Association Between Perioperative Fibrinogen Levels and the Midterm Outcome in Patients Undergoing Elective Endovascular Repair of Abdominal Aortic Aneurysms.

BACKGROUND: We investigated the potential association between perioperative fibrinogen levels and outcome in patients undergoing elective endovascular abdominal aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). METHODS: Consecutive patients with an intact AAA undergoing elective EVAR with a specific bifurcated endograft (Endurant, Medtronic) were recruited between December 2012 and October 2016. Preoperative and 24-hr postoperative fibrinogen levels were recorded, and potential associations with outcome were tested. Primary outcome measures included endoleaks, lower limb ischemic complications, including endograft limb occlusion, and aneurysm-related reinterventions. RESULTS: Ninety-four patients (91 male, mean age 71.8 ± 8.0 years) with an intact AAA were enrolled in the study. The technical success was 98% (2 failures: 1 type Ia endoleak on completion angiography, 1 lower limb ischemia immediately postoperatively requiring femoral endarterectomy). There was 1 death during the first 30 days due to myocardial infarction (1%). Another patient died 15 months after the procedure from cardiac causes. During the existing follow-up (mean 14.8 ± 14.3 months), 14 patients (15%) developed an endoleak (4, type Ia endoleak and 10, type II endoleak), 6 patients (6.3%) had lower limb ischemia/endograft limb occlusion, and 10 patients (10.6%) required reintervention. Compared with the preoperative values, no significant change occurred with regard to the fibrinogen levels 24 hr after procedure (mean preoperative fibrinogen 360 ± 101 mg/dl vs 24-hr postoperative fibrinogen 349 ± 105 mg/dl, P = 0.1). Neither preoperative nor 24-hr postoperative fibrinogen levels were significantly associated with the development of endoleaks, lower limb ischemia, or reinterventions. However, the difference in fibrinogen levels (baseline to 24 hr after procedure) was significantly higher in patients with endoleaks (median -65 mg/dl vs. 15 mg/dl, P = 0.04). CONCLUSIONS: Perioperative fibrinogen levels may play a role in predicting midterm outcomes in patients undergoing elective EVAR and appears to be associated, directly or indirectly, with the development of endoleaks. Further studies are needed to investigate these findings and explore future therapeutic implications.

Retroperitoneal Liposarcoma Masquerading as an Impending Rupture of Inflammatory Abdominal Aortic Aneurysm.

BACKGROUND: We present a unique case scenario of a periaortic liposarcoma masquerading as an impending rupture of an inflammatory abdominal aortic aneurysm (AAA). METHODS AND RESULTS: A 57-year-old man was referred to our unit for an emergency endovascular repair of "an inflammatory AAA with computed tomography (CT) features of impending rupture." He underwent an uneventful endovascular repair with a bifurcated endograft (C3; Gore, Flagstaff, AZ). Seven weeks later, CT showed that the periaortic "mass" grew larger and asymmetric, and a CT-guided needle biopsy suggested the presence of a high-grade malignant mesenchymal tumor. He underwent laparotomy and excision of the retroperitoneal tumor en bloc with the anterior wall of the infrarenal aorta. The endograft acted as an excellent "safety net" providing adequate hemostatic control and obviating the need for aortic cross-clamping and repair of the aortic defect with a patch or tube graft. CONCLUSIONS: The learning point from the present case is that when faced with an inflammatory AAA and/or retroperitoneal fibrosis, the rare possibility of a retroperitoneal neoplasm should be kept in mind.

Endovascular Management of a Distally Migrated Bifurcated Endograft with a New Bifurcated Endograft.

A 75-year-old man presented with abdominal and lumbar pain 6 years after previous endovascular repair of an abdominal aortic aneurysm. At the time of the initial operation, the aneurysm measured 6.0 cm in maximum diameter and a bifurcated Anaconda (Vascutek) endograft had been implanted. This time, computed tomography showed a distally migrated endograft which had been folded within the sac and the aneurysm measured 8.4 cm in maximum diameter. We opted to treat this by endovascular means deploying a new bifurcated endograft with suprarenal fixation within the old one. We consider the different management options and discuss the associated technical difficulties.

Traumatic Knee Dislocation and Popliteal Artery Injury: A Case Series.

Popliteal artery injury is a potentially limb-threatening complication of traumatic knee dislocation. We describe 2 such cases that had been treated in our unit over the last decade. The first one was a 23-year-old woman who injured her right knee during a long jump competition, and the second was a 27-year-old man who had a motorbike accident. Both suffered traumatic knee dislocation along with significant ligament and neurovascular injuries. In the first patient, the popliteal artery was found thrombosed due to intimal rupture and required thrombectomy and vein patch repair, whereas in the second patient, the artery was completely transected and required end-to-end anastomosis. Both limbs were successfully revascularized and required subsequent orthopedic procedures to stabilize the knee joint. Traumatic knee dislocations are rare injuries that may be associated with potentially devastating vascular complications. A prompt diagnosis and timely arterial repair is of paramount importance if limb salvage is to be achieved.

Management of Postfasciotomy Wounds and Skin Defects Following Complex Vascular Trauma to the Extremities Using the External Tissue Extender System.

Management of large postfasciotomy wounds and/or skin and soft tissue defects after major vascular trauma to the extremities can be challenging. The External Tissue Extender (Blomqvist; ETE), a skin-stretching device, which consists of silicone tapes and plastic stoppers, approximates wound margins and facilitates delayed primary closure. We describe our experience with the use of ETE in 5 patients (4 males) with a total of 8 wounds (7 postfasciotomy, 1 soft tissue defect) over the past 12 years. The mean patient age was 32 (range 17-61) years. The wounds involved the lower limb in 3 patients and the upper limb in 2, whereas the injured arteries were the popliteal in 3, the axillary in 1, and the brachial in 1. The mean wound length was 24 cm (range 9-37 cm), and the mean number of ETE silicone tapes used per wound was 13 (range 5-19). The median duration of ETE therapy was 7 days (range 4-7). ETE therapy resulted in sufficient wound approximation to allow complete closure with conventional suturing in 7 out of the 8 wounds. Of these, one developed infection that required drainage, debridement, and resuturing. All wounds achieved satisfactory healing status and all limbs had been salvaged. In conclusion, the ETE is a useful, easy-to-use, and simple adjunct that may facilitate delayed primary closure of large postfasciotomy wounds or extensive skin and soft tissue defects following complex vascular trauma to the extremities.

Rupture after Previous Endovascular Aneurysm Repair due to Type IA Endoleak: Complete Endograft Preservation Is Feasible with Proximal Suturing, Aortic Neck Banding, and Sac Plication.

Rupture of an abdominal aortic aneurysm (AAA) after previous endovascular repair (EVAR) may require endograft explantation and replacement with a prosthetic surgical graft. Recent reports have suggested that total endograft removal during late surgical conversion in the nonruptured setting may not be necessary and that preserving functional parts of the endograft may improve results. Similar techniques may be used for ruptured cases diminishing the magnitude of an already difficult and complex procedure. We describe the successful treatment of a ruptured AAA after previous EVAR with complete endograft preservation by combining transmural endograft fixation with sutures, proximal aortic neck banding, and sac plication.