The Good, the Bad, and the Ugly

By John R. Laird, Jr, MD, Chief Medical Editor

Although there is no substitute for a randomized clinical trial with regard to advancing our knowledge in a particular field of medicine, there is still an important role for case-based learning. Lessons learned from watching a live case at a demonstration course or reading an exciting case report may make all the difference in the management of a patient in our daily practice. Whether it is "the good, the bad, or the ugly," for the interventionist, there is always something to be gained from the experience of our colleagues.

In this issue of Endovascular Today, we present a number of remarkable cases across the spectrum of vascular intervention. We start with an interesting venous intervention presented by George H. Meier, MD, RVT, FACS. Dr. Meier uses aggressive deep venous thrombosis management options to successfully treat a fellow physician with recurrent iliofemoral deep venous thrombosis and pulmonary embolus in the setting of a bifid external iliac vein. Tara M. Mastracci, MD; Roy K. Greenberg, MD; and Kate Pfaff, BS, present a case of a patient with a pelvic kidney arising from a sizeable abdominal aortic aneurysm treated using an off-the-shelf helical limb and a custom, fenestrated graft. This cases provides encouraging evidence for the future widespread use of helical branch technology.

There is always a lot to be learned from seeing our colleagues bail themselves out of trouble. David L. Dawson, MD, addresses stenting options for treating perforations and arteriovenous fistulae that have resulted from infrapopliteal endovascular procedures performed for limb-threatening ischemia. Donald T. Baril, MD, and Mark H. Wholey, MD, present two challenging endovascular cases this month, illustrating treatment of renal parenchyma hemorrhage in one and salvage of a displaced carotid filter in the other. Andrew Holden, MBChB, FRANZCR, presents a difficult renal artery stenting case, which illustrates recognition and successful treatment of stent malpositioning and antegrade dissection. Dr. Holden provides a helpful discussion and useful teaching points for management of this clinical occurrence.

We continue to face many challenges in the management of complex aortic pathology, and creative solutions are often required. Using a combination of stent grafts and covered stents, Shigeki Hirayama, MD; Yuji Kanaoka, MD; Makoto Sumi, MD; and Takao Ohki, MD, PhD, treated a large chronic thoracic and abdominal aortic dissection. Their article details this challenging case and concludes that endovascular treatment is a feasible option in select cases. Rodney A. White, MD; Carlos E. Donayre, MD; Irwin Walot, MD; Maurice Lippmann, MD; Dongyu Tony Fang, MD; and George Kopchock, BS, share a case in which endovascular intervention and lumbar drainage in a thoracic dissection patient rapidly resolved paraplegia after failed medical management. Lawrence Rajan, MD; Kathryn Dougherty; Igor Gregoric, MD; and Neil E. Strickman, MD, report on a patient with aortic disease who developed acute mesenteric vascular ischemia during endovascular aneurysm exclusion with visceral debranching.

My fellow Jack Wei Cheih Tan, MBBS, and I describe an interesting case of a patient who presents with acute-on-chronic mesenteric ischemia and underwent successful recanalization of an occluded superior mesenteric artery and severely diseased celiac trunk. Vinay Kumar, MD, describes carotid artery stenting of an elderly patient using the transbrachial approach rather than the more commonly used femoral approach. Dr. Kumar concludes that in patients with difficult aortic arch anatomy, this may often be the preferred approach.

Our Imaging & Diagnostics article comes from Peter S. Fail, MD, FACC, FACP, and Vinod Nair, MD, FACC, who assert that CTA is the ideal platform for the planning and follow-up of patients undergoing endovascular repair of thoracic aortic aneurysms. James Benenati, MD, discusses the evolving protocols and standards for evaluating peripheral arterial disease patients, describing when and how noninvasive testing can be successfully implemented. Our first featured interview for the New Year is with John R. Ross, MD, an expert in the care of dialysis patients. Dr. Ross discusses the importance of patient education, his practice's methods for graft and access site management, and the function of the American Society of Diagnostic and Interventional Nephrology, which provides certification for candidates in this field.

We hope that lessons learned from these cases will benefit you in the year to come as you face your own challenges. Best wishes for a happy and successful 2008!


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About Endovascular Today

Endovascular Today is a publication dedicated to bringing you comprehensive coverage of all the latest technology, techniques, and developments in the endovascular field. Our Editorial Advisory Board is composed of the top endovascular specialists, including interventional cardiologists, interventional radiologists, vascular surgeons, neurologists, and vascular medicine practitioners, and our publication is read by an audience of more than 22,000 members of the endovascular community.