The Role of Physician-Directed Duplex after Brachial Plexus Block in Arteriovenous Fistula Creation.

BACKGROUND: Best practice guidelines for dialysis access creation emphasize distal sites and autogenous tissue before more proximal sites and synthetic shunts. Pre-operative vein mapping is a useful modality to evaluate optimal access location; however, vein size is often underestimated secondary to patient hypovolemia, room temperature, and basal vascular tone. Supraclavicular brachial plexus blocks (BPB) are routinely performed to provide surgical anesthesia but also have known vasodilatory effects. Although many surgeons use both techniques, most do not repeat vein mapping after BPB to re-evaluate targets after block-mediated vasodilation. Therefore, we evaluated whether the role of physician-directed vein mapping after BPB resulted in more favorable access creations. METHODS: All patients who underwent primary ipsilateral access creation with physician-directed post-block duplex between 2017 and 2018 were evaluated. Vein mapping was reviewed for "theoretical access location" using the criterion of >2.5 mm vessels. Fistula preference was analogous to current indications with the following order of preference: wrist radiocephalic, forearm radiocephalic, brachiocephalic, brachiobasilic, and finally prosthetic graft. RESULTS: Forty-three patients met inclusion criteria. In total, physician-directed duplex after regional block resulted in the creation of higher preference accesses than predicted in 62.8% of patients. In 34.9% the access was at the predicted level and only 2.3% were at a lower preference. Furthermore, there were no differences in the maturation rates between accesses placed at higher preference locations than predicted compared to those at expected sites (74% vs. 79%, P = 0.38). The overall revision rate for higher preference access was 22.2% compared to 23.1% for equal/lower preference accesses. Of those accesses that failed, 83.3% of new accesses were created at the original theoretical location while 17.7% required placement of a lower preference access. CONCLUSIONS: Physician-directed ultrasound after BPB allows for identification of more preferential targets for access creation compared to pre-operative vein mapping. For access created at more preferential locations than pre-operatively predicted prior to BPB, there was no difference in maturation rates compared to those created at the theoretical vein mapping location.

Late Open Repair of a Massive Common Iliac Artery Aneurysm after Endovascular Failure.

Giant Common Iliac Artery Aneurysms (CIAA) are an uncommon pathology that may present as a late complication after endovascular aortic repair secondary to aneurysmal degeneration with endoleak. We present an unusual case of a patient presenting 9 years after index endovascular CIAA exclusion with a painless abdominal mass found to be a 20+ cm CIAA secondary to type II endoleak from a recanalized coil embolized hypogastric artery. The patient underwent open aneurysmorrhaphy with ligation of the hypogastric artery.

Initial Post-Operative Visit Absenteeism is Associated With Worse Amputation-Free Survival after Tibial Angioplasty.

OBJECTIVES: Tibial revascularization is often performed in the setting of critical limb ischemia and tissue loss requiring close patient monitoring in the early post-operative period for worsening gangrene and/or ischemia. Multiple studies have shown loss to follow-up is an independent risk factor for poor outcomes in several vascular procedures. Therefore, we evaluated the risk factors relating to loss to follow up against outcomes in patients undergoing tibial endovascular procedures with the hypothesis that poor post-operative visit compliance is associated with decreased amputation-free survival rates. METHODS: We performed a single-institution retrospective chart review of patients who underwent therapeutic endovascular tibial revascularization between 2014-2018. Patient follow-up and outcomes of death or major amputation (trans-tibial/trans-femoral) were followed up to 36-months post-operatively. Patients who had undergone previous infra-geniculate interventions or reached mortality/major amputation within 30-days post-operatively were excluded from analysis. RESULTS: We identified 89 patients who met inclusion criteria. The overall rate of attendance at less than <1 month, 1-6 months, 6-15 months and 15-36 months post-operatively were 60%, 64%, 60 and 40% respectively. 16% of patients had complete loss to follow-up. Patients without tissue loss (≤ Rutherford 4) were less likely to attend early <1 month and 1-6 month follow-up intervals. Notably, absenteeism from the first immediate post-operative visit was a significant risk factor for further absenteeism at 1-6 months (51% vs. 26%; P = 0.01) and at greater than 6-month follow-up (48% vs. 31%; P = 0.05). Compared to the cohort of all patients, failure to follow-up within 1 month was associated with a decrease in attendance from 64% to 26% at 1-6 months and 63-31% at more than 6 months. Missing the first post-operative visit was also associated with decreased amputation-free survival (P = 0.04). CONCLUSIONS: Absenteeism from the first post-operative visit is associated with worse amputation-free survival and a significant risk factor for further absenteeism from post-operative care. Given these results, ensuring close immediate post-operative follow up is essential to improving outcomes in patients undergoing tibial revascularization.

Clinically occult amyloidosis derived from leukocyte chemotactic factor 2 (ALECT 2) with cardiac involvement complicating renal transplantation: case report and literature review.

INTRODUCTION: Amyloidosis derived from leukocyte chemotactic factor 2 (ALECT2) may be associated with slowly progressive renal failure that is clinically unsuspected at the time of transplantation. While this is typically clinically insignificant, we report a case with extensive systemic ALECT2 amyloidosis that also involved the myocardium, contributing to perioperative death post renal transplantation. CASE DESCRIPTION: A 72-year-old Hispanic woman presented for renal transplantation due to end-stage renal disease secondary to hypertension. She was bradycardic on admission. Cardiac workup prior to transplantation had not identified an infiltrative process. Post-transplant hypotensive bradycardic arrests lead to multiorgan failure, anoxic brain injury, and death. Autopsy revealed massive amyloid deposition in the native kidneys, adrenals, spleen, and less extensive infiltration of liver and myocardium. Cardiac intramural vasculature from venules to capillaries, arterioles, and arteries showed amyloid deposition. Mass spectrometry revealed ALECT2 as the amyloidogenic protein. DISCUSSION: ALECT2 is a systemic amyloidosis that typically involves kidneys, adrenals, spleen, and liver. It may be clinically unsuspected at the time of renal transplantation and should be considered in older patients, especially from higher ALECT2 amyloid prevalence populations. Complications related to systemic disease may add to morbidity or mortality post-transplantation. Cardiac involvement in ALECT2 amyloidosis has not been previously identified as a significant clinical or autopsy finding, but our case demonstrates that the cardiovascular system may indeed rarely be involved by ALECT2 amyloidosis in cases with extensive systemic disease, and it may be associated with significant clinical sequelae.

Complex endovascular repair of type B aortic dissection and predicting left arm ischemia: a case report.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the gold standard for surgical management of descending thoracic aortic pathology. Depending on the anatomy, TEVAR often requires deployment across the origin of the left subclavian artery (LSA) to obtain a proximal seal, thus potentially compromising perfusion to the left upper extremity (LUE). However, in most patients this is generally well tolerated without revascularization due to collateralization from the left vertebral artery (LVA). CASE PRESENTATION: We present a complex 59-year-old Caucasian patient case of TEVAR with a history of prior arch debranching and intraoperative LSA coverage requiring subsequent LSA embolization and emergency take-back for left carotid-subclavian bypass. CONCLUSION: The purpose of this case report is to highlight an often overlooked anatomic LVA variant and an atypical, delayed presentation of acute LUE limb ischemia.

Frailty is a Poor Predictor of Postoperative Morbidity and Mortality After Ruptured Abdominal Aortic Aneurysm.

BACKGROUND: Frailty has gained prominence as a predictor of postoperative outcomes across a number of surgical specialties, vascular surgery included. The role of frailty is less defined in the acute surgical setting. We assessed the prognostic value of frailty for patients undergoing surgery for a ruptured abdominal aortic aneurysm (rAAA). METHODS: A single-institution retrospective chart review of all patients undergoing surgical intervention for rAAA between January 1, 2011 and November 27, 2019 was performed. Frailty was assessed for each patient using the modified frailty index (mFI), a validated frailty metric based on the Canadian Study of Health and Aging. Frailty was defined as an mFI ≥0.27. The performance of the mFI was compared to that of the Vascular Study Group of New England (VSGNE) rAAA mortality risk score. Chi square, Fisher's exact, and t tests, were used to evaluate for associations between frailty and in-hospital outcomes. Univariate and multivariate logistic regression were used to obtain odds ratios for in-hospital mortality. A receiver operating characteristic (ROC) curve was generated to compare the predictive value of the mFI and VSGNE score for in-hospital mortality. RESULTS: Sixty patients were identified during the study period with an in-hospital mortality rate of 37%. Twenty-one patients were deemed frail by mFI metric and included all patients with known myocardial infarction, stroke with a neurologic deficit or dependent functional status, however the mortality rate did not differ significantly based on frailty status (33% nonfrail vs. 43% frail, P= 0.47). Frailty status was not significantly different for patients with acute kidney injury (10% nonfrail vs. 10% frail), prolonged intubation (13% vs. 5%), abdominal compartment syndrome (8% vs. 10%), and Type I or Type III endoleak (8% vs. 19%). On multivariate analysis controlling for systolic blood pressure <70 mm Hg, suprarenal aortic control, and creatinine >2.0 mg/dl, the mFI produced an adjusted odds ratio (aOR) of 0.7 (95% confidence interval [CI]: 0.2-3.0). The ROC curve for the mFI produced an area under the curve (AUC) of 0.55 (P= 0.55) for in-hospital mortality while that of the VSGNE score produced an AUC of 0.69 (P= 0.02). CONCLUSIONS: The mFI did not significantly predict in-hospital outcomes after rAAA in this cohort. This suggests that the baseline health status of a patient with rAAA may play a less significant role in their postoperative prognosis than their acuity on presentation.

Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy.

BACKGROUND: Anesthesia modalities for carotid endarterectomy continue to vary nationally. We evaluated and compared short-term outcomes after carotid endarterectomy with general anesthesia (GA) and regional anesthesia (RA) in both symptomatic and asymptomatic patients. METHODS: The 2011-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (PUFs) with merged Vascular Procedure-Targeted PUFs for carotid endarterectomy were queried for patients undergoing carotid endarterectomy. Postoperative complications, mortality, and hospital length of stay in patients undergoing GA or RA were compared. RESULTS: A total of 14,447 patients were evaluated: 12,389 (85.7%) with GA and 2,058 (14.3%) with RA. The use of GA was inversely associated with patients' age (88.0% in patients aged 22-64 years vs. 83.4% in patients aged ≥80 years, P < 0.0001) and with symptomatic presentation (odds ratio [OR] = 1.25; 95% confidence interval [CI]: 1.13-1.38). There were no differences between GA and RA for in-hospital mortality, 30-day mortality, or postoperative complications of transient ischemic attack, stroke, bleeding, acute renal failure, or restenosis. However, rates of cranial nerve injury were significantly higher in GA than in RA (2.9% vs. 1.7%, respectively; P < 0.002) and confirmed by multivariable analysis (OR = 1.68; 95% CI: 1.19-2.39). Total operative time was also longer for GA than for RA (median: 115 minutes; Interquartile range (IQR): 89-145 versus median: 93 minutes; IQR: 76-119, respectively; P < 0.0001). Hospital length of stay was greater in GA than in RA (median: 1 day; IQR 1-2 vs. median: 1 day; IQR 1-1, respectively; P < 0.0001), as were 30-day readmission rates (6.7% vs. 5.4%, respectively; P = 0.02). CONCLUSIONS: Iatrogenic nerve injury is a feared complication of carotid endarterectomy, especially in elective asymptomatic patients. RA reduces the rate of cranial nerve injury compared with GA. RA is also not inferior to GA for postoperative complications with the benefit of shorter operative times, lengths of hospital stay, and decreased 30-day readmission rates. Consideration should be given to more widespread adoption of this underused anesthesia modality.

Concomitant Aorto-Caval Reconstruction for Inferior Vena Cava Leiomyosarcoma.

BACKGROUND: Leiomyosarcoma of the inferior vena cava (IVC) is a rare smooth muscle neoplasm typically presenting in the fifth to sixth decades of life with both intraluminal and extraluminal growth patterns. Surgical resection remains the gold standard for nonmetastatic disease and often requires vascular reconstruction. We present an atypical case of leiomyosarcoma involving both the IVC and infrarenal abdominal aorta necessitating reconstruction with intraoperative veno-venous bypass. METHODS: A 63-year-old man initially presenting with back pain was found to have a large mass adjacent to the IVC on MRI, subsequently confirmed to be leiomyosarcoma by biopsy. After 6 months of neoadjuvant chemotherapy, the patient was taken for resection. However, intraoperatively the tumor was found to involve the aorta necessitating combined aorto-caval reconstruction. To facilitate en-bloc resection of the tumor, the aorta was reconstructed first followed by the inferior vena cava using veno-venous bypass. RESULTS: Postoperatively, the patient was taken to the intensive care unit for resuscitation and had an uncomplicated hospital course. He was discharged to rehab 6 days postoperatively and at one year remains free of significant tumor burden with patent aorto-caval bypass grafts. CONCLUSIONS: Primary leiomyosarcoma of the IVC is estimated to have aortic involvement in <10% of cases and concurrent aorto-caval reconstruction can be a well-tolerated option in good surgical candidates. Furthermore, veno-venous bypass can be a useful tool for accomplishing successful oncologic resections. With interdisciplinary collaboration between surgical oncologists, urologists, and vascular surgeons, difficult pathologies can be addressed with good patient outcomes.

Extravascular reconstruction of a congenitally absent inferior vena cava.

Congenital absence of the inferior vena cava is an uncommon venous anomaly with treatment algorithms consisting of predominately medical management. We present a case of a 36-year-old man with venous ulcers who had failed conservative treatment for recurrent venous ulcers. From a catheter directed approach, we were able to develop an extravascular retroperitoneal space and perform an iliocaval reconstruction with Wallstents. At 1-year postoperatively, his leg pain and edema had resolved, and had achieved resolution of his venous ulceration.

Intraoperative transradial angiography augments safe hysterectomy for uterine fibroids in the setting of ambiguous arterial anatomy: a case report.

BACKGROUND: Transfemoral access is the traditional gold standard for uterine artery angiography; however, transradial access is gaining in popularity because of its decreased complication profile and patient preference. We present a case of a patient who underwent successful total abdominal hysterectomy for symptomatic uterine fibroids with ambiguous pelvic vasculature that would have been otherwise aborted if it were not for intraoperative transradial access angiography. CASE PRESENTATION: A 52-year-old Caucasian woman presented to her gynecologist for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. During preoperative imaging, a 15-cm mass consistent with a uterine fibroid was identified, and the patient's gynecologist decided to treat her with surgical resection, given the fibroid's size. The procedure was halted upon discovery of a complicated vascular plexus at the fundus of the uterus, and an intraoperative vascular consult was requested. The vascular operator used a transradial access to perform pelvic angiography in real time to identify the complicated pelvic vasculature, which allowed the gynecologist to surgically resect the uterine fibroid. The patient was discharged on postoperative day 4 without any complications. CONCLUSIONS: Intraoperative imaging is a useful technique for the identification of complicated anatomical structures during surgical procedures. The successful outcome of this case demonstrates an additional unique benefit of transradial access and highlights an opportunity for interdisciplinary collaboration for management of complicated surgical interventions.

Use of liposomal bupivacaine in the postoperative management of posterior spinal decompression.

OBJECTIVE The aim in this paper was to evaluate the efficacy of long-acting liposomal bupivacaine in comparison with bupivacaine hydrochloride for lowering postoperative analgesic usage in the management of posterior cervical and lumbar decompression and fusion. METHODS A retrospective cohort-matched chart review of 531 consecutive cases over 17 months (October 2013 to February 2015) for posterior cervical and lumbar spinal surgery procedures performed by a single surgeon (J.J.) was performed. Inclusion criteria for the analysis were limited to those patients who received posterior approach decompression and fusion for cervical or lumbar spondylolisthesis and/or stenosis. Patients from October 1, 2013, through December 31, 2013, received periincisional injections of bupivacaine hydrochloride, whereas after January 1, 2014, liposomal bupivacaine was solely administered to all patients undergoing posterior approach cervical and lumbar spinal surgery through the duration of treatment. Patients were separated into 2 groups for further analysis: posterior cervical and posterior lumbar spinal surgery. RESULTS One hundred sixteen patients were identified: 52 in the cervical cohort and 64 in the lumbar cohort. For both cervical and lumbar cases, patients who received bupivacaine hydrochloride required approximately twice the adjusted morphine milligram equivalent (MME) per day in comparison with the liposomal bupivacaine groups (5.7 vs 2.7 MME, p = 0.27 [cervical] and 17.3 vs 7.1 MME, p = 0.30 [lumbar]). The amounts of intravenous rescue analgesic requirements were greater for bupivacaine hydrochloride in comparison with liposomal bupivacaine in both the cervical (1.0 vs 0.39 MME, p = 0.31) and lumbar (1.0 vs 0.37 MME, p = 0.08) cohorts as well. None of these differences was found to be statistically significant. There were also no significant differences in lengths of stay, complication rates, or infection rates. A subgroup analysis of both cohorts of opiate-naive versus opiate-dependent patients found that those patients who were naive had no difference in opiate requirements. In chronic opiate users, there was a trend toward higher opiate requirements for the bupivacaine hydrochloride group than for the liposomal bupivacaine group; however, this trend did not achieve statistical significance. CONCLUSIONS Liposomal bupivacaine did not appear to significantly decrease perioperative narcotic use or length of hospitalization, although there was a trend toward decreased narcotic use in comparison with bupivacaine hydrochloride. While the results of this study do not support the routine use of liposomal bupivacaine, there may be a benefit in the subgroup of patients who are chronic opiate users. Future prospective randomized controlled trials, ideally with dose-response parameters, must be performed to fully explore the efficacy of liposomal bupivacaine, as the prior literature suggests that clinically relevant effects require a minimum tissue concentration.

Scavenger receptor class A member 5 (SCARA5) and suprabasin (SBSN) are hub genes of coexpression network modules associated with peripheral vein graft patency.

OBJECTIVE: Approximately 30% of autogenous vein grafts develop luminal narrowing and fail because of intimal hyperplasia or negative remodeling. We previously found that vein graft cells from patients who later develop stenosis proliferate more in vitro in response to growth factors than cells from patients who maintain patent grafts. To discover novel determinants of vein graft outcome, we have analyzed gene expression profiles of these cells using a systems biology approach to cluster the genes into modules by their coexpression patterns and to correlate the results with growth data from our prior study and with new studies of migration and matrix remodeling. METHODS: RNA from 4-hour serum- or platelet-derived growth factor (PDGF)-BB-stimulated human saphenous vein cells obtained from the outer vein wall (20 cell lines) was used for microarray analysis of gene expression, followed by weighted gene coexpression network analysis. Cell migration in microchemotaxis chambers in response to PDGF-BB and cell-mediated collagen gel contraction in response to serum were also determined. Gene function was determined using short-interfering RNA to inhibit gene expression before subjecting cells to growth or collagen gel contraction assays. These cells were derived from samples of the vein grafts obtained at surgery, and the long-term fate of these bypass grafts was known. RESULTS: Neither migration nor cell-mediated collagen gel contraction showed a correlation with graft outcome. Although 1188 and 1340 genes were differentially expressed in response to treatment with serum and PDGF, respectively, no single gene was differentially expressed in cells isolated from patients whose grafts stenosed compared with those that remained patent. Network analysis revealed four unique groups of genes, which we term modules, associated with PDGF responses, and 20 unique modules associated with serum responses. The "yellow" and "skyblue" modules, from PDGF and serum analyses, respectively, correlated with later graft stenosis (P = .005 and P = .02, respectively). In response to PDGF, yellow was also associated with increased cell growth. For serum, skyblue was also associated with inhibition of collagen gel contraction. The hub genes for yellow and skyblue (ie, the gene most connected to other genes in the module), scavenger receptor class A member 5 (SCARA5) and suprabasin (SBSN), respectively, were tested for effects on proliferation and collagen contraction. Knockdown of SCARA5 increased proliferation by 29.9% ± 7.8% (P < .01), whereas knockdown of SBSN had no effect. Knockdown of SBSN increased collagen gel contraction by 24.2% ± 8.6% (P < .05), whereas knockdown of SCARA5 had no effect. CONCLUSIONS: Using weighted gene coexpression network analysis of cultured vein graft cell gene expression, we have discovered two small gene modules, which comprise 42 genes, that are associated with vein graft failure. Further experiments are needed to delineate the venous cells that express these genes in vivo and the roles these genes play in vein graft healing, starting with the module hub genes SCARA5 and SBSN, which have been shown to have modest effects on cell proliferation or collagen gel contraction.