Popliteal access for iliofemoral occlusive disease in the office-based catheter laboratory.

OBJECTIVE: Popliteal access as an alternative to conventional femoral access has not been reported in the office-based catheter laboratory setting (OBL) and may be perceived to have higher risks. The purpose of this study was to evaluate the safety and efficacy of popliteal access for the endovascular treatment of iliofemoral arterial occlusive disease in an OBL setting. METHODS: From October 2018 to October 2023, a total of 1408 interventions for peripheral artery disease were performed in our OBL. A cohort of 27 popliteal access consecutive procedures for femoral and iliac artery occlusions were studied. All interventions were done using a micropuncture needle under ultrasound guidance. All patients were discharged 1 hour after completion of the procedure. Indications for popliteal access were presence of aortoiliac stent grafts, aortobifemoral or aortoiliac bypasses, difficult contralateral or antegrade femoral access, and flush superficial femoral artery occlusions. Procedures were determined to be successful upon complete resolution of the target lesions and safety was measured perioperatively and at 90 days. Patency was determined clinically, by arterial duplex examination, and by need for reintervention for ≤2 years. RESULTS: We performed 27 popliteal access procedures in 25 patients (21 complete femoral artery occlusions, 6 severe stenosis). Iliac disease was present in nine. Indications for popliteal access were existing aortoiliac stent graft in 11, aortobifemiliac bypass in 4, noncrossable iliac occlusions in 3, failed antegrade femoral access in 4, flush superficial femoral artery occlusion in 3, and bilateral common femoral artery disease precluding access in 2. Trans-Atlantic Inter-Society Consensus classification preoperatively was B, 4; C, 4; and D, 19. Treatments included atherectomy/balloon angioplasty and stent in 12, balloon angioplasty and stenting in 4, atherectomy/balloon angioplasty in 5, and balloon angioplasty alone in 6. Successful opening of occlusions occurred in 25 of 27 patients (92.5%). No complications or major adverse cardiac events occurred, except one asymptomatic small popliteal arteriovenous fistula. Of the 25 successful procedures, the duplex patency at 3, 6, and 12 months was 19/20 (95%), 11/15 (69.3%), and 11/13 (61%). Rutherford Classification improved from a preoperative value of >4 in 24 of 27 (89%) to a postoperative value of <2 at 1 month in 23 of 23 (100%), at 3 months in 19 of 20 (95%), at 6 months in 11 of 15 (69.3%), and at 12 months in 11 of 13 (61%). Freedom from reintervention at 3 months occurred in 19 of 20 (95%), at 6 months in 13 of 15 (86%), and at 12 months in 12 of 13 (79%). CONCLUSIONS: Popliteal artery access for complex iliofemoral disease is safe and effective and should be considered as a valid alternative option in the OBL setting.

Bovine xenograft pericardial patch use for definitive single stage repair of a large esophageal defect: a case report.

BACKGROUND: Large esophageal perforations are challenging and often treated with exclusion or resection. This case demonstrates the feasibility of definitive surgical repair of a large esophageal perforation using large bovine pericardial patch. CASE: A patient with missed Boerhaave Syndrome underwent transesophageal echocardiography causing worsening perforation and sepsis. At thoracotomy and faced with a large esophageal defect, a large Bovine pericardial patch was used for repair with omentopexy. The patient recovered promptly and at 8 months was asymptomatic with satisfactory studies. CONCLUSION: Xenograft pericardium is available and widely used for vascular reconstructions. It's use for primary repair of large esophageal perforations should be considered.

Giant intrathoracic teratoma presenting with cachexia and severe dyspnea.

BACKGROUND: This case highlights the challenges of preoperative differential diagnosis and management in a patient with an uncommon clinical presentation of giant intrathoracic teratoma. The age of the patient, location and size of the tumor, and clinical presentation makes this case unique. Typically, intrathoracic teratomas are found between the ages of 20-30, they are located in the anterior mediastinum, and tumors larger than 25 cm clinically present with cough or dysphagia. CASE PRESENTATION: A giant intrathoracic teratoma presents in a 51-year-old female as a mid to posterior mediastinal mass compressing the whole left lung with symptoms of depression, anorexia, unintentional weight loss, and cachexia. Due to her severe deconditioning she was optimized for 1 month in a skilled nursing facility with aggressive physical therapy and enteral nutrition. She underwent left thoracotomy with complete resection of the tumor. In follow up her BMI had improved, and she was regaining strength. CONCLUSIONS: Complete resection was achieved via left thoracotomy after aggressive rehabilitation.

Retrograde type A dissection after endovascular stenting of the descending thoracic aorta. Is the risk real?

OBJECTIVE: Retrograde type A dissection during or after endoluminal graft repair of the descending thoracic aorta is a potentially lethal complication unique to thoracic endografting. Our aim is to increase its awareness and to review possible etiological factors. METHODS: Two hundred and eighty-seven patients with different thoracic aortic pathologies were treated with endovascular prostheses over the last 6 years (February 2000 to March 2006) under a single-site protocol. A retrospective review was conducted to identify any retrograde aortic dissections by both chart and film review. Factors that may have contributed to its formation were also documented. This population was analyzed for the complication of retrograde aortic dissection as well as the factors related to its occurrence. RESULTS: Seven patients (2.4%) with a gender distribution of three males and four females experienced a retrograde type A dissection within this sample at a median of 202 days. The mean age was 74 years (range 53-83). Aortic pathologies included aortic dissections (n=6) and thoracic aortic aneurysm (n=1). There were (n=3) 43% retrograde type A dissections identified within the perioperative period. Balloon angioplasty was performed in 71.4% (n=5). Two female patients (28.6%) had this event identified within their initial hospitalization with fatal consequences. Overall mortality was 57% (n=4) with extension of dissection the primary cause of death n=3 and open surgical repair (n=1) after an extension of retrograde dissection. CONCLUSIONS: Female gender, use of stent-grafts for dissection and possible aggressive balloon angioplasty may play a role in the cause of retrograde type A dissection. A close surveillance program is recommended when using thoracic endografts outside the recommended device instructions for use.

Video-assisted wedge resection and local radiotherapy for peripheral lung cancer in high-risk patients: the Cancer and Leukemia Group B (CALGB) 9335, a phase II, multi-institutional cooperative group study.

OBJECTIVES: This study examined the feasibility of thoracoscopic wedge resection and radiotherapy for clinical T1 lesions in patients with compromised cardiopulmonary status. METHODS: In this phase II, prospective, multicenter, cooperative group trial, high-risk patients had one or more of the following risk factors: forced expiratory volume in 1 second less than 40%, carbon monoxide diffusing capacity in lung less than 50%, and maximum oxygen consumption less than 45 mm Hg. Patients underwent video-assisted wedge resection followed by local (56 Gy) radiotherapy. The primary end point was the proportion of patients whose disease could be completely resected and who received radiotherapy without treatment complications. RESULTS: Between September 1995 and September 1999, a total of 65 patients were accrued, of which 58 were eligible (52% male, median age 69 years). Pathologic staging resulted in upgrading to T2 or greater in 16 of 58 cases (28%) and in reassessment as benign in 10 of 58 cases (17%). Conversion to thoracotomy was required in 10 cases (17%), including 1 of 10 benign T1-size lesion (10%), 4 of 35 non-small cell lung cancer T1 lesions (13%), and 5 of 14 non-small cell lung cancer T2 lesions (31%). Resection margins were positive in 5 patients: 6% of T1 and 23% of T2. Surgery was aborted in 2 cases (3.5%), and operative mortality was 4%. Overall operative failure rates of video-assisted wedge resection were 20% for benign T1-size lesions, 22% for T1 non-small cell lung cancer, 21% for all T1 lesions, 50% for T2 non-small cell lung cancer, and 29% for all lesions in this study (clinical T1). Prolonged air leaks occurred in 10%, pneumonia in 6%, and respiratory failure in 4%. Thirty-one patients were eligible for radiotherapy; 3 of them refused, and 1 died before treatment. Among the 28 patients who received radiotherapy, severe dyspnea was noted in 3 patients (11%) and moderate pneumonitis in 4 (14%). CONCLUSIONS: Clinical staging in high-risk patients is often inaccurate (45% difference from pathologic staging). Intention to treat clinically staged T1 disease by video-assisted wedge resection is associated with a high failure rate. Pathologically staged T1 lesions can be successfully resected in 75% of cases; however, narrow resection margins remain a concern.

Axillary vein thrombosis induced by an increasingly popular oscillating dumbbell exercise device: a case report.

A 53 year-old male presented with a one-day history of a swollen arm and dull, aching pain in the right upper extremity. The patient reported commencing exercising daily over the prior week with a modified, oscillating dumbbell; commonly referred to as a Shake Weight. Imaging revealed an occlusive thrombus in the right axillary, proximal brachial and basilic veins. The patient was treated with a 24-hour tPA infusion followed by mechanical thrombectomy, balloon angioplasty, and stent placement for a residual thrombus and stenosis. The patient was discharged the following day on warfarin and aspirin. This is the first report of effort-induced thrombosis of the upper extremity following the use of a modified, oscillating dumbbell. Due to the growing popularity of modified dumbbells and the possible risk for axillary vein thrombosis, consideration should be made to caution consumers of this potential complication.

Surgical revascularization in patients with poor left ventricular function: on- or off-pump?

BACKGROUND: Patients with left ventricular dysfunction and low ejection fraction (EF) are at high-risk of complication and mortality after coronary artery bypass grafting (CABG). The potential success of off-pump CABG in this high-risk population has yet to be determined. The purpose of this study is to compare the outcome of off-pump coronary artery bypass (OPCAB) and conventional coronary artery bypass (CCAB) in patients with poor left ventricular function, all from a single institution. METHODS: Data on patient demographics, preoperative risk factors, operative and postoperative outcomes were collected retrospectively on all patients having undergone isolated CABG between January 1, 1998, and October 31, 2001. RESULTS: A total of 77 patients (31 OPCAB/46 CCAB) were identified as having an ejection fraction (EF) of < or = 0.35. Of these, 52 had EF < or = 0.30 (21 OPCAB/31 CCAB) and 31 patients had EF < or = 0.25 (10 OPCAB/21 CCAB). Operative mortality was 3.2% after the OPCAB procedure versus 10.9% for the CCAB (p = 0.39). Use of intraaortic balloon pump (6.5%) was rarely required. The OPCAB procedure resulted in significantly less requirement for blood transfusions (p < 0.05), fewer distal anastomoses per patient (p < 0.01), and a higher incidence of atrial fibrillation (p < 0.05) compared with CCAB. CONCLUSIONS: Patients with poor left ventricular function may undergo surgical revascularization using off-pump technique with relatively good results and low mortality levels. The lower number of grafts performed on the off-pump procedure did not seem to affect clinical outcomes.

Avoiding aortic clamping during coronary artery bypass using an automated anastomotic device.

In its current application, off-pump coronary artery bypass grafting (OPCAB) requires clamping of the aorta to perform the proximal anastomosis. One of the important theoretical advantages of OPCAB is to avoid the undesirable effects of cross-clamping of the aorta. We report our early experience with a technique of no aortic clamping using the St. Jude aortic connector system in 11 patients.

A feasibility study of the safety and efficacy of a combined clopidogrel and aspirin regimen following off-pump coronary artery bypass grafting.

OBJECTIVE: Effective antiplatelet therapy may decrease the risk of complications following off-pump coronary artery bypass surgery (CABG). We prospectively evaluated the safety and early efficacy of a combined regimen of clopidogrel and aspirin starting immediately after off-pump CABG. METHODS: One hundred thirty-five consecutive off-pump CABG patients received clopidogrel (75 mg/day) and aspirin (325 mg/day) orally or initially through a nasogastric tube for 3 months, commencing within 6 hours of surgery. Additionally, heparin (10,000 IU/day) was given subcutaneously during the first 4 postoperative days. Clinical events, including death, myocardial infarction (MI), reintervention, angiographically documented graft occlusion, stroke, pulmonary embolism (PE), deep vein thrombosis (DVT), and hemorrhagic events, were recorded. All patients were followed up for 3 months. RESULTS: Thirteen of 135 off-pump CABG patients had treatment discontinued before discharge because of refractory atrial fibrillation requiring warfarin sodium (Coumadin) (6 patients), gastrointestinal bleeding (1 patient), DVT (1 patient), PE (1 patient), and death (4 patients). The remaining patients were followed up for 3 months. At 1 month, the incidences of the following events were: 3.0% cerebrovascular accidents (3 strokes and 1 transient ischemic attack), 3.0% MI, 0.7% DVT, and 0.7% hemothorax. At 3 months, no additional events had occurred except for 1 patient developing DVT and 2 additional patients developing MI. Coronary angiography was indicated in these last 2 patients. All grafts were found to be patent. However, a native vessel required percutaneous intervention (stenting) in one of these patients. CONCLUSIONS: Early administration of a combined regimen of clopidogrel and aspirin following off-pump CABG is safe and is associated with a relatively low incidence of major adverse cardiac events, bleeding, PE, and DVT. Consequently, its routine administration after off-pump CABG is recommended.

Influence of Innovative Techniques on Midterm Results in Patients with Minimally Invasive Direct Coronary Artery Bypass and Off-Pump Coronary Artery Bypass.

Abstract Background: There is a paucity of midterm results comparing the efficacy of minimally invasive direct coronary artery bypass (MIDCAB) and off-pump coronary artery bypass (OPCAB) with standard coronary artery bypass grafting (CABG). In addition, the advent of innovative techniques may have improved midterm results for patients who undergo MIDCAB and OPCAB (MID-OPCAB). The purpose of this study was to evaluate the midterm survival results of higher-risk patient groups who have undergone CABG or MID-OPCAB with or without the use of innovative techniques. Methods: From January 1992 through March 2002, 3670 consecutive patients underwent coronary artery bypass procedures, and their predicted surgical risks were calculated according to the logistic EuroSCORE. The cases of 52 MIDCAB patients and 1796 CABG patients with similar higher-risk EuroSCOREs (11.5 versus 11.4, respectively) who underwent operations from January 1992 to December 1997 were compared (study A). The cases of 89 patients with MID-OPCAB (employing "innovative techniques") and 796 patients with CABG (EuroSCORE, 13.2 versus 13.3, respectively) whose operations took place between 1998 and 2002 were also compared (study B). The National Death Index was used to access mortality data, and Kaplan-Meier curves were constructed for each group of patients. Numbers of arterial grafts, numbers of anastomoses, major complications, in-hospital lengths of stay (LOS), and 30-day mortality rates were noted. Results: In study A, there were no significant differences in the 30-day mortality rates (2.5% versus 3.9%), incidences of major complications (11.5% versus 16.6%), and LOS (13 days versus 11.7 days) for the MID-OPCAB and CABG patients, respectively. CABG patients received more arterial grafts (47.1% versus 28.9%; P =.011), received more distal anastomoses (3.4 versus 2.7; P <.001), and had better survival as estimated by Kaplan-Meier curves (94.5 months versus 82.1 months; P =.023). In study B, there were no differences in 30-day mortality rates (3.1% versus 2.3%) and incidences of major complications (10.1% versus 12.7%) for MID-OPCAB and CABG patients, respectively. CABG patients received more arterial grafts (72% versus 57.3%; P =.004) and more distal anastomoses (3.5 versus 2.8; P <.001). However, LOS was shorter for MID-OPCAB patients (7.2 days versus 9.6 days; P =.019), and there was no difference in survival time as estimated by Kaplan-Meier curves (47 months versus 46.4 months; P =.534). Conclusions: The advent of innovative surgery significantly improved LOS and "equalized" the rate of survival to 5 years in higher-risk MID-OPCAB patients, compared with similar-risk CABG patients.

Migration of a fractured inferior vena cava filter strut to the right ventricle of the heart: a case report.

A 23 year old woman presented with sudden onset retrosternal chest pain following an attempt to move a heavy object from her vehicle. Multiple fractured struts of an inferior vena cava filter were identified in the distal right and left pulmonary artery branches, and in the free wall of the right ventricle. A small pericardial effusion was noted. Because of the depth of penetration into the right ventricle, it was perceived not to be amenable to endovascular retrieval. Over several days of observation, she continued to have progressive retrosternal and left shoulder pain. She underwent exploratory sternotomy and extraction of a strut that was partially protruding from the right ventricle and abrading the diaphragmatic pericardium. The patient recovered quite well and was discharged on the third postoperative day.

Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies.

OBJECTIVES: The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease. BACKGROUND: The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials. METHODS: Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies. RESULTS: Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results. CONCLUSIONS: Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.

Endovascular management of adult coarctation and its complications: intermediate results in a cohort of 22 patients.

OBJECTIVE: To determine the safety and effectiveness of current endovascular treatment in adult patients with thoracic aortic coarctation and its complications. METHODS: A cohort of 22 patients was treated for late presenting primary or recurrent coarctation or aneurysmal formation at varying intervals following childhood intervention. RESULTS: Ten patients with recently discovered de novo coarctations were treated with balloon-expandable stents, and an endoluminal graft (ELG) was used in one additional patient. In the other 11 patients with recurrent lesions, three underwent repeat balloon dilation and stenting; eight patients with recurrence with aneurysms received ELGs. The gradients across the coarctation decreased from 49 + 16 to 4 + 7 mmHg (p = 0.001), and the diameters increased from 10 + 4 to 19 + 4mm (p = 0.001). In five of the eight patients (63%) with aneurysms, the ELG covered the subclavian artery, and a carotid subclavian bypass was necessary. Two patients required iliac artery access. No early major complications occurred. At mean follow-up of 31 + 15.6 months, one patient with type II leak resolved spontaneously and another developed neck dilation and type I leak, requiring a second ELG placement. All patients except one had improvements in symptoms and better hypertension control. CONCLUSIONS: We conclude that primary or secondary endovascular intervention in adults with de novo or recurrent coarctation and aneurysms is feasible with good intermediate results.

EACTS/ESCVS best practice guidelines for reporting treatment results in the thoracic aorta.

Endovascular treatment of the thoracic aorta (TEVAR) is rapidly expanding, with new devices and techniques, combined with classical surgical approaches in hybrid procedures. The present guidelines provide a standard format for reporting results of treatment in the thoracic aorta, and to facilitate analysis of clinical results in various therapeutic approaches. These guidelines specify the essential information and definitions, which should be provided in each article about TEVAR: It is hoped that strict adherence to these criteria will make the future publications about TEVAR more comparable, and will enable the readership to draw their own, scientifically validated conclusions about the reports.

Novel approaches for the treatment of the aberrant right subclavian artery and its aneurysms.

We report a minimally invasive, hybrid endovascular approach that was used to treat two patients with aberrant right subclavian arteries. The first patient was a 50-year-old woman who presented with dysphagia lusoria. She underwent endovascular plugging and depressurization of the aberrant artery and a carotid-subclavian bypass using right supraclavicular access. The second patient, a 77-year-old woman who presented with a 5.5-cm aneurysm at the origin of a previously bypassed aberrant artery on the distal aortic arch, was treated using bilateral carotid-subclavian bypasses through neck incisions and a thoracic endoluminal graft exclusion of the arch aneurysm that covered both subclavian arteries.

Is it safe to cover the left subclavian artery when placing an endovascular stent in the descending thoracic aorta?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the left subclavian artery may be safely covered with a descending thoracic aortic stent without a prior carotid-subclavian artery bypass or transposition procedure. Altogether 2612 abstracts were identified. Forty-five non-randomized control trials and 213 non-controlled papers were found using the reported search and all these were read in full to search for coverage of the left subclavian artery. From these papers, 20 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We identified 20 studies with more than 10 cases of left subclavian artery coverage without prior revascularisation. Aggregating the data from all these studies we found 498 covered left subclavian arteries. Complications included 13 strokes (2.6%), 8 cases of paraplegia or paraparesis (1.6%) and 6 endoleaks due to subclavian backflow (1.2%). Of note there were 51 cases of ischaemia or other symptoms attributable to poor blood flow (10%), which resulted in 20 post-procedural revascularisations (4%). In three studies the mean pressure drop in the left arm was between 36 and 48 mmHg after left subclavian occlusion. We conclude that coverage of the left subclavian artery has a low, but not insignificant, incidence of side-effects. This incidence must be balanced with the urgency of the procedure and may be acceptable in emergency or salvage situations. However, in non-emergency cases we recommend that the carotid arteries, the vertebral arteries and the Circle of Willis are fully assessed by tests such as duplex ultrasound, angiography, CT or MRI scanning. An absent right vertebral artery, diseased carotid arteries or an incomplete Circle of Willis is a contraindication to left subclavian artery coverage without prior transposition or bypass grafting of the left subclavian artery.