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Differences in Aortic Diameter Measurements With Intravascular Ultrasound and Computed Tomography After Blunt Traumatic Aortic Injury
JOURNAL OF VASCULAR SURGERY Volume 64, Number 2
Abstracts 545
Endovascular Versus Open Bypass Surgery for TASC D Femoropopliteal Lesions in Patients With Critical Limb Ischemia Jason T. Nieves, MD, Gagan Singh, John Laird, William Pevec, Misty Humphries, MD. UC Davis Medical Center, Sacramento, Calif
Fig. Observed expected morbidity rates for open and endovascular abdominal aortic aneurysm repair stratified by size of aneurysm.
Objective: The TransAtlantic Inter-Society Consensus II (TASC II) recommendation for treatment of type D lesions of the femoral-popliteal arteries is surgical revascularization. However, more physicians use an “endovascularfirst” approach for these lesions because of relatively recent advancements in technology and decreased procedural morbidity. The hypothesis is that endovascular interventions have comparable outcomes to surgical bypass for TASC II D lesions in patients with critical limb ischemia (CLI). Methods: A retrospective review was performed of all patients with CLI and infrainguinal TASC II D lesions who underwent open or endovascular intervention at our institution between 2007 and 2015. The primary outcomes were limb events, defined as any reintervention needed after the initial procedure, and major amputations (above the ankle). Kaplan-Meier analysis was used to analyze the primary outcomes and mortality. The standard errors for the reported analyses were all <10%. Cox proportional hazards modeling was used to adjust for covariates. Results: Fifty patients and 61 limbs with CLI and infrainguinal TASC D disease were identified. Open revascularization was performed on 30 limbs; 31 underwent endovascular treatment. The mean patient age was 72 6 13 years. There was a higher rate of end-stage renal disease (10 vs 0; P ¼ .008) and
favoring earlier repair in this group. However, endovascular repair still results in fewer complications than open repair across all size strata.
Differences in Aortic Diameter Measurements With Intravascular Ultrasound and Computed Tomography After Blunt Traumatic Aortic Injury Maria Ceja Rodriguez, BA, Augustus Realyvasquez, Joseph Galante, MD, William Pevec, MD, Misty Humphries, MD. University of California, Davis, Davis, Calif Objective: Intravascular ultrasound (IVUS) has been recommended as an adjunct to thoracic endovascular aortic repair (TEVAR) because computed tomography (CT) in injured patients with vasoconstriction due to shock may inaccurately determine the true aortic diameter. Hypothesis: CT underestimates aortic diameter in trauma patients compared with IVUS. Methods: Patients treated by TEVAR for blunt aortic injury from June 2013 to 2016 were reviewed. Cases in which IVUS was not used and those without complete CT and IVUS images were excluded. Threedimensional reconstructions were used to derive centerline diameters of the aorta proximal and distal to the injury. IVUS diameters were taken from adventitial measurements of the aorta. Measurements were made by an investigator blinded to the graft implanted. Descriptive statistics were used to compare patients with concordant diameter (group 1) to patients with discordant diameters (group 2). Results: A total of 24 blunt thoracic aortic injuries were repaired with TEVAR during the study period; complete data were available for 16. The mean age of the patients was 43 (618) years, and 12 of the patients were men. The median time from injury to CT was 2.5 hours (interquartile range, 0.9-8.5) and to TEVAR, 18 hours (interquartile range, 3-48). Graft diameters chosen by CT and IVUS imaging were the same in five cases (group 1). In 11 cases, the graft diameters based on IVUS were one size larger than those determined by CT (group 2). There were no significant differences in the lowest systolic blood pressure (98 vs 92; P ¼ .53), mean fluid resuscitation in the first 24 hours (4.9 vs 5.0 L; P ¼ .97), or 24-hour transfusion requirements (130 vs 1311 mL; P ¼ .11) between groups 1 and 2, respectively. In group 2, the graft size chosen for surgery correlated more with measurements obtained from CT than from IVUS (9 vs 2). Conclusions: TEVAR has become the standard therapy for blunt aortic injury despite a dearth of long-term outcome data. Preoperative CT frequently underestimates aortic diameter compared with intraoperative IVUS. As thoracic aortic diameters are known to increase with advancing age, the implications of this finding will be determined by future evaluations of late outcomes in this relatively young population.
Fig 1. Comparison of limb events.
Fig 2. Comparison of amputation rates.
Abstracts 545
Endovascular Versus Open Bypass Surgery for TASC D Femoropopliteal Lesions in Patients With Critical Limb Ischemia Jason T. Nieves, MD, Gagan Singh, John Laird, William Pevec, Misty Humphries, MD. UC Davis Medical Center, Sacramento, Calif
Fig. Observed expected morbidity rates for open and endovascular abdominal aortic aneurysm repair stratified by size of aneurysm.
Objective: The TransAtlantic Inter-Society Consensus II (TASC II) recommendation for treatment of type D lesions of the femoral-popliteal arteries is surgical revascularization. However, more physicians use an “endovascularfirst” approach for these lesions because of relatively recent advancements in technology and decreased procedural morbidity. The hypothesis is that endovascular interventions have comparable outcomes to surgical bypass for TASC II D lesions in patients with critical limb ischemia (CLI). Methods: A retrospective review was performed of all patients with CLI and infrainguinal TASC II D lesions who underwent open or endovascular intervention at our institution between 2007 and 2015. The primary outcomes were limb events, defined as any reintervention needed after the initial procedure, and major amputations (above the ankle). Kaplan-Meier analysis was used to analyze the primary outcomes and mortality. The standard errors for the reported analyses were all <10%. Cox proportional hazards modeling was used to adjust for covariates. Results: Fifty patients and 61 limbs with CLI and infrainguinal TASC D disease were identified. Open revascularization was performed on 30 limbs; 31 underwent endovascular treatment. The mean patient age was 72 6 13 years. There was a higher rate of end-stage renal disease (10 vs 0; P ¼ .008) and
favoring earlier repair in this group. However, endovascular repair still results in fewer complications than open repair across all size strata.
Differences in Aortic Diameter Measurements With Intravascular Ultrasound and Computed Tomography After Blunt Traumatic Aortic Injury Maria Ceja Rodriguez, BA, Augustus Realyvasquez, Joseph Galante, MD, William Pevec, MD, Misty Humphries, MD. University of California, Davis, Davis, Calif Objective: Intravascular ultrasound (IVUS) has been recommended as an adjunct to thoracic endovascular aortic repair (TEVAR) because computed tomography (CT) in injured patients with vasoconstriction due to shock may inaccurately determine the true aortic diameter. Hypothesis: CT underestimates aortic diameter in trauma patients compared with IVUS. Methods: Patients treated by TEVAR for blunt aortic injury from June 2013 to 2016 were reviewed. Cases in which IVUS was not used and those without complete CT and IVUS images were excluded. Threedimensional reconstructions were used to derive centerline diameters of the aorta proximal and distal to the injury. IVUS diameters were taken from adventitial measurements of the aorta. Measurements were made by an investigator blinded to the graft implanted. Descriptive statistics were used to compare patients with concordant diameter (group 1) to patients with discordant diameters (group 2). Results: A total of 24 blunt thoracic aortic injuries were repaired with TEVAR during the study period; complete data were available for 16. The mean age of the patients was 43 (618) years, and 12 of the patients were men. The median time from injury to CT was 2.5 hours (interquartile range, 0.9-8.5) and to TEVAR, 18 hours (interquartile range, 3-48). Graft diameters chosen by CT and IVUS imaging were the same in five cases (group 1). In 11 cases, the graft diameters based on IVUS were one size larger than those determined by CT (group 2). There were no significant differences in the lowest systolic blood pressure (98 vs 92; P ¼ .53), mean fluid resuscitation in the first 24 hours (4.9 vs 5.0 L; P ¼ .97), or 24-hour transfusion requirements (130 vs 1311 mL; P ¼ .11) between groups 1 and 2, respectively. In group 2, the graft size chosen for surgery correlated more with measurements obtained from CT than from IVUS (9 vs 2). Conclusions: TEVAR has become the standard therapy for blunt aortic injury despite a dearth of long-term outcome data. Preoperative CT frequently underestimates aortic diameter compared with intraoperative IVUS. As thoracic aortic diameters are known to increase with advancing age, the implications of this finding will be determined by future evaluations of late outcomes in this relatively young population.
Fig 1. Comparison of limb events.
Fig 2. Comparison of amputation rates.