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BACKGROUND: Uveal melanoma often metastasizes to the liver, portending a poor prognosis. Melphalan/hepatic delivery system (HDS) via percutaneous hepatic perfusion (PHP) is a minimally invasive means of circulating high-dose chemotherapy through the affected liver. This study evaluated melphalan/HDS use as either first-line or second-line treatment to guide treatment sequencing. PATIENTS AND METHODS: A retrospective review included patients with hepatic-dominant metastatic uveal melanoma who underwent melphalan/HDS treatment via PHP from 2008 to 2023. RESULTS: A total of 30 patients were identified; 53.3% female, with a median age of 63.5 years (37-78 years). Median follow-up time was 14.5 months. First-line therapies included melphalan/HDS (n = 17), liver-directed (n = 7), and immunotherapy (n = 6). Second-line therapies included melphalan/HDS (n = 6), immunotherapy (n = 5), and liver-directed (n = 3). Median hepatic progression-free survival (hPFS) for first-line melphalan/HDS, immunotherapy, and liver-directed therapy was 17.6/8.8/9.2 months, respectively (P = 0.002). Median hPFS for second-line melphalan/HDS, immunotherapy, and liver-directed therapy was not reached/14.7/7.5 months, respectively (P < 0.001). Median overall PFS for first-line melphalan/HDS, immunotherapy, and liver-directed therapy was 15.4/8.8/9.2 months, respectively (P = 0.04). Median overall PFS for second-line melphalan/HDS, immunotherapy, and liver-directed therapy was 22.2/14.7/7.5 months, respectively (P = 0.001). CONCLUSIONS: Melphalan/HDS via PHP for metastatic uveal melanoma to the liver was found to have significantly improved hPFS and overall PFS when used as first-line therapy compared with immunotherapy or liver-directed therapy. PHP continued to demonstrate improved hPFS and PFS when used as second-line therapy compared with second-line immunotherapy or liver-directed therapy.
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BACKGROUND AND OBJECTIVES: Primary cutaneous leiomyosarcoma (cLMS), a rare, typically intradermal tumor, has previously been reported to exhibit an indolent course of disease with zero-to-low risk of local recurrence or distant metastasis. This study seeks to evaluate recurrence and survival of cLMS patients through study of its clinicopathologic and treatment characteristics. METHODS: All patients included underwent resection of primary cLMS at this institution between 2006 and 2019. A retrospective cohort study analysis of clinicopathologic characteristics, treatment, recurrence, and overall survival was performed. Data was assessed through descriptive statistics and outcome measures assessed by Cox proportional models and log-rank tests. RESULTS: Eighty-eight patients with cLMS were evaluated. The majority were men (n = 68, 77%) and Caucasian (n = 85, 97%), with median age at diagnosis of 66 years (range 20-96). 65% of tumors were located on the extremities, with a median size of 1.3 cm (range .3-15). Assessment revealed low (n = 41, 47%), intermediate (n = 29, 33%), and high (n = 18, 20%) grade tumors, demonstrating extension into subcutaneous tissue in 38/60 (60%), with 3 patients exhibiting extension into muscle (3%). All underwent resection as primary treatment with median 1 cm margins (range .5-2). With median follow-up of 27.5 months (IQR 8-51; range 1-131), no low-grade cases had recurrence or death while there was a recurrence rate of 19.1% (9/47) and death rate of 8.5% (4/47) in intermediate- to high-grade cases. CONCLUSIONS: Primary tumor resection of cLMS provides excellent local control for low-grade tumors as no low-grade cases experienced recurrence. For patients with intermediate- to high-grade tumors, there is potential for local recurrence, distant metastasis, and death, and therefore surveillance following treatment is encouraged.
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Leiomiosarcoma , Neoplasias Cutáneas , Masculino , Humanos , Femenino , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Leiomiosarcoma/cirugía , Leiomiosarcoma/patología , Estudios Retrospectivos , Neoplasias Cutáneas/cirugía , Neoplasias Cutáneas/patología , Modelos de Riesgos Proporcionales , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/patología , PronósticoRESUMEN
Acral lentiginous melanoma is a rare subtype of melanoma generally associated with poor outcomes, even when diagnosed at an early stage. The tumor genetic profile remains poorly understood, but it is known to have a suppressed immune environment compared to that of non-acral cutaneous melanomas, which limits therapy options. There is significant attention on the development of novel therapeutic approaches, although studies are limited due to disease rarity. For local disease, wide local excision remains the standard of care. Due to frequent under-staging on preoperative biopsy, wider margins and routine sentinel lymph node biopsy may be considered if morbidity would not be increased. For advanced disease, anti-PD1 monotherapy or combination therapy with anti-PD1 and anti-CTLA4 agents have been used as first-line treatment modalities. Anti-PD1 and anti-CTLA4 combination therapies have been shown to be particularly beneficial for patients with BRAF-mutant acral lentiginous melanoma. Other systemic combination regimens and targeted therapy options may be considered, although large studies with consistent results are lacking. Regional and intralesional therapies have shown promise for cutaneous melanomas, but studies generally have not reported results for specific histologic subtypes, especially for acral melanoma. Overall, the unique histologic and genetic characteristics of acral lentiginous melanoma make therapy options significantly more challenging. Furthermore, studies are limited, and data reporting has been inconsistent. However, more prospective studies are emerging, and alternative therapy pathways specific to acral lentiginous melanoma are being investigated. As further evidence is discovered, reliable treatment guidelines may be developed.
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The treatment landscape for advanced and metastatic melanoma has drastically changed in recent years, with the advent of novel therapeutic options such as immune checkpoint inhibitors and targeted therapies offering remarkable efficacy and significantly improved patient outcomes compared to traditional approaches. Approximately 50% of melanomas harbor activating BRAF mutations, with over 90% resulting in BRAF V600E. Tumors treated with BRAF inhibitor monotherapy have a high rate of developing resistance within six months. Combination therapy with MEK inhibitors helped to mitigate this treatment resistance and led to improved outcomes. Due to the up-regulation of PD-1/PD-L1 receptors in tumors treated with BRAF/MEK inhibitor therapy, further studies included a third combination agent, anti-PD-1/PD-L1 inhibitors. This triple combination therapy may have superior efficacy and a manageable safety profile when compared with single or double agent therapy regimens.
Effective treatment of advanced and metastatic melanoma can be challenging. Newer treatment methods for patients with BRAF-mutated tumors include a combination of drugs with different complementary mechanisms. These drugs include BRAF-inhibitors, MEK-inhibitors, and PD-1/PD-L1 inhibitors. When these three medications are used in combination, patients may have better response rates and survival outcomes, when compared to using just one or two of these medications together. Toxicity rates are higher with a triple-medication regimen, so careful patient selection is important to consider.
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BACKGROUND: Despite increased adoption of the robotic platform for complex hepatobiliary resections for malignant disease, little is known about long-term survival outcomes. This is the first study to evaluate the postoperative outcomes, and short- and long-term survival rates after a robotic hepatectomy for five major malignant disease processes. METHODS: A prospectively collected database of patients who underwent a robotic hepatectomy for malignant disease was reviewed. Pathologies included colorectal liver metastases (CLM), hepatocellular carcinoma (HCC), Klatskin tumor, intrahepatic cholangiocarcinoma (IHCC), and gallbladder cancer (GC). Data are presented as median (mean â± âstandard deviation) for illustrative purposes. RESULTS: Of the 210 consecutive patients who underwent robotic hepatectomy for malignant disease, 75 (35 â%) had CLM, 69 (33 â%) had HCC, 27 (13 â%) had Klatskin tumor, 20 (10 â%) had IHCC, and 19 (9 â%) had GC. Patients were 66 (65 â± â12.4) years old with a BMI of 29 (29 â± â6.5) kg/m2. R0 resection was achieved in 91 â%, and 65 â% underwent a major hepatectomy. Postoperative major complication rate was 6 â%, length of stay was four (5 â± â4.3) days, and 30-day readmission rate was 17 â%. Survival at 1, 3, and 5-years were 93 â%/75 â%/72 â% for CLM, 84 â%/71 â%/64 â% for HCC, 73 â%/55 â%/55 â% for Klatskin tumor, 80 â%/69 â%/69 â% for IHCC, 79 â%/65 â%/65 â% for GC. CONCLUSION: This study suggests a favorable 5-year overall survival benefit with use of the robotic platform in hepatic resection for colorectal metastases, hepatocellular carcinoma, intrahepatic cholangiocarcinoma, Klatskin tumor, and gallbladder cancer. The robotic platform facilitates fine dissection in complex hepatobiliary operations, with a high rate of R0 resections and excellent perioperative clinical outcomes.
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Neoplasias de los Conductos Biliares , Carcinoma Hepatocelular , Colangiocarcinoma , Neoplasias Colorrectales , Neoplasias de la Vesícula Biliar , Tumor de Klatskin , Neoplasias Hepáticas , Procedimientos Quirúrgicos Robotizados , Humanos , Persona de Mediana Edad , Anciano , Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/secundario , Tumor de Klatskin/cirugía , Hepatectomía , Neoplasias de la Vesícula Biliar/cirugía , Colangiocarcinoma/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/cirugía , Conductos Biliares Intrahepáticos/patología , Neoplasias de los Conductos Biliares/cirugía , Neoplasias Colorrectales/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: As the first comprehensive investigation into hospital readmissions following robotic hepatectomy for neoplastic disease, this study aims to fill a critical knowledge gap by evaluating risk factors associated with readmission and their impact on survival and the financial burden. METHODS: The study analyzed a database of robotic hepatectomy patients, comparing readmitted and non-readmitted individuals post-operatively using 1:1 propensity score matching. Statistical methods included Chi-square, Mann-Whitney U, T-test, binomial logistic regression, and Kaplan-Meier analysis. RESULTS: Among 244 patients, 44 were readmitted within 90 days. Risk factors included hypertension (p â= â0.01), increased Child-Pugh score (p â< â0.01), and R1 margin status (p â= â0.05). Neoadjuvant chemotherapy correlated with lower readmission risk (p â= â0.045). Readmissions didn't significantly impact five-year survival (p â= â0.42) but increased fixed indirect hospital costs (p â< â0.01). CONCLUSIONS: Readmission post-robotic hepatectomy correlates with hypertension, higher Child-Pugh scores, and R1 margins. The use of neoadjuvant chemotherapy was associated with a lower admission rate due to less diffuse liver disease in these patients. While not affecting survival, readmissions elevate healthcare costs.
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Hepatectomía , Neoplasias Hepáticas , Readmisión del Paciente , Puntaje de Propensión , Procedimientos Quirúrgicos Robotizados , Humanos , Readmisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/economía , Hepatectomía/economía , Hepatectomía/efectos adversos , Masculino , Femenino , Procedimientos Quirúrgicos Robotizados/economía , Procedimientos Quirúrgicos Robotizados/efectos adversos , Persona de Mediana Edad , Factores de Riesgo , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/economía , Anciano , Modelos Logísticos , Estudios Retrospectivos , Tasa de Supervivencia , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/economía , Costos de Hospital/estadística & datos numéricos , AdultoRESUMEN
BACKGROUND: The robotic platform is growing in popularity for hepatobiliary resections. Although the learning curve for basic competency has been reported, this is the first study to analyze the learning curve to achieve long-term mastery on a decade of experience with more than 500 robotic hepatectomies. METHODS: After institutional review board approval, 500 consecutive robotic hepatectomies from 2013 to 2023 were analyzed. Cumulative sum (CUSUM) analysis using operative duration was used to determine the learning curves. RESULTS: A total of 500 patients were included in this study: composed of 230 men (46.0 %) and 270 women (54.0 %), aged 63.0 (61.0 ± 14.6) years, with a body mass index of 28.0 (29.0 ± 8.0) kg/m2, a Model for End-Stage Liver Disease score of 7 (8 ± 3.0), an albumin-bilirubin score of -3.0 (-3.0 ± 0.6), and a Child-Pugh score of 5.0 (5.0 ± 0.7). Operative duration was 235.0 (260.1 ± 131.9) minutes, estimated blood loss was 100.0 (165.0 ± 208.1) mL, tumor size was 4.0 (5.0 ± 3.5) cm, and 94.0 % of patients achieved R0 margins. The length of hospital stay was 3.0 (4.0 ± 3.7) days, with 4.0 % of patient having major complications. Of note, 30-day readmission was 17.0 %, 30-day mortality was 2.0 %, and 90-day mortality was 3.0 %. On CUSUM analysis, the learning curve for minor resection (n = 215) was 75 cases, major resection (n = 154) was 100 cases, and technically challenging minor resection (n = 131) was 57 cases. Gaining more experience in performing surgical procedures resulted in shorter operative duration, lower blood loss, higher R0 resections, and lower major postoperative complications. CONCLUSION: The minimum number of robotic hepatectomies to overcome the learning curves for mastery of minor, major, and technically challenging minor resections was significant. Our study can help guide surgeons in their early experience to optimize patient safety and outcomes.
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Hepatectomía , Curva de Aprendizaje , Tempo Operativo , Procedimientos Quirúrgicos Robotizados , Humanos , Masculino , Procedimientos Quirúrgicos Robotizados/educación , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Femenino , Persona de Mediana Edad , Hepatectomía/educación , Hepatectomía/métodos , Anciano , Tiempo de Internación/estadística & datos numéricos , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/patología , Estudios Retrospectivos , AdultoRESUMEN
Locoregionally advanced and metastatic melanoma represent a challenging clinical problem, but in the era of immune checkpoint blockade and intralesional and infusional therapies, more options are available for use. Isolated limb infusion (ILI) was first introduced in the 1990s for the management of advanced melanoma, followed by the utilization of isolated extremity perfusion (ILP). Following this, intralesional oncolytic viruses, xanthene dyes, and cytokines were introduced for the management of in-transit metastases as well as unresectable, advanced melanoma. In 2015, the Food and Drug Administration (FDA) approved the first oncolytic intralesional therapy, talimogene laherparepvec (T-VEC), for the treatment of advanced melanoma. Additionally, immune checkpoint inhibition has demonstrated efficacy in the management of advanced melanomas, and this improvement in outcomes has been extrapolated to aid in the management of in-transit metastatic disease. Finally, percutaneous hepatic perfusion (PHP), also approved by the FDA, has been reported to have a significant impact on the treatment of hepatic disease in uveal melanoma. While some of these treatments have less utility due to inferior outcomes as well as higher toxicity profiles, there are selective patient profiles for which these therapies carry a role. This review highlights intralesional and infusional therapies for the management of metastatic melanoma.
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BACKGROUND: Difficulty scoring system (DSS) has been established for laparoscopic hepatectomy and serves as useful tools to predict difficulty and guide preoperative planning. Despite increased adoption of robotics and its unique technical characteristics compared with laparoscopy, no DSS currently exists for robotic hepatectomy. We aimed to introduce a new DSS for robotic hepatectomy. METHODS: A total of 328 patients undergoing a robotic hepatectomy were identified. After removing the first 24 major and 30 minor hepatectomies using cumulative-sum analysis, 274 patients were included in this study. Relevant clinical variables underwent linear regression using operative time and/or estimated blood loss (EBL) as markers for operative difficulty. Score distribution was analyzed to develop a difficulty-level grouping system. RESULTS: Of the 274 patients, neoadjuvant chemotherapy; tumor location, size, and type; the extent of parenchymal resection; the need for portal lymphadenectomy; and the need for biliary resection with hepaticojejunostomy were significantly associated with operative time and/or EBL. They were used to develop the difficulty scores from 1 to 49. Grouping system results were group 1 (less demanding/beginner), 1 to 8 (n = 39); group 2 (intermediate), 9 to 24 (n = 208); group 3 (more demanding/advanced), 25 to 32 (n = 17); and group 4 (most demanding/expert), 33 to 49 (n = 10). When stratified by group, age, previous abdominal operation, Child-Pugh score, operative duration, EBL, major resection, 30-day mortality, 90-day mortality, and length of stay were significantly different among the groups. CONCLUSION: In addition to established variables in laparoscopic systems, new factors such as the need for portal lymphadenectomy and biliary resection specific to the robotic approach have been identified in this new robotic DSS. Internal and external validations are the next steps in maturing this robotic DSS.
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Pérdida de Sangre Quirúrgica , Hepatectomía , Neoplasias Hepáticas , Tempo Operativo , Procedimientos Quirúrgicos Robotizados , Humanos , Hepatectomía/métodos , Masculino , Femenino , Persona de Mediana Edad , Procedimientos Quirúrgicos Robotizados/métodos , Anciano , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/mortalidad , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Escisión del Ganglio Linfático/métodos , Adulto , Terapia Neoadyuvante , Estudios Retrospectivos , Carga Tumoral , Carcinoma Hepatocelular/cirugía , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/mortalidad , Anciano de 80 o más Años , Laparoscopía/métodosRESUMEN
Esophageal cancer is a significant health concern, with the robotic platform being increasingly adopted for transhiatal esophagectomy (THE). While literature exists regarding the cost of robotic THE and its benefits, there is limited data analyzing cost and concurrent hospital reimbursement based on payor or provider. This study aimed to compare hospital reimbursement after robotic THE for patients with Medicare versus private insurance. With IRB approval, a prospective study of 85 patients from 2012 to 2022 who underwent robotic THE was conducted. Private insurance was defined as coverage excluding Medicare, Medicaid, or self-pay. Statistical analyses involved Student's t test, Chi-square test, and Fisher's exact test, with p ≤ 0.05 considered statistically significant. Data are presented as median (mean ± standard deviation). Among the 85 patients, 64 had Medicare, and 21 had private insurance. Medicare patients exhibited more frequent history of prior abdominal or thoracic surgeries (41% vs 10%, p < 0.01). Both groups showed no differences in factors like sex, body mass index, ASA classification, operative duration, estimated blood loss, conversions to 'open', tumor size, and major postoperative complications (Clavien-Dindo ≥ III). Similarly, metrics such as hospital stay duration, in-hospital mortality, 30-day readmission, and various financial components including total and variable costs, hospital reimbursement, and net margin were consistent across both. Despite Medicare patients being older and often having a broader operative history, hospital costs and reimbursements did not differ from patients with private insurance post-robotic THE. The robotic platform appears to mitigate potential disparities in hospitalization costs and hospital reimbursement for THE between Medicare and private insurance.
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Medicare , Procedimientos Quirúrgicos Robotizados , Estados Unidos , Humanos , Anciano , Esofagectomía , Estudios Prospectivos , Procedimientos Quirúrgicos Robotizados/métodos , Costos de HospitalRESUMEN
Maintenance of hemodialysis access for end-stage renal disease continues to be a major challenge for vascular surgeons, nephrologists, and primary care physicians. This case report highlights the complication and treatment of lower extremity central venous stenosis, allowing continued dialysis access for a patient with limited remaining fistula options. This stenosis resulted from the prolonged use of a lower extremity central venous catheter. This case highlights the importance of imaging the central veins in obstruction of lower extremity fistulas. Once detected, as in the upper extremity, this can be effectively treated using balloon dilation and stenting.
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Angioplastia/instrumentación , Derivación Arteriovenosa Quirúrgica , Cateterismo Venoso Central/efectos adversos , Fallo Renal Crónico/terapia , Extremidad Inferior/irrigación sanguínea , Diálisis Renal , Stents , Vena Cava Inferior , Trombosis de la Vena/terapia , Presión Venosa Central , Circulación Colateral , Constricción Patológica , Humanos , Masculino , Persona de Mediana Edad , Flebografía , Flujo Sanguíneo Regional , Resultado del Tratamiento , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/fisiopatología , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiología , Trombosis de la Vena/fisiopatologíaRESUMEN
BACKGROUND: A rare appendiceal malignancy is characterized by both glandular and neuroendocrine histology. It often presents with dissemination of the perforated tumor to peritoneal surfaces. Current treatments involve systemic chemotherapy, cytoreductive surgery and perioperative intraperitoneal chemotherapy. METHODS: The impact of clinical, histological and treatment-related characteristics on survival were evaluated and subjected to univariate statistical analyses. All patients had stage IV disease and were treated by a uniform treatment strategy. Survival was determined from onset of disease until death or most recent follow-up. RESULTS: There were 47 patients available for study of whom 17 were male. Median age was 48 with a range of 27-65. None or a single symptom vs. 2 or more symptoms had a significant effect on survival. Median survival of the entire cohort was 45 months and 34.88% and 8.72% of patients survived 5 and 10 years, respectively. The use of neoadjuvant chemotherapy showed no impact on survival. Patients with a peritoneal cancer index (PCI) of 0-20 as compared to PCI > 20 survived longer (p = 0.012). The survival of patients able to have a complete resection as compared to an incomplete resection of disease was significant (p = 0.0087). The type of perioperative chemotherapy did not alter survival. CONCLUSIONS: These data show that patients with a lesser extent of disease with a complete cytoreduction had an improved prognosis. No benefit from systemic or perioperative regional chemotherapy was apparent. With long-term follow-up, patients with the combined glandular and neuroendocrine histology exhibiting peritoneal metastases have a guarded prognosis.
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Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias del Apéndice/terapia , Tumor Carcinoide/terapia , Neoplasias Complejas y Mixtas/terapia , Neoplasias Peritoneales/terapia , Adenocarcinoma/complicaciones , Adenocarcinoma/secundario , Administración Intravenosa , Adulto , Anciano , Neoplasias del Apéndice/complicaciones , Neoplasias del Apéndice/patología , Tumor Carcinoide/complicaciones , Tumor Carcinoide/secundario , Procedimientos Quirúrgicos de Citorreducción , Doxorrubicina/administración & dosificación , Femenino , Fluorouracilo/administración & dosificación , Humanos , Quimioterapia Intraperitoneal Hipertérmica , Infusiones Parenterales , Leucovorina/administración & dosificación , Masculino , Persona de Mediana Edad , Mitomicina/administración & dosificación , Terapia Neoadyuvante , Estadificación de Neoplasias , Neoplasia Residual , Neoplasias Complejas y Mixtas/patología , Tumores Neuroendocrinos , Periodo Perioperatorio , Neoplasias Peritoneales/complicaciones , Neoplasias Peritoneales/secundario , Pronóstico , Tasa de Supervivencia , Evaluación de SíntomasRESUMEN
BACKGROUND: Opioid misuse is currently plaguing the US. Efforts to reduce this include opioid prescribing education (OPE). Orthopaedic residents often prescribe opioids but, their education is unknown. METHODS: A survey was sent to orthoapedic residency program directors (PDs) regarding their program's controlled substance (CS) policies and knowledge of local CS regulations. RESULTS: There were 60 (36.8%) completed surveys. 54 (90.0%) programs allow resident outpatient opioid prescribing. Nine (16.7%) programs require individual DEA registration and 7 (13.0%) were unsure about DEA registrations. State laws regarding PDMP utilization and OPE for fully licensed physicians were correctly answered by 52 (86.7%) and 43 (71.6%), respectively. 27 (45.0%) programs had a mandatory OPE. Six (10.0%) PDs were unsure about a mandatory OPE. 16 (48.5%) programs that did not confirm an OPE were considering adding one. CONCLUSIONS: The majority of programs permit residents outpatient opioid prescribing; less than half provide mandatory OPE. Several PDs were unaware local CS prescribing regulations and education. This study demonstrates opportunities to improve OPE among orthopaedic residencies and PDs' knowledge regarding CS regulations.
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Analgésicos Opioides/administración & dosificación , Sustancias Controladas/administración & dosificación , Prescripciones de Medicamentos , Educación de Postgrado en Medicina , Internado y Residencia , Ortopedia/educación , Control de Medicamentos y Narcóticos , Humanos , Ejecutivos Médicos , Pautas de la Práctica en Medicina , Encuestas y Cuestionarios , Estados UnidosRESUMEN
A high proportion of patients with severe systemic atherosclerotic disease present with the involvement of both the coronary and aortoiliac arteries. For these patients with multiple comorbidities and high surgical risk, it is critical to minimize the overall physiologic burden of the operation when possible. Furthermore, with severe or complete occlusion of vascular supply to the lower extremities, it is beneficial to avoid two-stage surgeries because of the high risk of irreversible ischemia necessitating amputation. In select cases, a single combined operation without entering the abdominal cavity may be a reliable option. We present a case with excellent results using the technique of coronary artery bypass grafting (CABG) and extra-anatomic ascending aorta to bifemoral grafting through median sternotomy and subcutaneous tunneling. Furthermore, there is a wide variation in anticoagulation reversal practices among surgeons after performing these combined grafting operations. We administered only half of the ideal calculated protamine dose for reversal of heparinization, which achieved favorable results in our patient. Overall, with symptomatic occlusion of the coronary and aortoiliac arteries, combined CABG and extra-anatomic aortobifemoral grafting with subcutaneous tunneling is a reliable surgical option. The indication for this approach should be tailored to the anatomy of the lesion and the urgency of the clinical scenario.