Changes in Anesthesia Can Reduce Periprocedural Urinary Retention After EVAR.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs provide a streamlined approach for expedient postoperative care of high-volume procedures. Endovascular aortic repair (EVAR) has become standard treatment for abdominal aortic aneurysms and implementation of an early recovery program is warranted. Postoperative urinary retention (POUR) remains a problem lending to longer hospital stays and patient discomfort. We aim to demonstrate the utility of monitored anesthetic care (MAC) plus local anesthesia as a modality to minimize urinary retention following EVAR. METHODS: Single-center retrospective review from January 2017 to March 2020 of all patients undergoing standard elective EVAR under general anesthesia or MAC anesthesia. Local anesthetic at vessel access sites was used in all patients under MAC. Ruptured pathology and female sex were excluded from analysis. Patient characteristics, operative details, prostate measurements, and outcomes were abstracted from the electronic medical record. Urinary retention was defined as any requirement of straight catheterization, urinary catheter replacement, or discharge with urinary catheter. Chi square tests and logistic regression were used to determine predictors associated with POUR and increased hospital length of stay. RESULTS: Among 138 patients who underwent EVAR, eight (5.8%) were excluded due to ruptured pathology. Of the cohort, 113 (86.9%) were male with mean age of 73 years. Excluding female patients, 63 (55.8%) male patients underwent general anesthesia and 50 (44.3%) underwent MAC. Male patients under general anesthesia were more likely to have intra-operative urinary catheter placement when compared to MAC (82.5% vs. 36%, respectively; P < 0.001). POUR was identified in 17 patients (13.1%) of the entire study population with 15 events (88.2%) occurring in males. Excluding patients who were admitted to the ICU, twenty-two (19.5%) male patients stayed past postoperative day (POD) one, of which those who developed POUR were more likely to experience compared to those without POUR (45.6% vs. 9.7%, respectively; P = 0.001). On multivariable analysis, male patients who received MAC had a lower risk of developing POUR (OR 0.09, 95% CI 0.02-0.50). POUR was not associated with elective urinary catheter placement nor with pre-existing conditions such as diabetes, urinary retention, benign prostatic hypertrophy (BPH), or use of BPH medications. Additionally, neither prostate size nor volume was associated with developing POUR among male patients. CONCLUSION: MAC plus local anesthesia is associated with decreased rates of POUR after elective EVAR in male patients. ERAS pathways during elective EVAR interventions should implement MAC plus local anesthesia as an acceptable anesthetic option, where appropriate, in order to reduce urinary retention rates and subsequently decrease hospital length of stay in this patient cohort.

Ipsilateral carotid bypass outcomes in hostile neck anatomy.

OBJECTIVE: To determine differences in outcomes among patients undergoing ipsilateral carotid bypass with hostile or normal neck anatomy. METHODS: Single-center retrospective review of all ipsilateral extracranial carotid bypasses performed between 1998 and 2018. RESULTS: Forty-eight patients underwent ipsilateral carotid bypass from the common carotid artery to either the internal carotid artery or carotid bifurcation during the study period. Seven patients were excluded owing to either a lack of follow-up or missing data. The indications for intervention included infected patches, aneurysmal degeneration, symptomatic and asymptomatic stenosis or restenosis, carotid body tumors, neck malignancy, and trauma. In 25 procedures (61%), there was a hostile neck anatomy defined as a prior history of external beam neck irradiation or neck surgery. Among this group, 12 pectoralis muscle flaps were performed for reconstructive coverage. Conduits included polytetrafluorethylene (n = 21), great saphenous vein (n = 9), superficial femoral artery (n = 7) and arterial homograft (n = 4). All superficial femoral artery conduits were used in the hostile neck group (P = .03). The overall mean time of follow-up was 22 months, with all bypasses remaining patent with no significant clinical stenosis. The 30-day ipsilateral stroke and myocardial infarction rates were 4.88% each, all within the hostile neck group, with no 30-day mortalities for the entire cohort. One-third of the muscle flaps were performed in the setting of infected patches (P = .02) with no significant differences in perioperative outcomes with use. The overall median hospital length of stay was significantly increased in patients receiving muscle flap coverage (3.0 vs 7.0 days; P = .04). CONCLUSIONS: In patients with a complex carotid pathology, ipsilateral carotid bypass is an effective solution for carotid reconstruction. Different conduits should be used depending on the indication. Muscle flap coverage should be considered in hostile settings when primary wound closure is not feasible.

Sarcopenia predicts mortality and adverse outcomes after endovascular aneurysm repair and can be used to risk stratify patients.

BACKGROUND: Endovascular aneurysm repair (EVAR) is currently the most common treatment of abdominal aortic aneurysms. Potential predictors of long-term survival after EVAR include physiologic, functional, and cognitive status, but assessments of these conditions have been difficult to standardize. Objective radiographic findings, such as skeletal muscle atrophy, or sarcopenia, may provide an additional means for selection of patients. This study investigates sarcopenia as a method to predict 1-year survival in patients undergoing EVAR. METHODS: A single-institution retrospective review was conducted of all patients who underwent elective EVAR from September 2002 to June 2014. Patients with an available periprocedural computed tomography (CT) scan and clinical data were included in the analysis. Normalized total psoas cross-sectional area (nTPA) was measured on axial CT images using the area of the bilateral psoas muscle at the third lumbar vertebral level normalized to the square of patient height. A threshold for optimal estimate of sarcopenia based on nTPA was determined using a receiver operating characteristic curve. Sarcopenia was evaluated as an independent risk predictor using univariate, multivariate, and survival analysis. RESULTS: A total of 272 EVAR-treated patients were evaluated, including 237 men and 35 women with a median age of 72 years and mean body mass index of 28.6 kg/m2. There was a significant increase in overall mortality in patients in the lowest quartile of nTPA (Q1, 23.53%; Q2, 13.24%; Q3, 7.35%; Q4, 5.88%; P = .01). The estimated nTPA threshold for increased mortality after EVAR was 500 mm2/m2. Using this threshold, sarcopenia accounted for 57% of the risk effect in our 1-year survival model. CONCLUSIONS: Sarcopenia can assist in identifying EVAR candidates who are less likely to benefit from surgery. It can be readily evaluated from preoperative CT scans and may be a useful tool in evaluation of abdominal aortic aneurysm patients with applications in risk evaluation and telemedicine.

Peripheral artery reconstructions using cryopreserved arterial allografts in infected fields.

OBJECTIVE: Cryopreserved human arterial allografts are a recognized acceptable alternative for vascular reconstruction when other traditional conduits are either unavailable or contraindicated. We reviewed our experience using cryopreserved arterial allografts for peripheral artery reconstructions in contaminated and infected surgical fields. METHODS: A single-center, retrospective review was conducted of 57 patients who underwent a peripheral vascular reconstruction using a cryopreserved arterial allograft from January 2002 through July 2017. Indications for repair included removal of infected prosthetic bypass (n = 29), revascularizations in contaminated fields (n = 11), primary arterial repair in the setting of infection (n = 10), and infected vascular closure devices (n = 7). Aorta-based repairs were excluded. Demographics, index procedural details, postoperative complications, and conduit patency were analyzed. Primary end points included conduit-related mortality and graft failure as measured by reinfection, hemorrhage, or aneurysmal degeneration. Mean follow-up for the study is 27.8 months (range, 2-125 months). RESULTS: A total of 57 peripheral vascular reconstructions using cryopreserved arterial allografts were performed during the 15-year period. Among the 22 women and 35 men treated, the mean age was 61 years. The vascular beds involved included iliofemoral (n = 39), femoropopliteal or femoral-distal (n = 10), axillosubclavian or brachial (n = 2), mesenteric (n = 3), and carotid (n = 3) arteries. Adjunctive muscle flap coverage of the allograft conduit was performed in the majority of cases (61%; n = 35). The 30-day mortality was 9%; one death was directly related to conduit insertion. The 30-day conduit-related complication rate was 14% and included hemorrhage from the graft requiring return to the operating room (n = 4) and graft infection (n = 4). The late conduit-related complication rate was 15.8% and included graft infection (n = 1), graft thrombosis (n = 3), major amputation resulting from conduit failure (n = 1), pseudoaneurysm degeneration requiring repair (n = 2), graft hemorrhage (n = 1), and symptomatic graft stenosis (n = 1). CONCLUSIONS: A cryopreserved arterial allograft is a useful alternative conduit for peripheral vascular reconstruction in infected or contaminated surgical fields when other autologous or prosthetic conduits are either unavailable or contraindicated. In the immediate postoperative period, these repairs demonstrate acceptable resistance to graft failure and reinfection, particularly in conjunction with adjunctive rotational muscle flap coverage. Late conduit-related complications appear to be infrequent.

Polytetrafluoroethylene Is a Safe and Effective Interposition Conduit for Caval Reconstruction After Resection of Primary Leiomyosarcoma of the Inferior Vena Cava.

BACKGROUND: Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare soft tissue sarcoma. Techniques for caval reconstruction after tumor resection vary widely. Our single-center experience serves as one of the largest reviews of caval reconstruction using polytetrafluoroethylene (PTFE) interposition grafts published in the past 10 years. METHODS: We conducted a single-center retrospective review of all patients who had undergone surgical resection of IVC leiomyosarcomas since January 1, 2007. Information regarding the procedure and patient-specific data was obtained from the institution's electronic medical record. RESULTS: We identified 4 patients (3 women and 1 man) who had undergone surgical resection for IVC leiomyosarcoma with PTFE graft reconstruction. Adjunct procedures (i.e., arteriovenous fistulas) were not used to maintain graft patency. There was no perioperative mortality within our patient population. One patient returned within 30 days with an acute kidney injury associated with a partially occlusive thrombus in the proximal part of the PTFE conduit. Another patient was found to have infolding of the PTFE graft due to inappropriate graft oversizing at the time of the index operation. Two patients developed distant metastases within a year of surgery, despite having tumor-free margins at the time of the initial operation. All the PTFE interposition grafts remained patent throughout the follow-up without the need for an additional intervention. CONCLUSIONS: PTFE interposition graft may be a safe and effective conduit for caval reconstruction after resection of a primary leiomyosarcoma of the IVC, but further research is necessary to establish appropriate management guidelines.

There Is Limited Value in the One Month Post Endovascular Aortic Aneurysm Repair Surveillance Computed Tomography Scan.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) is the preferred first-line treatment for abdominal aortic aneurysms. Current postprocedure surveillance recommendations by manufacturers are a 1-month computed tomography angiography (CTA) followed by a 12-month CTA in most circumstances. The objective of this study is to determine the utility of the 1-month CTA following elective EVAR and determine if initial surveillance at 6-month CTA is appropriate. METHODS: A single-center retrospective chart review of all elective EVARs at a tertiary medical center over a 12-year period was conducted. Patients were excluded if postoperative surveillance imaging was not available. Data analysis encompassed demographics, chart review, and imaging including angiogram and cross-sectional imaging to asses for endoleaks and other findings. RESULTS: There were 363 patients who underwent elective EVAR and had available postoperative imaging during the study period. Within the 1-month follow-up, a CTA group of 316 patients was detected with 98 (31%) endoleaks. Of these, 5 (1.5%) required intervention: 1 for infolding of an iliac limb and 4 for type I endoleak which was present on completion angiogram-3 in patients treated outside of instructions for use and 1 with a type Ib endoleak on intraoperative completion imaging. In the 158 patients with 1 and 3-month CTAs, there were 47 persistent endoleaks, 9 previously undetected endoleaks not seen in 1-month CTA, and 13 resolved endoleaks. Three patients (1.2%) underwent intervention for type II endoleak and aneurysm expansion. In 47 patients with only a 6-month CTA, there were 16 endoleaks not seen on completion angiography and 2 of which were treated with reintervention-1 for a type I endoleak and 1 for a type II endoleak. CONCLUSIONS: There is limited utility to 1-month surveillance CTA in patients undergoing elective EVAR within the device instructions for use that has no evidence of type I endoleak on completion angiography. It is safe to start routine EVAR surveillance at 6 months in this patient population. This has implications when considering bundled and value-based payments in the longitudinal care of abdominal aortic aneurysm patients.

Ten-year review of isolated spontaneous mesenteric arterial dissections.

OBJECTIVE: Isolated spontaneous dissection of the superior mesenteric artery (SMA) and celiac artery (CA) remains a rare condition; however, it has been increasingly noted incidentally on diagnostic imaging. The purpose of this study was to examine the natural history and outcomes of patients presenting with isolated spontaneous mesenteric artery dissection (SMAD). We hypothesized that most SMADs can be treated nonoperatively. METHODS: This was a single-center retrospective review of patients presenting with the diagnosis of SMAD between 2006 and 2016. Data analysis included demographics, clinical data, radiologic review, treatment, and outcomes. RESULTS: A total of 77 patients were found to have CA dissection, SMA dissection, or both in the absence of aortic dissection diagnosed on computed tomography or magnetic resonance imaging. The average age was 56 years (range, 26-86 years), 80% were male, and 10 patients (13%) had underlying connective tissue disorders. The majority, 64%, presented with symptoms including abdominal pain, back pain, and chest pain; the remaining 36% were asymptomatic. Combined SMA and CA dissection was found in 14 (18%) patients; 33 (43%) presented with isolated CA dissection, and 30 (39%) presented with isolated SMA dissection. Only four patients required intervention. Mesenteric bypass was performed in two patients, and SMA endarterectomy with patch angioplasty was performed in one patient for signs of bowel ischemia. No patient required bowel resection. The two bypasses were anastomosed to a branch of the SMA, and complete lumen restoration was seen on long-term imaging follow-up. One patient underwent stent grafting of the CA and hepatic artery for aneurysmal degeneration 1 month after diagnosis. The remaining 73 patients were managed nonoperatively; 40 (52%) were treated with a short course of anticoagulation, 23 (30%) were treated with antiplatelet therapy, and 10 (13%) were treated with observation alone. No other late interventions or recurrences were noted during a mean follow-up of 21 months. CONCLUSIONS: Whereas isolated SMAD poses a risk of visceral ischemia, most patients presenting with this diagnosis can be treated nonoperatively with a short course of antiplatelet or anticoagulant therapy. Only a small number of patients require surgical revascularization for bowel ischemia.

Impact of Body Mass Index on Outcomes after Mesenteric Revascularization for Chronic Mesenteric Ischemia.

BACKGROUND: Historically, patients with chronic mesenteric ischemia (CMI) are underweight with a low body mass index (BMI). However, with the recent obesity epidemic many of these patients now are overweight with a high BMI. We evaluated the impact of BMI on outcomes after mesenteric revascularization for CMI. METHODS: A retrospective chart review of patients undergoing open or endovascular mesenteric revascularization for CMI between January 2000 and June 2015 was performed. Demographics, comorbidities, BMI, Society for Vascular Surgery-combined comorbidity score, treatment modality, postoperative complications, reintervention, and all-cause mortality were analyzed. The primary end point for the study was all-cause mortality at 5 years. Patients were stratified using the World Health Organization BMI criteria. Univariate, Kaplan-Meier survival, and multivariate analyses were performed. RESULTS: In the study period, 104 unique patients underwent mesenteric revascularization for CMI, for 77 of whom BMI information was available. Of these 77, 30 patients were treated by endovascular revascularization, and 47 patients were treated by open revascularization. Overall, 27 (35.1%) were overweight or obese with a BMI ≥25. Median follow-up time was 41 months. High BMI patients were less likely to have weight loss at the time of surgery (P = 0.004). Stratified by BMI <25 versus BMI ≥25, 5-year survival for patients treated by open revascularization was 90% versus 50% (P = 0.02); survival for patients treated by endovascular revascularization was 27% vs. 53% (P = 0.37). Multivariate survival analysis identified active smoking, hypertensive chronic kidney disease, open repair with the use of venous conduit instead of prosthetic conduit (P < 0.001), and history of peripheral arterial disease (PAD) (P = 0.002), as independent predictors of increased all-cause mortality. CONCLUSIONS: BMI needs to be considered in assessing and counseling patients on outcomes of mesenteric revascularization for CMI, as a BMI over 25 is associated with poorer long-term survival after open revascularization. Smoking, hypertensive chronic kidney disease, PAD, and open repair with the use of venous conduit are independent predictors of long-term mortality after mesenteric revascularization independent of BMI.

Management of hemothorax after thoracic endovascular aortic repair for ruptured aneurysms.

Background Thoracic aortic aneurysm rupture is often a fatal condition. Emergent thoracic endovascular aortic repair (TEVAR) has emerged as a suitable treatment option. Unfortunately, respiratory complications from hemothorax continue to be an important cause of morbidity and mortality even after successful management of the aortic rupture. We hypothesize that early hemothorax decompression after TEVAR for ruptured aneurysms decreases the rate of postoperative respiratory complications. Methods Single-center, retrospective eight-year review of ruptured thoracic aneurysms treated with TEVAR. Results Seventeen patients presented with ruptured degenerative thoracic aortic aneurysms, all of which were successfully treated emergently with TEVAR. The mean age was 74 years among the 12 (70.6%) men and 5 (29.4%) women treated. Inpatient and 30-day mortality rates for the entire cohort were both 17.6% (three patients). The 90-day mortality rate was 47.1% (eight patients). Thirty-day morbidities of the entire cohort included stroke ( n = 1, 5.9%), spinal cord ischemia ( n = 3, 17.6%; only one was temporary), cardiac arrest ( n = 4, 23.5%; 3 were fatal), respiratory failure ( n = 5, 29.4%), and renal failure ( n = 5, 29.4%). A large hemothorax was identified in the majority of patients ( n = 14, 82.4%). While six (42.9% of 14) patients had immediate chest tube decompression on the day of index procedure, three (21.4% of 14) patients had decompression on postoperative day 1, 4, and 7, respectively. Although not statistically significant, there were trends toward higher rates of respiratory failure (50.0% vs. 16.7%, P = 0.198) and 90-day mortality (62.5% vs. 33.3%, P = 0.280) for patients with delayed or no hemothorax decompression when compared to patients with immediate hemothorax decompression. Conclusions The morbidity and mortality of ruptured degenerative thoracic aortic aneurysms remains high despite the introduction of TEVAR. In this single-center experience, there was a trend toward decreased respiratory complications and increased survival with early chest decompression of hemothorax after TEVAR.

Hybrid Endovascular Aortic Aneurysm Repair: Preservation of Pelvic Perfusion with External to Internal Iliac Artery Bypass.

BACKGROUND: Diminished pelvic arterial flow as a result of intentional coverage/embolization of internal iliac arteries (IIA) during isolated endovascular common iliac artery aneurysm (CIAA) repair or endovascular repair of abdominal aortic aneurysms (EVAR) may result in symptomatic pelvic ischemia. Although generally well tolerated, in severe cases, pelvic ischemia may manifest as recalcitrant buttock claudication, vasculogenic impotence, or perineal, vesicle, rectal, and/or spinal cord ischemia. Branched graft technology has recently become available; however, many patients are not candidates for endovascular repair with these devices. Therefore, techniques to preserve pelvic arterial flow are needed. We reviewed our outcomes of isolated endovascular CIAA repair or EVAR in conjunction with unilateral external-internal iliac artery bypass. METHODS: Single-center, retrospective review of 10 consecutive patients who underwent hybrid endovascular abdominal aortic aneurysm (AAA) or CIAA repair with concomitant external-internal iliac artery bypass between 2006 and 2015. Demographics, index procedural details, postoperative symptoms, hospital length of stay (LOS), follow-up imaging, and bypass patency were recorded. RESULTS: The cohort of 10 patients was all men with a mean age of 71 years (range: 56-84). Hybrid repair consisted of contralateral IIA coil embolization followed by EVAR with external iliac artery-internal iliac artery (EIA-IIA) bypass. All EIA-IIA bypasses were performed via a standard lower quadrant retroperitoneal approach with a prosthetic bypass graft. Technical success was 100%, and there were no perioperative deaths. One patient developed transient paraplegia, 1 patient had buttock claudication on the side of his hypogastric embolization contralateral to his iliac bypass, and 1 developed postoperative impotence. 20% of patients sustained long-term complications (buttock claudication and postoperative impotence). Mean LOS was 2.8 days (range: 1-9 days). Postoperative imaging was obtained in 90% of patients, and mean follow-up was 10.8 months (range: 0.5-36 months). All bypasses remained patent. CONCLUSIONS: Although branched graft technology continues to evolve, strategies to maintain adequate pelvic circulation are necessary to avoid the devastating complications of pelvic ischemia. We have demonstrated that a hybrid approach combining EVAR or isolated endovascular common iliac artery exclusion with a unilateral external-internal iliac bypass via a retroperitoneal approach is well tolerated with a short LOS and excellent patency rates.

Why Temporary Filters Are Not Removed: Clinical Predictors in 1,000 Consecutive Cases.

BACKGROUND: Compared to permanent inferior vena cava (IVC) filters, higher complication rates occur with long-term use of temporary IVC filters. We aimed to identify patient clinical factors at the time of placement that could predict failure to remove a temporary IVC filter. METHODS: A retrospective review was performed of both vascular surgery and interventional radiology prospective databases between December 2008 and December 2013. We analyzed a total number of 1,024 consecutive, temporary IVC filters stratified by whether retrieval was attempted or made permanent. Univariate, multivariate, and prediction modeling analyses with internal validation were performed on abstracted data, which included risk factors, treatment modalities, and indications for IVC filter placement. RESULTS: Of 1,024 temporary IVC filters, removal was attempted in 60% and no attempt at removal (kept permanent) in 40%. Of the 619 with attempted removal, the overall successful retrieval rate was 95%. The majority of filters were not attempted to be removed because of persistent filter indications (360 cases). Risk factors associated with IVC filter permanence included male sex, older age, history, or indication of venous thromboembolism (VTE) with inability to anticoagulate, malignancy, and neurologic condition. Risk factors most predictive of permanence in the multivariate model were malignancy (odds ratio [OR]: 3.0, P < 0.001) or neurologic disorder (OR: 2.69, P = 0.0005). Validation revealed our model had a sensitivity of 60.4% and specificity of 69.9%. CONCLUSIONS: Our study shows that patients who are more likely to have a temporary IVC filter kept permanent are more likely to be older males with a history of malignancy, neurologic condition, or VTE. These factors are also predictive of permanence and can be used in our predictive model to provide insight into the significant preoperative risk factors that should play into the decision-making process.

Incidence of acute lower extremity venous thrombosis after percutaneous endovascular aneurysm repair.

BACKGROUND: Improvements in endovascular aortic aneurysm repair (EVAR) have led many physicians to embrace a purely percutaneous approach using the suture-mediated "preclose" technique. Whereas there are a number of theoretical benefits, the rate of periprocedural iatrogenic acute deep venous thrombosis (DVT) is unknown. We sought to determine the incidence of acute DVT after percutaneous EVAR (PEVAR). METHODS: This was a single-center, retrospective review of 52 consecutive patients undergoing elective PEVAR. Demographics, procedural data, and postprocedure lower extremity venous duplex ultrasound data were analyzed by univariate statistical analysis. RESULTS: Among the 52 patients, the average age was 73 years, and the majority were men (n = 44). Only 6% (n = 3) had a prior history of DVT. The majority of procedures were performed under general anesthesia (n = 51 [98%]) with systemic intravenous heparin. Protamine was used in only 13 cases (25%). Sheath sizes ranged from 9F to 20F, with an average of 16F, and closure was achieved using the preclose technique. Postprocedure chemoprophylaxis was administered to 85% of patients (n = 44) during their hospitalization. Median length of stay was 1 day. Acute DVT was identified in 8% of patients (n = 4) on postoperative day 1. Among the 4 DVTs, 25% were femoropopliteal (n = 1) and 75% were calf vein DVTs (n = 3). On follow-up imaging 2 weeks later, 75% of DVTs were resolved. Among the four patients with acute DVT on postoperative day 1, three had associated risk factors: history of DVT (n = 2), active smokers (n = 1), and obesity (body mass index >30; n = 3). The remaining patient had no risk factors but developed an ipsilateral calf vein DVT. CONCLUSIONS: The risk of acute DVT after PEVAR is low. Lower extremity venous duplex ultrasound screening is not necessary unless there exist preclinical risk factors or postprocedural clinical indications suggestive of DVT.

Inadvertent Arterial Placement of Central Venous Catheters: Diagnostic and Therapeutic Strategies.

BACKGROUND: Central venous catheterization (CVC) is among the most ubiquitous medical procedures. Inadvertent arterial placement of the catheter presents a challenging dilemma to the interventionalist. Treatment options include: removal and manual compression, off-label use of percutaneous closure devices and/or stent grafts, and open surgical removal. Potential sequelae include bleeding, thrombosis, stroke, limb ischemia, neurologic deficit, and death. Our aim is to evaluate the use of open and endovascular techniques for the management of iatrogenic carotid, subclavian, and brachiocephalic arterial injuries related to inadvertent arterial CVC placement. METHODS: Retrospective chart review revealed 13 patients with iatrogenic arterial injuries related to inadvertent arterial CVC placement over a 5-year period at Northwestern Memorial Hospital using Current Procedural Terminology codes and interventional radiology and vascular databases. Presenting features, radiographic diagnosis, therapeutic maneuvers, and outcomes were reviewed. RESULTS: Endovascular therapy was instituted in 10 cases with 3 requiring an adjunctive open procedure. In the endovascular therapy group, stent grafts were used in 5 patients and 4 patients were managed with percutaneous closure devices. In 1 patient, multiple embolization procedures were performed in an attempt to close a large innominate artery arteriovenous fistula (AVFs) that ultimately required sternotomy and surgical ligation for complete closure. Primary open repair was carried out in 3 patients. Two patients developed embolic stroke before therapy and removal, with 1 death reported at 36-month follow-up. Overall success rate with a single intervention was 100% (4 of 4) with closure devices, 80% (4 of 5) covered stents, 0% (0 of 1) with embolization, and 100% (3 of 3) with open intervention. Overall complication rate was 7% (1 of 13) requiring further open, invasive intervention. CONCLUSIONS: Management of carotid, subclavian, and brachiocephalic arterial injuries from attempted jugular or subclavian venous cannulation can be challenging. The risk of embolic phenomenon associated with arterial catheterization, and the noncompressible anatomic location at the base of the neck frequently prevent simple removal. We use a strategy of immediate computed tomography or magnetic resonance to facilitate the most appropriate therapy. Endovascular treatment with covered stent grants, percutaneous closure devices, and embolization offer good results when selected appropriately based on imaging evaluation. However, more complex cases with associated pseudoaneurysms and/or AVFs with larger catheters may require definitive open repair.

Surgical management of aortitis with early aneurysmal dilation.

BACKGROUND: Aortitis is a rare and serious condition that requires expedient surgical evaluation. Diagnosis is generally made by computed tomography (CT). Surgery is most often performed when significant aneurysmal changes have already occurred. Outcomes of early surgical management of aortitis with early aneurysmal dilation have not been reported previously. METHODS: A retrospective review of open abdominal aortic repairs performed from 1999 to 2009 at a single center was done from a prospectively collected database. Patients with a confirmed radiographic appearance of aortitis and treated surgically were selected. Demographic, clinical, and surgical data of patients with aortitis showing early aneurysmal changes (aortic diameter <4 cm) were then analyzed. All aortitis cases with >4-cm aortic diameters and with prosthetic aortic grafts were excluded. RESULTS: During the observation period, 421 open abdominal aortic repairs were performed. Of these, 10 (2.4%) were identified as having primary aortitis without significant aneurysmal changes. The mean age of the patients was 62 (range 48-77) years. There were 6 (60%) men and 4 (40%) women in the cohort. Four patients (40%) had culture-negative aortitis, whereas 6 (60%) had positive microbial cultures at the time of diagnosis. Paravisceral involvement was seen in 8 (80%) cases. All patients underwent in situ repair with aortic homografts. Mean operative time was 348 minutes and mean estimated blood loss was 2475 mL. Median follow-up time was 23.1 months with a range of 1.7-51.4 months. Operative mortality was 0%, and 1 late death occurred at 23 months postoperatively. There were 9 significant in-hospital (30-day) events occurring in 5 patients, including 3 cardiovascular events, 2 pulmonary events, 3 acute renal failures, and 1 deep surgical site infection. CONCLUSIONS: Aortitis is an uncommon indication for aortic repair. Infectious aortitis is most commonly confirmed by microbiologic studies, but a significant number of cases have no demonstrable microbial source. Outcomes after early surgical management for aortitis with small aneurysms demonstrated improved mortality when compared with series reviewing outcomes in aortitis patients with large mycotic aneurysms.

Secondary interventions after elective thoracic endovascular aortic repair for degenerative aneurysms.

OBJECTIVE: We assessed the incidence and outcomes of graft-related secondary interventions (ie, open conversion or proximal or distal extensions) after elective thoracic endovascular aortic repair (TEVAR) for aneurysmal disease. METHODS: An institutional review of TEVAR for descending thoracic aortic aneurysms (DTAAs), between 2000 and 2011, was performed. Only elective TEVAR for DTAA using commercially available endografts was selected. Emergent cases, nonaneurysmal aortic pathology (ie, transection, pseudoaneurysm, dissection), and cases that used physician-modified devices were excluded. The incidence of unplanned graft-related secondary interventions was examined and outcomes were analyzed. RESULTS: During the study period, 83 patients underwent elective TEVAR for DTAA that met the inclusion criteria. Subsequent graft-related secondary interventions were required in eight patients (10%). The mean interval to the secondary intervention was 31.8 months. Endoleak was the most common indication. Patients who required secondary interventions were significantly younger (mean age, 58 ± 12 vs 69 ± 11 years; P < .05). Operative mortality (<30 day) was zero, with one aneurysm-related late death occurring at 2 years after the secondary intervention. Factors that predisposed the need for secondary interventions were fusiform morphology of the aneurysm (P = .05) and extent of graft coverage in the proximal landing zone <3 cm (P < .05). Size of the aneurysm treated and the type of device used were not significant factors leading to secondary intervention. CONCLUSIONS: Intermediate and long-term results of elective TEVAR for DTAA demonstrate good durability, with acceptable rates of graft-related secondary interventions. Age, fusiform aneurysm morphology, and extent of proximal landing zones <3 cm were significant factors that led to subsequent secondary interventions.

Overcoming obstacles to resident-patient continuity of care.

OBJECTIVE: Because continuity of care (CC) is a necessary component of resident education, this analysis was done to understand what keeps CC between residents and patients low and how it can be most effectively improved. BACKGROUND: Many authors lament low CC between residents and patients, especially in the era of duty hour regulations. Some have tried lengthening rotations, some have tried increasing clinic attendance, and some have argued for various training models. Little detailed analysis has been done to identify root causes of low CC or ways to improve it. METHODS: Two months of charts were reviewed to estimate baseline CC on a vascular surgery rotation. Probability theory and engineering simulations were used to determine whether CC can be enhanced by (a) lengthening rotations, (b) altering observed logistical patterns, (c) using a "resident return" model where residents are able to see patients postoperatively even if moved to a different rotation, or (d) employing an apprenticeship model. RESULTS: Baseline analysis showed residents had 0% CC given 131 opportunities to do so. Probability analysis and the simulation outcomes suggest that rotation length plays a minor role in achieving CC. Logistical changes showed some improvement in CC, but not as much as using an apprenticeship rotation model. CONCLUSIONS: The limitations placed on CC by rotation duration are real, but lengthening the rotation does not meaningfully resolve the gap between acceptable CC levels and actual levels. Although CC can be enhanced with longer rotations if coupled with the use of the resident return model, the greater barrier to CC is the logistical patterns such as where residents spend time, how cases are assigned, and the lack of an alert system to inform residents about returning postoperative patients. The apprenticeship model enables residents to achieve CC closer to that of the faculty.

Early versus delayed carotid endarterectomy in symptomatic patients.

BACKGROUND: Delayed carotid endarterectomy (CEA) after a stroke or transient ischemic attack (TIA) is associated with risks of recurrent neurologic symptoms. In an effort to preserve cerebral function, urgent early CEA has been recommended in many circumstances. We analyzed outcomes of different time intervals in early CEA in comparison with delayed treatment. STUDY DESIGN: Retrospective chart review from a single university hospital tertiary care center between April 1999 and November 2010 revealed 312 patients who underwent CEA following stroke or TIA. Of these 312 patients, 69 received their CEA within 30 days of symptom onset and 243 received their CEA after 30 days from symptom onset. The early CEA cohort was further stratified according to the timing of surgery: group A (27 patients), within 7 days; group B (17), between 8 and 14 days; group C (12), between 15 and 21 days; and group D (12), between 22 and 30 days. Demographic data as well as 30-day (mortality, stroke, TIA, and myocardial infarction) and long-term (all-cause mortality and stroke) adverse outcome rates were analyzed for each group. These were also analyzed for the entire early CEA cohort and compared against the delayed CEA group. RESULTS: Demographics and comorbid conditions were similar between groups. For 30-day outcomes, there were no deaths, 1 stroke (1.4%), 0 TIAs, and 0 myocardial infarctions in the early CEA cohort; in the delayed CEA cohort, there were 4 (1.6%), 4 (1.6%), 2 (0.8%), and 2 (0.8%) patients with these outcomes, respectively (P > .05 for all comparisons). Over the long term, the early group had one ipsilateral stroke at 17 months and the delayed group had two ipsilateral strokes at 3 and 12 months. For long-term outcomes, there were 16 deaths in the early CEA cohort (21%) and 74 deaths in the delayed CEA cohort (30%, P > .05). Mean follow-up times were 4.5 years in the early CEA cohort and 5.8 years in the delayed CEA cohort. CONCLUSIONS: There were no differences in 30-day and long-term adverse outcome rates between the early and delayed CEA cohorts. In symptomatic carotid stenosis patients without evidence of intracerebral hemorrhage, carotid occlusion, or permanent neurologic deficits early carotid endarterectomy can be safely performed and is preferred over delaying operative treatment.

A comparative study of the bell-bottom technique vs hypogastric exclusion for the treatment of aneurysmal extension to the iliac bifurcation.

INTRODUCTION: A significant proportion of patients undergoing endovascular aneurysm repair (EVAR) have common iliac artery aneurysms (CIAA). Aneurysmal involvement at the iliac bifurcation potentially undermines long-term durability. METHODS: Patients with CIAA who underwent EVAR were identified in two teaching hospitals. Bell-bottom technique (BBT; iliac limb ≥20 mm) or internal iliac artery embolization and limb extension to the external iliac artery (IIE + EE) were used. Outcome between these two approaches was compared. RESULTS: We identified 185 patients. Indication for EVAR included asymptomatic abdominal aortic aneurysm (AAA) in 157, symptomatic or ruptured aneurysm in 19, and CIAA in nine. Mean AAA diameter was 59 mm. Among 260 large CIAAs that were treated, BBT was used to treat 166 CIAA limbs, and 94 limbs underwent IIE + EE. Total reintervention rates were 11% for BBT (n = 19) and 19.1% for IIE + EE (n = 18; P = .149). Rates of reintervention for type Ib or III endoleak were 4% for BBT (n = 7) and 4% for IIE + EE (n = 4; P > .99). The difference in limb patency rates was not significant. The 30-day mortality rate was 1%. Median follow-up was 22 months. Complications did not differ significantly between the two groups; however, the combined incidence of perioperative complications and reinterventions was higher in the IIE + EE group (49% vs 22%; P = .002). CONCLUSIONS: The combined incidence of perioperative complications and reinterventions is significantly higher with IIE + EE than with BBT; therefore, when feasible, BBT is desirable.

Does a contralateral carotid occlusion adversely impact carotid artery stenting outcomes?

BACKGROUND: Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood. METHODS: A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years). RESULTS: Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant). CONCLUSION: A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.