Transcervical Carotid Artery Stenting Using a Prosthetic Arterial Conduit: Case Series of a Novel Surgical Technique.

We present a series of 4 patients with carotid restenosis following carotid endarterectomy (CEA) who underwent transcervical carotid artery stenting (CAS) using a novel prosthetic conduit technique. The patients were high risk for repeat CEA (short and obese necks) and had contraindications to transfemoral CAS (bovine arch, prior dissection). CAS was thus performed via a transcervical approach with a polytetrafluoroethylene conduit anastomosed to the proximal common carotid artery. The addition of a conduit allowed stent placement via a secure, stable platform. All patients recovered from their procedure without incident and are free from restenosis at follow-up.

Percutaneous Treatment of Multiple Recurrent Thromboembolization from a Descending Thoracic Aortic Intimal Sarcoma.

Aortic intimal sarcomas are rare tumors that may result in distal embolic ischemia. Here, we present a patient who presented with crescendo lower extremity and mesenteric ischemic events from malignant macroembolism. Management with percutaneous pharmacomechanical thromboembolectomy enabled restoration of distal perfusion and minimally invasive collection of tumor sample to confirm the suspected diagnosis of aortic sarcoma. The patient underwent definitive aortectomy and reconstruction and is recovering well.

Repair of ruptured abdominal aortic aneurysm after cardiac arrest.

OBJECTIVE: Cardiac arrest in patients with ruptured abdominal aortic aneurysm (rAAA) is not uncommon and associated with significantly increased mortality. Although it has been suggested as a contraindication to aortic repair, the prognostic implications of preoperative cardiac arrest in the face of rAAA are controversial. The purpose of this structured review is to analyze the reported outcomes of patients with rAAA and preoperative cardiac arrest. METHODS: English language single- and multi-institutional series reporting outcomes of patients with rAAA and cardiac arrest were identified by systematic literature search and review. An aggregate analysis and structured review of outcomes after subsequent aortic repair was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The primary outcome was short-term overall mortality. RESULTS: Sixteen studies involving 2669 patients with rAAA were analyzed, including 334 (13%) with preoperative cardiac arrest. Cardiac arrest was associated with significantly increased mortality compared with patients with rAAA without arrest (86% vs 44%; P < .0001), although cardiac arrest in isolation was poorly predictive of mortality. Four patients were treated by endovascular aortic repair, and all survived. Shorter resuscitation times and return of signs of life prior to aortic repair are associated with improved survival, and long-term functional outcomes among survivors have been reported. CONCLUSIONS: Mortality among patients with rAAA and preoperative cardiac arrest is high but not prohibitive. Aortic repair should not be withheld from such patients who are otherwise reasonable candidates for intervention, provided resources for emergent aortic repair are available.

Nonoperative Management of Traumatic Aortic Pseudoaneurysms.

BACKGROUND: Current blunt thoracic aortic injury (BTAI) guidelines recommend early repair of traumatic pseudoaneurysms (PSAs) due to risk for subsequent aortic rupture. Recent analyses indicate that early repair is required only in the setting of high-risk features, while delayed repair is safe and associated with lower morbidity and mortality in appropriately selected patients. To evaluate the appropriate indications for nonoperative management (NOM) of traumatic PSAs, we performed a systematic review of studies reporting outcomes for this management strategy. We hypothesized that NOM is safe in appropriately selected patients with traumatic aortic PSAs. METHODS: English language single- and multi-institutional series reporting NOM of traumatic thoracic aortic PSAs were identified by systematic literature search and review. A descriptive analysis was performed of NOM, with stratification by lesion size and patient follow-up. The primary outcomes were late aortic intervention, aortic-related death, and all-cause mortality. RESULTS: Eighteen studies, which included 937 patients with traumatic PSAs, were analyzed. One hundred ninety-one patients were managed nonoperatively. The primary indication for NOM was prohibitive risk for aortic repair due to severe comorbidities or concurrent injuries. Where reported, PSAs with <50% circumferential involvement accounted for 88% of lesions selected for NOM. Late interventions were required in 4% of patients. Inpatient aortic-related mortality was 2%, and all-cause inpatient mortality was 32%. Although survival at up to 4-7 years was reported, postdischarge follow-up after PSA NOM was limited to <1 year in most studies. CONCLUSIONS: NOM of traumatic aortic PSAs is a common practice in BTAI series reporting lesion-specific management, and is associated with low rates of treatment failure. These findings suggest that routine early repair may not be required for traumatic PSAs, particularly for lesions limited to <50% of the aortic circumference. Definitive repair can be delayed until patient stability and repair timing can be guided by assessment of lesion stability on follow-up imaging.

Non-White Race is an Independent Risk Factor for Hospitalization for Aortic Dissection.

OBJECTIVE: To evaluate racial differences in the burden of aortic dissection. DESIGN: Retrospective analysis of a comprehensive state-wide inpatient database. SETTING: Acute care hospitals in the state of Maryland, 2009 - 2014. PARTICIPANTS: All hospitalized adults with aortic dissection (AD), stratified by race. MAIN OUTCOME MEASURES: Statewide and county-level population adjusted hospitalization rates, access to specialty aortic care, and mortality. RESULTS: Of 3,719,412 admissions to Maryland hospitals during the study period, 3,190 had AD (.09%; 1665 White, 1525 non-White). Non-White race was more common in patients with AD than without (48% vs. 41%, P<.0001). Adjusted for statewide demographics, admission for AD was 1.4 times more common among non-Whites (11 vs. 8 per 100,000, P<.0001). Non-White race was an independent risk factor for AD admission (OR 1.5, 95% CI 1.4 - 1.7). Among patients with AD, non-Whites were younger and more often female, but had similar or lower rates of cardiovascular comorbidities. Non-White race was not associated with decreased access to care or increased mortality. CONCLUSION: Hospitalization for AD is more common among non-Whites, who develop AD at younger ages despite fewer comorbidities. While clinical correlates are limited from this dataset, this may reflect more severe pathophysiology related to clinical or socioeconomic factors among non-Whites. Further study is warranted to better define this disparity and identify high-risk subgroups who may benefit from aggressive primary prevention.

Use of immediate dermal fat graft for scalp contour defect following resection of arteriovenous malformation.

Arterial venous malformations (AVMs) are rare conditions that are difficult to manage. Therapeutic options include selective embolization with or without surgical excision. Recurrence, however, is high despite correction of the primary abnormality. Cosmetic concern is among the indications for treatment, particularly if the AVM occurs on the face or scalp. Historically, AVM excision and the residual defect correction have been performed separately. We present the first case reported of a successful embolization and interval excision with immediate reconstruction using a dermal fat graft, as a novel approach to correct soft tissue defect following the resection of an AVM. A 35-year-old man presented with a 20-year history of a nonpulsating mass posterior to the hairline in the right frontoparietal region, measuring 4.0 cm on its longest axis. Embolization of the AVM was achieved by injecting N-butyl cyanoacrylic acid and ethiodol. One month after embolization, surgical excision of the mass was performed. The resulting disfiguring contour defect was immediately corrected using a dermal fat graft harvested from the groin. At 4 months' follow-up, the graft was viable with no evidence of resorption or epidermal cyst formation. In addition, there was no recurrence of the AVM and no complications at the donor site. This case demonstrates the utility of a dermal fat grafts in correcting the impending defect in 1 stage avoiding a second-stage procedure and significant period of cosmetic disfigurement. This method should be considered as a treatment option for patients requiring moderately sized AVM excisions in cosmetically sensitive areas.

Liver abscess as a complication of laparoscopic gastric banding bariatric surgery.

BACKGROUND: The World Health Organization has identified the rapidly growing prevalence of obesity as one of today's serious health problems. Various surgical interventions categorized collectively as bariatric surgery now play an ever-increasing important role as the only known effective treatment for severe obesity. Laparoscopic gastric bypass is currently the most frequent bariatric surgical procedure performed. However, the laparoscopic adjustable gastric band (LAGB) is rapidly gaining in popularity as a minimally invasive surgical option with anticipated similarly efficacious outcomes. Gastric band erosion following LAGB is an uncommon yet potentially serious complication unique to this form of weight loss surgery. METHODS: Case report and literature review. RESULTS: We report a case of a pyogenic liver abscess related to a LAGB procedure. Apropos to this case, we review the presumed pathophysiologic mechanism of this particular infectious process, and discuss this and other complications associated with LAGB operations. CONCLUSIONS: As LAGB bariatric procedures become more popular, clinicians need to be aware of uncommon, but potentially serious complications unique to this form of weight loss surgery.