Evaluating the impact of an interdisciplinary integrated limb preservation service operating concurrently with a single-specialty service.

BACKGROUND: This study examined the efficacy of an interdisciplinary limb preservation service (LPS) in improving surgical outcomes for diabetic foot ulcer (DFU) patients compared to traditional care. METHODS: Data from January 1, 2017 to September 30, 2020 were retrospectively reviewed. An interdisciplinary LPS clinic began on August 1, 2018, coexisting with a preexisting single specialty service. Primary outcomes were major/minor amputation rates and ratios and hospital length of stay. Surgical endpoints pre- and post-LPS launch were compared. RESULTS: Among 976 procedures for 731 unique DFU patients, most were male (80.4%) and Hispanic (89.3%). Patient demographics were consistent before and after LPS initiation. Major amputation rates decreased by 45.5% (15.4%-8.4%, p = 0.001), with outpatient procedures increasing over 5-fold (3.3% pre-LPS to 18.7% post-LPS, p < 0.001). Hospital stay reduced from 10.1 to 8.5 days post-LPS (p < 0.001). The major to minor amputation ratio declined from 22.4% to 12.7%. CONCLUSIONS: The interdisciplinary LPS improved patient outcomes, marked by fewer major amputations and reduced hospital stays, suggesting the model's potential for broader application.

Dual-Lumen Stenting of Dissected Superior Mesenteric Artery During Fenestrated Branched Endovascular Repair of a Post-dissection Thoracoabdominal Aortic Aneurysm.

PURPOSE: Long-segment aortic branch dissections have been considered a relative contraindication for fenestrated-branched endovascular aneurysm repair (FB-EVAR). This case report describes a technique of dual-lumen stenting of a fully-dissected superior mesenteric artery (SMA) to preserve patency of the true and false lumens during FB-EVAR. CASE REPORT: A 67-year-old man presented with a 6.0 cm extent III chronic post-dissection thoracoabdominal aortic aneurysm. The patient had highly-complex anatomy including dissection of the entire SMA. The true and false lumens of the dissected SMA were noted to be supplying different branches, requiring preservation of both lumens. The patient underwent a staged physician-modified FB-EVAR. A modified endograft containing 5 fenestrations and 1 branch cuff was introduced and the celiac, true-lumen SMA, and 3 renal arteries were sequentially catheterized using staggered deployment of the modified endograft. The false lumen SMA stent was catheterized via the branch cuff. Molded parallel grafting ("eye-of-the-tiger") technique was used to achieve double D configuration between the true and false lumens of the SMA. CONCLUSION: This case demonstrates feasibility of dual-lumen stenting to incorporate dissected target vessels during FB-EVAR while preserving flow to both the true and false lumens and the second-order branches they supply. CLINICAL IMPACT: We report a novel technique that allows incorporation of branch vessels affected by long segment dissection during fenestrated branched endovascular aortic repairs. This has potential advantage of preserving flow to all secondary branches of the dissected target vessels, while reducing the risk of type Ic endoleak.

Perioperative Factors Associated With Intraoperative Transfusion in Patients Undergoing Major Lower Limb Amputation.

BACKGROUND: Intraoperative transfusions in vascular patients undergoing major lower limb amputations (LLAs) are associated with worse postoperative outcomes. METHODS: We conducted a retrospective study from 2015 to 2020 to identify perioperative factors associated with the need for intraoperative transfusion for patients undergoing below knee or above knee amputations secondary to vascular disease. RESULTS: A total of 65 patients with major LLAs were identified, 39 (60%) with below knee and 26 (40%) with above knee amputations. There were 15 (23%) patients who were transfused intraoperatively and 50 (77%) who were not. Six (15%) of the below knee patients and 9 (34%) of the above knee patients required intraoperative transfusion. Of the variables studied, only preoperative hemoglobin (8.6 ± .4 vs 9.9 ± .2 g/dL, P = .01), change in hemoglobin (-.1 ± .4 vs .8 ± .2 g/dL, P = .01), estimated intraoperative blood loss (416 ± 168 vs 126 ± 14 mL, P = .04), and operative duration (116 ± 19 min. vs 89 ± 6 min, P = .046) were associated with a transfusion requirement with these patients having a longer length of stay (42 [13-76] vs 21 [12-31] days, P = .04) and a higher risk of mortality (33% vs 10%, P = .03). DISCUSSION: The study is limited by a small sample size from a single institution. However, patients who received an intraoperative transfusion had a lower starting hemoglobin, higher estimated blood loss, required longer hospital stays, and were at a higher risk for post-discharge mortality.

Use of a bovine pericardial patch angioplasty for completion of a complicated end to side anastomosis of a recipient vessel in the free flap reconstruction of a radiated wound: A case report.

Soft tissue sarcomas treated by extensive surgical resection and adjuvant radiation can lead to large tissue deficits that require free flap repair. Significant radiation can further compromise vessels necessitating novel therapeutic approaches. We describe an 82-year-old man who presented with a posterior thigh sarcoma and underwent wide local tumor resection and immediate reconstruction with a microvascular free flap. Due to radiated recipient vessels, this case required bovine patch angioplasty as a conduit for end to side anastomosis. Initial resection and pathology revealed a large myxofibrosarcoma. Wide local resection and radiotherapy resulted in a large irradiated soft tissue defect of 26 x 15 x 4 cm with exposed, radiation damaged neurovascular structures, and a lack of available regional flap options. The planned free flap, a 30 x 8 cm skin island from the left latissimus dorsi muscle with end-to-side anastomosis to the popliteal artery was complicated by friability of the vessel wall and insufficient perfusion. Given the extent of resection and radiation, there were no alternative recipient vessels present within the field. A bovine pericardial patch angioplasty of 2.5 cm in length was performed to the diseased popliteal vessel and an end to side anastomosis was successfully performed between the thoracodorsal artery and the patch. Improved reperfusion of the free flap was noted immediately following anastomosis indicating completion of the anastomosis of our complicated recipient vessel. During the uncomplicated postoperative course, the flap had good perfusion with Doppler signals present, and incision sites intact at discharge from acute hospitalization. Recurrent sarcomas that have undergone extensive resection and radiotherapy pose significant reconstructive challenges. For defects that require free tissue reconstruction when there are limited options for healthy, recipient vessels, bovine pericardial patch angioplasty may act as a robust conduit for diseased vessels.

Evolution of WIfI: Expansion of WIfI Notation After Intervention.

Nearly a decade ago, the Society for Vascular Surgery (SVS)'s wound, ischemia, and foot Infection (WIfI) classification was first developed to help assess overall limb threat. However, managing conditions such as diabetic foot ulcer and chronic limb-threatening ischemia can be complex. For instance, certain investigative findings might initially be pending such as the level of ischemia or extent of infection before the final classification is established. In addition, wounds evolve rapidly, and the current classification does not allow for tracking their progression over time during treatment. Therefore, we propose a supplemental consistent notation for scoring WifI re-assessment during treatment of a threatened limb inspired by the cancer staging before and after neoadjuvant treatment classification system. Thus, we describe the re-scoring system and how to use it. Our suggestion supports a coherent method to longitudinally communicate characteristics of a threatened limb. This has potential to support high quality interdisciplinary, patient-centered care and enhance the use of this classification in research. Further work is required to validate this modification of a common language of risk.

Physician-modified fenestrated endograft for postdissection thoracoabdominal aortic aneurysm following provisional extension to induce complete attachment and renal artery stenting.

We have described a patient with a history of type A-11 dissection repair, who subsequently underwent thoracic endovascular aortic repair with distal bare metal dissection stents (provisional extension to induce complete attachment) and renal artery stenting for malperfusion. During the next 3 years, the thoracoabdominal aorta had continued to enlarge to 6.9 cm, despite false lumen embolization and thoracic endovascular aortic repair extension. Given the continued aortic enlargement, physician-modified fenestrated endovascular aortic repair was performed within the prior aortic and renal stents with successful aneurysm sealing. The results from the present case have illustrated that continued aneurysmal degeneration can occur after provisional extension to induce complete attachment and that subsequent physician-modified fenestrated endovascular aortic repair is feasible.

Transposition of anomalous left vertebral to carotid artery during the management of thoracic aortic dissections and aneurysms.

OBJECTIVES: Preservation of antegrade flow to the left vertebral artery (LVA) is often achieved by transposition or bypass to the left subclavian artery during zone 2 thoracic endovascular aortic repair. An anomalous LVA (aLVA) originating directly from the aortic arch is a common arch variant with a reported incidence of 4% to 6%. In addition, 6% to 10% of vertebral arteries terminate in a posterior inferior cerebellar artery, increasing the risk of stroke if not revascularized. Few series of aLVA to carotid transposition have been reported. The aim of this study was to evaluate the outcomes of patients who underwent aLVA to carotid transposition for the management of aortic disease. METHODS: A retrospective review of all aLVA-carotid transpositions performed for the management of thoracic aortic dissection or aneurysm at a single center from 2018 to 2021 was performed. The primary outcomes were postoperative stroke and patency of the transposed aLVA. Secondary outcomes were spinal cord ischemia, postoperative cranial nerve injury, and Horner's syndrome. RESULTS: Seventeen patients underwent aLVA to carotid transposition as an adjunct to management of aortic disease during the study period. Most were men (n = 14) and the mean age was 54 ± 16 years. The primary indication for aortic repair was dissection in 10, aneurysm in 6, and Kommerell diverticulum in 1. Nine patients underwent zone 2 thoracic endovascular aortic repair, seven received open total arch repair, and there was one attempted total endovascular arch repair that was aborted owing to unfavorable anatomy. Twelve transpositions were performed before or concomitant with planned aortic repair owing to high-risk cerebrovascular anatomy (three posterior inferior cerebellar artery termination, six dominant aLVA, four intracranial LVA stenosis), and two were performed postoperatively for treatment of type II endoleak. LVA diameter ranged from 2 to 6 mm (mean, 3.3 mm). The mean operative time for transposition was 178 ± 38 minutes, inclusive of left subclavian artery revascularization, and the mean estimated blood loss was 169 ± 188 mL. No patients experienced 30-day postoperative spinal cord ischemia, stroke, or mortality. There were two cases of postoperative hoarseness, presumably owing to recurrent laryngeal nerve palsy, both of which resolved within 4 months. There were no cases of Horner's syndrome. At follow-up (mean, 306 days; range, 6-714 days), all transpositions were patent. CONCLUSIONS: Vertebral-carotid transposition is a safe and effective adjunct in the management of aortic disease with anomalous origin of the LVA.

Physician-Modified Fenestrated Endovascular Repair for Iatrogenic Innominate Vein Injury.

Iatrogenic innominate vein injuries are rare complications associated with internal jugular venous catheters. These complications are accompanied by high morbidity and mortality rates in patients with severe underlying medical conditions. Without proper treatment, emergency surgery may be needed due to acute cardiac tamponade or hemothorax. Endovascular repair can be advantageous for patients with significant medical comorbidities. Herein, we report the case of a 62-year-old female with an iatrogenic injury to the innominate vein at the subclavian vein and internal jugular confluence due to a malpositioned left internal jugular catheter. A customized fenestrated endograft was positioned with fenestration oriented to the internal jugular vein and a new tunneled catheter was inserted across the fenestration into the superior vena cava upon removal of the malpositioned catheter. In addition, a brachio-basilic arteriovenous fistula was created. At one month follow-up, the patient had a palpable thrill over the arteriovenous fistula and a functioning tunneled catheter.

Comparative early results of in situ fenestrated endovascular aortic repair and other emergent complex endovascular aortic repair techniques for ruptured suprarenal and thoracoabdominal aortic aneurysms at a regional aortic center.

INTRODUCTION: Emergent endovascular repair of suprarenal (SRAAAs) and thoracoabdominal aortic aneurysms (TAAAs) poses a significant challenge due to the need for branch vessel incorporation, time constraints, and lack of dedicated devices. Techniques to incorporate branch vessels have included parallel grafting, physician-modified endografts, double-barrel/reversed iliac branch device, and in situ fenestration (ISF). This study describes a single-center experience and the associated outcomes when using these techniques for ruptured SRAAAs and TAAAs. METHODS: A retrospective review of patients who underwent endovascular repair of ruptured SRAAAs and TAAAs from July 2014 to March 2021 with branch vessel incorporation was performed. Clinical presentation, intraoperative details, and postoperative outcomes of those who underwent ISF were compared with those who underwent repair using non-ISF techniques. The primary outcome of interest was in-hospital mortality. Secondary outcomes were major adverse events including myocardial infarction, respiratory failure, renal dysfunction, new onset dialysis, bowel ischemia, stroke, and spinal cord ischemia. RESULTS: Forty-two patients underwent endovascular repair for ruptured SRAAAs and TAAAs, 18 of whom underwent ISF repair. Seventy-two percent of ISF patients were hypotensive before surgery, compared with 46% of the patients who underwent repair using non-ISF techniques (physician-modified endografts, parallel grafting, or double-barrel/reversed iliac branch device). The total procedural and fluoroscopy times were similar between the two groups despite a greater mean number of branch vessels incorporated with the ISF technique (3.1 vs 2.2 per patient, P = .015). In-hospital mortality was 19% for all ruptures and 25% for ruptures with hypotension. Compared with the non-ISF group, in-hospital mortality trended lower in the ISF group (11% vs 25%, P = .233), reaching statistical significance when comparing patients who presented with hypotension (8% vs 45%, P = .048). The rate of major adverse events was 57% across all techniques and did not significantly differ between the ISF and non-ISF groups, with postoperative renal dysfunction being the most frequent complication (48%). Overall, ISF became the most commonly used technique later in the study period. CONCLUSIONS: Although emergent endovascular repair of ruptured SRAAAs/TAAAs remains a challenge, a number of techniques are available for expeditious treatment. In this series, ISF was associated improve survival, including a fivefold reduction in mortality in patients presenting with hypotension, and has now become the dominant technique at our center. Despite these advantages, postoperative complications and reinterventions are common. Further experience and longer-term follow-up are needed to validate these initial results and assess durability.

Impact of Perioperative Blood Transfusion in Anemic Patients Undergoing Infra Inguinal Bypass.

OBJECTIVE: Patients who present with lower extremity ischemia are frequently anemic and the optimal transfusion threshold for this cohort remains controversial. We sought to evaluate the impact of blood transfusion on postoperative major adverse cardiac events (MACE), including myocardial infarction, dysrhythmia, stroke, congestive heart failure, and 30-day mortality for these patients. METHODS: All consecutive patients who underwent infra-inguinal bypass at our institution from 2011 to 2020 were included. Perioperative red blood cell transfusion was the primary exposure, and the primary outcome was MACE. Univariate and multivariable analyses were performed to assess the impact of patient and procedural variables, including red blood cell transfusion, stratified by hemoglobin (Hgb) nadir: <7, 7-8, and >8 g/dL. RESULTS: Of the 287 patients reviewed for analysis, 146 (50.9%) had a perioperative transfusion (mean: 1.6 ± 3 units). Patients who received a transfusion had a mean nadir Hgb of 8.3 ± 1.0 g/dL, compared to 10.1 ± 1.7 g/dL without a transfusion. The overall incidence of MACE was 15.7% (45 of 287 patients). Univariate analysis demonstrated that MACE was associated with blood transfusion (P = 0.009), lower Hgb nadir (P = 0.02), and higher blood loss (P = 0.003). On multivariate analysis, transfusion was independently associated with MACE for patients with a Hgb nadir >8 g/dL (OR: 3.09; P = 0.006), but not for patients with Hgb nadir 7-8 g/dL (OR: 0.818; P = 0.77). Additionally, patients with MACE had significantly longer length of hospital stay than for patients without (13 vs. 7.7 days, P = 0.001). CONCLUSIONS: For patients undergoing infra-inguinal bypass, receiving a red blood cell transfusion with a Hgb nadir >8 g/dL was associated with a 3-fold increase in MACE, with nearly twice the length of stay. For patients with a Hgb 7-8 g/dL, transfusion did not increase or reduce the incidence of MACE. These findings suggest no benefit of blood transfusion for patients with Hgb nadir >7 g/dL and harm for Hgb >8 g/dL, however causation cannot be proven due to the retrospective nature of the study and randomized studies are needed to confirm or refute these findings.

Early Results and Technical Tips of Combining Iliac Branch Endoprostheses with Fenestrated Aortic Stent Grafts during Endovascular Repair of Complex Abdominal and Thoracoabdominal Aortic Aneurysms.

BACKGROUND: Concomitant iliac artery aneurysms can pose challenges during repair of complex abdominal and thoracoabdominal aortic aneurysms. In fenestrated aortic aneurysm repairs (FEVAR), preservation of internal iliac perfusion is important to minimize risk of spinal cord ischemia. Currently, most commonly used fenestrated stent grafts and the only approved iliac branch devices are manufactured by different companies in the United States. We report our experience with combining Iliac Branch Endoprosthesis (IBE) (W.L. Gore and Associates, Flagstaff, AZ) and fenestrated stent grafts, using the Zenith platform (Cook Medical, Bloomington, IN). METHODS: Retrospective review of consecutive patients who underwent FEVAR at a single institution from September, 2015 to June, 2020 was performed. Patients were deemed high-risk for open repair. Fenestrated aortic components implanted were either physician-modified or custom manufactured. Cases in which IBEs were deployed during FEVAR were specifically reviewed. Anatomic details were obtained from preoperative CT scans. Postoperative outcomes such as mortality, technical success, major adverse events, limb patency, limb-related endoleaks and re-intervention rates were assessed. RESULTS: During the study period, 171 patients underwent FEVAR at our institution. Among those, 15 patients had unilateral IBE implantation during FEVAR, while one received bilateral IBE implantation. Fourteen cases involved physician-modified fenestrated endograft, and Zenith Fenestrated (Cook Medical, Bloomington, IN) in combination with Excluder bifurcated main body and IBE (W.L. Gore and Associates, Flagstaff, AZ). Mean operative, and fluoroscopy times were 340.2 minutes, and 65.4 minutes respectively. A total of 67 viscerorenal target vessels (mean = 3.9, range =_3-5) and 15 internal iliac arteries were incorporated, with a mean of 160 cc contrast used. Completion angiograms were free of type 1 and type 3 endoleaks. Technical success was 100%. There was no perioperative mortality. One patient developed spinal cord ischemia post-operative day two with neurological recovery. At mean follow-up of 430 days, overall survival was 100% with no aneurysm-related mortalities. Limb patency remained 100%. There were no type 3 endoleaks while one patient had a type 1B endoleak that is currently being monitored. There was one re-intervention for type 1C renal branch graft endoleak. CONCLUSION: Combining IBE with FEVAR allows internal iliac preservation during endovascular repair of complex abdominal aortic aneurysms, with encouraging early results.

Caudally directed in situ fenestrated endografting for emergent thoracoabdominal aortic aneurysm repair.

We previously described a transfemoral antegrade in situ laser fenestration technique (in situ fenestrated endovascular abdominal aortic aneurysm repair) for ruptured thoracoabdominal aortic aneurysms. In the present report, we have described an alternative technique of caudally directed in situ fenestrated endografts using upper extremity access for branch vessel incorporation. This technique involves partial deployment of the aortic stent graft in the thoracic aorta to achieve proximal control, followed by sequential branch incorporation using a laser probe through a steerable sheath, from the upper extremity access. The advantages of the technique include rapid proximal aortic control before branch incorporation without target vessel prestenting and separation of in situ fenestration from the target branch vessel origin, facilitating cannulation of angulated branch vessels.

Professionalism in (vascular) surgery: What does it mean?

A publication in the August 2020 issue of the Journal of Vascular Surgery, "Prevalence of unprofessional social media content among young vascular surgeons," brought the concept of professionalism in the vascular surgery community to the forefront. In response to the methodology used in the article, and the definitions of professionalism, a global backlash from health care providers and lay people ensued. The article has since been retracted; however, its publication highlighted the need to reexamine current definitions and philosophies surrounding professionalism in medicine and surgery that may be discriminatory and exclusive. The term professionalism has no standard definition as evidenced by varying definitions among different societies and organizations. The lack of a structured, universally accepted definition of professionalism in the medical and surgical communities has resulted in no standard by which to measure the actions of physicians and surgeons. The definition of professionalism need not be complex and should not vary among specialties and societies. In its most simplistic form, the core definition of "professionalism" embedded in the volumes of publications, guidelines, and charters that exist on the subject of professionalism in medicine is respect. We propose a tiered approach to define professionalism in medicine that builds on fundamental principles of respect and inclusivity, and includes actionable steps at three levels: (1) individual, (2) organizational, and (3) societal. Through this approach, any physician, regardless of specialty, practice type or location, can apply these concepts to ensure they consistently embody what it means to be "professional."

Use of Inner Branches During Physician-Modified Endografting for Complex Abdominal and Thoracoabdominal Aortic Aneurysms.

OBJECTIVES: Endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms have been performed widely in an increasing number of centers, utilizing custom-manufactured or physician-modified stent grafts containing fenestrations and side-arm branches for visceral and renal artery incorporation. Alternatively, inner branch configurations may be useful in complex anatomy, where application of fenestrations or side-arm branches can be challenging. Our study aims to evaluate the incidence of target vessel instability when incorporated with inner branch configurations, and report clinical outcomes of patients who underwent fenestrated/branched endovascular aortic repairs (F-BEVAR) containing one or more inner branches. METHODS: We reviewed patients who underwent F-BEVAR with at least one inner branch configuration for complex abdominal or thoracoabdominal aortic aneurysms at Keck Hospital of University of Southern California from 2014 to 2020. Endpoints were mortality, major adverse events (MAE), technical success, and target vessel instability. Target vessel instability was assessed using follow-up computed tomography (CT) and duplex imaging. RESULTS: Out of the 175 patients who underwent F-BEVAR for complex abdominal and TAAA during the study period, 17 patients had at least one inner branch configuration. All were deemed high-risk for open repair with multiple cardiovascular and/or pulmonary comorbidities. Eight (47%) patients had extent I, II, III thoracoabdominal aortic aneurysms, and 10 (59%) had prior aortic repairs. A total of 68 target vessels were incorporated (mean = 4 vessels/patient, range=1~6), of which 40% were inner branch configurations, most commonly for renal arteries. Technical success was 94.1%. There was one perioperative mortality due to massive myocardial infarction, as well as one patient who needed temporary hemodialysis. No device-related mortalities were observed. At 30 days, primary inner branch patency was 100% with no target vessel instability or reintervention. At mean follow-up of 5.8 months, the overall survival was 94% with one patient who expired from unknown cause. Overall primary inner branch patency was 96.3%, due to occlusion of a long lumbar artery branch with no clinical sequelae. CONCLUSION: Inner branch configurations can provide a safe alternative technique of branch incorporation during complex endovascular aortic repair.

Effect of infrainguinal bypass tunneling technique on patency and amputation in patients with limb ischemia.

OBJECTIVE: We investigated the association of tunneling technique on patency and amputation in patients undergoing lower extremity bypass for limb ischemia. METHODS: The National Vascular Quality Initiative database infrainguinal bypass module from 2008 to 2017 was queried for analysis. We excluded cases with non-great saphenous vein grafts, grafts using multiple segments, aneurysmal disease indications, bypass locations outside the femoral to below the knee popliteal artery or tibial arteries, and missing data on tunneling type and limb ischemia. The main exposure variable was the tunneling type, subcutaneously vs subfascially. Our primary outcomes were primary patency and amputation. The secondary outcomes included primary-assisted patency and secondary patency. Univariate and multivariate logistic regression models were used. RESULTS: A total of 5497 bypass patients (2835 subcutaneous and 2662 subfascial) were included. Age, race, graft orientation (reversed vs not reversed), bypass donor and recipient vessels, harvest type, end-stage renal disease, smoking, coronary artery bypass graft, congestive heart failure, P2Y12 inhibitor at discharge, surgical site infection at discharge, and indication (rest pain vs tissue loss vs acute ischemia) were analyzed for an association with the tunneling technique (P < .05). Multivariate analyses demonstrated that the tunneling type was not associated with primary patency, primary-assisted patency, secondary patency, or major amputation (P > .05). CONCLUSIONS: Compared with subfascial tunneling, the superficial tunneling technique was not associated with primary patency or major amputation in limb ischemia patients undergoing infrainguinal bypass with a single-segment great saphenous vein.

Complications associated with lumbar drain placement for endovascular aortic repair.

OBJECTIVE: We reviewed the complications associated with perioperative lumbar drain (LD) placement for endovascular aortic repair. METHODS: Patients who had undergone perioperative LD placement for endovascular repair of thoracic and thoracoabdominal aortic pathologies from 2010 to 2019 were reviewed. The primary endpoints were major and minor LD-associated complications. Complications that had resulted in neurological sequelae or had required an intervention or a delay in operation were defined as major. These included intracranial hemorrhage, symptomatic spinal hematoma, cerebrospinal fluid (CSF) leak requiring intervention, meningitis, retained catheter tip, arachnoiditis, and traumatic (or bloody) tap resulting in delayed operation. Minor complications were defined as a bloody tap without a delay in surgery, asymptomatic epidural hematoma, and CSF leak with no intervention required. Isolated headaches were recorded separately owing to the minimal clinical impact. RESULTS: A total of 309 LDs had been placed in 268 consecutive patients for 222 thoracic endovascular aortic repairs, 85 complex endovascular aortic repairs (EVARs; fenestrated branched EVAR/parallel grafting), and 2 EVARs (age, 65 ± 13 years; 71% male) for aortic pathology, including aneurysm (47%), dissection (49%), penetrating aortic ulcer (3%), and traumatic injury (0.6%). A dedicated neurosurgical team performed all LD procedures; most were performed by the same individual, with a technical success rate of 98%. Radiologic guidance was required in 3%. The reasons for unsuccessful placement were body habitus (n = 2) and severe spinal disease (n = 3). Most were placed prophylactically (96%). The overall complication rate was 8.1% (4.2% major and 3.9% minor). Major complications included spinal hematoma with paraplegia in 1 patient, intracranial hemorrhage in 2, meningitis in 2, arachnoiditis in 3, CSF leak requiring a blood patch in 3, bloody tap delaying the operation in 1, and a retained catheter tip in 1 patient. Patients who had undergone previous LD placement had experienced significantly more major LD-related complications (12.2% vs 3%; P = .019). The rate of total LD-associated complications did not differ between prophylactic and emergent therapeutic placements (8.1% vs 7.7%; P = 1.00) nor between major or minor complications. On multivariate analysis, previous LD placement and an overweight body mass index were the only independent predictors of major LD-related complications. CONCLUSIONS: The complications associated with LD placement can be severe even when performed by a dedicated team. Previous LD placement and overweight body mass index were associated with a significantly greater risk of complications; however, emergent therapeutic placement was not. Although these risks are justified for therapeutic LD placement, the benefit of prophylactic LD placement to prevent paraplegia should be weighed against these serious complications.

Periscope sandwich stenting as an alternative to open cervical revascularization of left subclavian artery during zone 2 thoracic endovascular aortic repair.

OBJECTIVE: Revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) maintains collateral circulation to decrease ischemic complications, including stroke, spinal cord ischemia, and upper extremity ischemia. Both open surgical and endovascular LSA revascularization techniques have been described, each with unique risks and benefits. We describe our "periscope sandwich" technique for the LSA during zone 2 TEVAR, which maintains antegrade access to the distal abdominal aorta if subsequent interventions are necessary. Technical results and short-term outcomes are compared with LSA open surgical debranching. METHODS: A single-institution retrospective review was performed for patients requiring zone 2 TEVAR with LSA revascularization by periscope sandwich technique or open surgical debranching with subclavian to carotid transposition (SCT) or carotid-subclavian bypass (CSB). The presenting aortic disease and perioperative details were recorded. Intraoperative angiography and postoperative computed tomography images were reviewed for occurrence of endoleak and branch patency. RESULTS: Between January 2013 and December 2018, the LSA was revascularized by periscope sandwich in 18 patients, SCT in 22 patients, and CSB in 13 patients. Compared with open surgical debranching, periscope sandwich had a lower median estimated blood loss (100 mL vs 200 mL for pooled SCT and CSB; P = .03) and lower median case duration (133.5 minutes vs 226 minutes; P < .001). Contrast material volume (120 mL vs 120 mL; P = .98) and fluoroscopy time (13.1 minutes vs 13.3 minutes; P = .92) did not differ significantly between the groups. There was no difference in aorta-related mortality (P = .14), and LSA patency was 100%. Median follow-up for the periscope sandwich group was 11 months, with an overall estimated 91% freedom from gutter leak at 6 months. CONCLUSIONS: LSA periscope sandwich technique provides safe and effective LSA revascularization during zone 2 TEVAR. LSA periscope sandwich can be used emergently with off-the-shelf endovascular components and facilitates future branched-fenestrated endovascular repair of thoracoabdominal aortic diseases.

Physician-modified fenestrated endovascular repair of type 1A endoleaks from polymer-based low-profile endografts.

PURPOSE: There have been increasing number of endovascular aortic aneurysm repair performed in hostile necks using newer generation technology including polymer-based proximal sealing devices such as the Ovation system. Unique design features of the device can pose challenges during endovascular salvage of type 1A endoleak. We describe two cases of successful application of physician-modified fenestrated endografting, in order to repair type 1A endoleaks following endovascular aortic aneurysm repair with ovation system. TECHNIQUE: In both cases, multi-fenestrated endografts were custom-modified using preloaded wire technique on Cook Zenith Alpha thoracic stent grafts at the back table. Under general anesthesia, left brachial cut down and a single percutaneous femoral access were performed. Staggered deployment of fenestrated endograft, accompanied by sequential catheterization of target vessels, facilitated correct alignment of fenestrated endograft. Infolding of fenestrated endograft inside the Ovation main body resulted in leg claudication, and repaired with balloon expandable covered tent. Prophylactic deployment of balloon expandable covered stent was performed in the second case. Both cases showed resolution of type 1A endoleak. CONCLUSION: Fenestrated endovascular repair is feasible for proximal failure of Ovation endografts. Careful planning and advanced skill set in complex endovascular aortic repair are required, as well as detailed knowledge of the failed endografts.

The periumbilical incision for anterior lumbar interbody fusions.

The traditional retroperitoneal approach for the anterior lumbar interbody fusion (ALIF) uses a longitudinal paramedian incision. In this study, we use a discrete periumbilical incision. A 270-degree semicircular incision is made around the umbilicus and the subcutaneous tissue is dissected radially at a 45-degree angle, creating a mound around the umbilical stalk. Once the anterior sheath is encountered, the steps of the operation converge with those of the traditional approach. In this study, 30 patients underwent a periumbilical ALIF with an average of 2.1 levels fused. Perioperative outcomes were comparable to those described in the ALIF literature. No patients experienced complications attributable to the periumbilical incision.