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A Multi-Institutional Experience in Vascular Ehlers-Danlos Syndrome
Journal of Vascular Surgery
Abstracts
e3
Volume 65, Number 3
Heel Wounds Predict Poor Outcomes After Infrapopliteal Revascularization Abhisekh Mohapatra, MD, Jon C. Henry, MD, Efthymios D. Avgerinos, MD, Rabih A. Chaer, MD, Steven A. Leers, MD, Aureline Boitet, MD, Michael J. Singh, MD, Eric S. Hager MD. University of Pittsburgh Medical Center, Pittsburgh, PA Objective: Ischemic heel ulcerations are generally thought to carry a poor prognosis. We hypothesized that patients undergoing infrapopliteal revascularization for heel wounds, either bypass or endovascular intervention, would have lower wound healing rates and amputation-free survival than patients with forefoot wounds. Methods: Retrospective chart review was performed of patients who presented between 2006 and 2013 to our institution with ischemic foot wounds and infrapopliteal arterial disease and underwent either pedal bypass or endovascular tibial artery intervention. Data were collected on patient demographics, comorbidities, wound characteristics, procedural details, and postoperative outcomes, then analyzed by initial wound classification. The primary outcome was major amputation or death. Results: There were 398 limbs that underwent treatment for foot wounds; accurate wound data were available in 380 cases. There were 101 bypasses and 279 endovascular interventions, with mean follow-up of 24.6 and 19.9 months, respectively (P ¼ .02). Heel wounds represented 12.1% of the total, with the remainder being forefoot wounds; there was no difference in treatment modality by wound type (P ¼ .94). Of 46 heel wounds, 5 (10.9%) had clinical or radiographic evidence of calcaneal osteomyelitis. Patients with heel wounds were more likely to have diabetes mellitus (P ¼ .03) and renal insufficiency (P ¼ .004); 36.9% of wounds healed within 1 year, with no difference by wound location (P ¼ .30). Endovascular treatment was associated with improved healing of forefoot wounds (P ¼ .02) but not of heel wounds (P ¼ .14). Major amputation rate at 1 year was 17.8%, with no difference by wound location (P ¼ .81) or treatment type (P ¼ .33). Three-year major amputation-free survival (Fig) was 43.8% with a forefoot wound and 20.8% with a heel wound (P ¼ .03). In a multivariate analysis, heel wounds and endovascular intervention were both predictors of major amputation or death; however, there was significant interaction such that bypass improved outcomes in patients with forefoot wounds (hazard ratio, 1.97; P < .001) but not in those with heel wounds (hazard ratio, 0.79; P ¼ .53). Conclusions: Patients presenting with heel ulceration who undergo infrapopliteal revascularization are prone to lower amputation-free survival despite equivalent wound healing and regardless of treatment modality.
Background: Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine the impact of poor tibial runoff on the patient-centered outcomes following tibial endovascular intervention. Methods: A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford class 4 and 5) were identified. Angiograms were reviewed in all cases to assess tibial runoff. Each dorsalis pedis, lateral plantar, and medial plantar artery was assigned a score according to the reporting standards of the Society for Vascular Surgery (0, no stenosis >20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, less than half the vessel length occluded; 3, more than half the vessel length occluded). A foot score (dorsalis pedis + medial plantar + lateral plantar + 1) was calculated for each foot (1 to 10). Two runoff score groups were identified: <7 and >7. Patient-oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (MALE; above-ankle amputation of the index limb) or major reintervention (new bypass graft, jump/interposition graft revision) were evaluated. Results: There were 1134 patients (56% male; average age, 59 years) who underwent tibial intervention for critical ischemia; 94% had hypertension, 70% had diabetes mellitus, 63% had hyperlipidemia, and 33% had chronic renal insufficiency (47% of these on hemodialysis). Technical success was 99% with a mean of two vessels treated per patient and a mean pedal runoff score of 6. Overall MALE was equivalent at 90 days after the procedure. At 5 years, vessels with compromised runoff (scores $7) had significantly lower ulcer healing and a lower limb salvage rate. Patients with poor runoff had significantly lower clinical efficacy, amputationfree survival, and MALE at 5 years (Table).
Table. Outcomes Runoff score <7
Runoff score $7
No. of limbs at risk
600
534
d
High-risk PIII score
18%
30%a
.01
P value
Mortality
1%
1%
NS
Morbidity
3%
5%b
.04
Ulcer healing without amputation, %
73 6 4
25 6 3
.01
5-year clinical efficacy, %, mean 6 SEM
48 6 4
20 6 8a
.01
5-year amputation-free survival, %, mean 6 SEM
45 6 3
17 6 9a
.01
5-year MALE, %, mean 6 SEM
50 6 5
11 6 6a
.01
MALE, Major adverse limb events; NS, not significant; PIII, Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III); SEM, standard error of the mean. a P < .01 compared with runoff score <7. b P < .05 compared with runoff score <7.
Fig. Amputation-free survival by wound location.
Author Disclosures: A. Mohapatra: None; J. C. Henry: None; E. D. Avgerinos: None; R. A. Chaer: None; S. A. Leers: None; A. Boitet: None; M. J. Singh: None; E. S. Hager: None.
Outcomes of Tibial Endovascular Interventions in Patients with Poor Pedal Runoff Hallie E. Baer-Bositis, MD, Taylor D. Hicks, MD, Georges M. Haider, MD, Lori L. Pounds, MD, Matthew J. Sideman, MD, Maureen K. Sheehan, MD, Mark G. Davies MD, PhD, MBA. University of Texas Health Science Center-San Antonio, San Antonio, TX
Conclusions: Pedal runoff score can easily identify those patients who will not achieve ulcer healing and limb salvage after tibial intervention. Defining such subgroups will allow stratification of the patients and appropriate application of interventions. Author Disclosures: H. E. Baer-Bositis: None; T. D. Hicks: None; G. M. Haider: None; L. L. Pounds: None; M. J. Sideman: None; M. K. Sheehan: None; M. G. Davies: None.
A Multi-Institutional Experience in Vascular Ehlers-Danlos Syndrome Sherene Shalhub, MD, MPH,1 Kelli Hicks, BS,1 Karen Woo, MD,2 Dawn Coleman, MD,3 Frank Davis, MD,3 Giovanni De Caridi, MD, PhD,4 K. Nicole Weaver, MD,5 Erin Miller, MS, CGC,6 Marc Schermerhorn, MD,7 Katie Shean, MD,7 Gustavo Oderich, MD,8 Mauricio Ribiero, MD, PhD,8 Cole Nishikawa, MD,9 Kristofer M. Charlton-Ouw, MD,10
e4
Journal of Vascular Surgery
Abstracts
March 2017
Christian-Alexander Behrendt, MD,11 Sebastian Debus, MD, PhD,11 Yskert von Kodolitsch, MD,12 Devin Zarkowsky, MD,13 Richard J. Powell, MD,13 Melanie Pepin, MS, CGC,14 Peter Byers, MD,15 Peter Lawrence MD2. 1University of Washington, Seattle, WA; 2Division of Vascular Surgery, University of California Los Angeles, Los Angeles, CA; 3Section of Vascular Surgery, University of Michigan, Ann Arbor, MI; 4Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy; 5Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cinncinnati, OH; 6The Heart Institute and Division of Human Genetics at Cincinnati Children’s, Cinncinnati, OH; 7 Beth Israel Deaconess Medical Center, Boston, MA; 8Mayo Clinic Division of Vascular Surgery, Rochester, MN; 9University of California, Davis Medical Center, Sacramento, CA; 10Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX; 11 Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany; 12Department of Cardiology, University Heart Center, Hamburg, Germany; 13Division of Vascular Surgery, DartmouthHitchcock Medical Center, Lebanon, NH; 14Medical Genetics, Department of Pathology, Seattle, WA; 15Medical Genetics, Department of Pathology, University of Washington, Seattle, WA Objective: Vascular Ehlers-Danlos syndrome (VEDS) is a rare connective tissue disorder with >700 mutations in the COL3A1 gene affecting collagen type III production. Limited data exist regarding the consequent aortic and branch vessel aneurysms and dissections, presentation, and treatment outcomes. This study aimed to provide a description of a contemporary cohort of patients diagnosed with VEDS. Methods: This was a multi-institutional retrospective cohort study of patients diagnosed with VEDS between 2000 and 2015. Demographics, family history, diagnosis modality, COL3A1 mutations, vascular disease, and management data were collected. Data were presented as median and ranges. Patients with confirmed causative COL3A1 mutations were analyzed for vascular disease. Results: Eleven institutions identified 173 (35.3% male) patients with VEDS. Median age at diagnosis was 26.5 (range, 0.1-81) years by genetic testing, skin biopsy, and clinical criteria in 63%, 3%, and 18% of the cases, respectively. In 16.2%, the diagnosis method was unknown. A family history of confirmed or suspected VEDS, sudden death, stroke, or myocardial infarction was documented in 47.4% of the cases. Arterial dissections or aneurysms were diagnosed in 81 cases (51.9% male). At the time of data collection, 11.6% of the patients died at a median age of 37 (range, 19-70) years, with 95% due to vascular complications. COL3A1 mutation data were available for 79 cases (46.9% male, 5 null mutations). In 15.2% of the cases, the COL3A1 mutations were found to be noncausative. Among those with a causative mutation, 42 (62.9%) were diagnosed with arterial dissections or aneurysms (50% male, 3 null mutations) at a median age of 31.5 (range, 12-79) years. This involved the carotid/vertebral, mesenteric/renal, and iliac arteries in 35.7%, 47.6%, and 31% of the cases, respectively. Aortic involvement occurred in 23.8% of the cases. Mortality in this group was 16.7% at a median age of 43 (range, 22-70) years. Vascular interventions were undertaken in 15 (35.7%) cases (10 open, 5 endovascular), of which 3 were for rupture (thoracic aorta, abdominal aorta, and splenic artery). Conclusions: This is a large, multi-institutional descriptive study of patients diagnosed with VEDS. The study highlights the importance of establishing a precise diagnosis by confirming a causative COL3A1 mutation. This is a first step toward an accurate understanding of the disease and operative outcomes, thus facilitating clear guidelines for management. Author Disclosures: S. Shalhub: None; K. Hicks: None; K. Woo: None; D. Coleman: None; F. Davis: None; G. De Caridi: None; K. Weaver: None; E. Miller: None; M. Schermerhorn: None; K. Shean: None; G. Oderich: None; M. Ribiero: None; C. Nishikawa: None; K. M. Charlton-Ouw: None; C. Behrendt: None; S. Debus: None; Y. von Kodolitsch: None; D. Zarkowsky: None; R. J. Powell: None; M. Pepin: None; P. Byers: None; P. Lawrence: None.
Fig. Superior mesenteric artery (SMA) dissection remodeling computed tomography angiography of a patient presenting with spontaneous SMA dissection (A). He was treated with anticoagulation, but over a period of 9 days, he progressed to complete SMA occlusion with symptoms of bowel ischemia (B). He was treated with mesenteric bypass to a branch of the SMA with restoration of low to the true lumen (C). Author Disclosures: C. E. Morgan: None; M. K. Eskandari: None; H. E. Rodriguez: None.
Evolution of Type II Endoleaks Based on Different Ultrasound-Identified Patterns Spyridon Monastiriotis, MD, Ignatius Lau, MD, Shang Loh, MD, John Ferretti, MD, Apostolos Tassiopoulos, MD, Nicos Labropoulos. SUNY at Stony Brook, Stony Brook, NY
Ten-Year Review of Isolated Spontaneous Mesenteric Arterial Dissections Courtney E. Morgan, MD, Mark K. Eskandari, MD, Rodriguez MD. Northwestern University, Chicago, IL
Objective: Isolated spontaneous dissection of the superior mesenteric artery (SMA) and celiac artery (CA) remains a rare condition but has been increasingly noted incidentally on diagnostic imaging. We sought to study the natural history and outcomes of patients presenting with isolated spontaneous mesenteric artery dissections (SMADs), hypothesizing that most SMADs can be treated nonoperatively. Methods: This was a single-center retrospective review of patients presenting with the diagnosis of SMAD between 2006 and 2016. Data analysis included demographics, clinical data, radiologic review, treatment, and outcomes. Results: A total of 78 patients were found to have isolated CA or SMA dissection diagnosed on computed tomography or magnetic resonance imaging. Average age was 56 years (range, 26-86); 80% were male. Nine patients (12%) had underlying arterial disease; five had fibromuscular dysplasia, and four had segmental arterial mediolysis. The majority, 64%, presented with symptoms including abdominal pain, back pain, and chest pain; the remaining 36% were asymptomatic. Combined SMA and CA dissection was found in 14 (18%) patients, whereas 33 (42%) presented with isolated CA dissection and 31 (40%) presented with isolated SMA dissection. Only four patients required intervention. Mesenteric bypass was performed in two patients, and SMA endarterectomy with patch angioplasty was performed in one patient for signs of bowel ischemia. No patient required bowel resection. The two bypasses were anastomosed to a branch of the SMA, and complete lumen restoration was seen on long-term imaging follow-up (Fig). One patient underwent stent grafting of the CA and hepatic artery for aneurysmal degeneration 1 month after diagnosis. The remaining 74 patients were managed nonoperatively; 40 (55%) were treated with a short course of anticoagulation, 23 (31%) were treated with antiplatelet therapy, and 10 (14%) were treated with observation alone. No other later interventions or recurrences were noted during a mean follow-up period of 21 months. Conclusions: Whereas isolated SMAD poses a risk of visceral ischemia, most patients presenting with this diagnosis can be treated nonoperatively with a short course of antiplatelet or anticoagulant therapy. Indications for surgical intervention include bowel ischemia and aneurysmal degeneration.
Heron E.
Objective: The objective of this study was to delineate the specific types of waveforms that exist in type II endoleaks (T2ELs) and their effect on the aneurysmal sac size.
Abstracts
e3
Volume 65, Number 3
Heel Wounds Predict Poor Outcomes After Infrapopliteal Revascularization Abhisekh Mohapatra, MD, Jon C. Henry, MD, Efthymios D. Avgerinos, MD, Rabih A. Chaer, MD, Steven A. Leers, MD, Aureline Boitet, MD, Michael J. Singh, MD, Eric S. Hager MD. University of Pittsburgh Medical Center, Pittsburgh, PA Objective: Ischemic heel ulcerations are generally thought to carry a poor prognosis. We hypothesized that patients undergoing infrapopliteal revascularization for heel wounds, either bypass or endovascular intervention, would have lower wound healing rates and amputation-free survival than patients with forefoot wounds. Methods: Retrospective chart review was performed of patients who presented between 2006 and 2013 to our institution with ischemic foot wounds and infrapopliteal arterial disease and underwent either pedal bypass or endovascular tibial artery intervention. Data were collected on patient demographics, comorbidities, wound characteristics, procedural details, and postoperative outcomes, then analyzed by initial wound classification. The primary outcome was major amputation or death. Results: There were 398 limbs that underwent treatment for foot wounds; accurate wound data were available in 380 cases. There were 101 bypasses and 279 endovascular interventions, with mean follow-up of 24.6 and 19.9 months, respectively (P ¼ .02). Heel wounds represented 12.1% of the total, with the remainder being forefoot wounds; there was no difference in treatment modality by wound type (P ¼ .94). Of 46 heel wounds, 5 (10.9%) had clinical or radiographic evidence of calcaneal osteomyelitis. Patients with heel wounds were more likely to have diabetes mellitus (P ¼ .03) and renal insufficiency (P ¼ .004); 36.9% of wounds healed within 1 year, with no difference by wound location (P ¼ .30). Endovascular treatment was associated with improved healing of forefoot wounds (P ¼ .02) but not of heel wounds (P ¼ .14). Major amputation rate at 1 year was 17.8%, with no difference by wound location (P ¼ .81) or treatment type (P ¼ .33). Three-year major amputation-free survival (Fig) was 43.8% with a forefoot wound and 20.8% with a heel wound (P ¼ .03). In a multivariate analysis, heel wounds and endovascular intervention were both predictors of major amputation or death; however, there was significant interaction such that bypass improved outcomes in patients with forefoot wounds (hazard ratio, 1.97; P < .001) but not in those with heel wounds (hazard ratio, 0.79; P ¼ .53). Conclusions: Patients presenting with heel ulceration who undergo infrapopliteal revascularization are prone to lower amputation-free survival despite equivalent wound healing and regardless of treatment modality.
Background: Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine the impact of poor tibial runoff on the patient-centered outcomes following tibial endovascular intervention. Methods: A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford class 4 and 5) were identified. Angiograms were reviewed in all cases to assess tibial runoff. Each dorsalis pedis, lateral plantar, and medial plantar artery was assigned a score according to the reporting standards of the Society for Vascular Surgery (0, no stenosis >20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, less than half the vessel length occluded; 3, more than half the vessel length occluded). A foot score (dorsalis pedis + medial plantar + lateral plantar + 1) was calculated for each foot (1 to 10). Two runoff score groups were identified: <7 and >7. Patient-oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (MALE; above-ankle amputation of the index limb) or major reintervention (new bypass graft, jump/interposition graft revision) were evaluated. Results: There were 1134 patients (56% male; average age, 59 years) who underwent tibial intervention for critical ischemia; 94% had hypertension, 70% had diabetes mellitus, 63% had hyperlipidemia, and 33% had chronic renal insufficiency (47% of these on hemodialysis). Technical success was 99% with a mean of two vessels treated per patient and a mean pedal runoff score of 6. Overall MALE was equivalent at 90 days after the procedure. At 5 years, vessels with compromised runoff (scores $7) had significantly lower ulcer healing and a lower limb salvage rate. Patients with poor runoff had significantly lower clinical efficacy, amputationfree survival, and MALE at 5 years (Table).
Table. Outcomes Runoff score <7
Runoff score $7
No. of limbs at risk
600
534
d
High-risk PIII score
18%
30%a
.01
P value
Mortality
1%
1%
NS
Morbidity
3%
5%b
.04
Ulcer healing without amputation, %
73 6 4
25 6 3
.01
5-year clinical efficacy, %, mean 6 SEM
48 6 4
20 6 8a
.01
5-year amputation-free survival, %, mean 6 SEM
45 6 3
17 6 9a
.01
5-year MALE, %, mean 6 SEM
50 6 5
11 6 6a
.01
MALE, Major adverse limb events; NS, not significant; PIII, Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III); SEM, standard error of the mean. a P < .01 compared with runoff score <7. b P < .05 compared with runoff score <7.
Fig. Amputation-free survival by wound location.
Author Disclosures: A. Mohapatra: None; J. C. Henry: None; E. D. Avgerinos: None; R. A. Chaer: None; S. A. Leers: None; A. Boitet: None; M. J. Singh: None; E. S. Hager: None.
Outcomes of Tibial Endovascular Interventions in Patients with Poor Pedal Runoff Hallie E. Baer-Bositis, MD, Taylor D. Hicks, MD, Georges M. Haider, MD, Lori L. Pounds, MD, Matthew J. Sideman, MD, Maureen K. Sheehan, MD, Mark G. Davies MD, PhD, MBA. University of Texas Health Science Center-San Antonio, San Antonio, TX
Conclusions: Pedal runoff score can easily identify those patients who will not achieve ulcer healing and limb salvage after tibial intervention. Defining such subgroups will allow stratification of the patients and appropriate application of interventions. Author Disclosures: H. E. Baer-Bositis: None; T. D. Hicks: None; G. M. Haider: None; L. L. Pounds: None; M. J. Sideman: None; M. K. Sheehan: None; M. G. Davies: None.
A Multi-Institutional Experience in Vascular Ehlers-Danlos Syndrome Sherene Shalhub, MD, MPH,1 Kelli Hicks, BS,1 Karen Woo, MD,2 Dawn Coleman, MD,3 Frank Davis, MD,3 Giovanni De Caridi, MD, PhD,4 K. Nicole Weaver, MD,5 Erin Miller, MS, CGC,6 Marc Schermerhorn, MD,7 Katie Shean, MD,7 Gustavo Oderich, MD,8 Mauricio Ribiero, MD, PhD,8 Cole Nishikawa, MD,9 Kristofer M. Charlton-Ouw, MD,10
e4
Journal of Vascular Surgery
Abstracts
March 2017
Christian-Alexander Behrendt, MD,11 Sebastian Debus, MD, PhD,11 Yskert von Kodolitsch, MD,12 Devin Zarkowsky, MD,13 Richard J. Powell, MD,13 Melanie Pepin, MS, CGC,14 Peter Byers, MD,15 Peter Lawrence MD2. 1University of Washington, Seattle, WA; 2Division of Vascular Surgery, University of California Los Angeles, Los Angeles, CA; 3Section of Vascular Surgery, University of Michigan, Ann Arbor, MI; 4Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy; 5Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cinncinnati, OH; 6The Heart Institute and Division of Human Genetics at Cincinnati Children’s, Cinncinnati, OH; 7 Beth Israel Deaconess Medical Center, Boston, MA; 8Mayo Clinic Division of Vascular Surgery, Rochester, MN; 9University of California, Davis Medical Center, Sacramento, CA; 10Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX; 11 Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany; 12Department of Cardiology, University Heart Center, Hamburg, Germany; 13Division of Vascular Surgery, DartmouthHitchcock Medical Center, Lebanon, NH; 14Medical Genetics, Department of Pathology, Seattle, WA; 15Medical Genetics, Department of Pathology, University of Washington, Seattle, WA Objective: Vascular Ehlers-Danlos syndrome (VEDS) is a rare connective tissue disorder with >700 mutations in the COL3A1 gene affecting collagen type III production. Limited data exist regarding the consequent aortic and branch vessel aneurysms and dissections, presentation, and treatment outcomes. This study aimed to provide a description of a contemporary cohort of patients diagnosed with VEDS. Methods: This was a multi-institutional retrospective cohort study of patients diagnosed with VEDS between 2000 and 2015. Demographics, family history, diagnosis modality, COL3A1 mutations, vascular disease, and management data were collected. Data were presented as median and ranges. Patients with confirmed causative COL3A1 mutations were analyzed for vascular disease. Results: Eleven institutions identified 173 (35.3% male) patients with VEDS. Median age at diagnosis was 26.5 (range, 0.1-81) years by genetic testing, skin biopsy, and clinical criteria in 63%, 3%, and 18% of the cases, respectively. In 16.2%, the diagnosis method was unknown. A family history of confirmed or suspected VEDS, sudden death, stroke, or myocardial infarction was documented in 47.4% of the cases. Arterial dissections or aneurysms were diagnosed in 81 cases (51.9% male). At the time of data collection, 11.6% of the patients died at a median age of 37 (range, 19-70) years, with 95% due to vascular complications. COL3A1 mutation data were available for 79 cases (46.9% male, 5 null mutations). In 15.2% of the cases, the COL3A1 mutations were found to be noncausative. Among those with a causative mutation, 42 (62.9%) were diagnosed with arterial dissections or aneurysms (50% male, 3 null mutations) at a median age of 31.5 (range, 12-79) years. This involved the carotid/vertebral, mesenteric/renal, and iliac arteries in 35.7%, 47.6%, and 31% of the cases, respectively. Aortic involvement occurred in 23.8% of the cases. Mortality in this group was 16.7% at a median age of 43 (range, 22-70) years. Vascular interventions were undertaken in 15 (35.7%) cases (10 open, 5 endovascular), of which 3 were for rupture (thoracic aorta, abdominal aorta, and splenic artery). Conclusions: This is a large, multi-institutional descriptive study of patients diagnosed with VEDS. The study highlights the importance of establishing a precise diagnosis by confirming a causative COL3A1 mutation. This is a first step toward an accurate understanding of the disease and operative outcomes, thus facilitating clear guidelines for management. Author Disclosures: S. Shalhub: None; K. Hicks: None; K. Woo: None; D. Coleman: None; F. Davis: None; G. De Caridi: None; K. Weaver: None; E. Miller: None; M. Schermerhorn: None; K. Shean: None; G. Oderich: None; M. Ribiero: None; C. Nishikawa: None; K. M. Charlton-Ouw: None; C. Behrendt: None; S. Debus: None; Y. von Kodolitsch: None; D. Zarkowsky: None; R. J. Powell: None; M. Pepin: None; P. Byers: None; P. Lawrence: None.
Fig. Superior mesenteric artery (SMA) dissection remodeling computed tomography angiography of a patient presenting with spontaneous SMA dissection (A). He was treated with anticoagulation, but over a period of 9 days, he progressed to complete SMA occlusion with symptoms of bowel ischemia (B). He was treated with mesenteric bypass to a branch of the SMA with restoration of low to the true lumen (C). Author Disclosures: C. E. Morgan: None; M. K. Eskandari: None; H. E. Rodriguez: None.
Evolution of Type II Endoleaks Based on Different Ultrasound-Identified Patterns Spyridon Monastiriotis, MD, Ignatius Lau, MD, Shang Loh, MD, John Ferretti, MD, Apostolos Tassiopoulos, MD, Nicos Labropoulos. SUNY at Stony Brook, Stony Brook, NY
Ten-Year Review of Isolated Spontaneous Mesenteric Arterial Dissections Courtney E. Morgan, MD, Mark K. Eskandari, MD, Rodriguez MD. Northwestern University, Chicago, IL
Objective: Isolated spontaneous dissection of the superior mesenteric artery (SMA) and celiac artery (CA) remains a rare condition but has been increasingly noted incidentally on diagnostic imaging. We sought to study the natural history and outcomes of patients presenting with isolated spontaneous mesenteric artery dissections (SMADs), hypothesizing that most SMADs can be treated nonoperatively. Methods: This was a single-center retrospective review of patients presenting with the diagnosis of SMAD between 2006 and 2016. Data analysis included demographics, clinical data, radiologic review, treatment, and outcomes. Results: A total of 78 patients were found to have isolated CA or SMA dissection diagnosed on computed tomography or magnetic resonance imaging. Average age was 56 years (range, 26-86); 80% were male. Nine patients (12%) had underlying arterial disease; five had fibromuscular dysplasia, and four had segmental arterial mediolysis. The majority, 64%, presented with symptoms including abdominal pain, back pain, and chest pain; the remaining 36% were asymptomatic. Combined SMA and CA dissection was found in 14 (18%) patients, whereas 33 (42%) presented with isolated CA dissection and 31 (40%) presented with isolated SMA dissection. Only four patients required intervention. Mesenteric bypass was performed in two patients, and SMA endarterectomy with patch angioplasty was performed in one patient for signs of bowel ischemia. No patient required bowel resection. The two bypasses were anastomosed to a branch of the SMA, and complete lumen restoration was seen on long-term imaging follow-up (Fig). One patient underwent stent grafting of the CA and hepatic artery for aneurysmal degeneration 1 month after diagnosis. The remaining 74 patients were managed nonoperatively; 40 (55%) were treated with a short course of anticoagulation, 23 (31%) were treated with antiplatelet therapy, and 10 (14%) were treated with observation alone. No other later interventions or recurrences were noted during a mean follow-up period of 21 months. Conclusions: Whereas isolated SMAD poses a risk of visceral ischemia, most patients presenting with this diagnosis can be treated nonoperatively with a short course of antiplatelet or anticoagulant therapy. Indications for surgical intervention include bowel ischemia and aneurysmal degeneration.
Heron E.
Objective: The objective of this study was to delineate the specific types of waveforms that exist in type II endoleaks (T2ELs) and their effect on the aneurysmal sac size.