RESUMEN
We present a case of embolization for post-angioplasty pseudoaneurysm of the internal mammary vein. A 62-year-old male presented to the emergency department with right upper extremity edema. One month prior, he underwent angioplasty of right cephalic, subclavian, and innominate veins for similar symptoms but felt they had worsened. Computed tomography with intravenous contrast revealed pseudoaneurysm of the right internal mammary vein, and the patient was taken emergently to the operating room where embolization was successfully performed. Central venous pseudoaneurysm is a rare complication of angioplasty and the unique considerations of the anatomic region necessitate discussion of the optimal treatment modality.
RESUMEN
OBJECTIVE: Patients in the Valiant Evo U.S. and international clinical trials had positive short-term outcomes; however, late structural failures, including type IIIb endoleaks have been recently discovered. Type IIIb endoleaks are serious adverse events because the repressurization of the aneurysm sac increases the risk of rupture. The purpose of the present study was to detail the imaging patterns associated with the structural failures with the aim of increasing awareness of failing graft presentation, early recognition, and prompt treatment. METHODS: The Valiant Evo clinical trial was a prospective, single-arm investigation of a thoracic stent graft system. With the recent late structural failures, sites were requested to submit all available imaging studies to date to allow the core laboratory to assess for structural failures such as type IIIb endoleaks, stent ring fractures, and stent ring enlargement. Of the 100 patients originally enrolled in the trial from 2016 to 2018, the core laboratory assessed the imaging studies performed at ≥1 year for 83 patients. RESULTS: No structural failures of the graft were reported through 1 year of follow-up. At 1 to 4 years, graft structural failures were detected in 11 patients with descending thoracic aortic aneurysms. Of the 11 patients, 5 had a type IIIb endoleak. Four of the five had imaging findings showing stent fractures consistent with the location of the graft seam and one had a type IIIb endoleak attributed to calcium erosion with no stent fracture or ring enlargement. Of the four patients with stent fracture in line with the graft seam, three underwent a relining procedure that successfully excluded the type IIIb endoleak. One of these three patients died 4 days later of suspected thoracic aortic rupture because the distal thoracic endovascular aortic repair extension had been landed in a previously dissected and fragile section of the aorta. The remaining six patients had had stent ring enlargement. One of the six patients had had persistent aneurysm expansion from the time of implantation onward and had died of unknown causes. The remaining five patients have continued to be monitored. CONCLUSIONS: In the present preliminary analysis, the imaging patterns associated with type IIIb endoleaks, stent fractures, and stent ring enlargement appear to be related to the loss of seam integrity or detachment of the stent rings from the surface of the graft material. The imaging patterns we have detailed should be closely monitored using computed tomography angiography surveillance to allow structural failures to be promptly identified and treated.
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Aneurisma de la Aorta Torácica/cirugía , Aortografía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Angiografía por Tomografía Computarizada , Endofuga/diagnóstico por imagen , Procedimientos Endovasculares/instrumentación , Falla de Prótesis , Stents , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Implantación de Prótesis Vascular/efectos adversos , Ensayos Clínicos como Asunto , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Análisis de Falla de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Diseño de Prótesis , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: As endovascular therapy becomes increasingly complex, adjunct techniques such as upper extremity arterial access facilitate visceral branch interventions. The purpose of this study was to assess the viability of axillary artery percutaneous access in endovascular repair. METHODS: Records of all patients undergoing axillary artery percutaneous access as part of an endovascular intervention from December 2015 to December 2016 were examined. Demographics of the patients (age, sex, medical comorbidities, smoking status, and anticoagulation) were documented. Each case was examined for technical success and perioperative complications, including hematoma, brachial plexus injury, and return to the operating room. Early functional outcomes were assessed using clinic follow-up documentation. RESULTS: During the study interval, 25 axillary artery punctures in a total of 19 patients were performed for endovascular intervention. The mean age was 72 years; most patients were male (68%), and the cohort had a typical vascular comorbidity profile (hypertension in 84%, hyperlipidemia in 90%, diabetes in 21%, coronary artery disease in 58%, and chronic obstructive pulmonary disease in 47%; 90% were active or former smokers). Axillary access was obtained as part of complex endovascular aneurysm repair in 13 patients, mesenteric vessel intervention in 3 patients, and iliac intervention in 3 patients. Sheath size was most frequently 6F (6 punctures) or 7F (15 punctures). Closure devices included Perclose (Abbott Vascular, Santa Clara, Calif) in 36% and Angio-Seal (Terumo Interventional Systems, Somerset, NJ) in 64%. There were two perioperative deaths and one instance of return to the operating room for hematoma. There was no perioperative stroke, axillary occlusion, or severe brachial plexus injury. One patient had transient ipsilateral postoperative thumb numbness, and one patient had residual bleeding after closure requiring manual pressure. CONCLUSIONS: Percutaneous axillary artery access is a viable strategy to facilitate complex endovascular interventions. This technique avoids the need for brachial or axillary artery exposure and allows larger sheath sizes because of the caliber of the axillary artery. There were no major neurologic or ischemic complications. This technique is a relatively safe and practical alternative to approaches involving exclusively femoral and brachial access.
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Arteria Axilar , Cateterismo Periférico/métodos , Procedimientos Endovasculares/métodos , Anciano , Anciano de 80 o más Años , Arteria Axilar/diagnóstico por imagen , Cateterismo Periférico/efectos adversos , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Punciones , Radiografía Intervencional , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Safe and efficient endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA) requires advanced infrastructure and surgical expertise not available at all US hospitals. The objective was to assess the impact of regionalizing r-AAA care to centers equipped for both open surgical repair (r-OSR) and EVAR (r-EVAR) by vascular surgeons. METHODS: A retrospective review of all patients with r-AAA undergoing open or endovascular repair in a 12-hospital region. Patient demographics, transfer status, type of repair, and intraoperative variables were recorded. Outcomes included perioperative morbidity and mortality. RESULTS: Four hundred fifty-one patients with r-AAA were treated from 2002 to 2015. Three hundred twenty-one patients (71%) presented initially to community hospitals (CHs) and 130 (29%) presented to the tertiary medical center (MC). Of the 321 patients presenting to CH, 133 (41%) were treated locally (131 OSR; 2 EVAR) and 188 (59%) were transferred to the MC. In total, 318 patients were treated at the MC (122 OSR; 196 EVAR). At the MC, r-EVAR was associated with a lower mortality rate than r-OSR (20% vs 37%, P = 0.001). Transfer did not influence r-EVAR mortality (20% in r-EVAR presenting to MC vs 20% in r-EVAR transferred, P > 0.2). Overall, r-AAA mortality at the MC was 20% lower than CH (27% vs 46%, P < 0.001). CONCLUSIONS: Regionalization of r-AAA repair to centers equipped for both r-EVAR and r-OSR decreased mortality by approximately 20%. Transfer did not impact the mortality of r-EVAR at the tertiary center. Care of r-AAA in the US should be centralized to centers equipped with available technology and vascular surgeons.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Regionalización/métodos , Procedimientos Quirúrgicos Vasculares/organización & administración , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/mortalidad , Hospitales Comunitarios/estadística & datos numéricos , Humanos , Estudios Retrospectivos , Centros de Atención Terciaria/estadística & datos numéricos , Resultado del TratamientoRESUMEN
OBJECTIVE: Endovascular aneurysm repair (EVAR) has become the mainstay of treatment for abdominal aortic aneurysms (AAAs) requiring repair. Delayed rupture after EVAR represents a rare but potentially fatal complication. The purpose of this study was to review the frequency and characteristics of patients presenting with secondary rupture and to define the relationship between rupture after EVAR and initial compliance with instructions for use (IFU). METHODS: This is a retrospective study of a prospectively maintained database. Patients presenting with delayed rupture after EVAR were identified from January 2002 to December 2014. Medical records and imaging were reviewed to define anatomic characteristics and compliance with IFU criteria. Demographics, comorbidities, preoperative imaging, and long-term outcomes were analyzed. Patients were divided into two groups according to compliance with IFU criteria. Outcomes included type of repair (open vs secondary endovascular) as well as perioperative morbidity and mortality. RESULTS: A total of 3081 patients underwent EVAR for AAA from 2002 to 2014. Of the 3081 patients, 45 experienced delayed rupture after EVAR. The mean time interval between initial repair and rupture was 38 months. All patients with delayed ruptures had a type Ia endoleak. Mean follow-up after secondary repair was 44.1 months, and overall mortality was 6.7% (n = 3). Patients were divided in two groups according to compliance with IFU criteria: within the IFU and outside the IFU. There was no significant difference in comorbidities between the two groups except smoking, which was more frequent in the outside the IFU group (25% vs 21%; P = .03). Patients repaired outside the IFU had a higher incidence of type Ia endoleak before presenting with a rupture (44% vs 6%; P = .001), more frequently required open repair (44% vs 12%; P = .002), and had higher perioperative mortality (10.3% vs 0%; P = .01). On review of preoperative computed tomography scans, the outside the IFU group had larger aneurysm sac diameters (7.2 vs 5.6 cm; P = .04), larger proximal neck diameters (28 vs 24 mm; P = .01), shorter proximal necks (12 vs 21 mm; P = .007), and a higher degree of neck angulation >40 degrees (56 vs 11%; P < .001). CONCLUSIONS: Delayed rupture after EVAR is a rare but potentially fatal complication. In patients presenting with secondary rupture, EVAR performed outside the IFU was associated with higher perioperative mortality and need for open repair. Careful selection of patients based on AAA anatomy and adherence to the IFU criteria may reduce the incidence of delayed rupture.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/etiología , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/complicaciones , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Aortografía/métodos , Implantación de Prótesis Vascular/mortalidad , Angiografía por Tomografía Computarizada , Bases de Datos Factuales , Procedimientos Endovasculares/mortalidad , Femenino , Adhesión a Directriz , Humanos , Masculino , Persona de Mediana Edad , New York , Selección de Paciente , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Outcomes of open revascularization (OR) and endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) were analyzed to identify predictors of endovascular failure. METHODS: A retrospective study was performed of all consecutive patients with CMI (161 patients, 215 vessels) treated from 2008 to 2012. Demographics, comorbidities, clinical presentation, etiology, and treatment modalities were compared. Outcomes included technical success, restenosis requiring reintervention, complications, mortality, and hospital length of stay. RESULTS: There were 116 patients who were first treated with ER (72%) and 45 patients with OR (28%). Overall mortality was 6.8% (11/161). Among the ER patients, 27 developed restenosis and required OR (23%). Patients treated with ER were older (73 vs 66 years; P = .014), had similar comorbidities, and had higher rate of short lesions (≤2 cm) on preoperative angiograms (23% vs 47%; P = .004). Primary patency at 3 years was higher in the OR group compared with the ER group (91% vs 74%; P = .018). Long-term survival rates were higher in the ER group (95% vs 78%; P = .003). Hospital length of stay and intensive care unit length of stay were shorter in the ER group (<.001). Perioperative mortality (30-day) was not statistically significant between the groups (5.2% vs 11%; P = .165). A subgroup analysis was performed between the patients with successful ER and failure of ER requiring OR. Patients with failure of ER had significantly higher rates of aortic occlusive disease (86% vs 49%; P = .005) and long lesions ≥2 cm on angiography (57% vs 12%; P < .001) that were close to the mesenteric takeoff. Perioperative mortality was higher in the ER failure group (15% vs 2%; P = .009). CONCLUSIONS: ER has similar perioperative mortality and shorter hospitalization but higher rate of restenosis requiring reintervention compared with OR. Patients with ER who required reintervention appear to have longer lesions as well as higher rates of aortic occlusive disease on preoperative angiography. Patients who crossed over from ER to OR had higher perioperative mortality than either primary open or endovascular patients. These findings may guide treatment selection in patients with CMI undergoing ER or OR.
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Procedimientos Endovasculares/efectos adversos , Isquemia Mesentérica/terapia , Oclusión Vascular Mesentérica/terapia , Procedimientos Quirúrgicos Vasculares/efectos adversos , Anciano , Anciano de 80 o más Años , Angiografía , Enfermedad Crónica , Procedimientos Endovasculares/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Isquemia Mesentérica/diagnóstico por imagen , Isquemia Mesentérica/mortalidad , Isquemia Mesentérica/fisiopatología , Oclusión Vascular Mesentérica/diagnóstico por imagen , Oclusión Vascular Mesentérica/mortalidad , Oclusión Vascular Mesentérica/fisiopatología , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Modelos de Riesgos Proporcionales , Recurrencia , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Circulación Esplácnica , Factores de Tiempo , Insuficiencia del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND: Endovascular aneurysm repair (EVAR) is now the standard of care for elective infrarenal and ruptured abdominal aortic aneurysms (AAAs). Difficult proximal necks often require adjuvant measures to seal type 1 endoleaks. We believed this was a predictor of increased 30-day morbidity and mortality and reduced long-term survival. METHODS: We reviewed outcomes for all patients entered into our database between 2003 and 2010 who had EVAR for elective or ruptured AAAs. Patient demographics and operative indications were recorded. Operative procedures, including adjuvant procedures, such as Palmaz XL stent deployment, were documented. All postoperative deaths and morbidity were recorded. Long-term survival was calculated using life table analysis. Multivariate analysis was performed to determine significant predictors of early mortality. RESULTS: Between 2003 and 2010, 1470 patients underwent EVAR for AAA (1378 [93.7%] elective; 92 [6.3%] ruptured or emergent). Elective EVAR patients required Palmaz stent placement in 146 of 1378 (10.6%) cases; in emergent cases, Palmaz stents were required in 16 of 92 (17.4%) cases. This was not significantly different (P=0.06). Thirty-day mortality for elective EVAR was 1.6% (22/1378) compared with 21.7% (20/92) for emergent repair (P<0.0001). Thirty-day mortality among the 146 elective patients undergoing Palmaz stenting was 3.4% compared with 1.4% in the 1232 non-Palmaz stent elective EVAR patients (P=0.085). In emergency cases, the 30-day mortality for the 16 Palmaz patients was 25% compared to 21% for the 76 non-Palmaz stent patients (P=0.76). Among 30-day survivors, there were 428 of 1356 (31.6%) endoleaks identified in the elective patient group and 36 of 72 (50%) in the emergency group (P<0.005). Of the 146 elective patients requiring insertion of a Palmaz stent, 65 (44%) developed endoleaks, significantly more than the 370 of 1232 (30%) in non-Palmaz elective patients (P=0.0004). Among the emergency group, there were also significantly more endoleaks among the 30-day survivors who had a Palmaz stent deployed. In elective EVAR requiring Palmaz XL stents, 14% still had type 1 endoleaks at the end of their procedure; 13% still had type 1 endoleaks in the rupture EVAR Palmaz group. Multivariate analysis of all patients found that while female sex, AAA diameter, and estimated blood loss predicted 30-day mortality, deployment of a Palmaz stent did not. Long-term survival among Palmaz patients was not significantly different from non-Palmaz patients in the elective or emergent setting, although Palmaz patients required more secondary interventions. CONCLUSIONS: During EVAR, deployment of a Palmaz stent is more frequently required in patients with rupture, female sex, and larger sac size. However, Palmaz stent deployment itself is not an independent predictor of increased 30-day mortality in either the elective or emergency setting or of poorer long-term survival. However, they are associated with a greater number of postoperative endoleaks, especially type 1 endoleaks, and predict a greater need for secondary interventions.
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Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Quirúrgicos Electivos/métodos , Urgencias Médicas , Endofuga/prevención & control , Procedimientos Endovasculares , Hemorragia Posoperatoria/prevención & control , Stents , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aortografía , Prótesis Vascular , Endofuga/diagnóstico por imagen , Endofuga/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Análisis Multivariante , New York/epidemiología , Hemorragia Posoperatoria/diagnóstico por imagen , Hemorragia Posoperatoria/epidemiología , Diseño de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia/tendencias , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: To date, there are no published reports comparing hemodynamically (Hd)-stable and Hd-unstable patients with ruptured abdominal aortic aneurysms (r-AAAs) undergoing endovascular aneurysm repair (EVAR). This study evaluates outcomes of EVAR for r-AAA based on patient's Hd status METHODS: From 2002 to 2011, 136 patients with r-AAAs underwent EVAR and were categorized into two groups based on systolic blood pressure (SBP) measurements before EVAR: 92 (68%) Hd-stable (SBP ≥ 80 mm Hg) and 44 (32%) Hd-unstable (SBP <80 mm Hg for >10 minutes). All data were prospectively entered in a database and retrospectively analyzed. Outcomes included 30-day mortality, postoperative complications, the need for secondary reinterventions, and midterm mortality. The effect of potential predictors on 30-day mortality was assessed by χ(2) and logistic regression. RESULTS: Of the 136 r-AAA patients with EVAR, the Hd-stable and Hd-unstable groups had similar comorbidities (coronary artery disease, 63% vs 59%; hypertension, 72% vs 75%; chronic obstructive pulmonary disease, 21% vs 26%; and chronic renal insufficiency, 18% vs 18%), mean AAA maximum diameter (6.6 vs 6.4 cm), need for on-the-table conversion to open surgical repair (3% vs 7%), and incidences of nonfatal complications (43% vs 38%) and secondary interventions (23% vs 25%). Preoperative computed tomography scan was available in significantly fewer Hd-unstable patients (64% vs 100%; P < .05). Compared with Hd-stable patients, the Hd-unstable patients had a significantly higher intraoperative need for aortic occlusion balloon (40% vs 6%; P < .05), mean estimated blood loss (744 vs 363 mL; P < .05), incidence of developing abdominal compartment syndrome (ACS; 29% vs 4%; P < .01), and death (33% vs 18%; P < .05). ACS was a significant predictor of death; death in all r-EVAR with ACS was significantly higher compared with all r-EVAR without ACS (10 of 17 [59%] vs 22 of 119 [18%]; P < .01). CONCLUSIONS: EVAR for r-AAA is feasible in Hd-stable and Hd-unstable patients, with a comparable incidence of conversion to open surgical repair, nonfatal complications, and secondary interventions. Hd-stable patients have reduced mortality at 30 days, whereas Hd-unstable patients require intraoperative aortic occlusion balloon more frequently, and have an increased risk for developing ACS and death.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Hemodinámica , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/fisiopatología , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/mortalidad , Rotura de la Aorta/fisiopatología , Aortografía/métodos , Oclusión con Balón , Pérdida de Sangre Quirúrgica/prevención & control , Presión Sanguínea , Distribución de Chi-Cuadrado , Comorbilidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Hipertensión Intraabdominal/mortalidad , Modelos Logísticos , Masculino , Persona de Mediana Edad , New York/epidemiología , Valor Predictivo de las Pruebas , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
PURPOSE: Delayed abdominal aortic aneurysm (AAA) rupture is a well recognized complication of endovascular aneurysm repair (EVAR). We wanted to evaluate the frequency, etiology, and outcomes of delayed AAA rupture following EVAR, and identify treatment options that facilitate improved survival. METHODS: From 2002 to 2009, 1768 patients underwent elective and emergent EVAR. At a mean follow-up of 29 months, 27 (1.5%) patients presented with delayed AAA rupture and required repair by either open surgical conversion or endovascular means. All data were prospectively collected in a vascular registry, and outcomes analyzed. RESULTS: Over a mean follow-up of 29 months, the incidence of delayed AAA rupture after elective EVAR was 1.4% (24 of 1615 patients), and after emergent EVAR for ruptured AAA was 2.8% (3 of 106 patients). Of the 27 delayed AAA rupture patients, 20 (74%) were considered "lost to follow-up," and, at presentation, 17 (63%) patients had Type 1 endoleak with stent graft migration, three (11%) had Type 1 endoleak without stent graft migration, five (19%) had Type 2 endoleak, and two (7%) had undetermined etiology for aneurysm rupture. Fifteen (55%) patients underwent open surgical repair via retroperitoneal approach with partial (n = 8; 53%) or complete (n = 7; 47%) stent graft explants and aortoiliac reconstruction, 11 (41%) patients underwent a second EVAR, and one (4%) patient refused treatment and died. Supraceliac aortic clamp was required in three (20%) patients with open surgical conversion, and supraceliac occlusion balloon was required in two (18%) patients with EVAR. There were three (11%) postoperative deaths; two following open surgical conversion and one following EVAR. One additional redo-EVAR patient has undergone successful elective conversion to open surgical repair for persistent type II endoleak and increase in AAA size. CONCLUSIONS: Delayed AAA rupture following EVAR can be successfully managed in most patients by open surgical conversion or secondary EVAR. The approach to each patient should be individualized; complete stent graft explant is not necessary in most patients; a secondary EVAR for delayed AAA rupture with or without an elective conversion to open surgical repair remains a viable option. Vigilant routine follow-up is needed for all patients after EVAR.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/fisiopatología , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/fisiopatología , Rotura de la Aorta/terapia , Oclusión con Balón , Femenino , Hemodinámica , Humanos , Masculino , Reoperación , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Successful thoracic endovascular aneurysm repair (TEVAR) requires adequate proximal and distal fixation and seal. We report our experience of planned celiac artery coverage during endovascular repair of complex thoracic aortic aneurysms (TAA). METHODS: Since 2004, 228 patients underwent TEVAR under elective (n=162, 71%) and emergent circumstances (66, 29%). Patients with inadequate distal stent grafts landing zones during TEVAR underwent detailed evaluation of the gastroduodenal arcade with communicating collaterals between the celiac and superior mesenteric artery (SMA) by computed tomography angiography and intraoperative arteriogram. If needed, in presence of a patent SMA and demonstration of collaterals to the celiac artery, the stent grafts were extended to the SMA with celiac artery coverage. Furthermore, instances when further lengthening of distal thoracic stent graft landing zone was needed to obtain an adequate seal, the SMA was partially covered with the endograft, and a balloon expandable stent was routinely deployed in proximal SMA to maintain patency. Outcome data were prospectively collected and analyzed retrospectively. RESULTS: Thirty-one of 228 (14%) patients with TEVAR required celiac artery interruption; 24 (77%) had demonstrable collaterals to the SMA. Twelve (39%) of 31 patients underwent additional partial SMA coverage by stent graft, and proximal SMA stent. The majority of patients were females (n=20, 65%), the mean age was 74 years (range 55-87 years), and the mean TAA size was 6.5 cm. Postoperative complications included visceral ischemia in 2 (6%) patients, paraplegia in 2 (6%) patients, and death in 2 (6%) patients. All type 1b endoleaks (n=2, 6%) and type 2 endoleaks vial retrograde flow from the celiac artery (n=3, 10%) were successfully treated by transfemoral coil embolization. Over a mean follow-up of 15 months, there have been no other complications of mesenteric ischemia, spinal cord ischemia, SMA in-stent stenosis, or conversion to open surgical repair. CONCLUSIONS: Our findings suggest that celiac artery coverage to facilitate adequate distal sealing during TEVAR with complex TAA is relatively safe in the presence of SMA-celiac collaterals. Pre-existing SMA stenosis can be successfully treated by balloon expandable stents during TEVAR, and endoleaks arising from distal stent grafts attachment site or via retrograde flow from the celiac artery can be successfully managed by transfemoral coil embolization. Although early results are encouraging, long-term efficacy of these procedures remains to be determined and vigilant follow-up is needed.
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Angioplastia de Balón , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Arteria Celíaca/cirugía , Procedimientos Endovasculares , Oclusión Vascular Mesentérica/terapia , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/instrumentación , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/fisiopatología , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Arteria Celíaca/diagnóstico por imagen , Arteria Celíaca/fisiopatología , Circulación Colateral , Constricción Patológica , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/etiología , Masculino , Arteria Mesentérica Superior/diagnóstico por imagen , Arteria Mesentérica Superior/fisiopatología , Oclusión Vascular Mesentérica/diagnóstico por imagen , Oclusión Vascular Mesentérica/mortalidad , Oclusión Vascular Mesentérica/fisiopatología , Persona de Mediana Edad , New York , Paraplejía/etiología , Diseño de Prótesis , Sistema de Registros , Estudios Retrospectivos , Stents , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
PURPOSE: This study evaluated the outcomes of secondary procedures after endovascular aneurysm repair (EVAR). METHODS: From 2002 to 2009, 1768 patients underwent EVAR for treatment of 1662 elective (94%) and 106 emergent (6%) infrarenal abdominal aortic aneurysm (AAA) with a variety of Food and Drug Administration-approved and commercially available stent grafts. Postoperative follow-up included clinical examination, pulse volume recording, duplex ultrasound imaging, and computed tomography and magnetic resonance angiography at 1, 6, and 12 months, and yearly thereafter. Patients with type I and III endoleaks, unexplained endotension, limb occlusion, stent graft migration, with and without type I endoleak, and aneurysm rupture underwent secondary interventions. Type II endoleak at >6 months without a decrease in the aneurysm sac underwent translumbar embolization. Data were prospectively collected. RESULTS: EVAR was performed in 1768 patients. During a mean follow-up of 34 (SD, 30.03) months, 339 patients (19.2%) required additional secondary procedures for aneurysm-related complications, including type I (n = 51, 15.0%), type II (n = 136, 40.1%), and type III (n = 5, 1.5%) endoleaks; endotension (n = 8, 2.4%), stent graft migration proximal fixation site (n = 46, 13.6%), stent graft iliac limb thrombosis or stenosis (n = 25, 7.4%), subsequent iliac aneurysm formation (n = 39, 11.5%), or aneurysm rupture after EVAR (n = 29, 8.6%). The mean age was 74 (SD, 9.15) years. Mean AAA size was 5.7 (SD 3.24) cm. Compared with secondary procedures for AAA rupture, the nonrupture patients had a significantly lower mortality (1.6% vs 17.2%, P < .05) and a higher likelihood of being managed by endovascular means (98.8% vs 44.8%, P < .05). When nonruptured EVAR patients required urgent secondary procedures for type I endoleaks and stent graft migration or limb thrombosis, the mortality was 6.0% vs 0.5% for elective procedures (P < .05). CONCLUSIONS: Our long-term EVAR experience indicates that 18% of patients require additional secondary procedures, and most of these patients can be managed by endovascular means with an acceptable overall mortality of 2.9%. Most type I and II endoleaks can be successfully treated by transluminal embolization, and most patients with delayed aneurysm rupture after EVAR can be successfully managed by endovascular or open surgical repair.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Stents , Anciano , Anciano de 80 o más Años , Rotura de la Aorta/etiología , Rotura de la Aorta/terapia , Implantación de Prótesis Vascular/efectos adversos , Embolización Terapéutica , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Femenino , Migración de Cuerpo Extraño/terapia , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Stents/efectos adversos , Trombosis/etiología , Trombosis/terapia , Resultado del TratamientoRESUMEN
PURPOSE: Historically thoracic aortic rupture secondary to trauma was treated with cardiopulmonary bypass and open surgery. With the advent of endovascular grafting, physicians have the ability to reconstruct the thoracic aortic transection using a less invasive technique. In this study, we examine our experience with stent graft repair of thoracic transections secondary to trauma. METHODS: The medical records of patients treated at a level I trauma center from 2005 to 2008 were reviewed. Those patients who had an aortic transection treated with an endograft were identified and evaluated for in-hospital mortality and morbidity and concurrent injuries. Demographics, procedural details, and outcomes were analyzed. RESULTS: Over a 3-year period, 18 thoracic aortic transections secondary to trauma were identified in patients with a mean age of 43 (range, 16-80). Primary technical success was 100%. None of the patients required explant or open repair during this time period. In-hospital mortality was 2 of 18 (11%); all patients had multiple trauma including long bone fractures. The subclavian artery origin was covered by the stent graft in 9 of the 18 patients. The mean estimated blood loss per procedure was 222 cc. No patient in this series had postoperative paraplegia. Follow-up ranged from 1 to 50 months with an average of 13 months. There have been no late explantation or device failures identified. CONCLUSION: Endovascular repair of traumatic thoracic aortic transections can be performed safely with a relatively low mortality and morbidity and should be the procedure of choice for patients presenting with traumatic thoracic aortic ruptures.
Asunto(s)
Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Heridas y Lesiones/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/lesiones , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/mortalidad , Aortografía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , New York , Selección de Paciente , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Centros Traumatológicos , Resultado del Tratamiento , Heridas y Lesiones/complicaciones , Heridas y Lesiones/diagnóstico por imagen , Heridas y Lesiones/mortalidad , Adulto JovenRESUMEN
Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality when compared to the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help ones ability to deal with not just the technical aspects of these procedures, but also address some of the challenges including: the availability of preoperative CT, the choice of anesthesia, percutaneous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs. aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.
Asunto(s)
Aneurisma Roto/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Endoscopía/métodos , Procedimientos Quirúrgicos Vasculares/métodos , Humanos , Resultado del TratamientoRESUMEN
PURPOSE: Although endovascular repair of thoracic aortic aneurysm has been shown to reduce the morbidity and mortality rates, spinal cord ischemia remains a persistent problem. We evaluated our experience with spinal cord protective measures using a standardized cerebrospinal fluid (CSF) drainage protocol in patients undergoing endovascular thoracic aortic repair. METHODS: From 2004 to 2006, 121 patients underwent elective (n = 52, 43%) and emergent (n = 69, 57%) endovascular thoracic aortic stent graft placement for thoracic aortic aneurysm (TAA) (n = 94, 78%), symptomatic penetrating ulceration (n = 11, 9%), pseudoaneurysms (n = 5, 4%) and traumatic aortic transactions (n = 11, 9%). In 2005, routine use of a CSF drainage protocol was established to minimize the risks of spinal cord ischemia. The CSF was actively drained to maintain pressures <15 mm Hg and the mean arterial blood pressures were maintained at >/=90 mm Hg. Data was prospectively collected in our vascular registry for elective and emergent endovascular thoracic aortic repair and the patients were divided into 2 groups (+CSF drainage protocol, -CSF drainage protocol). A chi(2) statistical analysis was performed and significance was assumed for P < .05. RESULTS: Of the 121 patients with thoracic stent graft placement, the mean age was 72 years, 62 (51%) were male, and 56 (46%) underwent preoperative placement of a CSF drain, while 65 (54%) did not. Both groups had similar comorbidities of coronary artery disease (24 [43%] vs 27 [41%]), hypertension (44 [79%] vs 50 [77%]), chronic obstructive pulmonary disease (18 [32%] vs 22 [34%]), and chronic renal insufficiency (10 [17%] vs 12 [18%]). None of the patients with CSF drainage developed spinal cord ischemia (SCI), and 5 (8%) of the patients without CSF drainage developed SCI within 24 hours of endovascular repair (P< .05). All patients with clinical symptoms of SCI had CSF drain placement and augmentation of systemic blood pressures to >/=90 mm Hg, and 60% (3 of 5 patients) demonstrated marked clinical improvement. CONCLUSION: Perioperative CSF drainage with augmentation of systemic blood pressures may have a beneficial role in reducing the risk of paraplegia in patients undergoing endovascular thoracic aortic stent graft placement. However, selective CSF drainage may offer the same benefit as mandatory drainage.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Líquido Cefalorraquídeo , Drenaje , Complicaciones Posoperatorias/prevención & control , Isquemia de la Médula Espinal/prevención & control , Anciano , Anciano de 80 o más Años , Protocolos Clínicos , Femenino , Humanos , Masculino , Estudios Prospectivos , Resultado del TratamientoRESUMEN
PURPOSE: In our transition from elective abdominal aortic aneurysm (AAA) to emergent ruptured AAA (r-AAA) repair with endovascular techniques, we recognized that the availability of endovascularly trained staff in the operating rooms and emergency departments, and adequate equipment were the limiting factors. To this end, we established a multidisciplinary protocol that facilitates endovascular repair (EVAR) of r-AAA. METHODS: In January 2002, we instituted a multidisciplinary approach that included the vascular surgeons, emergency department physicians, anesthesiologists, operating room staff, radiology technicians, and availability of a variety of stent-grafts to expedite EVAR of r-AAAs. Five patients with symptomatic, not ruptured AAAs suitable for EVAR underwent simulation of patients presenting to the emergency department with r-AAAs. Emergency department physicians alerted the on-call vascular surgery team (vascular surgeon, vascular resident or fellow) and the operating room staff, emergently performed an abdominal computed tomography (CT) scan in only hemodynamically stable patients with systolic blood pressures > or =80 mm Hg, and transported the patient to the operating room. The vascular surgeon informed the operating room staff to set up for EVAR and open surgical repair in an operating room equipped with interventional capabilities. The operating room setup was rehearsed with the anesthesiologists, operating room staff, and radiology technicians who were knowledgeable of the sequence of steps involved. Since then, 40 patients have undergone emergent EVAR for r-AAAs with general anesthesia. RESULTS: No complications developed in any of the symptomatic (simulation) patients, and 40 (95%) of 42 patients with r-AAAs had a successful EVAR with Excluder (n = 27, 68%), AneuRx (n = 9, 23%), or the Zenith (n = 4, 10%) stent-grafts. The mean age was 73 years (range, 54 to 88 years), and pre-existing comorbidities included coronary artery disease in 26 (65%), hypertension in 23 (58%), chronic obstructive pulmonary disease in 7 (18%), renal insufficiency not on dialysis in two (5%), and diabetes in nine (23%). Fourteen (38%) patients were diagnosed with r-AAAs at another hospital and subsequently were transferred to us, and 26 (62%) presented directly to the emergency department at our institution. At the initial presentation, 30 patients (75%) were hemodynamically stable and either had a CT scan at an outside hospital or in the emergency department, and 10 (25%) hemodynamically unstable patients with systolic blood pressures <80 mm Hg were rushed to the operating room for EVAR without a preoperative CT scan. The mean time from the presumptive diagnosis of a r-AAA in the emergency department to the operating room for EVAR was 20 minutes (range, 10 to 35 minutes), and the mean operative time from skin incision to closure was 80 minutes (range, 35 to 125 minutes). Seven patients (18%) needed supraceliac aortic occlusion balloon, and six (15%) needed aortouniiliac stent-grafts. The mean blood loss was 455 mL (range, 115 to 1100 mL). Two patients each (5%) developed myocardial infarction, renal failure, and ischemic colitis, seven (18%) developed abdominal compartment syndrome, and seven (18%) died. Over a mean follow-up of 17 months, three patients with endovascular r-AAA repair required four secondary procedures. CONCLUSIONS: The early results show that emergent endovascular treatment of hemodynamically stable and unstable patients is associated with a limited mortality of 18% once a standardized protocol is established. There is an increased recognition of emerging complications with an endovascular approach, and a synchrony of disciplines must be developed to initiate a successful program for endovascular treatment of r-AAAs.
Asunto(s)
Aneurisma Roto/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/métodos , Protocolos Clínicos , Anciano , Anciano de 80 o más Años , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Tratamiento de Urgencia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Simulación de Paciente , Estudios Prospectivos , Diseño de Prótesis , Stents , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , TriajeRESUMEN
Atherosclerotic renal artery stenosis is a significant cause of poorly controlled hypertension and progressive renal dysfunction leading to ischemic nephropathy and other end-organ damage. The optimal treatment of renovascular disease contributing to hypertension and renal dysfunction is not known. This study compares the anatomic and functional outcomes of both open and endovascular therapy for chronic, symptomatic atherosclerotic renal artery disease. We performed a retrospective analysis of records from patients who underwent renal arterial interventions, endovascular or open bypass, between January 1984 and January 2004. Principal indications for intervention were hypertension (51%), chronic renal insufficiency (13%), and hypertension and elevated creatinine (36%). A total of 247 patients (109 males; mean age 69 +/- 10, range 44-89 years) underwent 314 interventions (109 open procedures; 205 angioplasties, 71% with stent placement). There was a significant difference in 30-day mortality (4% vs. <1%; p < 0.005) between the open and endoluminal groups, but not at 1, 3, or 5 years. Patients in the open group had a higher primary patency rate at 5 years (83 +/- 5% vs. 76 +/- 6%; p = 0.03), but patients in the endoluminal group had a higher assisted primary patency rate at 5 years (92 +/- 5% vs. 84 +/- 5; p = 0.03). There was no significant difference between both treatment groups in cumulative freedom from presenting symptom or in freedom from dialysis and renal-related death. Patients who presented with hypertension were more likely to have shown improvement in their blood pressure with endoluminal intervention at 1, 3, and 5 (59 +/- 6% endoluminal vs. 83 +/- 5% open; p = 0.01) years. From these results we conclude that open repair and endoluminal repair of atherosclerotic renal artery stenosis have similar immediate and long-term functional and anatomic outcomes. Patients who present with hypertension may have greater benefit with an endoluminal repair.
Asunto(s)
Arteriosclerosis/cirugía , Obstrucción de la Arteria Renal/cirugía , Anciano , Angioplastia , Arteriosclerosis/mortalidad , Femenino , Humanos , Hipertensión Renovascular/mortalidad , Hipertensión Renovascular/cirugía , Tablas de Vida , Masculino , Complicaciones Posoperatorias/epidemiología , Arteria Renal/cirugía , Obstrucción de la Arteria Renal/mortalidad , Estudios Retrospectivos , Stents , Análisis de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVES: This study was performed to determine whether there is deterioration in renal function during follow-up in patients who have undergone endovascular aneurysm repair (EVAR), as recommended by the device manufacturers; to determine whether suprarenal fixation correlates with impairment of renal function; and to explore the potential implication of life-long surveillance of renal function with contrast-enhanced computed tomography. METHODS: One hundred forty-six consecutive patients underwent EVAR at our institution. Data from 113 of these patients who were free from preoperative renal insufficiency or postoperative renal disease were analyzed. Fifty-three patients received infrarenal (IR) fixation devices, and 60 patients received suprarenal (SR) fixation devices. All SR fixation devices were placed under investigational device exemption protocols. The average follow-up was 688 days. Sixty-five consecutive patients who had undergone open repair of an abdominal aortic aneurysm (AAA) served as the control group. RESULTS: Preoperative creatinine concentration, intraoperative blood loss, contrast volume, and number of contrast-enhanced procedures were not significantly different between the IR and SR groups. Two renal artery occlusions (1 SR, 1 IR; P=NS) were identified, and 8 renal infarcts (5 SR, 3 IR; P=NS). There was an increase in mean creatinine concentration in the open AAA, IR, and SR fixation groups at each time point in the analysis. Mean elevation in creatinine concentration at 12, 24, and 36 months was 0.10, 0.10, and 0.04 mg/dL, respectively, for open AAA repair; 0.20, 0.21, and 0.28 mg/dL for IR fixation; and 0.15, 0.21, and 0.12 mg/dL for SR fixation. At life table analysis, renal impairment at 36 months was seen in 36% +/- 9% of patients in the IR group, 25% +/- % of patients in the SR group, and 19% +/- 6% of patients in the open AAA group (P=.04 for IR fixation vs open AAA repair). CONCLUSIONS: A decrease in kidney function is seen after EVAR, regardless of fixation level, that is independent of renal disease and renal arterial occlusion. In patients with normal renal function the site of proximal fixation does not affect postoperative creatinine concentration. The decrease in renal function is likely related to the repetitive administration of contrast agent.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Medios de Contraste/efectos adversos , Insuficiencia Renal/etiología , Anciano , Aneurisma de la Aorta Abdominal/sangre , Implantación de Prótesis Vascular/métodos , Creatinina/sangre , Femenino , Estudios de Seguimiento , Humanos , Masculino , Insuficiencia Renal/sangre , Insuficiencia Renal/diagnóstico por imagen , Estudios Retrospectivos , Técnicas de Sutura/efectos adversos , Tomografía Computarizada por Rayos X/métodosRESUMEN
OBJECTIVE: Percutaneous intervention for symptomatic renal artery atherosclerosis is rapidly replacing surgery in many centers. This study evaluated the anatomic and functional outcomes of endovascular therapy for atherosclerotic renal artery stenosis on a combined vascular surgery and interventional radiology service at an academic medical center. METHODS: This was a retrospective analysis of patients who underwent renal artery angioplasty with or without stenting between January 1990 and June 2002. Indications included hypertension (86%) and rising serum creatinine concentration (55%). One hundred forty-six patients (80 women; average age, 71 years [range, 44-89 years]) underwent 183 attempted interventions (64 to treat bilateral stenosis). Forty-five percent of patients had significant bilateral disease: 27% had greater than 50% bilateral stenosis, and the remainder had nonfunctioning, absent, or occluded vessels. RESULTS: Of 183 planned interventions, technical success (<30% residual stenosis) was achieved in 179 vessels (98%) with placement of 137 stents (75%). Thirty-day mortality was 0.7%. The major morbidity rate was 4%, and the procedure-related complication rate was 18%. Five-year cumulative patient mortality was 25%. Primary patency, assisted primary patency, and recurrent stenosis rates were 82% +/- 9%, 100% +/- 0%, and 30% +/- 7%, respectively, at 5 years. Within 3 months of the procedure, 52% of patients who received treatment of hypertension demonstrated clinical benefit (hypertension improved or cured), which was maintained in 68% of patients at 5 years. Serum creatinine concentration was lowered or stabilized in 87% of patients within 3 months of the procedure, but this benefit, including freedom from dialysis, was maintained in only 45% of patients at 5 years. CONCLUSIONS: Endovascular intervention for symptomatic atherosclerotic renal artery stenosis is technically successful. There were excellent patency and low recurrent stenosis rates. There is immediate clinical benefit for most patients, but divergent long-term functional outcomes. Endovascular interventions modestly enhance the care of the patient with hypertension, but poorly preserve long-term renal function in the patient with chronic renal impairment.
Asunto(s)
Angioplastia/métodos , Arteriosclerosis/terapia , Obstrucción de la Arteria Renal/terapia , Centros Médicos Académicos , Adulto , Anciano , Anciano de 80 o más Años , Arteriosclerosis/complicaciones , Femenino , Humanos , Hipertensión/etiología , Hipertensión/terapia , Fallo Renal Crónico/etiología , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , New York , Recurrencia , Obstrucción de la Arteria Renal/etiología , Estudios Retrospectivos , Stents , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular/fisiologíaRESUMEN
BACKGROUND: During the past decade, our practice of performing carotid endarterectomy (CEA) has changed dramatically, most notably by an abrupt shift from routine to selective preoperative angiography, reliance on defined care plans with full-time nurse practitioner oversight, and increasing reliance on eversion endarterectomy and cervical block anesthesia. This study was designed to determine whether these shifts in policy have been associated with lower costs without sacrificing clinical outcome. METHODS: All patients undergoing CEA from July 1993 to December 2000 were identified, and inpatient and outpatient charts were reviewed. Cost data were obtained from the central hospital accounting system and converted to 2001 dollars. Thirty-day outcomes and costs were quantified each year and compared between each of 2 temporally well-defined groups: those undergoing "routine" versus "selective" angiography and those cared for before and after defined patient care protocols were instituted. RESULTS: A total of 1168 CEAs were analyzed. Thirty-day combined stroke and death rate was 3.1%, and no trends or significant differences over time were seen. From 1993 to 2000 the cost of CEA fell from $9302 to $6216 (P<.0002), and length of stay was reduced 1 full day (P=.005). Institution of "selective" angiography was associated with an immediate cost savings of approximately $2000 per case (P<.0001), and nurse practitioner oversight along with institution of defined clinical protocols with a $530 (P<.05) decline in nonoperating room-related costs. CONCLUSIONS: Changes in policy from routine to selective angiography, reliance on defined postoperative care pathways, eversion endarterectomy, and cervical block anesthesia have been associated with significant cost savings, with no compromise in clinical outcome at our institution.