Vascular Surgery 2023

We are rapidly approaching the 2-year anniversary since Vascular Surgery became a distinct speciality in surgery. Dr Chan addressed the importance of the subspeciality Vascular Nurse as an essential partner in modern vascular service. Dr Pang reviewed his 3-year results of advanced endovascular interventions for high-grade Trans-Atlantic Inter-Society Consensus-Class D (TASC-D) femoropopliteal inventions, and compared patency and clinical outcomes with the traditional bypass operations. [Extracted from the article] Copyright of Surgical Practice is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Recurrent Liver Abscess in a Non-Toxic Patient

Introduction: Liver abscesses are caused by direct spread from peritonitis, biliary tract infection or via hematogenous seeding from a distant source. Most are polymicrobial, however Escherichia coli and Klebsiella pneumoniae are the most common offending pathogens. Patients usually present with pain, fever, and clinical signs of infection. We describe a case of spontaneous liver abscess in a non-toxic patient that recurred 10 years after a previous abscess. Case Description/Methods: A 73-year-old-man with a history of type 2 diabetes mellitus, hypertension, CAD status post CABG and PCI 3 years ago, and abdominal aortic aneurysm status post endovascular aneurysm repair presented with 2 weeks of dark urine. After receiving his COVID-19 booster and influenza vaccinations, he developed flu-like symptoms with a self-resolving fever of 101.8degreeF. He had dark amber urine without dysuria or hematuria. Later, he experienced generalized weakness and decreased oral intake. Outpatient labs showed elevated liver function tests, and he was told to present to the ED. On arrival, he was afebrile with stable vitals. Physical exam was unremarkable. Laboratory evaluation showed a hemoglobin of 11.7 g/dL, sodium of 133 mEq/L, creatinine of 1.4 mg/dL, aspartate aminotransferase of 117 U/L, alanine aminotransferase of 212 U/L, alkaline phosphatase of 825 U/L, total bilirubin of 4.1 mg/dL, and direct bilirubin of 2.1 mg/dL. Triple-phase CT showed a 2.8 cm mass in the right liver lobe with linear enhancement. Ultrasound showed mixed echogenicity measuring 3.6 x 2.9 x 3.3 cm in segment 8 of the liver. On further evaluation, patient had an E. coli abscess diagnosed 10 years prior, managed with antibiotics and drainage. At that time, the abscess was within the right inferior liver lobe, similar to his current abscess. LFTs downtrended. Abscess was aspirated, with culture growing oxidase negative, gramnegative rods, likely E. coli. Patient started on ceftriaxone and metronidazole, to undergo colonoscopy as an outpatient and rule out colonic bacterial translocation. Discussion(s): Pyogenic liver abscess can result in significant morbidity and mortality because of worsening infection and sepsis. Abscesses occur because of spread from adjacent infection or after recent surgeries. Recurrence is very rare. Here, we describe a very unusual case of a pyogenic liver abscess growing E. coli in a non-toxic patient, with the same location and causative organism as an abscess managed 10 years prior. (Figure Presented).

Polytrauma patient with lateral thoracic spondyloptosis: case report and literature review

Background: Spondyloptosis is caused by high force trauma. The vast majority of cases occur in the sagittal plane and at transition points where ridged sections meet more flexible regions. Lateral thoracic spondyloptosis is extremely rare and there is no current consensus on the optimal treatment plan. Case Description: Here we present a case of a previously physically healthy 24-year-old polytrauma patient after he was struck as a pedestrian by a motor vehicle. Of note the patient was found to have lateral spondyloptosis between T9-10 with complete spinal cord transection. The patient also sustained multi-ligamentous left knee injury, pelvic fractures, open comminuted left tibia and fibular fracture, lacerated liver, bilateral renal lacerations, ischemic bowel, and an aortic arch pseudoaneurysm. Conclusion(s): Lateral thoracic spondyloptosis is a devastating injury with an extreme rate of persistent neurologic deficits. There is no unanimously accepted treatment because of the rarity if the injury and the poor outcomes that patients face. Additionally, patients who experience high level trauma often develop severe psychiatric illness, and the importance of identifying risk factors and implementing care early may improve patient outcomes.Copyright © AME Medical Journal.

Sudden Rupture of Abdominal Aortic Aneurysm in COVID19 Patients.

PURPOSE: The purpose of the paper is to report the clinical outcomes of 4 patients with ruptured abdominal aortic aneurysm (AAA) during (3 patients) or immediately after (1 patient) moderate-severe SARS-CoV-2 infection. We discuss COVID-19-related mechanisms which could impact AAA rupture. PATIENTS AND METHODS: During the period of the pandemic (March 2020-May 2021), we performed surgery in 18 patients with ruptured AAA. Four patients were affected by moderate or severe SARS-CoV-2 infection (in 3 patients the rupture occurred during the infection and in 1 patient 3. months after discharge from the hospital). Two patients underwent open repair and 2 endovascular surgery. RESULTS: No postoperative mortality and no major complication occurred. Rapid growth of the AAA in comparison with a previous Duplex scan was evident in all 4 patients. CONCLUSIONS: Family doctors and vascular surgeons should be aware about the possibility of AAA degeneration in patients with moderate-severe COVID19 infection. The risk is increased by steroid therapy which is essential in more advanced stages of the infection. In this clinical setting, endovascular repair is a valid choice.

37th Turkish Cardiology Congress

The proceedings contain 160 papers. The topics discussed include: effects of anemia on TAVR outcomes;the impact of moderate to severe mitral regurgitation on mortality in patients undergoing transcatheter aortic valve implantation;comparison between PeRcutanEous and surgical femoral access for endovascular aortic repair in patients with type III aortic dissection (PRECLOSE trial);comparison of systemic immune-inflammation index levels in patients with isolated coronary artery ectasia versus patients with obstructive coronary artery disease and normal coronary angiogram;recurrent acute coronary syndrome, how successful are we in risk modification and guideline recommendations?;characteristics of the patients with atrioventricular conduction block after ST segment elevation myocardial infarction and its clinical importance;let's not deprive the COVID-19 patient from percutaneous coronary intervention;and the association between invasive microvascular function and CMR-derived microvascular injury indicators and left ventricular function and infarct size at 1-month after reperfused STEMI.

Hybrid Management of an Aortobronchial Fistula after Patch Aortoplasty for Aortic Coarctation in a Patient with SARS-CoV-2 Pneumonia: Case Report and Review of the Literature.

Aortobronchial fistula is a rare cause of repeated hemoptysis and a potentially fatal condition if left untreated. We present the case of a 40-year-old man with repeated hemoptysis, excessive cough, and epistaxis ongoing for several days after SARS-CoV-2 pneumonia diagnosis. The patient had a history of patch aortoplasty for aortic coarctation and aortic valve replacement with a mechanical valve for aortic insufficiency due to bicuspid aortic valve at the age of 24. Computed tomography scan performed at presentation revealed a severely dilated ascending aorta, a thoracic aorta pseudoaneurysm at the site of the former coarctation, an aortobronchial fistula suggested by the thickened left lower lobe apical segmental bronchus in contact with the pseudoaneurysm and signs of alveolar hemorrhage in the respective segment. The patient was treated with thoracic endovascular aneurysm repair (TEVAR) after prior hemi-aortic arch debranching and transposition of the left common carotid artery and subclavian artery through a closed-chest surgical approach. Our case report together with a systematic review of the literature highlight the importance of both considering an aortobronchial fistula in the differential diagnosis of hemoptysis in patients with prior history of thoracic aorta surgical intervention, regardless of associated pathology, and of taking into account endovascular and hybrid techniques as an alternative to open surgical repair, which carries a high risk of morbidity and mortality.

A RARE CASE OF COVID-19-INDUCED AORTITIS

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Aortitis is a type of vasculitis that refers to inflammation of the aortic wall. Most common causes are rheumatologic disorders and bacterial infection. Here, we report a viral cause of aortitis induced by COVID-19. CASE PRESENTATION: A 73 year old female with history of coronary artery disease, chronic kidney disease, COPD, hypertension, pulmonary embolism on Eliquis and abdominal aortic aneurysm (AAA) status post repair presented with acute hypoxemia secondary to Covid-19 pneumonia. Of note, patient was vaccinated against COVID-19. CT abdomen at admission demonstrated a known infrarenal AAA with increased degree aortic wall thickening, concerning for aortitis. Aortitis was initially thought to be due to endovascular infection from possible bacteremia rather than surgical site infection as the patient had the AAA repair almost a year prior. Given that bacterial aortitis could result in death, blood cultures were obtained and she was started on Vancomycin and Rocephin. Rapid Plasma Reagin was ordered to rule out syphilis. She had titer of 1-2 which was thought to be false positive as fluorescent treponemal antibody absorption test was negative. After blood cultures and inflammatory markers were negative, antibiotics were discontinued. Aortitis was attributed to COVID. Patient was treated with DEXA-ARDS protocol. Repeat CT abdomen after 8 days no longer showed gross evidence of aortitis. Patient was discharged home with home healthcare. DISCUSSION: Aortitis, a rare complication of COVID-19, has been reported. A proposed mechanism of this pathogenesis involves acute endotheliitis, where endothelial cells infected by virions become infiltrated by neutrophils and mononuclear cells, leading to apoptosis and lymphocytic endotheliitis [1]. Later, these arteries move through the stages of an accelerated karyolysis, accumulation of apoptotic bodies, caspase granules, and fibrinoid substances, leading to leukocytoclastic vasculitis [1]. This inflammatory reaction is followed by deposition of polyclonal antigen-antibody immune complexes, which is a type III hypersensitivity acute vasculitis [2]. Our patient's history of AAA repair predisposed her to increased endothelial dysfunction. After other bacterial infectious causes and post-surgical complications were ruled out, patient was treated with steroids. Most cases of COVID induced aortitis have been treated with prednisone that required treatment for around 1 month [3]. Here, we present a patient treated with DEXA-ARDS with resolution of aortitis. CONCLUSIONS: Due to the novelty, the understanding of exact pathogenesis and long term effects of COVID-19 induced aortitis is limited. However, our case does serve to support prior case reports of COVID-19 aortitis that showed clinical and radiologic response to steroids. Further research is warranted to diagnose and treat aortitis in order to avoid life threating complications. Reference #1: Varga, Zsuzsanna, et al. "Endothelial cell infection and endotheliitis in COVID-19.” The Lancet 395.10234 (2020): 1417-1418. Reference #2: Roncati, Luca, et al. "Type 3 hypersensitivity in COVID-19 vasculitis.” (2020): 108487-108489. Reference #3: Dhakal, Pravash et al. "Aortitis in COVID-19.” IDCases vol. 24 (2021): e01063. doi:10.1016/j.idcr.2021.e01063 DISCLOSURES: No relevant relationships by Jessica Lee No relevant relationships by Thong Ngo No relevant relationships by Marrian Sedrak No relevant relationships by Hena Yagnik

Inner Branch Endovascular Repair in Complex Secondary Aortic Intervention in Case of Abdominal and Thoraco-Abdominal Aneurysmal Progression: An Early Single Centre experience

Introduction: Aortic aneurysmal disease is an evolving pathology: when treating an aortic aneurysm, we must consider the possibility of a thoraco-abdominal evolution aneurysm, which might lead to further treatments. In case of challenging anatomies (narrow aortic lumen at the level of visceral arteries, aortic wall thrombus, true lumen in an aortic dissected aneurysm, and focal aortic narrow diameter), unfavourable both for fenestrated endovascular aneurysm repair (FEVAR) and branched endovascular aneurysm repair (BEVAR), an inner branched custom made device could represent a potential feasible solution. Inner branched endografts have a typical configuration that combines the advantageous characteristics of both fenestrated and side branched endografts, thus showing advantages over other custom made grafts. Our study aimed to investigate the potential role of this technique in a broad variety of aortic anatomies unfavourable for FEVAR and BEVAR, in patients who received different previous aortic treatments. Methods: In our institution, between July 2018 and July 2020, 20 consecutive patients underwent a FEVAR/BEVAR procedure to treat complex abdominal aortic aneurysm or thoracic aortic aneurysm. Nine patients who were deemed untreatable with a fenestrated/branched graft due to aortic anatomy and/or previous treatments were treated with a custom made, four inner branch E-xtra design endograft (I BEVAR). All patients were treated for a complex aortic abdominal and thoraco-abdominal aneurysm: two patients were previously treated with frozen elephant trunk and TEVAR;three patients were previously treated with TEVAR;and one with TEVAR + abdominal aortic surgical treatment. Two patients received abdominal aortic surgical treatment only. The last patient was previously treated with EVAR, which was then complicated with a type 1A endoleak (EL). Five of six TEVARs were placed before BEVAR as staged procedures, to decrease spinal cord ischaemia risk. All patients had a lumbar cerebrospinal fluid drainage during the BEVAR procedure. In total, the bridging stents placed included 43 balloon expandable and four self-expandable stents. Results: In our experience, all cases were treated with a four inner branch endograft with a total revascularisation of 36 target vessels. Technical success was achieved in all nine cases (100%), with precise deployment of the inner branched endograft and effective engagement and bridging of all branches. Major clinical complications occurred in three (33%) patients: one case of continuous veno-venous haemofiltration treatment for a transient acute renal failure in a chronic renal disease;one case of hepatic decompensation in patient with a chronic cirrhosis, which led to liver failure (Child Pugh C10, MELD 19, still under medical treatment);and one patient with a pulmonary infection disease (COVID-19 related), which then resolved. No patient suffered spinal cord ischaemia. The mean follow up was 12.8 months ± 6.79 months, with an estimated one year survival rate of 89%. One patient with a thrombophilic disorder died on postoperative day 48 as a result of multiple organ failure after acute four inner branches simultaneous occlusion. During follow up, the target vessel primary patency rate was 89%, associated with four (11%) bridging stent ELs. At 30 days, computed tomography angiography detected five BS ELs in four patients: one type III BS EL (2.7%), and four type I BS ELs (11%). Re-intervention was needed in one patient (11%) with a type III and I BS EL associated with an aneurysm sac enlargement treated with bridging stent relining in the left renal artery and superior mesenteric artery. Conclusion: Our experience shows the feasibility of treating complex aortic anatomies with an inner branched graft in patients which were anatomically unfit for FEVAR/BEVAR treatment, allowing complex visceral vessels recanalisation and an adequate sealing. When a re-intervention is needed, we have to consider that previous surgical and endovascular treatments modify the aortic anatomy, and the graft deploy ent may be tougher, with a higher risk of malrotation. Inner branched endograft could be a valid option in case of complex anatomies, but long term follow up is needed.

The Management of Popliteal Artery Aneurysms With Acute Limb Ischemia in the Vascular Quality Initiative

Objective: Endovascular popliteal artery aneurysm (PPA) repair has acceptable outcomes compared with open repair for elective therapy. However, endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well studied. This project compares the outcomes of urgent endovascular and open repair of PAA presenting with ALI. Methods: The Vascular Quality Initiative database for peripheral vascular interventions and infrainguinal bypass was reviewed for popliteal artery aneurysms presenting with ALI. The characteristics and outcomes of patients undergoing urgent open and endovascular repair were compared. Results: Urgent PAA repair for ALI constituted 10.5% (N = 571) of all PAA repairs with no change in proportion during the study period. The majority (80.6%, n = 460) of urgent repairs were open. However, the proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021 with a sharp increase after 2019 (Fig). Patients undergoing endovascular repair were more likely to be African American (3.6% vs 3.3%, P =.044) and older (71.2 ± 12.5 vs 68.0 ± 11.8) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%, P =.006) but less likely to have chronic kidney disease (66.1% vs 69.6%, P =.027) compared with patients undergoing open repair (Table). Open PAA repair was more likely to be associated with bleeding (20.8% vs 2.7%, P <.001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days, P <.001), and less likelihood of discharge home (64.9% vs 70.3%, P =.051). The perioperative major amputation rate was 7.5% with no difference in major amputations between the two treatment strategies even at 1 year. However, patients receiving endovascular repair had significantly higher inpatient (1.1% vs 0%, P <.001), 30-day (6.3% vs 0.4%, P <.001), and 1-year (16.5% vs 8.4%, P =.02) mortality compared with open repair (Table). Multivariable regression analysis suggested that endovascular repair was independently associated with increased 30-day mortality, but not 1-year mortality compared with open repair. Conclusions: The utilization of endovascular PAA has exponentially increased during the coronavirus pandemic. Even though endovascular repair is associated with decreased complications and resource utilization, it should be offered selectively in the urgent setting for ALI because of concern with perioperative mortality. [Formula presented] [Formula presented]

The Colt Device for Treating Thoraco-Abdominal Aneurysms - Concept and Clinical Results

Objective: To report results of application a new stent graft design for the treatment of patients with thoraco-abdominal aneurysms (TAAAs), which was co-invented by a vascular surgeon. This is a retrospective observational study. Methods: The Colt is a self-expanding stent graft, composed of nitinol metal stents creating a special exoskeleton with asymmetric springs covered with polyester material. The Colt device offers some advantages over existing stent graft options. The main body is available in two different diameters on both ends and in three different lengths. It has four branches pointing downward and coming from the main stent graft at two levels. It offers the physician an opportunity to decide which branch to choose for the target vessel. It may be implanted alone or extended proximally and distally. Balloon expandable and/or self-expanding stent grafts are used to create the visceral branches. In complex extensive aneurysms, the procedure is divided into two or three stages to minimize the risks of spinal cord ischemia. Results: Between August 2015 and December 2021, twenty-two Colt stent grafts were implanted in twenty males and two females (aged 56–81) with TAAAs (eight Type II; twelve Type III; two Type IV). The mean aneurysm diameter was 73.4 mm (range 64–83). All patients were asymptomatic. Eighty-five target vessels were reconstructed using either self-expanding or balloon-expandable stent grafts. Fourteen bifurcated, six custom-made tubes and two aortouniiliac (AUI) stent grafts were used as distal extensions to the Colt device. Completion angiography revealed no type I endoleaks. Five patients had Type II endoleaks which were treated conservatively. There were no intraoperative deaths. One patient died on the 7th postoperative day from multiorgan failure. We did not observe any other complications within 30 days after implantation. One patient died from Covid-19 two months after discharge. Follow-up ranged from three to 75 months. There was no migration or dislocation of the docking station or proximal and distal extensions. All Colt device prostheses remained patent, however, two branches leading to the coeliac trunk were found occluded at the time of the 12-month CTA, without any symptoms. In two patients, there were late problems with three renal bridging stent grafts. One of the Type II endoleaks resolved spontaneously after one year, while four others remain under observation. No patient had an increase in sac diameter. Conclusions: Results from the current series are promising. The Colt stent graft can be applied to a large variety of TAAA anatomies, which may facilitate the development of new “off-the-shelf” devices in the future.

Running a safe aortic service in the COVID-era

Introduction: Within the Covid-19 pandemic, elective surgery has been cancelled to increase critical care capacity. With two thirds of abdominal aortic aneurysm ruptures lethal, it is important to consider how to run a safe aortic service within the pandemic. Vascular patients have an increased risk of mortality from Covid-19. By considering ambulatory care, shortening hospital stay and discharging to level 1 care for non-complex infrarenal endovascular aneurism repairs (EVAR), critical care capacity can be kept available and exposure to nosocomial Covid-19 can be reduced. Method: A retrospective audit of EVAR patient's documentation examined the ASA, level of postoperative care, time to discharge, geographical and personal care factors. These were compared with pre-established criteria deeming suitability for ambulatory or ward level care. Results were presented locally and subsequent reaudit conducted. Results: The initial audit included 40 records. 30% of patients were potential targets for ambulatory care with the median discharge on postoperative day 3. All patients were admitted to the high dependency unit (HDU) with 12.5% of patients receiving treatment that required a HDU level of care. Upon reaudit, 8 records were included with all patients admitted to HDU and the median day of discharge postoperative day 2. Notably, 37.5% patients were discharged on postoperative day 1 and a day of surgery admission (DOSA) process was implemented. Conclusions: By reviewing a health board's EVAR caseload, suitability for short stay EVARs can be assessed. Implementing an early discharge and DOSA process keeps care capacity available and may protect against nosocomial Covid-19.

Survey on anesthesiology in vascular surgery and COVID-19 pandemic impact

Patients undergoing vascular surgery are multi-pathological and complex. In recent years there has been a significant increase in the number of patients undergoing endovascular surgery. The Cardiac, Vascular and Thoracic section of the Spanish Society of Anesthesiology and Resuscitation (SEDAR) designed a telematic survey based on 29 questions using Google Forms® that was sent to all members of this society. A total of 204 anesthesiologists answered questions structured in blocks: 1. Carotid endarterectomy;2. Abdominal and thoracic aortic aneurysm repair;3. Lower limb arterial and venous surgery;4. Impact of the COVID-19 pandemic on vascular surgical scheduling;5. Enhanced recovery after vascular surgery;6. Other questions. Despite certain differences in anesthetic management, locoregional anesthesia is a widely used technique. The three determinants for the anesthesiologist's performance are the patient, his or her pathology and the idiosyncrasy of each center. Currently, accelerated recovery programs in vascular surgery are not widely implemented in Spain. Finally, the results show that during the first wave of the COVID-19 pandemic, vascular surgery was practically reduced to urgent and emergent surgery, following the anesthetic and surgical recommendations of the different scientific societies, including SEDAR and SEACV.

Development of symptomatic inflammatory aneurysm treated with endovascular repair in coronavirus disease 2019-infected patient.

The sequelae and complications of coronavirus disease 2019 infection have continued to emerge during this pandemic era. Although the long-term effects are continually being monitored and studied, we have been seeing more acute and subacute medical complications requiring a thorough discussion and, sometimes, adjustment of our standard of care and intervention. In the present report, we describe a case of an acute, symptomatic inflammatory or mycotic abdominal aortic aneurysm in a patient with coronavirus disease 2019 who had undergone urgent endovascular repair.