Prediction of postprocedural filter debris after transcarotid revascularization.

OBJECTIVE: Transcarotid revascularization (TCAR) is a technique in which cerebral flow reversal is utilized as embolic protection during carotid stenting. The presence, or absence, of filter debris created during TCAR could potentially be a surrogate to characterize carotid lesions at high risk for embolization and, therefore, explored in this investigation. METHODS: A retrospective review of TCARs performed within the Indiana University and Memorial Hermann (McGovern Medical School at UTHealth) Health Systems to capture demographics and preoperative variables. A mixed effect multivariate logistic regression model was created to discern the best predictors of intraoperative filter debris. RESULTS: During the study period, from December 2015 to December 2021, we captured filter debris status in 693 of 750 patients containing 323 cases of filter embolization at case completion. With respect to demographics and indications, we found a higher incidence of neck radiation (2.7 vs. 7.1%, p = 0.01) and a more pronounced Charlson Comorbidity Index (CCI; 5.3 ± 0.3 vs 5.7 ± 0.3, p < 0.01) in the filter debris cohort while contralateral carotid occlusion (6.6 vs. 2.9%, p = 0.05) and clopidogrel usage (87.3 vs. 80.1%, p = 0.03) were less common. Longer intraoperative flow reversal (8.0 ± 1.2 vs 10.5 ± 1.2, p < 0.01) and fluoroscopy time (4.0 ± 0.6 vs 5.1 ± 0.6, p < 0.01) were also seen in those with filter debris. These findings remained when a mixed effect univariate logistic regression model was used to account for differences in filter debris reporting between locations. After multivariable modeling, we found that reverse flow time and CCI remained predictive of filter debris while the presence of a contralateral carotid occlusion was still protective. CONCLUSION: In our combined experience, the creation of visible filter debris after TCAR seems to be independently associated with extended reverse flow time and elevated CCI while a contralateral carotid occlusion was protective.

Transcarotid artery revascularization is safe in necks with anatomy hostile for carotid endarterectomy.

OBJECTIVE: The outcomes associated with transcarotid revascularization (TCAR) have proved to be noninferior to the historical results established for carotid endarterectomy (CEA). Therefore, TCAR has been increasingly offered to patients with neck anatomy hostile for traditional CEA. The present investigation was completed to evaluate whether a difference exists for patients undergoing TCAR in de novo anatomy with unviolated surgical planes compared with those undergoing TCAR in necks with hostile anatomy. METHODS: The demographic data and outcomes were captured at two high-volume TCAR institutions from December 2015 to December 2021 via a query of two parallel, prospectively maintained, carotid intervention databases at these two health institutions. A hostile neck anatomy was defined as a history of previous ipsilateral neck radiation, oncologic dissection, or CEA. Univariate analysis was performed to compare the two cohorts at an α of 0.05. RESULTS: During the inclusion period, the data from 750 TCARs were captured, including 108 procedures in hostile neck anatomy and 642 in de novo necks. No significant differences were found in the baseline comorbidity burden using the Charlson comorbidity index or the indication for revascularization. Intraoperatively, no significant increase in case complexity was observed with respect to those with a hostile neck, except for the operative time, which was 10% longer (69.5 vs 63.4 minutes; P = .01). The flow reversal and fluoroscopic times, blood loss, radiation exposure, and contrast use were identical. Postoperatively, no differences were observed between the hostile and de novo necks with respect to stroke (0.9% vs 2.5%; P = .49), myocardial infarction (0.9% vs 0.2%; P = .27), and death (0% vs 1.5%; P = .37). Additionally, hematoma formation and the need for reintervention did not seem to vary between the two groups. Similarly, no differences in the two cohorts were noted during follow-up. CONCLUSIONS: According to the findings from our large, dual-institutional series, the performance of TCAR in surgical fields traditionally hostile for CEA was not associated with increased intraoperative complexity or postoperative morbidity.

Institutional Experiences with Transfemoral Compared to Transcarotid Stenting.

BACKGROUND: Transcarotid artery revascularization (TCAR) is a new surgical technique that is gaining popularity over the transfemoral method (TF-CAS) as the preferred strategy to deliver a carotid stent. This investigation was performed to evaluate the real-world perioperative and long-term outcomes of both techniques at the health system level. METHODS: A retrospective review of prospectively maintained carotid revascularization databases were performed at 2 high-volume TCAR centers in the United States to extract consecutive TF-CAS and TCAR procedures. The characteristics and outcomes associated with these 2 modalities were compared at the preoperative and perioperative points by univariate methods. The Kaplan-Meier methodology was utilized to calculate the long-term stroke and death trends. RESULTS: From 2008-2021, 1,058 carotid stents were implanted at our institutions, consisting of 750 TCARs and 308 TF-CAS procedures. Patients undergoing TF-CAS were older (68.2 ± 0.6 vs. 73.1 ± 0.3 years, P < 0.01) and unhealthier by Charlson Comorbidity Index (4.9 ± 0.1 vs. 5.5 ± 0.1, P < 0.01). Additionally, TF-CAS patients had more high-risk anatomic characteristics, such as restenosis after previous carotid surgery (27.0% vs. 9.5%, P < 0.01), previous ipsilateral neck surgery (38.8% vs. 11.5%, P < 0.01), irradiated ipsilateral field (20.4% vs. 4.5%, P < 0.01), and a contralateral carotid occlusion (10.4% vs. 4.6%, P < 0.01). The incidence of symptomatic lesions was the same (40.1% vs. 36.9%, P = 0.35). Within the operating room, TCAR outperformed TF-CAS with respect to operative time (83.2 ± 2.6 vs. 64.3 ± 0.9 min, P < 0.01), radiation exposure (769.9 ± 144.3 vs. 232.7 ± 19.1 mGys, P < 0.01), fluoroscopic time (17.8 ± 1.1 vs. 4.5 ± 0.1 min, P < 0.01), and contrast volume (75.2 ± 2.4 vs. 22.6 ± 0.4 mLs, P < 0.01). In the 30-day perioperative period, ipsilateral stroke (2.8% vs. 2.3%, P = 0.65), contralateral stroke (1.0% vs. 0.1%, P = 0.07), and death (1.0% vs. 1.2%, P > 0.99) were similar between modalities. None of these endpoints, including a composite of stroke and death (4.8% vs. 3.6%, P = 0.38), reached statistical significance. Additionally, we found no differences with respect to stroke-free survival between modalities during follow-up by Kaplan-Meier analysis (P = 0.30). CONCLUSIONS: In this combined experience from 2 large health systems, TCAR was associated with less intraoperative complexity, as measured by operative time, radiation exposure, and contrast volume. Although stroke and death seemed to be less frequent in patients undergoing transcervical stenting, this did not reach statistical significance.

Transcarotid Revascularization Associated Extended Reverse Flow Duration is Not a Harbinger of Poor Perioperative Outcomes.

BACKGROUND: Transcarotid revascularization (TCAR) is a carotid stenting technique in which an external shunt between the common carotid artery and femoral vein is created to induce cerebral flow reversal as protection against procedure-related plaque embolism. We completed this analysis to determine if prolonged cerebral flow reversal was associated with adverse perioperative outcomes. METHODS: A retrospective review of a combined carotid revascularization database separately maintained at 2 high-volume TCAR health systems was completed. Procedures with captured intraoperative reverse flow duration was included, stratified into two cohorts at a cut-off of 8 mi, and examined with univariate analysis. RESULTS: Within the predesignated study period, 800 patients received a carotid stent via the TCAR technique at Indiana University Health (n = 350) and Memorial Hermann Health Systems (n = 450). In 132 of these procedures, the duration of reverse flow time was not captured and, therefore, excluded from further analysis. Using our prespecified cutoff for extended reverse flow duration (ERFD), we generated 256 cases, leaving an additional 412 procedures completed with a short reverse flow duration. Baseline comorbidities were comparable with respect to individual diagnoses but the overall disease burden in ERFD patients was slightly higher by Charlson Comorbidity Index (5.3 ± 0.1 vs. 5.7 ± 0.1, P = 0.02). With respect to indications and high anatomic risk criteria, both groups were similar, with exception of the presence of a surgically inaccessible carotid bifurcation, which was more frequent in the ERFD procedures (5.3% vs. 10.2%, P = 0.02). Intraoperatively, more blood loss (40.9 ± 2.2 vs. 48.9 ± 2.9 mLs, P = 0.03), operative time (55.2 ± 0.8 vs. 76.3 ± 1.6 min, P < 0.01), radiation (126.3 ± 17.5 vs. 281.9 ± 28.5 mGys, P < 0.01), contrast volume (19.9 ± 0.4 vs. 26.9 ± 0.9 mLs, P < 0.01), and fluoroscopy time (3.3 ± 0.8 vs. 6.3 ± 0.3 min, P < 0.01) were noted in the patients with extended flow reversal. However, this did not increase the risk of stroke (2.7% vs. 2.0%, P = 0.61), myocardial infarction (0.5% vs. 0%, P = 0.53), or death (1.2% vs. 0.4%, P = 0.41) in the 30-day perioperative period. CONCLUSIONS: Extended cerebral flow reversal, defined here as greater than 8 min, was not associated with increased risk of stroke, myocardial infarction, or death in this institutionally derived series.

Outcomes in Endoscopic and Operative Transgastric Pancreatic Debridement.

OBJECTIVES: Select patients with anatomically favorable walled off pancreatic necrosis may be treated by endoscopic (Endo-TGD) or operative (OR-TGD) transgastric debridement (TGD). We compared our experience with these 2 approaches. SUMMARY BACKGROUND DATA: Select necrotizing pancreatitis (NP) patients are suitable for TGD which may be accomplished endoscopically or surgically. Limited experience exists contrasting these techniques exists. METHODS: Patients undergoing Endo-TGD and OR-TGD at a single, high-volume pancreatic center between 2008 and 2019 were identified from a prospective database. Patient characteristics, procedural details, and outcomes of these 2 groups were compared. RESULTS: Among 498 NP patients undergoing necrosis intervention, 160 (32%) had TGD: 59 Endo-TGD and 101 OR-TGD. The groups were statistically similar in age, comorbidity, pancreatitis etiology, necrosis anatomy, pancreatitis severity, and timing of TGD from pancreatitis insult. OR-TGD required 1.1 ±â€Š0.5 and Endo-TGD 3.0 ±â€Š2.0 debridements/patient. Fewer hospital readmissions and repeat necrosis interventions, and shorter total inpatient length of stay were observed in OR-TGD patients. New-onset organ failure [Endo-TGD (13%); OR-TGD (13%); P = 1.0] was similar between groups. Hospital length of stay after TGD was significantly longer in patients undergoing Endo-TGD (13.8 ±â€Š20.8 days) compared to OR-TGD (9.4 ±â€Š6.1 days; P = 0.047). Mortality was 7% in Endo-TGD and 1% in OR-TGD (P = 0.04). CONCLUSIONS: Operative and endoscopic transgastric debridement achieve necrosis resolution with different temporal and procedural profiles. Clear multidisciplinary communication is essential to determine appropriate approach to individual necrotizing pancreatitis patients.

Dual Institutional Experience with Transcarotid Artery Revascularization.

INTRODUCTION: Transcarotid artery revascularization (TCAR) is a hybrid open and endovascular technique to treat carotid stenosis. The purpose of this study is to present a large cohort of patients who underwent TCAR at 2 high-volume TCAR health systems. METHODS: This study was a retrospective chart review of all instances of TCAR within the Memorial Hermann Health System and Indiana University Health, from December 2015-January 2022, using the ENROUTE Neuroprotection Device (Silk Road Medical, Sunnyvale, CA). We report patient demographics, intraoperative metrics, 30-day results and long-term results. RESULTS: In all, 750 patients underwent TCAR in the designated time period. Average patient age was 73 years, with 68% being male. Overall, 53.9% of patients had coronary artery disease, 45.4% had diabetes, and 36.9% were symptomatic. Technical success was achieved in 98.8% of patients with conversion to open endarterectomy in 1.1%. Average reverse flow time was 9.1 minutes with length of stay greater than 1 day 38%. Ipsilateral stroke rate within 30 days was 2.3% and long-term cumulative stroke rate was 3.0%. Death within 30 days occurred in 1.2% of patients and in 5.9% over long-term follow up. In all, 1% of patients required reintervention. CONCLUSIONS: TCAR is a safe and effective treatment modality for carotid artery stenotic disease. Its outcomes are similar to historical results associated with carotid endarterectomy, long considered the gold standard.

Trousseau Syndrome in a 25-Year-Old Woman with Occult Colon Malignancy, Lynch Syndrome, and Chronic Thromboembolic Pulmonary Hypertension.

We present a rare case of thrombosis associated with an occult colon malignancy (Trousseau syndrome) in a 25-year-old woman who also presented with previously unidentified Lynch syndrome and acute-on-chronic thromboembolic pulmonary hypertension. Staged treatment included bilateral pulmonary endarterectomy under deep hypothermic circulatory arrest, followed 11 days later by laparoscopic subtotal colectomy and creation of a primary anastomosis. The patient tolerated both procedures well and recovered normal functional status. Final pathologic analysis of the resected colon mass revealed a pT3N0, stage IIA adenocarcinoma; no adjuvant therapy was administered. At her one-year follow-up visit, the patient was cancer-free, remained on lifelong apixaban anticoagulation, and was undergoing routine monitoring and genetic counseling. This case highlights the need for multidisciplinary management of a patient with severe chronic thromboembolic pulmonary hypertension and a concomitant malignancy.

Safety of Transcarotid Revascularization in Patients with a Contraindication to Dual Antiplatelets.

OBJECTIVE: Current carotid artery stenting practice guidelines recommend dual antiplatelets to reduce major adverse cardiovascular events during and after transcarotid revascularization (TCAR). However, some patients are poor candidates for this regimen, due to preexisting need for anticoagulation, allergies, and/or risk of major bleeding. Therefore, this investigation was performed to review outcomes associated with patients undergoing TCAR while on alternative medication regimens to determine safety and efficacy. METHODS: A retrospective review was performed of a combined database created by the combination of institutional carotid revascularization archives maintained at 2 high-volume TCAR health systems. Patients taking dual antiplatelets were compared to those on nontraditional medications with respect to demographics and perioperative and long-term outcomes. RESULTS: Between our 2 member institutions, 729 TCAR procedures, consisting of 549 patients on dual antiplatelets and 180 on alternative treatments, qualified for study inclusion and analyzed. The cohort not taking dual antiplatelets presented with a heavier comorbidity burden by Charlson Comorbidity Index (5.3 ± 2.2 vs 6.1 ± 2.2, P < .01). Additionally, these patients underwent higher risk revascularization procedures, as they had a higher proportion of symptomatic lesions (34.6% vs 43.0%, P = .03). Despite these deviations in baseline characteristics, similar outcomes between groups were observed in the 30-day perioperative period with respect to stroke (2.2% vs 2.8%, P = .58), death (1.3% vs 1.1%, P > .99), and myocardial infarction (.4% vs 0%, P > .99). Similarly, rates of reintervention (1.6% vs 1.1%, P > .99), hematoma formation (2.4% vs 2.2%, P > .99), and stent thrombosis (.5% vs .6%, P > .99) were consistent, regardless of antiplatelet status. At follow-up of 25.4 and 29.1 months, respectively, for the dual antiplatelet and alternative treatment cohorts, no deviations with respect to reintervention, stroke, myocardial infarction, or stent thrombosis were noted. However, there was an increased risk of death (5.4% vs 13.5%, P = .02) in the alternative regimen group. CONCLUSION: In this small series of TCARs, patients not maintained on dual antiplatelets did not experience more perioperative adverse events after TCAR. However, more studies, in larger series, are required to verify and validate these findings.

Intracardiac extension of chondroblastic osteosarcoma.

Intravascular tumour extension invading the intracardiac space is rarely seen with osteosarcoma. We present a patient with a history of previously resected pelvic osteosarcoma who was later found to have a local recurrence with continuous intravascular extension from the right femoral vein to the right atrium. Preoperative imaging studies initially described extensive thrombus burden, and a multidisciplinary approach involving open and percutaneous thrombectomy was planned. Intraoperative inspection and pathological analysis revealed unresectable malignant solid tumour rather than thrombus. Though exceedingly rare, the possibility of metastatic tumour must be considered when planning treatment strategies for these patients.

Impact of time between diagnosis to treatment in Acute Type A Aortic Dissection.

There is a paucity of data describing the effect of time interval between diagnosis and surgery for Acute Type A Aortic Dissection. We describe our 8-year experience and investigate the impact of time interval between symptom onset, diagnosis and surgery on outcomes. Retrospective single-center study utilizing our Society of Thoracic Surgeons registry and patient records. Subjects were grouped by time interval between radiographic diagnosis and surgical treatment: Group A (0-4 h), Group B (4.1-8 h), Group C (8.1-12 h), and Group D (12.1 + h). Data were analyzed to identify factors associated with mortality and outcomes. 164 patients were included. Overall mortality was 21.3%. Group C had the greatest intervals between symptom onset to diagnosis to surgery, and also the highest mortality (66.7%). Preoperative tamponade, cardiac arrest, malperfusion, elevated creatinine, cardiopulmonary bypass time, and blood transfusions were associated with increased mortality, while distance of referring hospital was not. Time intervals between symptom onset, diagnosis and surgery have a significant effect on mortality. Surgery performed 8-12 h after diagnosis carries the highest mortality, which may be exacerbated by longer interval since symptom onset. Time-dependent effects should be considered when determining optimal strategy especially if inter-facility transfer is necessary.

Preoperative stroke before cardiac surgery does not increase risk of postoperative stroke.

The optimal time when surgery can be safely performed after stroke is unknown. The purpose of this study was to investigate how cardiac surgery timing after stroke impacts postoperative outcomes between 2011-2017 were reviewed. Variables were extracted from the institutional Society of Thoracic Surgeons database, statewide patient registry, and medical records. Subjects were classified based upon presence of endocarditis and further grouped by timing of preoperative stroke relative to cardiac surgery: Recent (stroke within two weeks before surgery), Intermediate (between two and six weeks before), and Remote (greater than six weeks before). Postoperative outcomes were compared amongst groups. 157 patients were included: 54 in endocarditis and 103 in non-endocarditis, with 47 in Recent, 26 in Intermediate, and 84 in Remote. 30-day mortality and postoperative stroke rate were similar across the three subgroups for both endocarditis and non-endocarditis. Of patients with postoperative stroke, mortality was 30% (95% CI 4.6-66). Timing of cardiac surgery after stroke occurrence does not seem to affect postoperative stroke or mortality. If postoperative stroke does occur, subsequent stroke-related mortality is high.

Comparison of 'post-patent ductus arteriosus ligation syndrome' in premature infants after surgical ligation vs. percutaneous closure.

OBJECTIVE: To compare the incidence of post-PDA ligation syndrome after surgical vs. percutaneous closure of PDAs in very low birth weight (VLBW) infants. STUDY DESIGN: Cohort study comparing 59 infants who underwent surgical ligation with 25 infants who underwent percutaneous closure. Comparisons between groups were made using two-sample t-tests and a Fisher's exact test. Comparisons of pre vs. post variables within each group were made using paired t-tests. RESULTS: Patients who underwent surgical ligation had a higher need for initiation of post-procedure hemodynamic support (12/59 vs. 0/24, p = 0.016), a higher post-procedure peak FiO2 (0.64 vs. 0.43, p = 0.004), and a larger absolute change in peak FiO2 (0.23 vs. 0.09, p = 0.008). CONCLUSION: VLBW infants who had percutaneous closure of their PDA did not experience post ligation syndrome and had less escalation of respiratory support compared with infants who underwent surgical ligation.

Urgent Endovascular Repair of an Anterior Tibial Artery Aneurysm: Case Report and Literature Review.

True aneurysms of the anterior tibial artery are rare with less than 20 published reports in the literature. We report an urgent endovascular repair of a true anterior tibial artery aneurysm in a patient with Ehlers-Danlos type IV, vascular type. This approach resulted in an uneventful recovery without the elevated risks associated with open vascular repair in the setting of connective tissue disorder. Continuous follow-up in the subsequent 4 years has demonstrated durability and efficacy of the original intervention.