Outcomes of Femoral Popliteal Bypass in Octogenarians.

INTRODUCTION: Femoral-popliteal bypass (FPB) surgery is a common lower extremity revascularization procedure. As the population continues to age, this procedure is being performed increasingly on older patients. This study investigated whether outcomes differ in this population. MATERIALS AND METHODS: Patients over and less than 80 years old who underwent FPB between 2009-2013 were queried using an existing hospital registry. Demographics, comorbidities, intraoperative complications, perioperative outcomes, and two-year patencies were compared. RESULTS: Twenty-four patients in the octogenarian cohort (OC) and 72 patients in the non-octogenarian cohort (NOC) were identified. There was a lower prevalence of smoking (p=0.018) and higher prevalence of hypertension (p=0.021) among octogenarians. Other medical characteristics were similar (p<0.05). There were no differences in use of vein versus PTFE (p=0.002) as a conduit, or above (OC 20.0% vs. NOC 36.7%), versus below knee (OC 80.0% vs. NOC 63.3%) distal anastomosis (p>0.05) between the groups. There was a difference (p<0.01) in indication for procedure (OC/NOC): claudication (0%/44%), limb salvage (71%/31%), and rest pain (29%/25%). There were no differences in 30-day readmissions (17% vs. 21%; p=0.59) or incidence of postoperative (25% vs. 19%; p=0.56) or intraoperative complications (8.3% vs. 4.2%; p=0.52). Length of stay (LOS) was longer and statistically significant in octogenarians (12 days vs. 7 days; p=0.032) and remained significant after multivariate linear regression (p=0.015). Patencies in OC were lower and dropped faster after six months; however, there were no statistically significant differences in patencies at any time interval (p>0.05). The position of the distal anastomosis relative to the knee, conduit type, and indication were not independently predictive of patency outcomes (p>0.05). CONCLUSION: The safety and efficacy of FPB in octogenarians is similar to the general population despite LOS in octogenarians being 5.98 days longer. While the difference in indication suggests that vascular surgeons are more conservative in treating octogenarians, our analysis did not reveal significant differences between populations and suggests that lower extremity bypass can be performed safely with comparable results in this cohort. A larger cohort is needed to validate these results.

Acute thrombotic manifestations of coronavirus disease 2019 infection: Experience at a large New York City health care system.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel coronavirus that has typically resulted in upper respiratory symptoms. However, we have encountered acute arterial and venous thrombotic events after COVID-19 infection. Managing acute thrombotic events from the novel virus has presented unprecedented challenges during the COVID-19 pandemic. In our study, we have highlighted the unique treatment required for these patients and discussed the role of anticoagulation for patients diagnosed with COVID-19. METHODS: The data from 21 patients with laboratory-confirmed COVID-19 disease and acute venous or arterial thrombosis were collected. The demographics, comorbidities, home medications, laboratory markers, and outcomes were analyzed. The primary postoperative outcome of interest was mortality, and the secondary outcomes were primary patency and morbidity. To assess for significance, a univariate analysis was performed using the Pearson χ2 and Fisher exact tests for categorical variables and the Student t test for continuous variables. RESULTS: A total of 21 patients with acute thrombotic events met our inclusion and exclusion criteria. Most cases were acute arterial events (76.2%), with the remainder venous cases (23.8%). The average age for all patients was 64.6 years, and 52.4% were male. The most prevalent comorbidity in the group was hypertension (81.0%). Several markers were markedly abnormal in both arterial and venous cases, including an elevated neutrophil/lymphocyte ratio (8.8) and D-dimer level (4.9 µg/mL). Operative intervention included percutaneous angiography in 25.00% of patients and open surgical embolectomy in 23.8%. Most of the patients who had undergone arterial intervention had developed a postoperative complication (53.9%) compared with a 0% complication rate after venous interventions. Acute kidney injury on admission was a factor in 75.0% of those who died vs 18.2% in the survivors (P = .04). CONCLUSIONS: We have described our experience in the epicenter of the pandemic of 21 patients who had experienced major thrombotic events from infection with COVID-19. The findings from our cohort have highlighted the need for increased awareness of the vascular manifestations of COVID-19 and the important role of anticoagulation for these patients. More data are urgently needed to optimize treatment and prevent further vascular complications of COVID-19 infections.

Placement of Simultaneous Inferior Vena Cava Filter During Emergent Open Pulmonary Thromboembolectomy.

BACKGROUND: This study retrospectively reviewed results of simultaneous (SIM) inferior vena cava (IVC) filter and separate (SEP) IVC filter placement with open pulmonary thromboembolectomy (PTE) in pulmonary embolism and its clinical outcomes. MATERIALS AND METHODS: From November 2006 to May 2014, 23 patients (14 females and 9 males; median age 58 years; range, 21-88 years) underwent emergent PTE for submassive (12) or massive (11) pulmonary embolism (PE). All had a preoperative computed tomography (CT) scan and echocardiography consistent with right ventricular (RV) strain. Mean cardiopulmonary bypass times and temperatures; chest tube outputs; length of stay; perioperative complications; and survival were compared between groups. RESULTS: There were 13 patients in the SIM group and 10 in the SEP group. PE consisted of 14 acute (60.9%) and nine acute on chronic (39.1%). There were seven deaths (30.4%). Median follow up was 44 days (range, 2-2204 days). Follow up was 81% complete in surviving patients. Actuarial survival at one and three years was 83% for the SIM group and 43% for the SEP group, respectively. There were no differences in cardiopulmonary bypass (CPB) times and temperatures, chest tube outputs, or length of stay between groups. Using multivariable logistic regression, we found SIM was associated with increased survival (p=0.09). Further analysis showed patients >55 years in the SEP group were at significantly higher risk of death (hazard ratio [HR]=7.1:1; 95% confidence interval [CI]: 1.55, 32.5, p=0.011). CONCLUSION: IVC filter placement can be performed simultaneously and safely at PTE. Age >55 years and PTE with IVC filter placed separately were at significantly higher risk of death. A larger cohort is needed to evaluate efficacy of simultaneous IVC filter placement and PTE.

The Use of Branched Endografts for the Aortic Arch in the Endovascular Era.

The endovascular realm has steadily increased its footing in the treatment of the aorta and all of its territories since the foundational case in 1990 by Parodi. The aortic arch, however, continues to be one of the last bastions for treatment via open surgery, which remains the gold standard. Significant comorbidity and prior cardiac surgery prevent open surgery from being the only preferred option, allowing novel endovascular procedures to be considered. Since 1999, more advanced endovascular systems have been created by companies such as Cook Medical, Bolton Medical, Medtronic, Endospan, Gore Medical, and, recently, Kawasumi. The unique shape and angulation of the aortic arch often require the use of custom-made grafts, though arch reconstruction may also include in situ or back-table physician alterations to off-the-shelf devices. The goal of branched endografts is to exclude the aneurysm, while maintaining flow to supra-aortic trunk vessels. Technical success and device durability are limited by the physical constraints of the aortic arch, though greater experience may yield better patient outcomes. Typically, the initial stent-graft (SG) is introduced and deployed into the arch first. Bridging SG are then inserted via axillary or carotid access. Most often, the bridging SG extends from the innominate branch to the distal innominate, and from the left carotid branch to the left common carotid. The major concern is that manipulation of catheters and wires, both within the carotid arteries and aortic arch, create the potential for emboli leading to stroke and paraplegia. The development of endovascular-only techniques for aortic arch pathology will only increase with the aging population of the United States and associated accumulation of comorbidities, making open surgery too grave of a risk.

Hybrid Repair Techniques for Complex Aneurysms and Dissections Involving the Aortic Arch and Thoracic Aorta.

Aortic aneurysms involving the ascending aorta, aortic arch, and descending thoracic aorta have been a challenging entity to surgically treat for over 60 years. Despite the mortality of the disease, early open surgical procedures also had significant morbidity and mortality. The inherent risk in treating multiple anatomic segments simultaneously led to the innovation of the staged elephant trunk (ET) approach by Borst in 1983. To avoid the thoracotomy and associated complications related to the second stage of the procedure, an endovascular completion paradigm was begun by Volodos in 1991. This theoretical hybrid technique combinined shorter and less elaborate open supra-aortic trunk debranching with less invasive endovascular exclusion and has grown since then in terms of different approaches and case volume. The rise of thoracic endovascular aortic repair (TEVAR) combined with debranching bypass has allowed certain lesions to be treated without a large scale intrathoracic open surgical procedure. The complexity and extensiveness of certain lesions, however, has necessitated a hybrid approach such as the frozen elephant trunk (FET) and the standard ET with second stage TEVAR. The former has been used to treat multifocal degenerative aneurysms, chronic dissections with aneurysm, and acute extensive dissections. After conventional proximal aortic replacement, a stent-graft (SG) is delivered antegrade through the transected arch where it is sutured proximally and then "frozen" distally via endovascular means. The FET has the advantage of avoiding a second stage, but potentially introduces a greater rate of spinal cord ischemia compared to the standard elephant trunk. Improvements on the FET procedure have included the development of more advanced hybrid SG such as the Vascutek® Thoraflex™ Hybrid graft (Vascutek Ltd, Scotland, UK), which consists of a distal en,dograft sealed to a proximal four-branched Vascutek Gelweave™ Vascutek Ltd, Scotland, UK) and incorporated sewing collar. While open surgery continues to be a component of complex aortic arch aneurysms, the development of hybrid devices that can bridge the gap between open and endovascular surgery will continue to flourish.

Mycotic Popliteal Artery Aneurysm With Rapid Enlargement Post-Bypass.

Popliteal artery aneurysms (PAAs) are the most common type of peripheral artery aneurysms. Mycotic aneurysms involving the popliteal artery are quite rare and can occur as either a primary de novo infection or a secondary infection from another site. To our knowledge, there are no previous case reports on mycotic PAA in which Staphylococcus epidermidis was the primary etiologic pathogen. We present the case of a 55-year-old male who presented with complaints of lower extremity pain and swelling, malaise, and low-grade temperatures for two weeks and was found to have a PAA. He underwent left femoral-popliteal bypass grafting with expanded polytetrafluoroethylene (ePTFE) graft and ligation of the aneurysm. On postoperative day 10, he experienced acute swelling and pain in his lower extremity with foot drop and was found to have rapid enlargement of his aneurysm sac on imaging. He was returned to the operating room emergently where he underwent aneurysmectomy via a posterior fossa approach. Cultures and gram staining of the aneurysm sac were consistent with Staphylococcus epidermidis. As noted above, this case of mycotic PAA was treated with standard vascular surgical techniques, yet it proceeded to enlarge acutely. PAAs that rapidly expand or rupture after surgical interventions may be a sign of infection.

Utility of compression immediately after venous closure: Does it matter?

BACKGROUND: Leg compression after venous closures for 24-48 hours or longer is commonplace and controversial. OBJECTIVE: The goal of our study was to evaluate compression immediately post-venous closures and its associated costs. METHODS: Records were retrospectively reviewed after consecutive therapies of sclerotherapy, mechanochemical ablation (MOCA) & radiofrequency ablation (RFA) from 1 clinic with 2 cohorts: 7/2/13-10/15/15 were immediately ACE-wrapped for 3-5 days (AW, N = 52) and 10/20/15-1/5/16 were non ACE-wrapped (NAW, N = 49). All procedures were performed in an outpatient office setting of one surgeon (P.L.). Follow-up was within 1 week and 3 months with ultrasounds. Financial data of ACE wraps and ABD pads were assessed. RESULTS: Closures consisted of consecutive therapies of sclerotherapy (4 patients); MOCA (44 patients) and RFA (53 patients). No statistical difference existed in age (p = 0.61), sex (p = 0.2063); race (0.3689), CAD (p = 0.1442), ESRD (p = 0.2914), diabetes mellitus (p = 0.8943), hypertension (p = 0.681), COPD (p = 0.38), or smoking (p = 0.3628). NAW group had higher rate of hyperlipidemia (p = 0.0225), obesity (p = 0.0283), MOCA and sclerotherapy (p = 0.0005). No difference existed in pain (p = 0.8897); wound complications were too small to perform analysis; and swelling was greater in AW group compared to NAW group (p = 0.0132, OR 3.3951, CI 1.269; 9.0834). Closure rates were 98% and 100% in AW and NAW groups, respectively. NAW were only a total cost savings of $1.58 per leg per procedure. CONCLUSION: AW for compression after vein closures confers no benefit in postoperative period with no effect on closure rates; may be associated with increased swelling, discomfort, and wound complications while increasing unnecessary and negligible monetary costs. Larger sample size is needed to validate these conclusions.

Shockwave lithotripsy facilitates large-bore vascular access through calcified arteries.

BACKGROUND: Our objective is to explore the Peripheral Intravascular Lithotripsy (IVL) System in the treatment of calcific access vessels during thoracic endovascular aortic repair (TEVAR), endovascular aortic repair (EVAR), and transcatheter aortic valve intervention. METHODS: This retrospective, single-center study evaluated the outcomes of patients undergoing TEVAR, EVAR, or transcatheter aortic valve intervention with severe calcific arterial disease between July 2018 and August 2019. Maximum circumferential calcification, length of calcification, and inner/outer diameter measurements were collected with curved planar reformation by medical imaging software (Aquarius APS, TeraRecon, Foster City, Calif). Effective luminal gain was calculated using the minimal inner diameter and the largest bore passed within the vessel lumen. End points included technical success, mortality, adverse events, and requirement for bail out maneuvers. Technical success was defined as successful delivery and deployment of device or endograft. RESULTS: Nine patients were included (mean age, 79.3 ± 9.79 years; range, 59-97 years]). four transcatheter aortic valve replacement, one TEVAR, one EVAR, and three fenestrated EVAR. Six patients (66.7%) had more than one artery treated; the segments treated included common iliac artery (seven patients [77.8%]), the external iliac artery (seven patients [77.8%]), and the common femoral artery (one patient [11.1%]). The average inner iliac vessel diameter was 3.38 ± 0.99 mm (range, 1.87-4.72 mm). The average outside diameter of device introduced was 7.2 ± 0.94 (range, 6.3-8.8 mm) with 229% effective luminal gain. Technical success was achieved in 100% of cases with a 0% mortality. Adjunctive measures were needed in five cases (55.6%). One vessel perforation was controlled with covered stent (Viabahn; W. L. Gore & Associates, Flagstaff, Ariz) deployment. Dissection was identified in two cases requiring stent placement. Two cases required the use of the Terumo International Systems SOLOPATH Balloon Expandable TransFemoral System (Terumo Interventional Systems, Somerset, NJ). One case deployed a Viabahn stent applying the "crack and pave" technique. CONCLUSIONS: As the population of the United States ages, calcified arterial disease will become an everyday clinical conundrum. Furthermore, the procedures for which the IVL system is geared toward facilitating will likely also increase in use. The IVL system is an additional tool in the vascular surgeon's armamentarium to obtain large-bore access in these calcified vessels. Further studies are needed to better assess the clinical effectiveness of the IVL system.

Spontaneous recanalization of a total occlusion of an infrarenal abdominal aorta after left axillary-bifemoral bypass.

Acute aortic occlusion is an infrequent clinical event with high morbidity and mortality. Management is determined by the cause of the occlusion, with thromboembolectomy used for embolic events and bypass for thrombotic events. After bypass, recanalization of a total aortic occlusion has been sparsely reported. We present a case of a total occlusion of an infrarenal abdominal aorta that was managed surgically with a left axillary-bifemoral bypass. Imaging performed 6 months postoperatively revealed a spontaneously recanalized aorta and occluded bypass graft.

Cervical Spine Deformity: Indications, Considerations, and Surgical Outcomes.

Cervical spinal deformity (CSD) in adult patients is a relatively uncommon yet debilitating condition with diverse etiologies and clinical manifestations. Similar to thoracolumbar deformity, CSD can be broadly divided into scoliosis and kyphosis. Severe forms of CSD can lead to pain; neurologic deterioration, including myelopathy; and cervical spine-specific symptoms such as difficulty with horizontal gaze, dysphagia, and dyspnea. Recently, an increased interest is shown in systematically studying CSD with introduction of classification schemes and treatment algorithms. Both major and minor complications after surgical intervention have been analyzed and juxtaposed to patient-reported outcomes. An ongoing effort exists to better understand the relationship between cervical and thoracolumbar spinal alignment, most importantly in the sagittal plane.

Mechanochemical ablation as an alternative to venous ulcer healing compared with thermal ablation.

OBJECTIVE: We aimed to compare mechanochemical ablation (MOCA) and thermal ablation (radiofrequency ablation and endovenous laser therapy) for venous ulcer healing in patients with clinical class 6 chronic venous insufficiency. METHODS: Electronic medical records were reviewed of patients with venous ulcers who underwent truncal or perforator ablation between February 2012 and November 2015. These records contained history of venous disease and ulcer history, procedures, complications, follow-up, method of wound care, and current status of the ulcer. The patients were grouped according to the method of ablation for comparison. RESULTS: In 66 patients, 82 venous segments were treated, 29 with thermal methods and 53 with MOCA; 16% of patients had prior venous intervention. Before ablation, three patients in the thermal group had a history of deep venous thrombosis compared with seven in the MOCA group. On average, patients treated with MOCA were older (thermal ablation, 57.2 years; MOCA, 67.9 years; P = .0003). Ulcer duration before intervention ranged from 9.2 months for thermal ablation to 11.2 months for MOCA (P = NS). In total, 74% of patients treated with MOCA healed their ulcers compared with 35% of those treated with thermal ablation (P = .01). A healed ulcer was defined as elimination of ulcer depth and superficial skin coverage. The mean time to heal was 4.4 months in the thermal ablation group compared with 2.3 months with MOCA (P = .01). The mean length of follow-up was 12.8 months after thermal ablation and 7.9 months after MOCA (P = .02). Both age (P = .03) and treatment modality (P = .03) independently had an impact on ulcer healing on multiple logistic regression analysis. All but two patients were treated with an Unna boot after venous ablation. Complications included readmission of two patients with nonaccess-related infections, one nonocclusive deep venous thrombosis, and one late death unrelated to the procedure second to pneumonia in the setting of advanced colon cancer. There were three recurrent ulcers at 1 week, 2 months, and 7 months after MOCA that rehealed with Unna boot therapy and continued compression. CONCLUSIONS: MOCA is safe and effective in treating chronic venous ulcers and appears to provide comparable results to methods that rely on thermal ablation. Younger age and use of MOCA favored wound healing. MOCA was an independent predictor of ulcer healing. Randomized studies are necessary to further support our findings.

Primary solitary retro-clival amyloidoma.

BACKGROUND: Amyloidosis encompasses a group of disorders sharing the common feature of intercellular deposition of amyloid protein by several different pathogenetic mechanisms. Primary solitary amyloidosis, or amyloidoma, is a rare subset of amyloidosis in which amyloid deposition is focal and not secondary to a systemic process or plasma cell dyscrasia. CASE DESCRIPTION: This 84-year-old female presented with history of multiple syncopal episodes, dysphagia, and ataxia. Motor strength was 3+/5 in the right upper extremity. Rheumatoid factor, cyclic citrullinated peptide (CCP), and anti-nuclear antibody (ANA) were normal. Serum and urine immune-electrophoresis detected no abnormal bands. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a non-enhancing soft-tissue mass extending from the retro-clivus to C2 posteriorly, eccentric to the right with severe mass effect on the upper cervical medullary junction. Endoscopic trans-nasal debulking of the retro-clival mass was performed with occiput to C5 posterior instrumentation for spinal stabilization. CONCLUSIONS: Primary solitary amyloidosis, unlike other forms of amyloidosis, has an excellent prognosis with local resection. Diagnosis requires special stains and a degree of suspicion for the disease. This is the first report to document an endoscopic trans-nasal approach for removal of a primary solitary amyloidosis of the retro-clivus. Management of vertebral amyloidoma involves aggressive local resection of the tumor when feasible and spine stabilization as the degree of tumor involvement mandates. Complete evaluation for the diagnosis of systemic amyloidosis is essential for the management and prognostication. Surgeons encountering such lesions must maintain high suspicion for this rare disease and advise pathologists accordingly to establish the correct diagnosis.

Absent congenital cervical pedicle nearly misdiagnosed as a facet dislocation: A case report.

BACKGROUND: Cervical spinal injury encompasses up to 1.5% of all pediatric injuries. Children, and more specifically infants, are a difficult subset of patients to obtain neurological exam in the setting of trauma, thus necessitating the use of cervical X-rays, CT scans, and MRI imaging. CASE DESCRIPTION: A healthy, 15-month-old boy had an unwitnessed fall down a flight of stairs and received a CT scan of the head and cervical spine in the emergency department due to cephalohematoma and mechanism of injury. The patient was initially diagnosed with a unilateral facet dislocation but after additional imaging and rigorous interdisciplinary discussions, the patient was correctly diagnosed with a congenitally absent left C5 pedicle. Surgical intervention was not pursued and the patient was discharged home with close follow up. CONCLUSION: In the acute trauma setting, congenital absent cervical pedicle can be difficult to differentiate from unilateral facet dislocation and may require the use of advanced imaging and close communication between the neurosurgery and radiology departments. Given the high morbidity and mortality involved in the repair of facet dislocation in a child, it is crucial to maintain high degree of clinical suspicion for absent spinal pedicle. In this case, the patient nearly underwent surgical intervention, but was ultimately able to be discharged home with no symptoms or deficits after correct diagnosis.