The Effect of Patient Oral Intake Status on Abdominal Aortic Ultrasound Visualization.

BACKGROUND: The standard abdominal aortic duplex ultrasound protocol requires fasting for 8-12 hours prior to examination in attempt to reduce bowel gas and improve visualization. Such practice results in frequent testing delays and patient non-compliance. The aim of this study was to determine whether fasting improves visualization of the abdominal aorta in patients undergoing duplex ultrasound or influences diagnostic properties. METHODS: This was a prospective, randomized, double-blind imaging trail at a single institution. Ninety patients were randomized to one of three dietary groups, including NPO, clear liquids or control (regular diet). Diagnostic ultrasound examinations were performed by accredited Registered Vascular Technologists who remained blinded to the patients' diet. Sonographers commented on the presence of limited visualization in the study based on their ability to accurately measure aortic diameter. Examination results were randomly assigned to interpreting physicians who were also blinded to the patients' diet. Following interpretation, the reading physician was asked to comment whether they had sufficient information for a conclusive diagnostic interpretation. RESULTS: All ultrasound studies were deemed diagnostic by the interpreting physician regardless of the patients' dietary status. Limited visualization was reported in 19 of the 90 study patients (21.1%) with no significant difference existing between the dietary groups (P = 0.344). The NPO group contained the most patients with studies deemed to have limited visualization. CONCLUSION: Oral intake status did not affect visualization of the abdominal aorta or the rate of diagnostic studies in patients undergoing DUS at a single center. These results suggest that dietary restrictions prior to DUS evaluation of the abdominal aorta is unnecessary.

Emergent carotid endarterectomy versus stenting in acute stroke patients with tandem occlusion.

OBJECTIVE: Acute stroke due to tandem cervical internal carotid artery (ICA) and intracranial large-vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. In this study, we report our institutional outcomes with two approaches: emergent carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: Patients with tandem ICA-ILVO were identified in a prospective mechanical thrombectomy (MT) database between July 2012 and April 2016. Patients had a concomitant complete ICA origin occlusion and occlusion of the intracranial ICA or M1 or M2 middle cerebral artery segment. Baseline characteristics, procedural data, and treatment times were reviewed. End points included good recanalization of both ICA and ILVO, symptomatic intracerebral hemorrhage (defined by clinical decline of >4 points on the National Institutes of Health Stroke Scale), and functional outcome at 90 days. RESULTS: Forty-five patients had tandem ICA-ILVO occlusion; 27 patients underwent emergent CAS and 12 patients underwent emergent CEA after MT. Successful Thrombolysis in Cerebral Infarction grade 2B/3 recanalization was achieved in 92% of the CEA and 96% of the CAS patients (P = .53). Three CAS patients (11%) and none of the CEA patients had symptomatic intracerebral hemorrhage (P = .54). At 90 days, 75% (9/12) of the CEA patients were functionally independent compared with 70% (19/27) in the CAS group (P = 1.0). No deaths were noted in the CEA group compared with five (18.5%) in the CAS arm (P = .30). CONCLUSIONS: Our study indicates that early recanalization with MT followed by emergent CEA is safe and feasible, which suggests that both CAS and CEA should be considered in the emergent treatment of patients with tandem occlusion.

Reintervention after EVAR and open surgical repair of AAA: a 15-year experience.

OBJECTIVE: This study examined the frequency and reason for reinterventions and their impact on survival in contemporaneously treated cohorts of EVAR and open surgical repair (OSR) patients. BACKGROUND: EVAR has largely replaced OSR for anatomically appropriate AAA because of improved short-term outcomes. However, EVAR is associated with a notable reintervention rate. METHODS: Data for patients undergoing elective AAA repair between 1996 and 2011 were collected and analyzed to assess time from initial procedure to reintervention and rate of reintervention. Patient demographics, comorbidities, number and type of reinterventions, graft type, and timing of reintervention were analyzed. RESULTS: A total of 1144 patients underwent AAA repair; 558 had EVAR and 586 had OSR. In 76 EVAR patients, 123 reinterventions were performed; 46 reinterventions were performed in 30 OSR patients (P < 0.0001). Endoleak was responsible for 66% of EVAR reinterventions; colonic ischemia, bleeding, and incisional hernias caused 30%, 22%, and 22% of OSR reinterventions, respectively. Time to first reintervention was shorter in OSR patients (P < 0.001) and was related to AAA size (P < 0.001). Early reintervention at the index procedure in OSR patients had a 23% mortality rate. If reinterventions were not required, survival curves were similar. Current endografts require fewer reinterventions than earlier generation endografts. CONCLUSIONS: Reintervention was more common with EVAR and occurred later. Early reintervention after OSR is associated with significant mortality. If early reintervention in OSR patients can be avoided, there is no early survival advantage to EVAR. Current endografts require fewer reinterventions than earlier devices.

Hyperemic maximal venous outflow unmasks symptomatic lower extremity venous obstruction.

Venous obstruction is an underappreciated and often unrecognized component of the pathophysiology of symptomatic chronic venous disease (CVD). Moreover, standard methods used to detect venous obstruction, such as maximal venous outflow, are inadequate as they typically test patients at rest and in the supine position when the pathophysiology of CVD is defined in the upright patient performing exercise. This report describes a patient with incapacitating venous claudication in whom standard noninvasive venous function tests were normal and whose phlebography was interpreted as showing no evidence of venous obstruction. A postocclusive reactive hyperemic technique was used to unmask significant outflow obstruction, leading to operative correction and subsequent symptom resolution.

Lower extremity arterial inflow is adversely affected in patients with venous disease.

BACKGROUND: Lower extremity chronic venous disease is due to venous hypertension resulting from reflux and/or obstruction. Studies of venous valvular function have validated and quantified valve closure times defining normal and abnormal valve function, and investigators have categorized the amount of venous reflux with validated criteria. However, hemodynamics of venous outflow obstruction remains poorly defined. The purpose of this study is to assess whether chronic venous disease alters arterial inflow at rest or during hyperemic limb challenge, and whether there are differences in patients with primary chronic venous insufficiency (1 degrees CVI) versus those with postthrombotic venous disease. METHODS: Twenty-two normal limbs and 32 limbs in patients with chronic venous disease (C-3 or greater) were examined between September 2006 and January 2008. Chronic venous disease patients consisted of 22 postthrombotic patients and 10 with 1 degrees CVI. Arterial inflow was measured at rest using venous occlusion plethysmography and after induced arterial inflow using postocclusive reactive hyperemia (PORH). Volume changes were recorded with volume plethysmography. A minimum of 10 minutes elapsed between the resting and PORH measurements of arterial inflow. RESULTS: Resting arterial inflow was greater in patients with 1 degrees CVI when compared to normal patients (2.81 vs 1.26, P = .008) and to patients with postthrombotic venous disease (2.81 vs 1.13, P = .03). There was a 7.3-fold increase in maximal arterial inflow in normal patients during PORH versus a 4.8-fold increase in patients with postthrombotic venous disease (P = .015). Patients with 1 degrees CVI had a marked attenuation of maximal arterial inflow during hyperemic limb challenge, demonstrating only a twofold increase relative to their baseline resting arterial inflow (P = .08). CONCLUSION: Increases in arterial inflow during a hyperemic limb challenge are less robust in patients with postthrombotic venous disease than in normal volunteers. These data suggest that the pain of venous claudication may in part be due to a diminished arterial inflow response.

Recombinant activated factor VII as an adjunct to packing for liver injury with hepatic venous disruption.

Injuries to the juxtahepatic veins represent a small proportion of all liver injuries but constitute the most challenging and deadly form of hepatic trauma. Recombinant activated factor VII, established as a crucial therapy for enhancing hemostasis in hemophiliacs with inhibitors, has also been used to correct coagulopathy after traumatic injury. We report two children with hepatic venous injury requiring perihepatic packing and recombinant activated factor VII to successfully control hemorrhage.

Elective endovascular and open repair of abdominal aortic aneurysms in octogenarians.

OBJECTIVES: Endovascular aortic aneurysm repair (EVAR) is an increasingly popular treatment option for patients with abdominal aortic aneurysms (AAA), although open repair is considered the standard by virtue of its durability. Octogenarians, as a subgroup, may stand to benefit the most by EVAR. The purpose of this study is to review operative results and durability of open AAA repair and EVAR in octogenarians. METHODS: From May 1996 to August 2006, 150 patients aged >or=80 years underwent elective repair of their infrarenal AAA. Eighty-one underwent EVAR and 69 had open repair. Demographic data, aneurysm specifics, comorbidities, operative morbidity and mortality, intensive care unit and hospital length of stay, and late outcomes were analyzed. RESULTS: In the EVAR group, 27 of 81 (33%) patients died during a mean follow-up of 25 months. In the open repair group, 34 of 69 (49%) patients died during a mean follow-up of 43 months. The median survival time for EVAR was 350 weeks (range, 145-404 weeks) compared with 317 weeks (range, 233-342 weeks) for the open repair group. A Kaplan-Meier log-rank analysis showed no difference in early or long-term survival between EVAR and open repair (P = .13). EVAR was associated with decreased blood loss, decreased length of intensive care unit and hospital stays, and a greater number of patients discharged to home. CONCLUSIONS: EVAR and open repair are comparable in safety and efficacy in octogenarians. Operative repair outcomes remain acceptable. Mid- and long-term survival are similar, indicating no survival advantage of one procedure compared with the other.