Combined carotid endarterectomy and transcatheter aortic valve replacement: Technique and outcomes.

BACKGROUND: Stroke and transient ischemic attack after transcatheter aortic valve replacement results in significantly higher morbidity and mortality. Severe carotid artery disease may be a contributing factor to this increased risk. We report our technique and outcomes of combined carotid endarterectomy (CEA) with transcatheter aortic valve replacement (TAVR). METHODS: From March 2013 to November 2017 a total of 753 TAVRs were performed at our institution for symptomatic severe aortic stenosis. Of this group, 16 patients underwent concomitant TAVR and CEA. A retrospective review was performed to assess risk, outcomes, and short-term survival. RESULTS: Sixteen patients underwent concomitant CEA/TAVR procedures for severe carotid and severe aortic stenosis. The mean Society of Thoracic Surgeons (STS) Risk Score was 7.0 ± 4.7. All patients had severe carotid artery stenosis and aortic stenosis. Nine patients had a transfemoral TAVR approach and eight patients had a transapical TAVR approach. The mean length of stay was 6.4 ± 3.7 days. At 30 days there were no cerebrovascular events and no mortalities. CONCLUSIONS: The use of concomitant CEA and TAVR in patients with severe aortic stenosis and severe carotid stenosis can be done safely without increased risk of complications. This approach may reduce the risk of stroke associated with TAVR in appropriately selected patients.

Results of staged carotid endarterectomy and coronary artery bypass graft in patients with severe carotid and coronary disease.

BACKGROUND: To evaluate our experience with staged carotid endarterectomy (CEA) followed by coronary artery bypass grafting (CABG) within the perioperative period for patients with severe carotid and coronary artery disease. METHODS: From 1998 to August of 2010, 40 patients who were referred for isolated coronary surgery were found to have significant carotid disease. All patients underwent CEA followed by subsequent CABG within 30 days of the CEA. Severe carotid stenosis was defined as >70%. RESULTS: Average patient age was 65.5 ± 10.6 years and 32 (80%) were male. Severe carotid stenosis was unilateral in 37 of the patients, bilateral in 3, and asymptomatic in 37. Patients underwent CEA with either patch angioplasty or eversion technique. General anesthesia with selective shunting was used in all cases. There were zero deaths, zero strokes, and one myocardial infarction (MI) (2.5%) immediately after CEA. After CEA, CABG was performed within 30 days. The average interval between procedures was 6.87 days. There were two (5.0%) deaths, one from MI and the other from multisystem organ failure. There were two strokes (5.0%), with one having permanent effects. The perioperative mortality, stroke, and MI rates after both operations were 5.0%, 5.0%, and 5.0%, respectively. CONCLUSIONS: Staging of CEA followed by CABG in the immediate perioperative period may be an acceptable approach to patients with severe carotid and coronary disease. Despite the presence of known severe coronary disease, the performance of CEA under general anesthesia as the initial procedure was well tolerated. We propose that this strategy may be a possible option for patients who present with severe disease in both coronary and carotid distributions. The results of our study, though based on a limited cohort, suggest that this approach of staged CEA-CABG within the perioperative period <30 days is reasonable.

Challenging neck anatomy is associated with need for intraoperative endovascular adjuncts during endovascular aortic aneurysm repair (EVAR).

BACKGROUND: The purpose of this study was to determine which proximal seal zone characteristics were predictive of early and late type Ia endoleak development after endovascular aortic aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysmal disease. METHODS: We evaluated 146 patients who underwent EVAR between January 2006 and March 2007. In the cohort, high-resolution computed tomography images of 100 (68.5%) patients were available, which showed detailed measurement of proximal neck parameters, including diameter, length, calcification, thrombus, suprarenal and infrarenal angles, and reverse taper morphology. Postprocessing of digital data sets was performed to obtain centerline-of-flow measurements. Relevant medical records and follow-up computed tomography scans were reviewed. RESULTS: Mean age of the patients was 72.7 years, with 78% being male. Of these patients, 66% did not satisfy the instructions for use for the Zenith EVAR device, and 50% did not satisfy the instructions for use for the AneuRx device. Nine patients had intraoperative type Ia endoleaks. A 100% assisted primary technical success rate was achieved with the adjunctive use of angioplasty (n = 4), uncovered stent (n = 3), and extension cuff (n = 2) placement. There was a significant association between type Ia endoleak development and magnitude of the infrarenal angle (p < 0.01); however, other parameters were not significant. At follow-up (mean, 587 days), no patient had a type Ia endoleak, and there were no aneurysm-related deaths. CONCLUSIONS: Our data indicate that infrarenal angle is related to intraoperative type Ia endoleak occurrence, but other factors often thought to be indicative of adverse neck anatomy are not significant predictors. Moreover, all type Ia endoleaks in this cohort were successfully eliminated intraoperatively, and durability was confirmed on postoperative surveillance. These data demonstrate that challenging neck anatomy is associated with the need for intraoperative endovascular adjuncts, and that effective and durable aneurysm exclusion should still be expected.

Strategies and outcomes of cardiac surgery in Jehovah's Witnesses.

BACKGROUND: Jehovah's Witnesses (JW) are a Christian faith, with an estimated 1.1 million members in the United States, well recognized for their refusal of blood and blood products. JW may not be considered for cardiac surgery due to perceived higher risks of morbidity and mortality. This study reviews our contemporary strategies and experience with JW undergoing routine and complex cardiac surgery. METHODS: From November 2001 to April 2010, 40 JW were referred for cardiac surgery at a single quaternary referral institution. A retrospective analysis of demographic data, perioperative management, and clinical outcomes was examined. Published validated clinical risk calculator and model for prediction of transfusion were used to identify high-risk patients (risk of mortality >6% or probability of transfusion >0.80). RESULTS: The mean age was 70 (± 9.5) years with 21 men and 19 women. Patients were classified as high risk (45%, n = 18) and low risk (55%, n = 22) with demographics and comorbidities listed in Table 2. Operative procedures included: isolated coronary artery bypass grafting (CABG) (n = 19), isolated valve replacement/repair (n = 7), valve/CABG (n = 7), reoperative valve replacement (n = 4), reoperative CABG (n = 2), valve/ascending aorta replacement (n = 1), and CABG/ascending aorta replacement (n = 1). All JW were evaluated by The Department of Bloodless Medicine to individually define acceptable blood management strategies. The mean preoperative hemoglobin was 14.1 g/dL (±1.6). Overall mortality was 5% (n = 2) all of which were in the high-risk group. DISCUSSION: Using a multidisciplinary approach to blood management, JW can safely undergo routine and complex cardiac surgery with minimal morbidity and mortality.

The effect of immunosuppression on lower extremity arterial bypass outcomes.

BACKGROUND: Myointimal hyperplasia is a pathologic result of the body's natural inflammatory response to injury of the blood vessels and a leading cause of peripheral arterial bypass failure. Because immunosuppressive agents are known to abate inflammation, we hypothesized the superior outcome of lower extremity bypass in renal transplant recipients compared with the hemodialysis population. METHODS: The vascular surgery registry at a single tertiary care center was retrospectively reviewed to identify patients who underwent lower extremity bypass procedures. All patients with a history of renal transplantation were selected for analysis. A consecutive group of bypass patients with dialysis-dependent renal failure was selected as a control cohort. The primary endpoint was amputation-free survival. RESULTS: Vascular reconstruction for chronic peripheral vascular disease yielded an amputation-free survival rate of 82% at 1 year for the those in the control group as compared with only 22% in the those with a history of renal transplantation (p = 0.02), which corresponded exactly with primary patency at 1 year. Patients were operated on for severe claudication (n = 1), rest pain (n = 1), and tissue loss (n = 17). There was no difference between the groups with regard to indication for operation or comorbid conditions. CONCLUSIONS: These data suggest a deleterious effect of immunosuppression on outcome of lower extremity bypass procedures at the doses required to prevent allograft rejection. This finding, which has been scarcely reported, underscores the importance of peripheral vascular disease screening in the transplant population and early intervention when clinically indicated.

Thoracic endovascular aortic repair of an aberrant right subclavian artery: technique and long-term outcome.

BACKGROUND: Aberrant right subclavian artery (ARSA) is the most common congenital arch anomaly, which can be complicated by aneursymal dilation at its ostium. We describe a successful repair of an ARSA with a three-stage operative procedure using a left carotid to subclavian bypass, coiling of the ARSA, and thoracic endovascular aortic repair with long-term clinical and radiographic follow-up.

Preoperative statin is associated with decreased operative mortality in high risk coronary artery bypass patients.

BACKGROUND: Statins are widely prescribed to patients with atherosclerosis. A retrospective database analysis was used to examine the role of preoperative statin use in hospital mortality, for patients undergoing isolated coronary artery bypass grafting (CABG.) METHODS: The study population comprised 2377 patients who had isolated CABG at Allegheny General Hospital between 2000 and 2004. Mean age of the patients was 65 +/- 11 years (range 27 to 92 years). 1594 (67%) were male, 5% had previous open heart procedures, and 4% had emergency surgery. 1004 patients (42%) were being treated with a statin at the time of admission. Univariate, bivariate (Chi2, Fisher's Exact and Student's t-tests) and multivariate (stepwise linear regression) analyses were used to evaluate the association of statin use with mortality following CABG. RESULTS: Annual prevalence of preoperative statin use was similar over the study period and averaged 40%. Preoperative clinical risk assessment demonstrated a 2% risk of mortality in both the statin and non-statin groups. Operative mortality was 2.4% for all patients, 1.7% for statin users and 2.8% for non-statin users (p < 0.07). Using multivariate analysis, lack of statin use was found to be an independent predictor of mortality in high-risk patients (n = 245, 12.9% vs. 5.6%, p < 0.05). CONCLUSIONS: Between 2000 and 2004 less than 50% of patients at this institution were receiving statins before admission for isolated CABG. A retrospective analysis of this cohort provides evidence that preoperative statin use is associated with lower operative mortality in high-risk patients.

Effect of glucagon-like peptide-1 (GLP-1) on glycemic control and left ventricular function in patients undergoing coronary artery bypass grafting.

Increasing evidence suggests that tight glycemic control improves clinical outcomes after coronary artery bypass grafting (CABG). However, the risk for hypoglycemia with insulin often results in less aggressive glycemic control. Glucagon-like peptide-1 (GLP-1) is a naturally occurring peptide whose insulinotropic effects are predicated on the glucose concentration, minimizing the risk for hypoglycemia. This study was conducted to examine whether perioperative treatment with GLP-1 would affect glycemic control and improve hemodynamic recovery after CABG. Twenty patients with coronary heart disease and preserved left ventricular function who were scheduled to undergo CABG were randomized to receive standard therapy at the discretion of the surgeon or treatment with GLP-1 (1.5 pmol/kg/min) as a continuous infusion beginning 12 hours before CABG and continuing for 48 hours. Perioperative hemodynamics, the left ventricular ejection fraction, plasma glucose, and requirements for insulin drips and inotropic support were monitored. There were no differences between groups in the preoperative, postoperative, or 7-day left ventricular ejection fraction (GLP-1 61 +/- 4%, control 59 +/- 3%) or cardiac index at 18 hours (GLP-1 3.0 +/- 0.2 L/min/m(2), control 3.3 +/- 0.4 L/min/m(2)). However, the control group required greater use of inotropic and vasoactive infusions during the 48 hours after the operation to achieve the same hemodynamic result. There were also more frequent arrhythmias requiring antiarrhythmic agents in the control group. GLP-1 resulted in better glycemic control in the pre- and perioperative periods (GLP-1 95 +/- 3 mg/dl, control 140 +/- 10 mg/dl, p

Short-term predictors and long-term outcome after ruptured abdominal aortic aneurysm repair.

Few data exist in regard to long-term and functional outcome after ruptured abdominal aortic aneurysm (rAAA) repair. The present study provides such follow-up and defines the impact of variables used to grade resuscitation efforts [base deficit (BD) and core temperature (cT)]. One hundred forty-seven patients presenting with rAAA were retrospectively reviewed. Overall perioperative mortality was 35 per cent (51/147) and mean age was 72 years. Survival data were available for 99 per cent of patients with a mean and median follow-up of 45 months. Life table analysis revealed one-, 2-, and 5-year survival to be 81, 75, and 58 per cent, respectively. Eighty-three per cent of patients reported a quality of life equal to that of their preoperative status. Both initial cT (P = 0.02) and BD (P = 0.03) were significantly associated with perioperative mortality. Using a logistic regression model cT remained a significant factor (P = 0.006) associated with survival. Smoking, hypertension, diabetes, chronic obstructive pulmonary disease, mode of transportation, and surgeon's training were not significant. Despite the advanced age of the present cohort, acceptable perioperative mortality and long-term survival rates were attained. The majority of patients resumed a lifestyle comparable to that of their preoperative state; therefore, long-term longitudinal follow-up suggests that aggressive management with rapid correction of BD and cT results in excellent functional outcome.

Left pleural effusion after coronary artery bypass decreases with a supplemental pleural drain.

BACKGROUND: This prospective study was undertaken to determine the incidence of symptomatic left pleural effusion after coronary artery bypass grafting, and to determine if routine drainage of the pleural cavity with a supplemental flexible drain reduces this incidence. METHODS: The clinical course of study patients was prospectively recorded during the initial hospitalization and at 6-weeks after surgery. All patients had a mediastinal and a left pleural tube, which were removed on the 1st postoperative day. The supplemental drain system was implanted in a subset of patients and remained in place for 3 to 5 days. A symptomatic effusion was defined as one that required thoracentesis, tube thoracostomy, or readmission for treatment. RESULTS: A total of 460 patients were studied, of whom 115 had a supplemental drain. The two groups (supplemental drain versus control) were equivalent with respect to age, gender distribution, and comorbid diseases. The incidence of symptomatic left pleural effusion for the entire group was 9.8% (45 of 460). Symptomatic left pleural effusion occurred in 11.9% (41 of 345) patients when only chest tubes were used, and in 3.5% (4 of 115) when a supplemental drain was placed. This difference was significant (F ratio 7.583, p < 0.005). There were no complications from the supplemental drain. CONCLUSIONS: The incidence of symptomatic left pleural effusion can be greatly reduced with the use of a supplemental pleural drain that remains in place for several days after surgery.