Operative and 1-Year Outcomes of the Custom-Made Fenestrated Anaconda Aortic Stent Graft-A UK Multicenter Study.

BACKGROUND: Early and 1-year outcomes are presented for fenestrated endovascular aneurysm repair (FEVAR) of complex aortic aneurysmal disease with the custom-made Anaconda fenestrated stent graft in 101 patients. METHODS: Retrospective site-reported data from the first 101 elective cases (2010-2014) from 4 UK centers were studied to evaluate patient demographics, aneurysm morphology, clinical success, and 1-year outcomes in patients undergoing fenestrated aneurysm repair with the custom-made Anaconda device. RESULTS: 101 fenestrated grafts (median age 76, 85% male) were implanted with a total of 255 fenestrations (196 renal arteries, 48 superior mesenteric artery, and 11 celiac arteries) with 3% mortality, 98.4% target vessel patency (TVP) at 30 day follow-up. Although 15 type I or III endoleaks were demonstrated at completion angiography, all 10 type Ia endoleaks resolved spontaneously. Survival by Kaplan-Meier analysis was 97% and 91% at 1 month and 1 year, respectively; with 75.8% showing reduction in abdominal aortic aneurysm diameter and only 1 patient with sac expansion. Freedom from loss of TVP was 97.6%. CONCLUSIONS: Custom-made fenestrated Anaconda devices demonstrate low procedural mortality and a high rate of technical and clinical success at 30 days and 1 year.

Arteriovenous fistula formations: key to vascular surgical training.

PURPOSE: To highlight missed training opportunities in daycase surgery for trainees to acquire competency in vascular anastomosis by performing arteriovenous fistula (AVF) formations. METHODS: Operative Room Management Information System records were reviewed for AVF procedures in daycase and general theatres at a UK Foundation Trust between 2007 and 2012. Data collected included procedure, procedure time (PT), patient length of stay (LOS), readmissions within 30 days of procedure and lead and assistant surgeons involved. RESULTS: Of 199 daycase AVF procedures reviewed, 59.3% (n=118) were brachiocephalic formations and 34.2% (n=68) radiocephalic formations. Trainees attended 41.2% of daycase AVF procedures and were lead surgeon in 7.3% of these. Mean PT was 64 minutes for consultants compared with 56 minutes for trainees, with no significant difference (p=0.297). Median patient LOS was less than 24 hours for both groups. Six daycase AVF procedures resulted in patient readmission within 30 days; five of these were operated on by consultants and one by a staff grade. During the same period, 258 AVF procedures were performed in general theatres. Trainees attended 64.3% of AVF formations performed in general theatres and were lead surgeon in 5.8% of these. CONCLUSIONS: Trainees attended and led few daycase AVF formations despite no significant difference in PT, patient LOS or readmission rate between consultant-led and trainee-led cases. Trainees attended more AVF formations performed in general theatres than daycase. However, trainees led a greater proportion of daycase AVF formations, possibly due to a less complex case mix that is more suitable for training.

Endovascular management of delayed complete graft thrombosis after endovascular aneurysm repair.

Graft thrombosis rates after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms vary widely in published series. When thrombosis does occur, it usually involves a single limb and occurs within 3 months of stent-graft insertion. If the entire endoprosthesis is thrombosed, treatment may be challenging because femoro-femoral crossover graft insertion is not an option and a greater volume of thrombus is present, thus making thrombolysis more difficult. We present two cases of delayed thrombosis after EVAR involving the entire stent-graft. These were successfully treated by a combined surgical and endovascular technique, and patency has been maintained in both cases to date.

Autologous thrombin for treatment of pseudoaneurysms.

Femoral pseudoaneurysms arise in up to 2% of patients after femoral cannulation for cardiac catheterisation. We used autologous thrombin for percutaneous obliteration of pseudoaneurysms occurring after catheterisation. We prepared autologous thrombin isolates from blood of ten patients with femoral pseudoaneurysms, and injected this solution into the pseudoaneurysms with duplex imaging guidance. We then assayed thrombin activity. All pseudoaneurysms were successfully thrombosed without substantial complications, although three patients needed a repeat procedure within 24 h. We have shown that autologous thrombin-induced thrombosis of pseudoaneurysms is reliable, simple, safe, and cheaper than commercial bovine or human thrombin, and avoids risks of anaphylaxis and contamination with prions.