Increased Mortality in Octogenarians Undergoing Endovascular Aortic Aneurysm Repair for Smaller Aneurysms Warrants Caution

BACKGROUND

Geriatric patients constitute a growing portion of the general population, with particular increase in the prevalence of octogenarians. The incidence and prevalence of abdominal aortic aneurysms (AAAs) have been clearly shown to be associated with advancing age. The effect of advanced age in outcomes from endovascular aneurysm repair (EVAR) is unclear. We study the effect of advanced age, as an independent risk factor for mortality in octogenarian geriatric patients (OGPs) compared to nonoctogenarian geriatric patients (NOGPs) undergoing EVAR.

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Procedure-Targeted Vascular database was queried for geriatric patients (>65 years) undergoing EVAR for symptomatic and asymptomatic indications. A multivariable logistic regression analysis was performed comparing outcomes between OGPs and NOGPs.

RESULTS

Of the 10,490 geriatric patients who underwent EVAR, 7,508 (71.6%) were NOGPs and 2,982 (28.4%) were OGPs. Octogenarians were more often female (82.3% vs. 76.7%). In comparison to NOGPs, fewer OGPs were treated for AAA <5.5 cm (46.7% vs. 54.9%, P < 0.001) and AAA <5.0 cm (19.2% vs. 24.0%, P < 0.001). Nearly 90% of male and over 80% of female NOGPs and OGPs treated for AAA <5.0 cm were asymptomatic. Octogenarian geriatric patients (OGPs) had less dyspnea (15.3% vs. 17.3%, P = 0.01), chronic obstructive pulmonary disease (16.1% vs. 20.5%, P < 0.001), diabetes (12.7% vs. 17.8%, P < 0.001), and smoking (13.2% vs. 36.3%, P < 0.001) compared to NOGPs. Octogenarian geriatric patients (OGPs) were found to have a greater length of stay (2 days vs. 1 day, P < 0.001), as well as rate of mortality (3.4% vs. 1.7%, P < 0.001). Both symptomatic and asymptomatic OGPs had a higher rate of mortality than their NOGP counterparts (symptomatic 16% vs. 9.5%, P < 0.001; asymptomatic 1.3% vs. 0.5%, P < 0.001). Multivariate logistic regression analysis showed OGPs to have increased overall associated risk of mortality compared to NOGPs (odds ratio (OR) 1.88, confidence interval (CI) 1.39-2.54, P < 0.001), as well as in the symptomatic (OR 1.54, CI 1.06-2.23, P < 0.001) and asymptomatic cohorts (OR 2.66, CI 1.59-4.45, P < 0.001).

CONCLUSIONS

Octogenarian geriatric patients (OGPs) accounted for over a quarter of geriatric patients undergoing EVAR. This elderly group was associated with an increased rate and risk of mortality compared to NOGPs, even when controlling for known risk factors for mortality. Given this increased risk of mortality in OGPs undergoing EVAR, elective treatment of AAAs in this advanced age group should be performed with caution, particularly in those with diameters in which the risk of rupture may not warrant repair.

Management of acute aortoiliac arterial thrombosis in patients with the novel coronavirus disease 2019: A case series and systematic review of the literature

Objectives

Venous thrombosis has been widely described in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; however, arterial thrombosis has rarely been reported. This study aims to assess the incidence, risk factors, interventions, and outcomes of acute aortoiliac arterial thrombosis in patients with active SARS-CoV-2 infections.

Methods

We present seven SARS-CoV-2-positive patients from our institution who acutely developed thrombi in the aortoiliac arterial system (7/2020-1/2021). A systematic review of the literature on aortoiliac arterial thrombosis in patients with SARS-CoV-2 infections in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was also performed. The available data from all reported cases in the literature and at our institution were analyzed.

Results

Thirty published articles and journal correspondences, including 52 patients, were reviewed and analyzed in addition to our institution's 7 cases. In total, 59 SARS-CoV-2-positive patients were found to have acute aortoiliac thrombosis. The abdominal aorta was the most frequent location for the development of a thrombus. Baseline demographics and medical comorbidities were not significantly different between the symptomatic and asymptomatic cohorts. Seventy-one percent of patients were symptomatic (lower limb ischemia: 75.0%, renal infarction: 20.0%, stroke: 12.5%, mesenteric ischemia: 10.0%). All patients with thrombus involving the ascending aorta, aortic bifurcation, or iliac artery developed thromboembolic or ischemic complications. All patients received systemic anticoagulation. Fifty-three percent of all patients were managed medically. Ninety-four percent of the asymptomatic patients were managed medically. One asymptomatic patient underwent endovascular aspiration of a mobile thrombus. Three (23.1%) deaths occurred in the asymptomatic cohort from hypoxic respiratory failure. Fourteen (36.8%) deaths occurred in the symptomatic cohort. The in-hospital mortality rate was 33.3% overall and 43.8% for patients with thrombi involving more than one aortoiliac segment.

Conclusions

The presence of thrombi in the aortoiliac arterial system appears to be a poor prognostic indicator for patients with active SARS-CoV-2 infections. Medical management of patients with asymptomatic aortoiliac thrombi may be considered. The presence of thrombi involving the ascending aorta, aortic bifurcation, or iliac artery may warrant consideration for operative intervention due to the risk for thromboembolic or ischemic complications. Further study is needed to fully delineate the risk factors, optimal treatment, and outcomes of arterial thrombosis in the setting of SARS-CoV-2 infection.

Intentional Bilateral Renal Artery Coverage During Ruptured Endovascular Paraanastomotic Pseudoaneurysm Repair

The development of a paraanastomotic pseudoaneurysm is a serious complication after open prosthetic reconstruction of the aorta for occlusive or aneurysmal disease. Open repair of these lesions has previously been associated with high rates of morbidity and mortality. Endovascular repair may provide suitable treatment for proximal paraanastomotic aortic bypass graft pseudoaneurysms in patients who are poor candidates for open surgery. Bilateral renal artery coverage may be necessary to achieve adequate fixation and seal during life-threatening emergency cases of pseudoaneurysm rupture. Due to the infrequency of reported cases, the consequences of bilateral renal artery occlusion during these complex procedures are poorly understood. We present a case of a proximal paraanastomotic aortobifemoral bypass pseudoaneurysm rupture that was managed using endovascular repair with intentional coverage of both renal arteries. We also review the contemporary literature on endovascular management of paraanastomotic aneurysms and discuss the role of bilateral renal artery coverage in treating select patients with complex ruptured aortic pathology.

Iatrogenic Arteriovenous Fistula Formation after Endovenous Laser Treatment Resulting in High-output Cardiac Failure: A Case Report and Review of the Literature

Formation of a clinically significant iatrogenic arteriovenous fistula after endovenous laser treatment of the great saphenous vein is an extremely rare complication. Because of the infrequency of reported cases, there is no clear consensus on how to best manage this complication. We present a unique case of an iatrogenic high-output superficial femoral artery-common femoral vein fistula resulting in right heart failure and a distal deep vein thrombosis. Deployment of a covered arterial stent graft resulted in resolution of the arteriovenous fistula and high-output cardiac state. Clinically significant arteriovenous fistulas resulting from inadvertent vessel injury during endovenous laser treatment appear to be amenable to percutaneous endovascular interventions. During these challenging endovascular cases, intravascular ultrasonography can be used to help delineate the morphology of the fistula tract and obtain vessel measurements to ensure accurate endoprosthesis sizing and placement.

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time

BACKGROUND

Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time.

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs.

RESULTS

Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P < 0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P < 0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P > 0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P = 0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P = 0.067).

CONCLUSIONS

The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.

Penetrating Abdominal Aortic Injury: Comparison of ACS-Verified Level-I and II Trauma Centers

OBJECTIVES

Penetrating abdominal aortic injury (PAAI) is a highly acute injury requiring prompt surgical management. When compared to surgeons at level-II trauma centers, surgeons at level-I trauma centers are more likely to take in-house call, and may more often be available within 15 minutes of patient arrival. Thus, we hypothesized that level-I trauma centers would have a lower mortality rate than level-II trauma centers in patients with PAAI.

METHODS

We queried the Trauma Quality Improvement Program database for patients with PAAI, and compared patients treated at American College of Surgeons (ACS)-verified level-I centers to those treated at ACS level-II centers.

RESULTS

PAAI was identified in 292 patients treated at level-I centers and 86 patients treated at level-II centers. Patients treated at the 2 center types had similar median age, injury severity scores and prevalence of diabetes, hypertension, and smoking (p > 0.05). There was no difference in the frequency of additional intra-abdominal vascular injuries (p > 0.05). Median time to hemorrhage control (level-I: 40.8 vs level-II: 49.2 minutes, p = 0.21) was similar between hospitals at the 2 trauma center levels. We found no difference in the total hospital length of stay or post-operative complications (p > 0.05). When controlling for covariates, we found no difference in the risk of mortality between ACS verified level-I and level-II trauma centers (OR:1.01, CI:0.28-2.64, p = 0.99).

CONCLUSION

Though the majority of PAAIs are treated at level-I trauma centers, we found no difference in the time to hemorrhage control, or the risk of mortality in those treated at level-I centers when compared to those treated at level-II trauma centers. This finding reinforces the ACS-verification process, which strives to achieve similar outcomes between level-I and level-II centers.

Access Type for Endovascular Repair in Ruptured Abdominal Aortic Aneurysms Does Not Affect Major Morbidity or Mortality

BACKGROUND

There are limited data on access type when treating ruptured abdominal aortic aneurysms (AAAs) with endovascular aneurysm repair (EVAR). Our study's objective was to evaluate if the type of access in ruptured AAAs affected outcomes.

METHODS

The Vascular Quality Initiative was queried from 2009 to 2018 for all ruptured AAAs treated with an index EVAR. Procedures were grouped by access type: percutaneous, open, and failed percutaneous that converted to open access. Patients with iliac access, both percutaneous and open access, and concurrent bypass were excluded. Baseline characteristics, procedure details, and outcomes were collected. Univariable and multivariable analyses were performed.

RESULTS

There were 1,206 ruptured AAAs identified-739 (61.3%) was performed by percutaneous access, 416 (34.5%) by open access, and 51 (4.2%) by failed percutaneous that converted to open access. Percutaneous access, compared with open access and failed percutaneous access, respectively, had the shortest operative time (min, median) (111 vs. 138 vs. 180, P < 0.001) and was most often performed under local anesthesia (16.7% vs. 5% vs. 9.8%, P < 0.001). The amount of contrast used was similar between the approaches. Univariable analysis comparing percutaneous access, open access, and failed percutaneous access showed differences in 30-day mortality (19.9% vs. 24.8% vs. 39.2%, P = 0.002), postoperative complications (33.7% vs. 40.2% vs. 54%, P = 0.003), and cardiac complications (18.2% vs. 19.8% vs. 34.7%, P = 0.018). However, multivariable analysis did not show access type to have a significant effect on cardiac complications, pulmonary complications, any complications, return to the operating room, or perioperative mortality. Open access was independently associated with a prolonged length of stay (means ratio 1.17, 95% confidence interval (CI) 1.04-1.33, P = 0.012). Factors independently associated with failed percutaneous were prior bypass (odds ratio (OR) 9.77, 95% CI 2.44-39.16, P = 0.001) and altered mental status (OR 2.45, 95% CI 1.17-5.15, P = 0.018).

CONCLUSIONS

Access type for ruptured AAAs was not independently associated with major morbidity or mortality but did have a differential effect on length of stay. Access during these emergent procedures should be based on surgeon preference and experience.

Unique Case of Recurrent Pelvic Congestion Syndrome Treated with Median Sacral Vein Embolization

BACKGROUND

Pelvic congestion syndrome (PCS) is defined as noncyclical pelvic pain or discomfort caused by dilated parauterine, paraovarian, and vaginal veins. PCS is typically characterized by ovarian venous incompetence that may be due to pelvic venous valvular insufficiency, hormonal factors, or mechanical venous obstruction.

METHODS

We describe a case of a 38-year-old multiparous female with a history of pelvic pressure, vulvar varices, and dyspareunia. She underwent left gonadal vein coil embolization in 2014 for PCS that lead to symptomatic relief of her pain. Four years later, the patient returned for recurrent symptoms. Magnetic resonance venogram demonstrated dilated pelvic varices. The previously embolized left gonadal vein remained thrombosed, and there was no evidence of right gonadal vein insufficiency. However, catheter-based venography revealed a large, dilated, and incompetent median sacral vein.

RESULTS

Pelvic venography demonstrated left gonadal vein embolization without any evidence of reflux. The right gonadal vein was also nondilated without reflux. Internal iliac venography showed large cross-pelvic collaterals and retrograde flow via a large, dilated median sacral vein. Coil embolization of the median sacral vein resulted in a dramatic reduction of pelvic venous reflux and resolution of symptoms.

CONCLUSIONS

Recurrence of PCS can occur after ovarian vein embolization through other tributaries in the venous network. The median sacral vein is a rare cause of PCS. We present an interesting case of a successfully treated recurrent PCS with coil embolization of an incompetent median sacral vein.

Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma

BACKGROUND

Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population.

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI.

RESULTS

From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001).

CONCLUSIONS

A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.

Incidence, morbidity, and mortality of traumatic superior mesenteric artery injuries compared to other visceral arteries

Objectives

Celiac artery, superior mesenteric artery, and inferior mesenteric artery injuries are often grouped together as major visceral artery injuries with an incidence of <1%. The mortality rates range from 38–75% for celiac artery injuries and 25–68% for superior mesenteric artery injuries. No large series have investigated the mortality rate of inferior mesenteric artery injuries. We hypothesize that from all the major visceral artery injuries, superior mesenteric artery injury leads to the highest risk of mortality in adult trauma patients.

Methods

The Trauma Quality Improvement Program (2010–2016) was queried for patients with injury to the celiac artery, superior mesenteric artery, or inferior mesenteric artery. A multivariable logistic regression model was used for analysis. Separate subset analyses using blunt trauma patients and penetrating trauma patients were performed.

Results

From 1,403,466 patients, 1730 had single visceral artery injuries with 699 (40.4%) involving the celiac artery, 889 (51.4%) involving the superior mesenteric artery, and 142 (8.2%) involving the inferior mesenteric artery. The majority of patients were male (79.2%) with a median age of 39 years old, and median injury severity score of 22. Compared to celiac artery and inferior mesenteric artery injuries, superior mesenteric artery injuries had a higher rate of severe (grade >3) abbreviated injury scale for the abdomen (57.5% vs. 42.5%, p < 0.001). The overall mortality for patients with a single visceral artery injury was 20%. Patients with superior mesenteric artery injury had higher mortality compared to those with celiac artery and inferior mesenteric artery injuries (23.7% vs. 16.3%, p < 0.001). After controlling for covariates, traumatic superior mesenteric artery injury increased risk of mortality (OR = 1.72, CI = 1.24–2.37, p < 0.01) in adult trauma patients, while celiac artery ( p = 0.59) and inferior mesenteric artery ( p = 0.31) injury did not. After stratifying by mechanism, superior mesenteric artery injury increased risk of mortality (OR = 3.65, CI = 2.01–6.45, p < 0.001) in adult trauma patients with penetrating mechanism of injury but not in those with blunt force mechanism (OR = 1.22, CI = 0.81–1.85, p = 0.34).

Conclusions

Compared to injuries of the celiac artery and inferior mesenteric artery, traumatic superior mesenteric artery injury is associated with a higher mortality. Moreover, while superior mesenteric artery injury does not act as an independent risk factor for mortality in adult patients with blunt force trauma, it nearly quadruples the risk of mortality in adult trauma patients with penetrating mechanism of injury. Future prospective research is needed to confirm these findings and evaluate factors to improve survival following major visceral artery injury.

Utilization of Carbon Dioxide Angiography and Percutaneous Balloon Angioplasty for Treatment of Transplant Renal Artery Stenosis

BACKGROUND

Transplant renal artery stenosis (TRAS) may lead to graft dysfunction and failure. Progressive deterioration of renal allograft function may be exacerbated by contrast-induced nephrotoxicity during iodine contrast administration for renovascular imaging of allografts. We present our institutional experience of endovascular management for TRAS using CO₂ digital subtraction angiography (CO₂-DSA) and balloon angioplasty to manage failing renal transplants.

METHODS

Four patients with renal allografts from March 2017-May 2018 were referred for graft dysfunction and pending renal transplant failure. Indications for referral included refractory hypertension, decreasing renal functioning, and elevated renovascular systolic velocities.

RESULTS

Median age of the four patients was 41.5 years (22-60 years). There were two male and female patients. Chronic hypertension and type 2 diabetes mellitus were the most common comorbidities. An average total of 75 mL of CO₂ was used, supplemented with 17.4 mL of iodinated contrast. All patients had improvements in renal function following intervention with a mean decrease in systolic and diastolic blood pressure of 25.8% and 21.4%, respectively. We also observed a mean decrease of BUN by 13.6% and creatinine by 37.4%. Additionally, eGFR increased by 37.7%. All allografts survived after surgery, and only one patient required repeat angioplasty for recurrence.

CONCLUSIONS

CO₂-DSA with balloon angioplasty can be successfully utilized to salvage deteriorating kidney allograft function in patients with TRAS.

Predictors of blunt abdominal aortic injury in trauma patients and mortality analysis

OBJECTIVE

Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI.

RESULTS

From 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001).

CONCLUSIONS

In the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.

Humerus fracture and combined venous injury increases limb loss in axillary or subclavian artery injury

OBJECTIVE

Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury.

METHODS

A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis.

RESULTS

Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001).

CONCLUSIONS

The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.

Successful Peritoneal Dialysis Catheter Placement in a New End-Stage Renal Disease Patient with Combined Antiphospholipid Syndrome and Factor XI Deficiency

Coagulopathies and bleeding disorders can affect dialysis outcomes by increasing the thrombosis risk at the arteriovenous access or by causing prolonged bleeding at access or catheter sites. We present the case of a 68-year-old woman with combined antiphospholipid syndrome and factor XI deficiency, with chronic prolongation of activated partial thromboplastin time that was not correctable with fresh-frozen plasma (FFP).The patient had a history of stroke, but was not on antiplatelet therapy because of mucocutaneous bleeding events. She had progressive renal failure attributed to her autoimmune disease, and a decision was made to pursue peritoneal dialysis (PD) when she reached end-stage kidney disease. She was admitted to the hospital the day before her planned PD catheter placement and was transfused with FFP and platelets before placement of a temporary hemodialysis catheter. One session of hemodialysis was performed to minimize uremic platelet dysfunction. The patient was given additional FFP and platelets at the time of PD catheter placement; desmopressin was not used. No thrombotic or bleeding complications occurred, and at 8 months out, the patient has been doing well on PD.In summary, careful perioperative planning led to successful PD initiation in a patient with combined bleeding and clotting disorders.

Endovascular Management of Concomitant Thoracic and Abdominal Aortic Ruptures Resulting from Brucellosis Aortitis

BACKGROUND

Acute aortic symptomatology is an unusual manifestation of Brucella melitensis infection. We present a rare case of acute multifocal thoracic and abdominal aortic ruptures arising from Brucellosis aortitis managed exclusively with endovascular surgery.

METHODS

A 71-year-old Hispanic male with a history of atrial fibrillation and prior stroke on chronic anticoagulation presented with shortness of breath and malaise. In addition, he had been treated approximately 1 year previously in Mexico for B. melitensis bacteremia after eating fresh unpasteurized cheese. Computed tomography (CT) angiography demonstrated an acute rupture of the descending thoracic aorta just proximal to the celiac trunk and synchronous rupture at the abdominal aortic bifurctation.

RESULTS

The patient was taken emergently to the hybrid operating room, where synchronous supraceliac thoracic aorta and abdominal aortoiliac stent grafts were deployed under local anesthesia. Completion angiography demonstrated total exclusion of the thoracic and abdominal extravasation with no evidence of endoleak. Twenty hours postoperatively, the patient became acutely obtunded and hypotensive. Repeat CT angiography demonstrated contrast extravasation at the level of the excluded aortic bifurcation. Emergent angiography confirmed a type II endoleak with free extraluminal rupture. Multiple coils were placed at the level of the aortic bifurcation between the left limb of the stent graft and the aortic wall to tamponade the endoleak. No further extravasation was noted on final aortography. Postoperatively, blood cultures confirmed the diagnosis of B. melitensis. The patient was treated with systemic doxycycline, gentamicin, and rifampin. Resolution of the acute event occurred without additional sequelae and he was discharged from the hospital to a rehabilitation facility.

CONCLUSIONS

Concomitant multifocal aortic ruptures arising from Brucellosis aortic infection is a very rare event. In this case, the patient was successfully treated with thoracic and abdominal endovascular stent-graft exclusion, coiling, and long-term targeted antibiotics.

Comparison of CT and Catheter Arteriography for Evaluation of Peripheral Arterial Disease

Computed tomographic arteriography (CTA) has emerged as a promising technique for less invasive imaging of the lower extremity arteries. The aim of this study was to determine the concordance between CTA and catheter arteriography (CA) in patients with peripheral arterial disease (PAD). Twenty-five patients underwent both CTA and CA, and each set of images was interpreted independently by 3 readers. The infrarenal arteries were divided into 16 segments, and each segment was scored as: 1 = stenosis <50%; 2 = 50–99% stenosis; 3 = occlusion. Modal scores from 3 readers were used to compare results for each segment, with CA assumed to represent true arterial anatomy. Agreement between CTA and CA readings was defined as: concordance (modal scores were identical); moderate discrepancy (MD) (modal scores differed by 1); or severe discrepancy (SD) (modal scores differed by 2). In total, 718 segments were assessed by both CTA and CA. For all segments, the sensitivity and specificity of CTA for <50% stenosis was 86% and 90%; for 50–99% stenosis, sensitivity and specificity were 79% and 89%; and for occlusion, 85% and 98%. Above-knee (AK) CTA scores had slightly better concordance of 86.1% than below-knee (BK) readings (82.3%) (p = 0.104). Severe discrepancies between AK CTA and CA scores were observed in 1.8% of segments compared to 5.4% of BK segments (p = 0.038). Poor CTA image quality was the cause in 20% of AK segments and 28% of BK segments. Poor CA image quality was the cause in 8% of AK and 7% of BK discrepancies. Registration disagreement (stenosis observed in a level in 1 study attributed to a different level in the other) accounted for 18% of AK and 17% of BK discrepancies. In 54% of AK and 48% of BK discrepancies, neither image quality nor registration errors were identified, indicating that inherent differences in the depiction of stenosis by CA and CTA were responsible. When discrepancies caused by registration error were excluded, SD observed in BK segments (4.0%) remained significantly higher than in AK segments (1.25%) (p = 0.029), and poor CTA quality image was the most common cause (76%) of severe BK discrepancies. In AK discrepancies without an identifiable technical cause, CTA uniformly showed more stenosis, suggesting greater CTA diagnostic precision in larger vessels. In general, agreement between CTA and CA was moderately good. Compared to CA, CTA may be better at depicting stenosis in large, proximal vessels owing to the superior accuracy of cross-sectional images in the measurement of stenosis. There appeared to be poorer CT resolution and higher frequency of severe discrepancies between CTA and CA in BK arteries.

Aortic Graft Infection: Update on Management and Treatment Options

Replacement of the abdominal aorta, whether by autogenous or prosthetic conduit, has been an a priori requisite in the vascular surgeon's armamentarium since its technical feasibility was described in the early 1950s. The Achilles' heel of this operation, in spite of the progress made over the last half century, is still, however, aortic graft infection. Though survival and limb salvage rates have improved over time—commensurate with advances in surgical technique, critical care, and antimicrobial agents—the prevention and treatment of aortic graft infection remains a formidable challenge to the vascular surgeon. The authors herein review the current literature on this topic with an emphasis on the surgical management options available and suggest an individualized operative strategy based on patient as well as microbial factors to attain the best possible outcome.

Early Outcome of Treatment of Chronic Mesenteric Ischemia

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.

Early Outcome of Treatment of Chronic Mesenteric Ischemia

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.

Vascular reconstruction plays an important role in the treatment of pancreatic adenocarcinoma

OBJECTIVE

Previous studies have proved the feasibility of performing a pancreaticoduodenectomy (Whipple operation) in patients with portal vein-superior mesenteric vein and hepatic artery invasion. We report our institutional experience with the use of a variety of vascular reconstructive methods during pancreatic resections for adenocarcinoma.

METHODS

A retrospective review was performed identifying all patients undergoing a Whipple operation or total pancreatectomy procedure from January 2003 to December 2013. All venous (portal vein-superior mesenteric vein) and arterial (superior mesenteric artery-hepatic artery) reconstructions were extracted and reviewed to determine survival and perioperative complications.

RESULTS

During the 10-year study period, 270 Whipple and total pancreatectomy procedures were performed, of which 183 were for adenocarcinoma of the pancreas. Of the 183 operations, a total of 60 (32.8%) vascular reconstructions were found, 49 venous and 11 arterial. Venous reconstruction included 37 (61.7%) primary repairs, four (6.7%) reconstructions with CryoVein (CryoLife, Inc, Kennesaw, Ga), three (5.0%) repairs with autologous vein patch, three (5.0%) autologous saphenous reconstructions, and two (3.33%) portacaval shunts. In addition, there were 11 (18.3%) arterial reconstructions (seven hepatic artery and four superior mesenteric artery). The 1-year survival for all reconstructions was 71.1%, which is equivalent to T3 lesions that did not receive vascular reconstruction (70.11%), with a median survival time of 575.28 days and 12 patients still alive. Survival time was comparable with each type of venous reconstruction, averaging 528 days (11 of 49 patients still alive). There was a total thrombosis rate of seven of 60 (11.6%), all of which were portal vein thrombosis: three in the primary repair group and four delayed thromboses seen in primary repair, CryoVein repair, and vein patch repair. There was no thrombosis in any patients after arterial reconstruction.

CONCLUSIONS

An aggressive approach for stage II pancreatic cancers with venous or arterial invasion can be performed with comparable results when it is executed by an experienced institution with skilled oncologic and vascular surgeons.

Geometric changes of the inferior vena cava in trauma patients subjected to volume resuscitation

OBJECTIVE

Dynamic changes in anatomic geometry of the inferior vena cava from changes in intravascular volume may cause passive stresses on inferior vena cava filters. In this study, we aim to quantify variability in inferior vena cava dimensions and anatomic orientation to determine how intravascular volume changes may impact complications of inferior vena cava filter placement, such as migration, tilting, perforation, and thrombosis.

METHODS

Retrospective computed tomography measurements of major axis, minor axis, and horizontal diameters of the inferior vena cava at 1 and 5 cm below the lowest renal vein in 58 adult trauma patients in pre-resuscitative (hypovolemic) and post-resuscitative (euvolemic) states were assessed in a blinded fashion by two independent readers. Inferior vena cava perimeter, area, and volume were calculated and correlated with caval orientation.

RESULTS

Mean volumes of the inferior vena cava segment on pre- and post-resuscitation scans were 9.0 cm(3) and 11.0 cm(3), respectively, with mean percentage increase of 48.6% (P < 0.001). At 1 cm and 5 cm below the lowest renal vein, the inferior vena cava expanded anisotropically, with the minor axis expanding by an average of 48.7% (P < 0.001) and 30.0% (P = 0.01), respectively, while the major axis changed by only 4.2% (P = 0.11) and 6.6% (P = 0.017), respectively. Cross-sectional area and perimeter at 1 cm below the lowest renal vein expanded by 61.6% (P < 0.001) and 10.7% (P < 0.01), respectively. At 5 cm below the lowest renal vein, the expansion of cross-sectional area and perimeter were 43.9% (P < 0.01) and 10.7% (P = 0.002), respectively. The major axis of the inferior vena cava was oriented in a left-anterior oblique position in all patients, averaging 20° from the horizontal plane. There was significant underestimation of inferior vena cava maximal diameter by horizontal measurement. In pre-resuscitation scans, at 1 cm and 5 cm below the lowest renal vein, the discrepancy between the horizontal and major axis diameter was 2.1 ± 1.2 mm (P < 0.001) and 1.7 ± 1.0 mm (P < 0.001), respectively, while post-resuscitation studies showed the same underestimation at 1 cm and 5 cm below the lowest renal vein to be 2.2 ± 1.2 mm (P < 0.01) and 1.9 ± 1.0 mm (P < 0.01), respectively.

CONCLUSIONS

There is significant anisotropic variability of infrarenal inferior vena cava geometry with significantly greater expansive and compressive forces in the minor axis. There can be significant volumetric changes in the inferior vena cava with associated perimeter changes but the major axis left-anterior oblique caval configuration is always maintained. These significant dynamic forces may impact inferior vena cava filter stability after implantation. The consistent major axis left-anterior oblique obliquity may lead to underestimation of the inferior vena cava diameter used in standard anteroposterior venography, which may influence initial filter selection.

Pancreaticoduodenal artery aneurysms secondary to median arcuate ligament syndrome may not need celiac artery revascularization or ligament release

INTRODUCTION

Median arcuate ligament syndrome (MALS) is a rare disorder defined by compression and narrowing of the celiac artery by the median arcuate ligament. The increased blood flow through the pancreaticoduodenal arcade can lead to the aneurysmal formation within the vessel. We report 3 cases of pancreaticoduodenal arterial aneurysms (PDAAs) in patients with MALS whose aneurysms were occluded, but celiac artery revascularization was not performed.

METHODS

Case 1: Asymptomatic 61-year-old female with no past medical history was referred to vascular surgery for evaluation of a PDAA incidentally found on computed tomography (CT) scan. The patient was taken for laparoscopic division of the median arcuate ligament; however, the release was incomplete. This was followed by endovascular coil embolization of the PDAA without celiac revascularization. The patient tolerated the procedure well with no complications and the 1-year follow-up shows no signs of aneurysm recurrence. Case 2: A 61-year-old male found to have an incidental PDAA on CT scan. The patient was taken for coil embolization without median arcuate ligament release. At the 1-year follow-up, the patient continues to be asymptomatic with no recurrence. Case 3: A 56-year-old male presented with a ruptured PDAA. He was taken immediately for coil embolization of the ruptured aneurysm. Postoperatively, the patient was identified to have MALS on CT scan. Because of his asymptomatic history and benign physical examination before the rupture, he was not taken for a ligament release or celiac revascularization. He continues to be asymptomatic at his follow-up.

RESULTS

PDAAs secondary to MALS are very rare and most commonly diagnosed at the time of rupture, which has a mortality rate that reaches approximately 30%, making early identification and treatment necessary. Standard treatment would include exclusion of the aneurysm followed by celiac revascularization; however, these 3 cases identify an alternative approach to the standard treatment.

CONCLUSION

Celiac revascularization may not be necessary in the asymptomatic patient with a PDAA who has close follow-up and serial imaging.