Diagnostic Yield of Abdominal Radiographs in the Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: Abdominal radiographs (ARs) are commonly used in the pediatric emergency department (PED). Their low diagnostic accuracy leads to overuse, excess radiation exposure, and increased resource usage. This study aims to assess the diagnostic yield of ARs in the evaluation of intraabdominal pathology in the PED. METHODS: Retrospective, cross-sectional study of patients aged 0 to 18 years with an AR who visited the PED between 2017 and 2019. Diagnostic yield was analyzed with sensitivity, specificity, positive predictive value, negative predictive value (NPV), and likelihood ratio. RESULTS: A total of 4288 ARs were identified, with a rate of 6%. The overall abnormal AR rate was 31%. The incidences of an abnormal AR in abdominal pain, vomiting, and constipation were 26%, 37%, and 50%, respectively. There was a 13% rate of clinically significant diagnoses. The AR diagnostic yield showed 44% sensitivity, 70% specificity, 17% positive predictive value, and 90% NPV ( P < 0.05). Unadjusted odds ratio analysis of positive AR and abdominal pain, vomiting, and constipation revealed an odds ratio of 0.68 (95% confidence interval [CI], 0.63-0.75), 1.22 (95% CI, 1.06-1.39), and 1.72 (95% CI, 1.54-1.91), respectively. CONCLUSIONS: There is a low rate of intraabdominal pathologic processes that an AR can identify. A normal AR does not change patient management, nor does it reduce the need for further radiologic imaging. Despite a good NPV, the AR is not a useful diagnostic tool in the PED because of its limited ability to rule in or rule out clinically significant diagnoses.

Improved perioperative mortality after secondary aortoenteric fistula repair and lessons learned from a 20-year experience.

BACKGROUND: Secondary aortoenteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes. METHODS: We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints. RESULTS: A total of 57 patients (63% male; n = 36) presented with SAEF (median age, 69 years; interquartile range [IQR], 61-74 years). Median follow-up time was 10 months (interquartile range, 3-21 months. The most common presenting symptoms were gastrointestinal bleeding (60%; n = 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n = 17) underwent extra-anatomic bypass with aortic ligation, 30% (n = 17) rifampin-soaked Dacron graft, 26% (n = 15) femoral vein (eg, neoaortoiliac system), and 14% (n = 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n = 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n = 35). Thirty-day mortality was 35% (n = 20) with no significant difference between 90 days (39%; n = 22) and 180 days (42%; n = 24). Morbidity was 70% (n = 40), with gastrointestinal (30%; n = 17; leak [9%]), pulmonary (25%; n = 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n = 32). One-year and 3-year survival was 54% ± 6% and 48% ± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P = .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P = .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome. CONCLUSIONS: In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center.

Treatment and Outcomes of Aortic Graft Infections Using a Decision Algorithm.

BACKGROUND: Aortic graft infection (AGI) is a rare but devastating complication requiring both explant of the infected prosthesis and lower extremity revascularization. Despite a variety of methods to treat AGI, there is a paucity of evidence that describes comparative outcomes. Moreover, controversy exists surrounding what the optimal repair strategy is with limited descriptions of how these techniques should be employed in this complex group of patients. Therefore, the purpose of this analysis was to review our experience with AGI management while highlighting a practice philosophy that can achieve acceptable outcomes. METHODS: All AGI patients between 2002-2019 were reviewed. The primary end-point was 30-day mortality. Secondary end-points included complications, re-infection, unplanned re-operation and all-cause mortality. Kaplan-Meier methodology was used to estimate time to events. Cox regression models were employed to identify association between patient factors and operative strategy with survival. Subgroup analysis included outcome comparison among four different operative approaches(extra-anatomic bypass with aortic ligation [EAB] and in-situ reconstruction [ISR] using either NAIS, cryopreserved allograft [Cryo], or antibiotic-soaked prosthetic grafts [Other]). RESULTS: 142 patients (male-69%, mean age 67 ± 11 years) were reviewed. Median time to AGI presentation was 52 (IQR 16-128) months. ISR was performed in 70% (n = 99)[ISR: NAIS-49% (n = 49), Cryo, 33% (n = 33) and Other-23% (n = 23)]. EAB was used in 26% (n = 37), of which 57% (n = 21) were staged repairs[no reconstruction, 4%: intraoperative death-2, AGI removal without reconstruction-2]. A graft enteric erosion/fistula was identified in 39% (n = 55). Mean follow-up time was 14 ± 27 (median 2.2[IQR 0.1-16]) months. Overall, 30-day mortality was 21% and 69% (n = 98) experienced a complication. The most common complications were pulmonary (35%;n = 50), vascular (28%;n = 39), gastrointestinal (22%;n = 31) and renal (21%;n = 30). Freedom from re-infection at one and three years was 78 ± 5% and 73 ± 6% while freedom from unplanned re-operation was 50 ± 5% and 40 ± 6%, respectively. Corresponding one- and five-year freedom from all-cause mortality was 67 ± 4% and 53 ± 4%. When stratified by the four different repair strategies, unadjusted rates of postoperative complications and mortality were not different. However, EAB patients had more renal complications. All-cause mortality predictors included age (HR 1.04, 95%CI 1.01-1.1; P = 0.003), CHF (HR 2.7, 1.3-5.7; P = 0.01), and graft enteric erosion/fistula (HR 2.2, 1.3-3.8;P = 0.005) while total graft excision was protective (HR 0.34, 0.2-0.7; P = 0.003). CONCLUSIONS: AGI repair, regardless of operative strategy, results in significant early morbidity, and mortality. The need for unplanned re-operation is common; however, long-term survival is acceptable in appropriately selected patients. Re-infection risk mandates life-long surveillance and consideration of indefinite anti-microbial suppression in certain subgroups. Due to the complexity and intensity of care, all AGI should be treated, when possible, at centers performing high-volume aortic surgery.

Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become a mainstay of therapy for acute and chronic type B aortic dissection (TBAD). Dynamic aortic morphologic changes, untreated dissected aorta, and persistent false lumen perfusion have significant consequences for reintervention after TEVAR for TBAD. However, few reports contrast differences in secondary aortic intervention (SAI) after TEVAR for TBAD or describe their influence on mortality. This analysis examined incidence, timing, and types of SAI after TEVAR for acute and chronic TBAD and determined their impact on survival. METHODS: All TEVAR procedures for acute and chronic TBAD (2005-2016) were retrospectively reviewed. Patients with staged (<30 days) or concomitant ascending aortic arch repair or replacement were excluded. Acuity was defined by symptom onset (0-30 days, acute; >30 days, chronic). SAI procedures were grouped into open (intended treatment zone or remote aortic site), major endovascular (TEVAR extension or endograft implanted at noncontiguous site), and minor endovascular (side branch or false lumen embolization) categories. Kaplan-Meier methodology was used to estimate freedom from SAI and survival. Cox proportional hazards were used to identify SAI predictors. RESULTS: TEVAR for TBAD was performed in 258 patients (acute, 49% [n = 128]; chronic, 51% [n = 130]). Mean follow-up was 17 ± 22 months with an overall SAI rate of 27% (n = 70; acute, 22% [28]; chronic, 32% [42]; odds ratio, 1.7; 95% confidence interval, 0.9-2.9; P = .07]. Median time to SAI was significantly less after acute than after chronic dissection (0.7 [0-12] vs 7 [0-91] months; P < .001); however, freedom from SAI was not different (1-year: acute, 67% ± 4%, vs chronic, 68% ± 5%; 3-year: acute, 65% ± 7%, vs chronic, 52% ± 8%; P = .7). Types of SAI were similar (acute vs chronic: open, 61% vs 55% [P = .6]; major endovascular, 36% vs 38% [P = .8]; minor endovascular, 21% vs 21% [P = 1]). The open conversion rate (either partial or total endograft explantation: acute, 10% [13/128]; chronic, 15% [20/130]; P = .2) and incidence of retrograde dissection (acute, 6% [7/128]; chronic, 4% [5/130]; P = .5) were similar. There was no difference in survival for SAI patients (5-year: acute + SAI, 55% ± 9%, vs acute without SAI, 67% ± 8% [P = .3]; 5-year: chronic + SAI, 72% ± 6%, vs chronic without SAI, 72% ± 7% [P = .7]). Factors associated with SAI included younger age, acute dissection with larger maximal aortic diameter at presentation, Marfan syndrome, and use of arch vessel adjunctive procedures with the index TEVAR. Indication for the index TEVAR (aneurysm, malperfusion, rupture, and pain or hypertension) or remote preoperative history of proximal arch procedure was not predictive of SAI. CONCLUSIONS: SAI after TEVAR for TBAD is common. Acute TBAD has a higher proportion of early SAI; however, chronic TBAD appears to have ongoing risk of remediation after the first postoperative year. SAI types are similar between groups, and the occurrence of aorta-related reintervention does not affect survival. Patients' features and anatomy predict need for SAI. These data should be taken into consideration for selection of patients, device design, and surveillance strategies after TEVAR for TBAD.

Contemporary outcomes of precision banding for high flow hemodialysis access.

OBJECTIVE: High-flow hemodialysis accesses are a well-recognized source of patient morbidity. Among available management strategies inflow constriction based on real-time physiologic flow monitoring offers a technically straightforward data-driven approach with potentially low morbidity. Despite the benefits offered by this approach, large contemporary series are lacking. METHODS: A retrospective review of a prospectively maintained clinical database was undertaken to capture patients undergoing precision banding within a signal tertiary care institution between 2010 and 2019. Multivariable logistic regression modeling of thrombosis within 30 days and re-banding within 1 year were performed. RESULTS: In total, 297 patients underwent banding during the study period for a total number of 398 encounters. Median [IQR] follow-up was 157 [52-373] days. Most accesses were upper arm with brachial artery inflow (84%) and half of the banding procedures were performed for flow imbalance based on exam, duplex, or fistulogram. Median flow rate reduction was 58%. The 30-day thrombosis rate after banding was 15 of 397 (3.8%) with a median time to event of 5.5 days (2-102). The re-banding rate within a year was 54 of 398 (14%) with a median time to re-banding of 134 days [56-224]. Multivariate logistic regression analysis using a univariate screen did not identify any predictors of 30-day thrombosis. Having a forearm radial-cephalic AVF compared to all other access types was protective against need for rebanding at 1 year (OR 0.12 95% CI 0.02-0.92, p = 0.04), as was flow imbalance as the indication for banding (OR 0.43 95% 0.23-0.79, p = 0.006). CONCLUSIONS: Precision banding offers an effective, low-morbidity approach for high-flow hemodialysis accesses. Early thrombosis is a rare event after precision banding, although in the long term, one in four patients will require re-banding to maintain control of flow volumes.

Outcomes After Endovascular Aortic Intervention in Patients With Connective Tissue Disease.

Importance: Endovascular treatment is not recommended for aortic pathologies in patients with connective tissue diseases (CTDs) other than in redo operations and as bridging procedures in emergencies. However, recent developments in endovascular technology may challenge this dogma. Objective: To assess the midterm outcomes of endovascular aortic repair in patients with CTD. Design, Setting, and Participants: For this descriptive retrospective study, data on demographics, interventions, and short-term and midterm outcomes were collected from 18 aortic centers in Europe, Asia, North America, and New Zealand. Patients with CTD who had undergone endovascular aortic repair from 2005 to 2020 were included. Data were analyzed from December 2021 to November 2022. Exposure: All principal endovascular aortic repairs, including redo surgery and complex repairs of the aortic arch and visceral aorta. Main Outcomes and Measures: Short-term and midterm survival, rates of secondary procedures, and conversion to open repair. Results: In total, 171 patients were included: 142 with Marfan syndrome, 17 with Loeys-Dietz syndrome, and 12 with vascular Ehlers-Danlos syndrome (vEDS). Median (IQR) age was 49.9 years (37.9-59.0), and 107 patients (62.6%) were male. One hundred fifty-two (88.9%) were treated for aortic dissections and 19 (11.1%) for degenerative aneurysms. One hundred thirty-six patients (79.5%) had undergone open aortic surgery before the index endovascular repair. In 74 patients (43.3%), arch and/or visceral branches were included in the repair. Primary technical success was achieved in 168 patients (98.2%), and 30-day mortality was 2.9% (5 patients). Survival at 1 and 5 years was 96.2% and 80.6% for Marfan syndrome, 93.8% and 85.2% for Loeys-Dietz syndrome, and 75.0% and 43.8% for vEDS, respectively. After a median (IQR) follow-up of 4.7 years (1.9-9.2), 91 patients (53.2%) had undergone secondary procedures, of which 14 (8.2%) were open conversions. Conclusions and Relevance: This study found that endovascular aortic interventions, including redo procedures and complex repairs of the aortic arch and visceral aorta, in patients with CTD had a high rate of early technical success, low perioperative mortality, and a midterm survival rate comparable with reports of open aortic surgery in patients with CTD. The rate of secondary procedures was high, but few patients required conversion to open repair. Improvements in devices and techniques, as well as ongoing follow-up, may result in endovascular treatment for patients with CTD being included in guideline recommendations.

Periprocedural Hydrogen Sulfide Therapy Improves Vascular Remodeling and Attenuates Vein Graft Disease.

Background Failure rates after revascularization surgery remain high, both in vein grafts (VG) and arterial interventions. One promising approach to improve outcomes is endogenous upregulation of the gaseous transmitter-molecule hydrogen sulfide, via short-term dietary restriction. However, strict patient compliance stands as a potential translational barrier in the vascular surgery patient population. Here we present a new therapeutic approach, via a locally applicable gel containing the hydrogen sulfide releasing prodrug (GYY), to both mitigate graft failure and improve arterial remodeling. Methods and Results All experiments were performed on C57BL/6 (male, 12 weeks old) mice. VG surgery was performed by grafting a donor-mouse cava vein into the right common carotid artery of a recipient via an end-to-end anastomosis. In separate experiments arterial intimal hyperplasia was assayed via a right common carotid artery focal stenosis model. All mice were harvested at postoperative day 28 and artery/graft was processed for histology. Efficacy of hydrogen sulfide was first tested via GYY supplementation of drinking water either 1 week before VG surgery (pre-GYY) or starting immediately postoperatively (post-GYY). Pre-GYY mice had a 36.5% decrease in intimal/media+adventitia area ratio compared with controls. GYY in a 40% Pluronic gel (or vehicle) locally applied to the graft/artery had decreased intimal/media area ratios (right common carotid artery) and improved vessel diameters. GYY-geltreated VG had larger diameters at both postoperative days 14 and 28, and a 56.7% reduction in intimal/media+adventitia area ratios. Intimal vascular smooth muscle cell migration was decreased 30.6% after GYY gel treatment, which was reproduced in vitro. Conclusions Local gel-based treatment with the hydrogen sulfide-donor GYY stands as a translatable therapy to improve VG durability and arterial remodeling after injury.

Insights From a Short-Term Protein-Calorie Restriction Exploratory Trial in Elective Carotid Endarterectomy Patients.

BACKGROUND: Open vascular surgery interventions are not infrequently hampered by complication rates and durability. Preclinical surgical models show promising beneficial effects in modulating the host response to surgical injury via short-term dietary preconditioning. Here, we explore short-term protein-calorie restriction preconditioning in patients undergoing elective carotid endarterectomy to understand patient participation dynamics and practicalities of robust research approaches around nutritional/surgical interventions. METHODS: We designed a pilot prospective, multicenter, randomized controlled study in patients undergoing carotid endarterectomy. After a 3:2 randomization to a 3-day preoperative protein-calorie restriction regimen (30% calorie/70% protein restriction) or ad libitum group, blood, clinical parameters, and stool samples were collected at baseline, pre-op, and post-op days 1 and 30. Subcutaneous and perivascular adipose tissues were harvested periprocedurally. Samples were analyzed for standard chemistries and cell counts, adipokines. Bacterial DNA isolation and 16S rRNA sequencing were performed on stool samples and the relative abundance of bacterial species was measured. RESULTS: Fifty-one patients were screened, 9 patients consented to the study, 5 were randomized, and 4 completed the trial. The main reason for non-consent was a 3-day in-hospital stay. All 4 participants were randomized to the protein-calorie restriction group, underwent successful endarterectomy, reported no compliance difficulties, nor were there adverse events. Stool analysis trended toward increased abundance of the sulfide-producing bacterial species Bilophila wadsworthia after dietary intervention (P = .08). CONCLUSIONS: Although carotid endarterectomy patients held low enthusiasm for a 3-day preoperative inpatient stay, there were no adverse effects in this small cohort. Multidisciplinary longitudinal research processes were successfully executed throughout the nutritional/surgical intervention. Future translational endeavors into dietary preconditioning of vascular surgery patients should focus on outpatient approaches.