Inferior Vena Cava Filter Long Term Complications and Retrieval Techniques: A Case Series and Literature Review.

INTRODUCTION AND IMPORTANCE: Long-term mechanical complications after inferior vena cava (IVC) filter placement include embedded or tilted filters, erosion of the vena cava, filter thrombosis. In the setting of caval thrombosis, patients may subsequently develop venous hypertension and post-thrombotic syndrome (PTS). Here we present three unique cases of IVC filter complications and surgical management. CASE PRESENTATION: A 30-year-old female presented with acute abdominal pain, revealing a duodenal perforation caused by an IVC filter eroding into her duodenum. A 42-year-old female with an IVC filter in place for 20 years due to a prior pulmonary embolism underwent laser-assisted retrieval of the filter due to concerns of caval adherence. A 48-year-old male with a history of DVT, venous stasis ulcer, and an IVC filter presented for filter retrieval. CLINICAL FINDINGS AND INVESTIGATIONS: The surgical techniques described in this report include complicated IVC filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis resulting in PTS. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience. INTERVENTION AND OUTCOMES: The surgical techniques described in this report include complicated inferior vena cava filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience. RELEVANCE AND IMPACT: Endovascular retrieval of long-term complicated IVC filters is challenging, but it can be a safely performed in many patients. However, open surgery may be necessary in selected patients.

Race-based outcomes of thoracic aortic aneurysms and dissections in the Global Registry for Endovascular Aortic Treatment.

OBJECTIVE: This study characterizes racial differences in presentation, as well as short- and long-term outcomes after endovascular treatment of thoracic aortic aneurysm (TAA) and type B aortic dissection (TBAD). METHODS: We queried the Gore Global Registry for Endovascular Aortic Treatment for thoracic endovascular aortic repairs (TEVARs) performed between 2010 and 2016 and followed through 2022. Pathologies represented were descending TAA, complicated TBAD, and uncomplicated TBAD. Using standard statistical tests, we compared overall and pathology-specific demographics, procedural factors, and outcomes among Black and White patients undergoing TEVAR. RESULTS: We identified 438 TEVAR cases, including 236 descending TAA, 121 complicated TBAD, and 74 uncomplicated TBAD. Overall, Black patients were younger and had a higher incidence of renal insufficiency (P = .001), whereas White patients had more chronic obstructive pulmonary disease (P = .003) and cardiac arrhythmias (P = .037). In patients treated for descending TAA, Black patients had increased device- and procedure-related complications (34.3% vs 17.4%; P = .014), conversion to open repair (2.9% vs 0%; P = .011) and type II endoleak (5.7% vs 1.0%; P = .040), but no differences in mortality, length of hospital stay, or major adverse cardiovascular events. Whereas outcomes of TEVAR for uncomplicated TBAD were comparable, Black patients more frequently presented with complicated TBAD than White patients (Black, 40.5% vs White, 24.8%; P = .008) and had subsequently greater reintervention rates (28.1% vs 12.4%; P = .012), all-cause mortality (hazard ratio, 4.28; 95% confidence interval, 1.74-10.5; P = .002) and aortic-related mortality (hazard ratio, 16.7; 95% confidence interval, 1.49-186; P = .022). CONCLUSIONS: Despite increased device- and procedure-related complications, similar short- and long-term outcomes are achieved in Black and White patients undergoing TEVAR for descending TAA and uncomplicated TBAD. However, Black patients are more likely to present with, require reintervention for, and suffer mortality from complicated TBAD.

Effect of Body Mass Index on Early Outcomes of Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: This study compares the presentation, management, and outcomes of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR), based on their weight status as defined by their body mass index (BMI). METHODS: Patients with primary EVAR for ruptured and intact abdominal aortic aneurysm (AAA) were identified in the National Surgical Quality Improvement Program database (2016-2019). Patients were categorized by weight status (underweight: BMI < 18.5 kg/m2, normal weight: 18.5-24.9 kg/m2, overweight: 25-29.9 kg/m2, Obese I: 30-34.9 kg/m2, Obese II: 35-39.9 kg/m2, Obese III: > 40 kg/m2). Preoperative characteristics and 30-day outcomes were compared. RESULTS: Of 3,941 patients, 4.8% were underweight, 24.1% normal weight, 37.6% overweight, and 22.5% with Obese I, 7.8% Obese II, and 3.3% Obese III status. Underweight patients presented with larger (6.0 [5.4-7.2] cm) and more frequently ruptured (25.0%) aneurysms than normal weight patients (5.5 [5.1-6.2] cm and 4.3%, P < 0.001 for both). Pooled 30-day mortality was worse for underweight (8.5%) compared to all other weight status (1.1-3.0%, P < 0.001), but risk-adjusted analysis demonstrated that aneurysm rupture (odds ratio [OR] 15.9, 95% confidence interval [CI] 8.98-28.0) and not underweight status (OR 1.75, 95% CI 0.73-4.18) accounted for increased mortality in this population. Obese III status was associated with prolonged operative time and respiratory complications after ruptured AAA, but not 30-day mortality (OR 0.82, 95% CI 0.25-2.62). CONCLUSIONS: Patients at either extreme of the BMI range had the worst outcomes after EVAR. Underweight patients represented only 4.8% of all EVARs, but 21% of mortalities, largely attributed to higher incidence of ruptured AAA at presentation. Severe obesity, on the other hand, was associated with prolonged operative time and respiratory complications after EVAR for ruptured AAA. BMI, as an independent factor, was however not predictive of mortality for EVAR.

Utility of Closed Suction Drains in Groin Incisions after Femoral Artery Exposure.

BACKGROUND: Surgical groin wounds are at risk of delayed healing and infection, leading to costly and prolonged postoperative recoveries. This study assesses the use of closed suction drains (CSDs) as a wound care adjunct in groin incisions to prevent surgical site infections (SSI). METHODS: A single-center retrospective review was performed on 210 consecutive patients after vascular surgery with common femoral artery exposure from 2016 to 2021. The cohort was divided into 2 groups, groins with and without CSD, looking for surgical site complications. A subgroup analysis comparing postoperative outcomes between complicated and uncomplicated groin incisions within both groups was also performed. RESULTS: Of 293 surgical groins, 20% (n = 59) had drains. Overall, the CSD group had higher SSI rates (14% vs. 5.6%), but also had higher proportion of smokers (92% vs. 83%; P = 0.019), diabetes (56% vs. 36%; P = 0.005), coronary artery disease (69% vs. 46%; P = 0.001), hyperlipidemia (69% vs. 51%; P = 0.01), and previous groin surgery (54% vs. 17%; P < 0.001). The higher risk of SSI was not significant after adjustment of these confounders. A separate analysis within each group showed SSI groins with CSD had lower reintervention rates (37.5%) than those without CSD (69%), as well as shorter length of hospital stay (7 [5-11] vs. 22 [7-25] days). CONCLUSIONS: Our study suggests that CSDs can be a beneficial adjunct for groin wounds after common femoral artery exposure in patients with comorbidities cited above. CSDs decrease the risk of reintervention and length of hospital stay.

Racial disparities in presentation and outcomes for endovascular abdominal aortic aneurysm repair.

OBJECTIVE: In the present study, we used a national database to identify racial differences in the presentation and outcomes for patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (EVAR) and identified areas for improving their care. METHODS: We queried the EVAR-targeted National Surgical Quality Improvement Program database (2016-2019) to identify patients who had undergone EVAR for both ruptured and nonruptured AAAs. The patients were categorized according to race (White, Black, and Asian). Patients with a history of abdominal aortic surgery or an indication other than AAAs were excluded. The data was analyzed using the χ2 and Kruskal-Wallis tests, presented as frequencies and percentages or median and interquartile range (IQR) for categorical and continuous variables, respectively. RESULTS: We identified 3629 patients (16.6% female), including 3312 White (91.3%), 248 Black (6.8%), and 69 Asian (1.9%) patients. Black patients were more frequently women (27.0%) compared with White patients (15.9%) and were younger (median age, 71 years; IQR, 64-77 years) than White (median age, 73 years; IQR, 67-79 years) and Asian (median age, 76 years; IQR, 67-81 years) patients (P < .001 for both). The incidence of smoking, congestive heart failure, and dialysis dependency was highest for Black patients, and the incidence of obesity was lowest for Asian patients. The AAAs in Black patients extended more frequently beyond the aortic bifurcation (P = .047). In Asian patients, the internal iliac arteries were more involved (P = .040). For Black patients, 29.8% of the EVARs were performed in a nonelective setting compared with 20.2% for the White and 15.9% for the Asian patients (P < .001). The aneurysm diameter, nonruptured symptomatic rate, and rupture rate were similar across the groups (P = .807). The operative time was prolonged for Black (median, 128 minutes; IQR, 96-177 minutes) compared with White (median, 114 minutes; IQR, 84-162 minutes) patients (P < .001). Postoperatively, Black patients were more likely to require blood transfusion (16.5%) and had prolonged length of hospital stay (median, 2 days; IQR, 1-4 days) compared with White (10.0%; median, 1 day; IQR, 1-3 days) and Asian (4.3%; median, 1 day; IQR, 1-3 days) patients (P = .001 and P < .001, respectively). Black patients also had a higher 30-day readmission rate (P = .038). On multivariate analysis, Black race was an independent factor for length of stay >1 day after both elective and nonelective EVAR and 30-day readmission for elective EVAR, but not 30-day mortality after elective and nonelective EVAR. CONCLUSIONS: In the present nationwide sample of EVAR cases, Black patients were more often women and younger. Despite similar rates of symptomatic and ruptured AAAs at presentation and 30-day mortality, Black patients more often presented and were treated during the same nonelective admission; they also had associated increased length of hospital stay and readmission. These findings signal a missed opportunity to diagnose, optimize, and treat this particular group of patients in an elective setting.

Percutaneous endovascular abdominal aortic aneurysm repair with monitored anesthesia care decreases operative time but not pulmonary complications.

OBJECTIVES: To report our experience and compare the results of percutaneous endovascular aortic aneurysm repair (PEVAR) performed under monitored anesthesia care (MAC) to PEVAR under general anesthesia (GA). METHODS: A retrospective review of patients who underwent non-emergency endovascular abdominal aortic aneurysm repair (EVAR) was completed. Patients were excluded if they had a complex repair, including fenestrated, branched, or parallel endografting. Demographics, operative data, 30-day mortality/morbidity and postoperative outcomes were analyzed. RESULTS: A total of 159 patients were identified with a median age of 69. 115 patients had PEVAR, 45 (39.1%) PEVAR MAC and 70 (60.9%) PEVAR GA. PEVAR MAC compared to PEVAR GA had decreased operative time (106 vs. 134 min, P < 0.001), time in the operating room (163 vs. 245 min, P = 0.016), and estimated blood loss (EBL) (115 vs. 176 mL P = 0.012). There was no statistically significant difference in the hospital length of stay (LOS) (1.9 vs. 2.7 days, P = 0.133), and post-operative complications including pulmonary (2.2 vs. 2.9%, P = 0.835). Forty-four patients had EVAR with a femoral cutdown (FC), including 14 PEVAR conversions. PEVAR conversion was associated with higher EBL (543 vs. 323 mL, P = 0.03), operative time (230 vs. 178 min, P = 0.01), and operating room time (307 vs. 275 min, P = 0.01) compared to planned EVAR with FC. CONCLUSIONS: PEVAR under MAC is associated with shorter time in the operating room compared to PEVAR under GA. PEVAR under MAC does however not decrease overall morbidities, including postoperative pulmonary complications.

Establishing and maintaining a remote vascular surgery aortic program: A single-center 5-year experience at the Veterans Affairs.

OBJECTIVE: We sought to detail the process of establishing a surgical aortic telehealth program and report the outcomes of a 5-year experience. METHODS: A telehealth program was established between two regional Veterans Affairs hospitals, one of which was without a comprehensive aortic surgical program, until such a program was established at the referring institution. A retrospective review was performed of all patients who underwent aortic surgery from 2014 to 2019. The operative data, demographics, perioperative complications, and follow-up data were reviewed. RESULTS: From 2014 to 2019, 109 patients underwent aortic surgery for occlusive and aneurysmal disease. Preoperative evaluation and postoperative follow-up were done remotely via telehealth. The median age of the patients was 68 years, 107 were men (98.2%), 28 (25.7%) underwent open aortic repair, and 81 (74.3%) underwent endovascular repair. Of the 109 patients, 101 (92.7%) had a median follow-up of 24.3 months, 5 (4.6%) were lost to follow-up or were noncompliant, 2 (1.8%) were noncompliant with their follow-up imaging studies but responded to telephone interviews, and 1 (0.9%) moved to another state. At the 30-day follow-up, eight patients (7.3%) required readmission. Four complications were managed locally, and four patients (3.6%) required transfer back to the operative hospital for additional care. CONCLUSIONS: Telehealth is a great tool to provide perioperative care and long-term follow-up for patients with aortic pathologies in remote locations. Most postoperative care and complications can be managed remotely, and patient compliance for long-term follow-up is high.

Traumatic Lower Extremity Vascular Injuries and Limb Salvage in a Civilian Urban Trauma Center.

BACKGROUND: Data on management of traumatic lower extreity arterial injuries comes largely from military experience and involves few civilian centers. This study reports on the experience of an urban trauma center and factors associated with limb loss. METHODS: A retrospective review of lower extremity arterial injuries between 2013 and 2020 at an academic urban level 1 trauma center was completed. Patients with lower extremity revascularization were included in the final data analysis. Demographics, clinical variables, operative details, type of revascularization, as well as 30-day morbidity and postoperative outcomes were analyzed. The primary outcome of interest was 30-day limb loss. Secondary outcomes included postoperative complications and functional outcomes. RESULTS: Seventy-five patients were included in our analysis. Sixty-nine were male (92%), mean age 33 ± 15 years, 50 patients had penetrating trauma (67%), mean injury severity score was 15 ± 9. Thirty-day limb loss was reported in 8 (11%). Factors associated with limb loss included female sex (P = 0.001), high body mass index (P = 0.001), blunt injury (P = 0.001), associated fractures (P = 0.005), significant soft tissue injury (P = 0.007), delayed repair after shunt placement (P = 0.003), bypass revascularization (P = 0.001), initial revascularization failure (P = 0.019), and wound complications (P < 0.001). Fifty-five patients had at least one return to the operating room (ROR), including 24 patients (32%) for complications related to their revascularization. These included delayed compartment syndrome (n = 7), revascularization failure (n = 9), bleeding (n = 3), and vascular surgical wound complications (n = 5). Mean length of hospital stay (LOS) for the cohort was 24 ± 20 days with 3 ± 3 ROR, in contrast patients who ultimately required amputation had LOS of 57 ± 21 days with 8 ± 4 ROR. Fifty-seven patients (76%) followed in clinic for a median 36 [14-110] days, with only 32 (43%) at >30 days. Twenty-three reported ambulation without assistance, 9 neuromotor deficit including 1 patient that had delayed amputation. CONCLUSION: Patients with blunt trauma and associated fracture and/or extensive soft tissue injury are at risk of limb loss. These injuries are often associated with postoperative wound complications, requiring aggressive soft tissue care that substantially increases ROR and LOS; Expectations for limb salvage in these patients should be tempered when the other associated factors with limb loss mentioned above are also present. When limb salvage is achieved, regaining full limb function remains a challenge.

The role of heparin in endovascular repair of blunt thoracic aortic injury.

OBJECTIVE: Early diagnosis and treatment are essential to improve survival of patients with blunt thoracic aortic injury (BTAI). Often, aortic surgical intervention may be delayed because of increased risk of bleeding with heparin, particularly in polytrauma victims. We believe that surgical delay may be remedied by proceeding without heparinization. This study reviewed the outcome of patients subjected to thoracic endovascular aortic repair (TEVAR) under full, low-dose, and no intraoperative systemic heparinization. METHODS: There were 77 cases of confirmed BTAI identified and retrospectively analyzed at a high-volume urban trauma center during a period of 15 years (March 2003-September 2017). Patients were stratified into three groups on the basis of the intraoperative use of heparin during TEVAR, as follows: full heparin (FH), low-dose heparin (LH), and no heparin (NH). Baseline characteristics including the patients' demographics, diagnostic laboratory data and imaging studies, operative reports, postoperative complications, embolic and bleeding outcomes, and mortality data were reviewed. RESULTS: Of the 77 total patients who underwent TEVAR for BTAI, 42 patients received full-dose heparinization, 18 received low-dose heparin, and 17 had no use of systemic heparin. There was no significant difference in age, sex, body mass index, or smoking history. The most common mechanism of injury was motor vehicle collision. Grade 3 (pseudoaneurysm) was the predominant type of BTAI (FH, 69.0%; LH, 61.1%; NH, 76.5%; P = .23). The mean interval between admission and repair was three times longer in the FH group than in the NH group (FH, 2.33 days; NH, 0.76 day; P = .091). The mean time in the intensive care unit was shorter in the NH group vs the FH group (15 days vs 26.21 days; P = .025). Thromboembolic and bleeding outcomes and mortality rates were comparable in all three groups; 57 patients continued follow-up for a mean time of 30.99 months. CONCLUSIONS: Our study shows no statistically significant difference in outcomes between the heparinized and nonheparinized groups. The primary benefit of the NH group is seen in time to repair. Although not statistically significant, the mean time to repair was three times longer in the FH group. Patients in the NH group also benefited from prompt intervention and treatment. Therefore, intraoperative heparinization in critically ill patients with BTAI undergoing TEVAR remains at the surgeon's discretion, although the lack of heparinization appears to be a safe and potentially faster alternative, particularly in the polytrauma patient.

Endovascular Aortoiliac Revascularization in a Patient with Spinal Cord Injury and Hip Contracture.

Treatment of chronic peripheral ischemic wounds in patients with spinal cord injury (SCI) can be technically challenging, especially if they have significant hip contracture. This article describes the endovascular aortoiliac revascularization of a paraplegic patient with hip contracture and a hostile abdomen. It also reviews the particularity of the peripheral arterial system in SCI patients.

Delayed presentation of a carotid pseudoaneurysm following penetrating neck trauma.

OBJECTIVE: Penetrating carotid trauma in a hemodynamically stable patient invariably presents with a pseudoaneurysm on initial imaging. Although extremely rare, delayed pseudoaneurysm formation has been reported. The purpose of this paper is to define this rare entity and propose a diagnostic and treatment plan. METHODS: We present a case of delayed presentation of carotid pseudoaneurysm following penetrating neck trauma. A systematic review of the literature was performed. RESULTS: A 21-year-old male presents to the trauma center after sustaining a gunshot wound to the left upper back resulting in a zone 2 hematoma and pneumothorax. Bullet fragment artifact interfered with computed tomography. Carotid angiogram was normal. The patient was discharged after 3 days. He returned to the Emergency Department 3 months later with a painful pulsatile hematoma. Computed tomography angiogram revealed a 6-cm pseudoaneurysm arising from the proximal left internal carotid artery (ICA). A left common carotid artery (CCA) to ICA bypass with reversed great saphenous vein was performed. The patient's post-operative course was uneventful, neurologic deficits improved, and he was discharged. CONCLUSION: Delayed presentation of traumatic pseudoaneurysms has been reported, although usually these cases are iatrogenic access complications in extremities. While endovascular therapies are first line for zone 1 and 3 vascular injuries, management of zone 2 injuries is still controversial. This patient was treated with a bypass due to the need to evacuate the hematoma that was exerting a mass effect in the neck.

Study habits centered on completing review questions result in quantitatively higher American Board of Surgery In-Training Exam scores.

PURPOSE: The American Board of Surgery In-Training Exam (ABSITE) is administered to all general surgery residents annually. Given the recent changes in the format of the examination and in the material being tested, it has become increasingly difficult for residents to prepare for the ABSITE. This is especially true for incoming postgraduate year (PGY) 1 residents because of the respective variability of the surgical clerkship experience. There have been many studies in the past that support the use of weekly assigned readings and examinations to improve ABSITE scores. Other studies have investigated the study habits of residents to determine those that would correlate with higher ABSITE scores. However, there is a lack of information on whether completing review questions plays an integral role in preparing for the ABSITE. We hypothesize that those residents who completed more review questions performed better on the ABSITE. METHODS: ABSITE scores of current and past general surgery residents at SUNY Downstate Medical Center, a university hospital, were reviewed (2009-2013). These residents were then polled to determine how they prepared for their first in-training examination. RESULTS: Average ABSITE percentile was 46.4. Mean number of review questions completed by residents was 516.7. Regression analysis showed that completion of more review questions was associated with a significantly higher percentile score on the ABSITE (p < 0.0027). Further analysis showed that for every 100 review questions completed by a PGY 1 resident taking the ABSITE for the first time, the ABSITE percentile score should improve by 3.117 ± 0.969. Average reported study time in hours/week was 9.26. Increased study time was also significantly correlated with higher ABSITE percentile scores (p < 0.007). Again, further analysis showed that for every 1h/wk spent studying, ABSITE percentile score should increase by 1.76 ± 0.62. The Kruskal-Wallis H test showed that studying in group vs individual settings had no effect on ABSITE performance (p = 0.20). It was also used to analyze primary study resource, which demonstrated that there was no significant difference in residents' performance based on their primary study source (p = 0.516). CONCLUSION: Recent changes in the format of the ABSITE to a 2-tiered examination in 2006 and subsequent plan to return to a unified test for all PGY levels has made preparation difficult. With a more focused, question-based approach to studying, residents may see a demonstrable improvement in their scores. Our study supports this hypothesis-showing that residents who complete more review questions had higher ABSITE percentile scores. In the past, it has been demonstrated that strong ABSITE scores are associated with higher written board scores. With the widespread adoption of the Surgical Council on Resident Education curriculum, we postulate that residency programs that rely on this review question-based curriculum will report improved ABSITE percentile scores and written board pass rates.

Antiretroviral therapy in a thousand patients with AIDS in Haiti.

BACKGROUND: The one-year survival rate of adults and children with the acquired immunodeficiency syndrome (AIDS), without antiretroviral therapy, has been about 30 percent in Haiti. Antiretroviral therapy has recently become available in Haiti and in other developing countries. Data on the efficacy of antiretroviral therapy in developing countries are limited. High rates of coinfection with tropical diseases and tuberculosis, along with malnutrition and limited laboratory monitoring of therapy, may decrease the efficacy of antiretroviral therapy in these countries. METHODS: We studied the efficacy of antiretroviral therapy in the first 1004 consecutive patients with AIDS and without previous antiretroviral therapy who were treated beginning in March 2003 in Port-au-Prince, Haiti. RESULTS: During a 14-month period, three-drug antiretroviral therapy was initiated in 1004 patients, including 94 children under 13 years of age. At enrollment, the median CD4 T-cell count in adults and adolescents was 131 per cubic millimeter (interquartile range, 55 to 211 per cubic millimeter); in children, a median of 13 percent of T cells were CD4-positive (interquartile range, 8 to 20 percent). According to a Kaplan-Meier survival analysis, 87 percent of adults and adolescents and 98 percent of children were alive one year after beginning treatment. In a subgroup of 100 adult and adolescent patients who were followed for 48 to 56 weeks, 76 patients had fewer than 400 copies of human immunodeficiency virus RNA per milliliter. In adults and adolescents, the median increase in the CD4 T-cell count from baseline to 12 months was 163 per cubic millimeter (interquartile range, 77 to 251 per cubic millimeter). In children, the median percentage of CD4 T cells rose from 13 percent at baseline to 26 percent (interquartile range, 22 to 36 percent) at 12 months. Treatment-limiting toxic effects occurred in 102 of the 910 adults and adolescents (11 percent) and 5 of the 94 children (5 percent). CONCLUSIONS: This report documents the feasibility of effective antiretroviral therapy in a large number of patients in an impoverished country. Overall, the outcomes are similar to those in the United States. These results provide evidence in support of international efforts to make antiretroviral therapy available to patients with AIDS in developing countries.