Aortic graft explants - A single institution analysis of incidence and outcomes.

OBJECTIVES: Explantation of both endovascular endovascular aneurysm repair and open aortic grafts is a procedure associated with high peri-operative risk, and the current study sought to determine the outcomes and trends over time in these patients. METHODS: This study examined data from all patients undergoing explant of an aortic graft (both open and endovascular) between January 2004 and December 2020 at a single centre. Variables analysed included comorbidities, duration to and indication for explantation, type of revascularization, in-hospital complications and mortality, duration of hospital and ICU stay, and out-patient mortality. RESULTS: Of 688 open and 1352 EVARs performed, 46 patients underwent 48 explants. Five were open grafts and 43 were endografts, equating to an explant rate of 0.73% of open and 3.18% EVARs. Average time to explant was 70 months, with patients presenting electively having a significantly longer duration to representation than those presenting emergently (51 vs 44 months, p=0.003). Indication for explant was endoleak in 70%, infection in 23%, and occlusion in 6%. Of the endoleaks, 61% of were Type 1, 22% Type II, 11% Type IV, and 6% Type V. On representation, 17 patients (35%) were symptomatic. Overall mortality rate was 8.3%, with a trend for higher mortality in emergent than elective presentations (11.8 vs 6.5%, p=0.55). There was no change in explant rate over time. CONCLUSIONS: Elective aortic graft explantation is associated with low mortality, despite its complexity and patient comorbidities. Patients presenting with symptoms suffered higher mortality and a longer post-operative course, suggesting that aortic graft explantation should be considered sooner rather than later, rather than persisting with repeated endovascular management.

Utility of Culturing Marginal Bone in Patients Undergoing Lower Limb Amputation for Infection.

Guidelines suggest culturing clinically uninfected bone at the margin after surgical resection for osteomyelitis, but little published evidence supports this procedure. To investigate whether culturing marginal bone after completing resection of infected bone affected antibiotic use or further surgical intervention, we collected data on sequential patients undergoing amputation for a foot infection at our tertiary care hospital between January 2014 and May 2015. We recorded patient age, sex, presence of diabetes mellitus, level of amputation, whether marginal bone was sent for culture, microbiology of any marginal bone specimens, type and duration of antibiotic therapy, and any further surgical resection. Among 132 patients, the mean age was 71.9 years, 103 (78.0%) were male, and 79 (59.8%) had diabetes. Treating surgeons sent marginal bone in 58 (43.9%) of these patients, 50 (86.2%) of which were culture positive. Patients with a positive bone culture were significantly more likely to undergo further surgical intervention (20.0% vs 6.1%, p = .047). For patients with diabetes, compared with those without, surgeons did not send marginal bone for culture more often (46% vs 42%, p = .72), nor did they undertake further surgical interventions more frequently (13.4% vs 10.1%, p = .89). Our results suggest that the clinicians used the marginal bone culture findings to make clinical decisions but do not clarify if there is a benefit to performing this procedure. Although patients whose proximal bone specimens were culture positive were more likely to undergo a surgical intervention, the reasons for, and benefit of, this additional surgery were unclear.

Factors Predicting Noncompliance with Follow-up after Endovascular Aneurysm Repair.

BACKGROUND: Although the potential for complications after endovascular aneurysm repair (EVAR) mandates lifetime follow-up, noncompliance with follow-up has been shown to be as high as 57%. We sought to investigate the incidence of noncompliance with follow-up in our patient population and to identify risk factors associated with this to allow implementation of targeted strategies to prevent loss to follow-up. METHODS: We carried out a review of consecutive patients undergoing EVAR at 2 Sydney hospitals between 1995 and 2015. Patients noncompliant with standard follow-up were compared with a control group of compliant patients. Data collected included baseline clinical characteristics, perioperative complications, and postoperative complications, as well as distance from treating centers. RESULTS: During the study period, 1,482 patients underwent EVAR, of which 338 patients (22.8%) were not compliant with follow-up. Patients noncompliant with follow-up were significantly more likely to be younger, have hypertension, and be current smokers. Patients who did not attend follow-up were also significantly more likely to be from a non-English-speaking background (28.4 vs. 17.9%; P = 0.01) and live closer to the treating institution (109 ± 151.5 vs. 150 ± 208.34 km; P = 0.01). CONCLUSIONS: Follow-up after EVAR remains suboptimal. The present study serves to demonstrate that several factors, especially current smoking and a non-English-speaking background, are associated with poor compliance with follow-up after EVAR in our patient population and represent a potential area of intervention to improve compliance.

Proton Pump Inhibitors and Cardiovascular Events: A Systematic Review.

BACKGROUND: Proton pump inhibitors (PPIs) are a commonly prescribed medication that recent data has linked to an increased risk of cardiovascular morbidity and all cause morbidity. The current study sought to perform a systematic review to investigate the link between PPIs and morbidity and mortality METHODS: A systematic review was carried out as per the PRISMA guidelines, with information databases including Pubmed, Medline, and the Cochrane Review Database. English-language studies of all types published from January 1990 to October 2016 were considered. Dichotomous analysis generating odds ratios was performed using RevMan Version 5.3. RESULTS: Thirty-seven studies were considered, of which five directly compared the effect of PPI use on mortality and/or cardiovascular morbidity (including 22,427 patients in mortality datasets, and 354,446 patients in morbidity datasets). For patients taking PPIs, all cause mortality (OR 1.68 [95% CI 1.53-1.84], p<0.001) and rate of major cardiovascular events (OR 1.54 [95% CI 1.11-2.13], p=0.01) were significantly higher. CONCLUSIONS: The current systematic review demonstrates that, in patients using PPIs, there was a significant increase in morbidity due to cardiovascular disease. Careful consideration should be given to the prescription of PPIs while clinical equipoise remains. Further research in the area is required.

Threatened limb from stingray injury.

We present the case of a 43-year-old female who suffered a stingray injury to her left ankle. The sting caused occlusion of the dorsalis pedis artery, causing dry gangrene of the medial forefoot. A below knee amputation was recommended but she was transferred for a second opinion. A Prostaglandin E1 infusion was commenced, resulting in alleviation of pain and improvement in perfusion. Amputation of great and second toes was performed, with the head of the first metatarsal preserved and covered via a cross-over skin flap raised from the contralateral leg. Achilles tendon lengthening was then performed to return the foot to a functional position. This case serves to highlight the utility of prostaglandin infusion, and the requirement for a multidisciplinary approach to critical limb ischemia in order to avoid major amputation.

Novel Use of an Iliac Branch Device in the Treatment of an Abdominal Aortic Aneurysm.

Iliac branch devices (IBDs) are commonly used to treat iliac artery aneurysms and maintain patency of the internal iliac artery or its branches. This case report illustrates another possible application for an IBD. We present the case of a 77-year-old male who underwent repair of his infrarenal aneurysm with an IBD as a bifurcated aortic stent-graft in a small diameter aorta to maintain bilateral common iliac artery patency.

Open versus Endovascular Repair of Arch and Descending Thoracic Aneurysms: A Retrospective Comparison.

BACKGROUND: Thoracic aortic aneurysms (TAAs) contribute significant mortality if left untreated, but surgical repair has historically carried substantial risks. METHODS: We sought to observe trends and outcomes of open and endovascular thoracic endovascular aneurysm repair thoracic aortic repairs, so conducted a retrospective review of all patients who presented for management of TAAs from 2003 to 2013 at 2 hospitals in Sydney, Australia. RESULTS: A total of 179 patients presented with TAAs over the study period, including 5 ruptures. Fifty-two were treated nonoperatively, with 127 surgically repaired. Operative duration was significantly shorter in endovascular than open repair of arch (193 ± 108 vs. 396 ± 98 min, P = 0.0001) and descending aneurysms (242 ± 116 vs. 422.5 ± 161 min, P = 0.003). There were no differences in mortality or complication rates (including paraplegia), duration of hospital or intensive care unit stay, or transfusion requirements between endovascular and open TAA repairs. CONCLUSIONS: Apart from reduced surgical duration, this study revealed no benefits of endovascular over open TAA repair. Overall morbidity and mortality were low, even in elderly patients.

Successful Management of a Large Internal Carotid Artery Aneurysm via Open Resection.

BACKGROUND Extracranial carotid artery aneurysms are rare pathologies associated with an increased risk of neurological events and cranial nerve dysfunction. While they often require prompt intervention, the preferred surgical management remains unclear due to the rarity of this pathology, with described surgical and endovascular techniques having unique benefit and risk profiles in the current literature. CASE REPORT We report an interesting case of an internal carotid artery aneurysm successfully managed via open resection in a female patient in her 70s. Our patient, who was otherwise well, initially presented with an isolated episode of dysarthria associated with hypertension. Her pathology was identified on routine work-up for a presumed neurological event in the setting of her symptoms, and the patient referred to our center for definitive surgical management given the associated risk of embolic events. Under our care, the patient underwent an open resection of the ICA aneurysm with primary repair of the vessel. Her intra-operative and post-operative courses were unremarkable, and the patient remained well with no neurological deficits at follow-up at 4 months. CONCLUSIONS Our case demonstrates that select patients presenting with internal carotid artery aneurysms and tortuous internal carotid arteries, who may be otherwise ineligible for endovascular treatment, may be amenable to resection of the aneurysm followed by primary repair of the vessel, negating the requirement for interposition grafts.

Medium-term outcomes of fenestrated endovascular repair of juxtarenal abdominal aortic aneurysms.

BACKGROUND: Abdominal aortic aneurysms pose a substantial clinical burden, and a significant proportion are not anatomically suitable for open repair or standard endovascular aneurysm repair (EVAR), instead requiring fenestrated EVAR (fEVAR). We sought to compare clinical outcomes and trends over time in patients undergoing fEVAR in Australia. METHODS: We conducted a retrospective analysis of all patients undergoing fEVAR at a tertiary referral centre between 2010 and 2015, including outcomes and complications, both as inpatients and after discharge. RESULTS: Thirty-nine patients underwent fEVAR during the study period, with mean age of 75 years and mean aneurysm size of 61 mm. One hundred and thirty-four target vessels were treated and inhospital mortality was 5% (two patients). There were nine inhospital, eight Type II and one Type III endoleaks. Ten patients suffered acute kidney injury, one of whom required dialysis. Mean follow-up was 14.5 months (range: 0-46.7). Target vessel patency was 99.2% at follow-up. There were six Type II endoleaks at follow-up, and two patients died during the follow-up period (of non-aneurysm-related causes). CONCLUSION: fEVAR is an effective treatment with low morbidity and mortality, and we have demonstrated excellent survival and target vessel patency at a mean follow-up of 14 months. Endoleak rates were low, despite the high complexity of the aneurysms treated.

Pseudoaneurysm of the thoracic aorta following botulinum toxin injection to the esophagus.

Aortic pseudoaneurysms are uncommon and are usually secondary to penetrating trauma. We describe the presentation and management of an elderly woman who suffered a pseudoaneurysm of the descending thoracic aorta several days after receiving botulinum toxin injection to the esophagus. Urgent thoracic endovascular aortic repair was performed, and long-term antibiotic therapy was commenced. Despite a slow initial clinical recovery, she returned to an independent lifestyle, with radiographic resolution of the pseudoaneurysm seen at follow-up. This case illustrates that endovascular aortic repair is a suitable and safe treatment option for this unusual presentation.

Trends in pulmonary embolism morbidity and mortality in Australia.

INTRODUCTION: Pulmonary embolism (PE) is a common cause of morbidity and mortality. In this study, we investigated patterns of morbidity and mortality from PE in Australia. MATERIALS & METHODS: Australian government databases were used to extract data on age and sex specific rates of mortality between 1997 and 2007, and hospital separations between 1998/9 and 2009/10 to examine changes over time and between age and sex groups. RESULTS: In 2007, 320 deaths were ascribed to PE in Australia, corresponding to a mortality rate of 1.73 per 100,000 population per year. Between 1997 and 2007, the Australian mortality rate decreased in both sexes, but this was significant only in females. By comparison, in 2009/10 there were 9,847 hospital separations for PE, corresponding to a rate of 53.1 per 100,000 population per year. In contrast to the fall in mortality rates, hospital separation rates significantly increased over the study period. Females had higher rates of morbidity and mortality from PE than males. While the mortality rates among the elderly population decreased significantly (from 48.4 to 34.3 per 100,000 population per year in those aged over 85 years), there were significant increases in PE mortality in the younger female age groups. CONCLUSIONS: Although mortality rates are decreasing, PE remains a significant cause of morbidity and mortality in Australia, especially in females and the elderly. The burden of morbidity and mortality from PE in Australia is comparable to that found in America and a number of European countries.