Preoperative risk score for mortality within 3 years of visceral segment fenestrated endovascular aortic repair.

OBJECTIVE: The purpose of this study was to create a risk score for the event of mortality within 3 years of complex fenestrated visceral segment endovascular aortic repair utilizing variables existing at the time of preoperative presentation. METHODS: After exclusions, 1916 patients were identified in the Vascular Quality Initiative who were included in the analysis. The first step in development of the risk score was univariable analysis for the primary outcome of mortality within 3 years of surgery. χ2 analysis was performed for categorical variables, and comparison of means with independent Student t-test was performed for ordinal variables. Variables that achieved a univariable P value less than 0.1 were then placed into Cox regression multivariable time dependent analysis for the development of mortality within 3 years. Variables that achieved a multivariable significance of less than 0.1 were utilized for the risk score, with point weighting based on the beta-coefficient. Variables with a beta coefficient of 0.25 to 0.49 were assigned 1 point, 0.5 to 0.74 2 points, 0.75 to 0.99 3 points, and 1.0 to 1.25 4 points. A cumulative score for each patient was then summed, the percentage of patients at each score experiencing mortality within 3 weeks was then calculated, and a comparison of score outcomes was conducted with binary logistic regression. Area under the curve analysis was performed. RESULTS: The primary outcome of mortality within 3 years of surgery occurred in 12.8% of patients (245/1916). The mean age for the study population was 73.35 years (standard deviation [SD], 8.26 years). The mean maximal abdominal aortic aneurysm (AAA) diameter was 60.43 mm (SD, 10.52 mm). The mean number of visceral vessels stented was 3.3 (SD, 0.76). Variables present at the time of surgery that were included in the risk score were: hemodialysis (3 points); age >87, chronic obstructive pulmonary disease, hypertension, AAA diameter >77 mm (all 2 points); and body mass index <20 kg/m2, female sex, congestive heart failure, active smoking, chronic renal insufficiency, age 80 to 87 years, and AAA diameter 67 to 77 mm (all 1 point). BMI >30 kg/m2 (mean, 34.46 kg/m2) and age <67 years were protective (-1 point). Testing the model resulted in an area under the curve of 0.706. Hosmer and Lemeshow goodness of fit test for logistic regression utilizing the 15 different risk score total groups revealed a model predictive accuracy of 87.3%. Significant escalations in 3-year mortality were noted to occur at scores of 6 and greater. Mean AAA diameter was significantly larger for patients who had higher risk scores (P < .001). CONCLUSIONS: A novel risk score for mortality within 3 years of fenestrated visceral segment aortic endograft has been developed that has excellent accuracy in predicting which patients will survive and derive the strongest benefit from intervention. This facilitates risk-benefit analysis and counseling of patients and families with realistic long-term expectations. This potentially enhances patient-centered decision-making.

Risk Factors Associated with Spinal Cord Ischemia During Aortic Aneurysm Repair.

BACKGROUND: The risk of spinal cord ischemia (SCI) with aortic aneurysm repair can cause significant neurological morbidity. Prevention of SCI is critical. We sought to identify risk factors that predispose to SCI that may guide strategies to mitigate the occurrence of SCI during and following these procedures. METHODS: This study includes all adults who underwent atraumatic, unruptured, thoracic, and suprarenal aortic aneurysm repairs (endovascular or open) at our institution over 11 years (2010-2020). Our database included patient demographics, aneurysm anatomic features, and operative characteristics and an extreme gradient boost (XGB) machine method was used to develop a predictive model for SCI. The model was trained on an 80% randomly stratified cohort of the data and tested on the remaining 20% testing cohort. Shapley values were used to determine the most important predictive factors of SCI and decision trees were used to identify risk factor threshold values and highest risk factor combinations. RESULTS: Information was collected for 174 adult patients undergoing thoracic and suprarenal aortic repair from 2010 to 2020. Fifty eight percent of the patients were male. Ninety seven (55.7%) patients had open aortic repair and 87 (44.3%) had endovascular repair. Twenty seven (15%) of all patients had major complications and were considered to have SCI. The XGB model converged over the training cohort with a testing cohort accuracy of 0.841 [Sensitivity = 75%, Specificity = 68%] and area under the curve of receiver operating characteristic of 0.774. The XGB model identified older age (> 65 years), history of neurologic disease, hyperlipidemia, diabetes, coronary artery disease, heart failure, poor renal function, < 6 months since last aortic repair, chronic anticoagulant use, preoperational anemia (Hemoglobin < 9), thrombocytopenia (platelet < 90,000), coagulopathy (prothrombin time > 15s and activated partial thromboplastin time > 40s), hypotension (mean arterial pressure < 70 mm Hg), longer operations (> 100 min), aneurysms longer than 5 cm, and anatomic location of aneurysm caudal to T-11 as risk factors for SCI in all types of aortic repair. Diabetic and heart failure patients undergoing longer operations (> 100 min) with thrombocytopenia or aneurysms longer than 5 cm were at the highest risk. CONCLUSIONS: The XGB model accurately identified risk factors of SCI with aortic aneurysm repair that may guide patient selection, timing of surgery, and strategies to minimize the risk of SCI.

Extended Use of the Candy-Plug Technique with the Cook Dissection Stent.

Inducing false lumen (FL) thrombosis is crucial to achieve aortic remodeling when treating aortic dissection. One method to achieve FL thrombosis is modifying a graft and placing a plug inside it known as the candy-plug (CP) technique. CP stent graft is typically placed at the level of the celiac artery (CA) as noted by the original authors. Here, we present a case where the CP had to be placed distal to the CA but also require placing a bare metal dissection stent in the true lumen to oppose the radial force and expand the true lumen as well as to prevent re-entry tear in the visceral segment in the future.

A rare case of fibromuscular dysplasia involving multiple vascular beds.

OBJECTIVE: Fibromuscular dysplasia rarely involves vessels other than the renal and carotid arteries. We present a case of a rare fibromuscular dysplasia involving multiple vascular beds in a young female patient with history of spontaneous coronary artery (SCAD). METHODS: This is a case report with review of the literature using PubMed search for other cases of fibromuscular dysplasia that involves multiple vascular beds and its association with SCAD. The patient agreed to publish her case including her images. RESULTS: Fibromuscular dysplasia involving multiple vascular beds in a young female patient with prior coronary dissection is rarely reported in the literature. CONCLUSION: Fibromuscular dysplasia affecting multiple vascular beds is rare but should be suspected in patients with SCAD, particularly young female patients.

Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Pulmonary embolism response team implementation improves awareness and education among the house staff and faculty.

A subset of high-risk pulmonary embolism (PE) patients requires advanced therapy beyond anticoagulation. Significant variation in delivery of care has led institutions to standardize their approach by developing Pulmonary Embolism Response Team (PERT). We sought to assess the impact of PERT implementation on house staff and faculty education. After implementation of PERT, we employed a targeted educational intervention aimed to improve PERT awareness, familiarity with treatment options, role of echocardiogram and Doppler ultrasound, and knowledge of acute PE risk stratification tools. We conducted an anonymous survey among the house staff and faculty before and after intervention to assess the impact of PERT implementation on educational objectives among clinicians. Initial and follow up samples included 115 and 109 responses. The samples were well represented across the subspecialties and all levels of training, as well as junior and senior faculty. Following the educational campaign, awareness of the program increased (72.2-92.6%, p < 0.01). Proportion of clinicians with reported comfort level of managing PE increased (82.4-90.8%, p = 0.07). Proportion of clinicians with self-reported comfort with explaining all available treatment modalities to patients increased (49.1-67.9%, p = 0.005). Proportions of responders who correctly identified the role of echocardiography in risk stratification of patients with known PE increased (73.9-84.4%, p = 0.07). Accurate clinical risk stratification of acute PE increased (60.2-73.8%, p = 0.03). The implementation of a targeted educational program at a tertiary care center increased awareness of PERT among house staff and faculty and improved physician's accuracy of clinical risk stratification and comfort level with management of acute PE.

Clinical Experience with the Gore Hybrid Vascular Graft in Complex Revascularizations Demonstrates Safety and Efficacy.

BACKGROUND: Arterial revascularizations can present significant challenges when vessels are disadvantaged and advances in technology present the surgeon with innovative opportunities. A number of studies have used the GORE® Hybrid Vascular Graft (GHVG), and we have been using this device in arterial revascularizations since it came to market. The aim of this study is therefore to present a large single-center experience using the GHVG. This series presents patients with complex revascularizations in multiple vascular beds. METHODS: We retrospectively analyzed a single-center series of 43 patients who received a total of 56 GHVGs in complex revascularization procedures at Houston Methodist Hospital from March 2012 to April 2017. We excluded 5 patients (7 grafts in total) because of loss of follow-up. An additional 8 patients were excluded from the analysis (11 grafts in total) secondary to mortalities unrelated to their grafts (7 patients died during index hospitalization and 1 patient died shortly after discharge). RESULTS: Our results demonstrated an 18-month primary patency, assisted primary patency, and secondary patency of 82, 86, and 96%, respectively. These complex revascularizations included a total of 56 devices placed. GHVGs were placed in the external iliac artery (27/56), renal artery (12/56), common femoral artery (6/56), superficial femoral artery (4/56), common iliac artery (3/56), grafts (3/56), profunda femoris artery (1/56), and the superior mesenteric artery (1/56). Early mortality in patients (7/8) was because of the nature of their disease and not related to the surgical intervention. CONCLUSIONS: The GHVG has the ability to create a sutureless anastomosis in a disadvantaged vessel or to promote a potentially better outcome by either avoiding prolonged ischemia to visceral branches or avoiding extensive abdominal or retroperitoneal exposure in an iliofemoral bypass. These results demonstrate the value of the GHVG in complex revascularizations not amenable to traditional open surgical bypass. LEVEL OF EVIDENCE: IV.

The Use of the Agatston Calcium Score in Predicting Carotid Plaque Vulnerability.

BACKGROUND: The use of the Agatston calcium scoring method has been described extensively in the coronary circulation, but to date, it has not been investigated in the extracranial carotid domain. We sought to evaluate this calcium scoring method in its ability to predict carotid plaque vulnerability. METHODS: We retrospectively reviewed all computed tomography angiogram studies of the carotid arteries performed between March 2012 and March 2017 at a single institution. We identified 68 consecutive patients with 99 internal carotid arteries who met criteria for review. Total calcium was quantified by the Agatston scoring method using the OsiriX software. Stenosis severity was determined using North American Symptomatic Carotid Endarterectomy Trial criteria. The relation between Agatston score and degree of stenosis was evaluated using the Spearman's Rho coefficient (R). RESULTS: Of 99 internal carotid arteries, 71 were asymptomatic and 28 were symptomatic. Baseline characteristics were comparable, with no significant difference in patient characteristics. There were significant differences in mean Agatston scores for asymptomatic versus symptomatic arteries (121.95 ± 70.27 vs. 34.83 ± 47.77, P = 0.0098, 50%-69% stenosis; 151.07 ± 88.30 vs. 71.59 ± 77.27, P = 0.0006, 70%-99% stenosis). In both asymptomatic and symptomatic groups, Agatston calcium score increased as severity of stenosis increased. Higher Agatston score is protective against symptoms ipsilateral to the carotid lesion. CONCLUSIONS: Agatston calcium score may predict carotid plaque vulnerability, with higher scores associated with lower likelihood of developing symptoms ipsilateral to the carotid lesion. This score may be useful in predicting clinical behavior of carotid plaques.

Computed tomography angiography-fluoroscopy image fusion allows visceral vessel cannulation without angiography during fenestrated endovascular aneurysm repair.

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) is an evolving technique to treat juxtarenal abdominal aortic aneurysms (AAAs). Catheterization of visceral and renal vessels after the deployment of the fenestrated main body device is often challenging, usually requiring additional fluoroscopy and multiple digital subtraction angiograms. The aim of this study was to assess the clinical utility and accuracy of a computed tomography angiography (CTA)-fluoroscopy image fusion technique in guiding visceral vessel cannulation during FEVAR. METHODS: Between August 2014 and September 2016, all consecutive patients who underwent FEVAR at our institution using image fusion guidance were included. Preoperative CTA images were fused with intraoperative fluoroscopy after coregistering with non-contrast-enhanced cone beam computed tomography (syngo 3D3D image fusion; Siemens Healthcare, Forchheim, Germany). The ostia of the visceral vessels were electronically marked on CTA images (syngo iGuide Toolbox) and overlaid on live fluoroscopy to guide vessel cannulation after fenestrated device deployment. Clinical utility of image fusion was evaluated by assessing the number of dedicated angiograms required for each visceral or renal vessel cannulation and the use of optimized C-arm angulation. Accuracy of image fusion was evaluated from video recordings by three raters using a binary qualitative assessment scale. RESULTS: A total of 26 patients (17 men; mean age, 73.8 years) underwent FEVAR during the study period for juxtarenal AAA (17), pararenal AAA (6), and thoracoabdominal aortic aneurysm (3). Video recordings of fluoroscopy from 19 cases were available for review and assessment. A total of 46 vessels were cannulated; 38 of 46 (83%) of these vessels were cannulated without angiography but based only on image fusion guidance: 9 of 11 superior mesenteric artery cannulations and 29 of 35 renal artery cannulations. Binary qualitative assessment showed that 90% (36/40) of the virtual ostia overlaid on live fluoroscopy were accurate. Optimized C-arm angulations were achieved in 35% of vessel cannulations (0/9 for superior mesenteric artery cannulation, 12/25 for renal arteries). CONCLUSIONS: Preoperative CTA-fluoroscopy image fusion guidance during FEVAR is a valuable and accurate tool that allows visceral and renal vessel cannulation without the need of dedicated angiograms, thus avoiding additional injection of contrast material and radiation exposure. Further refinements, such as accounting for device-induced aortic deformation and automating the image fusion workflow, will bolster this technology toward optimal routine clinical use.

Short- and midterm results for internal jugular vein extension for short right renal vein kidney transplant.

Renal transplantation remains the definitive treatment for end-stage renal disease (ESRD). The shorter renal vein in right donor nephrectomies is associated with higher incidence of technical failure. We present here our experience with autologous internal jugular vein (IJV) conduits to facilitate living-donor transplants. Six patients underwent right, living-donor kidney transplant with simultaneous IJV harvest over a 1-year period. All had bilateral jugular duplex scans preoperatively and were placed on aspirin 81 mg postoperatively. Patient demographics, comorbidities, and laboratories were retrospectively queried. Postoperative follow-up and examination were performed per institutional protocol. The mean age and BMI were 51 ± 4.6 years and 30 ± 1.4 kg/m2 , respectively. An average 4.5 ± 0.5 cm of IJV was taken, and anastomosed exsitu, end to end to the renal vein. One patient developed a perinephric hematoma requiring reexploration and another expired during follow-up from septic shock of unknown etiology; there were no harvest site complications or deep vein thrombosis. All had immediate and stable graft function at 3.8 ± 1.7 (range: 0.7-11.3) months follow-up. Mean serum creatinine and estimated glomerular filtration rate were 1.3 ± 0.1 mg/dL and 55 ± 2.4 mL/min/1.73 m2 , respectively. Internal jugular vein extension of short right renal veins for kidney transplant is a viable technique for ESRD patients with promising results.

Lower Extremity Bypass Using Bovine Carotid Artery Graft (Artegraft): An Analysis of 124 Cases with Long-Term Results.

INTRODUCTION: Although biological grafts have been utilized as a vascular conduit in leg bypass for many years, reports of a bovine carotid artery graft (BCAG) in lower extremity revascularization have been scarce. This study analyzed the outcome of lower leg bypass using BCAG. METHODS: A retrospective review of a prospectively collected database of all patients undergoing lower extremity bypass using BCAG from 2002 to 2017 was performed. Clinical outcomes including graft patency and limb salvage were evaluated. RESULTS: A total of 124 BCAG (Artegraft, North Brunswick, NJ) were implanted in 120 patients for lower extremity revascularization. Surgical indications included disabling claudication in 12%, rest pain in 36%, tissue loss in 48%, and infected prosthetic graft replacement in 3%. Autologous saphenous vein was either inadequate or absent in 72% of patients. BCAG was used in 46 patients (37%) who had a prior failed ipsilateral leg bypass. Distal anastomosis was performed in the above-knee popliteal artery, below-knee popliteal artery, and tibial artery in 30 cases (25%), 32 cases (26%), and 48 cases (39%), respectively. Distal anastomotic patch was created in all tibial artery to allow BCAG-tibial reconstruction. The yearly primary patency rates in 5 years were 86.5, 76.4, 72.2, 68.3, and 67.5%, respectively. The corresponding yearly secondary patency rates were 88.5, 84.7, 82.4, 78.5, and 75.6%, respectively. The limb salvage rate at one year was 83.6% and at five years was 86.2% for patients with critical limb ischemia. Multivariate analysis showed poor runoff score (P = 0.03, 95% CI, 1.3-5.3; OR, 1.6) was independently associated with graft occlusion. CONCLUSION: BCAG is an excellent vascular conduit and provides good long-term results in lower extremity bypass.

Laparoscopic Peritoneal Dialysis Surgery is Safe and Effective in Patients with Prior Abdominal Surgery.

BACKGROUND: Despite the lower cost, improved early survival, and preservation of the remaining kidney function, peritoneal dialysis is used by only 8.8% of the dialysis population in the USA. Intraabdominal adhesions reported in 70-90% of patients with prior abdominal surgery (PAS) reduce the peritoneal surface area and may increase the intraoperative and postoperative morbidity. The objective of this study is to evaluate the outcomes of laparoscopic peritoneal dialysis (LPD) catheter placement in patients with and without PAS. METHODS: Patients who had LPD catheters placed between January 2014 and August 2016 were retrospectively reviewed. A Kaplan-Meier analysis was performed to assess the revision-free catheter survival (RFCS) and revision-assisted catheter survival (RACS) between the 2 groups. RESULTS: One hundred forty-two patients had had LPD catheter placed during the study time, 82 (58%) with PAS. Lysis of adhesions (LOA) was required in 26 patients (28%) with PAS. Demographics and comorbidities were similar, but more women had PAS (65% vs. 35%, P < 0.001). Seventeen patients (12%) required revision, with no difference between the 2 groups. Both RFCS and RACS were similar in patients without and with PAS (P = 0.38 and 0.98, respectively). RFCS was 73% vs. 64% at 1 year (no PAS versus PAS) and 62% vs. 51% at 2 years, whereas RACS was 84% vs. 77% at 1 year (no PAS versus PAS) and 69% vs. 68% at 2 years. Only 2 intraoperative complications occurred, namely a superficial liver injury and pelvic hematoma. Three complications (0.02%) occurred within 30 days, namely 1 peritonitis and 2 catheter malfunctions. Overall complication rate was 25%, predominantly poor drainage (17% and 22% for PAS and no PAS, respectively), and there were no differences between the subgroups. No deaths occurred within a year of surgery during the study follow-up. CONCLUSIONS: LPD and LOA can be performed safely in patients with multiple PAS. When possible, LPD catheters should be part of the vascular surgery training armamentarium and offered to patients with PAS.

Thromboembolic Risk of Endovascular Intervention for Lower Extremity Deep Venous Thrombosis.

BACKGROUND: This study evaluated the risk of thromboembolism during endovascular interventions in patients with symptomatic lower extremity deep vein thrombosis (DVT) METHODS: Clinical records of all patients who underwent endovascular interventions for symptomatic lower extremity DVT from 2001 to 2017 were retrospectively analyzed using a prospectively maintained database. Only patients who received an inferior vena cava (IVC) filter were included in the analysis. Trapped intrafilter thrombus was assessed for procedure-related thromboembolism. Clinical outcomes of thrombus management and thromboembolism risk were analyzed. RESULTS: A total 172 patients (mean age 57.4 years, 98 females) who underwent 174 endovascular DVT interventions were included in the analysis. Treatment strategies included thrombolytic therapy (64%), mechanical thrombectomy (n = 86%), pharmacomechanical thrombolysis (51%), balloon angioplasty (98%), and stent placement (28%). Thrombectomy device used included AngioJet (56%), Trellis (19%), and Aspire (11%). Trapped IVC filter thrombus was identified in 58 patients (38%) based on the IVC venogram. No patient developed clinically evident pulmonary embolism (PE). IVC filter retrieval was performed in 98 patients (56%, mean 11.8 months after implantation). Multivariate analysis showed that iliac vein occlusion (P = 0.04) was predictive for procedure-related thromboembolism. CONCLUSIONS: Iliac vein thrombotic occlusion is associated with an increased thromboembolic risk in DVT intervention. Retrievable IVC filter should be considered when performing percutaneous thrombectomy in patients with iliac venous occlusion to prevent PE.

Comparison of propaten heparin-bonded vascular graft with distal anastomotic patch versus autogenous saphenous vein graft in tibial artery bypass.

Introduction Heparin-bonded expanded polytetrafluoroethylene grafts (Propaten, WL Gore, Flagstaff, AZ, USA) have been shown to have superior patency compared to standard prosthetic grafts in leg bypass. This study analyzed the outcomes of Propaten grafts with distal anastomotic patch versus autogenous saphenous vein grafts in tibial artery bypass. Methods A retrospective analysis of prospective collected data was performed during a recent 15-year period. Sixty-two Propaten bypass grafts with distal anastomotic patch (Propaten group) were compared with 46 saphenous vein graft (vein group). Pertinent clinical variables including graft patency and limb salvage were analyzed. Results Both groups had similar clinical risk factors, bypass indications, and target vessel for tibial artery anastomoses. Decreased trends of operative time (196 ± 34 min vs. 287 ± 65 min, p = 0.07) and length of hospital stay (5.2 ± 2.3 days vs. 7.5 ± 3.6, p = 0.08) were noted in the Propaten group compared to the vein group. Similar primary patency rates were noted at four years between the Propaten and vein groups (85%, 71%, 64%, and 57%, vs. 87%, 78%, 67%, and 61% respectively; p = 0.97). Both groups had comparable secondary patency rates yearly in four years (the Propaten group: 84%, 76%, 74%, and 67%, respectively; the vein group: 88%, 79%, 76%, and 72%, respectively; p = 0.94). The limb salvage rates were equivalent between the Propaten and vein group at four years (84% vs. 92%, p = 0.89). Multivariate analysis showed active tobacco usage and poor run-off score as predictors for graft occlusion. Conclusions Propaten grafts with distal anastomotic patch have similar clinical outcomes compared to the saphenous vein graft in tibial artery bypass. Our data support the use of Propaten graft with distal anastomotic patch as a viable conduit of choice in patients undergoing tibial artery bypass.

Outcomes following operative management of thoracic outlet syndrome in the pediatric patients.

Objectives Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients. Methods Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed. Results Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (n = 60, 88%) or combined supraclavicular and infraclavicular incisions (n = 8, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4 ± 11.6 months. Long-term symptomatic relief was achieved in 94% of patients. Conclusions Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.

Echocardiographic assessment with right ventricular function improvement following ultrasound-accelerated catheter-directed thrombolytic therapy in submassive pulmonary embolism.

Introduction The objective of this study was to evaluate the efficacy of ultrasound-accelerated catheter-directed thrombolytic therapy in patients with submassive pulmonary embolism. Methods Clinical records of 46 patients with submassive pulmonary embolism who underwent ultrasound-accelerated catheter-directed pulmonary thrombolysis using tissue plasminogen activator, from 2007 to 2017, were analyzed. All patients experienced clinical symptoms with computed tomography evidence of pulmonary thrombus burden. Right ventricular dysfunction was present in all patients by echocardiographic finding of right ventricle-to-left ventricle ratio > 0.9. Treatment outcome, procedural complications, right ventricular pressures, and thrombus clearance were evaluated. Follow-up evaluation included echocardiographic assessment of right ventricle-to-left ventricle ratio at one month, six months, and one year. Results Technical success was achieved in all patients ( n = 46, 100%). Our patients received an average of 18.4 ± 4.7 mg of tissue plasminogen activator using ultrasound-accelerated thrombolytic catheter with an average infusion time of 16.5± 5.4 h. Clinical success was achieved in all patients (100%). Significant reduction of mean pulmonary artery pressure occurred following the treatment, which decreased from 36 ± 8 to 21 ± 5 mmHg ( p < 0.001). There were no major bleeding complications. All-cause mortality at 30 days was 0%. No patient developed recurrent pulmonary embolism during follow-up. During the follow-up period, 43 patients (93%) showed improvement of right ventricular dysfunction based on echocardiographic assessment. The right ventricle-to-left ventricle ratio decreased from 1.32 ± 0.18 to 0.91 ± 0.13 at the time of hospital discharge ( p < 0.01). The right ventricular function remained improved at 6 months and 12 months of follow-up, as right ventricle-to-left ventricle ratio were 0.92 ± 0.14 ( p < 0.01) and 0.91 ± 0.15 ( p < 0.01), respectively. Conclusion Ultrasound-accelerated catheter-directed thrombolysis is a safe and efficacious treatment for submassive pulmonary embolism. It reduces pulmonary hypertension and improves right ventricular function in patients with submassive pulmonary embolism.

Feasibility of three-dimensional magnetic resonance angiography-fluoroscopy image fusion technique in guiding complex endovascular aortic procedures in patients with renal insufficiency.

OBJECTIVE: Three-dimensional image fusion of preoperative computed tomography (CT) angiography with fluoroscopy using intraoperative noncontrast cone-beam CT (CBCT) has been shown to improve endovascular procedures by reducing procedure length, radiation dose, and contrast media volume. However, patients with a contraindication to CT angiography (renal insufficiency, iodinated contrast allergy) may not benefit from this image fusion technique. The primary objective of this study was to evaluate the feasibility of magnetic resonance angiography (MRA) and fluoroscopy image fusion using noncontrast CBCT as a guidance tool during complex endovascular aortic procedures, especially in patients with renal insufficiency. METHODS: All endovascular aortic procedures done under MRA image fusion guidance at a single-center were retrospectively reviewed. The patients had moderate to severe renal insufficiency and underwent diagnostic contrast-enhanced magnetic resonance imaging after gadolinium or ferumoxytol injection. Relevant vascular landmarks electronically marked in MRA images were overlaid on real-time two-dimensional fluoroscopy for image guidance, after image fusion with noncontrast intraoperative CBCT. Technical success, time for image registration, procedure time, fluoroscopy time, number of digital subtraction angiography (DSA) acquisitions before stent deployment or vessel catheterization, and renal function before and after the procedure were recorded. The image fusion accuracy was qualitatively evaluated on a binary scale by three physicians after review of image data showing virtual landmarks from MRA on fluoroscopy. RESULTS: Between November 2012 and March 2016, 10 patients underwent endovascular procedures for aortoiliac aneurysmal disease or aortic dissection using MRA image fusion guidance. All procedures were technically successful. A paired t-test analysis showed no difference between preimaging and postoperative renal function (P = .6). The mean time required for MRA-CBCT image fusion was 4:09 ± 01:31 min:sec. Total fluoroscopy time was 20.1 ± 6.9 minutes. Five of 10 patients (50%) underwent stent graft deployment without any predeployment DSA acquisition. Three of six vessels (50%) were cannulated under image fusion guidance without any precannulation DSA runs, and the remaining vessels were cannulated after one planning DSA acquisition. Qualitative evaluation showed 14 of 22 virtual landmarks (63.6%) from MRA overlaid on fluoroscopy were completely accurate, without the need for adjustment. Five of eight incorrect virtual landmarks (iliac and visceral arteries) resulted from vessel deformation caused by endovascular devices. CONCLUSIONS: Ferumoxytol or gadolinium-enhanced MRA imaging and image fusion with fluoroscopy using noncontrast CBCT is feasible and allows patients with renal insufficiency to benefit from optimal guidance during complex endovascular aortic procedures, while preserving their residual renal function.

Impact of cumulative intravascular contrast exposure on renal function in patients with occlusive and aneurysmal vascular disease.

OBJECTIVE: Patients with occlusive or aneurysmal vascular disease are repeatedly exposed to intravascular (IV) contrast for diagnostic or therapeutic purposes. We sought to determine the long-term impact of cumulative iodinated IV contrast exposure (CIVCE) on renal function; the latter was defined by means of National Kidney Foundation (NKF) criteria. METHODS: We performed a longitudinal study of consecutive patients without renal insufficiency at baseline (NFK stage I or II) who underwent interventions for arterial occlusive or aneurysmal disease. We collected detailed data on any IV iodinated contrast exposure (including diagnostic or therapeutic angiography, cardiac catheterization, IV pyelography, computed tomography with IV contrast, computed tomographic angiography); medication exposure throughout the observation period; comorbidities; and demographics. The primary end point was the development of renal failure (RF) (defined as NFK stage 4 or 5). Analysis was performed with the use of a shared frailty model with clustering at the patient level. RESULTS: Patients (n = 1274) had a mean follow-up of 5.8 (range, 2.2-14) years. In the multivariate model with RF as the dependent variable and after adjusting for the statistically significant covariates of baseline renal function (hazard ratio [HR], 0.95; P < .001), diabetes (HR, 1.8; P = .007), use of an angiotensin-converting enzyme inhibitor (HR, 0.63; P = .03), use of antiplatelets (HR, 0.5; P = .01), cumulative number of open vascular operations performed (HR, 1.2; P = .001), and congestive heart failure (HR, 3.2; P < .001), CIVCE remained an independent predictor for RF development (HR, 1.1; P < .001). In the multivariate survival analysis model and after adjusting for the statistically significant covariates of perioperative myocardial infarction (HR, 3.9; P < .001), age at entry in the cohort (HR, 1.05; P = .035), total number of open operations (HR, 1.51; P < .001), and serum albumin (HR, 0.47; P < .001), CIVCE was an independent predictor of death (HR, 1.07; P < .001). CONCLUSIONS: Cumulative IV contrast exposure is an independent predictor of RF and death in patients with occlusive and aneurysmal vascular disease.

Validating common carotid stenosis by duplex ultrasound with carotid angiogram or computed tomography scan.

BACKGROUND: No consensus exists for duplex ultrasound criteria in the diagnosis of significant common carotid artery (CCA) stenosis. In general, peak systolic velocity (PSV) >150 cm/s with poststenotic turbulence indicates a stenosis >50%. The purpose of our study is to correlate CCA duplex velocities with angiographic findings of significant stenosis >60%. METHODS: We reviewed the carotid duplex records from 2008 to 2011 looking for patients with isolated CCA stenosis and no ipsilateral internal or contralateral carotid artery disease who received either a carotid angiogram or a computed tomography scan. We identified 25 patients who had significant CCA disease >60%. We also selected 74 controls without known CCA stenosis. We performed receiver operating characteristics analysis to correlate PSV and end-diastolic velocity (EDV) with angiographic stenosis >60%. The degree of stenosis was determined by measuring the luminal stenosis in comparison to the proximal normal CCA diameter. RESULTS: Most patients had a carotid angiogram (21/25), four only had a computed tomography angiography and four had both. Eighteen patients had history of neck radiation. The CCA PSV ≥250 cm/s had a sensitivity of 98.7% (81.5%-100%) and a specificity of 95.7% (92.0%-99.9%), CCA PSV ≥300 cm/s had a sensitivity of 90.9% (69.4%-98.4%) and a specificity of 98.7% (92.0%-99.9%). The CCA EDV ≥40 cm/s had a sensitivity of 95.5% (95% confidence interval of 75.1-99.8%) and specificity of 98.7% (92.0%-99.9%), EDV ≥60 cm/s had a sensitivity of 100% (75.1%-99.8%) and specificity of 87% (94.1-100%), and EDV ≥70 cm/s had a sensitivity of 86.4% (64.0%-96.4%) and specificity of 100% (94.1%-100%). The presence of both PSV <250 cm/s and EDV <60 cm/s had a 98.7% negative predictive value, and the presence of both PSV ≥250 cm/s and EDV ≥60 cm/s had 100% positive predictive value. CONCLUSIONS: Establishing CCA duplex criteria to screen patients with significant stenosis is crucial to identify those who will need further imaging modality or treatment. In our laboratory, CCA PSV ≥250 cm/s and EDV ≥60 cm/s are thresholds that can be used to identify significant (>60%) CCA stenosis with a high degree of accuracy.