Effect of Direct Oral Anticoagulants Versus Warfarin on Patency in High-Risk Bypass Patients.

BACKGROUND: The use of warfarin for anticoagulation in thromboembolic disease has been the mainstay of treatment. Direct oral anticoagulants (DOACs) have demonstrated equivalent anticoagulant effects, without increased bleeding risks or need for frequent monitoring. However, the role of DOACs remains unclear in the setting of replacing warfarin for high-risk peripheral artery disease (PAD) interventions. The purpose of this study is to evaluate the efficacy of DOACs compared to warfarin during the postoperative period in patients that underwent a lower extremity high-risk bypass (HRB). METHODS: The study is a single institution, retrospective review of all lower extremity HRBs between January 2012 and June 2021, who were previously placed on or started on anticoagulation with a DOAC or warfarin. The HRB group included all patients undergoing femoral to above or below knee bypass with an adjunct procedure, or below knee bypass with synthetic or composite vein conduit. All demographics, preoperative factors, and complications were evaluated with respect to DOAC versus warfarin. RESULTS: A total of 44 patients (28 males; average age 68.8 ± 10.9) underwent an HRB during the study period. There were no significant differences in demographics and preoperative characteristics between the 2 groups. Among patient comorbidities, coronary artery disease was found to be significantly higher in patients on DOACs (P = 0.03). The 12-month primary patency rate was 83.3% versus 57.1%, for DOAC versus warfarin respectively (P = 0.03). Multivariate analyses revealed that <30-day reinterventions contribute to 12-month patency (P = 0.02). CONCLUSIONS: Patients who underwent lower extremity HRB with postoperative DOAC appeared to exhibit higher graft patency rates than those who were placed on warfarin. Due to their low incidence of undesirable side effects and the lack of frequent monitoring, DOACs could be considered a safe alternative to warfarin in the postoperative period for patients with HRB.

Open conversion after failed endovascular aneurysm repair is increasing and its 30-day mortality is higher than that after primary open repair.

BACKGROUND: Endovascular aneurysm repair (EVAR) has become the preferred treatment of abdominal aortic aneurysms (AAAs). Recent studies have demonstrated that cases of EVAR failure repair and subsequent open conversion have increased. The aim of the present study was to evaluate the national trend of annual cases and assess the 30-day outcomes of conversion to open repair after failed EVAR compared with primary open repair. METHODS: The National Surgical Quality Improvement Program database was queried for relevant Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes to identify patients who had undergone conversion to open repair or primary open repair of nonruptured AAAs from 2009 to 2018. The annual trend of cases was assessed, and the perioperative outcomes of both procedures were compared. Multivariable logistic regression analyses were conducted to identify independent perioperative factors associated with mortality. RESULTS: Of the 9635 patients with nonruptured AAAs included in the present analysis, 9250 had undergone primary repair and 385 had required open conversion. During the 10-year period, the annual number of cases of open conversion had steadily increased and that of primary repair had decreased. The incidence of postoperative complications was similar between both groups, except for cardiac arrest, which had occurred more frequently in the open conversion group. The 30-day mortality was higher in the open conversion group than in the primary group (9.6% vs 3.9%; P < .0001). Open conversion was also independently associated with higher odds of death (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.8-2.4; P < .0001). When the average mortality in both groups was compared between the first and last 5 years, no difference was found (open conversion: 9.8% vs 9.5% [P = 1.00]; primary repair: 3.6% vs 4.2% [P = .19]). Other perioperative factors independently associated with mortality included increased age (OR, 1.8; 95% CI, 1.5-2.1; P < .0001), American Society of Anesthesiologists class ≥III (OR, 2.7; 95% CI, 1.1-6.6; P = .029), insulin-dependent diabetes (OR, 2.0; 95% CI, 1.2-3.3; P = .005), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.1-1.8; P = .006), the presence of dyspnea at rest (OR, 3.3; 95% CI, 1.8-6.1; P < .0001), and a high preoperative hematocrit (OR, 0.94; 95% CI, 0.93-0.97; P < .0001). CONCLUSIONS: Open conversion to treat nonruptured AAAs after failed EVAR was independently associated with higher mortality. Also, the annual cases of open conversion have continued to increase without any significant changes in postoperative mortality. This highlights the danger of open conversion and stresses the need for better solutions to prevent and manage EVAR failure.

Intraoperative fusion imaging during transcarotid artery revascularization.

Background: Transcarotid artery revascularization (TCAR) with reverse-flow neuroprotection has emerged as an alternative to transfemoral carotid artery stenting and carotid endarterectomy. However, it requires fluoroscopic guidance, exposing the patient and surgeon to radiation. Although fusion-guided endovascular aneurysm repair has been demonstrated to significantly decrease this radiation risk, not much is known about similar outcomes for TCAR. The purpose of this study is to evaluate the outcomes at a single institution using fusion-guided imaging during TCAR compared with regional TCAR cases in the Vascular Quality Initiative (VQI) registry without fusion imaging. Methods: A retrospective analysis was conducted of data collected from all patients undergoing TCAR with fusion-guided imaging (TCAR-F) at our hospital and patients undergoing TCAR alone within the VQI database. The primary outcomes included the total operative time, dose area product, fluoroscopy time, contrast usage, and flow-reversal time. The demographics and preoperative risk factors were also assessed in both groups. Continuous outcomes were compared using the Welch t test. Categorical outcomes were compared using the Fisher exact test. Results: A total of 30 TCAR-F cases (January 2019 to May 2022) at our institution were compared against the regional VQI dataset (n = 2535). The TCAR-F cases had a lower dose area product (5.67 vs 93.1 Gy cm2; P < .0001), shorter fluoroscopy time (8.07 vs 16.4 minutes; P < .0001), and less contrast usage (13.49 vs 76.7 mL; P < .0001) compared with the regional averages of the same. The TCAR-F cases had a longer total operative time (117.3 vs 80.9 minutes; P < .0001) and flow-reversal time (14.4 vs 11.7 minutes; P = .025) compared with the regional cases. Conclusions: The results from this pilot study comparing TCAR-F patients at a single institution with VQI regional TCAR patients suggest that TCAR-F cases use less radiation and contrast compared with TCAR without fusion imaging. Fusion-guided imaging might provide radiation protection to both patients and surgeons and decrease contrast usage for the patient.

Contained abdominal aortic rupture secondary to follicular lymphoma invasion.

An 87-year-old woman with grade IIIb follicular lymphoma treated with rituximab had presented with nausea, emesis, and chest pain of 1 day duration. She was found to have a contained abdominal aortic rupture secondary to follicular lymphoma invasion. She safely and successfully underwent emergent endovascular aortic repair. We have described a rare case of extranodal disease in follicular lymphoma associated with abdominal aortic pseudoaneurysms, likely due to a combination of malignancy-induced chronic inflammation and radiation therapy and chemotherapy side effects.

Iliac vein aneurysms associated with May-Thurner anatomy.

A 61-year-old woman with May-Thurner anatomy status post recent hysterectomy was found to have two iliac vein aneurysms on postoperative magnetic resonance imaging. Transfemoral venography showed the venous aneurysms received retrograde flow from the left internal iliac vein and the left common iliac vein (CIV) was compressed by the right common iliac artery. Both aneurysms were coil embolized and a left CIV stent was placed. Our initial experience suggests that iliac vein aneurysms may be caused by CIV compression and an endovascular approach is safe and effective to treat both lesions.

Persistent sciatic artery in a patient with unilateral acute lower extremity ischemia.

We report a rare case of a persistent sciatic artery in a 59-year-old woman who had presented with unilateral acute limb ischemia. A heparin infusion was started. A right lower extremity arterial duplex ultrasound scan showed an occluded superficial femoral artery and underwent catheter-directed thrombolysis of her right popliteal artery, which was fed by a persistent sciatic artery. After recovery, computed tomography angiography was performed, which confirmed a persistent sciatic artery of the right lower extremity. The patient had presented with thrombotic disease secondary to atherosclerosis of popliteal and tibial arteries, in contrast to the more commonly seen aneurysmal disease with thrombosis.

Small bowel intussusception in marijuana users.

Intussusception occurs when one portion of bowel 'telescopes' into another due to a lead point created by a range of benign or pathologic process. Intussusception mostly occurs in children. Although adult intussusception (AI) is rare, accounting for <5% of intestinal obstructions, it is more concerning in adults as malignancy accounts for nearly 65% of lead points in AI. Patients present with severe abdominal pain concerning for an acute abdomen along with a degree of bowel obstruction. We have experienced a total of 11 patients within recent years presenting with symptoms of an acute abdomen due to AI. None of these patients were found to have a pathologic process creating a lead point. However, we found that all of them were marijuana users. In this report, we compare their management, hospital course and review of the literature discussing proposed mechanisms that suggest an association between cannabis and intussusception.

Repurposing a Small Community Hospital Surgical Residency Program in an Epicenter of the COVID-19 Pandemic.

BACKGROUND: COVID-19 put a stop to the operative experience of surgical residents, leaving reassignment of the team, to the frontlines. Each program has adapted uniquely; we discuss how our surgical education changed in our hospital. STUDY DESIGN: A retrospective review of changes in general surgery cases, bedside procedures, and utilization of residents before and during the pandemic. Procedures were retrieved from electronic medical records. Operating room (OR) cases 1 month before and 5 weeks after the executive order were collected. Triple lumen catheter (TLC), temporary hemodialysis catheter (HDC), and pneumothorax catheter (PC) insertions by surgical residents were recorded for 5 weeks. RESULTS: Before the pandemic, an average of 27.9 cases were done in the OR, with an average of 10.1 general surgery cases. From March 23 to April 30, 2020, the average number of cases decreased to 5.1, and general surgery cases decreased to 2.2. Elective, urgent, and emergent cases represented 83%, 14.6%, and 2.4% prior to the order and 66.7%, 15.1%, and 18.2%, respectively, after the order. Bedside procedures over 5 weeks totaled to 153, 93 TLCs, 39 HDCs, and 21 PCs. CONCLUSION: Repurposing the surgical department for the concerns of the pandemic has involved all surgical staff. We worked with other departments to allocate our team to areas of need and re-evaluated daily. The strengths of our team to deliver care and perform many bedside procedures allowed us to meet the demands posed by this disease while remaining as a cohesive unit.