Initial Outcomes of the Gore TAG Thoracic Branch Endoprosthesis for Endovascular Repair of Blunt Thoracic Aortic Injury.

BACKGROUND: Endovascular repair of blunt thoracic aortic injury (BTAI) has dramatically reduced the morbidity and mortality of intervention. Injuries requiring zone 2 coverage of the aorta traditionally require left subclavian artery (LSA) sacrifice or open revascularization. Furthermore, these injuries are associated with an increased risk of in-hospital mortality and long-term morbidity. Here we report 1-year outcomes of total endovascular repair of BTAI with the GORE® TAG® Thoracic Branch Endoprosthesis for LSA preservation. METHODS: Across 34 investigative sites, 9 patients with BTAI requiring LSA coverage were enrolled in a nonrandomized, prospective study of a single-branched aortic endograft. The thoracic branch endoprosthesis device allows for graft placement proximal to the LSA and incorporates a single side branch for LSA perfusion. RESULTS: This initial cohort included 8 male and 1 female patient with a median age of 43 (22, 76) and 12 months of follow-up. Five total years of follow-up are planned. All participants had grade 3 BTAI. All procedures took place between 2018 and 2019. The median injury severity score was 2 (0, 66). The median procedure time was 109 min (78, 162). All aortic injuries were repaired under general anesthesia and with heparinization. A spinal drain was used in one patient. Post-deployment balloon angioplasty was conducted in one case at the distal landing zone. There was one asymptomatic LSA branch occlusion 6 months after repair. It was attributed to the purposeful proximal deployment of the branch stent to accommodate an early vertebral takeoff. The occlusion did not require revascularization. There were no strokes, mortalities, or aortic adverse events (migration, endoleak, native aortic expansion, dissection, or thrombosis) through 12 months of follow-up. CONCLUSIONS: Initial cohort outcomes suggest that endovascular repair of zone 2 BTAI is feasible and has favorable outcomes using the thoracic branch device with LSA preservation. Additional cases and longer-term follow-up are required for a definitive assessment of the device's safety and durability in traumatic aortic injuries.

Contemporary management and outcomes of peripheral venous aneurysms: A multi-institutional study.

OBJECTIVE: Extremity venous aneurysms result in the risk of pulmonary embolism (PE) and chronic venous insufficiency. At present, owing to the rarity of these aneurysms, no consensus for their treatment has been established. The purpose of the present study was to review the presentation, natural history, and contemporary management of extremity venous aneurysms. METHODS: We performed a retrospective, multi-institutional review of all patients with extremity venous aneurysms treated from 2008 to 2018. A venous aneurysm was defined as saccular or fusiform with an aneurysm/vein ratio of >1.5. RESULTS: A total of 66 extremity aneurysms from 11 institutions were analyzed, 40 of which were in a popliteal location, 14 iliofemoral, and 12 in an upper extremity or a jugular location. The median follow-up was 27 months (range, 0-120 months). Of the 40 popliteal venous aneurysms, 8 (20%) had presented with deep vein thrombosis (DVT) or PE, 13 (33%) had presented with pain, and 19 had been discovered incidentally. The mean size of the popliteal venous aneurysms presenting with DVT or PE was larger than that of those presenting without thromboembolism (3.8 cm vs 2.5 cm; P = .003). Saccular aneurysm morphology in the lower extremity was associated with thromboembolism (30% vs 9%; P = .046) and fusiform aneurysm morphology with a thrombus burden >25% (45% vs 3%). Patients presenting with thromboembolism were more likely to have had a thrombus burden >25% in their lower extremity venous aneurysm compared with those who had presented without thromboembolism (70% vs 9%). Approximately half of all the patients underwent immediate intervention, and half were managed with observation or antithrombotic regimen. In the non-operative cohort, three patients subsequently developed a DVT. Eight patients in the medically managed cohort went on to require surgical intervention. Of the 12 upper extremity venous aneurysms, none had presented with DVT or PE, and only 2 (17%) had presented with pain. Of the 66 patients in the entire cohort, 41 underwent surgical intervention. The most common indication was the absolute aneurysm size. Nine patients had undergone surgery because of a DVT or PE, and 11 for pain or extremity swelling. The most common surgery was aneurysmorrhaphy in 21 patients (53%), followed by excision and ligation in 14 patients (35%). Five patients (12%) had undergone interposition bypass grafting. A postoperative hematoma requiring reintervention was the most common complication, occurring in three popliteal vein repairs and one iliofemoral vein repair. None of the patients, treated either surgically or medically, had reported post-thrombotic complications during the follow-up period. CONCLUSIONS: Large lower extremity venous aneurysms and saccular aneurysms with thrombus >25% of the lumen are more likely to present with thromboembolic complications. Surgical intervention for lower extremity venous aneurysms is indicated to reduce the risk of venous thromboembolism (VTE) and the need for continued anticoagulation. Popliteal aneurysms >2.5 cm and all iliofemoral aneurysms should be considered for repair. Upper extremity aneurysms do not have a significant risk of VTE and warrant treatment primarily for symptoms other than VTE.

Five-year outcomes of endovascular repair of complicated acute type B aortic dissections.

OBJECTIVE: Thoracic endovascular aortic repair is the standard of care for acute complicated type B aortic dissections, but long-term single-device outcomes are limited. METHODS: Fifty patients were treated with the Valiant Captivia thoracic stent graft (Medtronic Inc, Santa Rosa, Calif) for acute complicated type B aortic dissections in this prospective, nonrandomized Dissection Trial. All-cause mortality, secondary procedures, and serious adverse events were assessed, and a core lab evaluated images for aortic remodeling. RESULTS: Compliance for both clinical and imaging follow-up was 78% (18 out of 23) for the available patients at 5 years. Notable baseline characteristics were 86% of patients (43 out of 50) had malperfusion, 20% (10 out of 50) had ruptures, and 94% (46 out of 49) had DeBakey class IIIB dissections. The 5-year freedom from dissection-related mortality, secondary procedures related to the dissection, and endoleaks was 83%, 86%, and 85%, respectively. After 5 years, 89% of patients (16 out of 18) had a completely thrombosed false lumen in the stented segment of the aorta and the true lumen diameter over the length of stent graft was stable or increased for 94% of patients (16 out of 17) while the false lumen diameter was stable or decreased in 77% (13 out of 17) after 5 years. CONCLUSIONS: In the Dissection Trial, patients experienced positive and sustained measures of aortic remodeling. Survival outcomes, need for secondary procedures, and adverse event rates were consistent with previous thoracic endovascular aortic repair studies. Although limitations exist with the follow-up compliance, the Valiant Captivia thoracic stent graft system was effective in the long-term management of acute complicated type B aortic dissections in this patient population with a challenging condition.

Aortic endograft sizing and endoleak, reintervention, and mortality following endovascular aneurysm repair.

OBJECTIVE: Endograft sizing for endovascular abdominal aortic aneurysm repair (EVAR) is not consistent despite published instructions for use (IFU). We sought to identify factors associated with over/undersizing, determine sex influence on sizing, and examine sizing effects on endoleak, reintervention, and mortality by analyzing data obtained from the W.L. Gore & Associates Global Registry for Endovascular Aortic Treatment (GREAT). METHODS: All patients enrolled in GREAT undergoing EVAR were included for analysis. Proximal/distal aortic landing zones were compared with device implanted to assess sizing as related to IFU. χ2/Fisher exact tests were used to evaluate associations between IFU sizing and demographics. Logistic regression modeling was used to identify predictors of outside IFU sizing. Cox proportional hazards regression analyzed the relationship between sizing and endoleak, device-related reinterventions, and all-cause/aortic mortality. RESULTS: There were 3607 EVAR subjects enrolled in GREAT as of March 2020. Of them, 1896 (53%) were within IFU for sizing, 791 (22%) were oversized, 540 (15%) were undersized, and 380 (10%) had both over- and undersized components. Factors predictive of use outside of IFU included female sex (P = .001), non-white race (P = .0003), decreased proximal neck length (P < .061), or larger iliac diameters (P < .0001). Women were more likely than men to have proximal neck undersizing and iliac limb oversizing, and men were more likely to have iliac limb undersizing. On multivariate analysis, undersizing of the proximal graft was associated with endoleak (hazard ratio [HR], 1.8) and aortic (HR, 60.5) and all-cause (HR, 18.0) mortality. Undersizing of iliac limbs was associated with endoleak (HR, 1.5) and device-related reintervention (HR, 1.4). Iliac limb outside IFU sizing was associated with aortic (HR, 2.6) and all-cause (HR, 1.3) mortality. Proximal and distal oversizing was not associated with adverse outcomes. Female sex was associated with mortality on univariate but not multivariate analysis. CONCLUSIONS: Women undergoing EVAR with GORE EXCLUDER abdominal aortic aneurysm Endoprosthesis (W.L. Gore & Associates Inc, Flagstaff, Ariz) are more likely to have proximal stent-graft undersizing and iliac limb oversizing, whereas men are more likely to have undersized iliac limbs. Proximal aortic graft undersizing is associated with endoleak and all-cause/aortic mortality, whereas undersizing of iliac limbs is associated with endoleak and device-related reintervention. Oversizing was not associated with adverse outcomes.

In-hospital outcomes and long-term survival of women of childbearing age with aortic dissection.

OBJECTIVE: In the present study, we defined the outcomes and effects of pregnancy in a cohort of women of childbearing age with acute aortic dissection (AAD). METHODS: We reviewed our database of AAD to identify all eligible female patients. Women aged <45 years were included. Data on pregnancy timing with respect to the occurrence of dissection, the demographic data, dissection extent, dissection treatment, dissection-related outcomes, overall maternal and fetal mortality, and genetic testing results were analyzed. RESULTS: A total of 62 women aged <45 years had presented to us with AAD from 1999 to 2017. Of the 62 women, 37 (60%) had had a history of pregnancy at AAD. Of these 37 patients, 10 (27%) had had a peripartum aortic dissection, defined as dissection during pregnancy or within 12 months postpartum. Of the 10 AADs, 5 were type A and 5 were type B. Three patients had presented with AAD during pregnancy (one in the second and two in the third trimester). Five patients (50%) had developed AAD in the immediate postpartum period (within 3 months) and two (20%) in the late postpartum period. For the immediate postpartum AADs (<3 months), four of the five patients delivered via cesarean section. Of these 10 peripartum AADs, 3 (30%) had occurred in patients with known Marfan syndrome. In-hospital mortality for those with peripartum AAD was 10% (1 of 10). Fetal mortality was 20% (2 of 10). CONCLUSIONS: The frequency of aortic dissection in women of childbearing age at our institution was low. However, pregnancy might increase the risk of those young women genetically predisposed to dissection events. From these data, this risk appears to be greatest in the immediate postpartum period, even for those who undergo cesarean section. Close clinical and radiographic surveillance is required for all women with suspected aortopathy, especially in the third trimester and early postpartum period.

Effectiveness of Standard Local Anesthetic Bupivacaine and Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Truncal Incisions: A Randomized Clinical Trial.

Importance: Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hours with standard bupivacaine. However, its effectiveness is unknown in truncal incisions for cardiothoracic or vascular operations. Objective: To compare the effectiveness of single-administration standard bupivacaine vs liposomal bupivacaine in patients undergoing truncal incisions. Design, Setting, and Participants: This randomized clinical trial enrolled patients undergoing sternotomy, thoracotomy, minithoracotomy, and laparotomy from a single cardiovascular surgery department in an academic medical center between November 2012 and June 2018. The study was powered to detect a Cohen effect size of 0.35 with a power of greater than 80%. Data analysis was performed from July to December 2018. Intervention: Patients were randomized to standard bupivacaine or liposomal bupivacaine. Main Outcomes and Measures: Pain was assessed over 3 postoperative days by the Numeric Rating Scale (NRS). Adjunctive opioids were converted to morphine equivalents units (MEU). NRS scores were compared using Wilcoxon rank-sum (3-day area under the curve) and 2-way nonparametric mixed models (daily scale score) to assess time-by-group interaction. Secondary outcomes included cumulative opioid consumption. Results: A total of 280 patients were analyzed, with 140 in each group (single-administration standard bupivacaine vs liposomal bupivacaine). Mean (SD) age was 60.2 (14.4) years, and 101 of 280 patients (36%) were women. Irrespective of treatment assignment, pain decreased by a mean of approximately 1 point per day over 3 days (ß = -0.87; SE = 0.11; mixed model regression P < .001). Incision type was associated with pain with patients undergoing thoracotomy (including minithoracotomy) reporting highest median (interquartile range [IQR]) pain scores on postoperative days 1 (liposomal vs standard bupivacaine, 6 [4-8] vs 5 [3-7]; P = .049, Wilcoxon rank-sum) and 2 (liposomal vs standard bupivacaine, 5 [4-7] vs 4 [2-6]; P = .003, Wilcoxon rank-sum) but not day 3 (liposomal vs standard bupivacaine, 3 [2-6] vs 3 [1-5]; P = .10, Wilcoxon rank-sum), irrespective of treatment group. Median (IQR) 3-day cumulative NRS was 12.0 (8.0-16.5) for bupivacaine and 13.5 (9.0-17.0) for liposomal bupivacaine (P = .15, Wilcoxon rank-sum) Furthermore, use of opioids was greater following liposomal bupivacaine compared with standard bupivacaine (median [IQR], 41.5 [21.3-73.8] MEU vs 33.0 [17.8-62.5] MEU; P = .03, Wilcoxon rank-sum). On multivariable analysis, no interaction by incision type was observed for mean pain scores or opioid use. Conclusions and Relevance: In this randomized clinical trial involving truncal incisions for cardiovascular procedures, liposomal bupivacaine did not provide improved pain control and did not reduce adjunctive opioid use compared with conventional bupivacaine formulation over 3 postoperative days. Trial Registration: ClinicalTrials.gov Identifier: NCT02111746.

Resection and replacement of thoracic aortic graft infections.

OBJECTIVES: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mortality. We evaluated our 22-year experience managing TAGI with extensive debridement, graft replacement, vascularized tissue coverage, and aggressive antibiotics. METHODS: We reviewed all consecutive patients with TAGI from 1991 to 2013. We also compared infected cases versus noninfected reoperative controls using a case-control design. Standard statistical methods were used for descriptive analysis, and Kaplan-Meier for survival analysis. RESULTS: We treated 32 TAGI patients, involving 19 ascending/arch (A/A) and 13 descending/thoracoabdominal (D/TAA) grafts, including 4 endografts. In total, 19 (59.4%) presented with pseudoaneurysm and 11 (34.4%) with aortic fistula. Vascularized tissue (omentum or muscle) coverage was possible in 22 (71.0%) patients. Thirty-day mortality occurred in 3 (9.4%) patients, with no 30-day mortality among those receiving vascularized graft coverage (P = .018). During follow-up, reinfection occurred in 8 patients (25% [4 A/A and 4 D/TAA]). Five-year overall (A/A 45.4% vs D/TAA 28.9%, P = .434) and reinfection-free (A/A 19.2%, D/TAA 27%, P = .409) survival was similar between groups. Long-term mortality was greater after endograft infection (100% vs 25% at 2.5 months, P = .0007) or aortobronchial fistulization (100% vs 37.9% at 6 months, P = .026). Time to reintervention was shorter in infected versus non-infected reoperative cases (31 vs 83 months, P < .0001), but there were no significant differences in long-term mortality after reoperation. CONCLUSIONS: TAGI continues to represent a highly morbid surgical challenge. Prompt antimicrobial coverage, debridement, graft replacement, and vascularized graft coverage, yielded best long-term results. Endograft infection and aortobronchial fistula had very poor prognoses.

Fewer Cardiopulmonary Complications and Shorter Length of Stay in Anterolateral Thoracolumbar Spine Exposures Using a Small-Incision Specialized Retractor System.

Objectives: One of the challenges of spine surgery is the need for adequate exposure of the anterolateral spinal column. Improved retractor systems with integrated lighting minimize the need for large thoracotomy, flank, or abdominal incisions. In 2013, we began using the NuVasive MaXcess® system via a minimal-access lateral incision for thoracic and thoracolumbar spine exposures. These small-access approaches may not offer adequate exposure when bleeding and other complications arise. We sought to determine the feasibility and outcomes of a minimal-access retractor during anterolateral spine exposures. Methods: An institutional-review-board-approved retrospective chart review was performed of all patients who underwent anterolateral thoracic and lumbosacral spine exposure at an academic hospital between December 1999 and April 2017. Cervical and posterior spine exposures were not included. Information regarding patient demographics, comorbid conditions, operative techniques, exposure, estimated blood loss, length of stay, and intraoperative and postoperative complications was collected. Data for standard exposure vs. minimally invasive exposures were compared. Results: Between December 1999 and April 2017, 223 anterolateral spinal exposures were performed at our institution. Of those, 122 (54.7%) patients had true lateral exposures, with 22 (18%) using the minimally invasive retractor. The mean age of our patient population was 57 years (19-89), with 65 (53%) men and a mean body mass index of 29.0 (17.4-58.6). In the standard exposure group, complications occurred in 22 (22%) patients, whereas only two (9%) complications occurred in the minimal-access group. There were no significant differences in overall intraoperative and postoperative complications, except for cardiopulmonary complications, which were reduced in the minimally invasive group (p < 0.019). Patients with minimally invasive exposure had a significantly shorter length of stay than those with standard exposure (7 vs. 13 days, p = 0.001). Conclusions: Minimal-access techniques using advanced retractor systems are both feasible and safe compared to standard techniques allowing for similar lateral spine exposure, but with smaller incisions, fewer cardiopulmonary complications, and shorter lengths of stay.

Characteristics of Trauma Mortality in Patients with Aortic Injury in Harris County, Texas.

BACKGROUND: The National Academies of Science have issued a call for zero preventable trauma deaths. The mortality characteristics in all patients with aortic injury are not well described. METHODS: All prehospital and hospital medical examiner records for deaths occurring in Harris County, Texas in 2014 were retrospectively reviewed, and patients with traumatic aortic injury were selected. The level of aortic injury was categorized by zone (0 through 9) and further grouped by aortic region (arch, zones 0 to 2; descending thoracic, zones 3 to 5; visceral abdominal, zones 6 to 8; infrarenal, zone 9). Multiple investigators used standardized criteria to categorize deaths as preventable, potentially preventable, or non-preventable. RESULTS: Of 1848 trauma deaths, 192 (10%) had aortic injury. There were 59 (31%) aortic arch, 144 (75%) descending thoracic, 19 (10%) visceral abdominal, and 20 (10%) infrarenal aortic injuries. There were 178 (93%) non-preventable deaths and 14 (7%) potentially preventable deaths, and none were preventable. Non-preventable deaths were associated with blunt trauma (69%) and the arch or thoracic aorta (93%), whereas potentially preventable deaths were associated with penetrating trauma (93%) and the visceral abdominal or infrarenal aorta (79%) (all p < 0.05). Half of potentially preventable deaths (n = 7) occurred at the scene, and half occurred at a trauma center. CONCLUSION: Potentially preventable deaths after aortic injury were associated with penetrating mechanism and injury to the visceral abdominal and/or infrarenal aorta. Optimal prehospital and ED treatment include temporizing hemorrhage control, hemostatic resuscitation, and faster transport to definitive treatment.

Heparin-bonded versus standard polytetrafluoroethylene arteriovenous grafts: A Bayesian perspective on a randomized controlled trial for comparative effectiveness.

BACKGROUND: Heparin-bonded polytetrafluoroethylene grafts were marketed to improve hemodialysis access outcomes but are twice the cost of standard polytetrafluoroethylene. We launched a randomized trial of heparin-bonded polytetrafluoroethylene versus standard polytetrafluoroethylene for hemodialysis access to compare patency. Since the trial began, additional studies were published with heterogeneous findings. We performed an interim analysis by Bayesian methods using prior probability from meta-analysis of existing literature. METHODS: NCT01601873 is a randomized, blinded trial of heparin-bonded polytetrafluoroethylene versus standard polytetrafluoroethylene for dialysis access at 5 sites. Planned sample size was 200 with 1-year primary patency as the primary endpoint. At interim analysis (50% of sample size at 1 year), we also performed a meta-analysis for 1-year primary patency with a random effects model to compute summary rate ratio and standard-error estimates. Meta-analysis estimates formed a prior probability for a Bayesian Cox regression model, and trial data were reanalyzed to develop posterior probability of heparin-bonded polytetrafluoroethylene effectiveness at our hypothesized effect size. Futility analysis was conducted using posterior probability estimates. RESULTS: One hundred and five patients were enrolled at the time of interim analysis. One-year primary patency was 34.9% in the heparin-bonded-polytetrafluoroethylene group vs 32.7% in the standard-polytetrafluoroethylene group (P = .884). Summary rate ratio from the meta-analysis (1,209 patients) was 0.87 favoring heparin-bonded polytetrafluoroethylene (P = .33). Posterior hazard ratio from Cox regression was 0.90 (credible interval 0.70-1.13) favoring heparin-bonded polytetrafluoroethylene, which was not significant. Bayesian posterior probability of the a priori hypothesized 20% better patency with heparin-bonded polytetrafluoroethylene was 24%. Sample size to detect superiority with the small observed effect size would require about 3,800 subjects. CONCLUSION: Current evidence does not demonstrate sufficiently large benefit of heparin-bonded polytetrafluoroethylene over standard polytetrafluoroethylene for dialysis access to justify higher cost. Given similar 1-year patency rates, a conclusive finding of superiority was judged to be infeasible, and the trial was stopped for futility.

Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Differences in quality of life outcomes after paraclavicular decompression for thoracic outlet syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures in the thoracic outlet. Decompression provides relief of TOS symptoms. However, little is known about long-term function and quality of life (QoL) from a patient's perspective. The purpose of this study was to evaluate surgical and QoL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach. METHODS: A prospectively maintained database was used to conduct a retrospective review of patients who underwent thoracic outlet decompression between August 2004 and August 2018. We excluded patients without complete follow-up data. Functional outcomes were assessed by the Derkash classification (poor, fair, good, excellent) using contingency table methods, and QoL was assessed by the 12-Item Short Form Health Survey (SF-12) using general linear models. SF-12 was scored by published criteria, and scale-specific and aggregate mental and physical health-related QoL scores were computed. Aggregate QoL scores range from 0 (terrible) to 100 (perfect). Secondary outcomes included mortality, complications, and duration of hospital stay. RESULTS: We performed 105 operations for TOS, and 100 patients with complete follow-up data were included in the study. Five patients were lost to follow-up. Median age was 35 (interquartile range, 24-47) years, and 58 (58%) were female. The median duration of hospital stay was 4 (interquartile range, 3-5.5) days. Of these patients, 46 had venous etiology, 8 arterial, 42 neurogenic, and 4 mixed vascular and neurogenic. Good or excellent Derkash results were reported in 77 (77%) patients, 46 of 54 (85%) of those with vascular TOS vs 31 of 46 (67%) of those with neurogenic etiology (P < .036). SF-12 score was obtained in 93 of 100 (93%) with a median duration from surgery of 6.1 (3.3-9.3) years. Patients with neurogenic TOS (NTOS) reported significantly lower aggregate mental health QoL than patients with vascular-only TOS (57 vs 59; P < .016). This effect persisted across the entire duration of follow-up and was unaffected by time from surgery (regression P for time = .509). In contrast, aggregate physical function QoL was unaffected by neurogenic etiology (P = .303), and all patients improved linearly with time (0.5 scale unit/y; P < .009). Three patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion or hemothorax requiring evacuation (n = 6), neurapraxia (n = 6), and lymph leak (n = 2) treated with tube thoracostomy. CONCLUSIONS: NTOS is associated with significantly worse functional outcome assessed by the Derkash classification. NTOS also demonstrated worse composite mental health QoL, which did not improve over time. In contrast, composite physical health QoL improved linearly with time from surgery regardless of etiology of TOS.

Clinical Characteristics and Long-Term Outcomes of Midaortic Syndrome.

BACKGROUND: Midaortic syndrome (MAS) is a rare congenital or acquired condition marked by segmental or diffuse stenosis of the distal thoracic and/or abdominal aorta and its branches. The optimal approach to medical or interventional management of MAS and long-term outcomes in adults are not well defined. We reviewed MAS cases to characterize the natural history of aortic disease, identify prognostic factors, and evaluate the durability of invasive interventions. METHODS: We conducted a retrospective review of patients with MAS who presented to Memorial Hermann Hospital and Baylor College of Medicine between 1997 and 2018. We categorized cases according to demographic and clinical manifestations, etiologies, the extent of aortic involvement, interventions, and vascular outcomes. RESULTS: We identified a cohort of 13 patients with MAS. The etiology of MAS was identified in 6 cases, including genetic syndromes (neurofibromatosis type 1 (2/13), Williams syndrome (1/13), fibromuscular dysplasia (2/13), and Takayasu arteritis (1/13)). Mean age at first documented clinical event was 25.2 (2-67) years, but cases with genetic etiologies presented significantly younger (18.2 years). The most common primary anatomic site was the suprarenal and infrarenal aorta (zones 5-8). Extra-aortic locations involved the renal (4/13), celiac (3/13), and superior mesenteric (3/13) arteries. Clinical manifestations included hypertension (13/13), claudication (9/13), and postprandial abdominal pain (5/13). All patients with available follow-up data underwent at least one surgical or endovascular intervention (range: 1-8). Postoperative complications included renal failure requiring postdischarge hemodialysis and respiratory failure. There were no deaths in long-term follow-up. CONCLUSIONS: MAS is a complex vasculopathy with substantial variability in clinical presentation and anatomic distribution. Extensive disease frequently requires multiple invasive interventions and results in refractory hypertension, which may predict subsequent clinical events. A multidisciplinary approach with long-term monitoring is essential for preservation of end-organ function and quality of life in this debilitating disease.

Propensity and impact of autologous platelet rich plasma use in acute type A dissection.

BACKGROUND: Coagulopathy in patients undergoing open repair of acute type A aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest is a common complication. Autologous platelet rich plasma is an intraoperative blood conservation technique, which has been shown in previous studies to promote hemostasis, leading to a reduction of blood product transfusions during elective aortic surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet rich plasma as a blood conservation technique during open surgical repair of acute type A aortic dissection. METHODS: We reviewed all acute type A aortic dissection cases using hypothermic circulatory arrest, excluding patients presenting in extremis. Perioperative transfusion requirements and clinical outcomes were analyzed. The end points analyzed included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay. Parsimonious and saturated propensity scores were calculated for platelet rich plasma use, and all outcomes were propensity adjusted. RESULTS: Between 2003 and 2014, 85 of 391 acute type A aortic dissection repairs used autologous platelet rich plasma. Mean age of patients was 58 ± 15 years, and 70% were male. Obstructive sleep apnea (22% vs 13%, P = .04) and baseline ejection fraction (57% ± 6.7% vs 55% ± 10%; P = .014) were higher in the autologous platelet rich plasma group. Intraoperative propensity-adjusted blood products, 2 units fewer packed red blood cells (P = .001), 4 units fewer fresh-frozen plasma (P = .001), 6 units fewer platelets (P = .001), 1.3 units fewer cell-savers (P = .002), and 5 units fewer cryoprecipitate (P = .001) were significantly reduced by autologous platelet rich plasma use. Significant unadjusted reduction in postoperative reoperation for bleeding (8% vs 17%, P = .046) after autologous platelet rich plasma was reported, although propensity adjustment eliminated significance (P = .079). No difference in stroke, cardiac, or renal complications was observed. Postoperative transfusion needed during the first 3 days was significantly reduced in the autologous platelet rich plasma group: 2 units fewer packed red blood cells (P = .13), 2 units fewer fresh-frozen plasma (P = .018), and 5 units fewer platelets (P = .001), when compared with those without autologous platelet rich plasma. Ventilation time was reduced by 3 days (P = .002), and intensive care length of stay was reduced by 3 days (P = .063) after intraoperative autologous platelet rich plasma use. CONCLUSIONS: The use of autologous platelet rich plasma in patients undergoing open repair of acute type A aortic dissection was associated with a reduction in intraoperative and postoperative blood transfusions, as well as decreased early postoperative morbidity.

Asymptomatic patients with unsuccessful percutaneous inferior vena cava filter retrieval rarely develop complications despite strut penetrations through the caval wall.

OBJECTIVE: We established a program for retrieval of inferior vena cava (IVC) filters within our hospital system. When percutaneous retrieval fails, we only recommend open surgical removal for symptoms and other complications. We examined our outcomes with conservative management of unsuccessful percutaneous retrieval and open surgical removal for symptomatic/complicated IVC filters. METHODS: All patients with history of IVC filter placement who were referred to us for retrieval between 2010 and 2016 were evaluated. Before retrieval, patients were evaluated for risk of future venous thromboembolic events and ongoing need for IVC filtration. Asymptomatic patients with unsuccessful percutaneous filter retrieval were recommended to have annual follow-up with plain abdominal radiographs and to take daily low-dose aspirin. Patients with symptoms referable to the indwelling filter and those with complications were offered open surgical removal. RESULTS: There were 213 patients with a history of IVC filter placement who underwent 220 percutaneous attempts for retrieving 214 IVC filters (four patients had two attempts, one patient had three attempts). Technical success in percutaneously retrieving the filter was 180 of 214 (84.1%) at a median of 5.5 months (interquartile range [IQR], 3.5-9.2) from implant. The median filter dwell time was significantly longer in unsuccessful compared with successful retrieval attempts (8.3 months [IQR, 4.3-15.1 months] vs 5.5 months [IQR, 3.2-8.7 months]; P = .011). Of the 34 filters in 33 patients that could not be retrieved percutaneously, all had either significant filter barb penetration through the caval wall or a tilt angle of greater than 15°. The majority of patients (67%) remained asymptomatic without any further complications over a mean follow-up of 24 months (IQR, 12-50 months). No asymptomatic patients developed symptoms or complications over the follow-up period. Two of the five patients who were symptomatic underwent open surgical removal via minilaparotomy. An additional six patients who failed percutaneous retrieval at other institutions were referred to us for open surgical removal owing to symptoms or complications. Technical success for all open surgical removal of IVC filters was 100%. All patients had resolution of their symptoms after percutaneous or open surgical removal. CONCLUSIONS: Asymptomatic patients with unsuccessful percutaneous IVC filter retrieval seem to have low complications in midterm follow-up despite significant filter strut penetration. Without symptoms or other complications, such patients do not require referral for open surgical filter removal. Symptomatic patients can expect low morbidity and resolution of symptoms after percutaneous or open surgical removal. Further studies are needed to determine the cost-effectiveness of routinely removing asymptomatic IVC filters.

Predictors of poor outcome in infrainguinal bypass for trauma.

BACKGROUND: Trauma remains a leading cause of morbidity and mortality worldwide. Vascular injuries are present in approximately 1% to 2% of trauma patients, with the majority of injuries occurring to the extremities. Trauma patients with vascular injuries have been shown to have increased morbidity and mortality as well as the need for increased resources compared with those without vascular injuries. This study aimed to determine predictors of poor outcomes in infrainguinal bypasses performed for traumatic arterial injury. METHODS: All patients admitted between September 1999 and July 2015 who underwent infrainguinal arterial bypass for trauma at a single level I trauma center were included for analysis. The primary outcome was a composite of thrombosis leading to graft abandonment, revision, amputation, or death. Data were analyzed by univariate descriptive and multiple logistic regression analyses. Long-term data were analyzed by Kaplan-Meier method. RESULTS: During the study period, 108 patients presented with and underwent infrainguinal arterial bypass for traumatic arterial injury. The cohort had a mean age of 35.8 years (16/108 female [15%]). The average Injury Severity Score was 15.2; admission glomerular filtration rate, 79.3 mL/min/1.73 m2; Mangled Extremity Severity Score (MESS), 6; and injury to operating room time, 5.1 hours. Of 108 patients, 37 (34%) had penetrating injury, 71 (66%) had blunt injury, 10 (9.3%) had diabetes mellitus, and 76 (70.4%) had a below-knee target for bypass. Univariate risk factors for poor outcome included age >40 years (odds ratio [OR], 3.27 [1.40-7.65]; P < .01), MESS ≥7 (OR, 5.19 [2.08-19.97]; P < .01), blunt mechanism (OR, 3.35 [1.24-9.07]; P = .02), popliteal artery injury (OR, 3.04 [1.22-7.6]; P = .02), and below-knee target vessel (OR, 4.32 [1.37-13.58]; P = .01). Concomitant orthopedic injuries (P = .08) were not associated with poor outcome. Baseline renal function, type of repair performed (end-to-side vs interposition bypass), injury to surgery time, surgeon's specialty, and associated venous injuries were not significantly predictive of poor outcome. MESS was strongly predictive of poor outcome, with probability rising as high as 95% when MESS reached 12. A score ≥7 (high MESS) was 73% sensitive and 70% specific to predict poor outcomes. Age (OR, 1.03/y; P < .05) and MESS ≥7 (OR, 3.6; P < .03) were persistent predictors of poor outcome in multivariable analysis. CONCLUSIONS: Poor outcomes in infrainguinal bypass for trauma are significantly predicted by the MESS, with poor outcomes occurring >50% of the time when MESS is ≥9 and >75% of the time when MESS is ≥11. Whereas amputation vs revascularization is a decision that also depends on nerve and soft tissue damage and other comorbidities, the MESS helps frame the data for the clinician and can aid in decision-making. Patients and family should understand that poor outcomes are more likely when MESS is ≥9. For patients with MESS ≥11, primary amputation can be considered.

Imaging characteristics of acute type A aortic dissection and candidacy for repair with ascending aortic endografts.

BACKGROUND: Acute type A aortic dissection (ATAD) remains associated with substantial short-term mortality, and despite increasing rates of surgical repair, as many as 10% to 20% of patients do not undergo surgery because of comorbidities and dissection-related complications. For patients unable to undergo open repair, previous attempts at endovascular treatment of ATAD used devices originally designed for deployment in the descending thoracic aorta. Industry has begun to support early investigational devices meant specifically for placement within the ascending aorta. We evaluated relevant aortic parameters to examine which patients may be candidates for repair with an ascending aortic endograft. METHODS: We reviewed 100 consecutive patients in our institutional ATAD database with contrast-enhanced computed tomography imaging on an Aquarius iNtuition workstation (TeraRecon, San Mateo, Calif), using curved planar reformatting (vessel tracking) and orthogonal views for measurements. We compared relevant aortic measurements against proposed criteria for future ascending endografts, including various landing zone diameters and intimal tear distances from the distal coronary ostium. RESULTS: Of the 100 patients examined, 39% had proximal intimal tears located outside the tubular ascending aorta. In all, 30% were excluded on the basis of either the presence of a prosthetic aortic valve or significant aortic insufficiency, and 6% were excluded on the basis of the presence of patent coronary artery bypass grafts from the ascending aorta. Many patients had multiple exclusion criteria, and based on various proposed criteria, overall candidacy ranged from 2% to 23%. If a maximum landing zone diameter of 42 mm and intimal tears as little as 20 mm distal to the distalmost coronary were considered treatable, only 8% of patients would have been candidates compared with 20% candidacy if aortic diameters up to 46 mm and intimal tears as little as 10 mm distal to the distalmost coronary were considered treatable. The most frequent single cause for exclusion was inadequacy of the proximal landing zone. Iliofemoral vascular access was also assessed and deemed adequate in >90% of cases. CONCLUSIONS: A minority of patients suffering ATAD would currently qualify for ascending aortic endografting on the basis of anatomic criteria alone. Future device designs should take into account these common anatomic exclusion criteria so that more versatile devices may be developed and commercially available to treat a larger number of patients.

Open Descending and Thoracoabdominal Aortic Repairs in Patients Younger Than 50 Years Old.

BACKGROUND: The purpose of this study was to redefine indications of open descending and thoracoabdominal aortic aneurysm repair in the younger population. METHODS: Between 1991 and 2017, 2012 patients undergoing descending and thoracoabdominal aortic aneurysm repair at our institution were divided into 2 groups for comparison: younger (<50 years; 276 [14%]) and older (≥50 years; 1736 [86%]). Patient demographics and perioperative outcomes were retrospectively reviewed. RESULTS: Younger patients had significantly more heritable thoracic aortic disease (HTAD; 53% vs 9%, P < .001) and chronic dissections (64% vs 26%, P < .001) and fewer comorbidities. The younger cohort underwent more extent II repairs (28% vs 15%, P < .001). Operative mortality was significantly lower in younger patients (6% vs 17%, P < .001). Significant disabling complications (composite of operative mortality, paraplegia/paraparesis, stroke, and dialysis) were seen in 17% of the younger patients and in 40% of older patients 40% (P < .001). In multivariate analysis, extent of repair and chronic obstructive pulmonary disease were independent predictors for significant disabling complications in the younger cohort. Additional aortic interventions were required in 12% in the younger group and in 4% in the older group (P < .001), and nearly one-third were in the treated segment (ie, treatment failure) in both groups. Younger patients requiring additional reintervention had significantly higher incidence of HTAD (66% vs 9%, P < .001). Survival rate was significantly higher in the younger patient group, with a 10-year survival rate of 74.6% ± 2.9% vs 40.7% ± 1.3% (log-rank P < .001). CONCLUSIONS: Patients younger than 50 years with descending and thoracoabdominal aortic aneurysm have low surgical risks, and open repairs can be performed with excellent short-term and durable long-term results. Open surgical repairs should be considered initially in younger patients requiring descending and thoracoabdominal aortic aneurysm repairs. HTAD warrants closer postoperative surveillance.