Identifying Risk Factors for Complications During Exposure for Anterior Lumbar Interbody Fusion.

Introduction An anterior approach to lumbar interbody fusion is a widely utilized method of access to the lumbar spine. Due to the potential for vascular complications with spine exposure, vascular surgeons are frequently included in the care of these patients as part of a team-based approach. Identifying risk factors for such complications is difficult and not well-defined in the literature. In this investigation, we evaluate the potential risk factors for complications during anterior lumbar inter-body fusion (ALIF). Methods This is a retrospective review of 106 patients who underwent ALIF at a single institution between May 1, 2007, and April 30, 2017. Patients were identified through operating room case logs and Current Procedural Terminology (CPT) codes correlating with ALIF. Vascular surgeons performed all anterior exposures. Patient demographics and data regarding their surgical care and postoperative course were obtained from a review of operative and progress notes in the electronic medical record. Statistical methods employed included a t-test for normally distributed data and the Wilcoxon rank-sum test for non-normally distributed data. Categorical variables were compared using Fisher's exact and chi-square tests. A logistic regression model was applied to predict complications by controlling other significant covariates. Results Of the 106 patients included in this analysis, 16 patients experienced a defined complication, giving an overall complication rate of 15%. Patients with complications were more likely to be of male gender (n=11, P=0.016), with older average age (54.6, P=0.017), with higher estimated blood loss, with higher use of blood products, and with higher use of cell-saver. A venous injury was the most common complication (n=11, 10.4%); ileus and nerve injury were the next most common (n=3, 2.8%). The 30-day mortality was 0%. Male gender demonstrated an odds ratio of 3.78 (P=0 .034) in a logistic regression model after adjusting for age and blood products. Conclusions Overall complication rates were comparable to those in the published literature and male gender was identified as a predictor for risk of complications in those undergoing ALIF. This is the first study to identify male sex as a risk factor for complications following ALIF. The results of this study will hopefully guide future studies in gaining more insight into the predictors of complications in larger series.

Fenestrated endovascular aneurysm repair with concomitant horseshoe kidney.

Horseshoe kidney (HSK) is a rare anatomic anomaly that poses surgical challenges in the setting of abdominal aortic aneurysm repair. An endovascular approach is safer for patients yet carries technical challenge because of variable renal vasculature. We present the case of a patient with an infrarenal abdominal aortic aneurysm and concomitant HSK who underwent successful repair with a custom fenestrated endograft with preservation of a midaortic renal artery. Complex endovascular aneurysm repair options for HSK include chimneys and fenestrated stent grafts. We suggest that the availability of custom fenestrated grafts and ongoing skill enhancement among vascular surgeons may make this approach more favorable.

Hybrid approach to complex vascular injury secondary to blast induced scapulothoracic dissociation.

Scapulothoracic dissociation is a rare but devastating injury complex involving high velocity blunt trauma to the osseous, muscular, neurologic, and vascular structures of the shoulder girdle. Often seen following a motor vehicle or motorcycle accident, this injury complex presents with vascular trauma in over 80% of cases. We present a unique case of scapulothoracic dissociation secondary to a self-inflicted shotgun wound to the shoulder, not previously reported in the literature. The patient presented in hemorrhagic shock, with an open wound to the chest, and a flaccid, pulseless left upper extremity. Imaging was consistent with subclavian artery transection with thrombosis. He underwent successful upper extremity revascularization with a hybrid approach including open wound exploration and endovascular repair of the subclavian artery. Furthermore, we review the diagnosis and treatment of scapulothoracic dissociation and discuss the safety of emerging hybrid vascular techniques in the management of subclavian and axillary vessel trauma.

Non-operative management of isolated spontaneous superior mesenteric artery dissection.

Isolated spontaneous superior mesenteric artery (SMA) dissection is a rare differential for patients presenting with abdominal pain. Due to limited cases reported, management strategies have been poorly defined. We present the case of a 49-year-old male with history of hypertension and ischemic colitis, presenting with abdominal pain. CT imaging demonstrated a thrombosed dissection of the SMA extending into second and third order braches. He was managed conservatively with therapeutic anticoagulation. His symptoms improved and upon discharge he was transitioned to aspirin and warfarin. Repeat CT imaging continued to show the dissection with resolution of the SMA thrombus. Spontaneous SMA dissection is exceedingly rare with no universally agreed upon standard of care for treatment. Operative intervention should be reserved for failed conservative management or vascular compromise. Understanding the current treatment options helps ensure a favorable patient outcome.

Popliteal artery entrapment syndrome presenting as acute limb ischemia in pregnancy.

Popliteal artery entrapment syndrome typically causes calf claudication in young active adults. Acute limb ischemia from popliteal artery thrombosis, embolization, or aneurysmal degeneration is less common. Chronic compression, histologic changes, and predisposing factors, such as vigorous exercise or hypercoagulability, play a role in these cases. We present the case of a 32-year-old pregnant woman with acute limb ischemia found to have popliteal artery thrombosis as a result of popliteal artery entrapment syndrome. Although many imaging modalities are available, pregnancy creates a unique situation in which consideration of irradiation and exposure to contrast material is important in diagnosis and treatment.

Percutaneous retrieval of an inferior vena cava filter causing right ureter obstruction.

Retrievable inferior vena cava filters (IVCFs) are known to provide safe and effective pulmonary embolism protection when used appropriately. Long-term complications have been reported over the past 10 years, including vena cava perforation, filter migration, strut fracture, and injury to adjacent structures. This article describes the case of a 44-year-old woman who presented with right ureteral obstruction from strut impingement by a Bard Recovery IVCF (Tempe, AZ, USA). The filter had been in place for 6 years, and the authors were successful in retrieving it using a percutaneous endovascular approach, despite an unexpected chronic right innominate vein occlusion. In addition to highlighting the technical feasibility of long-term retrieval, this case underscores the importance of an IVCF registry to improve retrieval rates. This close monitoring and timely retrieval of filters may help prevent serious long-term complications.

Identification of a genetic variant associated with abdominal aortic aneurysms on chromosome 3p12.3 by genome wide association.

OBJECTIVE: The goal of this project was to identify genetic variants associated with abdominal aortic aneurysms (AAAs). METHODS: A genome wide association study was carried out using pooled DNA samples from 123 AAA cases and 112 controls matched for age, gender, and smoking history using Affymetrix 500K single nucleotide polymorphism (SNP) arrays (Affymetrix, Inc, Santa Clara, Calif). The difference in mean allele frequency between cases and controls was calculated for each SNP and used to identify candidate genomic regions. Association of candidate SNPs with AAA was confirmed by individual TaqMan genotype assays in a total of 2096 cases and controls that included an independent replication sample set. RESULTS: A genome wide association study of AAA cases and controls identified a candidate AAA-associated haplotype on chromosome 3p12.3. By individual genotype analysis, four SNPs in this region were significantly associated with AAA in cases and controls from the original study population. One SNP in this region (rs7635818) was genotyped in a total of 502 cases and 736 controls from the original study population (P = .017) and 448 cases and 410 controls from an independent replication sample (P = .013; combined P value = .0028; combined odds ratio [OR] = 1.33). An even stronger association with AAA was observed in a subset of smokers (391 cases, 241 controls, P = .00041, OR = 1.80), which represent the highest risk group for AAA. The AAA-associated haplotype is located approximately 200 kbp upstream of the CNTN3 gene transcription start site. CONCLUSION: This study identifies a region on chromosome 3 that is significantly associated with AAA in 2 distinct study populations.

Hidradenitis suppurativa complicated by squamous cell carcinoma.

Hidradenitis suppurativa (HS) is a chronic inflammatory condition affecting the apocrine glands of the axilla, groin, and perianal region. Although it is a common condition, it is rarely associated with squamous cell carcinoma (SCC). There have been only 41 reports of this uncommon complication of HS in the literature. This study includes two uncommon presentations of HS associated with SCC along with a literature review. The first patient developed diffuse abdominal carcinomatosis from SCC in the anogenital region arising from HS. This is a rare event in patients with perianal SCC, with only one case previously described in the literature. The second patient developed malignant hypercalcemia, an uncommon complication of cutaneous SCC. The current report represents the largest review of the literature of patients with SCC secondary to longstanding HS. A recurrence rate of 48 per cent was observed after "curative" resection. Approximately half of the patients succumbed to their disease, and the grade of carcinoma was the only predictor of mortality. These two new cases underline the importance of close follow-up and aggressive management of patients with HS. Although the development of carcinoma is an uncommon event in HS, the consequences can be devastating with mortality approaching 50 per cent.

Campath-1H induction and the incidence of infectious complications in adult renal transplantation.

BACKGROUND: The purpose of this study was to evaluate adult renal transplantation patients who received a alemtuzumab (Campath-1H)-based induction protocol for the incidence of infectious complications. METHODS: We began using 30 mg Campath-1H intravenously for induction therapy in May 2003. The patients were treated with a maintenance regimen of tacrolimus or mycophenolate mofetil (MMF), and rapidly tapered prednisone; valganciclovir was used for CMV prophylaxis. Forty-nine adult patients who received renal transplants between May 1, 2003 and June 7, 2004 were included. The mean follow-up time was 13.7 months with a range of 10-24 months. Data were collected via a retrospective chart review. RESULTS: The infectious complications noted in the Campath-1H group were compared with a historical group of 56 patients receiving conventional immunosuppression. There was one case of cytomegalovirus (CMV) viremia and two cases of CMV disease (one pneumonitis and one enteritis). There were four cases of urinary tract infection and one extremity cellulitis. One patient developed Cryptococcal meningitis. Eight of the 49 (16%) patients in the Campath group had an infectious complication, compared to 18 out of 56 (32%) in the historical group. CONCLUSION: Campath-1H induction for renal transplantation appears to have a low incidence of associated infectious complications when compared to historical regimens.