Live Cases From Houston Methodist and Miami Vascular Show Complex Clinical Decisions

Live cases from Miami Cardiac and Vascular Institute as well as Houston Methodist were highlighted for audience members and a panel of experts in a session moderated by Chris Metzger, MD. The first case was from Houston and involved a 68-year-old man who had presented in 2017 for abdominal aortic aneurysm rupture, which was salvaged. He had renal failure after that and is currently on dialysis but has a donor lined up. The man has a 5.9 cm diameter fusiform aneurysm descending from the thoracic aorta that was unchanged in size and appearance since prior examination.

Led by Alan Lumsden, MD, the team showed the audience the imaging that had been used in the case. MR was done, but it was pointed out that MR does not show calcification, making CT also necessary. A 3D cone-beam CT image was acquired before the patient was prepped, and technology was used to fuse the images and correlate the MR signal with the cone beam CT calcification. With the fused image, vessel origins were marked and disease in the aortic wall was more clearly seen.

The operating team discussed the possibilities for treatment, including open repair. The appropriateness of treating the patient was also considered, given that renal failure increases mortality, but Dr. Lumsden pointed out that the previous rupture weighed heavily on the patient’s mind.

Due to safety reasons, Dr. Lumsden ultimately decided not to pursue a thoracic stent graft and said he would need to further discuss options with the patient. This case, he said, had been brought to a panel at the hospital and “no one was enthusiastic about opening his chest, but I’m beginning to think it’s the best option for this patient long term,” said Dr. Lumsden. “I’m thinking this needs to be done before his kidney transplant.”

The panel was asked whether an ongoing endovascular repair should be pursued, or whether an open repair should be done, with the patient subsequently undergoing his kidney transplant. A poll revealed divergence of opinions, with 34% choosing open repair, 33% choosing an endoconduit, 11% an expandable sheath, 11% a surgical conduit, and 11% stopping at this point and using a lower profile device.

Dr. Metzger commended the team on an interesting case, and compelling demonstration of technology and thought process. “We don’t need to go through and do a graft without the right considerations,” he said.

The next case was presented from Miami Cardiac and Vascular Institute. The patient was a 73-year-old man with Rutherford 5 critical limb ischemia (CLI) evidenced by non-healing bilateral heel wounds secondary to multilevel disease. The heel wounds had developed while the patient was hospitalized during recovery from a fall. He had a history of diabetes and stroke and was a former tobacco user.

The team described the internal discussion they had had prior to going live. The patient has multifocal disease and bilateral relatively short iliac stenosis, a left SFA occlusion, and likely has distal tibial disease. After considering all options, the team committed to an antegrade right access with the idea of working all the way to the foot from the right. Then they planned to come back and from the right access go down to the left to treat the both iliac stenoses along the way.

The panel then discussed tight disease in the SFA and whether they would fix the SFA and popliteal disease and stop to see if the patient gets better, or go to the posterior tibial once the SFA and popliteal are fixed. Further discussion included whether distal embolic protection should be used.

James Benenati, MD, a member of the operating team, commented that there is physiologically significant disease in the patient. “As far as distal protection, that’s an interesting point. We generally don’t use distal protection when doing balloon and stent procedures. If we do atherectomy we will use it, but in our practice we are not using atherectomy routinely in this type of case.”

He explained that they are planning to use a DCB with prolonged inflation, then go after the popliteal and make a reassessment. The operating team discussed with the audience whether the lesion being treated was a focal lesion or would need to be treated all the way down.

At this point, Dr. Metzger directed the audience to another case. Barry Katzen, MD, led the operating team treating a 90-year-old man with an enlarging 6.3 cm abdominal aortic aneurysm presenting for endovascular repair. The patient was initially managed conservatively due to renal insufficiency from polycystic kidney disease. The man was a former smoker and had a history of atrial fibrillation, treated lymphoma and lung cancer, dyslipidemia, and hypertension.

The patient had tortuous iliac vessels that made it hard to get a wire around. With some difficulty, the team was able to advance the device. In response to a question from the panel, Dr. Katzen explained that the team began with progressive dilatation and that the procedure had to be done under conscious sedation as a result of the patient’s age and respiratory risk.

The panel and team then discussed factors playing into the decision to operate on older patients, as well as outcomes from personal clinical experience with older patients, which were mostly positive. Frailty was highlighted as a major factor, and the panel agreed that 90-year-old patients vary greatly in what they can tolerate.

Dr. Katzen’s team tried different sheaths and ultimately planned to show a completion image the next day. Dr. Metzger commented that the case was a great example of overcoming challenging anatomy one step at a time.

—Lauren LeBano