Cryopreserved Allograft in the Management of Native and Prosthetic Aortic Infections.

BACKGROUND: The management of patients with aortic native and prosthetic infections is associated with significant morbidity and mortality. We describe a single-center experience with the use of cryopreserved allografts for the treatment of aortic infections, and compare outcomes with rifampin-soaked grafts and extra-anatomic bypass. METHODS: We retrospectively reviewed all patients who underwent an operative intervention for aortic infection at our tertiary care center from August 2007 to August 2017. Demographic data, preoperative work-up, procedural details, and outcomes were collected for each treatment modality. RESULTS: Thirty-two patients had aortic revascularization for aortic infection. Seventeen patients had cryopreserved allografts, 10 had rifampin-soaked grafts, and 5 had extra-anatomic bypass. Sixteen patients (50%) had native aortic infection and 16 patients (50%) had prosthetic aortic infection. Eighteen had involvement of the infrarenal abdominal aorta, 12 of the paravisceral aorta, and 2 of the descending thoracic aorta. Early mortality was 5.9% (1/17) for the cryopreserved group, 10% (1/10) for the rifampin-soaked group, and 40% (2/5) for the extra-anatomic bypass group. Early graft-related complications occurred in 1 patient (cryopreserved group). Mean follow-up was 34.8 months. Late death occurred in 4 patients with cryopreserved allografts, 2 with rifampin-soaked grafts and none with extra-anatomic bypass. Late graft-related complications occurred in 4 patients (cryopreserved group). Only 1 patient had recurrence of aortic infection (cryopreserved group) and 2 patients had limb loss (1 from the cryopreserved group and 1 from the rifampin-soaked group). At 1 month, 6 months, 1 year, and 3 years, estimated survival for patients with cryopreserved allografts was 94%, 82%, 75%, and 64%, respectively. CONCLUSIONS: The management of aortic infections is challenging. In patients who do not need immediate intervention, in situ aortic reconstruction with cryopreserved allografts is a viable treatment modality with relatively low morbidity and mortality.

Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms.

OBJECTIVE: It is not clear whether endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) results in an increase in renal insufficiency during the long term compared with open repair (OR). We reviewed our experience with AAA repair to determine whether there was a significant difference in postoperative and long-term renal outcomes between OR and EVAR. METHODS: A retrospective cohort study was conducted of all patients who underwent AAA repair between January 1993 and July 2013 at a tertiary referral hospital. Demographics, comorbidities, preoperative and postoperative laboratory values, morbidity, and mortality were collected. Patients with ruptured AAAs, preoperative hemodialysis, juxtarenal or suprarenal aneurysm origin, and no follow-up laboratory values were excluded. Preoperative, postoperative, 6-month, and yearly serum creatinine values were collected. Glomerular filtration rate (GFR) was calculated on the basis of the Chronic Kidney Disease Epidemiology Collaboration equation. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes guidelines. Change in GFR was defined as preoperative GFR minus the GFR at each follow-up interval. Comparison was made between EVAR and OR groups using multivariate logistics for categorical data and linear regression for continuous variables. RESULTS: During the study period, 763 infrarenal AAA repairs were performed at our institution; 675 repairs fit the inclusion criteria (317 ORs and 358 EVARs). Mean age was 73.9 years. Seventy-nine percent were male, 78% were hypertensive, 18% were diabetic, and 31% had preoperative renal dysfunction defined as GFR below 60 mL/min. Using a multivariate logistic model to control for all variables, OR was found to have a 1.6 times greater chance for development of immediate postoperative AKI compared with EVAR (P = .038). Hypertension and aneurysm size were independent risk factors for development of AKI (P = .012 and .022, respectively). Using a linear regression model to look at GFR decline during several years, there was a greater decline in GFR in the EVAR group. This became significant starting at postoperative year 4. AKI and preoperative renal dysfunction were independent risk factors for long-term decline in renal function. CONCLUSIONS: Although AKI is less likely to occur after EVAR, patients undergoing EVAR experience a significant but delayed decline in GFR over time compared with OR. This became apparent after postoperative year 4. Studies comparing EVAR and OR may need longer follow-up to detect clinically significant differences in renal function.

Cerebrovascular injuries found in acute type B aortic dissections are associated with blood pressure derangements and poor outcome.

OBJECTIVE: Cerebrovascular injury (CVI) is a recognized but underappreciated complication of acute type B aortic dissection (ATBAD). This study was performed to determine risk factors for CVI associated with ATBAD and, in particular, the possible contributory role of aggressive anti-impulse therapy. METHODS: A retrospective review of all patients presenting to a tertiary medical center with an ATBAD between January 2003 and October 2012 was conducted. All CVIs were adjudicated by a vascular neurologist and assigned a probable cause. The initial intensity of anti-impulse therapy was defined as the difference in mean arterial pressure (ΔMAP) from presentation to subsequent admission to the intensive care unit. RESULTS: A total of 112 patients were identified. The average age was 61 years; 64% were male, and 59% were African American. Twenty patients required operative intervention (14 thoracic endovascular aortic repairs and 6 open). CVI occurred in 13 patients (11.6%): 9 were hypoperfusion related (6 diffuse hypoxic brain injuries and 3 watershed infarcts), 2 were procedure related (both thoracic endovascular aortic repairs), 1 was an intracranial hemorrhage on presentation, and 1 was a probable embolic stroke on presentation. CVI patients had demographics and comorbidities comparable to those of the non-CVI patients. CVI was associated with operative intervention (54% vs 13%; P = .002). Thirty-day mortality was significantly higher in CVI patients (54% vs 6%; P < .001). Patients who suffered a hypoperfusion brain injury had a higher MAP on presentation to the emergency department (142 mm Hg vs 120 mm Hg; P = .034) and a significantly greater reduction in MAP (ΔMAP 49 mm Hg vs 15 mm Hg; P < .001) by the time they reached the intensive care unit compared with the non-CVI patients. CONCLUSIONS: In our series, CVI in ATBAD is more frequent than previously reported and is associated with increased mortality. The most common causes are related to cerebral hypoperfusion. Higher MAP on presentation and greater decline in MAP are associated risk factors for hypoperfusion-related CVI. A less aggressive approach to lowering MAP in ATBAD warrants further study in an attempt to reduce CVI in ATBAD.

Epithelioid Hemangioendothelioma Presenting as Inferior Vena Cava Obstruction Diagnosed Using an Endovascular Thrombectomy Device.

Epithelioid hemangioendothelioma is a rare vascular sarcoma that arises from the lining (intima) of blood vessels. We report a case of a 43-year-old male patient, who presented with inferior vena cava (IVC) obstruction and acute bilateral lower extremity deep vein thrombosis. Mechanical thrombectomy was performed with an endovascular thrombectomy device, followed by stent placement in the IVC. The initial pathology on the retrieved specimen obtained from the thrombectomy device revealed an undifferentiated neoplasm, and definitive surgical resection of the retroperitoneal soft-tissue tumor of the IVC documented a rare case of epithelioid hemangioendothelioma.

Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device.

OBJECTIVE: Mechanical assist devices have found an increasingly important role in high-risk interventional cardiac procedures. The Impella (Abiomed Inc, Danvers, Mass) is a percutaneous left ventricular assist device inserted through the femoral artery under fluoroscopic guidance and positioned in the left ventricular cavity. This study was undertaken to assess the incidence of vascular complications and associated morbidity and mortality that can occur with Impella placement. METHODS: We used a prospective database to review patients who underwent placement of an Impella left ventricular assist device in our tertiary referral center from July 2010 to December 2013. Patient demographics, comorbidities, interventional complications, and 30-day mortality were recorded. RESULTS: The study included 90 patients (60% male). Mean age was 66 years (range, 17-97 years). Hypertension was found in 69% of the patients, 37% were diabetic, 57% had a history of tobacco abuse, and 65% had chronic renal insufficiency. The median preprocedure cardiac ejection fraction was 30%. Most (87%) had undergone coronary artery intervention. Cardiogenic shock was documented in 67 patients (74%). The Impella was placed for an average of 1 day (range, 0-5 days). At least one vascular complication occurred in 15 patients (17%). Acute limb ischemia occurred in 12 patients; of whom four required an amputation and six required open or endovascular surgery. Other complications included groin hematomas and one pseudoaneurysm. All-patient 30-day mortality was 50%, which was not significantly associated with vascular complications. Female sex and cardiogenic shock at the time of insertion were associated with vascular complications (P = .043 and P = .018, respectfully). CONCLUSIONS: Vascular complications are common with placement of the Impella percutaneous left ventricular assist device (17%) and are related to emergency procedures. Vascular complications in this high-risk patient population frequently lead to withdrawal of care. These data provide quality improvement targets for left ventricular assist device programs.

Results of polytetrafluoroethylene-covered nitinol stents crossing the inguinal ligament.

OBJECTIVE: Placement of arterial endoprostheses across the inguinal ligament is generally thought to be contraindicated for fear of device kinking, fracture, or occlusion and possible obliteration of the deep femoral artery (DFA). We present a series of selected patients who underwent insertion of polytetrafluoroethylene-covered nitinol stents (Viabahn stent grafts. W. L. Gore and Associates Inc, Flagstaff, Ariz) crossing the middle common femoral artery (CFA) on an emergency basis or who were considered high risk for open surgery. METHODS: We treated 16 patients with 17 lesions adjacent to or within the CFA with stent grafts that originated in the common iliac (two) or external iliac (15) artery and terminated in the distal CFA (12), DFA (three), or superficial femoral (two) artery. Stent grafts were placed on an elective (10) or emergency (seven) basis for arterial occlusive disease (10), bleeding (six), and aneurysmal disease (one). Comorbidities favoring endovascular treatment were high medical risk (10) previous scarring (four), morbid obesity (two), and dense arterial calcification precluding open surgical repair (one). RESULTS: The DFA was deliberately sacrificed in one of the 17 cases. No patient suffered major complications after the procedure. All grafts remained patent based on duplex ultrasound imaging during follow-up (mean, 12.3 months; range, 1-58 months). Two patients required an additional endovascular intervention to treat inflow or outflow stenoses during follow-up, yielding a 2-year primary patency rate of 93.8% and assisted primary patency rate of 100%. CONCLUSIONS: These results suggest that selective placement of Viabahn stent grafts across the inguinal ligament to treat arterial occlusive disease or bleeding may prove to be safe, effective, and associated with acceptable patency rates. This strategy helps avoid complicated open arterial surgery in high-risk patients with associated multiple medical risk factors or hostile scarred groins.

Post-anastomotic venous stenosis after Optiflow deployment: An unexpected outcome.

Arteriovenous fistula failure represents a major cause of hospitalization and a significant economic burden for end-stage renal disease patients on hemodialysis. The Optiflow (Bioconnect Systems Inc., Ambler, PA) is a new device developed to improve arteriovenous fistula outcomes and decrease failure rates by reducing the risk of stenosis and improving maturation rates. This case report describes a 50-year-old male with hypertensive nephropathy on dialysis who had multiple arteriovenous fistula failures in the past. He was scheduled to undergo brachiocephalic fistula construction using the Optiflow device. After 8 months of use, the new fistula developed a peri-anastomotic venous stenosis, just distal to the Optiflow device. To our knowledge, this is the first time such a complication has been reported.