A prospective study of carbon dioxide digital subtraction versus standard contrast arteriography in the detection of endoleaks in endovascular abdominal aortic aneurysm repairs.

BACKGROUND: The objective of this study is to compare intraoperative endoleak detection by carbon dioxide digital subtraction angiography (CO(2)-DSA) during endovascular aortic aneurysm repair (EVAR) with standard iodinated contrast angiography (ICA). METHODS: Between 2006 and 2010, 76 patients with abdominal aortic aneurysms undergoing EVAR were enrolled in a prospective study. After EVAR, both an ICA and CO(2)-DSA completion study were performed. Two blinded vascular surgeons who were not involved with the EVAR separately interpreted the ICA and CO(2)-DSA results for the presence or absence of an endoleak. Identified endoleaks were classified by types. A third, "tie-breaker" blinded observer was used to resolve differences in interpretations. The sensitivity, specificity, negative predictive value, and positive predictive value were calculated for the ability of CO(2)-DSA to detect endoleaks. Cohen's κ statistic was used to assess interobserver agreement between the 2 initial interpreting surgeons. RESULTS: Of the 76 patients undergoing EVAR, 66 were men with average age of 76 years, a mean aneurysm size of 5.8 cm (range, 4-10 cm), and creatinine of 1 (standard deviation, 0.33). ICA identified 35 type I and 15 type II endoleaks, respectively, while CO(2)-DSA identified 40 type I and 10 type II endoleaks. Overall, CO(2)-DSA had a sensitivity of 0.84, specificity of 0.72, positive predictive value of 0.86, and negative predictive value of 0.69 of intraoperative endoleak detection, with respect to ICA as the criterion standard. The interobserver κ between surgeons for ICA was 0.56, for detection of any endoleak or type I endoleak with CO(2)-DSA was 0.58, and for detection of type II endoleak with CO(2)-DSA was 0.29. CONCLUSIONS: Interobserver agreement for the detection of endoleaks is superior with ICA compared to CO(2)-DSA. However, the sensitivity for detecting any endoleak and both the sensitivity and specificity for detecting type I endoleaks using CO(2)-DSA are acceptable. For detecting type II endoleaks using CO(2)-DSA, the sensitivity and positive predictive value are poor. Compared to ICA, CO(2)-DSA provides adequate images for endoleak detection during EVAR and is an acceptable alternative to ICA in patients at risk for contrast-related nephrotoxicity.

Predictors of wound complications following major amputation for critical limb ischemia.

OBJECTIVES: For patients with end-stage critical limb ischemia (CLI) who have already suffered over an extended period of time, a major amputation that is free of wound complications remains paramount. Utilizing data from the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP), the objective of this report was to determine critical factors leading to wound complications following major amputation. METHODS: ACS-NSQIP was used to identify patients ≥ 50 years, with CLI, and having an ipsilateral below-(BKA) or above-knee amputation (AKA). The primary outcome was wound occurrence (WO) defined by affirmative findings of superficial infection, deep infection, and/or wound disruption. The secondary outcome was 30-day mortality. Following univariate analyses, a multiple logistic regression was performed to identify predictive factors. RESULTS: Between January 1, 2005 and December 31, 2008, 4250 patients fulfilled inclusion criteria (2309 BKAs and 1941 AKAs). WOs were 10.4% for BKAs and 7.2% for AKAs. For BKAs, increasing elevation in international normalized ratio (INR) predicted more WOs (P = .008, odds ratio [OR] 1.5 for every integral increase in INR) as did age 50 to 59 compared with older patients (P = .002, OR 1.9). For AKAs, being a current smoker predicted more WOs (P = .0008, OR 1.8) as did an increasing body mass index (BMI) (P = .02, OR 1.3 for every 10 kg/m(2) increase in BMI). Mortality was 7.6% for BKAs and 12% for AKAs. Complete functional dependence was most predictive of mortality following AKA (P < .0001, OR 2.5). Medical comorbidities such as history of myocardial infarcation (MI) (OR 1.8), congestive heart failure (CHF, OR 1.6), and chronic obstructive pulmonary disease (COPD, OR 1.6) predicted mortality following BKA, while dialysis use (OR 2.4), CHF (OR 2.3), and COPD (OR 2.1) predicted mortality following AKA. CONCLUSIONS: Wound occurrences and mortality rates after major amputation for CLI continue to be a prevalent problem. Normalization of the INR prior to BKA should decrease WOs. Heightened awareness in higher risk patients with improved preventive measures, earlier disease recognition, better treatments, and increased education remain critical to improving outcomes in an already stressed patient cohort.

Predictors of Groin Access Pseudoaneurysm Complication: A 10-Year Institutional Experience.

OBJECTIVE: In clinical practice, the incidence of femoral pseudoaneurysms requiring repair is small, but at a tertiary care center, the repair rate is higher due to referrals. We sought to specifically study patients who suffered postcatheterization pseudoaneurysms requiring thrombin injection or operative repair and compare them to our routine transfemoral endovascular patients to identify predictors of clinically significant pseudoaneurysms. The underlying goal would be to identify what makes these patients that develop pseudoaneurysms different. METHODS: A search of our billing records for Current Procedural Technology (CPT) codes of these 2 procedures between January 2008 and April 2018 was combined with our institution's Peripheral Vascular Intervention Vascular Quality Initiative database spanning from January 2013 to December 2017. A comparison was then performed between patients who had the outcome of operative intervention for a pseudoaneurysm complication and those who did not, with the goal of elucidating patient demographics and periprocedural factors that would predict pseudoaneurysm formation using univariate and multivariate analyses. RESULTS: There were 77 patients who required thrombin injection or open repair for access-related pseudoaneurysms and 324 patients who did not. Complications occurred more often in patients who were older than 75 (40.2% vs 21.9%; P = .0009), female (57.1% vs 38.6%; P = .003), obese (59.7% vs 33.3%; P < .001), hypertensive (96.1% vs 79.3%; P = .0005), who received a sheath >6F (32.4% vs 13%; P < .0001), intraoperative and postoperative anticoagulation (77.3% vs 32.7% and 52.1% vs 24.2%, respectively; P < .0001), and periprocedural P2Y12 inhibitors (48.7% vs 28%; P = .0005). Less complications were observed in patients who had a closure device used (42.9% vs 8.45%; P < .0001) and protamine reversal (26.5% vs 13.3%; P = .0163). CONCLUSIONS: Our findings validate published reports that incriminate a larger sheath size, perioperative anticoagulation, and female gender as increasing the rate of access site complications, with the use of a closure device being protective.

Race independently impacts outcome of infrapopliteal bypass for symptomatic arterial insufficiency.

The impact of racial background on the outcome of lower extremity revascularization is unknown because a majority of studies have a preponderance of white patients. The charts of patients between 1988 and 2004 requiring infrapopliteal lower extremity revascularization were reviewed. Life-table analyses, the Cox proportional hazards model, and log-rank test were used to calculate graft patency and limb salvage. Bypasses were performed on 236 limbs in 225 patients. Mean follow-up was 18 +/- 1.5 months. Twenty-eight (12%) bypasses were performed on whites, 43 (18%) on African Americans, 148 (63%) on Hispanics, and 17 (7.2%) on patients of other races. African American race negatively correlated with primary-assisted patency (hazard ratio 2.9, P = .03), secondary patency (hazard ratio 3.64, P = .02), and limb salvage (hazard ratio 8, P = .006) compared with whites. African American race has a negative impact on the long-term outcome of infrapopliteal revascularization, regardless of disease stage or associated risk factors.

Current trends in the management of iatrogenic cervical carotid artery injuries.

This study was undertaken to elicit the opinion of experts regarding the management of iatrogenic injury to the carotid artery. A text questionnaire was transmitted by electronic mail to members of the Western Vascular Society concerning management of iatrogenic injury to the cervical carotid artery. Participants were asked to submit information regarding practice status and their preferred choices for the management of different clinical scenarios. The scenarios were: (1) large bore sheath (> 8.5F) cannulation of the carotid artery in anesthetized patients, (2) large bore sheath cannulation of the carotid artery in an awake patient, (3) delayed recognition of a misplaced sheath by > 4 hours, and (4) arterial puncture was recognized after only the entry needle (16-gauge) was introduced but before sheath insertion. Finally, the members were asked to comment on the management of abnormal findings on duplex scanning, such as intimal flap or pseudoaneurysm. A response rate of 42% was obtained (45/106 active members). Eighty-two percent of respondents had been in practice for longer than 10 years. Eighty-nine percent had seen this complication and 29% had cared for patients in whom subsequent neurologic deficit developed. The institutional incidence of such injury was 1-5 cases per year for 82% of respondents. Sixteen-gauge needle injury was managed by immediate removal and applied pressure by 98% of respondents. When large-bore sheath injury is recognized within 1 hour of insertion, 62% of respondents would remove the sheath and hold pressure, with or without obtaining a duplex ultrasound examination. However, if injury recognition was delayed for > 4 hours, 82% would proceed to surgery. Only 26% operated on asymptomatic carotid flap found on ultrasound, while the remaining 74% would base their decision on size and flow characteristics on ultrasound. The management of pseudoaneurysm differed significantly. Whereas 31% of respondents would manage this finding expectantly, 69% would proceed to surgery regardless of size or symptoms. Despite awareness of iatrogenic injury to the cervical carotid artery, the institutional incidence remains high. Two thirds of respondents would manage a misplaced sheath in the carotid artery nonoperatively if the injury was recognized immediately. However, if injury recognition was delayed for > 4 hours, the majority of respondents would remove the sheath surgically. While the management of intimal flap largely depended on size and flow characteristics, 69% of respondents would operate on a pseudoaneurysm regardless of size or symptoms. The results of this survey may serve as a guideline for the management of this potentially devastating injury.

Concomitant vascular procedures for malignancies with vascular invasion.

HYPOTHESIS: Contemporary reconstructive vascular techniques can be safely used to permit resection of tumors invading major vascular structures. DESIGN: Review of vascular surgery registry between January 1, 1987, and December 31, 2001. SETTING: An academic medical center and affiliated institutions. PATIENTS: Forty-nine patients (37 males and 12 females) aged 15 through 80 years (mean age, 55 years) who required concomitant vascular resection and reconstruction to allow complete tumor resection. MAIN OUTCOME MEASURES: Early (<30 days) morbidity and mortality, late (>30 days) vascular morbidity and mortality, primary patency of the vascular reconstruction, and tumor-free survival. RESULTS: Aortic resection with graft reconstruction was performed in 20 patients (41.7%) and inferior vena cava resection with reconstruction in 6 patients (12.5%). Five patients (10.4%) had both the aorta and inferior vena cava resected and reconstructed. Iliac, femoral, or popliteal reconstructions were performed in 15 patients (31.3%). Portal vein reconstruction was performed to permit resection of pancreatic neoplasms in 8 patients (16.7%). Resection and reconstruction of either a brachiocephalic vessel or superior vena cava was performed in 4 patients. Thirty-day mortality was 2.1%, as 1 patient died of a myocardial infarction following tumor resection with vascular reconstruction. Overall 30-day morbidity was 12.2%. Early vascular morbidity included bleeding from an arterial anastomosis and a compartment syndrome requiring fasciotomy. Primary patency of the vascular reconstructions at 24 months was 90% and tumor-free survival was 70%. Thirty-one patients (63%) were alive, without tumor recurrence and with a patent vascular reconstruction at 24 months. No patient died or lost a limb due to occlusion of the vascular reconstruction. CONCLUSION: Contemporary reconstructive vascular procedures permit resection of tumors that involve major vascular structures with acceptable early and late morbidity and mortality.

Endovascular management of iliofemoral venous occlusive disease.

New developments in the management of both acute and chronic iliac vein occlusive disease offer exciting options for the treatment of this often debilitating condition. Percutaneous clot removal using thrombolysis, mechanical thrombectomy, or a combination of the two is fast becoming the treatment of choice for patients presenting with acute iliofemoral deep vein thrombosis. Recanalization of chronic iliac vein occlusions with balloon angioplasty and stenting relieves symptoms of extremity swelling and pain in the majority of treated patients. Existing data provide convincing proof of the efficacy of endovascular recanalization procedures, and upcoming prospective, controlled trials will further clarify the role of these techniques in the therapeutic armamentarium.

Current endovascular management of atherosclerotic renal artery stenosis.

The recent advances in stent technology and renal endovascular management have provided a technically reproducible method of percutaneously treating atherosclerotic renal artery stenosis (RAS). In many centers, this has resulted in endovascular management being the primary therapy for atherosclerotic RAS. Although still controversial, it appears that endovascular management of RAS by primay stent deployment provides better blood pressure control than that afforded by best medical management. The impact on renal function is less than that found for hypertension, but there is evidence to suggest that the use of protection devices and primary stenting may enhance renal function outcomes. Whether the ultimate benefit of enhanced survival follows remains an important question and should be the subject of future prospective studies.

Influence of transmetatarsal amputation in patients requiring lower extremity distal revascularization.

When a transmetatarsal amputation (TMA) is required, successful long-term limb salvage is questioned. We evaluated the influence of TMA on limb salvage in patients undergoing lower extremity revascularization. Patients who had distal bypasses extending to the infrapopliteal arterial tree and adjunctive TMA were retrospectively reviewed. Limb salvage was determined with life-table analysis. Twenty-four patients (29 limbs) were evaluated: 15 male and 9 female. Average age was 64.2 years old. Gangrene was the indication for bypass and TMA in 25 (86.2%) patients. Seven limbs were lost to follow-up. Nine of the remaining 22 limbs required below-knee (8) or above-knee (1) amputations, seven limbs within the first 3 months. In the group of patients who had major amputations within the first 3 months, graft thrombosis was the cause of leg amputation in six (85.7%) cases. No significant predictors of early major amputation were identified. Limb salvage was 62 per cent at 1 year in the TMA group. In comparison, among historical controls requiring distal revascularization and no adjunctive toe or foot amputations, limb salvage was 76.5 per cent (P = NS). Long-term limb salvage is dependent on successful lower extremity revascularization. Requirement for TMA should not influence the decision for limb salvage.

Technical consideration in the management of chronic mesenteric ischemia.

Our aging population may result in a rise in the prevalence of chronic mesenteric ischemia. This report reviews our contemporary experience with a tailored surgical approach to chronic mesenteric ischemia. The medical records of 17 patients operated on for chronic mesenteric ischemia were retrospectively reviewed. Symptom-free survival and long-term patency documented by duplex scanning when available were also analyzed. Sixteen patients ranging in age from 32 to 80 years were included in the study. Seventy-five per cent of the patients were female. The most common preoperative complaints were postprandial abdominal pain and weight loss. Revascularization was tailored to the arterial anatomy and included bypass to the superior mesenteric artery (SMA) alone (eight), bypass to the celiac artery and SMA (six), SMA reimplantation onto the aorta (one), SMA/inferior mesenteric artery reimplantation (one), and transaortic endarterectomy of the celiac artery/SMA (one). Bypass conduits included Dacron (eight), saphenous vein (four), and polytetrafluoroethylene (two). Bypass grafts originated from the supraceliac aorta in 12 patients; the remaining bypass originated from the left limb of an aortofemoral graft. There was one perioperative death (mortality 5.6%). Follow-up duplex scans at a mean of 34 months (range 1-114) showed no graft thromboses. We conclude that a variety of surgical techniques can provide durable relief of mesenteric ischemia. A tailored approach to revascularization optimizes patency and provides long-term symptom-free survival.

Clinical importance of the "seat belt sign" in blunt trauma to the neck.

Currently a carotid duplex scan is the initial screening modality routinely used to evaluate occult extracranial carotid artery injuries secondary to blunt neck trauma. The objective of this study was to investigate the role of carotid artery duplex scanning in patients who suffered blunt trauma to the neck with a "seat belt sign." The medical records of 131 consecutive patients who sustained blunt trauma to the neck from a motor vehicle accident were reviewed. Patients with the cervical seat belt sign underwent a complete physical examination and carotid duplex scan in an accredited vascular laboratory. An intimal flap with severe carotid artery stenosis was found in one of 131 patients (0.76%). This patient has multiple injuries to the face, head, chest, lateralizing neurological signs, and a Glasgow Coma Scale score of 8. In an era of cost containment, resource consumption should target appropriate populations. A cervical seat belt sign should not serve as a sole indicator for evaluation of the carotid artery in the absence of other pertinent signs or symptoms.

Safety of carbon dioxide digital subtraction angiography.

OBJECTIVE: Reports of fatality following carbon dioxide digital subtraction angiography (CO2-DSA) have raised concerns regarding its safety. This study reviews the safety of CO2-DSA. DESIGN: Single-institution retrospective review. SETTING: Tertiary care teaching hospital in Los Angeles, California. PATIENTS: A total of 951 patients who underwent 1007 CO2-DSA procedures during a 21-year period. MAIN OUTCOME MEASURES: Preprocedure and postprocedure creatinine values and periprocedural morbidity and mortality. RESULTS: A total of 632 arterial CO2-DSA were performed; 527 were aortograms with or without extremity runoff; 100, extremity alone; and 5, pulmonary. Venous CO2-DSA included 187 inferior vena cavagrams, 182 hepatic or visceral, 5 extremity venograms, and 1 superior vena cavagram. Associated endovascular procedures were performed in 499 cases; 162 were arterial interventions including 62 endovascular aneurysm repairs, 53 visceral or renal percutaneous angioplasty with/without stent, 41 extremity percutaneous angioplasty with or without a stent, and 4 cases of thrombolysis or embolization; 176 caval filters, 98 transjugular intrahepatic portosystemic shunts, 54 transjugular liver biopsies, and 9 other venous interventions. The mean preprocedure creatinine level was 2.1 mg/dL; postprocedure, 2.1 mg/dL (P = .56). There were a total of 61 (6.1%) procedural complications including 4 (0.4%) mortalities. Two were procedure-related complications: 1, suppurative pancreatitis following aortogram; and 2, hepatic bleed following failed transjugular intrahepatic portosystemic shunts. Two were attributable to patient disease; 1, metastatic adenocarcinoma; and 2, refractory, end-stage cardiomyopathy. CONCLUSION: Carbon dioxide digital subtraction angiography is a versatile technique that can be safely used for diagnostic and therapeutic endovascular procedures. Morbidity and mortality are acceptable with preservation of renal function. Thus, CO2-DSA is a safe alternative to iodinated contrast.

Preliminary retrograde visceral artery reconstruction for thoracoabdominal aortic aneurysms.

The recent availability of thoracic endografts has expanded the options for treatment of thoracoabdominal aortic pathology. However, disease that involves the visceral aortic segment presents a special challenge due to the need to preserve mesenteric perfusion. We present three patients in whom preliminary retrograde visceral artery reconstruction was used as an adjunct prior to endovascular repair.

Carbon dioxide digital subtraction angiography-assisted endovascular aortic aneurysm repair in the azotemic patient.

OBJECTIVE: This report analyzes the safety and efficacy of carbon dioxide digital subtraction angiography (CO(2)-DSA) for EVAR in a group of patients with renal insufficiency compared with a concurrent group of patients with normal renal function undergoing EVAR with iodinated contrast angiography (ICA). METHODS: Between 2003 and 2005, 100 consecutive patients who underwent EVAR using ICA, CO(2)-DSA, or both were retrospectively reviewed, and preoperative, intraoperative, postoperative, and follow-up variables were collected. Patients were divided into two groups depending on renal function and contrast used. Group I comprised patients with normal renal function in whom ICA was used exclusively, and group II patients had a serum creatinine >or=1.5 mg/dL, and CO(2)-DSA was used preferentially and supplemented with ICA, when necessary. The two groups were compared for the outcomes of successful graft placement, renal function, endoleak type, and frequency, and the need for graft revision. Comparisons were made using chi(2) analysis, Student t test, and the Fisher exact test. RESULTS: A total of 84 EVARs were performed in group I and 16 in group II. Patient demographics and risk factors were similar between groups with the exception of serum creatinine, which was significantly increased in group II (1.8 mg/dL vs 1.0 mg/dL P < .0005). All 100 endografts were successfully implanted. Patients in group II had longer fluoroscopy times, longer operative times, and increased radiation exposure, and 13 of 16 patients required supplemental ICA. Mean iodinated contrast use was 27 mL for group II vs 148 mL in group I (P < .0005). Mean postoperative serum creatinine was unchanged from baseline, and 30-day morbidity was similar for both groups. No patient required dialysis. No patients died. Perioperatively, and at 1 and 6 months, the endoleak type and incidence and need for endograft revision was no different between groups. CONCLUSIONS: CO(2)-DSA is safe, can be used to guide EVAR, and provides outcomes similar to ICA-guided EVAR. CO2-DSA protects renal function in the azotemic patient by lessening the need for iodinated contrast and associated nephrotoxicity, but with the tradeoff of longer fluoroscopy and operating room times and increased radiation exposure.

Current guidelines produce competent endovascular surgeons.

OBJECTIVE: This study was conducted to evaluate the safety of percutaneous endovascular procedures (PEPs) during integration of endovascular skills into an urban academic vascular surgery practice and assess the hypothesis that currently accepted guidelines are a valid benchmark for endovascular competency. METHODS: From 2000 through 2004, an endovascular training paradigm was instituted to integrate endovascular procedures into an academic endovascular practice. The paradigm involved individual mentoring of vascular surgery faculty by a partner with mature endovascular skills. Mentoring continued until each surgeon achieved a procedural experience of 100 diagnostic angiograms and 50 percutaneous endovascular interventions. Once achieved, privileges were granted for independent endovascular practice. To assess the effectiveness of the training process and competency of the newly trained endovascular practitioner, the surgeon-specific 30-day incidence of major complications and deaths for all PEPs performed during and after the mentoring process was determined. Complications and deaths were assigned to the mentor during the training process and to the individual surgeon once endovascular privileges were granted. Complications were classified as local vascular, local nonvascular, or systemic/remote. RESULTS: From 2000 through 2004, 1208 PEPs were performed. During this time, three faculty surgeons achieved sufficient endovascular procedural experience and were granted endovascular privileges. Major complications consisted of 17 local vascular, three local nonvascular, and four systemic/remote. Three deaths occurred. Renal percutaneous transluminal angioplasty/stent procedures had the highest complication and death rate at 9%. The major complication and death rate per year was 1.8% to 4.9% (P = .32) and did not significantly vary. The major complication and death rate for all 1208 PEPs was 2.2%. The surgeon-specific complication and death rate was 1.9% to 3.6% (P = .14) and did not vary between surgeons. CONCLUSION: Endovascular skills can be safely transferred using a vascular surgeon-based training paradigm. When the training paradigm is directed at satisfying currently recommended guidelines for endovascular privileging, competent endovascular surgeons are the result.

Treatment options for traumatic pseudoaneurysms of the paravisceral abdominal aorta.

Penetrating gunshot wounds (GSWs) to the abdominal aorta are frequently lethal. Alternative management options for treatment of traumatic pseudoaneurysms of the abdominal aorta are illustrated by three patient case histories. Patient A sustained two GSWs to the abdomen (midepigastrium, right subcostal region). He was hypotensive in the field. Emergent laparotomy was undertaken with suture ligature of a celiac injury and distal pancreatectomy/splenectomy for a pancreatic injury. Postoperative abdominal CT for an intraabdominal infection with leukocytosis revealed a 4 cm traumatic pseudoaneurysm of the abdominal aorta that extended from the suprarenal aorta to the level of the renal arteries. Six weeks later, he underwent an open repair. Patient B sustained multiple GSWs to his right arm and right upper quadrant. He was hemodynamically stable. He underwent abdominal exploration for a grade 3 liver laceration. Postoperative abdominal CT revealed a supraceliac abdominal aortic pseudoaneurysm. An aortogram demonstrated a 1.5 cm defect in the aortic wall above the celiac trunk communicating with the inferior vena cava (IVC). He underwent endovascular repair with covered aortic stent graft. Patient C sustained multiple thoracoabdominal GSWs. He was hemodynamically stable. Emergent laparotomy revealed multiple left colonic perforations, two duodenal lacerations, and an unsalvageable left kidney laceration. Postoperatively, he developed a duodenal-cutaneous fistula with multiple intraabdominal abscesses. Serial CT scans revealed an enlarging infrarenal aortic pseudoaneurysm. He underwent angiographic coil embolization and intraarterial injection of thrombin into the pseudoaneurysm sac. The average time from injury to surgical treatment was 46 days (range 29-67). Postoperatively, none of the patients developed paraplegia. Advances in endovascular techniques have provided options to deal with traumatic pseudoaneurysms of the abdominal aorta. In a hemodynamically stable patient with a traumatic pseudoaneurysm, careful selection of a specific intervention can be tailored to the clinical scenario electively.

Hypoplasia of the descending thoracic and abdominal aorta: a report of two cases and review of the literature.

Hypoplasia of the thoracic and abdominal aorta, referred to as atypical, elongated, or diffuse coarctation, is an exceedingly rare cardiovascular anomaly. Congenital, acquired, inflammatory, and infectious etiologies have been described. Symptoms typically occur within the first three decades of life and include hypertension, lower extremity claudication, and mesenteric ischemia. The condition is considered a life-threatening emergency as a result of the complications associated with severe hypertension. Diagnosis is best made with angiography. Surgical bypass grafting is the optimal method of treatment and must be tailored depending on the distribution of disease. We report two cases of diffuse hypoplasia involving the thoracic and abdominal aorta treated with thoracic aorta to abdominal aorta bypass.

Gelatin-thrombin-based hemostatic sealant for intraoperative bleeding in vascular surgery.

Vascular surgical procedures may be prolonged because of intraoperative bleeding that is not easily controlled by cautery or suture ligation. This trial compared the ability of a new hemostat, FloSealTM Matrix (FM), with a known hemostat, Gelfoam(R) plus thrombin (GT), to control intraoperative bleeding. Patients undergoing vascular surgery procedures at four institutions were entered in the trial. After a bleeding site was identified, patients were randomized to one of the study agents: (1) FM, a cross-linked gelatin of bovine origin combined with thrombin, or (2) GT. The assigned agent was applied and the site observed for bleeding at 1, 2, 3, 6, and 10 min. The primary end point was cessation of bleeding within 10 min for the first identified site treated. Secondary end points were cessation of bleeding within 10 min for all sites and time to cessation of bleeding. Patients were assessed for morbidity at 30 days and 6-8 weeks after the operation. Analysis was performed on an intent-to-treat basis for analysis of hemostasis at 10 min and on protocol-valid patients for analysis of time to hemostasis. From our results we concluded that for patients undergoing vascular surgery procedures, the new topical hemostat, FloSeal Matrix, provides more rapid and effective hemostasis than Gelfoam plus thrombin.

Anticoagulation is an effective treatment for aortic mural thrombi.

BACKGROUND: Aortic mural thrombi (AMT) in the absence of aortic disease are rare. The appropriate indications and the efficacy of surgical thrombectomy, thrombolysis, and systemic anticoagulation remain controversial. METHODS: This study, set in an academic medical center, was a retrospective review of five patients with AMT in the absence of aortic disease who underwent treatment between 1997 and 2001. The main outcome measures were morbidity, mortality, and treatment outcome. RESULTS: Three patients were women, and ages ranged from 40 to 77 years. On admission, all patients had symptoms related to thrombus embolization (extremity pain or abdominal pain). Two patients had a history of venous thromboembolism (pulmonary embolism or deep venous thrombosis). Four patients had biochemical evidence of hypercoaguability, and the fifth had malignant disease. Coagulation disorders included increased homocysteine (n = 2) and factor VIII (n = 1), antithrombin III (n = 1) and protein C deficiency (n = 1), and familial dysfibrinogenemia (n = 1). AMT were located in the infrarenal (n = 1), suprarenal (n = 3), and descending thoracic (n = 1) aorta. One patient needed exploratory laparotomy and one needed lower extremity vascular procedures for visceral and limb-threatening ischemia, respectively. Treatment with systemic anticoagulation therapy resulted in complete resolution on follow-up computed tomographic scan or angiogram of the AMT at a median of 60 days. CONCLUSION: Most patients in whom AMT develops in the absence of underlying aortic disease have underlying coagulation disorders. Anticoagulation therapy alone allows resolution of AMT, with surgical intervention reserved for management of end organ ischemia from thrombus embolization.