Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy

OBJECTIVE

Left vertebral artery revascularization is indicated in surgery involving zone 2 of the aortic arch and is typically accomplished indirectly via subclavian artery revascularization. For aberrant left vertebral anatomy, direct revascularization is indicated. Our objective was to compare the outcomes of direct vertebral artery revascularization with indirect subclavian artery revascularization for treating aortic arch pathology and to identify predictors of mortality.

METHODS

A retrospective cohort study was conducted at a single tertiary hospital, including patients who underwent open or endovascular vertebral artery revascularization from 2005 to 2022. Those who underwent direct vertebral revascularization were compared with those who were indirectly revascularized via subclavian artery revascularization. The outcomes of interest were a composite outcome (any of death, stroke, nerve injury, and thrombosis) and mortality. Univariate logistic regression models were fitted to quantify the strength of differences between the direct and indirect revascularization cohorts. Cox regression was used to identify mortality predictors.

RESULTS

Of 143 patients who underwent vertebral artery revascularization, 21 (14.7%) had a vertebral artery originating from the aortic arch. The median length of stay was 10 days (interquartile range, 6-20 days), and demographics were similar between cohorts. The incidence of composite outcome, bypass thrombosis, and hoarseness was significantly higher in the direct group (42.9% vs 18.0%, P = .019; 33.3% vs 0.8%, P < .0001; 57.1% vs 18.0%, P < .001, respectively). The direct group was approximately three times more likely to experience the composite outcome (odds ratio, 3.41; 95% confidence interval, 1.28, 9.08); similarly, this group was approximately six times more likely to have hoarseness (odds ratio, 5.88; 95% confidence interval, 2.21, 15.62). There was no significant difference in mortality rates at 30 days, 1, 3, 5, and 10 years of follow-up. Age, length of hospital stay, and congestive heart failure were identified as predictors of higher mortality. After adjusting for these covariates, the group itself was not an independent predictor of mortality.

CONCLUSIONS

Direct vertebral revascularization was associated with higher rates of composite outcome (death, stroke, nerve injury, and thrombosis), bypass thrombosis and hoarseness. Patients with aberrant vertebral anatomy are at higher risks of these complications compared with patients with standard arch anatomy. However, after adjusting for other factors, mortality rates were not significantly different between the groups.

The Emotional Impact and Coping Mechanisms Following Adverse Patient Events Among Canadian Vascular Surgeons and Trainees

BACKGROUND

This study's objective is to evaluate the emotional experiences, coping mechanisms, and support resources for Canadian vascular surgeons and trainees following an adverse patient event or near miss.

METHODS

This is a cross-sectional survey study of all Canadian Society for Vascular Surgery (CSVS) members from October to November 2021. We collected data on participant experiences with adverse events, their emotional responses, the coping mechanisms used, and their perceptions on available support resources.

RESULTS

The survey was sent to 233 CSVS members yielding 66 responses. The majority (77%) of respondents had experiences with adverse event causing serious patient harm. The most common negative experience following an adverse event included feelings of negativity towards oneself, general distress, and anxiety about potential for future errors. The most common coping mechanism was seeking advice from a mentor or close colleague. Peers (82%) and senior colleagues (59%) were the most preferred sources of support. Most of the respondents would reach out to a mentor if they had 1, but 30% reported no mentor or close colleague for support.

CONCLUSION

Adverse patient events and near misses have serious negative impact on the lives of Canadian vascular surgeons and trainees. Peers and senior colleagues are the most desired source for support, but this is not universally available. Organized efforts are needed to bring awareness in our vascular surgery community on the ubiquitous nature and detrimental effects of adverse events.

Surgical management of intravenous leiomyomatosis with intracardiac extension

Intravenous leiomyomatosis is a rare smooth muscle tumor that is associated with uterine leiomyomas. Intravenous leiomyomatosis often presents with nonspecific abdominal and cardiac symptoms, making the diagnosis difficult. We present a comprehensive review of a case of a 52-year-old woman with intravenous leiomyomatosis with intracardiac extension, who was successfully treated with complete surgical resection.

A Comparison of Outcomes Between Open and Endovascular Arteriovenous Access Creation for Hemodialysis

OBJECTIVE

Preliminary outcomes for percutaneous endovascular autogenous access (endoAVF) have shown promising results; however, comparisons with surgical cohorts in dialysis populations are lacking. This study compares autogenous arteriovenous access created with the EverlinQ endoAVF system with accesses created by conventional surgical technique with respect to functional and patency related outcomes.

METHODS

This is a multicenter, retrospective review of autogenous arteriovenous accesses entered into a prospective database. Patients receiving radiocephalic, brachiocephalic, or endoAVF arteriovenous accesses between 2014 -2019 were included. Autogenous access maturation, primary patency, secondary patency, steal syndrome, and re-interventions were collected and analyzed using standard statistical and survival analyses.

RESULTS

A total of 369 accesses were created during the study period, including 61 endovascular accesses, 171 radiocephalic accesses, and 137 brachiocephalic accesses (median follow-up 17 months; range 1 - 71 months). Maturation failure at the end of follow-up was 27±6%, 27±5%, and 18±4% for endovascular, radiocephalic, and brachiocephalic accesses, respectively (p =.049 for brachiocephalic vs. endovascular accesses). Primary patencies at 12 and 24 months were 42±5% and 32±7% for endovascular accesses, 43±4% and 24±4% for radiocephalic accesses, and 42±4% and 29±4% for brachiocephalic accesses (p=.906). Secondary patencies at 12 and 24 months were 68±6% and 60±7% for endovascular accesses, 75±3% and 67±4% for radiocephalic accesses, and 91±3% and 81±4% for brachiocephalic accesses (p=.006 for brachiocephalic vs. endovascular accesses). There were no statistically significant differences in ischemic steal syndrome (3.3%, 4.1% and 8.0%; p=.229) or total reinterventions/year (1.0±3.1, 0.9±1.8, and 1.2±1.8; p=.289) for endovascular, radiocephalic, or brachiocephalic arteriovenous accesses, respectively.

CONCLUSIONS

EndoAVF compare favorably with respect to maturation and patency compared with surgically created accesses in a real-world cohort. Outcomes and reintervention rates are similar to conventional radiocephalic arteriovenous accesses, but are inferior with respect to patency and maturation to brachiocephalic accesses.

Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair

BACKGROUND

Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR.

METHODS

Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI.

RESULTS

Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52 hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9 days, P = 0.012), operative room time (262 vs. 209, P = 0.040), and perioperative mortality (28.6% vs. 4.1%, P = 0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P = 0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis.

CONCLUSIONS

Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.

An age-based comparison of fistula location, patency, and maturation for elderly renal failure patients

OBJECTIVE

Current Kidney Disease Outcomes Quality Initiative guidelines do not incorporate age in determining autogenous arteriovenous hemodialysis access placement, and the optimal initial configuration in elderly patients remains controversial. We compared patency, maturation, survival, and complications between several age cohorts (<65 years, 65-79 years, >80 years) to determine whether protocols should be modified to account for advanced age.

METHODS

All patients at two teaching hospitals undergoing a first autogenous arteriovenous access creation in either arm between 2007 and 2013 were retrospectively analyzed from a prospectively maintained database. Kaplan-Meier survival and Cox hazards models were used to compare access patency and risk factors for failure.

RESULTS

There were 941 autogenous arteriovenous accesses (median follow-up, 23 months; range, 0-89 months) eligible for inclusion; 152 (15.3%) accesses were created in those >80 years, 397 (42.2%) in those 65 to 79 years, and 392 (41.8%) in those <65 years. Primary patencies in patients >80 years, 65 to 79 years, and <65 years were 40% ± 4%, 38% ± 3%, and 51% ± 3% at 12 months and 12% ± 5%, 13% ± 3%, and 27% ± 3% at 36 months (P < .001). Primary assisted patencies were 72% ± 4%, 70% ± 2%, and 78% ± 2% at 12 months and 52% ± 5%, 52% ± 3%, and 67% ± 3% at 36 months (P < .001). Secondary patencies were 72% ± 4%, 71% ± 2%, and 79% ± 2% at 12 months and 54% ± 5%, 55% ± 3%, and 72% ± 3% at 36 months (P < .001). Radiocephalic patencies were lowest among older cohorts; in those >80 years, 65 to 79 years, and <65 years, they were 65% ± 7%, 67% ± 4%, and 77% ± 3% at 12 months and 41% ± 8%, 51% ± 5%, and 68% ± 4% at 36 months (P = .019). Secondary brachiocephalic access patencies in these cohorts were 78% ± 5%, 80% ± 3%, and 82% ± 3% at 12 months and 68% ± 7%, 66% ± 5%, and 77% ± 4% at 36 months (P = .206). Both the age groups 65 to 79 years and >80 years demonstrated superior brachiocephalic vs radiocephalic secondary patencies (P = .048 and P = .015, respectively); however, no differences between configuration and secondary patency were observed within the cohort <65 years. Radiocephalic access maturation failure at 12 and 24 months was 25% ± 3% and 29% ± 4% in those <65 years, 32% ± 3% and 39% ± 4% in those 65 to 79 years, and 40% ± 7% and 48% ± 8% in those >80 years (P = .006). Brachiocephalic access maturation failures were 17% ± 3% and 20% ± 3% at 12 and 24 months in those <65 years, 21% ± 3% and 25% ± 4% in those 65 to 79 years, and 18% ± 5% and 21% ± 5% in those >80 years (P = .740). On multivariate analysis, coronary disease, female sex, previous ipsilateral or bilateral catheters, radiocephalic configuration, and age >65 years were associated with secondary patency loss.

CONCLUSIONS

Patients aged 65 to 79 years and >80 years had inferior primary, primary assisted, and secondary patency and maturation compared with those <65 years. When stratified by configuration, radiocephalic accesses demonstrated lower patency and maturation compared with brachiocephalic accesses for patients aged 65 to 79 years and >80 years and were an independent predictor of secondary patency loss.