A mycotic aneurysm of a jejunal branch treated by aneurysmectomy without bowel resection.

Jejunal artery pseudoaneurysms are extremely rare, accounting for <1% of all visceral artery pseudoaneurysms. Fewer than 50 cases were reported in literature during the previous century. This case report describes the case of a 72-year-old man who underwent aneurysmectomy to treat a 21-mm mycotic jejunal artery pseudoaneurysm found in the setting of endocarditis. This pseudoaneurysm was treated with laparotomy, and gentle dissection of the tissues surrounding the pseudoaneurysm was performed before ligation and resection. This allowed for vascular collateral branch preservation, which, thus, avoided concomitant bowel resection. This report highlights the feasibility of this technique.

Treating a Large Thoracoabdominal Aneurysm With Aberrant Right Subclavian Artery With a Physician-Modified Graft.

CLINICAL IMPACT: Large thoracoabdominal aortic aneurysms due to chronic aortic dissection in patients with connective tissue disorders such as Loeys-Dietz syndrome present a challenging scenario, particularly in cases of variant anatomy and when patients are not candidates for conventional open repair. We demonstrate how by combining and modifying off-the-shelf devices during a hybrid procedure, one can create an endovascular solution tailored to the patient's complex anatomy, making use of an aberrant right subclavian artery, and allow for good clinical outcomes.

Safety of transition from a routine to a selective intensive care admission pathway after elective open aneurysm repair.

Background: There is a growing trend to implement intermediate care units to avoid unnecessary costs associated with intensive care unit (ICU) admission and associated resources. We sought to evaluate the safety of transitioning from a routine to a selective policy of postoperative transfer to the ICU for elective open abdominal aortic aneurysm (AAA) repair. Methods: This retrospective study included consecutive open elective AAA repair procedures performed at a single centre from Aug. 8, 2010, to Dec. 1, 2014. Patients were identified through a prospectively maintained database, and electronic charts were reviewed. Patients with interventions before Mar. 13, 2012, were routinely sent to the ICU after operation (group A). Patients treated after this date were sent directly to an intermediate care unit (group B) unless preoperative or intraoperative factors deemed them suitable for ICU admission. The primary outcome was in-hospital death; secondary outcomes were perioperative complications and length of stay. We used logistic and linear regression to determine the association between the use of an intermediate care unit and the primary and secondary outcomes after adjusting for confounders and clinically relevant covariates. Results: The cohort comprised 310 patients (266 men, 44 women) with a mean age of 69.7 (standard deviation 10.1) years and a mean AAA diameter of 61.2 mm (SD 9.6 mm). Groups A and B included 118 and 192 patients, respectively. Admission to the ICU was spared in 149 patients (77.6%) in group B. Only 2 patients (1.3%) in group B were subsequently admitted to the ICU. There was no statistically significant difference in in-hospital mortality or perioperative complications between the 2 groups on multivariable logistic regression. There was a nonsignificant trend toward slightly shorter length of stay in group B. Conclusion: In this single-centre experience with the majority of patients sent directly to an intermediate care unit, there was no statistically significant difference in mortality or morbidity between routine and selective ICU admission. Our results confirm the safety of a selective ICU admission pathway.

Contexte: La tendance est à la création d'unités de soins intermédiaires pour éviter les coûts inutiles entraînés par les séjours aux unités de soins intensifs (USI) et les ressources associées. La présente étude visait à évaluer la sécurité d'un transfert aux USI sélectif, plutôt que systématique, après la réparation ouverte élective d'un anévrisme aortique abdominal (AAA). Méthodes: Cette étude rétrospective portait sur des réparations ouvertes électives d'AAA consécutivement réalisées à un même centre pour la période du 8 août 2010 au 1er décembre 2014. Nous avons recensé les cas dans une base de données maintenue de manière prospective, puis avons étudié les dossiers électroniques. Les patients opérés avant le 13 mars 2012 ont été envoyés d'emblée à l'USI après l'intervention (groupe A). Ceux traités après cette date ont été transférés directement en soins intermédiaires (groupe B), sauf s'ils se qualifiaient pour l'admission à l'USI en raison de facteurs préopératoires ou intraopératoires. Le principal résultat à l'étude était les décès à l'hôpital; les résultats secondaires étaient les complications périopératoires et la durée du séjour. Un modèle de régression logistique a servi à déterminer les associations entre le transfert direct en soins intermédiaires et les résultats primaire et secondaires en tenant compte des facteurs de confusion et des covariables pertinentes sur le plan clinique. Résultats: La cohorte regroupait 310 patients (266 hommes et 44 femmes) dont l'âge moyen était de 69,7 ans (écart-type 10,1) et le diamètre moyen de l'AAA était de 61,2 mm (ET 9,6 mm). Les groupes A et B comptaient 118 et 192 patients, respectivement. L'admission aux soins intensifs a été évitée chez 149 patients (77,6 %) du groupe B. Seuls 2 (1,3 %) d'entre eux ont dû être admis à l'USI après coup. La régression logistique multivariable n'a montré aucune différence statistiquement significative entre les groupes à l'égard de la mortalité à l'hôpital et des complications périopératoires. Nous avons noté une réduction non significative de la durée de séjour pour le groupe B. Conclusion: Cette étude monocentrique où la majorité des patients ont été transférés directement en soins intermédiaires n'a pas révélé de différence statistiquement significative à l'égard de la mortalité et de la morbidité entre les admissions systématiques et sélectives aux USI. Nos résultats confirment que l'admission sélective en soins intensifs est une option sécuritaire.

Carotid endarterectomy after systemic thrombolysis in a stroke population.

OBJECTIVE: Vascular specialists are increasingly being requested to perform carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) for stroke patients, raising concerns about hemorrhagic complications. Few case series and registry reports have assessed the question, and even fewer studies have included a control group. The aim of this study was to evaluate the overall outcome of patients undergoing CEA after IVT and to compare them with contemporary patients with CEA after simple stroke (non-IVT group). It also aimed to evaluate the differences in outcomes of stroke patients requiring CEA between nonvascular and vascular centers. METHODS: The data of 169 consecutive patients who have undergone CEA after stroke in a single center was analyzed from January 2011 to December 2016, 27 of them (16%) having undergone previous IVT. A comparative analysis between the non-IVT and the IVT groups was performed. The time between stroke diagnosis and referral to a vascular specialist was also studied. RESULTS: Age, sex, and cardiovascular comorbidities were similar in both groups. Median time between stroke and CEA was 13 days (Q1-Q3, 8-23 days), with 16 of the 27 patients (59%) in the IVT group undergoing CEA less than 14 days after the initial event. There were three intracranial hemorrhages (2.1%) in the non-IVT group versus one (3.7%) in the IVT group (P = NS). The overall 30-day combined stroke and death rate was 7.1% (6.3% in the non-IVT group vs 11.1% in the IVT group; P = .70). The incidence of postoperative cervical hematoma requiring reoperation was similar in both groups (2.1% vs 3.7%; P = NS). The median time between diagnosis of stroke and referral to a vascular specialist was higher for patients in nonvascular centers compared with vascular centers (3.5 days vs 1.0 day; P < .001), which translated to fewer patients referred from nonvascular centers undergoing surgery in the 14-day window period (38% vs 67%; P < .001). CONCLUSIONS: In this retrospective analysis, CEA after IVT showed similar outcomes when compared with the overall CEA after stroke population. Stroke patients diagnosed in nonvascular centers were referred later than those in vascular centers and, although postoperative outcomes were similar, that was correlated with fewer patients undergoing surgery in a timely fashion.

An institutional study of time delays for symptomatic carotid endarterectomy.

OBJECTIVE: The aim of this study was to assess time delays between first cerebrovascular symptoms and carotid endarterectomy (CEA) at a single center and to systematically evaluate causes of these delays. METHODS: Consecutive adult patients who underwent CEAs between January 2010 and September 2011 at a single university-affiliated center (Centre Hospitalier de l'Université Montréal-Hôtel-Dieu Hospital, Montreal) were identified from a clinical database and operative records. Covariates of interest were extracted from electronic medical records. Timing and nature of the first cerebrovascular symptoms were also documented. The first medical contact and pathway of referral were also assessed. When possible, the ABCD2 score (age, blood pressure, clinical features, duration of symptoms, and diabetes) was calculated to calculate further risk of stroke. The nonparametric Wilcoxon test was used to assess differences in time intervals between two variables. The Kruskal-Wallis test was used to assess differences in time intervals in comparing more than two variables. A multivariate linear regression analysis was performed using covariates that were determined to be statistically significant in our sensitivity analyses. RESULTS: The cohort consisted of 111 patients with documented symptomatic carotid stenosis undergoing surgical intervention. Thirty-nine percent of all patients were operated on within 2 weeks from the first cerebrovascular symptoms. The median time between the occurrence of the first neurologic symptom and the CEA procedure was 25 (interquartile range [IQR], 11-85) days. The patient-dependent delay, defined as the median delay between the first neurologic symptom and the first medical contact, was 1 (IQR, 0-14) day. The medical-dependent delay was defined as the time interval between the first medical contact and CEA. This included the delay between the first medical contact and the request for surgery consultation (median, 3 [IQR, 1-10] days). The multivariate regression model demonstrated that the emergency physician as referral source (P = .0002) was statistically significant for reducing CEA delay. Patients who were investigated as an outpatient (P = .02), first medical contact with a general practitioner (P = .0002), and hospital center I as referral center (P = .045) were also found to be statistically significant to extend CEA delay when the model was adjusted over all covariates. In this center, there was no correlation between ABCD2 risk score and waiting time for surgery. CONCLUSIONS: The majority of our cohort falls short of the recommended 2-week interval to perform CEA. Factors contributing to reduced CEA delay were presentation to an emergency department, in-patient investigations, and a stroke center where a vascular surgeon is available.

Source of errors and accuracy of a two-dimensional/three-dimensional fusion road map for endovascular aneurysm repair of abdominal aortic aneurysm.

PURPOSE: To evaluate the accuracy and source of errors using a two-dimensional (2D)/three-dimensional (3D) fusion road map for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. MATERIALS AND METHODS: A rigid 2D/3D road map was tested in 16 patients undergoing EVAR. After 3D/3D manual registration of preoperative multidetector computed tomography (CT) and cone beam CT, abdominal aortic aneurysm outlines were overlaid on live fluoroscopy/digital subtraction angiography (DSA). Patient motion was evaluated using bone landmarks. The misregistration of renal and internal iliac arteries were estimated by 3 readers along head-feet and right-left coordinates (z-axis and x-axis, respectively) before and after bone and DSA corrections centered on the lowest renal artery. Iliac deformation was evaluated by comparing centerlines before and during intervention. A score of clinical added value was estimated as high (z-axis < 3 mm), good (3 mm ≤ z-axis ≤ 5 mm), and low (z-axis > 5 mm). Interobserver reproducibility was calculated by the intraclass correlation coefficient. RESULTS: The lowest renal artery misregistration was estimated at x-axis = 10.6 mm ± 11.1 and z-axis = 7.4 mm ± 5.3 before correction and at x-axis = 3.5 mm ± 2.5 and z-axis = 4.6 mm ± 3.7 after bone correction (P = .08), and at 0 after DSA correction (P < .001). After DSA correction, residual misregistration on the contralateral renal artery was estimated at x-axis = 2.4 mm ± 2.0 and z-axis = 2.2 mm ± 2.0. Score of clinical added value was low (n = 11), good (n= 0), and high (n= 5) before correction and low (n = 5), good (n = 4), and high (n = 7) after bone correction. Interobserver intraclass correlation coefficient for misregistration measurements was estimated at 0.99. Patient motion before stent graft delivery was estimated at x-axis = 8 mm ± 5.8 and z-axis = 3.0 mm ± 2.7. The internal iliac artery misregistration measurements were estimated at x-axis = 6.1 mm ± 3.5 and z-axis = 5.6 mm ± 4.0, and iliac centerline deformation was estimated at 38.3 mm ± 15.6. CONCLUSIONS: Rigid registration is feasible and fairly accurate. Only a partial reduction of vascular misregistration was observed after bone correction; minimal DSA acquisition is still required.

Reduction in allogeneic blood products with routine use of autotransfusion in open elective infrarenal abdominal aortic aneurysm repair.

BACKGROUND AND OBJECTIVES: Concern about allogeneic blood product cost and complications has prompted interest in blood conservation techniques. Intraoperative autotransfusion (IAT) is currently not used routinely by vascular surgeons in open elective infrareanl abdominal aortic aneurysm (AAA) repair. The objective of this study is to review our experience with IAT and its impact on blood transfusion. METHODS: We retrospectively reviewed the medical records of consecutive patients treated electively over a 4-year period and compared 2 strategy related to IAT, routine use IAT (rIAT) versus on-demand IAT (oIAT). Outcomes measured were number of units of allogeneic red blood cells and autologous red blood cells transfused intraoperatively and postoperatively, preoperative, postoperative, and discharge hemoglobin levels; postoperative infections; length of postoperative intensive care stay; and length of hospital stay. T-independent and Fisher exact test were used. RESULTS: A total of 212 patients were included, 38 (18%) in the rIAT and 174 (82%) in the oIAT. Groups were similar except for an inferior creatinine and a superior mean aneurysm diameter for the rIAT group. Patients in the rIAT group had a lower rate of transfusion (26% vs 54%, P = .002) and a lower mean number of blood unit transfused (0.8 vs 1.8, P = .048). These findings were still more significant for AAA larger than 60 mm (18% rIAT vs 62% oIAT, P = .0001). Postoperative hemoglobin was superior in the rIAT group (107 vs 101 g/L, P = .01). Mean postoperative intensive care length of stay was shorter for the rIAT group (1.1 vs 1.8 days, P = .01). No difference was noted for infection, mortality, or hospital length of stay. CONCLUSION: The rIAT reduced the exposure to allogeneic blood products by more than 50%, in particular for patients with AAA larger than 60 mm. These results support the use of rIAT for open elective infrarenal AAA repair.

Regional anesthesia for carotid surgery: less intraoperative hypotension and vasopressor requirement.

Regional anesthesia (RA) is the gold standard of neuromonitoring during carotid endarterectomy (CEA). Recent data show that RA for CEA is associated with fewer postoperative complications. The aim of the present study was to assess hemodynamic stability and vasoactive drug use for CEA performed under RA versus general anesthesia (GA). All patients undergoing CEA from January 2005 to January 2006 were identified from our prospective database. Electronic and paper charts were reviewed. Intraoperative monitoring data were reviewed retrospectively. Hypotension was defined as systolic blood pressure (SBP) <100 mm Hg and deemed prolonged if it lasted more than 10 min. Hypertension was defined as SBP >160 mm Hg. BP variation was defined as the difference between the highest and lowest SBP, and bradycardia as heart rate (HR) below 60. The data were expressed as means +/- standard deviation. Seventy-two consecutive patients underwent CEA: 25 under RA and 47 under GA. There was no difference in preoperative HR and BP. Most patients had symptomatic severe carotid stenosis (80% in RA vs. 85% in GA, nonsignificant). Intraoperatively, RA was associated with less BP variation (60 +/- 27 vs. 78 +/- 22 mm Hg, p = 0.005), bradycardia (5% vs. 63%, p < 0.001), hypotension (20% vs. 70%, p < 0.01), and prolonged hypotension (0% vs. 23%, p = 0.009) and more hypertension (80% vs. 47%, p = 0.007). Vasopressor requirements were less frequent under RA (20% vs. 77%, p < 0.001). There was no significant difference between groups in hypotension or hypertension episodes seen in the postoperative recovery room. RA was associated with less hypotension and less vasopressor used during CEA compared to GA. The improved hemodynamic stability may account for the lower incidence of complications after CEA.

Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm.

BACKGROUND: Percutaneous catheterization is a frequently-used technique to gain access to the central venous circulation. Inadvertent arterial puncture is often without consequence, but can lead to devastating complications if it goes unrecognized and a large-bore dilator or catheter is inserted. The present study reviews our experience with these complications and the literature to determine the safest way to manage catheter-related cervicothoracic arterial injury (CRCAI). METHODS: We retrospectively identified all cases of iatrogenic carotid or subclavian injury following central venous catheterization at three large institutions in Montreal. We reviewed the French and English literature published from 1980 to 2006, in PubMed, and selected studies with the following criteria: arterial misplacement of a large-caliber cannula (>/=7F), adult patients (>18 years old), description of the method for managing arterial trauma, reference population (denominator) to estimate the success rate of the therapeutic option chosen. A consensus panel of vascular surgeons, anesthetists and intensivists reviewed this information and proposed a treatment algorithm. RESULTS: Thirteen patients were treated for CRCAI in participating institutions. Five of them underwent immediate catheter removal and compression, and all had severe complications resulting in major stroke and death in one patient, with the other four undergoing further intervention for a false aneurysm or massive bleeding. The remaining eight patients were treated by immediate open repair (six) or through an endovascular approach (two) for subclavian artery trauma without complications. Five articles met all our inclusion criteria, for a total of 30 patients with iatrogenic arterial cannulation: 17 were treated by immediate catheter removal and direct external pressure; eight (47%) had major complications requiring further interventions; and two died. The remaining 13 patients submitted to immediate surgical exploration, catheter removal and artery repair under direct vision, without any complications (47% vs 0%, P = .004). CONCLUSION: During central venous placement, prevention of arterial puncture and cannulation is essential to minimize serious sequelae. If arterial trauma with a large-caliber catheter occurs, prompt surgical or endovascular treatment seems to be the safest approach. The pull/pressure technique is associated with a significant risk of hematoma, airway obstruction, stroke, and false aneurysm. Endovascular treatment appears to be safe for the management of arterial injuries that are difficult to expose surgically, such as those below or behind the clavicle. After arterial repair, prompt neurological evaluation should be performed, even if it requires postponing elective intervention. Imaging is suggested to exclude arterial complications, especially if arterial trauma site was not examined and repaired.

Totally laparoscopic aortic surgery: comparison of the apron and retrocolic techniques in a porcine model.

This study evaluated the learning curve for a second-year general surgery resident and compared 2 totally laparoscopic aortic surgery techniques in 10 pigs: the transretroperitoneal apron approach and the transperitoneal retrocolic approach. Five end points were compared: success rate, percentage of conversion, time required, laparoscopic anastomosis quality, and learning curve. The first 3 interventions required an open conversion. The last 7 were done without complications. Mean dissection time was significantly higher with the apron approach compared with the retrocolic approach. The total times for operation, clamping, and arteriotomy time were similar. All laparoscopic anastomoses were patent and without stenosis. The initial learning curve for laparoscopic anastomosis was relatively short for a second-year surgery resident. Both techniques resulted in satisfactory exposure of the aorta and similar mean operative and clamping time. Training on an ex vivo laparoscopic box trainer and on an animal model seems to be complementary to decrease laparoscopic anastomosis completion time.

Endovascular embolization of symptomatic arteriovenous fistulas secondary to lower-limb in situ venous bypass grafts.

PURPOSE: To evaluate the safety and efficacy of endovascular treatment of symptomatic arteriovenous (AV) fistulas associated with femoropopliteal in situ venous bypass grafts. MATERIALS AND METHODS: Twenty-one patients underwent embolization of symptomatic AV fistulas associated with lower-limb bypass with use of the saphenous vein (n = 16) or femoral vein (n = 5). The procedures were performed with microcatheters and metallic coils. Indications for embolization were venous congestion (n = 15) and arterial insufficiency (n = 6). Eight patients had persistent lower-limb edema, seven had painful inflammatory skin thickening, three had intermittent claudication, and three had nonhealing ulcers. RESULTS: Forty-four AV fistulas were embolized. Symptoms of venous congestion regressed completely in 12 of 15 patients (80%). Partial symptom improvement was achieved in three other patients (20%), two of whom had persistent lower-limb edema and bypass with use of the femoral vein. Five of six patients with ischemic symptoms (83%) had complete symptom relief. One patient (17%) whose ischemic ulcer did not recover despite successful embolization of AV fistulas required an amputation 4 months later. Overall, 17 of 21 patients (81%) showed complete recovery of clinical symptoms. There was no bypass occlusion during follow-up (mean, 17.5 months; range, 1-45 months). CONCLUSIONS: Embolization of symptomatic AV fistulas secondary to lower-limb in situ venous bypass is a safe and efficient alternative to surgical ligature. Complete regression of clinical symptoms is less likely when the bypass is performed with use of the femoral vein.

Pain and quality of life assessment after endovascular versus open repair of abdominal aortic aneurysms in patients at low risk.

PURPOSE: To compare functional autonomy, quality of life (QOL), and pain control after endovascular and open repair (OR) of abdominal aortic aneurysms. MATERIALS AND METHODS: Forty patients with a low surgical risk profile and anatomic compatibility for stent-graft therapy were randomized to receive OR or endovascular aneurysm repair (EVAR). Technical and clinical success as well as mortality were assessed in both groups and compared by Kaplan-Meier analysis. Functional autonomy and QOL were assessed by Karnofsky score and Short Form 36 (SF-36) questionnaire. Pain control was assessed by a numeric rating scale and Brief Pain Inventory questionnaire. QOL outcomes by means of the SF-36 and pain questionnaires were compared with use of mixed-effects models for repeated-measures analysis. RESULTS: All procedures were technically successful in both groups. Three late clinical failures requiring surgical conversion or repeated intervention were observed in the EVAR group and one was observed in the OR group. There was no significant difference between groups in terms of functional autonomy or QOL. No difference in pain level was evident during the early postoperative period, whereas the pain level was lower in the OR group after 1 month. Opioid analgesic drug consumption was significantly greater in the OR group during the postoperative period. Mean hospitalization duration was shorter in the EVAR group than in the OR group (4.5 days +/- 2.4 vs 11.5 days +/- 8.1; P= .001). CONCLUSION: EVAR has no advantage over OR in patients at low risk in terms of functional autonomy, QOL, and pain control. However, EVAR was associated with shorter hospitalization durations compared with OR.

Stent-graft placement for the treatment of thoracic aortic diseases.

The recent development of aortic stent-grafts has brought the management of thoracic aortic diseases into the realm of interventional radiology. Stent-graft placement is now an alternative to surgery for the treatment of descending thoracic aortic aneurysms, ulcers, and fistulas and is sometimes indicated in cases of mycotic aneurysm, posttraumatic aortic rupture, or thoracic descending aortic dissection. Pretreatment imaging is crucial for evaluating patient eligibility, selecting the appropriate stent-graft, and planning the intervention. Stent-graft treatment of long atherosclerotic aneurysms, lesions close to aortic branch vessels, and aortic dissections is subject to technical pitfalls, and adverse events such as endoleaks, stent migration or misplacement, aortic perforation, and vascular trauma will require specific interventions, although they occur in only a minority of patients. Thoracic stent-graft placement in good surgical candidates remains controversial because long-term results are unknown. However, short-term morbidity and mortality rates from endovascular treatment compare favorably with those from surgery, and stent-graft placement is proving to be a safe, minimally invasive, and effective treatment for thoracic aortic diseases and is already the best option in many affected patients who are poor surgical candidates.

Aortoduodenal fistula occurring after type II endoleak treatment with coil embolization of the aortic sac.

A bifurcated stent graft device was successfully deployed to exclude an asymptomatic abdominal aortic aneurysm (AAA) with adequate proximal aortic neck morphology. At 6 months, a type II endoleak was successfully embolized through a proximal perigraft channel with metallic coils. The patient was seen with upper gastrointestinal bleeding and a pulsatile abdominal mass 11 months later. Surgical exploration revealed an aortoduodenal fistula in the vicinity of the previous embolization. We discuss the possible causes of this complication and review the literature on the subject. We conclude that aortoduodenal fistula can occur after endovascular AAA repair despite the absence of endoleak or AAA diameter increase on follow-up computed tomographic scan.

Multiple mycotic aortic aneurysms due to Streptococcus pneumoniae.

Primary pneumococcal aortic mycotic aneurysms are rare clinical entities. Only a few cases have been reported in the literature. Extremely rare presentation is the occurrence of three simultaneous aneurysms. Treatment usually necessitates intravenous antibiotherapy combined with staged surgical interventions. This report highlights the case of a 52-year-old man with multiple Streptococcus pneumoniae mycotic aneurysms that were simultaneously and successfully treated during a one-stage surgical procedure. The aorta may be prone to infection, especially when its intima is structurally altered by pathologic processes like atherosclerosis, inflammation or trauma. Mycotic aneurysm is a rare but serious vascular condition needing urgent medical and surgical attention because of potential lethal complications.