Surgical Complications after Open Abdominal Aortic Aneurysm Repair: Intestinal Ischemia, Buttock Claudication and Sexual Dysfunction

[Cryopreservation of human spermatozoa or testicular tissue for fertility preservation]

Loss of reproductive capacity due to treatments for malignant or non-malignant diseases or even as a result of diseases themselves significantly impacts patients' quality of life. Cryopreservation of sperm from ejaculate is a well-established procedure for preserving the fertility of these patients and thus improving their quality of life in the long term. If cryopreservation of sperm from ejaculate is not possible, either because ejaculation cannot occur or no sperm can be found in the ejaculate, the preferred treatment option is (microsurgical) testicular sperm extraction (mTESE). Testicular sperm and ejaculated spermatozoa can be cryopreserved and later used for intracytoplasmic sperm injection (ICSI) treatment. The use of cryopreserved sperm for fertility treatment does not carry an increased risk of malformations in the offspring. If gonadotoxic therapy is necessary in pre- or early pubertal boys, the only option to preserve fertility in the long term is to cryopreserve spermatogonial stem cells from testicular tissue as part of the Androprotect© network. This is an experimental approach which has been available since 2012 across Germany and which is accompanied by intensive scientific work ( www.androprotect.de ).

A Cadaveric Case Study on the Abdomen: A Temple of Surprises

Femoro-femoral bypass grafts (FFBG) are performed to connect the major vessels of the lower extremities, such as the femoral arteries, to treat patients who have injured or occluded iliac arteries. Typically, patients with multiple comorbidities, such as heart failure, aneurysms, or diabetes, have a significantly higher risk of complications for open, invasive procedures to correct lower limb ischemia. This graft poses as an effective, less invasive option to treat lower-limb ischemia for higher-risk patients. This case study presents a finding of FFBG in an 82-year-old male cadaver during cadaveric dissection in the gross anatomy lab at Geisinger Commonwealth School of Medicine in Scranton, Pennsylvania. Based on the initial findings of cardiomegaly with a triple coronary artery bypass graft (CABG) and pulmonary hypertension in the thoracic cavity and evidence of massive umbilical hernioplasty involving extensive mesh repair, our initial assumption of an FFBG placement in this cadaver was to increase perfusion to lower limbs, circumventing the need for surgical intervention due to the above-mentioned comorbidities, which act as risk factors. However, the discovery of a massive abdominal aortic aneurysm (AAA) measuring 26 cm in circumference with evidence of dissection of its wall and the presence of a stent within the aorta and common iliac arteries placed there as an endovascular aneurysm repair (EVAR) procedure came as a surprise. Publication of such findings provides awareness to curious individuals about the existence of multiple health concerns an individual suffers and how the medical as well as surgical teams work together to provide optimal treatment care to improve their standard of living and prolong their lifespan.

Sexual dysfunction after open abdominal aortic aneurysm repair: 16 years' experience in a quaternary center and literature review

Background

Open abdominal aortic aneurysm (AAA) repair can lead to sexual dysfunction (SD) in men.

Objectives

To determine the prevalence of SD following open AAA repair, explore whether surgical techniques for aortic reconstruction can have a differential impact on the occurrence of SD, and summarize current knowledge in this field.

Methods

Retrospective review of 100 patients submitted to open AAA repair between 1995 and 2010 in a quaternary center. Sexual dysfunction was assessed according to questions from the modified International Index of Erectile Function (IIEF), considering the condition before surgical repair and 3 months after surgery. The chi-square test, Fisher's exact test, and Student's t test were used for statistical analyses.

Results

100 patients were included (mean age = 66.4 years old). Normal sexual activity, no sexual activity, erectile dysfunction, and retrograde ejaculation with preserved erectile function were found in 36%, 21%, 18%, and 24% of patients, respectively. The group of patients with no sexual activity was older (mean age = 72.3 years old vs 64.5 years old, p < 0.001). Erectile dysfunction prevalence was higher in patients submitted to an aorto-bifemoral bypass (p = 0.032). Retrograde ejaculation was more frequent in patients submitted to an aorto-aortic bypass (p = 0.007).

Conclusions

Sexual function is a frequent condition intimately associated with the aortic reconstruction technique. The literature review found contradictory results regarding whether the endovascular approach is protective compared with open repair, but clearly demonstrated the importance of techniques targeting preservation of the internal iliac artery and the superior hypogastric plexus.

Chemokine Receptor 2 Is A Theranostic Biomarker for Abdominal Aortic Aneurysms

Abdominal aortic aneurysm (AAA) is a degenerative vascular disease impacting aging populations with a high mortality upon rupture. There are no effective medical therapies to prevent AAA expansion and rupture. We previously demonstrated the role of the monocyte chemoattractant protein-1 (MCP-1) / C-C chemokine receptor type 2 (CCR2) axis in rodent AAA pathogenesis via positron emission tomography/computed tomography (PET/CT) using CCR2 targeted radiotracer 64 Cu-DOTA-ECL1i. We have since translated this radiotracer into patients with AAA. CCR2 PET showed intense radiotracer uptake along the AAA wall in patients while little signal was observed in healthy volunteers. AAA tissues collected from individuals scanned with 64 Cu-DOTA-ECL1i and underwent open-repair later demonstrated more abundant CCR2+ cells compared to non-diseased aortas. We then used a CCR2 inhibitor (CCR2i) as targeted therapy in our established male and female rat AAA rupture models. We observed that CCR2i completely prevented AAA rupture in male rats and significantly decreased rupture rate in female AAA rats. PET/CT revealed substantial reduction of 64 Cu-DOTA-ECL1i uptake following CCR2i treatment in both rat models. Characterization of AAA tissues demonstrated decreased expression of CCR2+ cells and improved histopathological features. Taken together, our results indicate the potential of CCR2 as a theranostic biomarker for AAA management.

IFABP levels predict visceral malperfusion in the first hours after open thoracoabdominal aortic repair

Introduction

Intestinal ischemia after open thoracoabdominal aortic repairs, is a rare but devastating complication, associated with high mortality. Notoriously challenging to diagnose, visceral malperfusion necessitates immediate surgical attention. Intestinal fatty acid-binding protein (IFABP) has been proposed as a biomarker for the diagnosis of intestinal wall damage. In this prospectively conducted, observational study we evaluated the diagnostic capacity of IFABP levels in patients' serum and their correlation with visceral malperfusion.

Methods

23 patients undergoing open thoracoabdominal aortic repairs were included in this study and 8 of them were diagnosed postoperatively with visceral malperfusion-defined as a partial or complete thrombotic occlusion of the superior mesenteric artery and/or the coeliac trunk. IFABP levels and laboratory parameters often associated with intestinal ischemia (leucocytes, CRP, PCT and lactate) were measured at baseline, directly postoperatively, and at 12, 24 and 48 h after surgery. Postoperative visceral malperfusion-as revealed in CT angiography-was assessed and the predictive ability of IFABP levels to detect visceral malperfusion was evaluated with receiver-operator curve analysis.

Results

Patients with visceral malperfusion had a relevant risk for a fatal outcome (p = .001). IFABP levels were significantly elevated directly postoperatively and at 12 h after surgery in cases of visceral malperfusion. High IFABP concentrations in serum detected visceral malperfusion accurately during the first 12 h after surgery, with the maximum diagnostic ability achieved immediately after surgery (AUC 1, Sensitivity 100%, Specificity 100%, p < .001).

Conclusion

We conclude, that IFABP measurements during the first postoperative hours after open thoracoabdominal aortic surgery can be a valuable tool for reliable and timely detection of visceral malperfusion.

Adjunct internal iliac artery procedures in the context of endovascular abdominal aortic aneurysm repair: anything to stress on the consent form?

Adjunct internal iliac artery (IIA) procedures, such as preoperative embolisation or coverage with iliac branch extensions, are not infrequent in the context of endovascular repair of abdominal aortic aneurysms. Moreover, on many occasions, these procedures are performed in a multi-stage approach by interventional radiologists prior to the main operation. Bearing in mind the potential complications of IIA occlusion when revascularization is not initially deemed necessary, various issues arise spanning from appropriate patient counselling to medicolegal consequences. Herein, we aim to provide a roadmap regarding appropriate patient consenting, highlighting the need for multidisciplinary approach of these patients.

AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis

Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.

Review of Malpractice Lawsuits in the Diagnosis and Management of Aortic Aneurysms and Aortic Dissections

OBJECTIVE

Aortic aneurysms and dissections are prevalent causes of morbidity and mortality. The management of aortic pathologies may be called into question in malpractice suits. Malpractice claims were analyzed to understand common reasons for litigation, medical specialties involved, patient injuries, and outcomes.

METHODS

Litigation cases in the Westlaw database from September 1st, 1987 to October 23 rd, 2019 were analyzed. Search terms included "aortic aneurysm" and "aortic dissection." Data on plaintiff, defendant, litigation claims, patient injuries, misdiagnoses, and case outcomes were collected and compared for aortic aneurysms, aortic dissections, and overall cases.

RESULTS

A total of 346 cases were identified, 196 involving aortic aneurysms and 150 aortic dissections. Physician defendants were emergency medicine (29%), cardiology (20%), internal medicine (14%), radiology (11%), cardiothoracic (10%) and vascular surgery (10%). Litigation claims included "failure to diagnose and treat" (61%), "delayed diagnosis and treatment" (21%), "post-operative complications after open repair" (10%) and "negligent post-operative care" (10%). Patients with aneurysms presented with abdominal (63%) and back pain (37%), while dissections presented with chest pain (78%), abdominal pain (15%), and shortness of breath (14%). Misdiagnoses included gastrointestinal (12%), other cardiovascular (9%), and musculoskeletal conditions (9%), but many were not specified (58%). Overall, 83% of cases were wrongful death suits. Injuries included loss of consortium (23%), emotional distress (19%), and bleeding (17%). In 53% of the cases, the jury ruled in favor of the defendant. 25% of cases ruled for the plaintiff. 22% of cases resulted in a settlement. The mean rewarded for each case was $1,644,590.66 (SD: $5,939,134.58; Range: $17,500-$68,035,462).

CONCLUSION

For aortic pathologies, post-operative complications were not prominent among the reasons why suits were brought forth. This suggests improvements in education across all involved medical specialties may allow for improved diagnostic accuracy and efficient treatment, which could then translate to a decrease in associated litigation cases.