Factors Associated With Increased Mortality After Isolated Abdominal Aortic Dissection Repair.

BACKGROUND: Postoperative mortality after open and endovascular repair of thoracic aortic dissection (AD) has been the focus of previous research. However, a little has been published on the far less common isolated abdominal aortic dissection (IAAD). The aim of our study was to identify risk factors associated with 30-day postoperative mortality in patients with IAAD. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was queried for patients who underwent open or endovascular AD repair from January 2010 to December 2015. Information regarding patient demographics, comorbidities, preoperative laboratory values, procedure details, and postoperative complications were analyzed, and predictors of 30-day mortality were identified. Risk stratification by the type of aortic repair and surgery setting was performed, and patient characteristics associated with mortality in each setting were determined. We employed chi-squared test, Student's t-test, and Mann-Whitney U test for the univariate analysis, while the multivariate analysis was performed using a stepwise binary logistic regression test. RESULTS: There were 229 patients who met the specified criteria, 15 died within 30 days postoperatively, and 214 survived beyond the same period (mortality rate was 6.5%). Among preoperative factors, a history of chronic obstructive pulmonary disease (COPD), preoperative ventilator dependence, preoperative transfusion of ≥1 unit packed RBCs, emergent operation, and advanced American Society of Anesthesiologists (ASA) class were associated with increased risk of mortality. Postoperative complications associated with a higher risk of mortality were acute kidney injury, mechanical ventilation ≥48 hours, unplanned intubation, myocardial infarction, septic shock, and blood transfusion. On multivariate analysis, risk factors independently associated with increased risk of mortality were a history of COPD (adjusted odds ratio [AOR], 10.5; P = 0.013), postoperative acute renal failure (AOR, 12.8; P = 0.003) and septic shock (AOR, 15.3; P = 0.014). CONCLUSIONS: Multiple preoperative and postoperative factors are associated with a high risk of death after IAAD repair. A better control of COPD and prevention of postoperative acute renal failure and septic shock may result in better outcomes.

Catheter-directed thrombolytic intervention is effective for patients with massive and submassive pulmonary embolism.

BACKGROUND: Massive pulmonary embolism (MPE) is a significant cause of mortality and, with submassive pulmonary embolism (SPE), is associated with chronic thromboembolic pulmonary hypertension, resulting in ongoing patient morbidity. Standard treatment is anticoagulation, although systemic thrombolytic therapy has been shown to reduce early mortality in patients with MPE and improve cardiopulmonary hemodynamics in patients with SPE. However, systemic lysis is associated with significant bleeding risk. Early reports of catheter-directed techniques (CDT) suggest favorable outcomes in patients with MPE and SPE with reduced risk of hemorrhage. The purpose of this study is to evaluate efficacy and safety outcomes in MPE and SPE patients treated with CDT. METHODS: Seventeen patients treated with CDT for MPE and SPE were clinically and hemodynamically evaluated. Patients were grouped by severity of pulmonary embolism: MPE (n = 5) or SPE (n = 12). Pre- and post-interventional measures were assessed, including pulmonary artery pressures (PAPs), cardiac biomarkers, tricuspid regurgitation, right ventricular (RV) dilatation, and systolic function. Nine patients had contraindications to systemic thrombolytic therapy. RESULTS: PAP was elevated in 94% at presentation. The average dose of recombinant tissue plasminogen activator (rt-PA) was 31 mg; 44 mg in MPE and 26 mg in SPE. Pre- and post-intervention PAPs were recorded in 13 patients. All demonstrated an acute reduction in posttreatment PAP, averaging 37%. At presentation, all MPE and 10 (83%) SPE patients showed both RV dilatation and reduced function on echocardiography, which normalized in 76% (13/17) and improved in 24% (4/17) after CDT. Patients who demonstrated left ventricle underfilling before CDT (2 [40%] MPE and 2 [20%] SPE) normalized after CDT. All MPE and 11 (92%) SPE patients had tricuspid regurgitation on echocardiography pretreatment, which resolved in 60% and 58% of MPE and SPE patients, respectively. One delayed mortality occurred in an MPE patient who was hypotensive and hypoxic at presentation. There was one puncture site bleed. CONCLUSIONS: CDT was successful in the acute management of patients with MPE and SPE. CDT rapidly restores cardiopulmonary hemodynamics using reduced doses of rt-PA. These observations suggest that CDT should be considered in MPE and SPE patients to rapidly restore cardiopulmonary hemodynamics, reduce acute morbidity and mortality, reduce bleeding complications, and potentially avoid long-term morbidity.

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.

Role of coexisting contralateral primary venous disease in development of post-thrombotic syndrome following catheter-based treatment of iliofemoral deep venous thrombosis.

BACKGROUND: It has been reported that early clot removal benefits patients with iliofemoral deep venous thrombosis (DVT) by removing obstruction and preserving valve function. However, a substantial number of patients who had successful clot removal develop post-thrombotic syndrome (PTS). Residual thrombus and rethrombosis play a part in this phenomenon, but the role of coexisting primary chronic venous disease (PCVD) in these patients has not been studied. METHODS: All patients who underwent catheter-based techniques of thrombus removal for symptomatic acute iliofemoral DVT during a 5-year period compose the study group. These patients were assessed for PTS by the Villalta scale, the Venous Clinical Severity Score (VCSS), and the Venous Insufficiency Epidemiological and Economic Study on Quality of Life (VEINES-QOL) questionnaire. The presence of coexisting PCVD was determined by clinical and duplex ultrasound findings in the contralateral leg at the time of the initial DVT diagnosis. Patients who had coexisting PCVD were compared with those without PCVD. RESULTS: Forty patients (40 limbs) were included in the study group. At initial diagnosis, 15 patients (38%) had coexisting symptomatic primary valve reflux in the unaffected limb. After thrombolysis, 9 of 40 limbs (22%) had complete lysis, 29 (73%) had ≥ 50% to 99% lysis, and 2 (5%) had <50% lysis. The mean percentage of lysis in patients with or without PCVD was similar (78% vs 86%; P = .13). Patients without coexisting PCVD had significantly better Villalta score and VCSS compared with those with coexisting PCVD (Villalta score, 2.52 vs 3.27, P = .014; VCSS, 2.96 vs 3.29, P = .005). Forty-five percent of patients (18 of 40) developed PTS. Patients who developed PTS had less clot lysis than those without PTS. This was true for patients with coexisting PCVD (60% vs 85%; P = .025) and in patients without PCVD (75% vs 89%; P = .013). There was no significant difference in the VEINES-QOL score between those with or without PCVD (79.5 vs 80.5; P = .9). Patients who had reflux in the treated limb after lysis had a five times greater chance for development of PTS compared with those who retained normal valve function during follow-up (odds ratio, 5.3; 95% confidence interval, 1.6-17.045). However, in patients with normal veins in the contralateral leg, the chance of development of PTS was 1.5 times higher if reflux was present in the treated limb (odds ratio, 1.49; 95% confidence interval, 0.043-10.253). CONCLUSIONS: Coexisting PCVD is a contributing factor to development of PTS after treatment of iliofemoral DVT with thrombus removal techniques.

Aneurysm of the tibio-peroneal trunk: case report.

Behcet's disease is an inflammatory disorder of unknown cause. It's a systemic disorder that may affect any system in the body. Vascular system involvement occurs in 25%-30%. The case presented here elicits both venous and arterial complications of Behcet's disease in the same patient. The patient presented to our emergency with signs and symptoms of ruptured tibioperoneal aneurysm that was treated both medically and surgically.