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This volume compiles accepted contributions for the 2nd Edition of the Colombian Computational Biology and Bioinformatics Congress CCBCOL, after a rigorous review process in which 54 papers were accepted for publication from 119 submitted contributions. Bioinformatics and Computational Biology are areas of knowledge that have emerged due to advances that have taken place in the Biological Sciences and its integration with Information Sciences. The expansion of projects involving the study of genomes has led the way in the production of vast amounts of sequence data which needs to be organized, analyzed and stored to understand phenomena associated with living organisms related to their evolution, behavior in different ecosystems, and the development of applications that can be derived from this analysis.

Full text of ' P THE M M THE /lOGNT SINAI JOURNAL DF MEDICINE DLGME 71 NUMBER JANUARY 2004 Minimally Invasive Vascular Surgery: The Evolution of Endovascular Therapy Michael L. Marin, Harold A. Mitty, Larry H. H oilier, and Valentin Faster, Guest Editors Part 2 CONTENTS Endovascular Treatment of Peripheral Arterial Aneurysms Nicholas J. Morrissey 1 I Endovascular Therapy for the Treatment of Arterial Trauma Claudie S. McArthur and; Michael L.

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Mann 4 Combined Open and Endovascular Techniques for the Treatment of Complex Vascular Disease Alfio Carroccio and David Spielvogel 12 Embolization of Complex Vascular Lesions Robert A. Lookstein and Jeffrey Guller 17 Endovascular Treatment of Neurovascular Disorders Aman B. Patel and David M. Johnson 29 Minimally Invasive Vein Surgery Steven M.

Elias and Krista L. Frasier 42 GRAND ROUNDS A Review of Heart Failure Treatment Gordon H. Guyatt and P.J. Devereaux 47! GENERAL articles Depression in Autopsy-Confirmed Dementia with Lewy Bodies and Alzheimer's Disease Steven C. Samuels, Adam M. Brickman, Jeremy A.

Burd, Dushyant P. Purohit, Pervaiz Q. Qureshi, and Michael Serby 55 The Surgical Management of Severe Obesity Daniel M. Herron 63 ■ ■ SAINT BARNABAS ■ ■ HEALTH CARE SYSTEM Veterans Affairs In Memoriam Sherman Kupfer, M.D. (1926-2003) Editor-in-Chief (1991-2003) Dr.

Sherman Kupfer, our editor-in-chief, died on December 1. 2003 at the age of 77 years, after a long illness. Brought up in New York City. Kupfer was a 1948 graduate of Cornell Medical School and subsequently began his career at Mount Sinai as an intern.

He then trained with two outstanding investigators, Carl J. In Cleveland (in cardiovascular physiology) and Robert F.

Pitts, at Cornell in New York (in renal physiology). This prepared him for a long, productive career in physiology and clinical ■ medicine. He returned to Mount Sinai for his residency in Medicine and, after serving two years in the US Air Force as chief of medicine at their base in Newfoundland, joined the faculty and staff of Mount Sinai Hospital, and subsequently Mount Sinai School of Medicine,. With which he had a long, close and continuous relationship until his death. It is difficult to portray the full flavor of his many contributions to medicine and to Mt. Sinai in this short space. They were varied and critical to both the Hospital and the Medical School.

Apart from his scientific contributions in renal and cardiovascular physiology and his clinical roles in kidney dialysis and transplantation, he held, with distinction, key administrative posts that were vital to the continued progress of the Medical Center. These roles included deputy dean, senior vice president for research and evaluation, director of the NIH- supported clinical research center, director of the artificial kidney unit, chairman of the institutional review board and research committee, and of the dean's committee for Mount Sinai's affiliated hospitals.

He achieved all this while still continuing his valued scientific teaching as professor of Medicine. In recognition of his many services to the Hospital and Medical School, the Mount Sinai Alumni Association, in 1993, awarded him their highest honor, the Jacobi Medallion. Kupfer became co-editor-in-chief of The Mount Sinai Journal of Medicine in 1 990 and shortly thereafter became the sole editor-in-chief. He continued in this role right up to the time of his death.

He had a great sense of the tradition of the Journal, which started in 1934 and has been continuously published since. Kupfer brought all his energies, intellect and wide medical knowledge to the Journal, to which he was intensely devoted. He had intimate knowledge of every facet of journal publication, in both the technical and editorial aspects. As an editor, he was especially concerned that articles in highly technical specialties be readily understood by physicians outside the specialty. This reflected Dr. Kupfer's gifts and zeal as a teacher - his eagerness to see medical knowledge disseminated widely within the profession and beyond. Kupfer shared his devotion with his wife of many years, Adele, who was herself a teacher and who predeceased him by just a few months.

He was also devoted to her and to their three children, Joel (M.D.). Kenneth and Marcia.

Their spouses, and their seven grandchildren. N The entire Mount Sinai community mourns the passing of Sherman Kupfer. We will miss him. Associate Editor for the Editorial Staff, Endovascular Treatment of Peripheral Arterial Aneurysms Nicholas J. Morrissey, M.D.

Abstract Aneurysmal degeneration of peripheral arteries occurs less frequently than aortic aneurysm. While rup- ture is the most common complication of aortic aneurysms, peripheral aneurysms frequently cause thrombosis or embolization of the involved vessels. It has generally been accepted that most peripheral aneurysms in good risk patients should be repaired to avoid the ischemic complications of thrombosis or embolization. Endovascular repair of abdominal aneurysms has revolutionized the treatment of aor- tic aneurysms. Endovascular techniques have been used to treat peripheral artery aneurysms with vary- ing success. Thrombosis of stent grafts has been a significant problem which has limited the success of this treatment.

At present, endovascular treatment of peripheral aneurysms must be reserved for selec- tive instances in very high risk patients. Until devices are developed which resist kinking and thrombo- sis, open surgery will remain the treatment of choice. Key Words: Endovascular treatment, peripheral arterial aneurysm, aneurysms.

Introduction Since the introduction of endovascular aortic aneurysm repair by Parodi in 1991(1), there has been a great deal of enthusiasm for endovascu- lar treatment of arterial pathology. Some stent grafts for abdominal aortic aneurysm (AAA) have been approved for use in the U.S. A num- ber are currently in various stages of develop- ment and investigation. Coil embolization of saccular aneurysms, which is generally not ap- plicable to most cases, represents a crude form of endovascular treatment since treatment must exclude the lesion while maintaining blood flow to the tissues distal to the aneurysm. The introduction of devices and strategies for treat- ment of peripheral and visceral aneurysms has proceeded at a slower pace because of the rela- tively rare nature of these lesions along with difficulties developing smaller diameter de- vices which can function effectively in the pe- ripheral vessels. Despite these challenges, en- dovascular treatment of peripheral aneurysms Address all correspondence to Nicholas J. Morrissey, M.D., Assis- tant Professor of Surgery, Division of Vascular Surgery, Box 1 273, Mount Sinai School of Medicine, One East 100th Street, New York, NY 10029; Nicholasjnorrissey@msnyuhealth.org has been performed in sufficient numbers of cases to allow some analysis.

Popliteal Aneurysms The popliteal artery is the most common site for an aneurysm of the peripheral arteries. They occur in 7.39 of 100,000 hospitalized men Patients with AAA have a 3. 1% risk of also hav- ing peripheral aneurysms while patients with peripheral aneurysms have a 70% risk of having AAA (2). Popliteal aneurysms are bilateral in 50-70% of cases (2). While rupture of popliteal aneurysms does occur, the most com- mon complications are thrombosis and distal embolization.

The amputation rate rises dramat- ically for symptomatic patients undergoing re- pair of popliteal aneurysms when compared to asymptomatic patients (3). It is therefore rec- ommended that aneurysms of 2 cm in diameter, or larger, be repaired electively (4-6). Success- ful stent-graft repair of popliteal aneurysms has been reported (7-12). Approximately 50% of cases failed and required reintervention, such as thrombolysis or angioplasty to maintain pa- tency at one year of follow-up. A review of 7 femoral and 13 popliteal aneurysms treated with endovascular techniques was published re- cently (13).

All aneurysms were treated with a © The Mount Sinai Journal of Medicine Vol. 1 January 2004 1 2 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 Wallgraft endoprosthesis. Of the 13 popliteal aneurysms treated, the one year successful ex- clusion rate was 100*^. While primary one year patency was 69^. Using thrombolysis in cases with thrombosis of the graft, and repeat en- dovascular procedures in cases of stent steno- sis, patency at one year was raised to 929c.

No patients suffered thromboembolic complica- tions related to the aneurysms and there were no amputations. While endovascular stent graft re- pair of popliteal aneurysms is possible and safe, patency, the duration of long-term is not known. Femoral Artery Aneurysms Femoral artery aneurysms are less common than the popliteal variety. While pseudoa- neurysms are relatively common after aorto- femoral reconstruction, true femoral artery aneurysms are rare. Due to the proximity of the femoral artery to the inguinal ligament, stent placement in the proximal femoral artery has had poor patency rates. Covered stents may be useful in treating aneurysms of the superficial femoral artery down to the above knee level.

In the series discussed above (13). 7 femoral arter- ies were successfully treated with Wallgraft en- doprostheses. The patency at one year was 1009^^. These data are encouraging but long- term follow-up is necessary before endovascu- lar repair can be recommended as first line ther- apy for femoral artery aneurysms.

Upper Extremity Arterial Aneurysms Aneurysms of the innominate, subclavian and axillary artery are rare. These lesions typ- ically result from trauma, thoracic outlet compression or post stenotic dilatation of Takayasu's arteritis. Other lesions may repre- sent typical degenerative aneurysm formation. Since these lesions are less common, the num- ber of patients who have had endovascular re- pair for such aneurysms is few. Many of these aneurysms were due to trauma (14). Covered stents have been used with excellent initial success rates to treat traumatic pseudoa- neurysms of the axillary and subclavian arter- ies (15, 16).

Sufficient long-term follow-up data are not yet available to prove the durabil- ity of endovascular stent grafting (EVSG) re- pair for upper extremity aneurysms, but the results published to date (14) are encouraging. Certainly, the performance of a larger study to prove efficacy and long-term durability is warranted. Visceral Artery Aneurysms Lesions of the celiac, superior mesenteric artery (SMA) and their branches are less com- mon than popliteal or femoral artery aneurysms. There are few large series (17. 18) of open treat- ment of visceral artery aneurysms because such lesions are rare.

Splenic artery aneurysms are found more frequently (60%), followed by the hepatic artery (20%) and superior mesenteric artery (5.5%). Visceral aneurysms are often di- agnosed after they have ruptured and when ur- gent surgery is needed to save the patient's life. When lesions are discovered incidentally or for symptoms other than rupture, the possibility of elective endovascular repair exists. Coil or thrombin embolization of renal and visceral artery aneurysms has been performed success- fully (19. Small stent-grafts also have seen limited success in the treatment of visceral artery aneurysms (21. In poor risk patients, coil embolization of the artery and the aneurysm may be possible if adequate collateral circulation as in some hepatic artery lesions. The current status of endovascular therapy of visceral aneurysms remains limited by technical factors such as stent size, wire and catheter capabilities and aneurysm neck size.

Most renal artery lesions remain better suited to open repair while mesenteric, hepatic and splenic arterial aneurysms can be treated ini- tially by an endovascular procedure. Summary Advances in endovascular technology for treatment of peripheral arterial aneurysms has proceeded slowly. While device design is simple, the challenges of small vessel diameter and loca- tion of peripheral lesions near joints and branch vessels has restricted the application of endo- grafting techniques.

Endovascular treatment of aneurysms in larger vessels, in segments without branches and distant from joints seem to achieve the best results. The efficacy of endovascular treatment in preventing the long-term sequelae of thrombosis, embolization, and rupture has not been shown. As endovascular devices are devel- oped for use in peripheral artery aneurysms, it will be necessary to evaluate them in prospective, multicenter trials with strict follow-up guidelines before their widespread use can be advocated.

References I. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.

Ann Vase.Surg 1991; 5:491 -499. 1 PERIPHERAL ARTERIAL ANEURYSMS -MORRISSEY 3 10 2. Femoral and popliteal aneurysms. In: Rutherford R, editor. Vascular surgery. Philadelphia; WB Saunders; 2000, 3.

Farina C, Cavallaro A, Schulz RD. Popliteal aneurysms.

Surg Gynecol Obstet 1989; I69(l):7-13. Duffy ST, Colgan MP, Sultan S, et al.

Popliteal aneurysms: a 10 year experience. Eur J Vase Endovasc Surg 1998; 16(3):2l8-222. Halliday AW, Taylor PR, Wolfe JH. The manage- ment of popliteal aneurysm: the importance of early surgical repair.

Ann R Coll Surg Engl 1991; 73(4):253- 257. Van Bockel JH, Brand R, Terpstra JL. Popliteal artery aneurysms.

Long-term follow-up of aneurysmal disease and results of surgical treatment. J Vase Surg 1991; 13(3):398-407. Kudeiko PE 2nd.

Alfaro-Franco C, Dietrich EB, Krajcer Z. Suc- cessful endoluminal repair of a popliteal artery aneurysm using the Wallgraft endoprosthesis. J Endovasc Surg 1998; 5(4):373-377.

Marin ML, Veith FJ, Panetta TF, et al. Transfemoral endolumi- nal stented graft repair of a popliteal artery aneurysm. J Vase Surg 1994; 19(4):754-757. Dietrich EB, Papazoglou K. Endoluminal grafting for aneurys- mal and occlusive disease in the superficial femoral artery: early experience.

J Endovasc Surg 1995; 2(3):225-239. Burger T, Meyer F, Tautenhahn J, et al.

Initial experiences with percutaneous endovascular repair of popliteal artery lesions using a new PTFE stent-graft. J Endovasc Surg 1998; 5(4):365-372. Van Sambeek MR, Gussenhoven EJ. Van der Lugt A, et al. Endovascular stent-grafts for aneurysms of the femoral and popliteal arteries. Ann Vase Surg 1999; 13(3):247-253. Muller-Hulsbeck S, Link J, Schwarzberg H, et al.

Percutaneous endoluminal stent and stent-graft placement for the treatment of femoropopliteal aneurysms: early experience. Cardiovasc Intervent Radiol 1999; 22(2):96- 102. Howell M, Krajcer Z, Dietrich EB, et al.

Wallgraft endoprosthe- sis for the percutaneous treatment of femoral and popliteal artery aneurysms. J Endovasc Ther 2002; 9( 1 ):76-8l. Hilfiker PR, Razavi MK, Kee ST, et al. Stent-graft therapy for subclavian artery aneurysms and fistulas: single-center mid- term results. J Vase Interv Radiol 2000; 1 1(5):578-584.

DuToit DF, Strauss DC, Blaszczyk M, et al. Endovascular treat- ment of penetrating thoracic outlet arterial injuries. Eur J Vase Endovasc Surg 2000; l9(5):489-495. Marin ML, Veith FJ, Panetta TF, et al. Transluminally placed endovascular stented graft repair for arterial trauma. J Vase Surg 1994; 20(3):466-72; discussion 472-473. Trastek VF, Pairolero PC, Joyce JW.

Splenic artery aneurysms. Surg 1982; 91: 694-699. Shanley CJ, Shah NL, Messina LM. Common splanchnic artery aneurysms: splenic, hepatic, and celiac. Ann Vase Surg 1996; 10:315-322.

Mclntyre TP, Simone ST. Stahlfeld KR. Intraoperative thrombin occlusion of a visceral artery aneurysm. J Vase Surg 2002; 36(2):393-395. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther 2002; 9(l):38-47. Endoluminal stent-graft repair of a renal artery aneurysm.

J Endovasc Ther 2002; 9(3):359-362. Hemorrhage from a right hepatic artery pseudoaneurysm: endovascular treatment with a coronary stent-graft. J Endovasc Ther 2002; 9(2):221-224. 31 iS e, a- )- )f ■e ir if )t I- it ll Endovascular Therapy for the Treatment of Arterial Trauma Claldie S. And Michael L. Marin, M.D.- Abstract Several factors may limit the success of conventional operative therapy for traumatic arterial injuries. In particular, the inaccessibility of the vascular lesion, anatomic distortion, and the inherent problems associated with operating in a traumatized and often contaminated field are among these limiting fac- tors.

As a result, endovascular therapy has emerged as an important potential alternative. This paper focuses on the application of endovascular therapy to the trauma patient, based on our experience and those previously published by other groups. Injuries to the carotid, femoral, axillary/subclavian and iliac arteries, as well as to the abdominal and thoracic aorta, have been success- fulK' managed by stent-grafting.

Despite the potential benefits of this mode of therapy, its long-term utility will depend on our abil- itv to overcome certain limitations associated with the technique, and on careful patient selection. Key Words: Endov a.scular treatment, arterial trauma, stent-grafting. Introduction Arterial injury, including dissection, occlu- sion, pseudoaneurysm and arteriovenous fis- tula (AVF) formation, may result from both penetrating and blunt trauma.

The success of current operative therapy for traumatic arterial injuries may be limited by several factors. The inaccessibility of the vascular lesion (e.g. Due to central vessel involvement), anatomic dis- tortion that results in venous hypertension with excessive bleeding, and inherent problems with operating in a traumatized and often contami- nated field, are among these limiting factors. Furthermore, the presence of multiple trauma or severe medical co-morbidities may increase the incidence of surgical complications and mortality (I ). The use of endovascular stent-grafts to ad- dress these limitations was first introduced by 'Vascular fellow and ^hief and Professor of.Surgery. Division of Vascular Surgery.

Department of Surgery. Mount Sinai.School of.Medicine..New York. NY Address all correspondence to Michael L. M.D., Division of Vascular Surgery, Department of Surgery, Box 127.3, Mount Sinai.School of Medicine. One East i(X)th Street. Dotter in 1969 (2). Over the past 12 years, en- dovascular grafting has been evaluated as an al- ternative to conventional surgical repair in the management of aneurysms and other vascular lesions.

The application of this form of therapy as well as other endovascular techniques for the management of vascular trauma offers many potential advantages. Angiography assists with the diagnosis of traumatic lesions such as inti- mal dissections and AVFs (3). Embolization techniques for hemostasis have been well stud- ied and are the standard for the management of bleeding from pelvic fractures (3). In addition, endovascular techniques can be utilized to help with vascular control, as an adjunct to surgery in regions where obtaining proximal or distal control is technically difficult. The use of en- dovascular stent-grafting for the definitive re- pair of traumatic lesions has been shown to be associated with a decrease in anesthetic require- ment, blood loss, and extent of dissection (4). High-velocity missiles can produce a signifi- cant amount of tissue damage, even if not sus- pected on initial examination due to the classi- cally small size of the entrance and exit wounds (5).

The inherent problems of graft placement in the setting of severe tissue damage, gross contamination and scar tissue formation make 4 © The Mount Sinai Journal of Medicine Vol. I January 2004 Vol. 1 ENDO VASCULAR THERAPY FOR ARTERIAL TRAUMA -McARTHUR 5 the use of a remote insertion site particularly advantageous in the trauma patient (6, 7). At present, the largest experience with en- dovascular graft therapy for the management of vascular trauma has been with the treatment of arterial pseudoaneurysms and AVFs (4, 6, 8- 13). Although the optimal timing of repair is still controversial (14, 15), this method is lim- ited to the stable patient. In the setting of severe ischemia or active hemorrhage, urgent conven- tional operative repair is still recommended (9). Similarly, the patient with an expanding hematoma or multiple traumatic injuries may not be a suitable candidate for endovascular graft therapy.

Stented grafts have been exten- sively studied and have demonstrated excellent technical success rates (16). In its use for arter- ial trauma, endovascular stent-grafting has proven safe and effective in preliminary inves- tigations (4). This paper focuses on the specific application of this technology to the trauma pa- tient. The discussion presents the potential ben- efits and disadvantages of the specific methods, reviews the current status of the field and avail- able data, and addresses the technology's future role within the field of trauma surgery. Techniques Clinical experience has demonstrated a wide variety of options for device use in the treatment of traumatic lesions (4, 10, 16, 17). In their current design, stented grafts for treating traumatic arterial injuries are composed of a stent rendered nonporous by an outer covering. The covering, whether polytetrafluoroethylene (PTFE), Dacron, polyester or other material, does not appear to influence outcome (9).

Some have used radially expandable, thin-walled Dacron grafts (16); others have used auto- genous vein (jugular or saphenous) sutured to a Palmaz stent (16, 18). At our institution, we have used Palmaz balloon-expandable metallic stents in conjunction with thin-walled PTFE graft material to perform arterial repair of pseudoaneurysm and AVFs. Precise delivery to the site of injury is performed under fluoro- scopic guidance. Heparin is used during inser- tion, but long-term anticoagulation has not been necessary.

An alternative device is the Corvita stent (Corvita, Inc./Schneider Corp./Boston Scien- tific Corp., Natick, MA) graft, which is fabri- cated from a self-expanding stent of braided wire. The Corvita stent-graft was the first com- mercially available endograft to enter into clin- ical trials. It has the distinct advantage of being able to be cut to the desired length in the oper- ating room prior to loading into a special deliv- ery sheath. The sheath has a special pusher catheter which is used for maintaining the graft in position while the outer sheath is being re- trieved. The Wallgraft (Schneider-Pfizer, Min- neapolis, MN) has a similar design and a poly- ester outer covering.

Another system, the Pas- sager Endograft System (Boston Scientific, Wa- tertown, MA), uses a nitinol thermal-expanding stent covered with an ultrathin woven polyester fabric. Another endograft device which has been successfully used for traumatic lesions is the Hemobahn™ graft, produced by W.L. Gore and associates (Flagstaff, AZ). This device is also fabricated from an ultra-thin ePTFE tube exter- nally supported by nitinol wire arranged in a helical coil fashion. Carotid Injuries Internal carotid artery (ICA) pseudo- aneurysms are often the result of a previous dis- section occurring either spontaneously or in as- sociation with an identifiable traumatic episode (19). The significant risk of life-threatening stroke or hemorrhage warrants strong consider- ation for treatment of these lesions, even if asymptomatic (19). Although standard treat- ment has been open surgical management, en- dovascular techniques have been utilized re- cently to address the problem (8, 19).

Conven- tional open repair is often technically difficult or impossible when exposure at the skull base requires mandibular disarticulation (5, 8, 19). In such a situation, endovascular repair pro- vides a potential alternative. Several centers have reported the use of bare stents to treat such aneurysms (19-22).

However, in the case of larger, wide-mouthed aneurysms (22), the aneurysms were not totally excluded by the Pal- maz stents alone and continued to be at risk for rupture and embolization. Complete aneurysm exclusion with an endovascular graft may be a more reasonable option in the case of large ICA aneurysms. Our colleagues recently described the suc- cessful use of an endovascular stented graft composed of a Palmaz balloon-expandable stent covered with a PTFE thin-wall vascular graft (Impra, Tempe, AZ), for the treatment of a 2 cm ICA pseudoaneurysm located at the skull base (8). Access may be obtained by either a femoral approach or direct operative exposure 6 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 of the common carotid artery at the base of the neck. Open exposure of the proximal carotid artery allow s blood flow to be arrested, thereby reducing the risk of embolization secondary to luminal manipulations. The patient remains asymptomatic on oral anticoagulation, and the aneurysm remains fully excluded. In addition to pseudoaneurysm formation, blunt carotid injury may result in intimal dis- section, for which standard therapy has been systemic anticoagulation (23).

Reported a series of six cases of progressive dissection or pseudoaneurysm formation fol- lowing blunt carotid injury (24). All six patients were successfully treated with covered stents w ithout the use of anticoagulation. Parodi et al. Reported 8 cases of traumatic internal or common carotid artery pseudo- aneurysms or AVFs treated with autogenous- vein-co ered stents, the Corvita endograft. Or the Wallgraft (25. Parodi reported one fail- ure related to external compression of the Pal- maz stent at the level of the base of the skull (25).

Determination of the potential benefit of using autogenous vein vs. A synthetic-covered stented graft in such patients needs to be ad- dressed in a controlled study. Whether exclu- sion of the aneurysm will prevent future expan- sion and potential rupture of the pseudo- aneurysm will require long-term evaluation. Femoral Artery Trauma With the rapid expansion in the use of inter- ventional procedures and the rising incidence of civilian-based (noncombatant) trauma. AVFs and pseudoaneurysms of the femoral arteries have become common vascular complications. Small AVFs may resolve spontaneously, but larger fis- tulas do not generally have the same benign prognosis (27.

Currently, surgical treatment is recommended for the prevention of complica- tions, including hemorrhage, thrombosis, com- pression of local neurovascular structures, ve- nous hypertension and congestive heart failure (6). Surgical repair is often technically diffi- cult, due to bleeding secondary to venous hyper- tension associated with the arterialized vascular bed (6).

We reported the first successful repair, in an IS-year-old youth, of a traumatic AVF caused by a bullet wound to the superficial femoral artery and vein, using a balloon-expandable, stented. PTFE-covered Palmaz stcnt-graft (6). At 5 months follow-up. The graft was still patent. Subsequently, a number of groups have re- ported on the treatment of traumatic femoral pseudoaneurysms and AVFs.

With technical suc- cess rates of 90-100% and one-year patency rates of 83-100% (4, 16, 26, 29). Although the I use of covered stent-grafts has been reported for the treatment of popliteal pseudoaneurysms and AVFs (3. The long-term patency of the grafts and adjacent vein has not been evaluated. Axiliary/Subclavian Trauma Penetrating axillary and subclavian artery trauma may result in the formation of a dissec- tion, pseudoaneurysm or AVF. Post-traumatic pseudoaneurysms of the subclavian and axillary arteries are rare, and like aneurysms of other ar- teries, can rupture, thrombose or embolize (31, 32).

Other mechanisms of injury include com- pression with contusion, avulsion, and traction from stretch or rotational stress (33). The surgi- cal approaches developed to repair such lesions include clavicular resection, median ster- notomy and thoracotomy, but these are each as- sociated with significant potential for morbidity (34). The approaches require extensive dissec- i tion, often with large volume of blood loss and! Prolonged hospital stay. Although the optimal management of such injuries is unclear, the role of endovascular stent-grafting for such lesions has expanded over the past decade (4, 11, 16, 26, 35-38).

Parodi reported on 12 patients who underwent endovascular grafting for the treatment of axil- lary or subclavian AVFs or pseudoaneurysms (26). In that series, one partial failure of the main stent occurred due to an additional AVF located in a branch of the subclavian artery. The AVF was closed successfully with a detachable balloon placed into the scapular branch of the thyrocervical trunk. All cases of longstanding AVF were associated with a significant stenosis at the site of injury that required dilation prior to graft implantation. In a collective review of 18 recent cases of axillary or subclavian artery j trauma managed with endovascular stent-graft therapy, a technical success rate of 94% was re- ported (10). Primary patency in these patients was 85% at a mean follow-up period of 18 months. Associated complication rate was 6%.

Mean length of hospital stay was 3.3 days. An- other group recently reported its experience with one patient with an embolizing traumatic subclavian artery aneurysm. The aneurysm was repaired with a polyester-covered nitinol stent with concomitant vein bypass of embolic brachial artery occlusion. At 24 months follow- up. Both bypasses were patent (37). 1 ENDOVASCULAR THERAPY FOR ARTERIAL TRAUMA-Mc ARTHUR Aorta or Iliac Artery Trauma Patients sustaining blunt trauma to the ab- dominal aorta often do not survive, due to the impact of the direct compressive force and as- sociated injuries.

In a recent review, the mortal- ity rate associated with blunt abdominal aortic injury was 24% (39). Injuries may include inti- mal disruption with dissection, intramural hematoma, pseudoaneurysms, as well as simple contusion to frank rupture (40, 41). Endovascu- lar stent-graft repair of such injuries has emerged as a therapeutic option in the case of stable aortoiliac injuries. Most experience has been with penetrating injuries of these vessels, either iatrogenic (related to surgery or catheter- ization procedures), or bullet injuries (10, 12, 42). In the presence of associated injuries or he- modynamic instability, conventional open re- pair should be undertaken.

Fifteen patients in recent reports underwent endovascular stent- graft repair of traumatic injuries to the abdomi- nal aorta or iliac arteries — injuries that were either AVFs or pseudoaneurysms (4, 13, 16, 35). Technical success of the procedures was 100%, with primary patencies of 100% at a mean follow-up period of 10.5 months (10). Isolated injuries to the iliac vessels have also been successfully treated with endovascu- lar grafting (43, 44).

Rupture of the iliac artery occurs in one of every 200 angioplasty proce- dures (45, 46). In these cases, emergent repair of an acute rupture of the external iliac artery during angioplasty by endovascular stent-graft is likely to be necessary, as reported by Formichi et al. The authors obtained tem- porary hemostasis using balloon tamponade fol- lowed by exchange for a Cragg-Endopro-Sys- tem-covered endoprosthesis to seal the injury. At follow-up more than 18 month later, the graft was still patent without endoleak. Thoracic Aortic Trauma Most blunt thoracic aortic injuries are caused by deceleration injuries, most often re- lated to motor vehicle accidents (47, 48).

Pa- tients who sustain trauma to the thoracic aorta, whether blunt or penetrating, usually do not survive (49). The few patients who survive the immediate injury often develop a chronic aortic aneurysm (50, 51). Open thoracic surgery for repair of a chronic traumatic aneurysm is asso- ciated with a mortality rate of 5-18%, due mainly to bleeding, heart failure or renal fail- ure, with associated morbidity rates as high as 50% (51, 52). In the case of acute aortic injury, the frequency of multiple traumatic injuries fur- ther increases the mortality rate (53-55). The presence of medical co-morbidities also con- tributes to a poorer prognosis (56). Due to the lack of prospective data regard- ing the optimal management of these injuries, controversy exists as to the indications for op- erative therapy. Minor injuries, including mural hematoma or intimal flap, usually resolve on their own (57).

Pseudoaneurysms, even small ones, rarely remain stable over time, and have a high risk of rupture, embolization, fistulization or compression of adjacent structures (57, 58). Nonoperative management can be considered only for simple lesions, for some patients with severe neurologic deficits, or for arterial in- juries not actively bleeding (57, 59, 60). For these patients, antihypertensive therapy with ni- troprusside or labetalol is recommended until a decision on aortic repair is reached (61). Never- theless, Finkelmeier et al. Reported that 33% of his patients with untreated chronic aortic aneurysm died of complications attributed to the aortic lesion, with 75% of deaths secondary to aneurysm rupture (51). Endovascular stent-grafting of traumatic thoracic injuries has begun to assume a role in the management of these injuries (62-65). Using this technique, the need for aortic clamp- ing is obviated.

This could potentially decrease the incidence of paraplegia, which has been re- ported to occur in 4-32% of cases after surgery for thoracoabdominal aortic aneurysm (66). Al- though several factors have been implicated in the pathophysiology of paraplegia in thoracic aortic surgery (66), duration of spinal cord is- chemia is undoubtedly a major factor (67). The endovascular approach does not allow for the reimplantation of intercostal arteries. However, in the case of nonpenetrating thoracic aortic in- jury, the location of the lesion is at the isthmus approximately 90% of the time (48, 68); there- fore, the area of repair usually does not involve segments with branches to the spinal cord (62). Respiratory failure is the most common complication following surgery for thoracic aortic aneurysms (69).

The elimination of tho- racotomy, especially in patients with existing pulmonary disease, will probably decrease the incidence of this complication, with an addi- tional benefit in hospital cost reduction. We will probably also see a decrease in other complica- tions, related to the decrease in operative blood loss, the minimal invasiveness of this form of therapy, and the reduced need for general anes- 8 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 thesia. (particularly in patients with serious risk factors for open repair). Several limitations must be addressed.

With most of these injuries occurring at the isthmus just beyond the origin of the subclavian artery, the length of the proximal neck may be insuffi- cient for adequate fixation of the stented graft if precise deployment is not achieved. This may result in either endoleak (incomplete aneurysm exclusion) or occlusion of the upper extremity intlow. Preprocedural left-subclavian-to-carotid transposition has been useful in increasing the proximal endograft landing zone. In addition, the relative rigidity of the stent-grafts currently used limits their ability to conform to the curved aortic contour of the distal arch or prox- imal descending aorta (62). Another problem that could limit benefits of a minimally invasive procedure may arise in the case of a large traumatic aneurysm, when com- pression of adjacent structures (e.g., mainstem bronchus) is unrelieved by simple surgical graft interposition. In such a case, removal of large amounts of intramural thrombus around a main- stem bronchus is necessary to relieve lung at- electasis (70).

Furthermore, heparin is required to prevent thrombosis caused by the obstruction of blood flow related to the large delivery sheath. In the acute trauma patient with coexist- ing injuries, this is potentially hazardous.

To date, a number of groups have reported on their experience with endovascular stent- graft repair of thoracic aortic trauma. One group reported a single case of a previously paralyzed patient who had sustained a bullet wound injury to the descending thoracic aorta at the level of Til. The pseudoaneurysm was discovered 3 months after the injury, and was repaired using a Dacron-covered (Dupont, Wilmington, DE) nitinol stent inserted via a retroperitoneal approach to the iliac artery. Fol- low-up studies failed to demonstrate the pres- ence of an endoleak or pseudoaneurysm (64). A second group reported on 10 patients who un- derwent repair of a traumatic thoracic aortic aneurysm (62).

In their study, modified Z-stents covered with either woven polyester or ex- panded PTFE graft material were used to treat 10 aneurysms, 9 of them located at the level of the isthmus. In this report, three major compli- cations were noted.

One patient developed an endoleak. Which was successfully treated with coil embolization. The second patient devel- oped thrombosis of the subclavian artery, which was treated by subclavian-carotid bypass. The last patient required stenting of the left main- stem bronchus to relieve left lung atelectasis. There were no other major or minor complica- tions, including paraplegia, embolization, respi- ratory failure, renal failure or myocardial in- farction. Another group reported two patients with distal descending thoracic aortic pseudoa- neurysms which received successful stent-graft repair (in which only the Til intercostal artery was sacrificed by endoluminal exclusion) (65). One recent study of endovascular graft treat- ment of acute bleeding from traumatic aortic rupture or aortobronchial fistula in 6 patients reported a 100% success rate, with no major complications (71).

Our own recent series of thoracic aortic stent-grafting using balloon-expandable and self-expandable endovascular grafts in 14 pa- tients included 5 traumatic injuries (72). In this series, graft insertion was technically success- ful in 1 1 of 14 patients (78%), with procedural failures related to graft migration and en- doleaks. Self-expanding devices were found to be associated with greater success, most likely related to the avoidance of asystole in obtaining precise device position. There were 2 deaths, as a result of microembolization and multiorgan system failure. Average length of hospital stay was 2.9 days.

The use of endovascular stent graft-repair for traumatic thoracic aortic in- juries, despite significant limitations to its ap- plication, will probably be shown to be of great benefit for selected patients in future studies. Discussion Since Parodi's first report of the use of en- dovascular stent-grafting for the treatment of aneurysms (73), the use of endovascular surgery has broadened to include the treatment of arterial trauma, although experience is lim- ited. Endoluminal grafts have been used to treat occlusive and aneurysmal arterial disease, with variable success (74). In comparison with stan- dard operative repair of traumatic injuries, this new, less invasive method appears to be associ- ated with less blood loss and a reduced require- ment for anesthesia. Less dissection in a trau- matized field is of particular advantage in the i case of arteriovenous fistulas with venous hy- j pertension, where standard surgical repair is no- toriously difficult and associated with large op- erative blood losses in the setting of either acute or chronic traumatic injury.

When suc- cessfully applied, the procedure also has the ad- vantage of greater simplicity and decreased op- erative time. Vascular surgeons are increasingly Vol. 1 ENDOVASCULAR THERAPY FOR ARTERIAL TRAUMA -McARTHUR 9 faced with older patients who have severe co- morbid illnesses that can increase operative morbidity and mortality; thus, the use of a min- imally invasive approach becomes increasingly necessary. Despite the potential benefits, eventual long-term utility will depend on our ability to overcome the limitations associated with this mode of therapy (75).

It is assumed that the full exclusion of aneurysms will lead to the elimi- nation of rupture potential. However, it is pos- sible that arterial pressure that is transmitted to the thrombosed, excluded circulation will lead to eventual aneurysm expansion and rupture. The fact that a decrease in the excluded aneurysm size has been observed is encourag- ing (12, 16); however, rupture has been ob- served following stent-graft repair of an aneurysm and a demonstrated decrease in aneurysm size (76).

The effects of a stent em- bedded in the wall of a vessel in preventing fu- ture expansion is not known (25). Long-term follow-up is necessary to determine this risk. Another possible problem in the use of this technology is the potential for development of intimal hyperplasia at the junction of the artery and the stent-graft. The Palmaz stent has been shown to be associated with only minimal inti- mal hyperplasia in experimental studies evalu- ating stenting of occlusive or stenotic iliac le- sions (77).

Difficulty in obtaining access accounts for occasional problems (25). Extending incisions and prolonging procedures or resorting to more invasive approaches often result in complica- tions ordinarily not associated with the usual procedure. Microembolization is a serious problem en- countered with endovascular surgery. In Par- odi's study (25), 3 of 4 patients who developed embolic complications died as a result. These procedures all involved technical difficulties in patients with large aneurysms.

Possible reasons for the increased potential for embolization in larger aneurysms were suggested by Parodi (25). These include both negotiation of the guidewire inside a large chamber with embolic material within it, and multiple manipulations resulting from miscalculation of aneurysm length.

In addition, device limitations exist and are the focus of current investigative work. Stent compression has been reported in the case of stent-graft repair of axillary-subcla- vian injury (10) due to compression between the clavicle and first rib. In these situations. The use of less rigid self-expanding devices has been advocated. References 1. Messina LM, Brothers TE, Wakefield TW, et al. Clinical charac- teristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional versus diagnostic procedures.

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Adjunctive therapy for spinal cord protection during thoracoabdominal aortic aneurysm repair. SeminThorac Cardiovasc Surg 1998; 10:35-39. Duhaylongsod FG, Glower DD, Wolfe WG.

Acute traumatic aortic aneurysm: the Duke experience from 1970-1990. J Vase Surg 1992; 15:331-343.

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Endovascular grafts in the treatment of thoracic aortic aneurysms and pseudoa- neurysms. Ann Vase Surg 2000; 14:230-238. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vase Surg 1991: 5:491 -499. Marin M, Veith F, Cynamon J, et al.

Transfemoral endovascular stented graft treatment of aorto-iliac and femoropopliteal occlu- sive disease for limb salvage. Am J Surg 1994; 168:156-162. White R, Donayre C, Walot L et al. Preliminary clinical out- come and imaging criterion for endovascular prosthesis development in high-risk patients who have aortoiliac and traumatic arterial lesions. J Vase Surg 1996; 24:556-571. Lumsden A, Allen R, Chaikof E, et al. Delayed rupture of aortic aneurysms following endovascular stent grafting.

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Stenting of the iliac arteries with the Palmaz stent: experience from a multicenter trial. Cardiovasclntervent Radiol 1992; 15:291-297. Combined Open and Endovascular Techniques for the Treatment of Complex Vascular Disease Alfio Carroccio. And David Spielvogel, M.D.- Abstract In an attempt to impro e the outcome follow ing aortic aneury sm repair, there has been an increased focus on endovas- cular technology as a minimally invasive means of treating various vascular pathologies. Stent-grafting of aortic aneury sms is an area where a less invasive approach may decrease the morbidity seen with conventional aneury sm repair.

As w ith other technologies, increased experience and impro ements in instrument design allow for applicability to a broader population of patients. Despite such impro ements.

Some patients' anatomic characteristics may make endo ascular repair unsuitable or too risky. When complex anatomy prohibits repair by endovascular means alone, a combination of consentional surgery and endo ascular therapy may be utilized in an effort to minimalize the invasiveness.

Using adjunctive surgical procedures, complex anatomy may be modified to allow for a safe and success- ful endo ascular aneury sm repair. In this paper. ^ e describe the modification of access vessels as well as fixation sites to facilitate the endo ascular U-eatment of aortic aneury sms. Key Words: Endograft. Aneurysm, open surgical reconstruction, endovascular techniques, thoracic aorta, iliac arteries. Introduction The introduction of endovascular technology has provided a minimally invasive means of treating various vascular pathologies. As with any technology, user experience as well as ad- vances in instrument design have given an in- creasing number of patients the option of en- dovascular therapy.

However, various anatomic characteristics might still render a patient un- suitable or at risk for complications following endovascular therapy. While future device mod- ifications may provide all patients with a mini- mally invasive option, a variety of combined surgical and endovascular approaches can now provide benefits of minimal invasiveness to a patient with complex anatomy in situations which would otherwise require more traditional invasive procedures. 'Fellow and -Assistant Professor. Department of Cardiothoracic Surgery. Mount Sinai Schsm repair J Vase Surg 2001; 34(6): 1050- 1054. Ramaswami G, Kaplan D. Endovascular stent grafting in the presence of aortic neck filling defects: early clinical experience.

J Vase Surg 2001: 33(2):340- 344. Albertini J, Kalliafas S, Travis S. Anatomical risk factors for proximal perigraft endoleak and graft migration follow- ing endovascular repair of abdominal aortic aneurysms. Eur J Vase Endovasc Surg 2000; 19(3):308-312. Fairman R, Srivastava S, et al. Endovascular grafting in patients with short proximal necks: an analysis of short-term results. Cardiovasc Surg 2000; 8(5):350-354.

Henretta JP, Karch LA, Hodgson KJ, et al. Special iliac artery considerations during aneurysm endografting.

Am J Surg 1999; 178(3):212-218. Fann JI, Dake MD. Semba CP, et al. Endovascular stent-grafting after arch aneurysm repair using the 'elephant trunk.'

Ann ThoracSurg 19-1105. Parodi JC, Ferreira M. Relocation of the iliac artery bifurcation to facilitate endoluminal treatment of abdominal aortic aneurysms.

J Endovasc Surg 1999; 6(4):342-347. Anderson JL, Berce M. Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther 2001; 8( 1):3- 15. Stanley BM, Semmens JB. Lawrence-Brown MM, et al. Fenes- tration in endovascular grafts for aortic aneurysm repair: new horizons for preserving blood flow in branch vessels.

J Endovasc Ther 200 1; 8( 1 ): 1 6 - 24. Chuter TA, Reilly LM. Surgical reconstruction of iliac arteries prior to endovascular aortic aneurysm repair.

J Endovasc Surg 1997;4:307-311. Wolf YCTillich M, Lee WA, et al. Impact of aortoiliac tortuos- ity on endovascular repair of abdominal aortic aneurysms: evaluation of 3D computer-based assessment.

J Vase Surg 2001; 34(4):594-599. Naslund TC, Edwards WH, Neuzil DF, et al. Technical compli- cations of endovascular abdominal aortic aneurysm repair J Va.sc Surg 1997; 26:502-509. Reilly LM, Kerlan RK, et al.

Endovascular repair of abdominal aortic aneurysms: getting out of trouble. Cardio- vasc Surg 1998:6:232-239.

Wain RA, Lyon R, Veith FJ, et al. Alternative techniques for management of distal anastomoses of aortofemoral and iliofemoral endovascular grafts.

J Vase Surg 2000; 32:307-314. Embolization of Complex Vascular Lesions Robert A. Lookstein, M.D., and Jeffrey Culler, M.D.

Abstract Embolization, first described nearly a century ago, has recently emerged as a durable first-line treat- ment of many vascular conditions particularly in the field of endovascular surgery. As technological advancements allow easier and safer access to small and remote lesions, embolization is being utilized more frequently to treat difficult lesions. This technology has been used most extensively in the treat- ment of abnormal arteriovenous communications, where it has emerged as a first-line therapy. Recently, the application of these techniques to treat visceral artery aneurysms has been explored, with encouraging results. The endovascular therapy of aortic aneurysms has revealed numerous other appli- cations for embolization therapy, including the treatment of iliac artery aneurysms and of failed aneurysm exclusion or endoleak. Embolization offers a minimally invasive treatment for lesions which have traditionally been considered inoperable, as well as those requiring extensive surgical resections and/or reconstructions that are associated with high morbidity.

Key Words: Embolization, endoleak, aneurysm, arteriovenous malformation. Introduction 'Embolization' means the intentional occlu- sion of a vessel by the introduction of some for- eign material. This technique has been used ex- tensively to occlude vessels in the last few decades as an alternative to traditional therapy or when traditional therapy has failed. Recently, embolization techniques have been employed more broadly and with greater precision and ease. As a result, this 'last resort' technique has quickly evolved into first-line therapy for many complex clinical conditions.

In this article, the specific role of this technology for the endovas- cular specialist will be reviewed, with attention to its use as an alternative to open surgery for the treatment of complex vascular lesions such as arteriovenous malformations, arteriovenous fistulae and visceral artery aneurysms, and as a From the Department of Radiology, Division of Vascular Inter- ventional Radiology, Mount Sinai School of Medicine, New York, NY. Address all correspondence to Dr. Lookstein, Department of Radiology, Division of Vascular Interventional Radiology, Box 1234, Mount Sinai School of Medicine, One East 100th Street.

New York, NY 10029; email: robert.lookstein® mssm.edu perioperative adjunct to the endovascular treat- ment of aortic aneurysms. History Embolization has only recently attracted in- terest for the treatment of vascular lesions, but the technique was first described almost a cen- tury ago. In 1930, Brooks described injecting a fragment of muscle attached to a silver clip into the internal carotid artery (1). Lussenhop and Spence, in 1960, injected spheres of methyl methacrylate into the surgically exposed com- mon carotid artery of a patient with an arteri- ovenous malformation fed by the middle cere- bral artery (2). Developments in catheter technology and embolic agents in the 1970s initiated the recent interest in embolization techniques.

The avail- ability of pre-shaped catheters and coaxial sys- tems permitted the subselective placement of catheters. This advancement in turn made pos- sible the selective delivery of embolic agents. In 1974, Lin et al.

Reported injecting silicone tubing through lumens only slightly larger than the embolization material (3). Later that year, Serbinenko described the use of detachable bal- loon catheters for embolization (4). Zanetti and © The Mount Sinai Journal of Medicine VoL 71 No. 1 January 20O4 17 18 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 Sherman introduced the tissue adhesive isobut i 2-cvanoacr late in the United States in 1972 (5). Carey and Grace described gelfoam particles as embolic agents in 1974 (6). Gianturco created the wool coil, which after subtle modifications is still in widespread use at present (7). Microcoils soon followed, allowing for the placement of coils through micro- catheters.

The Guglielmi detachable coil is a re- cent advancement in coil technology involving the introduction, through a microcatheter. Of a coil attached to a guidewire that may be de- tached after the passage of an electric current through the guidewire to dissolve the attach- ment. This allows for the repositioning of the coil after leaving the catheter and the possibil- ity for optimizing coil deployment (8). All of these devices have a place in embolization ther- apy and will be discussed as they relate to the clinical entities presented here (Fig. Since the entire spectrum of embolotherapy is fairly large, the discussion here will be lim- ited to embolization of visceral artery aneurysms, embolization-ablation therapy of abnormal arterio-venous communications, and embolization related to the endovascular repair of abdominal aortic aneurysms.

Visceral Artery Aneurysms A rare clinical entity, visceral artery aneurysm (VAA) remains a difficult, often cata- strophic diagnostic problem. Almost 25% pre- sent already ruptured, which can be fatal in nearly 10% of these patients (9). The symptoms, natural history, and outcome of visceral artery aneurysms depend on the vessels involved. (A) Emboli/ation coils with Dacron fibers available in si/es ranging from.^-12 mm in diameter. Photograph reproduced with permission from Cook (Bloomington. (B) Guglielmi detachable coils (GDC).

Photograph repro- duced with permission from Bf)ston Scientific (Fremont. Most common sites are the splenic, hepatic, su- perior mesenteric, gastroduodenal, and pancre- aticoduodenal arteries. Splenic artery aneurysms account for almost 60% of all splanchnic aneurysms.

Causes include medial degeneration with superimposed atherosclerosis, portal hy- pertension, infection, fibromuscular dysplasia, trauma, and pancreatitis. It is important to men- tion that splenic artery aneurysms are also asso- ciated with pregnancy with a significant associ- ated rate of rupture in the third trimester. As a result, other studies (10) have advocated aggres- sive treatment of these lesions in this specific population. Hepatic artery aneurysms usuall are secondary to some form of trauma. Superior mesenteric artery (SMA) aneurysms are typi- cally mycotic in origin. Traditional therapy consisted of surgical management with aneurysm repair and resec- tion. Today, endovascular embolization tech- niques offer a safe alternative that has shown excellent short-term success.

There are a lim- ited number of published reports (11-14) re- garding embolization of visceral arter aneurysms. Most series report on the use of coils for the procedure or a combination of coils and a liquid agent (Fig. Reported on another single-center experience with 37 patients with VAAs (11). Seventeen patients underwent surgery, 12 had transcatheter embolization, and 8 were observed. Only poor surgical candidates were referred for embolization. All embolizations were successful.

Although several required repeat interventions. One patient who underwent embolization of a splenic artery aneurysm had a small post-proce- dure splenic infarct which resolved sponta- neously.

The authors went on to comment thai embolization is quickly becoming the treatment of choice for these lesions in all patients. Advan- tages include precise localization of the aneurysms, better assessment of collateral flow, lower risk to the patients, and easier access to le- sions for which surgical exposure would be dif- ficult (11). Other authors have advocated the use of embolization rather than surgical repair as a first-line therapy for hepatic artery pseudo- aneurysms, because of the decreased morbidity associated with the former procedure (12).

Gabelman et al. In 2002 reported a single- center, 10-year experience with 25 patients that demonstrated a 92% initial success rate with coil embolization. Long-term follow-up showed only one recurrence after 12 months. It is im- portant to note that these patients must be fol- lowed with serial imaging to document success 71 No. 1 EMBOLIZATION -LOOKSTEIN 19 5?

A B 14 L Fig. (A) Cross-sectional imaging of splenic artery aneurysm in a 47-year-old female with hypertension. Selective celiac arteriogram demonstrates an aneurysm in the mid-portion of the splenic artery. (B) Selective splenic artery angiogram shows no flow into the aneurysm following coil embolization. Of the procedure and to monitor for future re- currence (13). Pilleul and Dugougeat showed the value of follow-up imaging in identifying incomplete embolization in 4 out of 18 patients treated in their series (14). With the more widespread use of radiologic imaging, visceral artery aneurysms are being detected with increasing frequency.

Because rupture of these lesions is associated with sig- nificant mortality and morbidity, treatment of asymptomatic patients is becoming a more pru- dent method of treatment. Endovascular em- bolization offers a low-risk alternative, espe- cially for high-risk patients. Abnormal Arteriovenous Communications Vascular malformations are currently one of the most challenging conditions to diagnose properly and treat effectively. Because these le- sions are relatively rare, few physicians have adequate experience with them.

The most important step in the manage- ment of patients with this condition is to prop- erly diagnose and classify the lesion. This will in turn can give a patient realistic treatment options and expectations. Vascular malforma- tions can currently be classified into four major categories: • hemangioma • arteriovenous fistula • arteriovenous malformation • venous malformation (15).

This classification can reliably differentiate be- tween lesions with different treatment options and differing prognoses. Hemangioma A hemangioma is a benign vascular neo- plasm, classically diagnosed in infancy.

This le- sion is characterized by a proliferative phase that is usually followed by spontaneous involu- tion. Hemangiomas occur in infancy in almost 10% of the population. They may be present at birth or soon after and may be multiple in up to 20% of cases. These lesions are more frequent in females (15). Clinically, these lesions may begin as small, red discoloration and can rapidly proliferate to eventually show ulcera- tion, bleeding, or infection.

The lesions fre- quently involute in the majority of cases by the beginning of adolescence. Any residual discol- oration can be readily treated by plastic surgery (16). Arteriovenous Fistula An arteriovenous fistula (AVF) is a direct communication between an artery and a vein. These lesions are usually acquired as a result of trauma. It is crucial to understand the physiol- ogy of these lesions in order to plan treatment. The basic architecture is that of a low-pressure sump. The flow through the fistula depends on the size and length of the communication.

This 20 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 connection will classically enlarge over time, first with hypertrophy of the feeding vessel and finally with hypertrophy of the draining vessel. Whenever the resistance in the venous outflow is less than that of the distal arterial bed, as is generally the case, then arterial flow to the tis- sue may be insufficient to sustain tissue viabil- ity. This will manifest itself as distal ischemic changes, claudication, skin and muscle atrophy, and even gangrene. Extensive collateral net- works typically accompany arteriovenous fistu- lae to supply the distal tissues. This is why sim- ple interruption of the feeding artery will not close down the fistula.

Other physiologic changes that can occur include venous hyper- tension and venous insufficiency, which can progress to changes seen in a left-to-right shunt, such as high-output heart failure. Treatment of the condition must aim at oc- clusion of the fistula with preservation of distal flow. In many instances, especially, those re- lated to trauma, the best results for treatment of these lesions still depend on surgical repair. This is certainly the case in short, side-to-side extremity fistula. At present, endovascular grafts can be used in limited settings but are not ideal for treating distal lesions or lesions lo- cated next to joints. For those lesions that are difficult to treat surgically due to complex anatomy or difficult access, embolization may be the initial treatment.

The embolization pro- cedure is directed at occluding the fistula or at isolating the artery that is feeding the fistula (Fig. The choice of material will usually de- pend on the specific setting, but typically will consist of large permanent agents such as coil>or detachable balloons ( 17) (Fig. Particulate or liquid agents are not routinely used for large lesions, due to the risk of shunting and resultant embolization of the pulmonary circulation.

After embolization, arteriovenous fistulae are considered cured and recurrences is rare. Im- proper embolization can turn a readily treatable lesion into a very complex one that may ulti- mately require surgical repair.

Arteriovenous Malformations Arteriovenous malformations (AVMs) are congenital anomalies that result from a focal failure of vascular differentiation in utero be- tween the fourth and tenth weeks of develop- ment. These are typically isolated lesions, which are not genetically transmitted. Depend- ing on the size and location, these lesions can be asymptomatic and undetected or can be sig- nificant clinical problems. AVMs can occur anywhere in the body but have 'predilections' for specific sites, including the central nervous system, the pelvis and the lower extremities. If the lesion is accessible for physical examina- tion, it will present as a pulsatile, non-tender mass. The draining veins can be quite promi- nent and the presenting symptom can often be venous hypertension in an affected extremit.

With skin thickening, edema and venous ulcera- Fig. (A) Pelvic angiogram demonstrates arteriovenous fistula (iliac artery: large arrow; iliac vein: small arrow) follow- ing transglutea! Pelvic lymph node biopsy. (B) Following coil embolization of the fistula, an angiogram from the left com- mon iliac artery demonstrates no arteriovenous shunting. 1 EMBOLIZATION - LOOKSTEIN 21 Fig. (A) Angiogram of the brachial artery (large arrow) shows a traumatic arteriovenous fistula which occurred follow- ing placement of a peripherally inserted central catheter (PICC) line (small arrow: brachial vein). (B) There is no flow in the fistula after placement of a single Guglielmi (GDC) coil in the fistulous tract.

When limb lesions present in childhood, limb length can be affected, usually by over- growth. Generalized cardiovascular effects from congenital AVMs are quite rare. These le- sions tend to grow slowly, but rarely some le- sions can show periods of rapid enlargement.

This classically occurs following a change in the hormonal environment or after unsuccessful surgical or radiological treatment. The first scen- ario is classically seen in female patients fol- lowing menarche or pregnancy. The second scen- ario occurs when a stable lesion is treated re- sulting in recruitment of new collaterals.

This will usually occur following ligation or proxi- mal embolization of feeding arteries (16). Cross-sectional imaging has become the stan- dard modality to properly diagnose these le- sions and plan treatment. CT angiography (CTA) and magnetic resonance angiography (MRA) can demonstrate the true extent of the lesion and show the relationship of the lesion to surrounding structures. These imaging studies can also serve as a baseline, which can be re- peated after treatment to monitor resolution or progression. Diagnostic angiography is not rou- tinely performed in these cases, but can give de- tailed depictions of the vascular anatomy, in- cluding the demonstration of enlargement and tortuosity of feeding arteries, a dense nidus of malformation and early opacification of drain- ing veins. Most malformations show one pri- mary feeding artery with multiple small sec- ondary feeders. When only the primary feeder is occluded, the secondary feeders will be re- cruited to supply the nidus.

AVMs are notoriously refractory to treat- ment. It is well known that these lesions can rarely be resected completely without tremen- dous blood loss and serious risk to the patient (18). Preoperative embolization can in certain instances convert an unresectable lesion into a resectable one.

At present, transcatheter em- bolization has a primary role in the manage- ment of these lesions. Although recent techno- logical advances in this field have made catheterization of these lesions less technically challenging, this must be tempered by the fact that improper embolization can worsen a previ- ously symptomatic lesion. Risk and long-term results must always be presented to the patient. Complete cures are rare, and as a result, asymp- tomatic lesions should not be interfered with, for fear of complicating the situation. Both the treating physician and the patient must be real- istic about the possibility of repeated future in- terventions. Each patient should be treated by a team that includes radiologists, vascular sur- geons, plastic surgeons, orthopedists, and anes- thesiologists. Many embolization materials are available for the treatment of these lesions.

All of these materials have been reported in the literature. With recent technological advancements, two agents have emerged as the choices for use in this setting: liquid adhesives and absolute alco- hol. They have become popular because it is possible to deposit these agents solely in the nidus and minimize any damage to surrounding vessels and tissues.

The liquid adhesives isobutyl cyanoacrylate (IBCA) and n-butyl cyanoacrylate (NBCA) have become the first line of therapy at many centers (16). These agents polymerize on contact with ionic mater- ial such as blood. They can be delivered 22 THE MOUNT SINAI JOURNAL OF MEDICINE January 20(M. J Endovasc Surg 1997; 4(3):312-315. Carpenter JR Golden MA. Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurvsms: comparison of transanerial and translumbar tech- niques.

J Vase Surg 2002: 35(l):23-29. Willoteaux S. Embolization of type II endoleaks after aortic stent-graft implantation: technique and immediate results. J Vase Surg 2001: 34(4):600 - 605. Endoleak after endovascular repair of abdominal aortic aneurysm. J Vase Surg 2001: 34(1):98- 105. Gorich J, Rilinger N, Sokiranski R, et al.

Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric artery approach. J Endovasc Ther 2000; 7(4):297-301. Retroperitoneal endoscopic ligation of lumbar and inferior mesenteric arteries as a treatment of persistent endoleak after endolu- minal aortic aneurysm repair. J Vase Surg 2000; 3 1(6): 1240 -1244. Lookstein RA, Falk A, Pukin L.

Embolization of type 1 endoleak following endovascular repair of aortic aneurysm [abstract]. 88th Scientific Assembly and Annual Meeting of the Radiologic Society of North America. Dec 1 -6, 2002. Endovascular Treatment of Neurovascular Disorders Aman B.

, and David M. Johnson, M.D.^ Abstract Endovascular therapy is a well-established treatment modality for a variety of cerebrovascular central nervous system disorders. The past few decades have witnessed dramatic improvements in the field of neuroendovascular surgery.

These techniques are now used in the treatment of intracranial aneurysms, vascular malformations, carotid stenoses, intracranial vascular stenoses and acute ischemic stroke. In many cases, these techniques provide minimally invasive alternatives to traditional surgery. In addi- tion, neuroendovascular approaches provide treatment options for conditions previously thought to be untreatable. Ongoing device developments and refinements continue to revolutionize tiie field. These refinements, along with a better understanding of the disease processes, will allow minimally invasive neuroendovascular techniques to be used for a wide spectrum of neurological diseases. Key Words: Endovascular therapy, intracranial aneurysms, arteriovenous malformations, carotid stenosis, intracranial stenosis, stroke, embolization, thrombolysis.

Introduction Patients with complex neurovascular disor- ders often present a great challenge to the neu- rovascular surgeon. Recent improvements in critical care and microneurosurgery have im- proved the outlook for many of these patients, who previously had little chance of survival. Despite these advances, the treatment of neu- rovascular disorders still poses unresolved problems.

Endovascular therapy offers a unique potential for providing elegant solutions to neu- rovascular problems. In addition, it provides minimally invasive alternatives to traditional surgery for the treatment of many vascular and nonvascular central nervous system disorders. Neuroendovascular surgery is based on re- mote access to neurovascular structures, and in- terventions are based on agents delivered within these compartments. These interventions I Assistant Professor, Departments of Neurosurfcry and Radiology and -Neuroradiology Fellow, Department of Radiology, Mount Sinai School of Medicine, New York, NY. Address all correspondence to Aman B. Patel, MD., Depart- ment of Neurosurgery, Box 1136, Mount Sinai School of Medi- cine, One East 100th Street, New York, NY 10029; Email: aman.patel @ msnyuhealth.org are performed in a superselective fashion, using 'image guidance.' Several important technical advances in image guidance have emerged dur- ing the past few decades.

The development of digital subtraction angiography (DSA) and other technological advances in radiography have made possible the development of rou- tinely safe catheterization of high-order vessels. Low-osmolarity, nonionic contrast media have reduced the risk of contrast material reaction. Finally, real-time fluoroscopy, or 'road-map- ping technique,' has been added to DSA to fur- ther reduce the toxicity from the burden of the contrast medium. The development of flexible microcatheters with steerable microwires allows access to high-order bifurcations of the cerebrovascular system.

The lumina of these microcatheters allow the use of solid, particulate and liquid embolic agents, such as polyvinyl alcohol (PVA) particles, metallic coils and n-butyl cyanoacrylate (NBCA), at specific sites of ab- normality. The ability to access these sites also allows the delivery of therapeutic agents. These agents may be pharmaceutical, catheter bound or implantable, such as tissue plasminogen acti- vator (t-PA), chemotherapeutic agents, angio- plasty balloons, stents and platinum microcoils. © The Mount Sinai Journal of Medicine Vol. 1 January 2004 29 30 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 This paper introduces major concepts of neuroendovascular surgery and explains princi- ples in olved in the treatment of selected neu- rovascular disorders. Endovascular Treatment of Aneurysms It is estimated that between 1-8% of the population harbors an intracranial aneurysm (1-3).

Long-term follow-up of patients with unruptured aneurysms has revealed annual rup- ture rates of 0.05-3%. With a cumulative rup- ture rate of 20% at 10 years and 35% at 15 years (4. Subarachnoid hemorrhage (SAH) from intracranial aneurysm rupture continues to be a devastating disease with high morbidity and mortality rates (Fig. Between 40 and 50% of patients with SAH will die because of their he- morrhages (5). The primary purpose of treat- ment of ruptured aneurysms is to prevent the often-fatal rebleed, allow aggressive treatment of posthemorrhage vasospasm and provide long-term protection against future aneurysmal rupture. Recent refinements in magnetic resonance imaging (MRl). Magnetic resonance angiogra- phy (MRA) and computed tomography angiog- raphy (CTA) have increased the number of un- ruptured aneurysms detected.

Most of these Fig. Axial nonconlrast head computed tomography (CT) scan showing extensive subarachnoid hemorrhage. Hyper- density corresponding to hemorrhage is seen within the basal cisterns.

Sylvian fissures and interhemispheric fissure (arrows). Aneurysms will be incidental findings and therefore asymptomatic. If a decision is made to treat these aneurysms, the primary goal of treat- ment is occlusion of the aneurysm, thereb; eliminating the risk of SAH. In addition, since most of these patients are asymptomatic, the morbidity and mortality rates of treatment need to be minimal. The goal of aneurysm therapy is to prevent rupture by excluding the aneurysm from the vessel lumen. Traditionally, this has been ac- complished by surgical clipping of the aneurysm. Embolization that utilizes blood ves- sels as natural channels to reach the aneurysm via the endovascular route provides a less inva- sive approach to treatment.

Treatment via the endovascular route has the special advantage of avoiding craniotomy, brain retraction, surgical vessel manipulation, possible injury to perforat- ing vessels, and possible postoperative infec- tion or epilepsy. It may also reduce post-treat- ment hospital stay and recovery time. An endovascular method using electrically detachable platinum coils has been developed, to provide a less invasive and safer approach to intracranial aneurysms (5-8). The Guglielmi Detachable Coils (GDC) (Target Therapeutics, Fremont. CA) are used to fill the aneurysmal sac, excluding it from the circulation. These coils are very soft, minimizing the trauma on the aneurysmal wall, allowing for maximum packing of aneurysm sac with a low risk of in- ducing rupture.

Since their first clinical use in the early 1990s, GDCs have been utilized in many neuroendovascular centers. To date, more than 80.000 patients have been treated via en- dovascular embolization (9). A GDC consists of a platinum coil soldered to a stainless steel delivery wire. The platinum portion is delivered to and detached within an aneurysm. This results in thrombosis and subse- quent fibrosis within the aneurysm, excluding it from the circulation. The coil is radiopaque and can be clearly distinguished from the much less opaque delivery wire.

The technique involves several steps. A di- agnostic angiogram is performed through the guiding catheter in order to obtain the best view of the aneurysm neck, well separated from the parent vessels. This will determine the 'work- ing projection' and the 'coilability' of the aneurysm.

Aneurysms with high dome-to-neck ratios, without incorporation of the parent ves- sels, are the most suitable for treatment. How- ever, new techniques, described below, are per- mitting treatment of wider-necked aneurysms. 1 NEUROENDO VASCULAR SURGERY -PATEL 31 All intravenous bolus of 3000-5000 U of hep- arin is administered prior to proceeding with embolization. This is followed by the adminis- tration of 1000 U/hr of intravenous heparin (5000 U/L) in the flushing solution. Road-mapping is performed, to obtain safe catheterization of the aneurysm with a micro- catheter and to deliver the first coil, avoiding any compromise of the parent vessel.

Subsequent coils are then deposited using either road-mapping or fluoroscopy, and using the first coil as the land- mark delineating the border between the aneurysm and the parent artery. When dense aneurysm packing is achieved, the procedure is terminated and the microcatheter is slowly re- moved from the aneurysm. A final post-treatment angiogram is obtained to assess the degree of aneurysm occlusion and the configuration and pa- tency of the distal vascular tree (Figs. Heparinization is reversed with protamine sulfate. In wide-necked aneurysms and in cases where there is some parent vessel impingement, the hep- arinization is not reversed and aspirin is adminis- tered, to reduce the risk of distal embolization. Since the risk of bleeding from incidental aneurysm is low, elective therapy must have a low complication rate to be warranted. Recent studies of endovascular aneurysm therapy have shown morbidity of 4-4.8% and mortality of 0-1% (10, 11).

This compares favorably with the complication rate of microsurgical therapy, for which morbidity and mortality rates of 10.9-17.5% and 2.6-3.9% respectively have been reported in recent meta-analyses (4, 12). Complications encountered during aneurysm coil embolization include thromboembolic event, aneurysm perforation, inadvertent parent vessel occlusion and death (13).

An angiograph) ot a 68-year-oid w oman w ith an incidental middle cerebral artery aneur>sm on magnetic resonance maging (MRI). Left internal carotid artery angiograms, (A) AP oblique and (B) lateral oblique, show a middle cerebral meurysm (arrows) with a small neck. Corresponding 3D rotational angiography images (C and D) also show the aneurysm arrows) and its relationship to the normal vessels. Post-embolization angiograms (E and F) show occlusion of the meurysm (arrows) and patency of the normal vessels. THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 V Fig. An angiography of a 48-year-old man who presented with an acute onset of severe headache.

Head CT scan showed a subarachnoid hemorrhage. A lateral oblique internal carotid artery angiogram (A) reveals a multilobulated anterior com- municating artery aneurysm (arrow). The 3D rotational angiography image (B) shows the aneurysm (arrow) and its rela- tionship to the normal vessels.

Post-embolization lateral oblique angiogram (C) shows occlusion of the aneurysm (arrow) and patency of the normal vessels. The long-term results of GDC coiling com- pare favorably with surgery in regard to clini- cal, neuropsychological and radiological out- comes (14). Patients who have undergone aneurysm coiling show less impairment during neuropsychological testing of verbal memory, flexible thinking, ability to resist interference and motor control. Additionally, they do not demonstrate the defects in executive function and memory seen with patients who have un- dergone aneurysm clipping (15).

The rates of delayed rebleeding after em- bolization have also been shown to be low. Be- tween 2 and 49c of patients will experience re- bleeding after endovascular therapy (16). Yearly rates of 0.4, 0.6 and 2.4% have been re- ported for years 1, 2 and 3 after therapy, with these rates dropping to 0 in the following three years (17). Rebleeding has also been shown to occur after aneurysm clipping in up to 2.7% of cases over 10 years (18).

E Sky Simulator Software Download on this page. The best long-term re- sults have been achieved with complete aneurysm occlusion. Therefore, selection of aneurysms with appropriate anatomy for en- dovascular occlusion will improve immediate and long-term results. The best results have been obtained with the endovascular occlusion of small aneurysms with small necks, while complete occlusion of wide-necked, large or giant aneurysms has been more difficult. New techniques developed to treat wide- necked, large or giant aneurysms have led to better occlusion rates (19, 20).

Balloon infla- tion across the neck of a wide-necked aneurysm allows dense packing of the aneurysm sac while protecting the parent vessel (21). A nondetach- able balloon is advanced to the aneurysm neck before the microcatheter is placed within the aneurysm. Once the microcatheter is positioned within the dome, the balloon is inflated, isolat- ing the vessel lumen. The first coil is posi- tioned, after which the balloon is deflated to as- sess for motion of the coil.

If the coil is stable, it is detached. Subsequent coils are then placed using the same technique until complete occlu- sion of the aneurysm is obtained. Improved coil packing can also be achieved by initially bridging the aneurysm neck with a stent. The mesh of the stent allows passage of a microcatheter into the aneurysm.

This micro- catheter is used to completely occlude the aneurysm with GDC coils (22). The stent al- lows coils to be retained within the aneurysm and complete aneurysm packing without coil herniation into the parent vessel (Fig. Re- cently, very small and flexible self-expandable stents have been FDA approved for use in the treatment of wide-necked aneurysms with coils. Intravascular Embolization of Brain Arteriovenous Malformations An arteriovenous malformation (AVM) con- sists of a nidus of coiled and tortuous vascular channels shunting blood from arterial feeders to draining veins. Successful treatment of brain AVMs requires a multidisciplinary approach.

The neuroimaging, anatomical, functional, and dynamic information regarding a patient with a brain AVM needs to be reviewed by vascular neurosurgeons, interventional neuroradiolo- gists, and radiosurgeons. The team then needs Vol. 1 NEUROENDO VASCULAR SURGERY -PATEL 33 IFig. An angiography of a 62-year-old woman who presented with an iatrogenic injury to the left vertebral artery (VA). Left VA angiogram (A) shows a traumatic pseudoaneurysm (arrow) at the level of C3. (B) A stent was placed across the origin of the aneurysm (arrows). (C) Embolization was performed by placing coils (large arrow) into the aneurysm through he stent mesh (small arrow).

(D) Post-embolization angiogram shows occlusion of the aneurysm (arrow) and patency of he left VA (LVA). [o discuss and formulate a strategic treatment Dlan, weighing the conservative approach vs. Radiosurgery vs. Embolization, or >ome combination of these. Approximately 53% of patients with this;ongenital lesion present with intracranial he- norrhage, 30% with seizures and an addi- ional 12% with progressive neurologic deficit 23).

The hemorrhage rate is 1.3-3.9% yearly 'or patients without previous bleeding. The isk of future hemorrhage increases to 33% for patients who have had a previous hemor- rhagic episode (24-26). The morbidity of AVM hemorrhage varies from 55-81% (27), while the mortality rate ranges from 10- 17% (27-29). The goal of therapy is complete obliteration of the vascular nidus. Until this is accom- plished, the risk of hemorrhage persists (30-32).

Endovascular embolization, micro- surgery and radiosurgery are used to treat these vascular malformations. Endovascular em- 34 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 bolization with liquid adhesive, particles or ethanol is the least successful of these modali- ties when used in isolation, leading to cure in only lOVc of patients (33-36). Embolic ther- apy, however, is a useful adjunct to micro- surgery or radiosurgery. Preoperative emboliza- tion reduces the flow into the AVM and poten- tially decreases the morbidity and mortality as- sociated with surgical therapy (Fig. In addition, the size of the nidus can be reduced to allow successful radiosurgical therapy, by de- creasing the volume of AVM targeted by radia- tion (37.

The embolization procedure is performed under heparinization, as described in the section on aneurysms. Microcatheterization of the feed- ing vessels is performed using a combination of flow -directed and wire-directed catheters. Pref- erentially, flow-directed catheters are used to re- duce the risk of wire injury to the delicate ves- sels supplying the AVM.

After catheterization of the feeding vessels, embolization of the feeding artery is performed, with or without emboliza- tion of the nidus of the AVM. Our preferred em- bolic material is n-butyl cyanoacrylate. Hs polymerization time, amount, and type of injec- tion are selected, depending upon the informa- tion gathered from the angiogram (39). After the embolization procedure is finished, sys- temic heparinization is reversed with prota- Fig. An angiography ot a 40-year-oid man who presented with intractable seizures. Axial noncontrast images show a large right frontal arteriovenous malformation (AVM).

The nidus (arrow) and draining vein (small double arrow) are seen on the CT scan. Angiographic images of the patient described in 1 ig. Pic-cmboli/ation angiogram (A) shows the AVM nidus (large arrow), arterial feeders (small arrows) and draining vein (arrowheads). Post-embolization lateral skull x-ray (B) shows embolic material from multiple embolization sessions (arrows). Final post-embolization angiogram (C) shows de- creased filling of the nidus (arrow ) and decreased opacification of the draining vein (arrowhead), indicating decreased ar- teriovenous shunting. 1 NEUROENDO VASCULAR SURGERY -PATEL 35 mine, and the patient is taken to the intensive care unit for an overnight stay. A staged transfemoral embolization is per- formed in most large or giant AVMs.

The time between embolizations can be 3 days to several w eeks, depending on the flow dynamics of the AVM and whether there are technical or clinical complications. The waiting period between the last embolization and surgery is 1-4 days.

If there is angiographic evidence of untoward oc-;t elusion or marked stagnation of the dominant la- venous drainage of a partially embolized AVM, then surgical resection of the AVM is performed as soon as possible. Carotid Stenting Cerebrovascular disease is the leading cause of neurologic disability and the third leading cause of death in the adult population of the United States. Approximately 700,000 people will have strokes this year (40). Ap- proximately 20-30% of these strokes are the result of carotid bifurcation atheromatous dis- ease (41). Carotid stenosis may cause ischemic events by reducing cerebral blood flow or by acting as sources of thromboemboli. Random- ized trials have established carotid endarterec- tomy to be an effective therapy for patients with significant carotid stenosis (42-44).

Ad- ditionally, carotid endarterectomy (CEA) may reduce the risk of ischemic events and overall,f, mortality for patients with asymptomatic stenosis (44, 45). However, CEA still has sig- nificant risks. Depending on the series, the pe- rioperative stroke rate varies from 1.5-9%, while cranial nerve palsies are seen in 7.6-27% of patients undergoing carotid en- darterectomy (46, 47).

Carotid stenting (CS) is a less invasive, per- cutaneous procedure that is being investigated as an alternative to CEA (Fig. CS may allow avoidance of some of the perioperative compli- cations associated with CEA, including wound complications, cranial nerve damage and the risks of general anesthesia (48). In addition, carotid stenting results in significantly less he- modynamic ischemia than endarterectomy, since there is minimal, if any, carotid occlusion time. Initial reports suggest that CS can be per- formed with a 30-day stroke/death rate compa- rable to that of CEA (49). Recent studies have Iw shown an acceptable long-term result as well ^' (50, 51).

At the present time, carotid stenting may be particularly useful for patients who are poor surgical candidates, have received prior radiation, or have bilateral lesions, restenosis or carotid dissections (Figs. Patients are premedicated with dual an- tiplatelet agents, usually aspirin and clopido- grel. Under local anesthesia, a baseline carotid angiogram is performed and the degree of stenosis is ascertained. The diameters of the stenosis and adjacent segments are measured. The patient is administered 5000 U heparin at the start of the procedure.

A 6 French sheath is introduced and advanced from the femoral artery to the common carotid artery. The tip is positioned just proximal to the stenosis.

A mi- crocatheter is then advanced over a flexible, angle-tipped guidewire (0.14 inch diameter) through the stenosis. Predilation with an angio- plasty balloon is performed if the stenosis is too narrow for the stent to pass prior to the place- ment of the stent across the stenosis.

Balloon angioplasty is then performed within the stent to achieve the appropriate vessel diameter (Figs. Final carotid and cerebral an- giograms are performed to assess for residual stenosis, vessel compromise, thrombus forma- tion, dissection and distant thromboembolic complications. There has been appropriate con- cern about the risk of thromboembolic events during carotid angioplasty and stent placement.

Several studies have documented the release of emboli during the procedure (52, 53). Newer techniques, including placement of a balloon or filter in the distal internal carotid artery (ICA), have shown promise, with fewer periprocedural ischemic events (52-54).

Intracranial Stenosis Atherosclerotic disease of the intracranial vessels accounts for approximately 6-29% of ischemic strokes. Despite antithrombotic ther- apy, many patients have additional ischemic events. In Thijs' study (55), 55.8% of patients who were treated with antithrombotic medi- cines had ischemic events during the treatment period. Patients with symptomatic stenosis of the posterior circulation have also been shown to have stroke rates of 8-40%, depending on the vessel involved (56-58). Additionally, the results of the External Carotid Internal Carotid Bypass Surgery Group have been similar to those of aspirin therapy alone (59). The poor prognosis with medical and surgical therapy has led to the search for alternative therapies.

The successful treatment of cervical carotid artery stenosis has led to the treatment of in- tracranial stenosis with angioplasty and/or 36 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 Fig. A 74-year-old man with a history of a right heinispheric stroke. Lateral right common carotid angiogram (A) demon- strates 95'7c stenosis (arrow) of the internal carotid artery. He was referred for angioplasty and stenting because of co-morbid disea.se. Angiogram after angioplasty and stenting (B) shows extent of stent (arrows) and no significant residual stenosis.

8...i; •■i.: in.ji,.iMi presented after.i rollcrbiading lall with severe back and neck pain. Left common caroiiu artery angiogram (A) shows carotid stenosis (arrows) and a traumatic aneurysm (arrowhead), indicating carotid dissection Posl-stenting angiogram (B) shows no residual stenosis across the stent (arrows) and slight decrease in filling of tlic aneurysm (arrowhead). Six-month follow-up angiogram (C) shows no residual or recurrent stenosis across the stent (ar rows) and complete occlusion of the aneurysm. 1 NEUROENDO VASCULAR SURGERY -PATEL 37 / ^4 A T r' 7 Fig.

A 40-year-old man who presented with left arm weakness and neck pain. Head CT scan showed a small infarct in the right putamen. Carotid duplex showed right carotid dissection and stenosis. AP (A) and lateral (B) right common carotid artery angiograms show dissection extending from the carotid bulb to the petrous segment (arrows).

Angiograms (C and D) after the placement of three telescoping stents (arrows) show reopening of the internal carotid artery with no significant residual stenosis. Stenting (Figs. Studies have shown technical success rates of 91-94% in reducing the degree of vessel stenosis (60, 61). However, compared with extracranial vessels, angioplasty of intracranial vessels has a higher complica- tion rate, with strokes occurring in 12-33% of cases (62-64). These complications are attrib- uted to vessel dissection, small vessel occlusion or thromboembolism. The placement of intravascular stents has been shown to reduce the complications of angioplasty by excluding the atherosclerotic plaque and re- gions of dissection from the vessel lumen. Addi- tionally, stent placement lowers the degree of residual stenosis and the rate of restenosis by re- ducing vessel elastic recoil (Figs.

In- tracranial stent use has previously been limited be- cause of difficulties in navigating small, tortuous vessels. However, with advances in catheter and stent technology, intracranial, stent-assisted angio- plasty is becoming a viable alternative (60). Stroke Therapy The majority of ischemic strokes are due to thromboembolic arterial occlusion (65), with 38 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 Fig. A 69-year-old man ith left hemispheric transient ischemic attacks (TIAs) was found on angiography (A) to ha e severe stenosis of the left internal carotid artery (ICA) at the petrous-cavernous junction (large arrow). Note the poor fill- ing of the distal left ICA (small arrow). (B) A stent (arrows) was placed across the stenosis.

(C) Post-stenting angiogram shows no residual stenosis across the stent (large arrows) and improved filling of the distal ICA (small arrow). 11..A 6S-_ ear-old man with histor of di//incss and inab:lit>to stand tor prolonged period^ oi mnc w ith.iui hcco ing symptomatic. Lateral (A) and AP (B) right vertebral artery angiograms show severe stenosis of the inid-basilai arti. Angiogram after angioplasty and stenting (C) shows no significant residual stenosis (arrow). 75% occurring in the ICA distribution (66). While mortality from middle cerebral artery strokes is low, there is a high morbidity, with only 20-25% of patients returning to an inde- pendent lifestyle.

Posterior circulation strokes are more ominous, with significant mortality rates, up to 86.4% in one study (67). Over the past few years, there has been in- tensive investigation of intravenous throm- bolytic therapy for the treatment of acute is- chemic stroke. At the present time, only tissue plasminogen activator (t-PA), when adminis- tered within three hours of symptom onset, has definitively been shown to be an effective ther- apy.

The benefits of this therapy were demon- strated in the National Institutes of Neurologic Disorders and Stroke (NINDS) sponsored trial in 1995 (68). This trial led to the FDA approval of t-PA for stroke treatment in June 1996. At present, only a small fraction of potentially eli- gible stroke patients are receiving treatment. The primary reason that patients are not eligible for this treatment is the very short, three-hour time window from symptom onset in which the agent should be administered. Intra-arterial re- combinant t-PA (rt-PA) is suggested to be moic effective than intravenous rt-PA. In local intra- arterial (lA) thrombolysis, fibrinolytic agents 71 No.

1 NEUROENDOVASCULAR SURGERY-PATEL 39 are infused distal to. Proximal to, and directly within thrombotic occlusions of mainstem cere- bral arteries, using an endovascular micro- catheter delivery system (Fig. Direct infu- sion of thrombolytic agent near the thrombus allows greater concentration of agent, fewer systemic effects, more rapid dissolution of large or multiple clots, and an opportunity to carry out gentle mechanical disruption of the clot with the delivery catheter and wire (69). I A thrombolysis also has a number of potential dis- advantages, including manipulation of a catheter within cerebral vessels, potentially in- creasing vulnerability to hemorrhage; the re- quirements for systemic heparinization during catheterization to deter catheter-induced throm- bosis; and delay in initiation of thrombolysis.

The procedure is labor and capital intensive, and the number of facilities skilled in lA throm- bolysis is small. Intra-arterial thrombolysis may be used in the anterior circulation (carotid circulation) up to 6 hours after onset of symptoms, although better results have been shown when adminis- tered within 3 hours (70). It is also used up to 12-24 hours after onset in posterior (verte- brobasilar) circulation lesions, because of the poor prognosis without therapy (67). Despite the increased rate of symptomatic hemorrhage with intra-arterial administration of rt-PA, many trials have still demonstrated improved clinical outcomes versus placebo. Of particular note is the first Phase III trial of lA thrombolysis, the Prolyse in Acute Cere- bral Thromboembolism II (PROACT II) trial (69). In PROACT II, patients within 6 hours of symptom onset with symptomatic Ml or M2 middle cerebral artery (MCA) occlusions were randomized to receive lA thrombolysis with sys- temic heparinization vs.

Heparinization alone. The prespecified primary outcome in PROACT II, a good or excellent score on the modified Rankin Scale of handicap, was achieved by 40% of the lA group vs. 25% of control patients (p=0.043). In addition, recanalization rates 2 hours after initiation of infusion were markedly increased in the lA group. Intracerebral hemor- rhage rates at 36 hours were increased in the lA group; however, no difference in overall mortal- ity between the two groups was observed. Another potential role for intra-arterial rt- PA is for postoperative stroke patients.

The risk of stroke is approximately 2.9% in the immedi- ate postoperative period (71). During a recent multicenter study of intra-arterial rt-PA admin- istered during the immediate postoperative per- iod, good results were obtained with only mini- mal complications. The local delivery of throm- bolytic agent reduces systemic effects.

Only pa- tients who had previously undergone intracra- nial surgery had an unacceptably high compli- cation rate (71). Further research is being conducted in the use of mechanical thrombolytic devices, as well as laser clot fragmentation (72). The advantages of these approaches include lack of systemic and hemorrhagic complications. Better public awareness is also needed, since fewer than 5% of eligible stroke patients actually receive thrombolytic therapy (73). In addition, faster Fig.

A 65-year-old woman who presented 3.5 hours after the onset of right-sided weakness and aphasia. Head CT scan did not show a hemorrhage or definite infarct.

An emergency angiogram (A) showed a left internal carotid artery (ICA) occlusion of the superior M2 branch of the middle cerebral artery (MCA) (arrow). Intra-arterial infusion of t-PA was begun distal to, within and proximal to the site of occlusion. Angiogram after infusion of 6 mg t-PA (B) shows partial reopening of the M2 branch and residual thrombus within the branch (arrow). Final angiogram (C) after infusion of 13 mg t-PA (C) shows reopening of the previously occluded M2 branch (arrow). 40 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 diagnosis with MR diffusion and CT perfusion may help to identify patients who can benefit from thrombolysis. Conclusions Neuroendovascular techniques provide in- novative solutions for many neurovascular dis- orders, including minimally invasive treatment options for many patients with complex neu- rovascular disorders. These techniques may allow for the treatment of previously 'untreat- able' disorders.

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And Krista L. Frasier' Abstract Advances in minimally invasive vein surgerv (MIVS) techniques made during the last decade have decreased operative morbidit. The number and size of incisions, operative time and recovery' time. The follow ing MIVS techniques will be discussed: 1. Transilluminated Powered Phlebectom (TIPP) TriVex^^' 2. Radiofrequency Ablation Greater Saphenous Vein (RFGSV) Closure® 3.

Laser Ablation Greater Saphenous N'ein (EVLT) 4. Subfascial Endoscopic Perforator Surger (SEPS) 5.

Percutaneous Vein V'ahe Bioprosthesis (PVVB) The techniques used in MIVS allow surgeons to manage venous pathophysiology associated with all three enous systems of the lower extremities. The results are comparable to those obtained with open procedures. Introduction Minimally invasive techniques for vein surgery have evolved over the last decade, rev- olutionizing the management of venous disease. Endoscopic, endovascular and mechanical methods have supplanted longstanding tradi- tional procedures and allow surgeons to manage the venous pathophysiology associated with all three (superficial, perforator and deep) venous systems in the lower extremities (1).

These techniques decrease operative morbidity, the number and size of incisions, operative time, and recovery time. In addition, the results are as durable as the open procedures, or more so. Center for Vein Disease. Division of Vascular Surgery and 'RVT Manager, Vascular Laboratory, Englewood Hospital and.Medical Center.

NJ, and -Assistant Clinical Pro- fessf)r of Surgery, Mount Sinai School of Medicine, New York, NY. Address all correspondence to Steven M.

FA.C5., Department of Surgery, Box 1263, Mount Sinai School of Medicine. One East lOOth Street. NY KX)29-6574. Elias has disclosed that he serves as consultant to Smith and Nephew. MA and US Surgical.

Norwalk, CT and is preceptor to VNUS Medical, San Jose. CA and Diomed, Inc., Andover, MA. With increased patient satisfaction and effective ^ wound healing rates in applicable instances. MIVS techniques include: 1. Transilluminated Powered Phlebectomy (TIPP) (TriVex', Smith and Nephew, Inc. Andover, MA) 2. Radio-frequency Ablation Greater Saphenous Vein (RFGSV) Closure® r (VNUS Medical, San Jose, CA) 3.

Laser Ablation Greater Saphenous Vein ^ (EVLT) 4. Subfascial Endoscopic Perforator Surgery (SEPS) 5. Percutaneous Vein Valve Bioprosthesis (PVVB) Each of these techniques is discussed, to provide an overview of corrective procedures available in the era of minimally invasive vein • surgery (MIVS). Discussion Transilluminated Powered Phlebectomy, TriVex™ Transilluminated Powered Phlebectomy (TIPP) is a mechanical method of ablating 42 © The Mount Sinai Jolrnai. Of Medicine Vol.

71 No 1 January 2(X)4 Vol. 1 MINIMALLY INVASIVE VEIN SURGERY -ELI AS 43 branch varicosities.

Traditional excision of branch varicosities utilizes either hook phlebec- tomy or stab avulsion, which typically involves multiple incisions (as many as 25-30) and an av- erage operative time of 1-3 hours. TIPR brand name TriVex™ (Transilluminated Varicose Vein Extraction), involves an average of 3.5 incisions and an operative time of 16-20 minutes (2). The TIPP technique, first developed by Chesire et al. (3), utilizes two devices, the transilluminator/irri- gator and the powered resector (Fig. The transilluminator/irrigator allows the surgeon to visualize the varicosities and infuse 1st and 2nd stage tumescent anesthesia before and after resection, which aids in partial exsan- guination of the veins, hemostasis. And pain re- lief (Fig.

The resector is placed immediately under or next to the varicosities in the subcuta- neous tissue. The veins are then suctioned into the rotating blade, where they are cut into small Fig. TriVex™ transilluminator/irrigator and powered re- sector. Courtesy of Smith & Nephew, Endoscopy, Andover, MA. Tumescent anesthesia causes hydrodissection, which aids in removal of the varicosities.

Courtesy of Smith & Nephew, Endoscopy, Andover, MA. Pieces and removed (Fig. Successful vein re- moval can be documented by transillumination. This technique has been utilized since early 2000, when the initial clinical trials were com- pleted (3). Advantages of this minimally inva- sive surgical technique are short operative time, minimal number of incisions, accurate removal of varicosities due to better visualization, and patient satisfaction comparable to satisfaction from traditional methods. Technical complica- tions are associated with inexperience and tend to occur early on in the learning curve. They consist primarily of bruising, hematoma forma- tion and fat necrosis.

These complications are similar to adverse events associated with tradi- tional excision and are minimized with experi- ence (4). TriVex^*' System Resector morcellating vein.

Courtesy of Smith & Nephew, Endoscopy, Andover, MA. Radiofrequency Ablation (Closure®) and Laser Ablation (EVLT) Greater Saphenous Vein Radiofrequency (Fig. 4) and laser ablation (Fig. 5) are endovascular approaches to saphe- nous vein incompetence. Traditional stripping and removal of the saphenous vein requires in- cision sites at the groin and knee or ankle level.

The open procedure requires either general or regional anesthesia. Morbidity from traditional stripping may include hematoma, pain and saphenous neuropathy. Endovenous ablation of the saphenous vein is performed by obtaining percutaneous access to the greater saphenous vein, most commonly at the level of the knee under duplex ultrasound guidance.

A guidewire is then advanced to the saphenofemoral junction, over which the Clo- sure® or EVLT catheter is passed (Figs. 4 and caunezer Fig 4. Radiofrequency catheter. Courtesy of VNUS Med- ical.

6F refers to diameter of catheter. KVLT fib^r Fis. Laser (h LTi fiber. The radiofrequency or laser energy is trans- mitted to the vein wall, causing it to contract and close.

Endovenous ablation of the saphe- nous vein is performed using local anesthesia and sedation. No incisions are necessary, and the patient can return to normal activity the fol- lowing day. Radio-frequency technology and laser ablation have been utilized for the past 5 years and 3 years respectively. More than 90% of saphenous veins remain closed two years after the procedure. These results compare fa- vorably with traditional procedures, with de- creased morbidity and increased patient satis- faction (Fig. Subfascial F^ndoscoplc Perforator Surgery Perforator incompetence is prevalent in pa- tients with venous stasis ulceration (more than Fig.

Remote incision sites for endoscope and ut>rkiri_ port incision for dissection and perforator clipping. 90% of patients have the condition) (7).

Under normal conditions, blood flows from the super- ficial system to the deep venous system via the perforator veins. Incompetent perforator veins cause venous pressure to be reversely directed toward the skin, resulting in venous hyperten- sion and stasis ulceration. Traditional methods of open perforator liga- tion (Linton's procedure) require incision to be made through edematous, infected fields within the ulcer bed. Wound dehiscence and significant postoperative pain are reported in 20-40% of pa- tients (8).

Hospital admission is usually necessar. Subfascial Endoscopic Perforator Surgers (SEPS) is an operative technique with an endo- scopic approach to incompetent perforator vein ligation. Incisions are made remote from the site of ulceration (Fig. 6), and balloon dissection is utilized to create a subfascial space using COt insufflation similar to laparoscopy (Fig.

These two factors minimize both wound compli- cations (by placing incision sites in healthy skin) and complaints of postoperative pain (by utilizing blunt balloon dissection). A 10 mm in- cision is used for placement of the endoscope and a 5 mm working port incision for dissection and perforator clipping (Fig. After placing the clips, the pressure in the veins is reduced, so that healing of any ulceration is enhanced.

Postoperative pain is minimal and patients are able to continue wound care the following day. Stasis ulcer healing rates and maintenance of healing 5 years after SEPS range from 90'/ for patients with a normally functioning deep ve- nous system to 75-80% for patients with deep venous insufficiency, when combined with com- pression therapy and wound care (9, 10). 1 MINIMALLY INVASIVE VEIN SURGERY -ELI AS 45 Balloon dissector age healing time for ulceration is six weeks. As with the other minimally invasive techniques, SEPS allows direct visualization of venous pathology with significantly lower morbidity.

Percutaneous Vein Valve Bioprosthesis A significant number of patients with venous stasis ulceration have associated deep venous in- sufficiency (11, 12). To date, surgeons have been hesitant to repair and improve deep venous flow hemodynamics; however, a few centers do ag- gressively treat deep venous incompetence.

Tra- ditional surgical methods include axillary vein valve transplant, valvuloplasty, and vein valve transposition (13). All of these methods require significant incisions and in-house recovery time. Percutaneous Vein Valve Bioprosthesis (PVVB) is a technique used to correct valvular incompetence by utilizing a percutaneous ap- proach to deliver a functioning vein valve to an incompetent segment of the deep venous system. The device consists of a glutaraldehyde-treated bovine jugular vein with a competent valve mounted on a nitinol stent (Fig. Percutaneous access is obtained at the level of the internal jugular vein.

A guidewire and introducer are ad- vanced to the level of the femoral vein (old nomenclature, 'superficial femoral'). The bovine valve is then passed along the introducer to the femoral vein at the site of valvular incom- petence and deployed (Fig. The technique is similar to a placement of a vena cava filter. This procedure is now in phase 1 clinical trials to evaluate safety and efficacy.

The poten- tial benefits of this minimally invasive ap- proach include: small remote incision, same- Fig. Bovine jugular vein mounted on nitinol stent. Cour- tesy of VenPro, Irvine. ^ ^^^^ f clipped -t*^ f perforator veins muscle Fig. (A) Endoscopic view of perforator vein prior to clipping.

(B) After clipping. 46 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004i day surgery, local anesthesia, and perhaps the ability to place multiple valves to mimic a nor- mally functioning deep venous system. Conclusion The advent of minimally invasive vein surgery techniques allows the surgeon to man- age venous pathophysiology associated with all three venous systems in the lower extremities. Percutaneous access site and vein valve implant site(s). Courtesy of VenPro. Many patients may require a combination ofl MIVS techniques to correct venous insuffi- ciency and stasis changes. These techniques* complement each other, and when combined, can enhance the clinical outcome.

MIVS can be performed as an outpatient procedure with few, if any. Small incisions. MIVS techniques, which incorporate endoscopy, transillumination, ultra- sound or fluoroscopy, also make it possible for the surgeon to visualize venous pathology. From the vascular surgeon's perspective, it is reassuring to 'see' the pathology. In addition, patient satisfaction is enhanced by minimal dis- comfort and less postoperative morbidity as compared to traditional open procedures. References 1.

O'Donnell TF. Lessons from the past guide the future: is his- tory- truly circular? J Vase Surg 1999: 30:775-786. Braxton JM, Bergan JJ. Outpatient varicose vein surgery with transilluminated powered phlebectomy.

Vase, Surg 2000: 34:547-555. Keagy B, et al.

Powered phlebectomy (TriVex) in treatment of varicose veins. Ann Vase Surg 2002; 16:488-494. Transilluminated powered phlebectomy: technique, pitfalls and results. American Venous 13th Annual Forum Meeting: 2001 Feb 22-25: Ft. Endovascular oblitera- tion of saphenous reflux: a multicenter study. J Vase Surg i 20-1196. Min RJ, Zimmet SE.

Isaacs MN, Forrestal MD. Endovenous I laser treatment of the incompetent greater saphenous vein. J i Vase Inter Radiol 200 1: 1 2( 1 0): 11 67 - 1 1 7 1. Nicolaides AN.

Prevalence and dis- tribution of incompetent perforating veins in chronic venous insufficiency. J Vase Surg 1998; 28:815-825. Stuart WR Adam DJ. Bradbury AW, Ruckley CV. Subfascial endoscopic perforator surgery is associated with significantly less morbidity and shorter hospital stay than open operation (Linton's procedure). Br J Surg 1997; 84:1364-1365.

Rhodes JM, et al. Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the Norih American subfascial endoscopic perforator surgery reg- istry. The North American Study Group. J Vase Surg 1999; 29:489-502. Subfascial endoscopic perforator surgery (SEPS) — 25 cases, lessons learned. Contemp Surg 1999; 55:265-269 1 1. Primary venous valve incompetence of the lower leg.

Am J Surg 1980; 140:218-224. Magnusson MB, Nelzen O, Risberg B. Sivertsson R.

A colour Doppler ultrasound study of venous reflux in patients with chronic leg ulcers. Eur J Vase Endovasc Surg 2001; 2 1:353.360.

Taheri SA, Lazar L, Elias SM, Marchand P. Vein valve trans plant. Surgery 1982;91:28-33. Grand Rounds A Review of Heart Failure Treatment Gordon H. M.ScJ -, and P.J.

Devereaux, M.D.' Abstract Heart failure is a common and costly medical condition. Ischemic heart disease and hypertension account for most cases of heart failure in developed countries. Estimates of the one-year mortality rates for patients with New York Heart Association (NYHA) Class n, ni, and IV are 10%, 20%, and 40%, respectively. Angiotensin-converting enzyme (ACE) inhibitors reduce mortality of heart failure patients by approximately 25% (odds ratio 0.77, 95% CI 0.67-0.88).

Larger doses of ACE inhibitors are more effective in preventing hospitalization than are lower doses. Angiotensin II receptor blockers (ARBs) are an alternative for patients who cannot tolerate ACE inhibitors because of their side effects (e.g., cough). Evidence for benefits of using combination of ACE inhibitors and ARBs is encouraging, but requires further study. For patients who cannot tolerate either ACE inhibitors or ARBs, vasodilator therapy with hydralazine and nitrates will probably provide benefit. (Diuretic therapy, while a mainstay of heart failure treatment, is primarily used for symptom relief.) There is also evidence that spironolactone reduces mortality (relative risk reduc- tion 30%, 95% CI 18-40%) for patients with NYHA class III and IV heart failure. When administering spironolactone to heart failure patients, monitoring for hyperkalemia is essential. After two centuries of use, randomized controlled trials have finally demonstrated that digoxin is effective in preventing hospitalizations (relative risk reduction 28%, 95% CI 21 -34%).

There is now overwhelming evidence that beta-blockers are safe for heart failure patients but that they reduce the risk of death for these patients by approximately 30%. In addition to these medical interventions, heart failure patients may also benefit from a number of non- pharmacological interventions. Key Words: Heart failure, digitalis, beta-blockers, anti-arrhythmic agents, anticoagulation, ventricular assist device, exercise, ran- domized controlled trials. Following the tenets of evidence-based med- icine (1), this paper will highlight results from randomized trials and insights from controlled trial methodology which guide us in managing patients with heart failure.

Epidemiology, Diagnosis, and Prognosis Studies of heart failure incidence suffer from lack of agreement regarding definition, from variability in methods and criteria, and from a paucity of population-based studies. Es- timates of heart failure incidence vary from From the 'Department of Medicine and -Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. Address all correspondence to Dr. Devereaux, McMaster University, Faculty of Health Sciences, Clinical Epidemiology and Biostatistics, Room 2C12, 1200 Main Street, West Hamilton, ON L8N 3Z5 Canada; email: philipj@mcmaster.ca Adapted from a Grand Rounds presentation to the Depart- ment of Medicine, Mount Sinai School of Medicine, New York, NY, on June 6, 2000, and updated as of March 2003.

1.0-5.0 per thousand per annum, increasing substantially with age to a level as high as 40 cases per thousand in those older than 75 years of age (2). This corresponds to a prevalence of 1% in those 50-59, and 10% in those older than 80 (3). Only about 5% of symptomatic pa- tients have severe heart failure (4). In the more industrialized countries, is- chemic coronary disease and hypertension ac- count for most cases of heart failure (5, 6). Valvular disease and viral, idiopathic and alco- holic cardiomyopathy do occur with somewhat lesser frequency. On occasion, clinicians may see thyroid disease and hemochromatosis, which are treatable causes of heart failure. All told, multiple hospitalizations, the many med- ications, and the home care requirements result in a yearly cost of treating heart failure patients that may be as high as $22,000 per person (7).

The classic heart failure symptoms of dys- pnea, orthopnea, and paroxysmal nocturnal dyspnea lack specificity — many patients with other conditions report identical symptoms (8). The same is true for the most easily detected © The Mount Sinai Journal of Medicine Vol. 1 January 2004 47 48 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 physical sign, peripheral edema (5). This prob- ably explains the findings of two studies that examined the accuracy of the diagnosis of heart failure by primary care physicians and found false positive rates of 417c' (9) and 55Vc (10). Physical findings of a third heart sound, ele- vated jugular veins, and pulmonary crackles are more specific (11). Though the last of these is prominent in one easily confused condition, pulmonary fibrosis.

The diagnosis may be more difficult for older patients, of whom 30-40% with heart failure may have primarily diastolic dysfunction (11). The chest radiograph is help- ful, despite the poor relationship between heart size and left ventricular function and between upper-lobe distension and pulmonary capillary wedge pressure (12). The limitations of history, physical examination, and chest radiographs lead experts to recommend routine echocardio- graphy for patients suspected to have heart fail- ure. B-natriuretic peptide shows promise as a laboratory test for differentiating between pa- tients with and without left ventricular dysfunc- tion, and may obviate the need for echocardio- gram for some patients (13). A clear picture of the prognosis for heart failure is also difficult, because while studies almost invariably classify patients according to the New York Heart Association (NYHA) func- tional classification, the between-observer agreement in NYHA class is poor (14). In any case, available evidence suggests that neither the incidence nor the prognosis of heart failure has changed dramatically over the last two decades (15).

Despite limitations of the studies, one-year survival rates of older patients with severe heart failure are no higher than 60% (16). A recent population-based study found that one-year mortality of patients hospitalized with heart failure was greater than 30%, with even poorer prognosis for older patients with multiple comorbidity (17). Reasonable current estimates would suggest one-year mortalities for NYHA Class II, III and IV patients of 10%, 20% and 40%, respectively. Management — Where to Look for Best F>vidence We offer our patients treatment for two rea- sons: to help them live longer and feel better. Uncontrolled observations, or observations from studies of weak design, may provide mis- leading estimates of treatment efficacy.

Ten years ago. We were offering heart failure pa- tients prophylactic anti-arrhythmic agents that we now know led to premature death, while with- holding beta blockers that would have helped them live both longer and better. The cardiology community was divided between vociferous ad- vocates of digoxin and equally vociferous oppo- nents. Only rigorously conducted, blinded, ran- domized controlled trials (RCTs) in which patient follow-up was complete and patients were ana- lyzed in the groups to which they were random- ized (18) have opened our eyes to the true bene- fits and harms of these interventions. RCTs are inevitably limited by random error, and by the particular patient population and intervention that the investigators choose to study. Meta-analyses that pool results across RCTs provide a powerful tool to help deal with both of these limitations. To avoid bias, meta- analyses must themselves be rigorously con- ducted.

For these systematic reviews, avoiding bias requires eligibility criteria that are both ex- plicit and appropriate (appropriate, in that across the range of pooled patients, interven- tions, outcomes and methodologies, we expect more or less the same treatment effect), and a comprehensive and reproducible search for rel- evant studies (19). Furthermore, investigators must evaluate the methodological quality of the original studies; poorly designed studies will yield biased estimates, regardless of the rigor of the meta-analytic methods. Finally, meta-ana- lysts must look carefully to see if study results are similar for different patients, interventions, measurements of outcome, and study method- ologies (20). Our summary of the evidence shall, wherever possible, rely on systematic re- views that meet these criteria.

Judging the Magnitude of Treatment Effects Because they must always trade off benefit and harm, clinicians cannot be satisfied with just knowing whether treatments work. They must attend also to the magnitude of the benefit patients can expect.

The relative risk reduction (RRR) provides one way of expressing the ex- tent to which treatments reduce the relative risk (RR) of an adverse outcome (for instance, the may cut the risk by '/2 or by 'A). However, be misleading.

For patients with a 2^' individuals with and without dementia. Brain donations were sought by JHH clinical staff and made by next-of-kin consent. Standardized neuropathological studies were conducted on the right hemisphere, after division of the brain specimens at the midsagittal level, as previously described by our group (16, 22).

Briefly, hematoxylin-eosin, modified Bielschowsky, modified thioflavin S, anti-J amyloid, anti-tau, and anti-ubiquitin (Dako Vol. 1 LEWY BODIES AND DEPRESSION -SAMUELS 57 Corp, Carpinteria, CA) were used to stain sections from paraffin-embedded blocks; the immunohistochemical method used was an avidin-biotin staining procedure with diamnobenzidine detection. Neuropathological assessment of severity of LB pathology was conducted in two ways. The first was with the Consortium to Establish a Registry for AD (CERAD) neuropathological battery (23), w hich included assessment of LBs in multiple high-power fields. Pathology ratings were made on a four-point scale (0 = absent, l=sparse, 2=moderate, and 3 = severe) in midfrontal cortex, superior midtemporal gyrus, inferior parietal lobule, occipital visual cortex, substantia nigra, nucleus basalis of Meynert, locus ceruleus, and dorsal ventral nucleus of thalamus.

For the purposes of this study, only ratings for the locus ceruleus and substantia nigra were included. In a subset of cases, a more quantitative estimate of cortical LB pathology was made by taking the sum of the direct LB count in three neocortical regions (i.e., superior/midfrontal gyrus, orbital frontal cortex and superior temporal gyrus), and in the anterior cingulate gyrus. The pathologist was blind to the clinical ratings of depression and the demographic characteristics of the subject, except for age. Grouped by DSM-IV category (e.g., 'significant weight change') and converted to a 9-point DSM-IV depression scale (see Table 1). Each patient's score was determined to be the sum of those items exhibited by the patient. Furthermore, subjects were divided into 3 groups based on their depression checklist score: major depression, minor depression, and no depression. 'Major depression' was defined TABLE 1 Conversion of PMCR Depression Checklist to DSM-IV Depression Checklist PMCR Depression Checklist DSM-IV Depression Checklist Depressed mood, dysphoria I Decreased interest or pleasure 2 in activities, anhedonia Depressed mood Anhedonia Weight loss without dieting 3.

Weight change Decreased appetite Weight gain or increased appetite 5. Early insomnia 7. Middle insomnia Insomnia or hypersomnia Clinical Assessment As part of a formal postmortem chart review (PMCR), depressive symptomatology was assessed using a 16-item checklist based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (24) criteria for major depression.

Specifically, a clinically trained rater carefully reviewed available data from JHH clinical records, which included admitting diagnoses, neurological and psychiatric consultation reports, nurses' notes, social work records, medication records, mental status testing, and all other medical records and laboratory studies, as reported in previous studies by our group (16, 22). For depressive symptoms, a score of present or absent for each criterion was assigned. The rater was blind to the neuropathological diagnoses. The results of this review were independently confirmed by a psychologist. Symptoms were endorsed as positive if they were present in the medical record.

The item was excluded if insufficient information was available to make the rating. Items from the PMCR checklist were then 8. Late insomnia, early morning awakening 9. Hypersomnia 10.

Psychomotor agitation 1 1. Psychomotor retardation 12.

Fatigue or loss of energy 6. Worthlessness, sinfulness, guilt 7. Delusional worthlessness, sin, guilt 15. Ruminations, inability to concentrate, indecisiveness Recurrent thought of death or 9. Suicide Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate Recurrent thoughts of death or suicidal ideation PMCR - postmortem chart review; DSM-IV = Diagnostic and Statistical Manual-IV 58 THE MOUNT SINAI JOURNAL OF MEDICINE January 2004 as 5 or more items, of which at least one was depressed mood or anhedonia. 'Minor depression' was defined either as 3 or 4 items, of which one was depressed mood or anhedonia. Minor depression was included because of the association with functional disability, increased resource utilization and mortality (25-28).

A subject was placed in the category of 'no depression' when the number of items ranged from 0-2. Validity of Postmortem Depression Assessment An independent sample (n=23) of JHH residents received postmortem assessment of depression symptomatology using the Hamilton Depression Scale (29).

The assessment was made by a comprehensive interview with an informant who knew the patient well. Hamilton Depression Scale (HAM-D) items were converted to DSM-IV Depression Checklist scores. An independent postmortem assessment of depression, as described above, was also conducted. To measure validity, the relationship between the sum of the DSM-IV Depression Checklist, derived from HAM-D scores, and the sum of the PMCR checklist scores were examined with Pearson's product moment correlations.

As the relationship between the two depression checklist scores was expected to be positive, a one-tailed test was conducted. The significant correlation (r=0.345, p=0.05) indicated adequate validity of the PMCR depression assessment. In addition to the determination of the depression severity, several other variables were examined. These included gender, age at death, age at placement into JHH, and duration of stay in JHH. Clinical Dementia Rating (CDR) scores were determined for the six months prior to death, as previously described (22).

Subject Selection Only subjects with a CDR score of 0.5 (questionable dementia) or greater were considered for analysis. Furthermore, subjects were excluded if quantitative assessment of cortical LBs and depression data were not available.

The remaining subjects (n = 55) represented the final sample and were subsequently divided into two groups based on neuropathological assessment. The AD group (n=39) met CERAD neuropathological criteria for definite AD and did not have any cortical Lewy body pathology. The DLB group (n=16) was defined as those cases in which cortical LB counts were greater than or equal to 1. This group contained both subjects with significant AD pathology (n=10) and subjects without significant AD pathology (n=6). The cohort in this study was part of a larger, ongoing clinical study of normal aging and early dementia. Results The AD and DLB groups did not differ in dementia severity, gender, age at admission to nursing home, or age at death (Table 2). TABLE 2 Deino^rciphic Comparison Between AD and DLB Subjects AD DLB p n=39 n=16 Age at 83.74 ± 7.49 81.96 ± 5.96 0.40 admission (years) Percent women 77 69 0.53 Dementia 3 4 0.34 severity (median CDR) AD - Alzheimer's disease; DLB = dementia with Lewy bodies; CDR = Clinical Dementia Rating Independent samples t-tests were conducted to compare the depression scale scores between the AD (mean score ± SD = 2.08 ± 1.95) and DLB (mean score ± SD = 2.69 ± 1.96) groups.

The two groups did not significantly differ: t(53) = -1.05, p=0.297. Effect size for this analysis, using Cohen's d (30), was 0.313.

According to Zakzanis's (21) interpretation of Cohen's (30) idealized population distribution, an effect size of 0.313 would indicate no effect, with approximately 78.7% overlap of depression scores between the two groups. The distribution of depressive symptomatology was compared between the two groups using Pearson's chi-square analysis for each item of the depression checklist. There were no statistically significant differences for any item; Table 3 displays the distribution of depressive symptoms. When percentages of subjects who met criteria for minor depression, major depression, or no depression were bl.