Fixed compared to mobile imaging arms for transcarotid artery revascularization.

OBJECTIVE: Transcarotid artery revascularization (TCAR) is a new surgical option for carotid artery stenosis. While this procedure is optimally performed in hybrid operating rooms (OR), it is currently unclear whether it could be safely performed using portable, C-arm fluoroscopy with equivalent results. The aim of this study is to determine whether there are differences in intraoperative and perioperative outcomes stratified by imaging modality. METHODS: A retrospective review of all TCAR procedures attempted within our health system was performed, capturing all cases between September 2017 and May 2022. Procedures were divided into 2 cohorts, based on whether they were performed in a hybrid OR or with portable, C-arm in a standard OR. Patient demographics, intraoperative results, and postoperative outcomes were compared using univariate strategies. RESULTS: A total of 503 patients were included for review, of which 422 were performed in a hybrid OR (84%) and 81 were performed using a portable C-arm (16%). Intraoperatively, an increased estimated blood loss (47.7 ± 54.7 vs 26.1 ± 26.9 mLs, p < 0.01) and operative time was found in the cases performed in a hybrid OR. However, the fluoroscopy time was lower (4.0 ± 2.6 vs 5.2 ± 5.8 min, p = 0.01) in the setting of advanced intraoperative imaging. Postoperatively, we found no differences with respect to myocardial infarction (0.2% vs. 0%, p > 0.99), stroke (2.4% vs. 2.5%, p = 0.96), or death (0.7% vs. 2.5%, p = 0.15) between groups. CONCLUSIONS: While there are some intraoperative variabilities between TCAR performed in hybrid versus standard ORs, postoperative outcomes are comparable. Therefore, the lack of a hybrid room should not be a deterrent to the adoption of TCAR.

Feasibility and Durability of the Modified Cabrol Coronary Artery Reattachment Technique.

BACKGROUND: This study evaluated the feasibility and durability of the modified Cabrol coronary reattachment technique after aortic root replacement. METHODS: The study retrospectively reviewed 370 patients who underwent aortic root replacement, during 1991 and 2018, and who were separated into 2 groups: a modified Carol (mCabrol) group (n = 84), consisting of patients with 1 or both coronary ostia reimplanted using a modified Cabrol technique; and a Carrel group (n = 286), consisting of patients with both coronary ostia reimplanted using the Carrel button technique. RESULTS: Baseline characteristics were similar in the 2 groups, except the mCabrol group had higher rates of redo sternotomy (74% vs 16%), chronic aortic dissection (58% vs 19%), and infection (14% vs 3%). In the mCabrol group, 60% had both coronary arteries reattached with the technique, and 40% of the procedures were unilateral. Operative mortality was significantly higher in mCabrol group compared with the Carrel group. However, in the stratified analysis for resternotomy, operative mortality between 2 groups were similar (16% vs 13%; P = .786). The survival rate at 5 years and 10 years was 68 ± 6% and 44 ± 6%, respectively, in the mCabrol group and 87 ± 2% and 80 ± 3%, respectively, in the Carrel group (log-rank P < .001). After propensity adjustment, chronic kidney disease and prior coronary artery bypass grafting, but not the modified Cabrol technique, were independent predictors of both operative mortality and follow-up mortality (operative, P = .518; follow-up, P = .080). A total of 47 (66%) of 71 discharged patients in the mCabrol group had follow-up imaging, and no Cabrol graft was occluded. Two patients in the mCabrol group required interventions related to the reattachment technique: 1 coronary ostial anastomosis stenosis and 1 graft-to-graft anastomosis pseudoaneurysm. CONCLUSIONS: The modified Cabrol reattachment technique was not predictive of increased mortality and has excellent patency.

Differences in quality of life outcomes after paraclavicular decompression for thoracic outlet syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures in the thoracic outlet. Decompression provides relief of TOS symptoms. However, little is known about long-term function and quality of life (QoL) from a patient's perspective. The purpose of this study was to evaluate surgical and QoL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach. METHODS: A prospectively maintained database was used to conduct a retrospective review of patients who underwent thoracic outlet decompression between August 2004 and August 2018. We excluded patients without complete follow-up data. Functional outcomes were assessed by the Derkash classification (poor, fair, good, excellent) using contingency table methods, and QoL was assessed by the 12-Item Short Form Health Survey (SF-12) using general linear models. SF-12 was scored by published criteria, and scale-specific and aggregate mental and physical health-related QoL scores were computed. Aggregate QoL scores range from 0 (terrible) to 100 (perfect). Secondary outcomes included mortality, complications, and duration of hospital stay. RESULTS: We performed 105 operations for TOS, and 100 patients with complete follow-up data were included in the study. Five patients were lost to follow-up. Median age was 35 (interquartile range, 24-47) years, and 58 (58%) were female. The median duration of hospital stay was 4 (interquartile range, 3-5.5) days. Of these patients, 46 had venous etiology, 8 arterial, 42 neurogenic, and 4 mixed vascular and neurogenic. Good or excellent Derkash results were reported in 77 (77%) patients, 46 of 54 (85%) of those with vascular TOS vs 31 of 46 (67%) of those with neurogenic etiology (P < .036). SF-12 score was obtained in 93 of 100 (93%) with a median duration from surgery of 6.1 (3.3-9.3) years. Patients with neurogenic TOS (NTOS) reported significantly lower aggregate mental health QoL than patients with vascular-only TOS (57 vs 59; P < .016). This effect persisted across the entire duration of follow-up and was unaffected by time from surgery (regression P for time = .509). In contrast, aggregate physical function QoL was unaffected by neurogenic etiology (P = .303), and all patients improved linearly with time (0.5 scale unit/y; P < .009). Three patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion or hemothorax requiring evacuation (n = 6), neurapraxia (n = 6), and lymph leak (n = 2) treated with tube thoracostomy. CONCLUSIONS: NTOS is associated with significantly worse functional outcome assessed by the Derkash classification. NTOS also demonstrated worse composite mental health QoL, which did not improve over time. In contrast, composite physical health QoL improved linearly with time from surgery regardless of etiology of TOS.

Coil embolization of a ruptured gastroduodenal artery pseudoaneurysm presenting with hemosuccus pancreaticus.

Hemosuccus pancreaticus is a rare form of upper gastrointestinal bleeding that accounts for roughly 1 in 1500 cases. It is characterized by hemorrhage from the ampulla of Vater secondary to rupture of a peripancreatic pseudoaneurysm or visceral artery pseudoaneurysm. Among the visceral artery pseudoaneurysms, gastroduodenal artery pseudoaneurysms are among the rarest. In this case report, we describe a successful coil embolization of a large ruptured gastroduodenal pseudoaneurysm in a patient with massive gastrointestinal bleeding.

Intraoperative Intercostal Nerve Cryoanalgesia Improves Pain Control After Descending and Thoracoabdominal Aortic Aneurysm Repairs.

BACKGROUND: We reviewed the efficacy of intraoperative intercostal nerve cryoanalgesia for pain control in patients undergoing descending and thoracoabdominal aortic aneurysm repairs. METHODS: During 2013 and 2017, 241 patients underwent descending and thoracoabdominal aortic aneurysm repair. Of those, 38 patients were treated with intraoperative cryoanalgesia to the intercostal nerves at the level of 4th to 10th under electromyography guidance and were compared with patients who did not receive cryoanalgesia. Both groups received multilevel paravertebral block and local infiltration with liposomal bupivacaine. Numerical pain scale scores and amount of opioid usage in morphine milligram equivalences on the first to fourth and eighth postoperative days were collected. We excluded patients from the study who were extubated after the third postoperative day or who were reintubated. RESULTS: One hundred twenty-six patients met the inclusion criteria: 28 in the cryoanalgesia group and 98 in the control group. Preoperative patient demographics were similar in both groups, except for more frequent chronic dissection in patients with cryoanalgesia (93% vs 65%, P = .004). Postoperative major complications, length of stay, and discharge to home were not significantly different in either group. However, median ventilation hours were significantly shorter in the cryoanalgesia group (5 vs 12 hours, P < .001). Opioid use was significantly less in the cryoanalgesia group after postoperative day 4. Indexed morphine milligram equivalences, adjusted with body surface area, and numerical pain scale scores were significantly lower in the cryoanalgesia group throughout the postoperative course. CONCLUSIONS: Intercostal nerve cryoanalgesia under electromyography guidance provided improved pain control and reduced narcotic use after descending and thoracoabdominal aortic aneurysm repairs compared with those who only received paravertebral block.

Endovascular Repair of Ruptured Ascending Aorta Secondary to Embolized Transcatheter Aortic Valve.

Since its approval by the United States Food and Drug Administration in 2011, transcatheter aortic valve replacement has revolutionized the treatment of aortic valvular disease with a rapid increase in use. Potentially fatal aortic complications are rare, occurring in 0.2% to 1.1% of cases-all reported in the early perioperative period. We present a case of a late ascending aortic pseudoaneurysm with rupture secondary to erosion by an embolized transcatheter aortic valve occurring 6 years after implantation. The patient was successfully treated with a commercially available, off-the-shelf aortic endograft.

Thoracic branched endograft for traumatic aortic pseudoaneurysm.

Thoracic endovascular aortic repair is the standard treatment for blunt traumatic aortic injuries (BTAI). Approximately 40% of patients with BTAI require left subclavian artery (LSA) coverage for adequate proximal seal. Intentional LSA coverage is not benign; it is associated with complications including stroke, spinal cord ischemia, vertebrobasilar, and left arm ischemia. To avoid these devastating complications, LSA revascularization is recommended before elective zone II thoracic endovascular aortic repair, but is often omitted during emergent cases. We report two cases of aortic zone II traumatic grade III BTAI (aortic pseudoaneurysm) that we successfully treated with the GORE prior to TAG thoracic branch endoprosthesis.

Optimal timing of type A intramural hematoma repair.

Acute type A aortic intramural hematomas (IMHs) are often included under the spectrum of acute aortic syndromes. The classical definition is the presence of hematoma in the media without identifiable intimal tear. Dissection occurring within two weeks of presentation is defined as acute. Acute type A IMH remains a subject of debate, especially regarding its definition and management. The classical theory of pathogenesis of IMHs is ruptured vasa vasorum in the aortic media. However, the majority of IMHs are now detected with an intimal defect using high-resolution computed tomography and intravascular ultrasound, which implies that IMHs may be a subset of aortic dissections (ADs), with very limited flow in the false lumen. Much controversy remains regarding IMH differences in presentation, diagnosis, and risk for progression. Geographic location and ethnicity, especially Asian vs. Western, possibly affect the natural history and outcomes of acute type A IMH. In this review, we describe the pathophysiology and management strategies for acute type A IMHs.

Successful cerebral protection during removal of large right atrial thrombus with AngioVac in a patient with patent foramen ovale and recent embolic stroke.

Complications associated with central venous catheterization include deep venous thrombosis and atrial thrombi, among others. Large thrombi, including intracardiac thrombi, have classically been managed medically or with open surgery. However, recent reports detail the utility of the AngioVac system (AngioDynamics, Latham, NY), a vacuum-assisted suction thrombectomy system using a venous-venous extracorporeal circuit. Here, we present the case of a critically ill woman with large right atrial thrombus, patent foramen ovale, and recent embolic stroke who underwent successful vacuum-assisted suction thrombectomy with use of the Sentinel Cerebral Protection System (Boston Scientific, Marlborough, Mass) for stroke prevention.

Extra-anatomical ascending-thoraco-abdominal bypass for aortic fistula after thoracic endovascular aortic repair.

Aortobronchial and aorto-oesophageal fistulae after thoracic endovascular aortic repair (TEVAR) for traumatic aortic injuries are rare but serious. Potentially fatal complications may occur years after the stent graft deployment. Surgical management is challenging. We report on a 33-year-old male with aorto-oesophageal fistula and a 25-year-old male with aortobronchial fistula-both of whom received TEVAR for traumatic aortic injury. Each underwent successful staged open surgical repair with extra-anatomical bypass from the ascending aorta to the thoraco-abdominal aorta, along with arch vessel reconstructions and debridement of infected lesions. They remained alive after 18 months.