Journal of Vascular Surgery
Volume 64, Number 3 Results: Four patients underwent transcaval embolization for an expanding aneurysm sac; 75% of the patients were male. The average age was 78.7 years. Average preintervention aneurysm sac size was 8.5 cm (6.7-10.6 cm). In two patients, previous transarterial/translumbar embolization attempts had failed. The technical success rate for transcaval embolization was 100%. The average ﬂuoroscopy time was 34.6 minutes. The average amount of contrast material administered was 60 mL. The number of coils deployed averaged 8.75 (3-11). There were no immediate postoperative complications. Follow-up ranged from 1 to 12 months. All patients remained free of endoleaks with stable or decreasing aneurysm sac size. No patients developed any complications associated with the inferior vena cava or femoral veins. Conclusions: Transcaval access is a safe and effective alternative method for treating type II endoleaks. In addition, it can be considered a primary or secondary approach after failed intra-arterial or translumbar attempts. Author Disclosures: T. Massimi: None; S. Duson: None; S. Abramowitz: None; R. Malik: None; M. Kiguchi: None; E. Woo: None.
Late Type II Endoleaks After Endovascular Aneurysm Repair Require Intervention More Frequently Than Early Type II Endoleaks Danielle M. Pineda, Samuel Tyagi, MD, Douglas A. Troutman, DO, Matthew J. Dougherty, MD, and Keith D. Calligaro, MD. Pennsylvania Hospital, Philadelphia, Pa Objective: Type II endoleaks (T2Els) are common complications after endovascular aneurysm repair (EVAR). We sought to determine if time at onset of T2Els correlated with the need to intervene on the basis of sac expansion or rupture. Methods: Between 1998 and 2015, we performed 462 EVARs that had complete duplex ultrasound (DU) follow-up. DU was used for routine surveillance, and computed tomography or arteriography was reserved for abnormal DU ﬁndings. We analyzed the need for intervention for T2Els on the basis of time at onset after EVAR. Interventions for T2Els were performed only for sac expansion >0.5 mm or rupture. We deﬁned late T2Els as being ﬁrst observed beyond 1 year of follow-up. Results: Of the 462 EVARs, 96 patients (21%) developed T2Els after implantation. Of these 96 patients, 65 (68%) had early and 31 (32%) had late T2Els (mean, 12 months; range, 0-112 months). T2Els resolved without treatment in 75% (49/65) of early T2Els compared with only 29% (9/31) of late T2Els (P < .0001). Intervention was required for only 8% (5/65) of patients with early T2Els (5 sac expansion, 0 rupture) compared with 55% (17/31) for late T2Els (16 sac expansion, 1 rupture; P < .0001). The remaining patients are still being observed for persistent T2Els with no sac growth (17% [11/65] early vs 16% [5/31] late; P ¼ .922). Conclusions: T2Els that developed after 1 year required intervention much more frequently than those identiﬁed during the ﬁrst postprocedure year. Less than one-third (29%) of T2Els that develop after 1 year will resolve spontaneously. T2Els that develop >1 year after EVAR should be observed with a more frequent surveillance protocol and possibly with a lower threshold to intervene. Author Disclosures: D. M. Pineda: None; S. Tyagi: None; D. A. Troutman: None; M. J. Dougherty: None; K. D. Calligaro: None.
Increased Mortality Associated With Subclavian to Carotid Artery Transposition for Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair Khanjan H. Nagarsheth, MD, MBA, RPVI, Viktor Dombrovskiy, MD, and Saum Rahimi, MD. Rutgers University-Robert Wood Johnson Medical School, New Brunswick, NJ Objective: Left subclavian artery (LSA) coverage is an acceptable method for achieving an adequate proximal seal zone in patients undergoing thoracic endovascular aortic repair (TEVAR). The optimal method of LSA revascularization is still unknown, with only small series present in the literature. We sought to compare LSA revascularization techniques performed for TEVAR. Methods: Patients with TEVAR and LSA coverage (Current Procedural Terminology code 33880) were selected in the Medicare Carrier and then MedPAR ﬁles 2007-2012, and outcomes in those with
carotid-subclavian artery bypass (CSB; 35506, 35606) or subclaviancarotid artery transposition (SCT; 33889) were compared. The c2 test, multivariable logistic regression, and t-test were used for analysis. Results: A total of 976 patients were evaluated: 702 with CSB and 274 with SCT; 64.2% patients were admitted electively. In bivariate analysis, there were no signiﬁcant differences between these two groups in patients’ demographic characteristics, comorbid measures, and rates of major postoperative complications. The greatest proportion of CSB (78.8%) was noted in major teaching hospitals; there were no signiﬁcant differences in use of SCT and CSB between urban and rural hospitals. However, in multivariable analysis with adjustment by patient age, gender and race, comorbidities, postoperative complications, admission type, and hospital characteristics, patients with SCT were more likely to die in the hospital after TEVAR than those with CSB (odds ratio [OR], 2.4; 95% conﬁdence interval [CI], 1.3-4.3). The other risk factors for hospital mortality were postoperative cardiac (OR, 3.0; 95% CI, 1.4-6.3) and respiratory (OR, 3.4; 95% CI, 1.9-6.2) complications, sepsis (OR, 4.3; 95% CI, 1.7-10.6), and occlusion of cerebral arteries (OR, 3.5; 95% CI, 1.7-7.1). At the same time, patients with CSB compared with those with SCT had greater hospital length of stay (12.3 6 11.2 vs 10.2 6 9.3 days; P ¼ .0025). They also were more likely to be readmitted to the hospital during 30 days after index discharge (OR, 1.6; 95% CI, 1.1-2.4). Likelihood of 30-day readmission was signiﬁcantly greater after nonelective surgery (OR, 1.5; 95% CI, 1.1-2.0). Conclusions: SCT is associated with a greater than twofold increase in in-hospital mortality compared with CSB. Randomized controlled trials comparing CSB and SCT are needed to elucidate reasons for this increased mortality. Author Disclosures: K. H. Nagarsheth: None; V. Dombrovskiy: None; S. Rahimi: None.
Endograft Coverage of the Left Subclavian Artery During Repair of Traumatic Thoracic Aortic Injury May Be Associated With Signiﬁcant Long-Term Morbidity Michael Madigan, MD, Elizabeth Genovese, MD, Mikhail Attaar, Louis Alarcon, MD, Michael Singh, MD, Michel Makaroun, MD, and Eric Hager. UPMC, Pittsburgh, Pa Objective: Coverage of the left subclavian artery (LSCA) during thoracic endovascular aortic repair (TEVAR) has reportedly minimal long-term sequelae. As it is being used frequently in traumatic aortic transection, we hypothesized that trauma patients with LSCA coverage may often require secondary interventions because of ischemic complications. Methods: We conducted a single-institution, retrospective chart review of 82 patients who underwent TEVAR for blunt aortic transection (20042014). Patient demographics, comorbidities, concomitant injuries, details of the intervention, and thoracic aortic injury grade were collected. The outcomes included were immediate and long-term mortality rates, stroke, endoleak, device migration, lesion regression, open conversion, and reintervention rates secondary to morbidity associated with LSCA coverage. Statistical analysis included c2 test, Fisher exact test, t-test, and Kaplan-Meier analysis. Results: Eighty-two patients were treated with TEVAR with a technical success rate of 100% and mean follow-up of 2.3 6 2.4 years. Fifty-eight patients had TEVAR without LSCA coverage, whereas 23 patients (28.0%) required either partial or complete coverage. The overall 30-day mortality rate was 7.3% (n ¼ 6), mostly due to associated injuries. Mortality was similar between those with and without LSCA coverage (6.9% vs 8.7%; P ¼ 1.0). Patients with LSCA coverage had signiﬁcantly more hemodynamic instability on presentation than those who did not require LSCA coverage (43% vs 19%; P ¼ .023). Adverse events and reinterventions associated with LSCA included one patient who died of concomitant trauma and one who died of an immediate, massive posterior stroke resultant from LSCA coverage. One patient was immediately revascularized because of previous left internal mammary artery-left anterior descending artery bypass, and one was revascularized because of immediate arm ischemia. Of the remaining 18 who were discharged without immediate revascularization, 5 required delayed revascularization for exertional arm pain or ischemia (Table). One-year survival rates were similar between groups (90.9% vs 91.3%; P ¼ .976). Conclusions: In this study, the LSCA required coverage in approximately a quarter of patients during TEVAR for traumatic aortic injury to