Thrombin injection for the treatment of mycotic gluteal aneurysm.

Gluteal aneurysms are rare entity, whose surgical or endovascular management is traditionally challenging. Infectious source being increasingly more common as the underlying etiology. We herein describe successful implementation of direct thrombin injection as another therapeutic option for these patients.

Spontaneous superior mesenteric artery dissection: report of 2 patients and review of management recommendations.

Spontaneous superior mesenteric artery dissection is rare and presents with variable symptomatology. Optimal treatment depends on the presentation; asymptomatic patients can be managed expectantly. Endoluminal intervention or open reconstruction is warranted in patients with persistent symptoms or intestinal ischemia. As more of these patients are identified with increasing utilization of computed tomography (CT), our understanding of the pathophysiology and best treatment will improve.

Variations in early outcomes of endovascular aneurysm repair with alternate endograft configurations.

BACKGROUND: Most endovascular abdomincal aortic aneurysm (AAA) repairs (EVARs) performed in the United States utilize a bifurcated configuration. The purpose of this study was to examine the effect of alternate graft configurations on early outcomes during EVAR. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective EVAR for AAA from 2005 to 2007 were stratified by configuration using CPT codes. Bifurcated configurations (CPT 34802, 34803, 34804) were compared to straight configurations such as tube or aortouni-iliac grafts (CPT 34800, 34805). Preoperative risk factors, intraoperative variables, 30-day outcome measures, and length of stay were compared. Composite morbidity included patients experiencing one or more of 21 complications defined by NSQIP protocol. Student's t-test and analyses of variance were used to compare variables. RESULTS: There were 3,264 patients who underwent EVAR, including 2,864 bifurcated endografts and 400 straight endografts. Composite morbidity was greater in patients receiving straight endografts compared to those receiving bifurcated endografts (15.2% vs. 9.3%, p < 0.001). Length of stay was greater in the "straight" cohort as well (4.9 + or - 6.9 vs. 3.3 + or - 5.6, p < 0.001). There was a trend toward increased mortality in the "straight" cohort, but it did not reach statistical significance (2% vs. 0.9%, p = 0.054). After controlling for the top 11 NSQIP predictors of mortality in vascular patients, graft configuration remained significant in the multivariable analysis for morbidity (odds ratio [OR] = 1.55, 95% confidence interval [CI[ 1.13-2.12, p = 0.006) and length of stay but not mortality (OR = 1.63, 95% CI 0.70-3.80, p = 0.263). CONCLUSION: EVAR using a tube or aortouni configuration is associated with increased complications and length of stay. These poorer outcomes may be related to factors that lead surgeons to choose these approaches.

Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization.

BACKGROUND: Little is known about the significance of blood transfusion in patients with peripheral arterial disease. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to examine the effect of intraoperative blood transfusion on the morbidity and mortality in patients who underwent lower extremity revascularization. METHODS: We analyzed data from the participant use data file containing vascular surgical cases submitted to the ACS NSQIP in 2005, 2006, and 2007 by 173 hospitals. Current procedural terminology codes were used to select lower extremity procedures that were grouped into venous graft, prosthetic graft, or thromboendarterectomy. Thirty-day outcomes analyzed were (1) mortality, (2) composite morbidity, (3) graft/prosthesis failure, (4) return to the operating room within 30 days, (5) wound occurrences, (6) sepsis or septic shock, (7) pulmonary occurrences, and (8) renal insufficiency or failure. Intraoperative transfusion of packed red blood cells was categorized as none, 1 to 2 units, and 3 or more units. Outcome rates were compared between the transfused and nontransfused groups using the chi(2) test and multivariable regression adjusting for transfusion propensity, comorbid and procedural risk. RESULTS: A total of 8799 patients underwent lower extremity revascularization between 2005 and 2007. Mean age was 66.8 +/- 12.0 years and 5569 (63.3%) were male. Transfusion rates ranged from 14.5% in thromboendarterectomy patients to 27.1% in prosthetic bypass patients (P < .05). After adjustment for transfusion propensity and patient and procedural risks, transfusion of 1 or 2 units remained significantly predictive of mortality, composite morbidity, sepsis/shock, pulmonary occurrences, and return to the operating room. The adjusted odds ratios for 30-day mortality ranged from 1.92 (95% confidence interval [CI] 1.36-2.70) for 1 to 2 units to 2.48 (95% CI 1.55-3.98) for 3 or more units. CONCLUSION: In a large number of patients undergoing lower extremity revascularization, we have found that there is a higher risk of postoperative mortality, pulmonary, and infectious complications after receiving intraoperative blood transfusion. Additional studies are necessary to better define transfusion triggers that balance the risk/benefit ratio for blood transfusion.

Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms.

BACKGROUND: The mortality of ruptured abdominal aortic aneurysm (rAAA) has decreased 3.5% per decade in the last 50 years to a current rate of 40%-50%. Reports have indicated that endovascular repair (EVAR) is feasible for rAAA and may offer potential benefits over open repair. We examined the National Surgical Quality Improvement Program (NSQIP) database to compare 30-day multicenter outcomes for EVAR vs open rAAA repair. METHODS: Patients that underwent rAAA repair in the NSQIP database from 2005 to 2007 were identified through a combination of Current Procedural Terminology (CPT) codes and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses. Preoperative comorbidities, operative duration and transfusion, and 30 day outcomes were evaluated using t tests or Chi-squared tests depending on the variable. A separate multivariable regression was performed for each outcome adjusting for all independently predictive preoperative and intraoperative risk factors. RESULTS: A total of 427 patients were identified and 76.8% of patients underwent open repair. The open repair groups exhibited lower albumin levels and higher percentage of patients with preoperative hematocrit (Hct) <38% and need for preoperative ventilation. The requirement for preoperative blood transfusion was similar. Patients undergoing open repair had much higher intraoperative transfusion requirements (11.8 +/- 8.9 vs 4.2 +/- 6.0 red blood cell units, P < .001). After adjustment for preoperative mortality risk factors, the mortality risk was higher for open repair versus EVAR (odds ratio 1.67, 95% confidence interval [CI] 0.91-3.05, P = .096) but did not reach significance. After similar adjustment the composite morbidity odds ratio for open repair versus EVAR was 1.82 (95% CI 1.11-2.99, P = .018) and the pulmonary adverse events odds ratio was 1.99 (95% CI 1.22-3.25, P = .006). Risks for the other outcomes were not significant. CONCLUSIONS: Composite 30-day morbidity risk is lower after EVAR vs open repair of rAAA. Open repair is associated with increased transfusion requirements. Performance of EVAR in rAAA patients with favorable anatomy could potentially result in improved outcome as compared with open repair.