Metabolic Syndrome but not Obesity Adversely Affects Outcomes after Open Aortoiliac Bypass Surgery.

BACKGROUND: Although the incident risk of peripheral artery disease increases in patients with metabolic syndrome, several authors report favorable outcomes in obese patients after arterial bypass surgery. We examine the effect of the so-called "obesity paradox" and metabolic syndrome on outcomes after open aortoiliac bypass surgery. METHODS: We identified patients between 2004 and 2015 who had open surgical bypass for aortoiliac occlusive disease. We excluded patients with endovascular repair and those treated primarily for aneurysmal disease. Variables that were analyzed included preoperative medical history, Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease II classification, Rutherford classification, intra-operative, and postoperative outcomes. Metabolic syndrome was defined by World Health Organization criteria: diabetes and 2 or more of dyslipidemia, hypertension, and obesity (body mass index > 30 kg/m2). Data were analyzed by stratified Kaplan-Meier and multiple Cox regression for outcomes including long-term mortality and reintervention rate. RESULTS: There were 154 open bypass surgery patients during the study period with a median age of 60 years (interquartile range [IQR] 53-68), median glomerular filtration rate 76.1 mL/min (IQR 54-102), and 58% female prevalence. In all, 53 patients had metabolic syndrome (4%), and 14 patients (9%) were obese but did not have metabolic syndrome. Primary bypass graft patency was 89.0 ± 2.7% at 1 year and 77.4 ± 4.1% at 5 years and was not significantly different between metabolic syndrome, obese, and nonmetabolic syndrome patients. Reintervention rate for the entire cohort was 25.3 ± 3.7% at 1 year and 40.6 ± 4.7% at 5 years. In those with and without metabolic syndrome, reintervention rate at 1 and 5 years was 33.0 ± 6.8% vs. 21.1 ± 4.2% and 56.1 ± 7.9% vs. 30.7 ± 5.4%, respectively (log-rank P = 0.003). In multivariable analyses, metabolic syndrome (hazard ratio [HR] 1.8, P = 0.036) and critical limb ischemia (CLI) (HR: 3.2, P = 0.001) were the only independent predictors of reintervention. Neither obesity nor the individual components comprising metabolic syndrome was a risk for reintervention. Multivariate analysis demonstrated age, female gender, CLI, and nonobesity as the independent risk factors for long-term mortality. CONCLUSIONS: Our study supports the "obesity paradox" that obesity by itself is not a risk factor for reintervention and was a protective factor for mortality after open aortoiliac bypass surgery. Bypass graft patency and major amputation rates were not affected. Although the individual components do not predispose to worse outcome, metabolic syndrome is a constellation of factors that, together, are associated with adverse events.

Indications and Outcomes of Open Inferior Vena Cava Filter Removal.

BACKGROUND: Despite recommendations for retrieval of inferior vena cava (IVC) filters, most are not removed in a timely manner. Longer IVC filter dwell times are associated with caval wall perforation and tilting that make percutaneous retrieval more difficult. Open IVC filter removal is generally reserved for patients with symptoms referable to the filter, such as chronic back and abdominal pain. We present our management algorithm and review of cases of open IVC filter removal. METHODS: Patients referred for management of implanted IVC filters from May 2010 to May 2016 were included. Demographic and imaging were reviewed for cases requiring open surgical removal. RESULTS: There were 221 percutaneous retrieval attempts in 218 patients. Successful retrieval occurred in 196 (89%) attempts. There were 7 patients who had open surgical IVC filter removal after failure of percutaneous retrieval. One patient had 2 filters and another had 3 filters. Except for 1 case with complications during the percutaneous retrieval procedure, the remaining patients all suffered from back or abdominal pain. All had significant filter strut penetration through the caval wall into adjacent structures. Postoperatively, all patients had relief of pain. There were no deaths and 1 patient had a minor ileus that spontaneously resolved. CONCLUSIONS: Patients who fail percutaneous IVC filter retrieval can expect low morbidity and prompt resolution of symptoms after open surgical removal via minilaparotomy.

Ogilvie's Syndrome in a Young Female With Chronic Constipation.

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction, is often encountered in post-surgical patients or those with serious comorbidities requiring intensive care. For this reason, it has rarely been reported in patients younger than 50 years without any predisposing risk factors. Our case report highlights a unique case of Ogilvie's syndrome in a young female with no recent trauma or surgical history. To that extent, we discuss risk factors that predisposed her to this condition, including her history of chronic constipation. We also emphasize the need for outpatient workups for such patients to prevent the worsening of their symptoms.

Coxsackievirus-Induced Myocarditis With Acute Onset of Heart Failure With Pleural Effusion.

This is a case of a 45-year-old Caucasian female with coxsackievirus-induced myocarditis. Myocarditis is an inflammation of the heart muscles, which can be difficult to diagnose at times because its symptoms overlap with other cardiovascular diseases. At times, when the patient presents, the full impact of the etiology would have either improved or resolved. In this case, the patient presented with symptoms closely resembling that of acute coronary syndrome but did not fit the typical age category. After lab and imaging workup, the coxsackievirus panel was positive, complicated with a new diagnosis of systolic heart failure with an ejection fraction of 30%-35% along with pericardial effusion.

Arthroplasty Versus Internal Fixation for the Treatment of Undisplaced Femoral Neck Fractures: A Retrospective Cohort Study.

OBJECTIVE: To compare the 24-month risk of mortality between arthroplasty and internal fixation for undisplaced femoral neck fractures (FNFs). DESIGN: Retrospective cohort study. SETTING: Secondary data analysis of 2 multinational randomized controlled trials. PARTICIPANTS: Patients aged 50 years or older with a FNF. INTERVENTION: Arthroplasty (n = 1441), including total hip arthroplasty and hemiarthroplasty, performed for a displaced FNF versus internal fixation (n = 734), including sliding hip screw or multiple cancellous screws, performed for an undisplaced FNF. MAIN OUTCOME MEASUREMENT: The primary outcome was mortality within 24 months of injury. Secondary outcomes included reoperation and health-related quality of life. RESULTS: The 24-month mortality rate was 15.0% (n = 327). Arthroplasty was associated with a significant reduction in the odds of mortality [adjusted odds ratio (aOR): 0.56, 95% confidence interval (CI): 0.44-0.72, P < 0.01] compared with treatment with internal fixation. 11.4% (n = 248) of the study patients required reoperation within 24 months of injury. The odds of reoperation were 59% lower with arthroplasty treatment than with internal fixation (aOR: 0.41, 95% CI: 0.32-0.55, P < 0.01). The 24-month SF-12 physical component scores were 2.7 points higher in arthroplasty patients compared with internal fixation patients (95% CI: 1.6-3.8, P < 0.01). CONCLUSIONS: Our findings suggest arthroplasty for a FNF may reduce the risk of mortality and reoperation compared with internal fixation of undisplaced fractures. This finding is counter to many current surgical practices but consistent with a mounting body of evidence. Before widespread adoption of arthroplasty for undisplaced fractures, these results should be confirmed in a definitive comparative trial. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Redo aortic root replacement reutilizing 22-year patent modified Cabrol grafts.

Long-term patency of modified Cabrol technique in composite aortic root replacement is not well documented. We report a unique case in which a patient presented for prosthetic valve dysfunction with patent Cabrol grafts 22 years after composite root replacement requiring redo aortic root. This case also demonstrates how modified Cabrol grafts can be reutilized in aortic root replacement without compromising adequate fluid dynamics.