Management of acute aortoiliac arterial thrombosis in patients with the novel coronavirus disease 2019: A case series and systematic review of the literature.

Objectives: Venous thrombosis has been widely described in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; however, arterial thrombosis has rarely been reported. This study aims to assess the incidence, risk factors, interventions, and outcomes of acute aortoiliac arterial thrombosis in patients with active SARS-CoV-2 infections. Methods: We present seven SARS-CoV-2-positive patients from our institution who acutely developed thrombi in the aortoiliac arterial system (7/2020-1/2021). A systematic review of the literature on aortoiliac arterial thrombosis in patients with SARS-CoV-2 infections in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was also performed. The available data from all reported cases in the literature and at our institution were analyzed. Results: Thirty published articles and journal correspondences, including 52 patients, were reviewed and analyzed in addition to our institution's 7 cases. In total, 59 SARS-CoV-2-positive patients were found to have acute aortoiliac thrombosis. The abdominal aorta was the most frequent location for the development of a thrombus. Baseline demographics and medical comorbidities were not significantly different between the symptomatic and asymptomatic cohorts. Seventy-one percent of patients were symptomatic (lower limb ischemia: 75.0%, renal infarction: 20.0%, stroke: 12.5%, mesenteric ischemia: 10.0%). All patients with thrombus involving the ascending aorta, aortic bifurcation, or iliac artery developed thromboembolic or ischemic complications. All patients received systemic anticoagulation. Fifty-three percent of all patients were managed medically. Ninety-four percent of the asymptomatic patients were managed medically. One asymptomatic patient underwent endovascular aspiration of a mobile thrombus. Three (23.1%) deaths occurred in the asymptomatic cohort from hypoxic respiratory failure. Fourteen (36.8%) deaths occurred in the symptomatic cohort. The in-hospital mortality rate was 33.3% overall and 43.8% for patients with thrombi involving more than one aortoiliac segment. Conclusions: The presence of thrombi in the aortoiliac arterial system appears to be a poor prognostic indicator for patients with active SARS-CoV-2 infections. Medical management of patients with asymptomatic aortoiliac thrombi may be considered. The presence of thrombi involving the ascending aorta, aortic bifurcation, or iliac artery may warrant consideration for operative intervention due to the risk for thromboembolic or ischemic complications. Further study is needed to fully delineate the risk factors, optimal treatment, and outcomes of arterial thrombosis in the setting of SARS-CoV-2 infection.

Intentional Bilateral Renal Artery Coverage During Ruptured Endovascular Paraanastomotic Pseudoaneurysm Repair.

The development of a paraanastomotic pseudoaneurysm is a serious complication after open prosthetic reconstruction of the aorta for occlusive or aneurysmal disease. Open repair of these lesions has previously been associated with high rates of morbidity and mortality. Endovascular repair may provide suitable treatment for proximal paraanastomotic aortic bypass graft pseudoaneurysms in patients who are poor candidates for open surgery. Bilateral renal artery coverage may be necessary to achieve adequate fixation and seal during life-threatening emergency cases of pseudoaneurysm rupture. Due to the infrequency of reported cases, the consequences of bilateral renal artery occlusion during these complex procedures are poorly understood. We present a case of a proximal paraanastomotic aortobifemoral bypass pseudoaneurysm rupture that was managed using endovascular repair with intentional coverage of both renal arteries. We also review the contemporary literature on endovascular management of paraanastomotic aneurysms and discuss the role of bilateral renal artery coverage in treating select patients with complex ruptured aortic pathology.

Iatrogenic Arteriovenous Fistula Formation after Endovenous Laser Treatment Resulting in High-output Cardiac Failure: A Case Report and Review of the Literature.

Formation of a clinically significant iatrogenic arteriovenous fistula after endovenous laser treatment of the great saphenous vein is an extremely rare complication. Because of the infrequency of reported cases, there is no clear consensus on how to best manage this complication. We present a unique case of an iatrogenic high-output superficial femoral artery-common femoral vein fistula resulting in right heart failure and a distal deep vein thrombosis. Deployment of a covered arterial stent graft resulted in resolution of the arteriovenous fistula and high-output cardiac state. Clinically significant arteriovenous fistulas resulting from inadvertent vessel injury during endovenous laser treatment appear to be amenable to percutaneous endovascular interventions. During these challenging endovascular cases, intravascular ultrasonography can be used to help delineate the morphology of the fistula tract and obtain vessel measurements to ensure accurate endoprosthesis sizing and placement.

Unique Case of Recurrent Pelvic Congestion Syndrome Treated with Median Sacral Vein Embolization.

BACKGROUND: Pelvic congestion syndrome (PCS) is defined as noncyclical pelvic pain or discomfort caused by dilated parauterine, paraovarian, and vaginal veins. PCS is typically characterized by ovarian venous incompetence that may be due to pelvic venous valvular insufficiency, hormonal factors, or mechanical venous obstruction. METHODS: We describe a case of a 38-year-old multiparous female with a history of pelvic pressure, vulvar varices, and dyspareunia. She underwent left gonadal vein coil embolization in 2014 for PCS that lead to symptomatic relief of her pain. Four years later, the patient returned for recurrent symptoms. Magnetic resonance venogram demonstrated dilated pelvic varices. The previously embolized left gonadal vein remained thrombosed, and there was no evidence of right gonadal vein insufficiency. However, catheter-based venography revealed a large, dilated, and incompetent median sacral vein. RESULTS: Pelvic venography demonstrated left gonadal vein embolization without any evidence of reflux. The right gonadal vein was also nondilated without reflux. Internal iliac venography showed large cross-pelvic collaterals and retrograde flow via a large, dilated median sacral vein. Coil embolization of the median sacral vein resulted in a dramatic reduction of pelvic venous reflux and resolution of symptoms. CONCLUSIONS: Recurrence of PCS can occur after ovarian vein embolization through other tributaries in the venous network. The median sacral vein is a rare cause of PCS. We present an interesting case of a successfully treated recurrent PCS with coil embolization of an incompetent median sacral vein.

Utilization of Carbon Dioxide Angiography and Percutaneous Balloon Angioplasty for Treatment of Transplant Renal Artery Stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) may lead to graft dysfunction and failure. Progressive deterioration of renal allograft function may be exacerbated by contrast-induced nephrotoxicity during iodine contrast administration for renovascular imaging of allografts. We present our institutional experience of endovascular management for TRAS using CO2 digital subtraction angiography (CO2-DSA) and balloon angioplasty to manage failing renal transplants. METHODS: Four patients with renal allografts from March 2017-May 2018 were referred for graft dysfunction and pending renal transplant failure. Indications for referral included refractory hypertension, decreasing renal functioning, and elevated renovascular systolic velocities. RESULTS: Median age of the four patients was 41.5 years (22-60 years). There were two male and female patients. Chronic hypertension and type 2 diabetes mellitus were the most common comorbidities. An average total of 75 mL of CO2 was used, supplemented with 17.4 mL of iodinated contrast. All patients had improvements in renal function following intervention with a mean decrease in systolic and diastolic blood pressure of 25.8% and 21.4%, respectively. We also observed a mean decrease of BUN by 13.6% and creatinine by 37.4%. Additionally, eGFR increased by 37.7%. All allografts survived after surgery, and only one patient required repeat angioplasty for recurrence. CONCLUSIONS: CO2-DSA with balloon angioplasty can be successfully utilized to salvage deteriorating kidney allograft function in patients with TRAS.

Locoregional Anesthesia Offers Improved Outcomes after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

BACKGROUND: General anesthesia (GA) and locoregional anesthesia (LA) are two anesthetic options for endovascular repair of ruptured abdominal aortic aneurysms (REVAR). Studies on elective endovascular repair of nonruptured aneurysms have indicated that in select patients, LA may provide improved outcomes compared with GA. We aimed to examine the 30-day outcomes in patients undergoing REVAR using GA and LA in a contemporary nationwide cohort of patients presenting with ruptured abdominal aortic aneurysms. METHODS: Patients who underwent REVAR using GA and LA from January 2011 through December 2015, inclusively, were studied in the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP)-targeted EVAR database. Univariate and multivariate analyses were used to compare preoperative demographics, operation-specific variables, and 30-day postoperative outcomes between the two groups. RESULTS: Six-hundred ninety patients were identified to have undergone REVAR from 2011 to 2015, of which 12.5% (86) were performed under LA. For the entire cohort, the mean age was 74.3 years, and 80% were male. Mean aneurysm size was 7.6 cm and did not differ between the two anesthetic groups. Major comorbidities were similar between both groups, except a slightly higher rate of congestive heart failure in the LA group (7.0% vs. 2.5%, P = 0.02). Proximal or distal aneurysm extent also did not differ between the two groups. There was a significantly higher rate of bilateral percutaneous access in the LA group (59.3% vs. 25.2%, P < 0.01). REVAR under LA had shorter mean operative time (132 vs. 166 min, P < 0.01) and lower rate of concomitant lower extremity revascularization (2.3% vs. 10.6%, P < 0.01). There were no differences in need for perioperative transfusion or any other adjunctive procedures. Ultimately, 30-day mortality was significantly lower in the LA group (16.3% vs. 25.2%, P < 0.01). This difference was more pronounced in the subgroup of patients with hemodynamic instability (15.4% vs. 39.4%, P < 0.01). The LA group also demonstrated significantly shorter intensive care unit (ICU) length of stay (3.0 vs. 5.0 days, P = 0.01) and low rates of postoperative pneumonia (3.5% vs. 10.9%, P = 0.03). After adjustment for demographics, comorbid conditions, hypotensive status, and aneurysm characteristics, there was a two-fold higher mortality in patients undergoing REVAR using GA versus LA, with a four-fold increase in the hemodynamically unstable cohort. CONCLUSIONS: The ACS NSQIP-targeted EVAR database shows that LA is used in only 12.5% of patients undergoing REVAR in this nationwide cohort. This rate does not change when examining the subset of patients who are hemodynamically unstable. Other benefits include shorter ICU lengths of stay and lower rates of pneumonia. These data suggest that LA should be considered in patients undergoing REVAR, regardless of hemodynamic instability.

Perioperative risk factors for hospital readmission after elective endovascular aortic aneurysm repair.

BACKGROUND: Elective endovascular aneurysm repair (EVAR) is generally well tolerated. However, the incidence of hospital readmission after EVAR and the risk factors and reasons for it are not well studied. This study sought to determine the incidence, to characterize the indications, and to identify perioperative patient-centered risk factors for hospital readmission within 30 days after elective EVAR. METHODS: All patients who underwent EVAR electively in 2012 to 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program Targeted Vascular database (n = 3886). Preoperative demographics, operation-specific variables, and postoperative outcomes were compared between those who were readmitted within 30 days of the index operation and those who were not. Multivariate logistic regression was then used to determine independent predictors of hospital readmission. RESULTS: The unadjusted 30-day readmission rate after EVAR was 8.2%. Of all readmissions, 55% were for reasons related to the procedure. Median time to readmission was 12 days. Significant preoperative risk factors associated with readmission were female sex, preoperative steroid use, congestive heart failure, and dialysis dependence (P < .05). Multiple postoperative medical complications were independently predictive of readmission, including myocardial infarction and deep venous thrombosis (P < .05). Surgical complications that were independently predictive of readmission were surgical site infection (odds ratio, 10.24; 95% confidence interval, 5.31-19.75; P < .01) and need for unplanned reoperation (odds ratio, 17.50; 95% confidence interval, 10.43-29.37; P < .01). Readmitted patients ultimately had significantly higher rates of 30-day mortality (3.5% vs 0.3%; P < .01). CONCLUSIONS: Hospital readmissions remain a costly problem after vascular surgery and are associated with 30-day mortality after elective EVAR. Whereas female sex and certain irreversible medical comorbidities are nonmodifiable, focusing on medical optimization and identifying those perioperative variables that can affect the need for post-EVAR interventions will be an important step in decreasing hospital readmission.

Comparison of percutaneous versus open femoral cutdown access for endovascular repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: Ruptured endovascular aortic aneurysm repair (REVAR) is being increasingly used to treat ruptured abdominal aortic aneurysms (rAAAs). However, the comparison between totally percutaneous (pREVAR) vs femoral cutdown (cREVAR) access for REVAR has not been studied. We used a national surgical database to evaluate the 30-day outcomes in patients undergoing pREVAR vs cREVAR. METHODS: Patients who underwent EVAR for rAAA between 2011 and 2014, inclusively, were studied in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular database. Univariate and multivariate analyses were used to compare preoperative demographics, operation-specific variables, and postoperative outcomes between those who had pREVAR and cREVAR. RESULTS: We identified 502 patients who underwent REVAR, of which 129 had pREVAR (25.7%) and 373 cREVAR (74.3%). Between 2011 and 2014, the use of totally percutaneous access for repair increased from 14% to 32%. Of all patients undergoing REVAR, 24% had bilateral percutaneous access, 2% had attempted percutaneous access converted to cutdown, 64% had bilateral femoral cutdowns, and 10% had single femoral cutdown. Univariate analysis showed there were no significant differences in age, gender, body mass index, AAA size, or other high-risk physiologic comorbidities between the two groups. There was also no difference in rates of preoperative hemodynamic instability (48.1% vs 45.0%; P = .55) or need for perioperative transfusion (67.4% vs 67.8%; P = .94). There was a higher incidence of use of regional anesthesia for pREVAR compared with cREVAR (20.9% vs 7.8%; P < .01). The incidence of postoperative wound complications was similar between both groups (4.8% vs 5.4%; P = .79), whereas hospital length of stay was shorter in the pREVAR group (mean difference, 1.3 days). Overall 30-day mortality was higher in the pREVAR group (28.7% vs 20.1%; P = .04), and operative time was longer (mean difference, 6.3 minutes). However, when pREVARs done in 2011 to 2012 were compared with those done in 2013 to 2014, 30-day mortality decreased from 38.2% to 25.3% and operative time decreased by 25 minutes (188 to 163 minutes). Multivariate analysis showed there were no significant differences in mortality, wound complications, hospital length of stay, or operative time between pREVAR and cREVAR. CONCLUSIONS: The ACS NSQIP targeted vascular database shows that there has been increased adoption of pREVAR in recent years, with improved mortality and operative time over the 4-year study period. At this point, pREVAR has not yet been shown to be superior to cREVAR for rAAA, but these outcome improvements are encouraging and likely attributable to increased operator experience.

Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease.

OBJECTIVE: Concern over perioperative and long-term durability of lower extremity revascularizations among active smokers is a frequent deterrent for vascular surgeons to perform elective lower extremity revascularization. In this study, we examined perioperative outcomes of lower extremity endovascular (LEE) revascularization and open lower extremity bypass (LEB) in active smokers with intermittent claudication (IC) and critical limb ischemia (CLI). METHODS: Active smokers undergoing LEE or LEB from 2011 to 2014 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular data set. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between LEE and LEB procedures. Subgroup analysis was performed for patients undergoing revascularization for IC and CLI independently. RESULTS: From 2011 to 2014, 4706 lower extremity revascularizations were performed in active smokers (37% of all revascularizations). In this group, 1497 were LEE (55.6% for CLI, 13.4% for below-knee pathology) and 3209 were LEB (68.9% CLI, 34.7% below-knee). Patients undergoing LEE had higher rates of female gender, hypertension, end-stage renal disease, and diabetes (all P ≤ .02). LEE patients also had a higher frequency of prior percutaneous interventions (22.7% vs 17.2%; P < .01) and preoperative antiplatelet therapy (82.3% vs 78.7%; P = .02). On risk-adjusted multivariate analysis, LEE patients had higher need for reintervention on the treated arterial segment than LEB (5.1% vs 5.2%; odds ratio [OR], 1.52; 95% confidence interval [CI], 1.08-2.13; P = .02) but had lower wound complications (3.1% vs 13.2%; OR, 0.32; 95% CI, 0.23-0.45; P < .01) and no statistically significant difference in 30-day mortality (0.6% vs 0.9%), myocardial infarction or stroke (1.1% vs 2.6%), or major amputation (3.2% vs 2.1%) in the overall cohort of active smokers. In the IC subgroup, myocardial infarction or stroke was significantly higher in the LEB group (1.9% vs 0.6%; OR, 1.83; 95% CI, 1.17-1.97; P = .03), although no difference was found in the CLI subgroup (2.8% vs 1.4%; OR, 0.75; 95% CI, 0.37-1.52; P = .42,). Also in IC group, there was a trend for lower major amputation rates ≤30 days in the LEE group, whereas in the CLI group, LEE had a trend toward higher risk of early amputation compared with LEB. CONCLUSIONS: In active smokers, LEB for IC and CLI requires fewer reinterventions but is associated with a higher rate of postoperative wound complications compared with LEE revascularization. However, the risk for limb amputation is higher in actively smoking patients when treated by LEE compared with LEB for CLI. Importantly, cardiovascular complications are significantly higher in actively smoking patients with IC undergoing LEB compared with LEE. This additional cardiovascular risk should be carefully weighed when proposing LEB for actively smoking patients with nonlimb-threatening IC.

Physiologic Cryoamputation in Managing Critically Ill Patients with Septic, Advanced Acute Limb Ischemia.

BACKGROUND: Certain critically ill patients with advanced acute limb ischemia with a nonviable extremity may be unsuitable for transport to the operating room to undergo definitive amputation. In these unstable patients, rapid regional cryotherapy allows for prompt infectious source control and correction of hemodynamic and metabolic abnormalities, thereby lessening the risk associated with definitive surgical amputation. We describe our refined technique for lower extremity physiologic cryoamputation and review our institutional experience. METHODS: After adequate analgesia is administered to the patient, a heating pad is secured circumferentially at the proximal amputation margin and the affected extremity is placed in a customized Styrofoam cooler. A circumferential seal is secured at the proximal chill zone without use of a tourniquet and dry ice is placed into the cooler to surround the entire affected leg. Delayed definitive lower extremity amputation is later performed when hemodynamic and metabolic derangements are corrected. RESULTS: We reviewed 5 patients who underwent lower extremity cryoamputation with this technique identified at our institution between 2005 and 2015. Age ranged from 31 to 79 years old. All presented with severe foot infection and septic shock requiring vasopressor support. All 5 patients stabilized hemodynamically following the initial cryoamputation and later underwent definitive lower extremity amputation, with a median time of 3 days following initial cryoamputation. CONCLUSIONS: Lower extremity physiologic cryoamputation is an effective, immediate bedside procedure that can provide local source control and the opportunity for correction of metabolic derangements in initially unstable patients to lessen the risk for definitive major lower extremity amputation. Refinement of the cryoamputation technique, as described in this report, allows for a predictable and reproducible physiologic amputation.

Endovascular Management of Concomitant Thoracic and Abdominal Aortic Ruptures Resulting from Brucellosis Aortitis.

BACKGROUND: Acute aortic symptomatology is an unusual manifestation of Brucella melitensis infection. We present a rare case of acute multifocal thoracic and abdominal aortic ruptures arising from Brucellosis aortitis managed exclusively with endovascular surgery. METHODS: A 71-year-old Hispanic male with a history of atrial fibrillation and prior stroke on chronic anticoagulation presented with shortness of breath and malaise. In addition, he had been treated approximately 1 year previously in Mexico for B. melitensis bacteremia after eating fresh unpasteurized cheese. Computed tomography (CT) angiography demonstrated an acute rupture of the descending thoracic aorta just proximal to the celiac trunk and synchronous rupture at the abdominal aortic bifurctation. RESULTS: The patient was taken emergently to the hybrid operating room, where synchronous supraceliac thoracic aorta and abdominal aortoiliac stent grafts were deployed under local anesthesia. Completion angiography demonstrated total exclusion of the thoracic and abdominal extravasation with no evidence of endoleak. Twenty hours postoperatively, the patient became acutely obtunded and hypotensive. Repeat CT angiography demonstrated contrast extravasation at the level of the excluded aortic bifurcation. Emergent angiography confirmed a type II endoleak with free extraluminal rupture. Multiple coils were placed at the level of the aortic bifurcation between the left limb of the stent graft and the aortic wall to tamponade the endoleak. No further extravasation was noted on final aortography. Postoperatively, blood cultures confirmed the diagnosis of B. melitensis. The patient was treated with systemic doxycycline, gentamicin, and rifampin. Resolution of the acute event occurred without additional sequelae and he was discharged from the hospital to a rehabilitation facility. CONCLUSIONS: Concomitant multifocal aortic ruptures arising from Brucellosis aortic infection is a very rare event. In this case, the patient was successfully treated with thoracic and abdominal endovascular stent-graft exclusion, coiling, and long-term targeted antibiotics.

Novel endovascular technique for removal of adherent PICC.

INTRODUCTION: Peripherally inserted central catheters (PICCs) are a popular alternative to central venous lines. PICCs can provide reliable long-term access for intravenous fluids, antibiotics and total parenteral nutrition. Multiple factors can contribute to difficult PICC removal including adherent fibrin and thrombus formation around the catheter. We discuss a novel endovascular retrieval technique to remove tightly adherent PICCs. CASE PRESENTATION: A 42-year-old male with history of chronic pancreatitis requiring intravenous pain medications, presented with right upper extremity single lumen PICC that could not be removed by standard techniques. The PICC line had been in place for approximately three years and was no longer functioning appropriately. Ultrasonography demonstrated thrombus alongside the length of the PICC. RESULTS: In order to remove the PICC we utilized a novel endovascular technique. A 0.018" mandril wire was passed through the lumen of the PICC. Next, a puncture alongside the PICC was performed to place a 6 French (Fr) sheath. A snare was then maneuvered through the sheath and used to capture the tip of the mandril wire. The snare, mandril wire and PICC where withdrawn in unison, looping the PICC tip within the basilic vein. The tip of the PICC was positioned near the antecubital fossa. A small incision was performed to capture the tip of the PICC to remove the catheter. DISCUSSION: Tightly adherent PICCs can result after prolonged intraluminal dwell times. We describe a novel endovascular technique that can be utilized for safe and successful removal of difficult embedded PICCs.

Influence of gender and use of regional anesthesia on carotid endarterectomy outcomes.

OBJECTIVE: Carotid endarterectomy (CEA) is the most commonly performed surgical procedure to reduce the risk of stroke. The operation may be performed under general anesthesia (GA) or regional anesthesia (RA). We used a national database to determine how postoperative outcomes were influenced by gender and type of anesthesia used. METHODS: All patients who underwent CEA between 2005 and 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program database (N = 41,442). Incidence of stroke and myocardial infarction (MI) within 30 days as well as other postoperative complications, operative time, and hospital length of stay were examined in groups separated by gender and anesthesia type. Multivariable logistic regression with effect modification was used to determine significant risk-adjusted differences between genders and type of anesthesia to assess outcomes after CEA. RESULTS: The male-to-female ratio among CEA cases performed was approximately 3:2. Most cases were performed under GA (85% male patients, 86% female patients). Adjusted multivariable analysis showed no statistical difference in rates of MI and stroke based on gender or type of anesthesia used. There were, however, higher 30-day postoperative local complications and MI (both P < .05) in those who had GA vs RA regardless of gender before adjustment. Total operative time was decreased (mean difference, -8.15 minutes; 95% confidence interval, -10.09 to -6.21; P < .001) and length of stay was increased (mean difference, 0.34 day; 95% confidence interval, 0.14-0.54; P < .02) in women, with statistical significance, whether RA or GA was used. CONCLUSIONS: On adjusted multivariate analysis, there is no statistically significant difference in postoperative incidence of MI or stroke between men and women undergoing CEA. Use of RA vs GA did not affect this finding. Furthermore, there was no correlation between gender and the type of anesthesia chosen. Women, however, experienced decreased operative times and increased length of stay regardless of anesthesia type.