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Posts Tagged ‘Aneurysm’

Improved Results for Treatment of Persistent type 2 Endoleak after Endovascular Aneurysm Repair: Onyx Glue Embolization

Posted in Cardiac & Vascular Repair Tools Subsegment, Carotid Artery, Cerebrovascular and Neurodegenerative Diseases, Health Economics and Outcomes Research, International Global Work in Pharmaceutical, ISO 10993 for Product Registration: FDA & CE Mark for Development of Medical Devices and Diagnostics, Medical Devices R&D Investment, Medical Imaging Technology, Image Processing/Computing, MRI, CT, Nuclear Medicine, Ultra Sound, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Technology Transfer: Biotech and Pharmaceutical, tagged Adhesive, Aneurysm, Boston, Coronary artery disease, Dimethyl sulfoxide, Drug-eluting stent, Endovascular aneurysm repair, EVOH, Harvard Medical School, Massachusetts General Hospital, onyx on June 28, 2013| 4 Comments »

Improved Results for Treatment of Persistent type 2 Endoleak after Endovascular Aneurysm Repair: Onyx Glue Embolization

Writer, Curator: Larry H Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN 

 

 

This report is an evaluation of onyx glue use in endovascular aneurysm repair. Onyx® is a non-adhesive liquid embolic agent used for the pre-surgical embolization of brain Arteriovenous malformations (bAVM).

Onyx is comprised of EVOH (ethylene vinyl alcohol) copolymer dissolved in DMSO (dimethyl sulfoxide), and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy.

A DMSO compatible delivery micro catheter that is indicated for use in the neuro vasculature (e.g. Marathon™, Rebar® or UltraFlow™ HPC catheters) is used to access the embolization site.

Onyx is available in two product formulations, Onyx 18 (6% EVOH) and Onyx 34 (8% EVOH).

http://www.ev3.net/assets/002/5231_w600h.jpg

Improved results using Onyx glue for the treatment of persistent type 2 endoleak after endovascular aneurysm repair. 

Abularrage CJ, Patel VI, Conrad MF, Schneider EB, Cambria RP, Kwolek CJ

Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass 02114, USA.

J Vasc Surg. 2012 Sep;56(3):630-6.  http://dx.doi.org/10.1016/j.jvs.2012.02.038.  Epub 2012 May 8.

Persistent type 2 (PT2) endoleaks (present ≥ 6 months) after endovascular aneurysm repair are associated with adverse outcomes, and

• selective secondary intervention is indicated in those patients with an expanding aneurysm sac.

This study evaluated the outcomes of secondary intervention for PT2.

From 1999 to 2007, 136 patients who underwent endovascular aneurysm repair developed PT2 and comprised the study cohort. Primary end points included

• PT2 resolution (secondary interventional success) and
• survival

 both  were evaluated using multiple logistic regression and Kaplan-Meier analyses

Fifty-one patients underwent a total of 68 secondary interventions for PT2 with expanding aneurysm sacs

• with a median postsecondary interventional follow-up of 13.7 months.

Secondary interventions included

• 20 inferior mesenteric artery coil embolizations,
• 17 Onyx glue embolizations,
• 11 aneurysm sac coil embolizations,
• 10 non-Onyx glue embolizations,
• 7 lumbar artery coil embolizations,
• 2 open lumbar ligations, and 1 graft explant.

The overall secondary interventional success rate was 43% (29 of 68). Onyx glue embolization was associated with

• a greater success rate when used as the initial secondary intervention (odds ratio, 59.61; 95% confidence interval, 4.78-742.73; P < .001). 

There was no difference in success between the different techniques when multiple secondary interventions were required. Five-year survival was 72% ± 0.08% and

• was unrelated to any of the secondary interventional techniques.

Secondary intervention for PT2 is associated with success in less than half of all cases. Onyx glue embolization was associated with greater long-term success

• when used as the initial secondary intervention.

Related articles

• The EVAR I trial: Endovascular vs. open abdominal aortic aneurysm repair [Classics Series] (2minutemedicine.com)
• Brain aneurysm treatments now have fewer complications, better outcomes (miamiherald.com)
• Super Glue Used to Seal Aneurysm in Baby’s Brain (ktla.com)
• The EVAR II trial: Endovascular approach when unfit for open aortic aneurysm repair [Classics Series] (2minutemedicine.com)
• Red Vascular Branch Endograft System: Aortic Aneursysm (proteinbreak.wordpress.com)
• ArterioVenous Malformation of the brain (pathologycloud.wordpress.com)

Competition in the Ecosystem of Medical Devices in Cardiac and Vascular Repair: Heart Valves, Stents, Catheterization Tools and Kits for Open Heart and Minimally Invasive Surgery (MIS)  (Aviva Lev-Ari)

https://pharmaceuticalintelligence.com/2012/06/22/competition-in-the-ecosystem-of-medical-devices-in-cardiac-and-vascular-repair-heart-valves-stents-catheterization-tools-and-kits-for-open-heart-and-minimally-invasive-surgery-mis/

Vascular Repair: Stents and Biologically Active Implants (larryhbern)

https://pharmaceuticalintelligence.com/2013/05/04/stents-biologically-active-implants-and-vascular-repair/

Drug Eluting Stents: On MIT’s Edelman Lab’s Contributions to Vascular Biology and its Pioneering Research on DES  (larryhbern)

https://pharmaceuticalintelligence.com/2013/04/25/contributions-to-vascular-biology/

Coronary Artery Disease – Medical Devices Solutions: From First-In-Man Stent Implantation, via Medical Ethical Dilemmas to Drug Eluting Stents  (Aviva Lev-Ari)

https://pharmaceuticalintelligence.com/2012/08/13/coronary-artery-disease-medical-devices-solutions-from-first-in-man-stent-implantation-via-medical-ethical-dilemmas-to-drug-eluting-stents/

Trans-apical Transcatheter Aortic Valve Replacement in a Patient with Severe and Complex Left Main Coronary Artery Disease (LMCAD) (larryhbern)

https://pharmaceuticalintelligence.com/2013/06/17/management-of-difficult-trans-apical-transcatheter-aortic-valve-replacement-in-a-patient-with-severe-and-complex-arterial-disease/

Transcatheter Aortic Valve Replacement (TAVR): Postdilatation to Reduce Paravalvular Regurgitation During TAVR with a Balloon-expandable Valve  (larryhbern)

https://pharmaceuticalintelligence.com/2013/06/17/postdilatation-to-reduce-paravalvular-regurgitation-during-transcatheter-aortic-valve-replacement/

Svelte Medical Systems’ Drug-Eluting Stent: 0% Clinically-Driven Events Through 12-Months in First-In-Man Study  (Aviva Lev-Ari)

https://pharmaceuticalintelligence.com/2013/05/28/svelte-medical-systems-drug-eluting-stent-0-clinically-driven-events-through-12-months-in-first-in-man-study/

Acute and Chronic Myocardial Infarction: Quantification of Myocardial Perfusion Viability – FDG-PET/MRI vs. MRI or PET alone  (Justin Pearlman, Aviva Lev-Ari)

https://pharmaceuticalintelligence.com/2013/05/22/acute-and-chronic-myocardial-infarction-quantification-of-myocardial-viability-fdg-petmri-vs-mri-or-pet-alone/

Biomaterials Technology: Models of Tissue Engineering for Reperfusion and Implantable Devices for Revascularization (larryhbern)

https://pharmaceuticalintelligence.com/2013/05/05/bioengineering-of-vascular-and-tissue-models/

Revascularization: PCI, Prior History of PCI vs CABG  (A Lev-Ari)

https://pharmaceuticalintelligence.com/2013/04/25/revascularization-pci-prior-history-of-pci-vs-cabg/

The ACUITY-PCI score: Will it Replace Four Established Risk Scores — TIMI, GRACE, SYNTAX, and Clinical SYNTAX  (A Lev-Ari)

https://pharmaceuticalintelligence.com/2013/01/03/the-acuity-pci-score-will-it-replace-four-established-risk-scores-timi-grace-syntax-and-clinical-syntax/

Absorb™ Bioresorbable Vascular Scaffold: An International Launch by Abbott Laboratories (Aviva Lev-Ari)

https://pharmaceuticalintelligence.com/2012/09/29/absorb-bioresorbable-vascular-scaffold-an-international-launch-by-abbott-laboratories/

Carotid Stenting: Vascular surgeons have pointed to more minor strokes in the stenting group and cardiologists to more myocardial infarctions in the CEA cohort. (A Lev-Ari)

https://pharmaceuticalintelligence.com/2012/09/21/carotid-stenting-vascular-surgeons-have-pointed-to-more-minor-strokes-in-the-stenting-group-and-cardiologists-to-more-myocardial-infarctions-in-the-cea-cohort/

Endovascular repair of cerebral aneurysm. (Photo credit: Wikipedia)

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Open Abdominal Aortic Aneurysm (AAA) repair (OAR) vs. Endovascular AAA Repair (EVAR) in Chronic Kidney Disease Patients – Comparison of Surgery Outcomes

Posted in Abdominal Aorta, Cardiac and Cardiovascular Surgical Procedures, Chemical Biology and its relations to Metabolic Disease, Frontiers in Cardiology and Cardiovascular Disorders, Imaging-based Cancer Patient Management, ISO 10993 for Product Registration: FDA & CE Mark for Development of Medical Devices and Diagnostics, Medical Imaging Technology, Image Processing/Computing, MRI, CT, Nuclear Medicine, Ultra Sound, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Uncategorized, tagged AAA, Abdominal aortic aneurysm, Aneurysm, Aorta, Aortic aneurysm, Endovascular aneurysm repair, Endovascular surgery, Inferior mesenteric artery, Invasiveness of surgical procedures, Larry H. Bernstein on June 28, 2013| 4 Comments »

Open Abdominal Aortic Aneurysm (AAA) repair (OAR) vs. Endovascular AAA Repair (EVAR) in Chronic Kidney Disease (CKD) Patients –  Comparison of Surgery Outcomes

Writer and Curator: Larry H. Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN 

This is a review of the effects of CKD on increased morbidity and mortality of abdominal aortic aneurysm repair.   The abdominal aorta has branches to the superior mesenteric arteries proximally, and below that both renal arteries, which also supply the adrenals (suprarenal).

Severe atherosclerosis with plaque buildup and separation of the media from the endothelium, can migrate down the addominal aorta before frank rupture of an aneurysm.   Abdominal aortic aneurysm often extends from below the the renal arteries, to the internal spermatic vessels, or as far as the iliacs.

http://l.yimg.com/a/i/edu/ref/ga/l/531.gif

           

http://upload.wikimedia.org/wikipedia/commons/thumb/4/4a/Contrast-enhanced_CT_scan_demonstrating_abdominal_aortic_aneurysm.jpg/120px-Contrast-enhanced_CT_scan_demonstrating_abdominal_aortic_aneurysm.jpg

Of the visceral branches, the celiac artery and the superior and inferior mesenteric arteries are unpaired, while the suprarenals, renals, internal spermatics, and ovarian are paired. Of the parietal branches the inferior phrenics and lumbars are paired; the middle sacral is unpaired. The terminal branches are paired.

AAA is most common in men over age 65 years.  If it is expanding AAA causes sudden, severe, and constant low back, flank, abdominal, or groin pain (internal spermatic branch).  The presence of a pulsatile abdominal mass is virtually diagnostic but is found in less than half of all cases.  At least 65% of patients with a ruptured AAA die from sudden cardiovascular collapse before arriving at a hospital.

http://upload.wikimedia.org/wikipedia/commons/thumb/a/ab/RupturedAAA.png/120px-RupturedAAA.png

EVAR for ruptured AAA

A study by Mehta et al assessed the effect of hemodynamic status on outcomes in 136 patients undergoing EVAR for ruptured AAAs.[1] The patients were divided into 2 groups:

(1) Hd-stable (systolic BP ≥80 mm Hg; n = 92 [68%]) and
(2) Hd-unstable (systolic BP < 80 mm Hg for >10 minutes; n = 44 [32%]).

The 30-day mortality, postoperative complications, need for secondary reinterventions, and midterm mortality were recorded. The 2 groups were found to be similar with respect to

• comorbidities,
• mean AAA maximum diameter (6.6 vs 6.4 cm),
• need for on-the-table conversion to open repair (3% vs 7%), and
• incidence of nonfatal complications (43% vs 38%) and secondary interventions (23% vs 25%).

1. intraoperative need for aortic occlusion balloon,
2.  mean estimated blood loss,
3. incidence of developing abdominal compartment syndrome (ACS), and
4. mortality

were all increased in the Hd-unstable group ([1]40% vs 6%, [2]744 vs 363 mL,[3] 29% vs 4%, and [4]33% vs 18%, respectively).

AAA repair 

Open Surgery

Requires direct access to the aorta through an abdominal or retroperitoneal approach

Endovascular: Involves gaining access to the lumen of the abdominal aorta, usually via small incisions over the femoral vessels; an endograft, typically a cloth graft with a stent exoskeleton, is placed within the lumen of the AAA, extending distally into the iliac arteries.  Approximately 90% of abdominal aortic aneurysms are infrarenal.

The important surgical and endovascular anatomic considerations include associated renal and visceral artery involvement (either occlusive disease or involved in the aneurysm process) and the iliac artery (either occlusive disease or aneurysms). The length of the infrarenal aortic neck is important in helping determine the surgical approach (retroperitoneal vs transabdominal) and the location of the aortic cross clamp.

Endovascular Aneurysm Repair

Endovascular repair first became practical in the 1990s and although it is now an established alternative to open repair, its role is yet to be clearly defined. It is generally indicated in older, high-risk patients or patients unfit for open repair. However, endovascular repair is feasible for only a proportion of AAAs, depending on the morphology of the aneurysm. The main advantages over open repair are that there is less peri-operative mortality, less time in intensive care, less time in hospital overall and earlier return to normal activity. Disadvantages of endovascular repair include a requirement for more frequent ongoing hospital reviews, and a higher chance of further procedures being required.  According to the latest studies, the EVAR procedure does not offer any benefit for overall survival or health-related quality of life compared to open surgery, although aneurysm-related mortality is lower.

http://upload.wikimedia.org/wikipedia/commons/thumb/9/95/Endovasc.jpg/220px-Endovasc.jpg

Aorta Anatomy and Pathology in AAA

The diameter of the aorta decreases in size from its thoracic portion to the abdominal and infrarenal portions. A normal aorta shows a reduction in medial elastin layers from the thoracic area to the abdominal portion. Elastin and collagen content are also reduced.  AAAs develop following degeneration of the media. The degeneration ultimately may lead to widening of the vessel lumen and loss of structural integrity.  

A multidisciplinary research program supported by the US National Heart, Lung, and Blood Institute identified proteolytic degradation of aortic wall connective tissue, inflammation and immune responses, biomechanical wall stress, and molecular genetics as mechanisms important in the development of AAA.  Similarly, surgical specimens of AAA reveal inflammation, with infiltration by lymphocytes and macrophages; thinning of the media; and marked loss of elastin.

Through gene microarray analysis, various genes involved in extracellular matrix degradation, inflammation, and other processes observed in AAA formation have been shown to be up-regulated, while others that may serve to prevent this occurrence are down-regulated. The combination of proteolytic degradation of aortic wall connective tissue, inflammation and immune responses, biomechanical wall stress, and molecular genetics represents a dynamic process that leads to aneurysmal deterioration of aortic tissue.

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1.  Mehta M, Paty PS, Byrne J, Roddy SP, Taggert JB, Sternbach Y, et al. The impact of hemodynamic status on outcomes of endovascular abdominal aortic aneurysm repair for rupture. J Vasc Surg. May 2013;57(5):1255-60. [Medline].

2.  Blanchard JF, Armenian HK, Friesen PP. Risk factors for abdominal aortic aneurysm: results of a case-control study. Am J Epidemiol. Mar 15 2000;151(6):575-83. [Medline].

3.  Lederle FA, Johnson GR, Wilson SE, Chute EP, Littooy FN, Bandyk D, et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med. Mar 15 1997;126(6):441-9. [Medline].

4.   Wassef M, Baxter BT, Chisholm RL, Dalman RL, Fillinger MF, Heinecke J, et al. Pathogenesis of abdominal aortic aneurysms: a multidisciplinary research program supported by the National Heart, Lung, and Blood Institute. J Vasc Surg. Oct 2001;34(4):730-8. [Medline].

5.   [Guideline] U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med. Feb 1 2005;142(3):198-202. [Medline]. [Full Text].

Impact of chronic kidney disease on outcomes after abdominal aortic aneurysm repair

Patel VI, Lancaster RT, Mukhopadhyay S, Aranson NJ, Conrad MF, et al.

J Vasc Surg. 2012 Nov;56(5):1206-13.      http://dx.doi.org/10.1016/j.jvs.2012.04.037. Epub 2012 Aug 1.

Chronic kidney disease (CKD) is associated with increased morbidity and death after open abdominal aortic aneurysm (AAA) repair (OAR). This study highlights the effect of CKD on outcomes after endovascular AAA (EVAR) and OAR in contemporary practice.

The National Surgical Quality Improvement Program (NSQIP) Participant Use File (2005-2008) was queried by Current Procedural Terminology (American Medical Association, Chicago, Ill) code to identify EVAR or OAR patients, who were grouped by CKD class as having mild (CKD class 1 or 2), moderate (CKD class 3), or severe (CKD class 4 or 5) renal disease. Propensity score analysis was performed to match OAR and EVAR patients with mild CKD with those with moderate or severe CKD. Comparative analysis of mortality and clinical outcomes was performed based on CKD strata.

We identified 8701 patients who were treated with EVAR (n = 5811) or OAR (n = 2890) of intact AAAs. Mild, moderate, and severe CKD was present in 63%, 30%, and 7%, respectively. CKD increased (P < .01) overall mortality, with rates of 1.7% (mild), 5.3% (moderate), and 7.7% (severe) in unmatched patients undergoing EVAR or OAR. Operative mortality rates in patients with severe CKD were as high as 6.2% for EVAR and 10.3% for OAR.

Severity of CKD was associated with increasing frequency of risk factors; therefore, propensity matching to control for comorbidities was performed, resulting in similar baseline clinical and demographic features of patients with mild compared with those with moderate or severe disease.

In propensity-matched cohorts, moderate CKD increased the risk of 30-day mortality

• for EVAR (1.9% mild vs 3.2% moderate; P = .013) and
• OAR (3.1% mild vs 8.4% moderate; P < .0001).

Moderate CKD was also associated with increased morbidity in patients treated with

• EVAR (8.3% mild vs 12.8% moderate; P < .0001) or
• OAR (25.2% mild vs 32.4% moderate; P = .001).

Similarly, severe CKD increased the risk of 30-day mortality

• for EVAR (2.6% mild vs 5.7% severe; P = .0081) and
• OAR (4.1% mild vs 9.9% severe; P = .0057).

Severe CKD was also associated with increased morbidity in patients treated with

• EVAR (10.6% mild vs 19.2% severe; P < .0001) or
• OAR (31.1% mild vs 39.6% severe; P = .04).

The presence of moderate or severe CKD in patients considered for AAA repair is associated with significantly increased mortality and therefore should figure prominently in clinical decision making. The high mortality of AAA repair in patients with severe CKD is such that elective repair in such patients is not advised, except in extenuating clinical circumstances.

Related articles

• Elective Open Suprarenal Aneurysm Repair in England from 2000 to 2010 an Observational Study of Hospital Episode Statistics (plosone.org)

• The EVAR I trial: Endovascular vs. open abdominal aortic aneurysm repair [Classics Series] (2minutemedicine.com)

• Abdominal Aortic Aneurysm Genetic Risk (23andme.com)

• The EVAR II trial: Endovascular approach when unfit for open aortic aneurysm repair [Classics Series] (2minutemedicine.com)

• Red Vascular Branch Endograft System: Aortic Aneursysm (proteinbreak.wordpress.com)

Related articles published on this Open Access Online Scientific Journal 

Effect of Hospital Characteristics on Outcomes of Endovascular Repair of Descending Aortic Aneurysms in US Medicare Population

Larry H. Bernstein, MD, FCAP 

https://pharmaceuticalintelligence.com/2013/06/27/effect-of-hospital-characteristics-on-outcomes-of-endovascular-repair-of-descending-aortic-aneurysms-in-us-medicare-population/

Abdominal Aortic Aneurysms (AAA): Albert Einstein’s Operation by Dr. Nissen

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/06/11/abdominal-aortic-aneurysms-aaa-albert-einsteins-operation-by-dr-nissen/

No Early Symptoms – An Aortic Aneurysm Before It Ruptures – Is There A Way To Know If I Have it?

Justin D Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/06/10/no-early-symptoms-an-aortic-aneurysm-before-it-ruptures-is-there-a-way-to-know-if-i-have-it/

First-of-Its-Kind FDA Approval for ‘AUI’ Device with Endurant II AAA Stent Graft: Medtronic Expands in Endovascular Aortic Repair in the United States

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/05/30/first-of-its-kind-fda-approval-for-aui-device-with-endurant-ii-aaa-stent-graft-medtronic-expands-in-endovascular-aortic-repair-in-the-united-states/

Abdominal Aortic Aneurysm: Endovascular repair and open repair resulted in similar long-term survival

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/12/03/abdominal-aortic-aneurysm-endovascular-repair-and-open-repair-resulted-in-similar-long-term-survival/

EUROPCR 2013, Paris 5/21-5/24, 2013 Conference for Cardiolovascular Intervention and Interventional Medicine

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/05/29/europcr-2013-paris-521-524-2013-conference-for-cardiolovascular-intervention-and-interventional-medicine/

Genomics & Genetics of Cardiovascular Disease Diagnoses: A Literature Survey of AHA’s Circulation Cardiovascular Genetics, 3/2010 – 3/2013

Aviva Lev-Ari, PhD, RN and Larry Bernstein, MD, FCAP

https://pharmaceuticalintelligence.com/2013/03/07/genomics-genetics-of-cardiovascular-disease-diagnoses-a-literature-survey-of-ahas-circulation-cardiovascular-genetics-32010-32013/

Competition in the Ecosystem of Medical Devices in Cardiac and Vascular Repair: Heart Valves, Stents, Catheterization Tools and Kits for Open Heart and Minimally Invasive Surgery (MIS)

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/06/22/competition-in-the-ecosystem-of-medical-devices-in-cardiac-and-vascular-repair-heart-valves-stents-catheterization-tools-and-kits-for-open-heart-and-minimally-invasive-surgery-mis/

Bioabsorbable Drug Coating Scaffolds, Stents and Dual Antiplatelet Therapy

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/05/29/bioabsorbable-drug-coating-scaffolds-stents-and-dual-antiplatelet-therapy/

Vascular Repair: Stents and Biologically Active Implants

Larry  Bernstein, MD, FCAP

https://pharmaceuticalintelligence.com/2013/05/04/stents-biologically-active-implants-and-vascular-repair/

Drug Eluting Stents: On MIT’s Edelman Lab’s Contributions to Vascular Biology and its Pioneering Research on DES

Larry H. Bernstein, MD, FCAP 

https://pharmaceuticalintelligence.com/2013/04/25/contributions-to-vascular-biology/

Coronary Artery Disease – Medical Devices Solutions: From First-In-Man Stent Implantation, via Medical Ethical Dilemmas to Drug Eluting Stents

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/08/13/coronary-artery-disease-medical-devices-solutions-from-first-in-man-stent-implantation-via-medical-ethical-dilemmas-to-drug-eluting-stents/

Survivals Comparison of Coronary Artery Bypass Graft (CABG) and Percutaneous Coronary Intervention (PCI) / Coronary Angioplasty

Larry Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/06/23/comparison-of-cardiothoracic-bypass-and-percutaneous-interventional-catheterization-survivals/

Trans-apical Transcatheter Aortic Valve Replacement in a Patient with Severe and Complex Left Main Coronary Artery Disease (LMCAD)

Larry Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/06/17/management-of-difficult-trans-apical-transcatheter-aortic-valve-replacement-in-a-patient-with-severe-and-complex-arterial-disease/

Transcatheter Aortic Valve Replacement (TAVR): Postdilatation to Reduce Paravalvular Regurgitation During TAVR with a Balloon-expandable Valve

Larry Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/06/17/postdilatation-to-reduce-paravalvular-regurgitation-during-transcatheter-aortic-valve-replacement/

Svelte Medical Systems’ Drug-Eluting Stent: 0% Clinically-Driven Events Through 12-Months in First-In-Man Study

Aviva Lev-Ari, PhD, RN

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Acute and Chronic Myocardial Infarction: Quantification of Myocardial Perfusion Viability – FDG-PET/MRI vs. MRI or PET alone  (Justin Pearlman, Aviva Lev-Ari)

https://pharmaceuticalintelligence.com/2013/05/22/acute-and-chronic-myocardial-infarction-quantification-of-myocardial-viability-fdg-petmri-vs-mri-or-pet-alone/

Biomaterials Technology: Models of Tissue Engineering for Reperfusion and Implantable Devices for Revascularization

Larry Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/05/05/bioengineering-of-vascular-and-tissue-models/

Revascularization: PCI, Prior History of PCI vs CABG

Aviva Lev-Ari, PhD, RN

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FDA Pending 510(k) for The Latest Cardiovascular Imaging Technology

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The ACUITY-PCI score: Will it Replace Four Established Risk Scores — TIMI, GRACE, SYNTAX, and Clinical SYNTAX

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2013/01/03/the-acuity-pci-score-will-it-replace-four-established-risk-scores-timi-grace-syntax-and-clinical-syntax/

Nitric Oxide and it’s impact on Cardiothoracic Surgery

Tilda Barliya, PhD

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CABG or PCI: Patients with Diabetes – CABG Rein Supreme

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/11/05/cabg-or-pci-patients-with-diabetes-cabg-rein-supreme/

To Stent or Not? A Critical Decision

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/10/23/to-stent-or-not-a-critical-decision/

Endothelin Receptors in Cardiovascular Diseases: The Role of eNOS Stimulation

Aviva Lev-Ari, PhD, RN

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Absorb™ Bioresorbable Vascular Scaffold: An International Launch by Abbott Laboratories

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/09/29/absorb-bioresorbable-vascular-scaffold-an-international-launch-by-abbott-laboratories/

Carotid Stenting: Vascular surgeons have pointed to more minor strokes in the stenting group and cardiologists to more myocardial infarctions in the CEA cohort.

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/09/21/carotid-stenting-vascular-surgeons-have-pointed-to-more-minor-strokes-in-the-stenting-group-and-cardiologists-to-more-myocardial-infarctions-in-the-cea-cohort/

New Drug-Eluting Stent Works Well in STEMI

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/08/22/new-drug-eluting-stent-works-well-in-stemi/

Global Supplier Strategy for Market Penetration & Partnership Options (Niche Suppliers vs. National Leaders) in the Massachusetts Cardiology & Vascular Surgery Tools and Devices Market for Cardiac Operating Rooms and Angioplasty Suites

Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2012/06/22/global-supplier-strategy-for-market-penetration-partnership-options-niche-suppliers-vs-national-leaders-in-the-massachusetts-cardiology-vascular-surgery-tools-and-devices-market-for-car/

Abdominal Aortic Aneurysm in Computer Tomography (Photo credit: Wikipedia)

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Effect of Hospital Characteristics on Outcomes of Endovascular Repair of Descending Aortic Aneurysms in US Medicare Population

Posted in Cardiac & Vascular Repair Tools Subsegment, FDA Regulatory Affairs, Frontiers in Cardiology and Cardiovascular Disorders, Health Economics and Outcomes Research, ISO 10993 for Product Registration: FDA & CE Mark for Development of Medical Devices and Diagnostics, Medical Devices R&D Investment, Medical Imaging Technology, Image Processing/Computing, MRI, CT, Nuclear Medicine, Ultra Sound, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Statistical Methods for Research Evaluation, Technology Transfer: Biotech and Pharmaceutical, Thoracic Aorta, tagged Aneurysm, Endovascular aneurysm repair, Harvard Medical School, Invasiveness of surgical procedures, Massachusetts General Hospital, University of Pittsburgh Medical Center, Vascular surgery on June 27, 2013| 5 Comments »

Effect of Hospital Characteristics on Outcomes of Endovascular Repair of Descending Aortic Aneurysms in US Medicare Population

Writer and Curator: Larry H. Bernstein, MD, FCAP 

and

Curator: Aviva Lev-Ari, PhD, RN 

Impact of hospital volume and type on outcomes of open and endovascular repair of descending thoracic aneurysms in the United States Medicare population.

Patel VI, Mukhopadhyay S, Ergul E, Aranson N, …., Cambria RP.

Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

Journal of vascular surgery 2013;    http://dx.doi.org/10.1016/j.jvs.2013.01.035

 

Open surgery for thoracic aortic aneurysm has had success, but it carries complication risks.  In 2004, a much less invasive procedure, thoracic endovascular repair (TEVAR) was introduced. It eliminated a need for open surgery in many patients, but not all were suitable candidtes .  The advances in endovascular technology and procedural breakthroughs  since it was introduced has contributed to a dramatic transformation of the specialty of thoracic aortic surgery. The decision of which patients require open surgery is necessarily determined by the limitations of the procedure and the condition of the patient.

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive alternative to conventional open surgical reconstruction for the treatment of thoracic aortic aneurysm. TEVAR procedures can be challenging and, at times, extraordinarily difficult.  Meticulous assessment of anatomy and preoperative procedure planning are absolutely paramount to produce optimal outcomes. The rapidly Increased use of TEVAR has produced favorable outcomes of TEVAR compared with open abdominal repair for descending thoracic aortic aneurysms (DTAs).   But the success of these procedure depends on requisite skills, and following guidelines intended for use in quality-improvement programs that assess the standard of care expected from all physicians who perform TEVAR procedures.

Currently, there is a diverse array of endografts that are commercially available to treat the thoracic aorta. Multiple studies have demonstrated excellent outcomes of thoracic endovascular aortic repair for the treatment of thoracic aortic aneurysms, with less reported perioperative morbidity and mortality in comparison with conventional open repair. Additionally, similar outcomes have been demonstrated for the treatment of type B dissections. However, the technology remains relatively novel, and larger studies with longer term outcomes are necessary to more fully evaluate the role of endovascular therapy for the treatment of thoracic aortic disease.

The MGH/Partners vascular surgeons evaluated the effect of case volume and hospital teaching status on clinical outcomes of intact DTA repair to gain an insight into whether there was a variability in DTAs outcomes based on hospital size, patient mix, number of procedures, staff characteristics, and teaching status.  This study was needed for establishing the type of procedure most suited to the type of patient, and to obtain the most accurate analysis of cost requirements based on resource allocation for reimbursement purposes.

The Medicare Provider Analysis and Review (MEDPAR) data set (2004 to 2007) was queried to identify open repair or TEVAR for DTA. Hospitals were stratified by DTA volume into high volume (HV; ≥8 cases/y) or low volume (LV; <8 cases/y) and teaching or nonteaching. The effect of hospital variables on the primary study end point of 30-day mortality and secondary end points of 30-day complications and long-term survival after open repair and TEVAR DTA repair were studied using univariate testing, multivariable regression modeling, Kaplan-Meier survival analysis, and Cox proportional hazards regression modeling.

They identified 763 hospitals performing 3554 open repairs and 3517 TEVARs. Overall DTA repair increased (P < .01) from 1375 in 2004 to 1987 in 2007. The proportion of hospitals performing open repair significantly decreased from 95% in 2004 to 57% in 2007 (P < .01), whereas

• those performing TEVAR increased (P < .01) from 24% to 76%.

Overall repair type shifted from open (74% in 2004, the year before initial commercial availability of TEVAR) to TEVAR (39% open in 2007; P < .01). The fraction of open repairs at LV hospitals

• decreased from 56% in 2004 to 44% in 2007 (P < .01), whereas
• TEVAR increased from 24% in 2004 to 51% in 2007 (P < .01).

Overall mortality during the study interval for

•  open repair was 15% at LV hospitals vs 11% at HV hospitals (P < .01), whereas
• TEVAR mortality was similar, at 3.9% in LV vs 5.5% in HV hospitals (P = .43).

LV was independently associated with increased mortality after open repair (odds ratio, 1.4; 95% confidence interval, 1.1-1.8; P < .01) but not after TEVAR. There was no independent effect of hospital teaching status on mortality or complications after open repair or TEVAR repair.

The total number of DTA repairs significantly increased after the introduction of TEVAR for DTA. Operative mortality for TEVAR is independent of hospital volume and type, whereas

• mortality after open surgery is lower at HV hospitals.

While the TEVAR mortality is significantly less than that of open surgery, the mortality in open surgery is higher for LV hospitals.  The data suggests that TEVAR can be safely performed across a spectrum of hospitals, whereas open surgery should be performed only at HV hospitals.

1. Standard of Practice for the Endovascular Treatment of Thoracic Aortic Aneurysms and Type B Dissections. Fanelli F, and  Dake MD.  Cardiovasc Intervent Radiol. 2009 September; 32(5): 849–860.  http://dx.doi.org/10.1007/s00270-009-9668-6  PMCID: PMC2744786
2. Thoracic aortic aneurysms and dissections: endovascular treatment. Baril DT, Cho JS, Chaer RA, Makaroun MS. Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. Mt Sinai J Med. 2010 May-Jun;77(3):256-69.  http://dx.doi.org/10.1002/msj.20178.

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Histopathological image of dissecting aneurysm of thoracic aorta in a patient without evidence of Marfan syndrome. The damaged aorta was surgically removed and replaced by artificial vessel. Victoria blue & HE stain. (Photo credit: Wikipedia)

Diagram of aortic aneurysm Figure A shows a normal aorta. Figure B shows a thoracic aortic aneurysm (which is located behind the heart). Figure C shows an abdominal aortic aneurysm located below the arteries that supply blood to the kidneys. (Photo credit: Wikipedia)

Thoracic aorta (Photo credit: Wikipedia)

Open Heart Surgery (Photo credit: Wikipedia)

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No Early Symptoms – An Aortic Aneurysm Before It Ruptures – Is There A Way To Know If I Have it?

Posted in Aortic Valve: TAVR, TAVI vs Open Heart Surgery, Atherogenic Processes & Pathology, Cardiac & Vascular Repair Tools Subsegment, Frontiers in Cardiology and Cardiovascular Disorders, Medical Devices R&D and Inventions, Origins of Cardiovascular Disease, Stents & Tools, Valves & Tools, tagged AAA, Abdominal aortic aneurysm, Albert Einstein, Aneurysm, Aortic aneurysm, Aortic valve replacement, Cambria, Carotid endarterectomy, Columbia University, Harvard Medical School, Massachusetts General Hospital, Operating theater, Vascular surgery, X-ray computed tomography on June 10, 2013| 9 Comments »

No Early Symptoms – An Aortic Aneurysm Before It Ruptures – Is There A Way To Know If I Have it?

Curator: Aviva Lev-Ari, PhD, RN

I shadowed Dr. Cambria in the Operating Room at MGH in January 2005 while he performed Carotid Endarterectomy following Aortic Valve Replacement performed by Dr. Jennifer D. Walker  in a sequence, first the Valve replacement, then the Endarterectomy.

Aneurysm

Published on Thursday, 15 November 2012 |  | 

This word has a Greek origin from the terms [aneurusma], composed of [ana] meaning “complete or throughout”, and [eurus] meaning “wide”, a “complete widening or dilation”. It is used to refer to the dilation of an artery. Aneurysms can be formed in any artery, although they have some preferred sites. The most common aneurysms are found in the aorta, arterial circle of Willis, the root of the cerebral arteries, and internal carotid arteries.Biomechanical studies suggest that once an aneurysm forms it will generally progress in its dilation until aneurysmal rupture. Because of turbulent flow within the aneurysm large clots are usually formed, which in turn can cause emboli.The image shows an excised infrarenal aortic abdominal aneurysm (AAA). The two common iliac arteries can be seen. If you click on the image you will be able to see the same aneurysm opened through its posterior wall and the clot that was contained inside.Photography by D.M.Klein

http://clinanat.com/mtd/153-aneurysm

On 6/11/2013, Efrain Miranda, Ph.D. commented on this article, as follows:

It is true that abdominal aortic aneurysms (AAA) are mostly asymptomatic, until they rupture. By luck, some are identified. An example was a AAA found in Albert Einstein by Dr. Nissen when Einstein went for abdominal surgery for something completely unrelated! In my experience, I have found many AAA’s in individuals who had a totally different cause of death.

Dr. Richard Cambria describes an Aortic Aneurysm and recalls the numerous risk factors associated with the condition.

VIEW VIDEO

http://www.empowher.com/aortic-aneurysm/content/there-are-no-early-symptoms-there-way-know-if-i-have-aortic-aneurysm-it-rupt

By Dr. Richard Cambria Expert April 12, 2011 – 10:08am

 

Dr. Cambria:
An aortic aneurysm can be most simply thoughts of as a weakening or ballooning of the aorta which is the body’s major and largest blood vessel. That’s important because this ballooning or weakening can eventually lead to the aneurysm bursting, which is usually a fatal event.

Aneurysms have been referred to as the ‘silent killer’ because in most cases these aortic aneurysms cause no symptoms or problems prior to bursting. Most aortic aneurysms occur in older patients, but there are a clearly defined set of risk factors which makes certain patients at higher risk of developing aortic aneurysms. These include, most importantly, a family history of aortic aneurysm disease, and by family history I mean, if your mother or father or a brother or sister had an aortic aneurysm, you are clearly at increased risk of developing an aneurysm.

20% of the patients that we treat for aortic aneurysms have a positive family history of aneurysm disease. You are also at higher risk for developing an aortic aneurysm if you are female, if you have a history of high blood pressure, if you have been a cigarette smoker, and if you have chronic obstructive pulmonary disease or emphysema, which is in turn related to long-term cigarette smoking.

If you are at risk for developing an aortic aneurysm there are simple diagnostic x-ray studies such as ultrasounds and CAT scans to accurately diagnose number one, whether or not an aneurysm is present, and more importantly, if it is present, to measure just how large it is because that’s the single most important factor in determining whether or not your aneurysm needs to be treated.

It’s important to detect and monitor aortic aneurysms before they reach the stage of bursting because treatment is then usually successful with an expected excellent recovery. Treatment of aortic aneurysms today is very effective and involves replacing the aneurysm with an artificial blood vessel.

There are a variety of different surgical treatments, some of them including minimally invasive operations known as stent grafts, which are applied today in many patients.

Mass General has been a leader in the northeast in the successful management of aortic aneurysms. More than a decade ago, we formed the Mass General Thoracic Aortic Center, which is a team-approach of vascular surgeons, cardiac or heart surgeons, and cardiologists to effectively manage thoracic aneurysms which are often the most challenging and clinically complex to treat.

About Dr. Richard Paul Cambria, M.D.:
Richard P. Cambria, M.D. is Professor of Surgery at Harvard Medical School and Chief, Division of Vascular/Endovascular Surgery at Massachusetts General Hospital. Dr. Cambria received his medical degree from the College of Physicians and Surgeons, Columbia University, in 1977. He trained in general and vascular surgery at Massachusetts General Hospital.

http://www.empowher.com/aortic-aneurysm/content/there-are-no-early-symptoms-there-way-know-if-i-have-aortic-aneurysm-it-rupt

Education & Awards

Dr. Cambria graduated from Columbia University, New York. He has 15 awards.

Awards
One of America’s Leading Experts on: Abdominal Aortic Aneurysm Aortic Aneurysm Aortic Diseases Aortic Rupture Arterial Occlusive Diseases Blood Vessel Prosthesis Implantation Carotid Endarterectomy Carotid Stenosis Kidney Failure Mesenteric Vascular Occlusion Spinal Cord Ischemia Thoracic Aortic Aneurysm Vascular Surgical Procedures
Castle Connolly America’s Top Doctors® (2002 – 2012)
Top Ten Doctors (2012) Vascular Surgery, Downtown, Boston, MA

http://www.vitals.com/doctors/Dr_Richard_Cambria.html#ixzz2VqxwIwMK

Publications & Research

Dr. Cambria has contributed to 164 publications.

Title Giant Cell Aortitis of the Ascending Aorta Without Signs or Symptoms of Systemic Vasculitis is Associated with Elevated Risk of Distal Aortic Events. Date February 2012 Journal Arthritis and Rheumatism

Title Long-term Outcomes of Patients Undergoing Endovascular Infrainguinal Interventions with Single-vessel Peroneal Artery Runoff. Date May 2011 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Management of Diseases of the Descending Thoracic Aorta in the Endovascular Era: a Medicare Population Study. Date October 2010 Journal Annals of Surgery Excerpt Read excerpt

Title The Effects of Systemic Hypothermia on a Murine Model of Thoracic Aortic Ischemia Reperfusion. Date August 2010 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Long-term Outcomes of Diabetic Patients Undergoing Endovascular Infrainguinal Interventions. Date August 2010 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Preoperative Variables Predict Persistent Type 2 Endoleak After Endovascular Aneurysm Repair. Date August 2010 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches: a Scientific Statement from the American Heart Association. Date August 2010 Journal Circulation

Title Balloon Expandable Stents Facilitate Right Renal Artery Reconstruction During Complex Open Aortic Aneurysm Repair. Date March 2010 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Preoperative Functional Status Predicts Perioperative Outcomes After Infrainguinal Bypass Surgery. Date March 2010 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Intermediate-term Outcomes of Endovascular Treatment for Symptomatic Chronic Mesenteric Ischemia. Date February 2010 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title A Multicenter Clinical Trial of Endovascular Stent Graft Repair of Acute Catastrophes of the Descending Thoracic Aorta. Date December 2009 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Effect of Pj34 on Spinal Cord Tissue Viability and Gene Expression in a Murine Model of Thoracic Aortic Reperfusion Injury. Date December 2009 Journal Vascular and Endovascular Surgery Excerpt Read excerpt

Title Secondary Intervention After Endovascular Abdominal Aortic Aneurysm Repair. Date October 2009 Journal Annals of Surgery Excerpt Read excerpt

Title Aortic Remodeling After Endovascular Repair of Acute Complicated Type B Aortic Dissection. Date September 2009 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Significant Perioperative Morbidity Accompanies Contemporary Infrainguinal Bypass Surgery: an Nsqip Report. Date September 2009 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Pj34, a Poly-adp-ribose Polymerase Inhibitor, Modulates Visceral Mitochondrial Activity and Cd14 Expression Following Thoracic Aortic Ischemia-reperfusion. Date August 2009 Journal American Journal of Surgery Excerpt Read excerpt

Title Thoracoabdominal Aneurysm Repair: Hybrid Versus Open Repair. Date July 2009 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Successful Use of Bivalirudin for Combined Carotid Endarterectomy and Coronary Revascularization with the Use of Cardiopulmonary Bypass in a Patient with an Elevated Heparin-platelet Factor 4 Antibody Titer. Date April 2009 Journal Anesthesia and Analgesia Excerpt Read excerpt

Title Atherosclerotic Peripheral Vascular Disease Symposium Ii: Controversies in Carotid Artery Revascularization. Date January 2009 Journal Circulation

Title Functional Outcome After Thoracoabdominal Aneurysm Repair. Date December 2008 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Outcomes Following Endovascular Abdominal Aortic Aneurysm Repair (evar): an Anatomic and Device-specific Analysis. Date August 2008 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Zenith Abdominal Aortic Aneurysm Endovascular Graft. Date August 2008 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Spinal Cord Complications After Thoracic Aortic Surgery: Long-term Survival and Functional Status Varies with Deficit Severity. Date August 2008 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Five-year Results of Endovascular Treatment with the Gore Tag Device Compared with Open Repair of Thoracic Aortic Aneurysms. Date June 2008 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Aortic Aneurysms. Date May 2008 Journal Journal of the American College of Radiology : Jacr

Title International Controlled Clinical Trial of Thoracic Endovascular Aneurysm Repair with the Zenith Tx2 Endovascular Graft: 1-year Results. Date March 2008 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Contemporary Management of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: Endovascular Versus Open. Date February 2008 Journal Circulation

Title Contemporary Management of Carotid Stenosis: Carotid Endarterectomy is Here to Stay. Date January 2008 Journal Perspectives in Vascular Surgery and Endovascular Therapy Excerpt Read excerpt

Title Long-term Durability of Open Abdominal Aortic Aneurysm Repair. Date November 2007 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Commentary On: Mas Jl, Chatellier G, Beyssen B, Et Al. Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis. N Engl J Med. 2006;355:1660-1671. Date November 2007 Journal Perspectives in Vascular Surgery and Endovascular Therapy Excerpt Read excerpt

Title Defining the High-risk Patient for Carotid Endarterectomy: an Analysis of the Prospective National Surgical Quality Improvement Program Database. Date October 2007 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Persistent Type 2 Endoleak After Endovascular Repair of Abdominal Aortic Aneurysm is Associated with Adverse Late Outcomes. Date July 2007 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Restenosis After Eversion Vs Patch Closure Carotid Endarterectomy. Date July 2007 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Surgical Revascularization Versus Endovascular Therapy for Chronic Mesenteric Ischemia: a Comparative Experience. Date July 2007 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Comparison of Risk-adjusted 30-day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Men. Date July 2007 Journal Journal of the American College of Surgeons Excerpt Read excerpt

Title Thoracoabdominal Aneurysm Repair: a 20-year Perspective. Date March 2007 Journal The Annals of Thoracic Surgery Excerpt Read excerpt

Title Stent-graft Versus Open-surgical Repair of the Thoracic Aorta: Mid-term Results. Date January 2007 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Intermediate Results of Percutaneous Endovascular Therapy of Femoropopliteal Occlusive Disease: a Contemporary Series. Date October 2006 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Long-term Outcomes After Endovascular Abdominal Aortic Aneurysm Repair: the First Decade. Date October 2006 Journal Annals of Surgery Excerpt Read excerpt

Title Poly Adenosine Diphosphate-ribose Polymerase Inhibitor Pj34 Abolishes Systemic Proinflammatory Responses to Thoracic Aortic Ischemia and Reperfusion. Date August 2006 Journal Journal of the American College of Surgeons Excerpt Read excerpt

Title Contemporary Results of Open Surgical Repair of Descending Thoracic Aortic Aneurysms. Date August 2006 Journal Seminars in Vascular Surgery Excerpt Read excerpt

Title Commentary on “extra-anatomic Visceral Revascularization and Endovascular Stent-grafting for Complex Thoracoabdominal Aortic Lesions”. Date May 2006 Journal Perspectives in Vascular Surgery and Endovascular Therapy

Title Multi-institutional Pivotal Trial of the Zenith Tx2 Thoracic Aortic Stent-graft for Treatment of Descending Thoracic Aortic Aneurysms: Clinical Study Design. Date May 2006 Journal Perspectives in Vascular Surgery and Endovascular Therapy Excerpt Read excerpt

Title Aortic Dissection: Perspectives in the Era of Stent-graft Repair. Date March 2006 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter

Title Current Results of Open Surgical Repair of Descending Thoracic Aortic Aneurysms. Date March 2006 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter

Title Late Results of Combined Carotid and Coronary Surgery Using Actual Versus Actuarial Methodology. Date December 2005 Journal The Annals of Thoracic Surgery Excerpt Read excerpt

Title Contemporary Results of Angioplasty-based Infrainguinal Percutaneous Interventions. Date November 2005 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Pj34, a Poly-adp-ribose Polymerase Inhibitor, Modulates Renal Injury After Thoracic Aortic Ischemia/reperfusion. Date October 2005 Journal Surgery Excerpt Read excerpt

Title Safety and Efficacy of Reoperative Carotid Endarterectomy: a 14-year Experience. Date July 2005 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Determinants of Carotid Endarterectomy Anatomic Durability: Effects of Serum Lipids and Lipid-lowering Drugs. Date May 2005 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Early Outcomes of Endovascular Versus Open Abdominal Aortic Aneurysm Repair in the National Surgical Quality Improvement Program-private Sector (nsqip-ps). Date May 2005 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Thoracoabdominal Aneurysm Repair: Anesthetic Management. Date March 2005 Journal International Anesthesiology Clinics

Title Endovascular Treatment of Thoracic Aortic Aneurysms: Results of the Phase Ii Multicenter Trial of the Gore Tag Thoracic Endoprosthesis. Date March 2005 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Poly(adenosine Diphosphate Ribose) Polymerase Inhibition Modulates Spinal Cord Dysfunction After Thoracoabdominal Aortic Ischemia-reperfusion. Date March 2005 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Current Status of Thoracoabdominal Aneurysm Repair. Date November 2004 Journal Advances in Surgery

Title Stenting for Carotid-artery Stenosis. Date October 2004 Journal The New England Journal of Medicine

Title Carotid Endarterectomy at the Millennium: What Interventional Therapy Must Match. Date September 2004 Journal Annals of Surgery Excerpt Read excerpt

Title Surgical Management of Popliteal Artery Embolism at the Turn of the Millennium. Date June 2004 Journal Annals of Vascular Surgery Excerpt Read excerpt

Title Regional Hypothermia with Epidural Cooling for Prevention of Spinal Cord Ischemic Complications After Thoracoabdominal Aortic Surgery. Date April 2004 Journal Seminars in Thoracic and Cardiovascular Surgery Excerpt Read excerpt

Title Preservation of Renal Function with Surgical Revascularization in Patients with Atherosclerotic Renovascular Disease. Date February 2004 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Durability of Aortouniiliac Endografting with Femorofemoral Crossover: 4-year Experience in the Evt/guidant Trials. Date June 2003 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Late Aortic and Graft-related Events After Thoracoabdominal Aneurysm Repair. Date February 2003 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Surgical Treatment of Complicated Distal Aortic Dissection. Date October 2002 Journal Seminars in Vascular Surgery Excerpt Read excerpt

Title Thoracoabdominal Aneurysm Repair: Results with 337 Operations Performed over a 15-year Interval. Date October 2002 Journal Annals of Surgery Excerpt Read excerpt

Title Clinical Outcome of Internal Iliac Artery Occlusions During Endovascular Treatment of Aortoiliac Aneurysmal Diseases. Date October 2002 Journal Journal of Vascular and Interventional Radiology : Jvir Excerpt Read excerpt

Title Evolving Experience with Thoracic Aortic Stent Graft Repair. Date July 2002 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Clinical Failures of Endovascular Abdominal Aortic Aneurysm Repair: Incidence, Causes, and Management. Date July 2002 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Regarding “analysis of Predictive Factors for Progression of Type B Aortic Intramural Hematoma with Computed Tomography”. Date July 2002 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter

Title Contemporary Management of Aortic Branch Compromise Resulting from Acute Aortic Dissection. Date July 2001 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Endovascular Stent-graft in Abdominal Aortic Aneurysms: the Relationship Between Patent Vessels That Arise from the Aneurysmal Sac and Early Endoleak. Date June 2001 Journal Radiology Excerpt Read excerpt

Title Regional Hypothermia with Epidural Cooling for Spinal Cord Protection During Thoracoabdominal Aneurysm Repair. Date April 2001 Journal Seminars in Vascular Surgery Excerpt Read excerpt

Title Endovascular Repair of Abdominal Aortic Aneurysms: Current Status and Future Directions. Date August 2000 Journal Ajr. American Journal of Roentgenology

Title Epidural Cooling for Spinal Cord Protection During Thoracoabdominal Aneurysm Repair: A Five-year Experience. Date July 2000 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Utility and Reliability of Endovascular Aortouniiliac with Femorofemoral Crossover Graft for Aortoiliac Aneurysmal Disease. Date July 2000 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

Title Surgical Renal Artery Reconstruction Without Contrast Arteriography: the Role of Clinical Profiling and Magnetic Resonance Angiography. Date January 2000 Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter Excerpt Read excerpt

http://www.vitals.com/doctors/Dr_Richard_Cambria/credentials
http://www.vitals.com/doctors/Dr_Richard_Cambria/credentials#ixzz2VqyhFZVd

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Cambria, RP, Clouse WD, Davison JK, Dunn PF, Corey M, Dorer D. Thoracoabdominal aneurysm repair: Results with 337 operations performed over a 15 year interval. Ann Surg 2002;236-471-79.

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Cambria RP and Black JH. Aortic dissection perspectives for the vascular/endovascular surgeon. In Rutherford (ed) Comprehensive Vascular and Endovascular Surgery 6 th , W. B. Saunders, Inc. (in press, 2004).

Cambria RP, Marone LK, Cloud WD, Dorer, DJ, Brewster, DC, LaMuraglia, GM, Watkins, MT, Kwolek, CJ. Preservation of renal functions with surgical revascularization in patients with atherosclerotic renovascular disease. J Vasc Surg 2004; 10.023.

http://www2.massgeneral.org/vascularsurgery/doctors/cambria.htm 

Abdominal Aortic Aneurysm – Case Study

by

Angela Rodriguez-Wong, MD, RVT, RPVI

Lois Eliassi, BS, RVT

http://www.navixdiagnostix.com/downloads/Navix%20-%20Q1%20’13%20Ultrasound%20Solutions.pdf

An aneurysm is defined as a focally dilated segment of an artery that is 1.5 times its normal diameter and involves all three arterial walls (intima, media and adventitia). Aneurysms can be found in the common femoral and popliteal arteries in the lower extremities, the splenic, mesenteric, and renal arteries in the abdomen, and also in the intracranial vessels. However, the most common is an abdominal aortic aneurysm (AAA) involving the aorta and iliac arteries.

Abdominal aortic aneurysms are generally asymptomatic and are discovered accidentally either by physician palpation or by a radiologic examination such as a chest or abdominal X-ray. The risk factors that increase the probability of developing a AAA are primarily smoking and family history. An abdominal aortic aneurysm can rupture and, according to the Centers for Disease Control and Prevention, ruptured AAA was the 10th leading cause of death in males between the ages of 65-74 in the United States in 2000.

The preferred method of screening for AAA is diagnostic ultrasound. According to the Journal of Vascular Surgery, diagnostic ultrasound performed by a registered vascular technologist has a sensitivity of 100 percent and a specificity of 96 percent for the detection of an infrarenal AAA. The abdominal aorta is considered aneurysmal when it measures >3.0 cm.

Because of its accuracy, diagnostic ultrasound not only has become an integral part in diagnosing AAA but is also an integral part in the evaluation of disease progression, the preoperative AAA evaluation, and the follow-up of AAA surgical repair. It is important to note that a rupture of an AAA is a surgical emergency and is difficult to evaluate with ultrasound due to the inability to easily demonstrate abdominal free fluid. If a rupture is suspected, it is recommended that other imaging modalities such as CT be employed to better demonstrate the ruptured aneurysm and any intra-abdominal free fluid.

Case Study – 

Abdominal Aortic Aneurysm – A 77 year-old male

Angela Rodriguez-Wong, MD, RVT, RPVI

Lois Eliassi, BS, RVT

Figure 1 Distal abdominal aortic aneurysm with mural thrombus.

Figure 2 Bifurcation of the aorta.

Case Study: A 77 year-old male with a past medical history of diabetes, hypertension, arthritis, aortic valve disease and heavy smoking was referred to Eastern Vascular Diagnostic Center with a 4.2 centimeter aneurysm. The patient denied any family history of aneurysm and is allergic to intravenous contrast. A physical exam found the patient alert with a blood pressure of 100/60 mmHg, a pulse of 58 and respiration of 16. Auscultation found a bruit in the left carotid artery, clear lungs, and a regular heart rhythm with an aortic systolic murmur. The patient had a well healed sub-costal incision on his abdomen. The physician was unable to palpate the aneurysms. The patient had an aortic valve replacement in 2007 and also a cholecystectomy. On May 12, 2012, a magnetic resonance imaging (MRI) scan without contrast was performed on the patient’s abdomen. The MRI found an AAA measuring greater than 3 cm with extensive plaque near the bifurcation. The aneurysm extended into the right common iliac artery (CIA) measuring 4.2 cm and into the left CIA measuring 3.1 cm. The MRI exam did not include the pelvis, so the extent of the iliac aneurysms was not clear. On July 31, 2012, the ultrasound was performed, demonstrating normal ankle brachial index (right-1.2, left-1.1) and a AAA measuring 3.9 cm which extended into the right and left CIA. The maximum diameter of the right CIA measures 4.1 cm with mural thrombus creating a residual lumen of 2.0 cm. The maximum diameter of the left CIA measures 4.3 cm, there is also mural thrombus noted but without significant appreciable diameter reduction within the vessel. A computed tomography (CT) scan of the abdomen and pelvis without contrast was performed on July 18th confirming the infrarenal AAA with extension into the iliac arteries bilaterally.

Surgery is recommended when an AAA reaches 5.0-5.5 cm in a male and 4.5-5.0 cm in females. Surgery, depending on the aneurysm, can be an open repair or an endovascular repair. In this patient, despite the size of the AAA being 4.1 cm, the disease also involved the bilateral common iliacs prompting the need for surgical intervention. The patient was cleared by cardiology and on July 31st had an AAA and bilateral Iliac aneurysm resection with a re-implantation of the inferior mesenteric artery and an Aorta to right Hypogastric bypass to maintain pelvic perfusion.

The U.S. Preventive Services Task Force has released a statement summarizing recommendations for screening for AAA. It states that screening benefits patients who have a relatively high risk for dying from an aneurysm; major risk factors are age 65 years or older, male sex, and smoking at least 100 cigarettes in a lifetime. The guideline recommends one-time screening with ultrasound for AAA in men 65 to 75 years of age who have ever smoked. No recommendation was made for or against screening in men 65 to 75 years of age who have never smoked, and it recommended against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age.

Angela Rodriguez-Wong, MD, RVT, RPVI 

awong@navixdiagnostix.com

Lois Eliassi, BS, RVT

leliassi@navixdiagnostix.com

Figure 3 Sagittal image of the right common iliac artery demonstrating the measurement of the aneurysm and the true lumen.

Figure 4 Coronal view of the left common iliac artery.

REFERENCES 

1. Anderson RN. Deaths: Leading causes for 2000. Natl Vital Stat Rep. 2002;50:1–85.

2. Kent KC, Zwolak RM, Jaff MR, et al. Screening for abdominal aortic aneurysm. J Vasc Surg. 2004;39:267–9.

3. Upchurch G Jr, Schaub T. Abdominal aortic aneurysm. American Family Physician. 2006;73(7), 1198-1204. http://www.aafp.org/afp/2006/0401/p1198.html

http://www.navixdiagnostix.com/downloads/Navix%20-%20Q1%20’13%20Ultrasound%20Solutions.pdf

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