Tissue expander breast reconstruction using prehydrated human acellular dermis.

INTRODUCTION: Human acellular dermal matrices help facilitate immediate tissue expander-implant breast reconstruction by providing support to the inferolateral pole, improving control of implant position, and enhancing early volume expansion. Although several freeze-dried human acellular dermal products have demonstrated reasonable safety and efficacy in immediate tissue expander-implant breast reconstruction, no dedicated studies have evaluated clinical outcomes of prehydrated human acellular dermal matrix (PHADM) in breast reconstruction. METHODS: The outcomes of 121 consecutive tissue expander reconstructions performed by the senior author using PHADM were evaluated. RESULTS: Mean intraoperative tissue expander fill volume was 256.6 ± 133 mL, 60% of final expander volume. Patients required an average of 3.2 additional expansions prior to tissue expander-to-implant exchange. Mean follow-up period after reconstruction was 44 ± 26.5 weeks. Complications occurred in 20 (16.5%) breasts, including 9 (7.4%) soft-tissue infections, 8 (6.6%) partial mastectomy flap necroses, and 2 (1.7%) seromas. Eleven (9.1%) breasts ultimately required explantation. Patients receiving radiation demonstrated a strong trend toward greater complications (30.8% vs. 13.7%, P = 0.0749). CONCLUSIONS: The outcomes and complication rates of PHADM tissue expander breast reconstruction are comparable to those reported with freeze-dried human acellular dermis.

Secondary infections of thoracic and abdominal aortic endografts.

PURPOSE: To review several cases of stent-graft infection with respective outcomes to identify clinical presentations and responses to treatment options. MATERIALS AND METHODS: The authors performed a single-center retrospective review of all secondary endograft infections from January 2000 to June 2007. Infections were identified from an institutional database containing all abdominal and thoracic endovascular aneurysm repairs (EVAR and TEVAR) performed at the treating hospital. RESULTS: From January 2000 to June 2007, 389 EVAR and 105 TEVAR were performed at the treating hospital. Ten endograft infections were identified (five EVAR and five TEVAR). Four infections occurred in grafts placed at outside institutions and six in grafts placed in-house. The in-house prevalence of EVAR and TEVAR infection is 0.26% and 4.77%, respectively. None were placed for a presumed pre-existing mycotic aneurysm. The mean time from the index procedure to the diagnosis of infection was 243.6 days +/- 74.5. Two patients who underwent EVAR presented with a contained rupture, and the remaining eight patients presented with constitutional symptoms and/or abscess formation on imaging studies. Microbiology cultures revealed Propionibacterium species (n = 3), Staphylcoccus species (n = 3), Streptococcus species (n = 2), and Enterobacter cloacae (n = 1). All EVAR patients underwent removal of the infected endograft and reconstruction with extraanatomic bypass (n = 3) or in situ homograft placement (n = 2). During a mean follow-up of more than 1 year, there were no recognized complications or recurrence of infection. Only one of the five TEVAR patients underwent removal and interposition grafting with an antibiotic-impregnated Dacron graft. The remaining four patients were medically managed--one patient survived and was placed in hospice care, two died of mycotic aneurysm rupture, and one died from multiorgan system failure secondary to sepsis. CONCLUSIONS: Graft-related septic complications following EVAR or TEVAR are rare but associated with significant mortality. Several surgical treatment options are available, each potentially equally successful. The effect of prophylactic antibiotic use during subsequent invasive procedures must be solidified.

Percutaneous Zenith endografting for abdominal aortic aneurysms.

A completely percutaneous approach to infrarenal abdominal aortic aneurysm (AAA) endografting has the theoretic benefits of being minimally invasive and more expedient. Our goal was to demonstrate the utility of this approach using a suprarenal fixation device and a suture-mediated closure system. We conducted a single-institution, retrospective review of 14 patients who underwent percutaneous AAA repair with the Zenith device between August 2003 and March 2007. Immediate and delayed access-related outcomes were examined over a mean follow-up of 12.1+/-2.0 months. Mean AAA size was 5.6 cm. Immediate arterial closure and technical success rate was 96% (27/28 vessels). One immediate hemostatic failure required open surgical repair. Over follow-up, one vessel required operative repair for new-onset claudication. No other immediate or delayed complications (thrombosis, pseudoaneurysm, infection, or deep venous thrombosis) were detected. A percutaneous approach for the treatment of AAA has several advantages over femoral artery cutdown but also has its own unique set of risks in the immediate and late postoperative period. Ultimately, the "preclose technique" can be safely applied for the Zenith device despite its large-bore delivery system.

Late Type III endoleak and graft failure of an Ancure stent-graft.

The authors report a case of a delayed type IIIb endoleak with sac expansion 6 years after an endovascular repair of an abdominal aortic aneurysm with an Ancure bifurcated stent-graft. The presumed etiology of the leak was secondary to erosion of the main body graft material by metal stents placed within the graft to correct kinking of the iliac limbs at the index operation. The endoleak was successfully treated by endovascular means with an aortouni-iliac device, contralateral iliac plug followed by a femoral-to-femoral bypass graft.

Breast implant procedures under conscious sedation: a 6-year experience in 461 consecutive patients.

BACKGROUND: Breast implant procedures are commonly performed using general anesthesia; however, patient apprehension, the potential for improved safety, lower costs, and faster recovery times have increased interest in the use of conscious sedation in plastic surgery. The authors examined the safety and efficacy of breast implant procedures performed under conscious sedation over a 6-year period using their standardized institutional protocol. METHODS: Between 2002 and 2008, 461 consecutive patients underwent breast implant procedures under conscious sedation using a protocol of preoperative intravenous diazepam along with intraoperative midazolam, fentanyl, and local anesthetic. All operative and follow-up data were recorded. Augmentation mammaplasty patients were further analyzed for conscious sedation medication dosing. RESULTS: The study population was divided into two groups (years 1 to 3 and years 4 to 6 of the study period) to analyze changes to the authors' regimen over time. In years 4 to 6, higher preoperative doses of diazepam (p = 0.01) allowed more effective local anesthesia administration, thereby reducing intraoperative fentanyl requirements (p < 0.0001). Midazolam doses and operating times did not differ significantly between groups. No patient required conversion to a deeper method of anesthesia. The overall complication rate was 4.34 percent. CONCLUSIONS: The authors' study demonstrates the safety and efficacy of conscious sedation in breast implant procedures. Higher preoperative doses of diazepam have significantly reduced fentanyl requirements, resulting in shorter recovery times, decreased postoperative nausea/vomiting, and elimination of unintended admissions. These benefits are obtained without increasing operative times or complications. The authors conclude that conscious sedation is the preferred method of anesthesia for most patients undergoing breast implant procedures.

Carotid stenting: risk factors for periprocedural stroke.

Carotid artery stenting is rapidly emerging as a minimally invasive alternative to carotid endarterectomy for the treatment of cervical carotid artery occlusive disease and stroke prevention. Periprocedural stroke risk still remains a concern despite improvements in technique and equipment. We will review technical, clinical and radiographic factors associated with an increased risk of stroke during carotid artery stenting. The primary focus will be on technical proficiency of the interventionalist, patient comorbid conditions (i.e., diabetes, coronary artery disease, renal failure and advanced age) and equipment (i.e., embolic protection systems and stent designs) that have been identified in the literature as predictors of poorer outcomes.