A comparison of endovascular repair to medical management for acute vs subacute uncomplicated type B aortic dissections.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has emerged as a viable option of treatment for uncomplicated type B aortic dissection (UTBAD) due to the potential for inducing favorable aortic remodeling. The aim of this study is to compare outcomes of UTBAD treated medically or with TEVAR in either the acute (1 to 14 days) or subacute period (2 weeks to 3 months). METHODS: Patients with UTBAD between 2007 and 2019 were identified using the TriNetX Network. The cohort was stratified by treatment type (medical management; TEVAR during the acute period; TEVAR during the subacute period). Outcomes including mortality, endovascular reintervention, and rupture were analyzed after propensity matching. RESULTS: Among 20,376 patients with UTBAD, 18,840 were medically managed (92.5%), 1099 patients were in the acute TEVAR group (5.4%), and 437 patients were in the subacute TEVAR group (2.1%). The acute TEVAR group had higher rates of 30-day and 3-year rupture (4.1% vs 1.5%; P < .001; 9.9% vs 3.6%; P < .001) and 3-year endovascular reintervention (7.6% vs 1.6%; P < .001), similar 30-day mortality (4.4% vs 2.9%; P < .068), and lower 3-year survival compared with medical management (86.6% vs 83.3%; P = .041). The subacute TEVAR group had similar rates of 30-day mortality (2.3% vs 2.3%; P = 1), 3-year survival (87.0% vs 88.8%; P = .377) and 30-day and 3-year rupture (2.3% vs 2.3%; P = 1; 4.6% vs 3.4%; P = .388), with significantly higher rates of 3-year endovascular reintervention (12.6% vs 7.8%; P = .019) compared with medical management. The acute TEVAR group had similar rates of 30-day mortality (4.2% vs 2.5%; P = .171), rupture (3.0% vs 2.5%; P = .666), significantly higher rates of 3-year rupture (8.7% vs 3.5%; P = .002), and similar rates of 3-year endovascular reintervention (12.6% vs 10.6%; P = .380) compared with the subacute TEVAR group. There was significantly higher 3-year survival (88.5% vs 84.0%; P = .039) in the subacute TEVAR group compared with the acute TEVAR group. CONCLUSIONS: Our results found lower 3-year survival in the acute TEVAR group compared with the medical management group. There was no 3-year survival benefit found in patients with UTBAD who underwent subacute TEVAR compared with medical management. This suggests the need for further studies looking at the necessity for TEVAR when compared with medical management for UTBAD as it is non-inferior to medical management. Higher rates of 3-year survival and lower rates of 3-year rupture in the subacute TEVAR group compared with the acute TEVAR group suggest superiority of subacute TEVAR. Further investigations are needed to determine the long-term benefit and optimal timing of TEVAR for acute UTBAD.

Blunt traumatic aortic injury in the elderly population.

OBJECTIVE: Blunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database. METHODS: Patients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management. RESULTS: During the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group. CONCLUSIONS: This study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.

Aortic Neck Dilatation Following Thoracic Endovascular Aortic Repair.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has become a mainstay of treatment for a variety of thoracic aortic pathologies. Expansion of the proximal aortic neck after endovascular repair of abdominal aortic aneurysms has been demonstrated; however, dilatation of the proximal aortic neck after TEVAR has not been well described. We sought to describe remodeling of the proximal neck following TEVAR. METHODS: This is a retrospective, single institution review of patients who underwent TEVAR for thoracic aortic aneurysm (TAA) and dissection with aneurysmal degeneration from 2010 to 2019. Postoperative computed tomography scans were reviewed and aortic diameter was measured in orthogonal planes using 3-dimensional centerline reconstruction software. The primary outcome was change in aortic diameter at the proximal aortic neck as compared to the initial postoperative computed tomography scan. Clinical and operative data were analyzed to identify factors associated with significant neck dilatation. RESULTS: Of 87 patients who underwent TEVAR during the study period, 30 met inclusion criteria. Median follow up was 20.5 months. Median age was 67 years, and 15 patients (50%) were female. The proximal aortic neck experienced an overall increase over time in aortic diameter. Five mm distal to the graft showed the greatest rate of expansion, with a median increase of 1.3, 2.9, and 6.2 mm at one year, two years, and three years, respectively. When comparing patients who had mean expansion at this location of >2.0 mm/year to patients who did not, a higher percentage had dissection pathology (81.8% vs. 31.6%, P = 0.008), had graft placement at aortic landing zone 2 (36.4% vs. 5.3%, P = 0.028), and were smokers (100% vs. 52.6%, P = 0.006). Higher percent oversizing was shown to be associated with significant aortic neck dilatation for true aneurysms only. CONCLUSIONS: Aortic neck dilatation occurs over time for the majority of patients following TEVAR with the distal neck experiencing the highest rate of expansion. Dissection pathology, aortic landing zone 2, and smoking were found to be associated with a higher rate of neck dilatation.

Ambulatory Status following Major Lower Extremity Amputation.

BACKGROUND: The ability to ambulate following major lower extremity amputation, either below (BKA) or above knee (AKA), is a major concern for all prospective patients. This study analyzed ambulatory rates and risk factors for nonambulation in patients undergoing a major lower extremity amputation. METHODS: A retrospective review of 811 patients who underwent BKA or AKA at our institution between January 2009 and December 2014 was conducted. Demographic information and co-morbid conditions, including the patients' functional status prior to surgery, at 6 months, and at latest follow up were recorded. Following exclusion criteria, 538 patients were included. Patients who were either independent or used an assistive device were considered ambulatory, while those who were completely wheelchair-dependent or bed-bound were considered nonambulatory. RESULTS: Pre-operatively, 83.1% of BKA patients were ambulatory, significantly more so than those undergoing AKA (44.9%, P < 0.0001). At 6-month follow-up these percentages dropped to 58.0% and 25.2%, respectively, for all patients. For patients who were ambulatory pre-operatively, 182/246 (73.9%) of BKA and 32/51 (62.7%) of AKA remained so post-amputation. Of those patients with both 6-month and greater than 1-year follow-up, there was no change in ambulatory status between the 2 time periods. On multivariable logistic regression, age greater than 70 years and female sex were associated with nonambulation post-operatively (P = 0.001, P = 0.015, respectively). None of the co-morbid conditions recorded (diabetes, renal insufficiency, end-stage renal disease, peripheral vascular disease, or body mass index > 35) was found to have a statistically significant correlation with post-operative ambulation using multivariable analysis. CONCLUSIONS: The majority of ambulatory patients undergoing a major amputation were able to remain ambulatory. Patients who failed to ambulate 6 months after their amputation, failed to resume ambulating. Age greater than 70 and female sex were found to have a statistically significant association with becoming nonambulatory following surgery.

Radiofrequency and laser vein ablation for patients receiving warfarin anticoagulation is safe, effective, and durable.

OBJECTIVE: The objective of this study was to evaluate the efficacy, durability, and safety of radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) of the great saphenous vein (GSV) and small saphenous vein (SSV) to treat symptomatic venous reflux in patients receiving therapeutic anticoagulation. METHODS: Patients treated at a single institution with RFA or EVLA while receiving warfarin (Coumadin) anticoagulation were identified retrospectively along with a consecutive sample of patients not receiving anticoagulation who were similarly treated. Patients' demographics, comorbidities, procedural details, and follow-up data were obtained from electronic medical records. Outcomes of interest included the rates of persistent vein ablation, bleeding, deep venous thrombosis (DVT), and endothermal heat-induced thrombosis. Groups were compared using χ2 tests, Fisher exact test, Kaplan-Meier curves, and Cox proportional hazard modeling. RESULTS: There were 100 procedures performed in 65 patients receiving anticoagulation and 127 procedures in 89 control patients. Mean follow-up time was 467 days. The most common indications for anticoagulation were atrial fibrillation (52%), remote DVT (29%), and mechanical heart valves (8%). Patients receiving anticoagulation were on average older (67 years vs 52 years), were more likely to be male (51% vs 27%), and had higher rates of coronary disease (9% vs 0%) and hypertension (55% vs 20%), although they were more likely to have never smoked (86% vs 69%). There were 127 RFA procedures (56%) and 100 EVLA procedures (44%); 189 procedures treated the GSV or its tributaries (83%), and 38 treated the SSV (17%). At 1 year, the target vessel remained ablated after 96% of procedures performed with anticoagulation and in 99% of controls; at 18 months, rates were 92% vs 95% (P = .96). Rates of persistent ablation did not differ significantly by vessel treated (P = .28), EVLA vs RFA (P = .36), or use of antiplatelet therapy (P = .92). One patient had bleeding from a phlebectomy site 2 days postprocedurally when supratherapeutic on warfarin; this was controlled with pressure. DVT in the ipsilateral leg occurred within 90 days after 1 of 100 (1%) procedures in patients receiving anticoagulation and 2 of 127 (1.6%) procedures in control patients; endothermal heat-induced thrombosis rates were similarly 1 of 100 (1%) procedures in patients receiving anticoagulation and 1 of 127 (0.8%) in control patients. CONCLUSIONS: This is the largest series to date reporting >30-day follow-up for patients undergoing venous ablation procedures while receiving anticoagulation and the longest follow-up reported of any series. Durability, safety, and efficacy of vein ablation in patients receiving anticoagulation are comparable to those in control patients. Anticoagulation should not be considered a contraindication to endothermal ablation of the GSV or SSV for symptomatic venous reflux.

High Prevalence and Mortality Associated with Upper Extremity Deep Venous Thrombosis in Hospitalized Patients at a Tertiary Care Center.

BACKGROUND: Upper extremity deep venous thrombosis (UEDVT) and its associated complications are increasing in incidence, but management strategies are largely derived from experience treating lower extremity deep venous thrombosis (LEDVT). The purpose of this study is to examine our single institution's experience with in-hospital venous thromboembolism (VTE), specifically the characteristics and outcomes of the UEDVT population as it compares to LEDVT. METHODS: This is a single tertiary care center retrospective cohort study of all consecutive inpatients diagnosed with acute VTE from June 2015 to December 2015. During this period, 4,495 patients underwent venous duplex examination (622 UE and 3,873 LE), identifying 83 inpatient DVTs. Chronic DVT and those diagnosed in the outpatient population were excluded. DVTs were classified as either provoked or unprovoked. Provoked DVT were defined as the presence of any of the following factors within 30 days prior to diagnosis: major surgery, immobilization (greater than 3 days of bedrest), trauma, infection requiring antibiotics, central venous access, pregnancy, and/or hormonal medication use. Inpatient pulmonary embolisms (PE) detected on chest computed tomography (CT) were also evaluated during this time frame. Patient data were collected, including age, gender, race, lifestyle factors, comorbidities, VTE risk factors, symptomatology at presentation, management including anticoagulation choice and filter placement if applicable, as well as discharge disposition. Statistical analysis was performed using GraphPad Prism 8.0 (GraphPad Software, San Diego, California), and a threshold P-value of <0.05 set for significance. RESULTS: During the study period, 83 DVTs (48 LEDVT, 35 UEDVT) and 24 PE were identified in 96 inpatients. Of these DVTs, 77.1% of these were defined as provoked. Eleven patients had simultaneous DVT and PE, and thirteen patients had PE with presumed occult pelvic or LEDVT. UEDVT patients had a higher proportion of comorbidities than LEDVT patients: coronary artery disease (25.7% vs. 13.1%, P = 0.16), congestive heart failure (20% vs. 6.6%, P = 0.09), as well as a trend toward higher incidence of malignancy (60% vs. 42.6%, P = 0.13). Of provoked VTE, UEDVT correlated more significantly with central venous catheters (88.4% vs. 12.5%, P=<0.0001), but was less commonly associated with prolonged bed rest (19.2% vs. 39.5%, P = 0.11). PE was diagnosed in 24/96 (25%) of the study population. Patients with LEDVT were found to have a significantly higher incidence of PE compared to those with UEDVT (34.4% vs. 8.6%, P = 0.006). Same-admission mortality for patients with VTE was 13/96 (13.5%). Of these, patients with UEDVT had significantly higher all-cause mortality than patients with LEDVT (28.5% vs. 4.9%, P = 0.004). When catheter-related UEDVT was excluded, there remained a significant difference in mortality between non-catheter-related UEDVT and LEDVT (33.3% vs. 4.9% P = 0.0119). CONCLUSIONS: This study demonstrates a high prevalence of UEDVT in hospitalized patients who experience VTE. Despite a lower incidence of synchronous PE, patients with UEDVT had a higher prevalence of significant medical comorbidities and higher all-cause mortality on the index hospital admission.

Factors Associated with Ipsilateral Limb Ischemia in Patients Undergoing Femoral Cannulation Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an important life-saving modality for patients with cardiopulmonary failure. Vascular complications, including clinically significant limb ischemia, may occur as a result of femoral artery cannulation for venoarterial (VA) ECMO. This study examines our institutional experience with femoral VA ECMO and the development of ipsilateral limb ischemia. METHODS: We performed a retrospective review of all consecutive patients undergoing femoral VA ECMO between 2011 and 2016. The primary endpoint was clinical evidence of limb-threatening ischemia. Multivariate logistic regression analysis was used to identify predictors for limb ischemia after cannulation. RESULTS: Between March 2011 and September 2016, 154 patients underwent femoral cannulation for VA ECMO. Overall in-hospital mortality was 59.7%. Clinically significant ipsilateral limb ischemia occurred in 34 (22%) patients; 7 required four-compartment fasciotomy, and 3 of these patients required amputation. On univariate analysis, a history of pulmonary disease, peripheral arterial disease, and stroke or transient ischemic attack was significantly associated with clinical limb ischemia. On multivariate analysis, younger age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93-0.99), diabetes (OR, 2.77; 95% CI, 1.08-7.12), pulmonary disease (OR, 3.86; 95% CI, 1.38-10.78), and peripheral arterial disease (OR, 13.68; CI, 2.75-68.01) were associated with limb ischemia. Lack of prophylactic distal perfusion catheter and arterial cannula size were not independently associated with limb ischemia. CONCLUSIONS: Femoral ECMO cannulation can be associated with significant limb ischemia necessitating surgical intervention. Younger patients, as well as those with a history of diabetes, pulmonary disease, and peripheral arterial disease, may be at increased risk for this complication.

Blast Cell Arterial Embolus in Acute Myelogenous Leukemia.

The link between coagulatory dysfunction in acute leukemias is well known, with patients having an increased risk of bleeding as well as thrombosis. Arterial thrombosis is particularly rare in this population however with only a few reported cases in the literature. We report the case of acute arterial occlusion secondary to a leukoblastic embolus causing limb-threatening ischemia in a patient with acute myelogenous leukemia. The patient was successfully treated surgically by open superficial femoral artery thrombectomy, common femoral endarterectomy with patch angioplasty, and percutaneous tibial embolectomy.

Pregnancy after bariatric surgery: the effect of time-to-conception on pregnancy outcomes.

BACKGROUND: At our medical center, female patients who have undergone bariatric surgery are advised to defer pregnancy for 2 years after surgery to avoid the following complications and their potential consequences for the fetus: inadequate gestational weight gain, inadequate postsurgical weight loss, hyperemesis gravidarum, nutritional deficiencies, gestational diabetes, and gestational hypertension. OBJECTIVES: To examine the effect of time from surgery to conception on pregnancy course and outcomes in bariatric patients. SETTING: University. METHODS: We identified 73 pregnancies in 54 women who became pregnant after undergoing bariatric surgery. Surgery to conception interval was compared between pregnancies that were carried to delivery and 8 pregnancies that resulted in spontaneous abortion. Of 41 pregnancies that were carried to delivery, 26 occurred in women who had undergone surgery less than 2 years before conception, and 15 occurred in women who had undergone surgery greater than 2 years before conception. Gestational age at delivery, number of neonatal intensive care unit admissions, gestational weight gain, hyperemesis gravidarum, nutritional deficiencies, gestational diabetes, and gestational hypertension during pregnancy were compared for the 2 groups. RESULTS: Eight patients who had spontaneous abortion had a significantly shorter time from surgery to conception. There were no significant differences between our 2 groups in rates of preterm deliveries, neonatal intensive care unit admission, gestational weight gain, hyperemesis, nutritional deficiencies, gestational diabetes, or gestational hypertension. CONCLUSIONS: Becoming pregnant within the first 2 years after bariatric surgery appears to have no effect on pregnancy course and outcomes. Women who miscarried had a significantly lower mean surgery to conception interval. These results fail to show an increased rate of pregnancy complications during the first 2 years after bariatric surgery.

The binding of benzoarylsulfonamide ligands to human carbonic anhydrase is insensitive to formal fluorination of the ligand.

It's the water that matters. Pairs of benzo- and perfluorobenzoarylsulfonamide ligands bind to human carbonic anhydrase with a conserved binding geometry, an enthalpy-driven binding, and indistinguishable binding affinities (see picture). These data support the pervasive theory that the lock-and-key model disregards an important component of binding: the water, which fills the binding pocket of the protein and surrounds the ligand.