Endometrial Stromal Sarcoma Metastatic from the Uterus to the Inferior Vena Cava and Right Atrium.

Endometrial stromal sarcoma metastases usually occur within the pelvis and rarely involve the great vessels or the heart. We present the case of a 55-year-old woman who was referred for endovascular therapy to treat presumed thrombosis of the inferior vena cava. The suspected thrombus was recalcitrant to endovascular removal with use of an AngioVac venous drainage device. Results of an intraprocedural transvenous biopsy revealed the mass to be the intravascular extension of an endometrial stromal sarcoma. The patient underwent surgical excision of the tumor, and, shortly thereafter, a hysterectomy and salpingo-oophorectomy. This complex case highlights both the rarity of malignancy masquerading as caval thrombus and the importance of multispecialty collaboration.

Postoperative complications after common femoral endarterectomy.

BACKGROUND: Common femoral endarterectomy (CFE) for limited arterial occlusive disease is considered a fairly low-risk operation of short duration. This study investigated the timing of 30-day outcomes as they related to hospital discharge and predicted the risk of operative mortality of this procedure. METHODS: All patients in the National Surgical Quality Improvement Program database who underwent isolated CFE between 2005 and 2010 were selected for the test sample. We identified postoperative mortality and morbidities occurring before and after hospital discharge. A risk calculator for 30-day mortality, developed in the test sample using logistic regression, was validated in a new sample of cases from 2011 to 2012. RESULTS: A total of 1843 CFEs reported from 2005 to 2010 met the inclusion and exclusion criteria. The average operative time was 146 ± 69.5 minutes (median, 133; interquartile range, 98-179 minutes), and 10% of patients needed to return to the operating room. The average length of stay was 4 ± 7.5 days (median, 3; interquartile range, 2-5 days); 91% of patients were discharged ≤ 1 week of surgery. Occurrences of cardiovascular events, renal dysfunction, and pulmonary complication were relatively low. There was 3.4% mortality and 8% wound-related complications, 30% and 86% of which occurred after hospital discharge, respectively. Overall, there was a 15% risk of combined mortality/morbidity, and >60% of these events occurred after discharge. The independent predictors of 30-day mortality were age, nonindependent functional status, preoperative dialysis, sepsis, emergency status, and American Society of Anesthesiologists Physical Status Classification 4 or 5, and the association between risk strata and death in the validation sample was strong (φ = 0.29) and significant (P < .001). CONCLUSIONS: CFE is not as "benign" a procedure as previously believed. The risks of death and wound complications are not insignificant, and a high percentage of these complications occurred after patients were discharged from the hospital. Patients should be carefully selected, especially in the elderly population, and close postoperative follow-up should be considered.

Comparison of outcomes for open abdominal aortic aneurysm repair and endovascular repair in patients with chronic renal insufficiency.

OBJECTIVE: This study investigates whether this practice is supported by multicenter prospectively collected data. BACKGROUND: Currently, open abdominal aortic aneurysm (AAA) repair (OPEN) is preferred over endovascular repair (EVAR) in patients with chronic renal insufficiency because of the concern that the contrast load used for EVAR may result in postoperative dialysis. METHODS: Patients who underwent EVAR and OPEN for infrarenal AAA were identified in the NSQIP database from 2005 to 2010. Preoperative renal function was assessed by estimated glomerular filtration rate (eGFR) calculated by the Chronic Kidney Disease Epidemiology Collaboration equation. Patients with chronic renal insufficiency were further stratified into 2 different groups: moderate (eGFR = 30-60 mL/min) and severe (eGFR <30 mL/min) renal dysfunction. Multivariate regression model was used for data analysis. RESULTS: We identified 13,191 patients who underwent AAA repair: 9877 patients underwent EVAR and 3314 underwent OPEN. Forty percent of patients had eGFR of less than 60 mL/min. OPEN in patients with moderate renal dysfunction resulted in significantly higher mortality, cardiovascular events, and combined outcomes. However, in patients with severe renal dysfunction, these outcomes were similarly high in both OPEN and EVAR. Most importantly, OPEN in patients with moderate renal dysfunction resulted in 5.2 times higher risk of dialysis. CONCLUSIONS: Contrary to current practice, and despite the use of contrast, EVAR should be the first choice in patients with moderate renal dysfunction if they have the appropriate anatomy. Higher threshold for AAA repair with either OPEN or EVAR should be applied in patients with severe renal dysfunction because postoperative complications were significantly high with either approach.

Use of the 8-F angio-seal vascular closure device in large-caliber arteriotomies.

PURPOSE: To evaluate the feasibility and safety of using the 8-F Angio-Seal vascular closure device (VCD) to seal large-caliber (>8-F) access sites during percutaneous endovascular interventions. METHODS: A retrospective review was undertaken of 42 consecutive patients (34 men; mean age 67.8 years, range 36-94) undergoing percutaneous peripheral interventions with sheaths ranging from 9-F to 12-F and subsequent closure using 8-F Angio-Seal VCDs. Single-wall puncture (n = 48) of the common femoral artery was guided by ultrasound in 46 cases and palpation in 2. Forty procedures required therapeutic heparinization during the interventional procedure; protamine was administered in only 5. Per protocol, manual pressure was held for 15 minutes. Clinical and/or imaging follow-up was available in all cases within 3 months after the procedure. RESULTS: Immediate technical success was achieved in all cases, with hemostasis obtained within 5 minutes (no oozing or hematoma). The overall complication rate was 4.1% (2/48); one hematoma requiring surgical repair occurred 10 hours after VCD deployment. An asymptomatic pseudoaneurysm was discovered on follow-up imaging and was treated with ultrasound-guided thrombin injection with complete resolution. CONCLUSION: The use of the 8-F Angio-Seal VCD to close large-caliber arteriotomies ranging from 9-F to 12-F is feasible and safe, with a low complication rate.

Results of staged carotid endarterectomy and coronary artery bypass graft in patients with severe carotid and coronary disease.

BACKGROUND: To evaluate our experience with staged carotid endarterectomy (CEA) followed by coronary artery bypass grafting (CABG) within the perioperative period for patients with severe carotid and coronary artery disease. METHODS: From 1998 to August of 2010, 40 patients who were referred for isolated coronary surgery were found to have significant carotid disease. All patients underwent CEA followed by subsequent CABG within 30 days of the CEA. Severe carotid stenosis was defined as >70%. RESULTS: Average patient age was 65.5 ± 10.6 years and 32 (80%) were male. Severe carotid stenosis was unilateral in 37 of the patients, bilateral in 3, and asymptomatic in 37. Patients underwent CEA with either patch angioplasty or eversion technique. General anesthesia with selective shunting was used in all cases. There were zero deaths, zero strokes, and one myocardial infarction (MI) (2.5%) immediately after CEA. After CEA, CABG was performed within 30 days. The average interval between procedures was 6.87 days. There were two (5.0%) deaths, one from MI and the other from multisystem organ failure. There were two strokes (5.0%), with one having permanent effects. The perioperative mortality, stroke, and MI rates after both operations were 5.0%, 5.0%, and 5.0%, respectively. CONCLUSIONS: Staging of CEA followed by CABG in the immediate perioperative period may be an acceptable approach to patients with severe carotid and coronary disease. Despite the presence of known severe coronary disease, the performance of CEA under general anesthesia as the initial procedure was well tolerated. We propose that this strategy may be a possible option for patients who present with severe disease in both coronary and carotid distributions. The results of our study, though based on a limited cohort, suggest that this approach of staged CEA-CABG within the perioperative period <30 days is reasonable.

Challenging neck anatomy is associated with need for intraoperative endovascular adjuncts during endovascular aortic aneurysm repair (EVAR).

BACKGROUND: The purpose of this study was to determine which proximal seal zone characteristics were predictive of early and late type Ia endoleak development after endovascular aortic aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysmal disease. METHODS: We evaluated 146 patients who underwent EVAR between January 2006 and March 2007. In the cohort, high-resolution computed tomography images of 100 (68.5%) patients were available, which showed detailed measurement of proximal neck parameters, including diameter, length, calcification, thrombus, suprarenal and infrarenal angles, and reverse taper morphology. Postprocessing of digital data sets was performed to obtain centerline-of-flow measurements. Relevant medical records and follow-up computed tomography scans were reviewed. RESULTS: Mean age of the patients was 72.7 years, with 78% being male. Of these patients, 66% did not satisfy the instructions for use for the Zenith EVAR device, and 50% did not satisfy the instructions for use for the AneuRx device. Nine patients had intraoperative type Ia endoleaks. A 100% assisted primary technical success rate was achieved with the adjunctive use of angioplasty (n = 4), uncovered stent (n = 3), and extension cuff (n = 2) placement. There was a significant association between type Ia endoleak development and magnitude of the infrarenal angle (p < 0.01); however, other parameters were not significant. At follow-up (mean, 587 days), no patient had a type Ia endoleak, and there were no aneurysm-related deaths. CONCLUSIONS: Our data indicate that infrarenal angle is related to intraoperative type Ia endoleak occurrence, but other factors often thought to be indicative of adverse neck anatomy are not significant predictors. Moreover, all type Ia endoleaks in this cohort were successfully eliminated intraoperatively, and durability was confirmed on postoperative surveillance. These data demonstrate that challenging neck anatomy is associated with the need for intraoperative endovascular adjuncts, and that effective and durable aneurysm exclusion should still be expected.

Retrograde migration and endovascular retrieval of a venous bullet embolus.

Venous bullet embolism is a rare and complicated occurrence reported in approximately 0.3% of penetrating trauma. The management of bullet emboli is decided on a case-by-case basis, balancing the risk of the embolus itself against those associated with extraction. We report a case of a 19-year-old man who sustained a gunshot wound to the anterior chest, which migrated to the left internal iliac vein in a retrograde fashion. We were able to successfully retrieve the missile using an endovascular approach, thereby minimizing the morbidity associated with an open procedure.

The effect of immunosuppression on lower extremity arterial bypass outcomes.

BACKGROUND: Myointimal hyperplasia is a pathologic result of the body's natural inflammatory response to injury of the blood vessels and a leading cause of peripheral arterial bypass failure. Because immunosuppressive agents are known to abate inflammation, we hypothesized the superior outcome of lower extremity bypass in renal transplant recipients compared with the hemodialysis population. METHODS: The vascular surgery registry at a single tertiary care center was retrospectively reviewed to identify patients who underwent lower extremity bypass procedures. All patients with a history of renal transplantation were selected for analysis. A consecutive group of bypass patients with dialysis-dependent renal failure was selected as a control cohort. The primary endpoint was amputation-free survival. RESULTS: Vascular reconstruction for chronic peripheral vascular disease yielded an amputation-free survival rate of 82% at 1 year for the those in the control group as compared with only 22% in the those with a history of renal transplantation (p = 0.02), which corresponded exactly with primary patency at 1 year. Patients were operated on for severe claudication (n = 1), rest pain (n = 1), and tissue loss (n = 17). There was no difference between the groups with regard to indication for operation or comorbid conditions. CONCLUSIONS: These data suggest a deleterious effect of immunosuppression on outcome of lower extremity bypass procedures at the doses required to prevent allograft rejection. This finding, which has been scarcely reported, underscores the importance of peripheral vascular disease screening in the transplant population and early intervention when clinically indicated.

Upper extremity arteriovenous fistulas induce modest hemodynamic effect on the in situ internal thoracic artery.

BACKGROUND: The left internal thoracic artery is the ideal conduit for coronary artery revascularization due to superior patency compared with venous grafts. The hemodynamic effects of an arterio-venous fistula on the native in situ internal thoracic artery and the potential for coronary flow steal after revascularization with the internal thoracic artery, are not well-characterized. METHODS: Fifteen chronic hemodialysis patients with functioning left upper extremity arterio-venous fistulas were evaluated with the use of transthoracic color Doppler analysis. Flow characteristics of the left and right internal thoracic arteries at baseline, with arterio-venous fistula occluded, and during hemodialysis were recorded. Peak systolic and diastolic velocities for the right and left internal thoracic arteries were calculated for each fistula state (occluded, open, and on-dialysis). One-way analysis of variance was used to compare the different means. RESULTS: Mean flow velocity calculations failed to identify any statistically significant differences between the ipsilateral and contralateral internal thoracic artery in any fistula state. In addition, mean internal thoracic flow velocities were similar between the different fistula states. CONCLUSIONS: Changes in arteriovenous fistula flow state did not significantly alter Doppler flow hemodynamics of either the ipsilateral or contralateral in-situ internal thoracic artery. Further studies of the possible effects on internal thoracic arteries used as pedicled coronary grafts may be required.