reported, but three occlusions occurred during follow-up at 4, 14, and 26 months. One patient required a tibial artery bypass for a nonhealing wound, and two were successfully repaired with open thrombectomy. All three occlusion patients had single-vessel runoff.
Based on our data, in general, I will not stent someone "with single-vessel outflow, and I also will not stent someone who, for some reason, can’t take antiplatelet agents," Dr. Cayne said.
Even when patients present urgently and the PAA has thrombosed, endovascular repair is not an option if there is only one outflow vessel. "I would do a bypass; there’s nothing wrong with open surgery," he said.
A recent unpublished review of 79 PAAs treated at Langone from 1998 to 2012 with both approaches found 5-year primary patencies of 67% for open repair and 80% for endovascular repair (P less than .05). Secondary patency was 90% in both groups.
One amputation occurred in the open group, but occlusion rates were higher using endovascular repair with one-vessel runoff (P = .003), Dr. Cayne said.
As expected, length of stay was shorter with endovascular repair (1.9 vs. 6.4 days; P less than .001).
Follow-up was longer for the 36 open PAAs than the 43 endovascular PAAs (75 vs. 34 months), but patients in both groups were similar with respect to age, comorbidities, PAA size, runoff, and symptoms, he said.
During a discussion following the presentation, some attendees said they still prefer to use bypass for all patients with PAA, and asked how candidates are selected for stent placement.
"Number one and most important is the anatomy," Dr. Cayne said. "The one advantage of endovascular repair is that if you have a patient too sick to get general or even regional anesthesia, you can do it under local [anesthesia] almost all the time with a small cutdown or puncture. But you do have that long discussion with the patient that this is a non–FDA-approved, off-label use. We provide them with the data, but some patients in New York will come in with pages and pages of literature and say, ‘Nope, I want a stent, I want this particular stent, and this is the way I want you to do it.’ "
The stent of choice at Langone has been Gore’s Viabahn covered stent graft, which is FDA approved for treating occlusive disease rather than PAA. The device is usually oversized by 10%-15%, but no more than that, because of the risk of graft infolding, Dr. Cayne said.
If more than one graft is needed, a maximum of no more than 1-mm size differential between grafts is suggested. A minimum overlap of 2-3 cm between grafts is also preferred.
Last year, surgeons reported a dismal 50% occlusion rate within just 6 weeks in the endovascular treatment of six PAAs using a novel, multilayer stent (Cardiatis’s Multilayer Aneurysm Repair System) (J. Endovasc. Ther. 2013;20:381-8), he observed.
Dr. Cayne reported receiving honoraria as a consultant from Cook Medical.
CHICAGO – Endovascular repair of popliteal artery aneurysms is a relatively safe and viable off-label alternative to open repair, but appropriate anatomy is essential. This includes a landing zone of at least 2 cm above and below the aneurysm, minimal discrepancy in size between the proximal and distal landing zones, and lack of extensive vessel tortuosity due to potential kinking of the endograft, Dr. Neal S. Cayne said at a symposium on vascular surgery sponsored by Northwestern University.
The risk of kinking and graft thrombosis also excludes patients who frequently flex their knee more than 90 degrees, such as carpenters and gardeners.
Patients with a contraindication to antiplatelet medication are also off limits, as clopidogrel (Plavix) has been shown to be a predictor of success, said Dr. Cayne, director of endovascular surgery at New York University Langone Medical Center.
In 2012, his team reported technical success in 25 of 26 endovascular popliteal artery aneurysm (PAA) repairs performed in 21 consecutive patients between January 2004 and January 2011, with the one technical failure due to stent graft infolding (J. Vasc. Surg. 2012;55:1647-53).
Primary and secondary patency rates were both 91.2% at 1 year, and were 85.5% and 91.2%, respectively, at 2 years. All patients were maintained on aspirin or clopidogrel.
No limb loss was reported, but three occlusions occurred during follow-up at 4, 14, and 26 months. One patient required a tibial artery bypass for a nonhealing wound, and two were successfully repaired with open thrombectomy. All three occlusion patients had single-vessel runoff.
Based on our data, in general, I will not stent someone "with single-vessel outflow, and I also will not stent someone who, for some reason, can’t take antiplatelet agents," Dr. Cayne said.
Even when patients present urgently and the PAA has thrombosed, endovascular repair is not an option if there is only one outflow vessel. "I would do a bypass; there’s nothing wrong with open surgery," he said.
A recent unpublished review of 79 PAAs treated at Langone from 1998 to 2012 with both approaches found 5-year primary patencies of 67% for open repair and 80% for endovascular repair (P less than .05). Secondary patency was 90% in both groups.
One amputation occurred in the open group, but occlusion rates were higher using endovascular repair with one-vessel runoff (P = .003), Dr. Cayne said.
As expected, length of stay was shorter with endovascular repair (1.9 vs. 6.4 days; P less than .001).
Follow-up was longer for the 36 open PAAs than the 43 endovascular PAAs (75 vs. 34 months), but patients in both groups were similar with respect to age, comorbidities, PAA size, runoff, and symptoms, he said.
During a discussion following the presentation, some attendees said they still prefer to use bypass for all patients with PAA, and asked how candidates are selected for stent placement.
"Number one and most important is the anatomy," Dr. Cayne said. "The one advantage of endovascular repair is that if you have a patient too sick to get general or even regional anesthesia, you can do it under local [anesthesia] almost all the time with a small cutdown or puncture. But you do have that long discussion with the patient that this is a non–FDA-approved, off-label use. We provide them with the data, but some patients in New York will come in with pages and pages of literature and say, ‘Nope, I want a stent, I want this particular stent, and this is the way I want you to do it.’ "
The stent of choice at Langone has been Gore’s Viabahn covered stent graft, which is FDA approved for treating occlusive disease rather than PAA. The device is usually oversized by 10%-15%, but no more than that, because of the risk of graft infolding, Dr. Cayne said.
If more than one graft is needed, a maximum of no more than 1-mm size differential between grafts is suggested. A minimum overlap of 2-3 cm between grafts is also preferred.
Last year, surgeons reported a dismal 50% occlusion rate within just 6 weeks in the endovascular treatment of six PAAs using a novel, multilayer stent (Cardiatis’s Multilayer Aneurysm Repair System) (J. Endovasc. Ther. 2013;20:381-8), he observed.
Dr. Cayne reported receiving honoraria as a consultant from Cook Medical.
CHICAGO – Endovascular repair of popliteal artery aneurysms is a relatively safe and viable off-label alternative to open repair, but appropriate anatomy is essential. This includes a landing zone of at least 2 cm above and below the aneurysm, minimal discrepancy in size between the proximal and distal landing zones, and lack of extensive vessel tortuosity due to potential kinking of the endograft, Dr. Neal S. Cayne said at a symposium on vascular surgery sponsored by Northwestern University.
The risk of kinking and graft thrombosis also excludes patients who frequently flex their knee more than 90 degrees, such as carpenters and gardeners.
Patients with a contraindication to antiplatelet medication are also off limits, as clopidogrel (Plavix) has been shown to be a predictor of success, said Dr. Cayne, director of endovascular surgery at New York University Langone Medical Center.
In 2012, his team reported technical success in 25 of 26 endovascular popliteal artery aneurysm (PAA) repairs performed in 21 consecutive patients between January 2004 and January 2011, with the one technical failure due to stent graft infolding (J. Vasc. Surg. 2012;55:1647-53).
Primary and secondary patency rates were both 91.2% at 1 year, and were 85.5% and 91.2%, respectively, at 2 years. All patients were maintained on aspirin or clopidogrel.
No limb loss was reported, but three occlusions occurred during follow-up at 4, 14, and 26 months. One patient required a tibial artery bypass for a nonhealing wound, and two were successfully repaired with open thrombectomy. All three occlusion patients had single-vessel runoff.
Based on our data, in general, I will not stent someone "with single-vessel outflow, and I also will not stent someone who, for some reason, can’t take antiplatelet agents," Dr. Cayne said.
Even when patients present urgently and the PAA has thrombosed, endovascular repair is not an option if there is only one outflow vessel. "I would do a bypass; there’s nothing wrong with open surgery," he said.
A recent unpublished review of 79 PAAs treated at Langone from 1998 to 2012 with both approaches found 5-year primary patencies of 67% for open repair and 80% for endovascular repair (P less than .05). Secondary patency was 90% in both groups.
One amputation occurred in the open group, but occlusion rates were higher using endovascular repair with one-vessel runoff (P = .003), Dr. Cayne said.
As expected, length of stay was shorter with endovascular repair (1.9 vs. 6.4 days; P less than .001).
Follow-up was longer for the 36 open PAAs than the 43 endovascular PAAs (75 vs. 34 months), but patients in both groups were similar with respect to age, comorbidities, PAA size, runoff, and symptoms, he said.
During a discussion following the presentation, some attendees said they still prefer to use bypass for all patients with PAA, and asked how candidates are selected for stent placement.
"Number one and most important is the anatomy," Dr. Cayne said. "The one advantage of endovascular repair is that if you have a patient too sick to get general or even regional anesthesia, you can do it under local [anesthesia] almost all the time with a small cutdown or puncture. But you do have that long discussion with the patient that this is a non–FDA-approved, off-label use. We provide them with the data, but some patients in New York will come in with pages and pages of literature and say, ‘Nope, I want a stent, I want this particular stent, and this is the way I want you to do it.’ "
The stent of choice at Langone has been Gore’s Viabahn covered stent graft, which is FDA approved for treating occlusive disease rather than PAA. The device is usually oversized by 10%-15%, but no more than that, because of the risk of graft infolding, Dr. Cayne said.
If more than one graft is needed, a maximum of no more than 1-mm size differential between grafts is suggested. A minimum overlap of 2-3 cm between grafts is also preferred.
Last year, surgeons reported a dismal 50% occlusion rate within just 6 weeks in the endovascular treatment of six PAAs using a novel, multilayer stent (Cardiatis’s Multilayer Aneurysm Repair System) (J. Endovasc. Ther. 2013;20:381-8), he observed.
Dr. Cayne reported receiving honoraria as a consultant from Cook Medical.
AT THE NORTHWESTERN VASCULAR SYMPOSIUM
Major finding: Five-year primary patency was 67% for open repair and 80% for endovascular repair (P less than .05).
Data source: Expert opinion and retrospective study of 79 popliteal artery aneurysm repairs.
Disclosures: Dr. Cayne reported receiving honoraria as a consultant from Cook Medical.
DRIL particularly effective for access-related hand ischemia
CHICAGO – The best strategy for access-related hand ischemia is to have a plan in place before it occurs.
"The whole approach for patients at high risk of developing hand ischemia is to think about it preoperatively" and devise a remedial plan, Dr. Thomas S. Huber said at the symposium. "I always tell our trainees and fellows: ‘What are you going to do in 20 minutes when the recovery room nurse says the patient has motor compromise and unbelievable hand pain?’ You have to have a remedial plan."
Access-related hand ischemia (ARHI), or steal syndrome, occurs in just 2% of radial artery–based access procedures, but up to 20% of brachial artery–based access procedures. Roughly half of these events are severe enough to merit remedial treatment. With more than 8 million arterial catheters placed perioperatively in the United States each year and 350,000 patients on dialysis, the numbers add up.
"There are multiple complementary treatment options that you ought to have in your armamentarium," said Dr. Huber, chief of vascular surgery and endovascular therapy, University of Florida Health Science Center, Gainesville, Fla.
"The DRIL has worked remarkably well for us."
The distal revascularization and interval ligation (DRIL) procedure involves a brachial-brachial bypass with ligation of the brachial artery immediately distal to the fistula anastomosis.
In their hands, DRIL significantly increased wrist-brachial and digital-brachial indices (0.31 and 0.25) in 126 patients undergoing 134 procedures from 2002 to 2011 (J. Vasc. Surg. 2013;57:451-8). Ischemic symptoms were relieved in 82% of patients, and the index access was salvaged in 85%.
"Really, the DRIL procedure has almost no impact on the success of the access," Dr. Huber said. "For those patients [in which] we perform the DRIL [procedure] before their access is mature, our maturation rate is comparable whether we do the DRIL or not."
Primary patency was 95% at 1 year and 78% at 5 years. The overall complication rate, driven mostly by wound complications, reached 27%, and 30-day mortality was 2%.
"I sheepishly stand before you to say that our mortality rate for all our access procedures is about 3%," he said. "It’s a pretty minimal operation so, my gosh, how could that possibly be? But it’s a very morbid population. In our country, the 1-year mortality rate for people starting dialysis is right at 23%. So they’re older, sicker patients, with a limited life expectancy."
All-cause mortality in the series was 28% and 79% at 1 and 5 years, respectively. Age greater than 40 years, grade 3 ischemia, any DRIL complication, and smoking history were all significant multivariable predictors of mortality.
An extensive list of clinical ARHI predictors has been identified, such as female sex, advanced age, and large conduits, but none reliably predicts when access should not be attempted, Dr. Huber said. The use of preoperative noninvasive imaging also is helpful to identify patients at risk for ARHI, but the predictive values have not been sufficient to avoid attempting the access procedure.
In their experience, presentation of hand ischemia has been trimodal, with a third of patients presenting within 7 days of their index procedure, a third within 7-30 days, and a third thereafter. A weak ulnar or radial pulse on physical exam after creating a dialysis access has misled some to dismiss hand ischemia, while a prior episode of ARHI is a red flag for high risk of recurrence.
"I would contend that the incidence of developing hand ischemia on the right arm if you had it on the left arm is about 100%," dispelling the concept of simply ligating the access that led to hand ischemia and then repositioning it on the contralateral extremity, Dr. Huber said.
Their overall treatment approach for ARHI in poor operative-risk patients, particularly older patients with a prosthetic access, is to proceed to ligation. Good-risk patients undergo some type of inflow assessment, and if a significant inflow lesion is present, it is corrected, usually at the same time as the DRIL, he said. Proximalization of the arterial inflow would be considered for patients with persistent symptoms and no available conduit, while DRIL is the go-to procedure for those with available vein conduits more than 3 cm in diameter, preferably the greater saphenous vein.
Noticeably absent in their algorithm is some type of flow-limiting strategy, such as banding, and the revision using distal inflow procedure. These approaches may have a role, but the published literature is somewhat inconclusive, Dr. Huber said at the symposium, sponsored by Northwestern University.
Despite the overwhelming number of Americans on dialysis, less than 300 DRIL cases have been reported in the literature since its introduction in 1988. The University of Florida experience has been corroborated by a recent report of complete symptom resolution in 82% of 81 DRIL procedures, with a 17% complication rate, and five-year access and bypass survival rates of 56% and 97% (J. Vasc. Surg. 2013;54:1073-8).
Surgeons in Texas reported full symptom resolution in 77% of 33 patients, but cautioned against potential complications such as bypass failure that led to gangrene and transmetacarpal amputation in one patient (J. Vasc. Access 2012;13:299-304).
Dr. Huber reported having no financial disclosures.
CHICAGO – The best strategy for access-related hand ischemia is to have a plan in place before it occurs.
"The whole approach for patients at high risk of developing hand ischemia is to think about it preoperatively" and devise a remedial plan, Dr. Thomas S. Huber said at the symposium. "I always tell our trainees and fellows: ‘What are you going to do in 20 minutes when the recovery room nurse says the patient has motor compromise and unbelievable hand pain?’ You have to have a remedial plan."
Access-related hand ischemia (ARHI), or steal syndrome, occurs in just 2% of radial artery–based access procedures, but up to 20% of brachial artery–based access procedures. Roughly half of these events are severe enough to merit remedial treatment. With more than 8 million arterial catheters placed perioperatively in the United States each year and 350,000 patients on dialysis, the numbers add up.
"There are multiple complementary treatment options that you ought to have in your armamentarium," said Dr. Huber, chief of vascular surgery and endovascular therapy, University of Florida Health Science Center, Gainesville, Fla.
"The DRIL has worked remarkably well for us."
The distal revascularization and interval ligation (DRIL) procedure involves a brachial-brachial bypass with ligation of the brachial artery immediately distal to the fistula anastomosis.
In their hands, DRIL significantly increased wrist-brachial and digital-brachial indices (0.31 and 0.25) in 126 patients undergoing 134 procedures from 2002 to 2011 (J. Vasc. Surg. 2013;57:451-8). Ischemic symptoms were relieved in 82% of patients, and the index access was salvaged in 85%.
"Really, the DRIL procedure has almost no impact on the success of the access," Dr. Huber said. "For those patients [in which] we perform the DRIL [procedure] before their access is mature, our maturation rate is comparable whether we do the DRIL or not."
Primary patency was 95% at 1 year and 78% at 5 years. The overall complication rate, driven mostly by wound complications, reached 27%, and 30-day mortality was 2%.
"I sheepishly stand before you to say that our mortality rate for all our access procedures is about 3%," he said. "It’s a pretty minimal operation so, my gosh, how could that possibly be? But it’s a very morbid population. In our country, the 1-year mortality rate for people starting dialysis is right at 23%. So they’re older, sicker patients, with a limited life expectancy."
All-cause mortality in the series was 28% and 79% at 1 and 5 years, respectively. Age greater than 40 years, grade 3 ischemia, any DRIL complication, and smoking history were all significant multivariable predictors of mortality.
An extensive list of clinical ARHI predictors has been identified, such as female sex, advanced age, and large conduits, but none reliably predicts when access should not be attempted, Dr. Huber said. The use of preoperative noninvasive imaging also is helpful to identify patients at risk for ARHI, but the predictive values have not been sufficient to avoid attempting the access procedure.
In their experience, presentation of hand ischemia has been trimodal, with a third of patients presenting within 7 days of their index procedure, a third within 7-30 days, and a third thereafter. A weak ulnar or radial pulse on physical exam after creating a dialysis access has misled some to dismiss hand ischemia, while a prior episode of ARHI is a red flag for high risk of recurrence.
"I would contend that the incidence of developing hand ischemia on the right arm if you had it on the left arm is about 100%," dispelling the concept of simply ligating the access that led to hand ischemia and then repositioning it on the contralateral extremity, Dr. Huber said.
Their overall treatment approach for ARHI in poor operative-risk patients, particularly older patients with a prosthetic access, is to proceed to ligation. Good-risk patients undergo some type of inflow assessment, and if a significant inflow lesion is present, it is corrected, usually at the same time as the DRIL, he said. Proximalization of the arterial inflow would be considered for patients with persistent symptoms and no available conduit, while DRIL is the go-to procedure for those with available vein conduits more than 3 cm in diameter, preferably the greater saphenous vein.
Noticeably absent in their algorithm is some type of flow-limiting strategy, such as banding, and the revision using distal inflow procedure. These approaches may have a role, but the published literature is somewhat inconclusive, Dr. Huber said at the symposium, sponsored by Northwestern University.
Despite the overwhelming number of Americans on dialysis, less than 300 DRIL cases have been reported in the literature since its introduction in 1988. The University of Florida experience has been corroborated by a recent report of complete symptom resolution in 82% of 81 DRIL procedures, with a 17% complication rate, and five-year access and bypass survival rates of 56% and 97% (J. Vasc. Surg. 2013;54:1073-8).
Surgeons in Texas reported full symptom resolution in 77% of 33 patients, but cautioned against potential complications such as bypass failure that led to gangrene and transmetacarpal amputation in one patient (J. Vasc. Access 2012;13:299-304).
Dr. Huber reported having no financial disclosures.
CHICAGO – The best strategy for access-related hand ischemia is to have a plan in place before it occurs.
"The whole approach for patients at high risk of developing hand ischemia is to think about it preoperatively" and devise a remedial plan, Dr. Thomas S. Huber said at the symposium. "I always tell our trainees and fellows: ‘What are you going to do in 20 minutes when the recovery room nurse says the patient has motor compromise and unbelievable hand pain?’ You have to have a remedial plan."
Access-related hand ischemia (ARHI), or steal syndrome, occurs in just 2% of radial artery–based access procedures, but up to 20% of brachial artery–based access procedures. Roughly half of these events are severe enough to merit remedial treatment. With more than 8 million arterial catheters placed perioperatively in the United States each year and 350,000 patients on dialysis, the numbers add up.
"There are multiple complementary treatment options that you ought to have in your armamentarium," said Dr. Huber, chief of vascular surgery and endovascular therapy, University of Florida Health Science Center, Gainesville, Fla.
"The DRIL has worked remarkably well for us."
The distal revascularization and interval ligation (DRIL) procedure involves a brachial-brachial bypass with ligation of the brachial artery immediately distal to the fistula anastomosis.
In their hands, DRIL significantly increased wrist-brachial and digital-brachial indices (0.31 and 0.25) in 126 patients undergoing 134 procedures from 2002 to 2011 (J. Vasc. Surg. 2013;57:451-8). Ischemic symptoms were relieved in 82% of patients, and the index access was salvaged in 85%.
"Really, the DRIL procedure has almost no impact on the success of the access," Dr. Huber said. "For those patients [in which] we perform the DRIL [procedure] before their access is mature, our maturation rate is comparable whether we do the DRIL or not."
Primary patency was 95% at 1 year and 78% at 5 years. The overall complication rate, driven mostly by wound complications, reached 27%, and 30-day mortality was 2%.
"I sheepishly stand before you to say that our mortality rate for all our access procedures is about 3%," he said. "It’s a pretty minimal operation so, my gosh, how could that possibly be? But it’s a very morbid population. In our country, the 1-year mortality rate for people starting dialysis is right at 23%. So they’re older, sicker patients, with a limited life expectancy."
All-cause mortality in the series was 28% and 79% at 1 and 5 years, respectively. Age greater than 40 years, grade 3 ischemia, any DRIL complication, and smoking history were all significant multivariable predictors of mortality.
An extensive list of clinical ARHI predictors has been identified, such as female sex, advanced age, and large conduits, but none reliably predicts when access should not be attempted, Dr. Huber said. The use of preoperative noninvasive imaging also is helpful to identify patients at risk for ARHI, but the predictive values have not been sufficient to avoid attempting the access procedure.
In their experience, presentation of hand ischemia has been trimodal, with a third of patients presenting within 7 days of their index procedure, a third within 7-30 days, and a third thereafter. A weak ulnar or radial pulse on physical exam after creating a dialysis access has misled some to dismiss hand ischemia, while a prior episode of ARHI is a red flag for high risk of recurrence.
"I would contend that the incidence of developing hand ischemia on the right arm if you had it on the left arm is about 100%," dispelling the concept of simply ligating the access that led to hand ischemia and then repositioning it on the contralateral extremity, Dr. Huber said.
Their overall treatment approach for ARHI in poor operative-risk patients, particularly older patients with a prosthetic access, is to proceed to ligation. Good-risk patients undergo some type of inflow assessment, and if a significant inflow lesion is present, it is corrected, usually at the same time as the DRIL, he said. Proximalization of the arterial inflow would be considered for patients with persistent symptoms and no available conduit, while DRIL is the go-to procedure for those with available vein conduits more than 3 cm in diameter, preferably the greater saphenous vein.
Noticeably absent in their algorithm is some type of flow-limiting strategy, such as banding, and the revision using distal inflow procedure. These approaches may have a role, but the published literature is somewhat inconclusive, Dr. Huber said at the symposium, sponsored by Northwestern University.
Despite the overwhelming number of Americans on dialysis, less than 300 DRIL cases have been reported in the literature since its introduction in 1988. The University of Florida experience has been corroborated by a recent report of complete symptom resolution in 82% of 81 DRIL procedures, with a 17% complication rate, and five-year access and bypass survival rates of 56% and 97% (J. Vasc. Surg. 2013;54:1073-8).
Surgeons in Texas reported full symptom resolution in 77% of 33 patients, but cautioned against potential complications such as bypass failure that led to gangrene and transmetacarpal amputation in one patient (J. Vasc. Access 2012;13:299-304).
Dr. Huber reported having no financial disclosures.
AT THE NORTHWESTERN VASCULAR SYMPOSIUM
Anatomy’s role is elusive in carotid stenting risk
CHICAGO – Pinning down the anatomic characteristics that increase the risk of stroke with carotid artery stenting continues to be a challenge, as demonstrated by a database study and literature review presented at a symposium on vascular surgery sponsored by Northwestern University.
"I am absolutely convinced that certain anatomic and plaque characteristics increase the risk of a stroke for patients with carotid artery stenting," Dr. Melina R. Kibbe said in presenting her study. "The studies are not consistent in the literature, but there is a pattern."
She presented a prospective database review that evaluated no less than a dozen anatomic variables in 381 carotid arteries stented at the university from 2001 to 2010. The mostly male (75%), asymptomatic (70%), and moderate- to high-risk cohort had an average age of 70.5 years.
Within 30 days of carotid stenting, there were six strokes and eight transient ischemic attacks (TIAs), for an overall neurologic event rate of 3.7%, she said. Three patients had a heart attack, and two died.
The risk of perioperative stroke or TIA was significantly increased only in patients with a higher degree of internal carotid artery (ICA) stenosis (87% stenosis vs. 81% stenosis; P = .03).
It also trended higher, but fell short of significance, in those with greater arch calcification (P = .06).
Surprisingly, no statistical association was found between neurologic events and arch type (P = .16), despite the clinical belief that increasing arch type can be associated with more difficulty accessing the target lesion, said Dr. Kibbe, professor of vascular surgery and surgical research at Northwestern University, Chicago.
Other variables with trends that failed to reach statistical significance included internal to common carotid artery angulation, tortuous carotid artery, ipsilateral external carotid artery (ECA) stenosis, plaque calcification, and lesion length.
Turning to the literature for more answers, Dr. Kibbe and her colleagues performed a review of eight carotid stenting studies between 1993 and 2013. These studies included SAPPHIRE, which demonstrated an association between type II and III arches and increased stroke risk. Two other studies implicated type II, type III, and bovine arches, while three other studies, including a systematic review that incorporated the EVA-3S study (Stroke 2011;42:380-8), found no association between arch type and stroke.
Still, Dr. Kibbe said she’s convinced no two patients are alike when it comes to arterial anatomy and called for data from pivotal trials like CREST to be reanalyzed for stroke, based on arch type and plaque characteristics.
"Even better, I’d like to see a prospective, randomized study that excludes patients for carotid artery stenting based on their anatomy; for example, excluding all type III arches," she said. "My own personal bias is that patients with type III arches should not have carotid stenting. We don’t need to push the envelope."
Interestingly, no study in the review has shown ICA stenosis to be a risk factor for stroke or TIA, although lesions with a higher degree of stenosis would be expected to contribute to perioperative stroke risk.
Arch calcification, ECA stenosis, and plaque calcification also failed to register as risk factors, despite their potential to increase the risk of embolization with wire or catheter manipulation, Dr. Kibbe observed.
Two studies found that lesions longer than 1 cm or 1.5 cm were predictive of stroke, while one study (Catheter Cardiovasc. Interv. 2012;80:321-8) linked stroke with ICA tortuosity, defined as a distal ICA angle of more than 60 degrees.
Conventional thinking would suggest that right-sided carotid stenting would also confer a greater stroke risk because selecting the right ICA requires crossing the orifice of the left ICA, but only the SAPPHIRE trial reported more strokes with right-sided lesions, she said.
Finally, Dr. Kibbe highlighted an anatomic scoring system for carotid artery stenting developed by an international panel of seven vascular surgeons and five interventional radiologists (Stroke 2009;40:1698-703). Based on expert consensus, the greatest risk factor is type III arch, followed in descending order of risk by arch atheroma, diseased common carotid artery, ECA disease, angulated distal ICA, bovine arch, and pinhole stenosis. The resulting color-coded, traffic-light scoring system looks rather busy, but is relatively easy to use and provides guidance on carotid stenting suitability for the novice physician, she said.
Dr. Kibbe reported having no financial disclosures.
CHICAGO – Pinning down the anatomic characteristics that increase the risk of stroke with carotid artery stenting continues to be a challenge, as demonstrated by a database study and literature review presented at a symposium on vascular surgery sponsored by Northwestern University.
"I am absolutely convinced that certain anatomic and plaque characteristics increase the risk of a stroke for patients with carotid artery stenting," Dr. Melina R. Kibbe said in presenting her study. "The studies are not consistent in the literature, but there is a pattern."
She presented a prospective database review that evaluated no less than a dozen anatomic variables in 381 carotid arteries stented at the university from 2001 to 2010. The mostly male (75%), asymptomatic (70%), and moderate- to high-risk cohort had an average age of 70.5 years.
Within 30 days of carotid stenting, there were six strokes and eight transient ischemic attacks (TIAs), for an overall neurologic event rate of 3.7%, she said. Three patients had a heart attack, and two died.
The risk of perioperative stroke or TIA was significantly increased only in patients with a higher degree of internal carotid artery (ICA) stenosis (87% stenosis vs. 81% stenosis; P = .03).
It also trended higher, but fell short of significance, in those with greater arch calcification (P = .06).
Surprisingly, no statistical association was found between neurologic events and arch type (P = .16), despite the clinical belief that increasing arch type can be associated with more difficulty accessing the target lesion, said Dr. Kibbe, professor of vascular surgery and surgical research at Northwestern University, Chicago.
Other variables with trends that failed to reach statistical significance included internal to common carotid artery angulation, tortuous carotid artery, ipsilateral external carotid artery (ECA) stenosis, plaque calcification, and lesion length.
Turning to the literature for more answers, Dr. Kibbe and her colleagues performed a review of eight carotid stenting studies between 1993 and 2013. These studies included SAPPHIRE, which demonstrated an association between type II and III arches and increased stroke risk. Two other studies implicated type II, type III, and bovine arches, while three other studies, including a systematic review that incorporated the EVA-3S study (Stroke 2011;42:380-8), found no association between arch type and stroke.
Still, Dr. Kibbe said she’s convinced no two patients are alike when it comes to arterial anatomy and called for data from pivotal trials like CREST to be reanalyzed for stroke, based on arch type and plaque characteristics.
"Even better, I’d like to see a prospective, randomized study that excludes patients for carotid artery stenting based on their anatomy; for example, excluding all type III arches," she said. "My own personal bias is that patients with type III arches should not have carotid stenting. We don’t need to push the envelope."
Interestingly, no study in the review has shown ICA stenosis to be a risk factor for stroke or TIA, although lesions with a higher degree of stenosis would be expected to contribute to perioperative stroke risk.
Arch calcification, ECA stenosis, and plaque calcification also failed to register as risk factors, despite their potential to increase the risk of embolization with wire or catheter manipulation, Dr. Kibbe observed.
Two studies found that lesions longer than 1 cm or 1.5 cm were predictive of stroke, while one study (Catheter Cardiovasc. Interv. 2012;80:321-8) linked stroke with ICA tortuosity, defined as a distal ICA angle of more than 60 degrees.
Conventional thinking would suggest that right-sided carotid stenting would also confer a greater stroke risk because selecting the right ICA requires crossing the orifice of the left ICA, but only the SAPPHIRE trial reported more strokes with right-sided lesions, she said.
Finally, Dr. Kibbe highlighted an anatomic scoring system for carotid artery stenting developed by an international panel of seven vascular surgeons and five interventional radiologists (Stroke 2009;40:1698-703). Based on expert consensus, the greatest risk factor is type III arch, followed in descending order of risk by arch atheroma, diseased common carotid artery, ECA disease, angulated distal ICA, bovine arch, and pinhole stenosis. The resulting color-coded, traffic-light scoring system looks rather busy, but is relatively easy to use and provides guidance on carotid stenting suitability for the novice physician, she said.
Dr. Kibbe reported having no financial disclosures.
CHICAGO – Pinning down the anatomic characteristics that increase the risk of stroke with carotid artery stenting continues to be a challenge, as demonstrated by a database study and literature review presented at a symposium on vascular surgery sponsored by Northwestern University.
"I am absolutely convinced that certain anatomic and plaque characteristics increase the risk of a stroke for patients with carotid artery stenting," Dr. Melina R. Kibbe said in presenting her study. "The studies are not consistent in the literature, but there is a pattern."
She presented a prospective database review that evaluated no less than a dozen anatomic variables in 381 carotid arteries stented at the university from 2001 to 2010. The mostly male (75%), asymptomatic (70%), and moderate- to high-risk cohort had an average age of 70.5 years.
Within 30 days of carotid stenting, there were six strokes and eight transient ischemic attacks (TIAs), for an overall neurologic event rate of 3.7%, she said. Three patients had a heart attack, and two died.
The risk of perioperative stroke or TIA was significantly increased only in patients with a higher degree of internal carotid artery (ICA) stenosis (87% stenosis vs. 81% stenosis; P = .03).
It also trended higher, but fell short of significance, in those with greater arch calcification (P = .06).
Surprisingly, no statistical association was found between neurologic events and arch type (P = .16), despite the clinical belief that increasing arch type can be associated with more difficulty accessing the target lesion, said Dr. Kibbe, professor of vascular surgery and surgical research at Northwestern University, Chicago.
Other variables with trends that failed to reach statistical significance included internal to common carotid artery angulation, tortuous carotid artery, ipsilateral external carotid artery (ECA) stenosis, plaque calcification, and lesion length.
Turning to the literature for more answers, Dr. Kibbe and her colleagues performed a review of eight carotid stenting studies between 1993 and 2013. These studies included SAPPHIRE, which demonstrated an association between type II and III arches and increased stroke risk. Two other studies implicated type II, type III, and bovine arches, while three other studies, including a systematic review that incorporated the EVA-3S study (Stroke 2011;42:380-8), found no association between arch type and stroke.
Still, Dr. Kibbe said she’s convinced no two patients are alike when it comes to arterial anatomy and called for data from pivotal trials like CREST to be reanalyzed for stroke, based on arch type and plaque characteristics.
"Even better, I’d like to see a prospective, randomized study that excludes patients for carotid artery stenting based on their anatomy; for example, excluding all type III arches," she said. "My own personal bias is that patients with type III arches should not have carotid stenting. We don’t need to push the envelope."
Interestingly, no study in the review has shown ICA stenosis to be a risk factor for stroke or TIA, although lesions with a higher degree of stenosis would be expected to contribute to perioperative stroke risk.
Arch calcification, ECA stenosis, and plaque calcification also failed to register as risk factors, despite their potential to increase the risk of embolization with wire or catheter manipulation, Dr. Kibbe observed.
Two studies found that lesions longer than 1 cm or 1.5 cm were predictive of stroke, while one study (Catheter Cardiovasc. Interv. 2012;80:321-8) linked stroke with ICA tortuosity, defined as a distal ICA angle of more than 60 degrees.
Conventional thinking would suggest that right-sided carotid stenting would also confer a greater stroke risk because selecting the right ICA requires crossing the orifice of the left ICA, but only the SAPPHIRE trial reported more strokes with right-sided lesions, she said.
Finally, Dr. Kibbe highlighted an anatomic scoring system for carotid artery stenting developed by an international panel of seven vascular surgeons and five interventional radiologists (Stroke 2009;40:1698-703). Based on expert consensus, the greatest risk factor is type III arch, followed in descending order of risk by arch atheroma, diseased common carotid artery, ECA disease, angulated distal ICA, bovine arch, and pinhole stenosis. The resulting color-coded, traffic-light scoring system looks rather busy, but is relatively easy to use and provides guidance on carotid stenting suitability for the novice physician, she said.
Dr. Kibbe reported having no financial disclosures.
EXPERT ANALYSIS AT A NORTHWESTERN VASCULAR SYMPOSIUM
Major finding: The risk of perioperative stroke or TIA was significantly increased only in patients with a higher degree of internal carotid artery (ICA) stenosis (87% stenosis vs. 81% stenosis; P = .03).
Data source: A retrospective study of 381 carotid arteries and an analysis of eight published studies.
Disclosures: Dr. Kibbe reported having no financial disclosures.
