Outcomes of Endovascular Treatment for Critical Limb Threatening Ischemia.

BACKGROUND: Critical limb threatening ischemia (CLTI), particularly in patients with ischemic ulceration has been associated with significant morbidity and mortality. Typically, endovascular therapy has been first-line therapy for our patients, but this strategy has come into question based upon the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Threatening Ischemia (BEST-CLI) trial data. METHODS AND RESULTS: For comparative purposes, we evaluated outcomes from 150 CLTI patients with ischemic ulceration treated with endovascular-first therapy. The mean age was 72 years in this predominate male, Caucasian, ambulatory group. The major co-morbidities were smoking history in 49% and diabetes mellitus in 67%.` Anatomic scoring, using Society for Vascular Surgery criteria, revealed only 35.6% had favorable anatomy (Global Limb Anatomical Staging System stage of 0,1) for long-term patency compared to 64.4% of limbs with unfavorable anatomy for long-term patency (Global Limb Anatomical Staging System stage 2,3). Stents were used in 47% of cases. Reintervention occurred in 36% over 24 months follow-up. At 12 and 24 months, the Kaplan-Meier projections for survival was 0.80 (0.73, 0.87) and 0.69 (0.59, 0.79); amputation was 0.69 (0.61, 0.77) and 0.59 (0.46, 0.71); amputation-free survival (AFS) was 0.56 (0.48, 0.65) and 0.38 (0.27, 0.50), respectively. Amputation was more common in those with reinterventions (P = 0.033). Mortality was predicted with ankle brachial index ≤0.40 or ≥1.30 (P = 0.0019) and the presence of infection (P = 0.0047). AFS was predicted by the presence of any infection (P = 0.0001). CONCLUSIONS: Despite technically successful endovascular treatment, patients who present with CLTI maintain a high-risk for limb loss and mortality. Amputation prevention must vigilantly address infection risk. These data correlate with outcomes from BEST-CLI trial enhancing applicability to patient-centered care.

Comparison of Complications and Cost for Transfemoral Versus Transcarotid Stenting of Carotid Artery Stenosis.

BACKGROUND: Options for endovascular treatment of carotid artery disease have been developed to compliment with carotid endarterectomy, transfemoral carotid artery stenting (TFCAS) and a hybrid approach with transcarotid artery revascularization (TCAR). We sought to capture endpoints outside of stroke, myocardial infarction (MI), and death involved with each procedure at our institution as well as evaluate cost. METHODS: Carotid stent procedures performed from 2014 to 2020 at our institution underwent comparative analysis based upon access site and type of stent procedure performed, TFCAS versus TCAR. Procedural details and outcomes were captured prospectively and included in the National Cardiovascular Data Peripheral Vascular Intervention Registry (NCDR-PVI). Further retrospective review was performed to evaluate endpoints beyond stroke, MI, and death. Total in-hospital cost, including administrative, capital and utilities (fixed cost), and labor and supplies (variable cost) were also evaluated. RESULTS: One hundred thirty-seven patients were reviewed. Seventy-seven were treated with TFCAS and 60 with TCAR. The mean age was 74 years, predominantly male (68%) and Caucasian (90%). Patients undergoing TFCAS were more likely to be symptomatic compared to those receiving TCAR (81.8% vs. 50.0%, P = <0.001). There were no statistically significant differences in event rates, including mortality, recurrent cerebrovascular accident / transient ischemic attack, or bleeding. Complications not captured in the NCDR-PVI database were more frequent in the TCAR group (21.7% vs. 5.2%, P = 0.004) and included pneumothorax (n = 2), neck hematoma (n = 8), and common carotid artery stenosis or injury (n = 3). Rates of complications in the TFCAS group (n = 4) were lower and limited to groin hematoma (n = 2), central retinal artery occlusion causing vision loss and a case of postoperative dysphagia. Geographic miss of initial stent placement was identified in 15.0% of TCAR patients and 2.6% (P = 0.008) of TFCAS patients. Restenosis rates on duplex ultrasound were similar between the two groups (14.6% of patients) and were not associated with symptoms. The mean follow-up interval was similar for both groups of 31.8 months for TCAR and 30.7 months for TFCAS (P = 0.797). There was a statistically significant difference in total cost with TCAR being more expensive ($22,315 vs. $11,001) driven by direct costs that included devices, imaging, and extended length of stay in the TCAR group (P < 0.001). There was no significant difference between stroke free survival (91.1% vs. 88.6%, P = 0.69) and mortality (78.1% vs. 85.2%, P = 0.677) at 3 years follow-up between TCAR and TFCAS, respectively. CONCLUSIONS: Both TFCAS and TCAR provide similar 3-year stroke and mortality risk/benefit and are distinctly different procedures. Both should be evaluated independently with analysis of variables beyond stroke, death, and MI. TFCAS is more cost-effective than TCAR in this single institution study.

Current Outcomes of Blunt Vertebral Artery Injuries.

BACKGROUND: There is no consensus on the treatment of blunt vertebral artery injuries, and studies are limited to small case series. We assessed the natural history and current management of these injuries. METHODS: We performed a retrospective study of a prospectively collected registry at a level I trauma center over a 5-year period. Additional information was gathered from patient charts and imaging review from electronic medical records. We analyzed demographics, mechanism of injury, Glasgow Coma Score, mortality, length of stay, associated injuries, Denver grading scale, neurological findings, level and laterality of injury, delay in diagnosis, treatment, and follow-up imaging. RESULTS: There were 13,080 trauma admissions during this time period yielding 141 patients with blunt vertebral artery injuries from 2013 to 2018 (1.1% incidence). Mean injury severity score (ISS) was 22 with a 30-day mortality of 14 (9.9%). An ISS of greater than 15 is associated with polytrauma and increased mortality. There were 112 (79.4%) associated cervical fractures. C6 and C7 were both equally the most common locations. There was one symptomatic injury manifesting as a cerebellar ischemic infarct. The degree of arterial injury was classified by the Denver grading scale. There were 61 (43.3%) instances of Denver grade I injuries, followed by grade IV at 36 (25.5%), grade II at 34 (24.1%), grade III at 8 (5.7%), and grade V at 1 (0.7%). The level of injury was recorded as follows: V2 = 67 (47.5%), V3 = 56 (39.7%), V1 = 48 (34%), V4 = 14 (9.9%). Medical therapy included aspirin in 93 patients (66%), 31 patients (22%) received systemic anticoagulation with heparin drip, and 2 patients (1%) were administered therapeutic Lovenox. A total of 15 patients (11%) received no medical treatment. There was one intervention in our series. Our only grade V injury was coil embolized. A total of 118 patients (84%) had follow-up imaging. Seventy-eight patients (96%) with grade I and grade II injuries did not worsen, and complete radiographic resolution was found in 50 patients (62%). Grade IV injuries persisted in 22 patients (75.9%). Median time to resolution for grade I and grade II injuries was 7 and 8 days, respectively. Most follow-up scans for grade I and II injuries occurred within 50 days. CONCLUSIONS: Posterior circulation stroke due to blunt vertebral artery injury is rare. In our experience, the natural course of blunt vertebral artery injury was benign and neither delay in medical treatment nor choice of antithrombotic had a significant impact on outcomes. In our series, only 3 (3.7%) grade I and II injuries worsened and were without any clinical sequelae. We suggest that routine serial imaging in grade I and II blunt vertebral injuries is not warranted.

Traumatic Aorto-Cisterna Chlyi Fistula with Treatment of Aortic Pseudoaneurysm with CT-Guided Thrombin Injection.

BACKGROUND: Only 3 cases of aorto-cisterna chyli fistula have been described in the literature but none with a resulting pseudoaneurysm (PSA). METHODS: A 68-year-old man presented following a motor vehicle collision. Imaging revealed a retroperitoneal hematoma with enhancement of the cisterna chyli, representing an aortic to cisterna chyli fistula. Three days later, computed tomography angiography showed resolution of the fistula, but revealed a PSA. The patient underwent arteriography that confirmed the PSA, and then a computed tomography-guided thrombin injection was performed. Follow-up imaging showed resolution of the PSA. RESULTS: Only 3 cases of aorto-cisterna chyli fistula have been described. We hypothesize that this fistula was caused from his L2 vertebral body fracture, which avulsed the lumbar artery and injured the cisterna chyli. The cisterna chyli provided an outflow tract for the aortic injury. We believe this type of fistula follows a benign clinical course. Aorto-cisterna chyli fistula is rare, and reports point to spontaneous resolution. Our case is unique in that the patient progressed from a fistula to a PSA. Options for treatment of this PSA include covered stent graft, open repair, coil embolization, or thrombin injection. CONCLUSIONS: This case report describes an extremely rare diagnosis and the natural history of this aorto-cisterna chyli fistula. Furthermore, the resulting aortic PSA was successfully treated with computed tomography-guided thrombin injection, which in the appropriate setting, should be considered an acceptable option.

Ligation of Common Iliac Artery Mycotic Aneurysm in a Neonate and Review of the Literature.

BACKGROUND: Mycotic aortoiliac aneurysms in neonates are rare. Surgical treatment has traditionally been the standard of care, but recent case reports have suggested that endovascular management of mycotic iliac aneurysms may also be safe and effective. In this case, we describe successful management of a mycotic aortoiliac aneurysm in a neonate with exploratory laparotomy and ligation of the left common iliac artery. METHODS: A full-term infant boy of uncomplicated delivery was transferred to our institution on day 2 of life after a barium enema concerning for small left colon syndrome. An umbilical artery catheter had been placed for monitoring but was removed before transfer. During his hospital course, he developed left leg edema and fever. He was found to have a mycotic aneurysm of the left common and internal iliac arteries, causing common iliac venous compression. A repeat ultrasound revealed the aneurysm measured a maximum of 12 mm in diameter and 26 mm in length. RESULTS: Treatment was delayed until the patient was clinically stable. He was monitored with serial ultrasounds, which showed no significant increase in aneurysmal size. A review of the literature supported the perception the aneurysm posed an impending risk to the patient. On day 16 of life, the neonate underwent ligation and excision of the left common iliac artery aneurysm. CONCLUSION: Our experience found ligation of the common iliac artery to be safe and effective, establishing that surgical reconstruction is not required.

Comparison of Low-Dose Catheter-Directed Thrombolysis with and without Pharmacomechanical Thrombectomy for Acute Lower Extremity Ischemia.

BACKGROUND: Catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombectomy (PMT) can dissolve/remove thrombus; PMT alone, however, may require the adjunctive use of CDT. The aim of this study was to compare the use of CDT with and without PMT for the treatment of acute lower extremity ischemia (ALI). METHODS: We retrospectively reviewed all patients with ALI who underwent CDT with or without PMT between January 2008 and April 2014 (n = 99). Patients with incomplete medical charts were excluded (n = 16). Remaining patients were divided into 2 cohorts: group 1 included patients who underwent PMT + CDT (n = 54); group 2 included those who underwent CDT alone (n = 29). Lesions were further characterized by anatomic location: iliac disease (n = 14), femoropopliteal disease (n = 53), tibial disease (n = 2), and multilevel disease (n = 14). Data collection included patient and limb characteristics, duration of treatment, complications, clinical outcomes, adjunctive interventions, and follow-up. RESULTS: No significant differences were seen between treatment groups in terms of patient characteristics, occlusion length and location, Rutherford class, median duration of ischemia time (P = 0.22), or mean lysis time (P = 0.58). Treatment groups were also similar with regard to outcomes, including periprocedure complications, patency, reintervention, limb salvage, and amputation-free survival. CONCLUSIONS: There was no different between PMT + CDT and CDT alone in terms of periprocedural complications or outcomes. In the quest to resolve ALI, initial thrombus extraction with PMT may not reduce the need, duration, or efficacy of CDT.

Nonoperative management of grade III blunt thoracic aortic injuries.

OBJECTIVE: Blunt thoracic aortic injuries (BTAIs) have historically been treated with open surgery; thoracic endovascular aortic repair (TEVAR), however, is rapidly becoming the standard of care for all grades of injury. Previous studies have shown successful, conservative management of low-grade (I and II) BTAI, but limited literature exists regarding nonoperative management (NOM) for high-grade BTAI. The purpose of this study was to evaluate NOM for grade III BTAI compared with TEVAR. METHODS: There were 75 patients diagnosed with BTAI between January 2004 and June 2015. Of these, 40 were excluded for different grades of BTAI (17), death before any treatment (6), and need for urgent open repair (17). The remaining 35 patients were divided into two groups by treatment approach: NOM (n = 18) and TEVAR (n = 17). Primary end points were complications and mortality. The secondary end point was difference in pseudoaneurysm and aortic diameter measurements between groups. RESULTS: The groups of patients were similar in age, gender, Injury Severity Score, length of stay, in-hospital mortality, and hospital-associated complications. There were four TEVAR-related complications: graft involutions (2), type I endoleak (1), and distal embolization (1). All TEVAR-related complications required either an adjunctive procedure at the time of the primary procedure or an additional procedure. No patients from the NOM group required operative intervention. There were seven in-hospital mortalities: two in the TEVAR group (11.8%) and five in the NOM group (27.8%; P = .402). One death in the NOM group was related to aortic disease. Follow-up computed tomography imaging revealed similar aortic-related outcomes between groups, with a high proportion showing resolved or improved aortic injury (NOM, 87.5%; TEVAR, 92.9%; P = .674). Initial computed tomography imaging showed similar aortic diameters between groups. The average diameter of the aorta distal to the subclavian artery was 22.6 mm in the NOM group vs 22.8 mm in the TEVAR group (P = .85). The average maximum diameter of the pseudoaneurysm was 30.1 mm in the TEVAR group and 29.9 mm in the NOM group (P = .90). The average ratio of diameter of the pseudoaneurysm to diameter of the aorta distal to the subclavian artery was 1.32 for the TEVAR group and 1.33 for the NOM group (P = .85). CONCLUSIONS: The natural history of grade III BTAIs is not well described. This study suggests that observation and NOM of grade III BTAI may be a reasonable therapeutic option in selected patients. It also speaks to the need for further delineation of the natural history of this injury. Serial imaging and long-term follow-up are necessary to monitor the progression of the pseudoaneurysm.

Measuring hand movement for suturing skill assessment: A simulation-based study.

BACKGROUND: To maximize patient safety, surgical skills education is increasingly adopting simulation-based curricula for formative skills assessment and training. However, many standardized assessment tools rely on human raters for performance assessment, which is resource-intensive and subjective. Simulators that provide automated and objective metrics from sensor data can address this limitation. We present an instrumented bench suturing simulator, patterned after the clock face radial suturing model from the Fundamentals of Vascular Surgery, for automated and objective assessment of open suturing skills. METHODS: For this study, 97 participants (35 attending surgeons, 32 residents, and 30 novices) were recruited at national vascular conferences. Automated hand motion metrics, especially focusing on rotational motion analysis, were developed from the inertial measurement unit attached to participants' hands, and the proposed suite of metrics was used to differentiate between the skill levels of the 3 groups. RESULTS: Attendings' and residents' performances were found to be significantly different from novices for all metrics. Moreover, most of our novel metrics could successfully distinguish between finer skill differences between attending and resident groups. In contrast, traditional operative skill metrics, such as time and path length, were unable to distinguish attendings from residents. CONCLUSION: This study provides evidence for the effectiveness of rotational motion analysis in assessing suturing skills. The suite of inertial measurement unit-based hand motion metrics introduced in this study allows for the incorporation of hand movement data for suturing skill assessment.

A mathematical model to predict length of stay in pediatric ATV accident victims.

BACKGROUND: Children under age 12 y represent 15% of all-terrain vehicle (ATV)-related deaths, and those under 16 y old represent >36% of deaths nationwide. In recent years, this has accounted for an increasing proportion of pediatric trauma victims and longer hospitalizations secondary to worsened injuries. We believe it is possible to create a simple mathematical model that can be used to predict hospital length of stay. METHODS: A retrospective review of the trauma registry was performed for all pediatric patients who were involved in ATV accidents from January 2000 to December 2009. Four hundred twenty pediatric patients were identified. A model to predict for total LOS in pediatric patients involved in ATV accidents was constructed. SPSS ver. 17 (SPSS Inc., Chicago, IL) was utilized to conduct all statistical analyses. Statistical significance of regression coefficients was assumed at a P < 0.05 level. RESULTS: We performed a hierarchical multiple regression analysis to build a model that would predict for total length of stay (LOS). A logarithmic transformation was employed on LOS as a dependent variable due to skewness. In Step 1, ISS accounted for a 25% increase in shared variance in LOS (P < 0.001). In Step 2, Glasgow Coma Score (GCS) accounted for 4.3% more variance in LOS (P < 0.001). Finally, in Step 3, the presence of a closed head injury further increased (3.6%) the amount of shared variance in the model (P < 0.001). The final model accounts for 32.9% of the shared variance in total LOS. When using the logarithmic transformation, the final model is: Total LOS = 1.00 + 0.05 injury severity score (ISS) - 0.06 (GCS) + 0.35 closed head injury (CHI). CONCLUSION: Based on our data and statistical analysis, we found it was possible to create a mathematical model that could predict hospital LOS in pediatric ATV accident victims.