Increasing disparity between Society for Vascular Surgery guidelines for infrarenal abdominal aortic aneurysm repair and real-world practice.

OBJECTIVE: The current Society for Vascular Surgery (SVS) guidelines, based on randomized controlled trials published more than a decade ago, recommend a minimum threshold diameter of 5.5 cm for infrarenal abdominal aortic aneurysm (iAAA) repair. It is unknown whether practice patterns with respect to size of repair have changed since the publication of these guidelines. We aimed to evaluate the real-world practice of vascular surgeons in our region with respect to iAAA size at the time of repair, whether this has changed over the past 12 years and if any changes were associated with the repair type, open vs endovascular. METHODS: The Vascular Study Group of New England (VSGNE) database was used to identify all patients who received iAAA repair between 2003 and 2015. The primary end point was to quantify the annual percentage of iAAAs repaired in different size categories (≥5.5 cm; <5.5 cm but ≥5.0 cm; <5.0 cm) over the study time period and by type of repair. The secondary end points were morbidity and mortality in these groups. We excluded nonelective cases (ruptured or symptomatic), patients with coexisting iliac artery aneurysms, and those missing critical data. RESULTS: A total of 5314 patients with iAAA repairs (1538 open, 3776 endovascular) were identified in the VSGNE database during the study period. In 40% (2110 of 5314) of patients, repair was performed for aneurysms <5.5 cm, with endovascular aneurysm repair (EVAR) comprising 75% (1581 of 2110) and open 25% (529 of 2110). More EVARs were performed for <5.5 cm in 2015 (46%) compared with 2003 (33%) (P < .05, n - 1 χ2) with an average increase of 1.1%/y. There was also a non-statistically significant increase in open repair of small aneurysms (0.7%/y; P = .759). Overall, 30-day mortality was 1.11% in the EVAR group (0.54% in <5.0 cm, 0.91% in ≥5.0 but <5.5 cm, and 1.55% in ≥5.5 cm), compared with 3% in the open group (2.88%, 1.79%, and 3.77%, respectively) with no significant change in mortality in either group over time. CONCLUSIONS: Despite the SVS guidelines suggesting surveillance rather than repair of iAAA <5.5 cm, an increasing proportion of repairs in the VSGNE database were performed below that threshold. The reasons for this are likely multifactorial and might include a lesser complexity and lower operative mortality for smaller aneurysms and markedly improved third- and fourth-generation stent graft technology with possibly better long-term survival. As such, it may be time to re-examine the current guidelines for iAAA repair.

In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas.

OBJECTIVE: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF. METHODS: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed. RESULTS: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality. CONCLUSIONS: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.

Emergency intraoperative vascular surgery consultations at a tertiary academic center.

OBJECTIVE: Vascular surgeons are frequently called on to provide emergency assistance to surgical colleagues. Whereas previous studies have included elective preoperative vascular consultations, we sought to characterize the breadth of assistance provided during unplanned intraoperative consultations at a single tertiary academic center. METHODS: We queried our institutional billing department during a 15-year period and reviewed the records (January 1, 2002-December 31, 2016) and identified unanticipated unplanned vascular surgery intraoperative consultations from all surgical services. Patients' demographics and comorbidities were recorded along with the consulting services, type of index operation, reasons for vascular consultation, regions of anatomic interventions, type of vascular interventions performed, and outcomes achieved. RESULTS: There were 419 emergency intraoperative consultations identified. Patients were 51% male, with an average age of 57 years and body mass index of 28.3 kg/m2. The most frequently consulting subspecialties included surgical oncology (n = 139 [33.2%]), cardiac surgery (n = 82 [19.6%]), and orthopedics (n = 44 [10.5%]). Index cases were elective/nonurgent (n = 324 [77.3%]), urgent (n = 27 [6.4%]), and emergent (n = 68 [16.2%]), with a majority involving tumor resection (n = 240 [57.3%]). The primary reasons for vascular consultation were revascularization (n = 213 [50.8%]), control of bleeding (n = 132 [31.5%]), assistance with dissection or exposure (n = 46 [11%]), embolic protection (n = 24 [5.7%]), and other (n = 4 [1.1%]). The primary blood vessel and anatomic field of intervention were categorized. Most cases (n = 264 [63%]) included preservation of blood flow, including primary arterial repair (n = 181 [43.2%]), patch angioplasty (n = 83 [19.8%]), bypass (n = 63 [15%]), and thrombectomy (n = 38 [9.1%]). Postoperative mean length of stay was 15 days, with 30-day and 1-year mortality of 7.2% and 26.5%. CONCLUSIONS: Vascular surgeons are called on to provide unplanned open surgical consultations for a wide variety of specialties over wide-ranging anatomic regions, employing a variety of skills and techniques. This study testifies to the essential services supplied to hospitals and our surgical colleagues along with the broad skills and training necessary for modern vascular surgeons.

Strategies and outcomes for aortic endograft explantation.

BACKGROUND: Failure of endovascular aneurysm repairs (EVARs) requiring open conversion remains a major challenge. We analyzed indications for repair, operative strategies, and outcomes with a focus on iliac artery degeneration after endograft removal. METHODS: A prospective, institutional database was reviewed to identify patients who underwent explantation of a failed EVAR device. Demographics, reason for failure, operative details including extent of endograft removal, and complications/survival were examined. Postexplantation computed tomography imaging was evaluated for iliac artery degeneration. RESULTS: There were 32 patients who underwent explantation from 2002 to 2017. Six patients were treated emergently for rupture. The majority were elderly (average age, 76 ± 8.5 years), white (100%) men (91%) who had their EVAR graft inserted 45.5 months (range, 0.3-86 months) before open conversion, usually at an outside institution (75%). Explanted endografts included nine AneuRx (Medtronic, Minneapolis, Minn), nine Excluder (W. L. Gore & Associates, Flagstaff, Ariz), four Endurant (Medtronic), three Zenith (Cook Medical, Bloomington, Ind), three Powerlink/AFX (Endologix, Irvine, Calif), one Aorfix (Lombard Medical, Oxfordshire, United Kingdom), one Talent (Medtronic), and two unknown. Failure was due to endoleak in 91% (type I, 38%; type II, 28%; type III, 13%; type V, 13%), infection in 6%, and occlusion/kinking in 3%. A previous attempt at endovascular salvage of EVAR occurred in 12 (37.5%) patients. Operative approach was transabdominal in 69% and retroperitoneal in 31%. Initial aortic clamp position was supraceliac in 31%, suprarenal in 31%, and infrarenal in 38%. Most patients had complete removal of their endograft (n = 19 [59%]), with 22 (69%) having at least the iliac limbs removed. Grafts with suprarenal fixation were more likely to have the upper main body left in situ (67% vs 17%; P = .029). The 30-day mortality was 6.3% (3.8% elective, 16.7% ruptured), and 31% had a major complication. Of the 23 patients who had follow-up imaging, there was a trend for more iliac degeneration (>5 mm in growth) in those who had the iliac limbs removed (29.4% vs 0%; P = .184). Three patients with iliac limb removal required subsequent iliac endovascular intervention (two for rupture). Patients who presented with a rupture had a decreased 5-year overall survival (33%) compared with those who were converted electively (59%). CONCLUSIONS: Both complete and partial endograft explantation, although morbid procedures, can be performed safely. Postoperative imaging surveillance is important, especially if the endograft has been removed from the iliac arteries, as degeneration can occur.

A model to demonstrate that endotension is a nonvisualized type I endoleak.

OBJECTIVE: Unexplained aneurysm growth despite multimodality imaging after endovascular aneurysm repair is often attributed to endotension. We tested a hypothesis that endotension may be from a type Ia endoleak pressurizing the aneurysm sac, without net forward flow, not visualized on standard angiographic imaging. METHODS: A patient-specific aortic aneurysm phantom was constructed of polyvinyl alcohol using three-dimensional molding techniques. A bifurcated stent graft was implanted, and the phantom was connected to a hemodynamic simulator for testing. Type Ia endoleaks were created using 7F catheters. Three scenarios were studied: complete exclusion (no endoleak), inflow with no sac outflow, and inflow with sac outflow. Imaging with digital subtraction angiography was performed at 48 kVp at 5 frames/s, followed by delayed imaging at 1 frame/min for 30 minutes. RESULTS: With no endoleak, the systemic pressure averaged 113 mm Hg and aneurysm sac pressure averaged 101 mm Hg. With an endoleak present without outflow, the systemic pressure averaged 116 mm Hg, the aneurysm sac pressure averaged 120 mm Hg, and endoleak flow was bidirectional with no net forward flow. With endoleak present with aneurysm sac outflow, the systemic pressure averaged 119 mm Hg, aneurysm sac pressure averaged 105.5 mm Hg, and net endoleak flow into the aneurysm sac was 21 mL/min across the endoleak channel. With digital subtraction imaging, the endoleak with no outflow was noted after >9 minutes of delayed imaging. CONCLUSIONS: In our model, the creation of a type Ia endoleak in the absence of sac outflow resulted in a mean pressure higher than the systemic mean pressure with zero net flow into the aneurysm sac. Consequently, the endoleak could only be visualized with markedly delayed imaging and not with standard contrast digital subtraction angiography like that used in clinical practice. Our findings suggest that endotension may in fact be the result of undetected endoleaks secondary to the limitations of present iodinated contrast imaging modalities.

Pharmacomechanical thrombectomy: 2015 update.

Pharmacomechanical Thrombectomy (PMT) is recognized as a recent advancement in the treatment of lower extremity deep venous thrombosis (DVT). Evidence for the use of this modality is growing rapidly, primarily based on anecdotal experience and large case series. Currently, the majority of patients with lower extremity DVT are treated with anticoagulation or compressive therapy without adjunctive surgical or interventional procedures. This article reviews the current evidence supporting the use of PMT over catheter directed thrombolysis or simple anticoagulation and the expected benefits that can be realized from each modality. In addition the relevant unique characteristics to each device currently available are described focusing on mechanism of action and potential side effects.

Parathyroid surgery can be safely performed in a community hospital by experienced parathyroid surgeons: A retrospective cohort study.

BACKGROUND: There is ongoing debate about the effectiveness and safety of performing parathyroid surgery in low-volume community hospitals. STUDY DESIGN/METHODS: Cases performed at community hospital by a group of 4 parathyroid surgeons (group 1) were reviewed. Cure and complication rates were analyzed in light of outcomes of an expert endocrine surgeon from high-volume academic center (group 2) as point of reference. RESULTS: During the respective time periods, 204 patients met inclusion criteria in group1 and 218 patients in group 2. Patient characteristics, biochemical tests, and performed localizing studies (ultrasound and sestamibi scan) were comparable between the two groups. Pathological findings, including adenoma, double adenoma, hyperplasia, and cancer were comparable. Each had comparable cure rates (97% and 99%) (p < 0.18) and complication rates (1% and 1%) (p < 0.93) for group 1 and 2, respectively. CONCLUSION: Our results showed that experienced parathyroid surgeons will achieve comparable excellent outcomes of parathyroid surgery at both community and academic-based centers. As the field of endocrine surgery evolves and matures, producing young fellowship-trained endocrine surgeons, there will be growing need for expanding the niche of endocrine surgery into community-based hospital settings, which eventually will contribute to expanding and equalizing access to high-quality surgical care across urban and rural areas.

Angiojet thrombolysis and vena cava filter insertion in a case of a duplicated inferior vena cava.

OBJECTIVES: Duplication of the inferior vena cava (IVC) complicates interventional procedures. This case report aims to shed light on this unusual anomaly and the preoperative considerations necessary when treatment of venous thromboembolism is undertaken. METHODS: An IRB approved case report of a 58 year old woman presented emergently with right lower extremity phlegmasia due to extensive thrombosis of her right iliofemoral and infrarenal portion of her duplicated IVC. RESULTS: The patient underwent IVC filter placement and rheolytic thrombectomy with thrombolysis using the Angiojet device followed by venoplasty and stenting of the iliofemoral system and right IVC. Complete symptomatic and radiographic resolution on duplex imaging was achieved at 1 year follow up. CONCLUSIONS: With adequate preoperative awareness of IVC anomalies and treatment options available satisfactory results can be achieved and complications minimized for this unique patient population.

Micro-laparoscopic colectomy: initial experience.

INTRODUCTION: Single-port surgery (SPS) has been growing in acceptance as an alternative to traditional laparoscopic surgery. With SPS, there are technical skills required that are not routine to standard laparoscopy. We explored the feasibility of micro-laparoscopic colectomy (MLC) using 3 mm instruments in patients eligible for standard laparoscopic surgery. METHODS: We performed an IRB approved retrospective review of all segmental colectomy performed by a single surgeon in selected patients using a micro-laparoscopic technique. We utilized two 3-mm trocars and one 12-mm Hasson umbilical incision, which was later widen for specimen extraction. RESULTS: Eighty patients underwent MLC: Twenty-six for diverticulitis, 26 for cancer, 22 for polyps, 3 for Crohn's disease, and 3 for volvulus. Eight patients were converted into either laparotomy or hand port (10 %) and three patients required the addition of one 5-mm trocar. Mean final extraction incision length was 3.9 cm. In cancer patients, the average lymph node harvest was 26 (range 13-70). The 30-day mortality was zero and the anastomotic leak rate was 1.3 %. CONCLUSIONS: MLC is safe and feasible when performing colon resections for benign and oncologic pathology. Extraction incision length is small and offers similar cosmesis to SPS without the steep learning curve needed to learn this technique.