Safety and feasibility of endovascular aortic aneurysm repair as day surgery.

OBJECTIVE: The adoption of endovascular aneurysm repair (EVAR) during the past two decades has led to significantly shorter length of stay as well as lower hospital resource use. Currently, most patients are admitted to the hospital after EVAR; however, there are no standard observation periods, and timing of discharge is based on clinical judgment. The aim of this study was to confirm the safety and feasibility of performing EVAR as outpatient surgery. METHODS: We developed criteria to identify patients for potential same-day discharge (infrarenal aneurysm, low perioperative risk, to be accompanied for first 24 hours). We then implemented a prospective trial that observed patients planned for same-day discharge and compared them with a historical control group (patients who had undergone EVAR during the previous 2 years and met same-day discharge criteria). Basic demographic and operative data as well as length of stay, inpatient and perioperative complications, emergency department visits, readmissions, reinterventions, and deaths were collected. The primary outcome was the 30-day complication rate, and the study was powered to assess noninferiority. RESULTS: Prospectively, we assessed 266 patients and planned 110 (41%) for outpatient EVAR (62% of historical controls met outpatient criteria). Demographic characteristics were similar between planned outpatients and historical controls. In planned outpatients, hospital stay was significantly shorter (0.7 ± 2.6 days vs 2.5 ± 6.9 days; P < .01), and 79% were discharged the same day of surgery. The 30-day follow-up was available for all study patients and 94% of control patients; there were no differences in complication (11% vs 9%), readmission (2% vs 4%), reintervention (4% vs 4%), or mortality (1% vs 1%) rates, but study patients had significantly more emergency department visits (15% vs 6%; P < .05). Unsuccessful same-day discharge was associated with longer operative times, increased blood loss, and use of general anesthesia. CONCLUSIONS: In selected patients undergoing elective EVAR, same-day discharge is feasible without increasing complication rates. Health resource utilization remains a challenge in transitioning to an outpatient model.

A National Survey on Teaching and Assessing Technical Proficiency in Vascular Surgery in Canada.

BACKGROUND: This survey aims to explore trainees' perspectives on how Canadian vascular surgery training programs are using simulation in teaching and assessing technical skills through a cross-sectional national survey. METHODS: A 10-min online questionnaire was sent to Program Directors of Canada's Royal College of Physicians and Surgeons' of Canada approved training programs in vascular surgery. This survey was distributed among residents and fellows who were studying in the 2013-2014 academic year. RESULTS: Twenty-eight (58%) of the 48 Canadian vascular surgery trainees completed the survey. A total of 68% of the respondents were part of the 0 + 5 integrated vascular surgery training program. The use of simulation in the assessment of technical skills at the beginning of training was reported by only 3 (11%) respondents, whereas 43% reported that simulation was used in their programs in the assessment of technical skills at some time during their training. Training programs most often provided simulation as a method of teaching and learning endovascular abdominal aortic or thoracic aneurysm repair (64%). Furthermore, 96% of trainees reported the most common resource to learn and enhance technical skills was dialog with vascular surgery staff. CONCLUSIONS: Surveyed vascular surgery trainees in Canada report that simulation is rarely used as a tool to assess baseline technical skills at the beginning of training. Less than half of surveyed trainees in vascular surgery programs in Canada report that simulation is being used for skills acquisition. Currently, in Canadian training programs, simulation is most commonly used to teach endovascular skills.

Heparin-induced thrombocytopenia causing graft thrombosis and bowel ischemia postendovascular aneurysm repair.

Heparin-induced thrombocytopenia (HIT) is an immune-mediated thrombocytopenia resulting from prior heparin exposure. It can be associated with limb- or life-threatening thrombotic events. Patients undergoing any vascular procedures including endovascular procedures that require heparin administration are at risk. There is very little reported in the literature with regards to thrombosis associated with HIT after endovascular aortic aneurysm repair. All reported cases of HIT thrombosis presented as acute arterial lower limb ischemia or deep vein thrombosis. In this report, we present a case of HIT complicated by stent graft thrombosis and bowel ischemia.

Midterm results following endovascular repair of blunt thoracic aortic injuries.

OBJECTIVE: Previous studies have focused on early outcomes of thoracic endovascular repair (TEVAR) of blunt thoracic aortic injuries (BTAIs). Late results remain ill-defined. The purpose of this study is to review the midterm results of our experience with endovascular repair of BTAIs. METHODS: A retrospective analysis was performed reviewing all endovascular repairs of BTAIs from 2002 to present. Preoperative, operative, and postoperative variables were recorded. Clinical end points included aortic-related mortality, stroke and paraplegia, hospital length of stay, procedure-related complications, endoleaks, and reinterventions. Computed tomography data sets were postprocessed for assessing integrity of stent grafts and late complications. RESULTS: A total of 24 cases of BTAIs treated with TEVAR were identified. Thoracic endovascular repair was successful in treating BTAIs in all patients and there were no instances of procedure-related death, stroke, or paraplegia. One access complication occurred, requiring an iliofemoral bypass. Actuarial survival estimates and freedom from reintervention at 5 years were 88.7% and 95.8%, respectively. No late endoleaks, stent fractures, or device migration were identified. One patient required a secondary intervention 1 year following the initial repair to treat a pseudocoarctation syndrome caused by a diaphragm at the distal half of the stented aorta. This was treated successfully with repeated endografting. CONCLUSIONS: Thoracic endovascular repair for BTAIs can be performed safely with low periprocedural mortality and morbidity. Midterm follow-up data presented in this report further support the therapeutic role of endoluminal approach for treating BTAIs in anatomically suitable patients.

Paraplegia prevention branches: a new adjunct for preventing or treating spinal cord injury after endovascular repair of thoracoabdominal aneurysms.

In this report, we describe a technique that could potentially be used for both prevention and treatment of spinal cord ischemia (SCI) in endovascular repair of thoracoabdominal aneurysms. This technique involves using a specially designed endograft with side branches (paraplegia prevention branches [PPBs]), which are left patent to perfuse the aneurysmal sac and any associated lumbar or intercostal arteries in the early postoperative period. The use of PPBs with this technique is feasible and allows for a temporary controlled endoleak that may be useful for preventing or reversing spinal cord injury. This technique may be considered as an adjunct to the more standard perioperative physiological manipulations such as permissive hypertension and spinal fluid drainage.

Reversible endotension associated with excessive warfarin anticoagulation.

An aortic aneurysm was successfully treated with an endovascular stent graft, with no evidence of endoleak and documented progressive aortic diameter reduction during the first 23 months. At 29 months, the patient had documented enlargement of the aneurysm sac associated with excessive anticoagulation with warfarin. No evidence of endoleak could be demonstrated with any diagnostic modality. Progressive aneurysm sac diameter regression was documented after reversal of excessive anticoagulation to therapeutic levels (international normalized ratio of 2 to 3). Strict monitoring of coagulation profile in patients after endovascular aneurysm repair requiring anticoagulation with warfarin is recommended to avoid this complication, which to our knowledge has not been previously reported.

Patient-reported quality of life after abdominal aortic aneurysm surgery: a prospective comparison of endovascular and open repair.

PURPOSE: This study evaluated and compared changes over time in health-related quality of life reported by patients with infrarenal abdominal aortic aneurysm (AAA) undergoing elective endovascular (EVAR) and open aneurysm (OR) repair. METHODS: A prospective, nonrandomized cohort of 76 patients (62 men, 14 women; age range, 42 to 89 years) undergoing elective, infrarenal AAA repair (EVAR, n = 43; OR, n = 33) at two university teaching hospitals during a 15-month period were administered the Medical Outcomes Study Short-Form 36-item (SF-36) health survey preoperatively and then 1 week, 1 month, and 6 months postoperatively. Patient demographics, procedural details, postoperative follow-up data, and SF-36 scores were compared between groups. RESULTS: Both groups had total SF-36 scores that were significantly lower than preoperative scores at 1 week and 1 month after surgery but were not significantly different from the preoperative scores at 6 months (OR 66.2 +/- 21.1 to 72.3 +/- 19.8, P > .1; and EVAR 61.0 +/- 17.7 to 58.7 +/- 19.4, P > .1). Six-month total SF-36 scores were significantly higher in the OR group compared with the EVAR group (mean 72.3 +/- 19.8 OR vs 58.7 +/- 19.4 EVAR; P = .009). In the postoperative period, a significant drop occurred in mean scores in six of the eight domains of the SF-36 in the OR patients (physical function, PF; role physical, RP; bodily pain, BP; vitality, VT; social function, SF; role emotional, RE) and five domains for EVAR patients (PF, RP, BP, SF, RE). In two domains, RE and PF, scores returned to baseline values significantly sooner in EVAR patients than in OR patients (RE, EVAR 1 month vs OR 6 months; and PF, EVAR 1 month vs OR 6 months). In the VT domain, no significant postoperative drop occurred in the EVAR group, but in the OR group, mean scores were significantly lower at 1 week and 1 month compared with preoperative values. In the domains of general health and mental health, no significant drop occurred in SF-36 score postoperatively in either group. CONCLUSIONS: Patient reported health-related quality of life after infrarenal AAA repair is significantly impaired in the early postoperative period but returns to baseline by 6 months in patients treated with EVAR and OR. Patients having EVAR had significantly more rapid return to preoperative scores in selected domains of the SF-36. Even though EVAR is associated with shorter and less invasive perioperative hospital course and fewer postoperative complications, EVAR patients had lower quality of life scores 6 months after surgery than OR patients.

Early outcomes after elective and emergent endovascular repair of the thoracic aorta.

BACKGROUND: Endovascular treatment of thoracic aortic pathology has emerged as a viable alternative to open surgical repair in both the elective and emergent settings. The aim of this study was to evaluate preoperative work-up, intra-operative strategy, and outcomes of endovascular stent-grafting of the thoracic aorta in patients undergoing elective repair and those undergoing emergent repair. METHODS: All patient information was obtained by a retrospective review of an established clinical database for all endovascular thoracic stent-graft cases. From October 1999 to August 2005, 70 patients were treated with endovascular stent-grafts for lesions of the thoracic aorta. Thirty-five patients had an elective endovascular procedure, and 35 patients had an emergent procedure. RESULTS: Thirty-five patients in the endovascular (EL) group were treated for aneurysm (n = 34) and type B dissection (n = 1). Thirty-five patients in the emergent (EM) group were treated for aneurysm (n = 10), intramural hematoma (n = 10), type B dissection (n = 7), traumatic rupture (n = 7), and aortoesophageal fistula (n = 1). Preoperative angiography was performed in 94.3% (33/35) of EL patients but in only 45.7% (16/35) EM patients (P < .005). The EM procedures had significantly shorter operative times, used lower contrast volumes, used fewer stent-graft components (mode 2, range 1 to 5 vs mode 1, range 1 to 3; P = .02), and spinal cerebrospinal fluid drains were used significantly less often (82.9% vs 57.1%, P = .04). Both groups had similar 30-day morbidity, mortality (0/35 EL vs 1/35 [2.9%] EM, P = .99), postoperative endoleak (9/35 [25.7%] EL vs 7/35 [20.0%] EM, P = .78), endovascular failure (3/35 [8.6%] EL vs 5/35 [14.3%] EM, P = .71), and patient survival. CONCLUSION: There are significant differences in the underlying pathology, preoperative evaluation, and operative course between elective and emergency treatment endovascular procedures for lesions of the thoracic aorta. Endovascular repair of thoracic aortic lesions can be accomplished with low perioperative mortality and morbidity rates, as well as acceptable endoleak and endovascular failure rates for both elective and emergency procedures.

Superficial femoral vein invasion by a benign neurofibroma in a non-neurofibromatosis patient: case report.

OBJECTIVE AND IMPORTANCE: Neurofibromas are benign neural sheath tumors arising from intraneural supporting cells. Such tumors are characteristic of neurofibromatosis Type I (von Recklinghausen disease) but also occur sporadically. Vascular involvement by neurofibromata is rare, but has been described in the past in the context of neurofibromatosis. There is, to our knowledge, no description of vascular involvement by a neurofibroma in a non-neurofibromatosis patient. CLINICAL PRESENTATION: A 40-year-old woman presented with a 4 year history of a right thigh mass associated with diffuse lower extremity pain. She had no other clinical manifestations of neurofibromatosis and no known family member with neurofibromatosis Type I. Magnetic resonance imaging scans revealed a well-defined solid mass in the anteromedial aspect of the right thigh closely associated with the superficial femoral vein. INTERVENTION: The vessel segment and encapsulated mass were resected "en bloc" after proximal and distal ligation of the vein. The pathological appearance of the mass was consistent with a benign neurofibroma that had infiltrated all layers of the vessel. CONCLUSION: Vessel invasion by a benign sporadic neurofibroma is a rare occurrence with potentially severe implications for the patient. It suggests that surgical removal of asymptomatic benign-appearing lesions of that type should be considered if they are adjacent to important anatomical structures.