In-Situ Fenestration of a PTFE Thoracic Aortic Stent Graft for Delayed Left Subclavian Artery Revascularization Following Frozen Elephant Trunk Repair of Type A Aortic Dissection.

Left subclavian artery revascularization during endovascular repair of aortic dissection is often accomplished by left carotid-subclavian artery bypass or transposition. In situ fenestration of thoracic stent grafts provides an alternative method of revascularization without manipulation of the left carotid artery. We describe a case whereby in situ laser fenestration, combined with catheter-directed thrombectomy, was utilized to revascularize a thrombosed left subclavian artery following a frozen elephant trunk repair of type A aortic dissection. A 75-year-old male presented with pericardial tamponade and aortic insufficiency, secondary to type A aortic dissection. Patient underwent an emergent replacement of the aortic root, valve, arch, and ascending aorta in the frozen elephant trunk configuration. The innominate and left carotid arteries were revascularized with a bifurcated bypass graft from the ascending aortic graft. The left subclavian artery (LSCA) was covered with an antegrade deployment of a cTAG stent graft. During the immediate postoperative period, the patient was found to have a dissection of the left common carotid artery (LCCA) and pseudoaneurysm of the bypass graft anastomosis. The left carotid artery was replaced up to the proximal internal carotid. During rehabilitation, the patient developed left subclavian steal syndrome, with a CT angiography demonstrating thrombosis of the subclavian origin, and duplex ultrasound showing a reversal of the left vertebral flow. In order to revascularize the left subclavian artery without using the left carotid as the inflow, the in situ laser fenestration technique was planned. The vertebral artery origin was protected with a neuroclip through a supraclavicular incision. Through a brachial artery cutdown, a 9Fr flex sheath was positioned at the origin of the subclavian artery. A suction thrombectomy catheter was used to create a central channel in the thrombus. A 0.035″ 3.2 mm over-the-wire laser atherectomy catheter was used to create a fenestration through the cTAG stent graft. The subclavian branch stent was stented with an iCast balloon-expandable covered stent, excluding the mural thrombus. The patient recovered well with resolution of symptoms and was discharged home. Postoperative CT scan showed patent left subclavian branch stent and no endoleak across the fenestration of the aortic stent graft. Delayed laser in situ fenestration of a PTFE stent graft can be performed safely. The vertebral artery protection and catheter-directed thrombectomy are important adjuncts to reduce the risk of posterior stroke.

Management of patients with acute aortic syndrome through a regional rapid transport system.

OBJECTIVE: The objective of this study was to describe the outcomes of patients with acute aortic syndrome (AAS) during and after transfer to a regional aortic center by a rapid transport system. METHODS: Review of patients with AAS who were transferred by a rapid transport system to a regional aortic center was performed. Data regarding demographics, diagnosis, comorbidities, transportation, and hospital course were acquired. Severity of existing comorbidities was determined by the Society for Vascular Surgery Comorbidity Severity Score (SVSCSS). The Acute Physiology and Chronic Health Evaluation II (APACHE II) score assessed physiologic instability on admission. Risk factors associated with system-related (transfer and hospital) mortality were identified by univariate and multivariate linear regression analysis. RESULTS: During a recent 18-month period (December 2013-July 2015), 183 patients were transferred by a rapid transport system; 148 (81%) patients were transported by ground and 35 (19%) by air. Median distance traveled was 24 miles (range, 3.6-316 miles); median transport time was 42 minutes (range, 10-144 minutes). Two patients died during transport, one with a type A dissection, the other of a ruptured abdominal aortic aneurysm. There were 118 (66%) patients who received operative intervention. Median time to operation was 6 hours. Type B dissections had the longest median time to operation, 45 hours, with system-related mortality of 1.9%; type A dissections had the shortest median time, 3 hours, and a system-related mortality of 16%. Overall, system-related mortality was 15%. On univariate analysis, factors associated with system-related mortality were age ≥65 years (P = .026), coronary artery disease (P = .030), prior myocardial infarction (P = .049), prior coronary revascularization (P = .002), SVSCSS of >8 (P < .001), abdominal pain (P = .002), systolic blood pressure <90 mm Hg at sending hospital (P = .001), diagnosis of aortic aneurysm (P = .013), systolic blood pressure <90 mm Hg in the intensive care unit (P < .001), and APACHE II score >10 (P = .004). Distance traveled and transport mode and duration were not associated with increased risk of system-related mortality. Only SVSCSS of >8 (odds ratio, 7.73; 95% confidence interval, 2.32-25.8; P = .001) was independently associated with an increase in system-related mortality on multivariate analysis. CONCLUSIONS: Implementation of a rapid transport system, regardless of mode or distance, can facilitate effective transfer of patients with AAS to a regional aortic center. An SVSCSS of >8 predicted an increased system-related mortality and may be a useful metric to assess the appropriateness of patient transfer.

Outcomes of Critical Limb Ischemia in an Urban, Safety Net Hospital Population with High WIfI Amputation Scores.

BACKGROUND: Patients presenting to a public hospital with critical limb ischemia (CLI) typically have advanced disease with significant comorbidities. The purpose of this study was to assess the influence of revascularization on 1-year amputation rate of CLI patients presenting to Los Angeles County USC Medical Center, classified according to the Society for Vascular Surgery Wound, Ischemia and foot Infection (WIfI). METHODS: A retrospective review of patients who presented to a public hospital with CLI from February 2010 to July 2014 was performed. Patients were classified according to the WIfI system. Only patients with complete data who survived at least 12 months after presentation were included. RESULTS: Ninety-three patients with 98 affected limbs were included. The mean age was 62.8 years. Eighty-two patients (84%) had hypertension and 71 (72%) had diabetes. Fifty (57.5%) limbs had Trans-Atlantic Inter-Society Consensus (TASC) C or D femoral-popliteal lesions and 82 (98%) had significant infrapopliteal disease. The majority had moderate or high WIfI amputation and revascularization scores. Eighty-four (86%) limbs underwent open, endovascular, or hybrid revascularization. Overall, one year major amputation (OYMA) rate was 26.5%. In limbs with high WIfI amputation score, the OYMA was 34.5%: 21.4% in those who were revascularized and 57% in those who were not. On univariable analysis, factors associated with increased risk of OYMA were nonrevascularization (P = 0.005), hyperlipidemia (P = 0.06), hemodialysis (P = 0.005), gangrene (P = 0.02), ulcer classification (P = 0.05), WIfI amputation score (P = 0.026), and WIfI wound grade (P = 0.04). On multivariable analysis, increasing WIfI amputation score (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.0-3.39) was associated with increased risk of OYMA while revascularization (OR 0.24, 95% CI 0.07-0.80) was associated with decreased risk of OYMA. CONCLUSIONS: The OYMA rates in this population were consistent with those predicted by the WIfI classification system. In this population, revascularization significantly reduced the risk of amputation. Comorbidities including diabetes mellitus and TASC classification did not moderate the association of WIfI amputation score with risk of 1-year major amputation.

Factors influencing maturation time of native arteriovenous fistulas.

BACKGROUND: To determine the factors influencing the maturation time of native arteriovenous fistulas. METHODS: A retrospective review was performed of hemodialysis patients from a single university-associated dialysis center from 2004 to 2009. Demographics, comorbidities, and insurance status were recorded. Maturation time was defined as the time from access creation until the access was able to be used regularly for hemodialysis for a period of 2 weeks. RESULTS: A total of 249 patients were identified during the study period who had an arteriovenous fistula created that successfully matured; 104 (42%) patients were women and 145 (58%) were men. Most of the patients were Hispanic (82%). Ninety-seven (39%) of the patients had Medicaid-type insurance and 133 (53%) had Medicare. The mean age was 51 years, and 190 (76%) of the patients had diabetes. The overall mean maturation time was 79 days. Women had a significantly longer time to fistula maturation than males (91.9 days vs. 70.5 days, P = 0.0028). Diabetics also had a significantly longer maturation time than nondiabetics (92.5 days vs. 75.4 days, P = 0.0004). Age did not have an effect on maturation time. On multivariable analysis, sex remained significant (P = 0.007), however, diabetes lost its significance. CONCLUSIONS: In this predominantly Hispanic hemodialysis population, women require longer fistula maturation times than men. The exact reasons for this are unknown based on this data. More study is required to determine the etiology of this gender discrepancy.

Adenocarcinoma of the esophagus in the young.

INTRODUCTION: Practitioners have noted a striking increase in the number of young patients under the age of 40 years old who develop esophageal adenocarcinoma. The aim of this study was to characterize the presentation, pathology and therapeutic outcome of these young patients. METHODS: The records of patients who presented to the Foregut Surgical Service at the University of Southern California with esophageal adenocarcinoma between 2000 and 2007 were retrospectively reviewed. The presentation, tumor stage and histology, therapy and outcome of the patients under the age of 40 were compared to those ≥40. RESULTS: Of the 374 patients reviewed, 20 (5 %) were under the age of 40. There were two patients in their second and 18 in their third decade of life. The youngest patient was 25 years old. A history of gastroesophageal reflux disease or Barrett's esophagus was less common in patients <40 than in those ≥40; 15 and 5 % compared to 61 and 46 %. Similarly, patients <40 had a significantly longer time interval between the onset of symptoms and the diagnosis of their cancer than those ≥40; 4.5 vs. 2 months, p = 0.04. They also had a higher prevalence of stage IV disease (30 vs. 6 %, p = 0.0003), a shorter time to recurrence (9.5 vs.19 month, p = 0.002), and a poorer median survival (17 vs. 43 month, p = 0.04). CONCLUSION: Esophageal adenocarcinoma in patients <40 years old commonly presents with an advanced stage of the disease and an associated poor survival. This is likely due to a low index of suspicion that dysphagia seen in younger patients is due to a malignancy.