Percutaneous thoracic endovascular aortic repair for ascending aortic pseudoaneurysm after prosthetic aortic valve repair.

Ascending aortic pseudoaneurysms are an uncommon and challenging surgical problem that requires intervention to avoid rupture and hemorrhage. Preceding cardiac procedures often compound the high rate of morbidity and mortality associated with open repair. A case is described of an iatrogenic pseudoaneurysm in a patient with a recently placed prosthetic aortic valve and a clinical course precluding repeat open operative procedure. An endovascular approach was used, with placement of a thoracic aorta endograft with temporary cardiac pacing and a double-curved Lunderquist wire to avoid instrumenting the prosthetic aortic valve. At 9 months of follow-up, the patient returned to his baseline activity status, and at 24 months, had no symptoms or signs of infection, and a computed tomography angiogram demonstrated pseudoaneurysm exclusion with no graft migration.

A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms.

OBJECTIVE: Two randomized trials to date have compared open surgery (OS) and endovascular (EVAR) repair for ruptured abdominal aortic aneurysm (rAAA); however, neither addressed optimal management of unstable patients. Single-center reports have produced conflicting data regarding the superiority of one vs the other, with the lack of statistical power due to low patient numbers. Furthermore, previous studies have not delineated between the outcomes of stable patients with a contained rupture vs those patients with instability. Our objective was to compare 30-day outcomes in patients undergoing OS vs EVAR for all rAAAs, focusing specifically on patients with instability. METHODS: Patients who underwent repair of rAAA were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database (2005 to 2010). Unstable patients with rupture were identified as those who were American Society of Anesthesiologists Physical Status Classification 4 or 5 requiring emergency repair with at least one of the following: preoperative shock, preoperative transfusion of >4 units, preoperative intubation, or preoperative coma or impaired sensorium. Univariable and multivariable logistic regression analyses were performed. RESULTS: Of the 1447 patients with rAAA, 65.5% underwent OS and 34.5% EVAR. Forty-five percent were unstable, and for these patients, OS was performed in 71.3% and EVAR in 28.7%. The 30-day mortality rate was 47.9% (OS, 52.8%; EVAR, 35.6%; P < .0001) for unstable rAAAs and was 22.4% for stable rAAAs (OS, 26.3%; EVAR, 16.4%; P = .001). Amongst patients with unstable rAAA, 26% had a myocardial infarction or cardiac arrest ≤ 30 days (OS, 29.0%; EVAR, 19.1%; P = .006), and 17% needed postoperative dialysis (OS, 18.7%; EVAR, 12.8%; P = .04). Amongst patients with stable rAAA, 13.6% had a myocardial infarction or cardiac arrest ≤ 30 days (OS, 14.9%; EVAR, 11.6%; P = .20), and 11.5% needed postoperative dialysis (OS, 13.3%; EVAR, 8.7%; P = .047). Multivariable analyses showed OS was a predictor of 30-day mortality for unstable rAAA (odds ratio, 1.74; 95% confidence interval, 1.16-2.62) and stable rAAA (odds ratio, 1.64; 95% confidence interval, 1.10-2.43). CONCLUSIONS: Approximately one-third of patients treated for rAAA undergo EVAR in NSQIP participating hospitals. Not surprisingly, unstable patients have less favorable outcomes. In both stable and unstable rAAA patients, EVAR is associated with a diminished 30-day mortality and morbidity.

Chronic compartment syndrome secondary to venous hypertension: fasciectomy for symptom relief.

Chronic compartment syndrome (CCS) from venous hypertension following lower leg deep venous thrombosis or severe venous insufficiency is rare and often difficult to diagnose. Although ileocaval stenting and thrombolysis have improved claudication symptoms related to outflow venous disease, chronic calf claudication from distal vein thrombosis and venous insufficiency have historically been managed with rest, compression, and elevation. Often, conservative options give inadequate symptom relief and active individuals are rarely compliant. We report the presentation, workup, and treatment with fasciectomy for lower leg CCS secondary to venous hypertension. Fasciotomy and fasciectomy have been used for atypical claudication secondary to classic overuse CCS with symptom relief for many individuals. This case illustrates the recognition of claudication induced by CCS secondary to venous insufficiency and an approach to treatment with fasciectomy with a promising outcome.

Rehospitalization to primary versus different facilities following abdominal aortic aneurysm repair.

OBJECTIVE: Reducing readmissions represents a unique opportunity to improve care and reduce health care costs and is the focus of major payers. A large number of surgical patients are readmitted to hospitals other than where the primary surgery was performed, resulting in clinical decisions that do not incorporate the primary surgeon and potentially alter outcomes. This study characterizes readmission to primary vs different hospitals after abdominal aortic aneurysm (AAA) repair and examines the implications with regard to mortality and cost. METHODS: Patients who underwent open or endovascular aneurysm repair for AAA were identified from the Centers for Medicare and Medicaid Services Chronic Conditions Warehouse, a random 5% national sample of Medicare beneficiaries from 2005 to 2009. Outcomes for patients who underwent AAA repair and were readmitted within 30 days of initial discharge were compared based on readmission location (primary vs different hospital). RESULTS: A total of 885 patients underwent AAA repair and were readmitted within 30 days. Of these, 626 (70.7%) returned to the primary facility, and 259 (29.3%) returned to a different facility. Greater distance from patient residence to the primary hospital was the strongest predictor of readmission to a different facility. Patients living 50 to 100 miles from the primary hospital were more likely to be readmitted to a different hospital compared with patients living <10 miles away (odds ratio, 8.50; P < .001). Patients with diagnoses directly related to the surgery (eg, wound infection) were more likely to be readmitted to the primary hospital, whereas medical diagnoses (eg, pneumonia and congestive heart failure) were more likely to be treated at a different hospital. There was no statistically significant difference in mortality between patients readmitted to a different or the primary hospital. Median total 30-day payments were significantly lower at different vs primary hospitals (primary, $11,978 vs different, $11,168; P = .04). CONCLUSIONS: Readmission to a different facility after AAA repair is common and occurs more frequently than for the overall Medicare population. Patients travelling a greater distance for AAA repair are more likely to return to different vs the primary hospital when further care is required. For AAA repair, quality healthcare may be achieved at marginally lower cost and with greater patient convenience for selected readmissions at hospitals other than where the initial procedure was performed.

Unplanned readmissions after vascular surgery.

OBJECTIVE: Existing literature on readmission after vascular surgery is limited. The upcoming reduction in Medicare reimbursement for institutions with high readmission rates mandates an accurate understanding of this issue. In this study, we characterize the frequency and causes of 30-day unplanned readmissions after elective vascular surgery. METHODS: Patients who underwent elective carotid endarterectomy (CEA), endovascular aortic repair (EVAR), open abdominal aortic aneurysm (oAAA) repair, or infrainguinal bypass grafting (BPG) were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2011 database (n = 11,246). Multivariable logistic regression was used to determine variables that contributed to 30-day unplanned readmissions for each surgery type. RESULTS: The unadjusted unplanned readmission rates after the four vascular procedures ranged from 6.5% for CEA to 15.7% for BPG. In multivariable analyses, patient comorbidities were associated with unplanned readmission after BPG and CEA (P < .05), whereas postoperative complications were more consistently associated with unplanned readmission after EVAR and oAAA repair (P < .05). For all procedures, complications leading to readmission developed more frequently after discharge. Thirty-day mortality was significantly higher in readmitted patients after BPG (1.9% vs 0.3%), EVAR (3.9% vs 0.1%), and CEA (2.2% vs 0.2%; P < .001 for each), but not after oAAA repair. CONCLUSIONS: Select comorbidities and postoperative complications contribute to unplanned readmissions after vascular surgery. The characteristics of readmitted patients vary with the type of procedure. Interventions designed to mitigate these factors have the potential to reduce unplanned readmissions but likely need to vary with the type of vascular treatment.

Clinical characteristics associated with readmission among patients undergoing vascular surgery.

OBJECTIVE: Readmission after a vascular surgery intervention is frequent, costly, and often considered preventable. Vascular surgery outcomes have recently been scrutinized by Medicare because of the high rates of readmission. We determined patient and clinical characteristics associated with readmission in a cohort of vascular surgery patients. METHODS: From 2009 to 2013, the medical records of all patients (n = 2505) undergoing interventions by the vascular surgery service at a single tertiary care institution were retrospectively reviewed. Sociodemographic and clinical characteristics were examined for association with 30-day readmission to the same institution. RESULTS: The 30-day readmission rate to the same institution was 9.7 % (n = 244). Procedures most likely to result in readmission were below-knee (25%), foot (22%), and toe amputations (19%), as well as lower extremity revascularization (22%). Patients covered by Medicaid (16.8%) and Medicare (10.0%) were most likely to be readmitted, followed by fee-for-service (9.5%), self-pay (8.0%), and health maintenance organizations (5.5%; P < .05). Patients urgently admitted were more likely to be readmitted (16.2%) than those electively admitted (9.1%; P < .01). Patient severity as rated using the All Patient Refined Diagnosis Related Groups software (3M Health Information Systems, Wallingford, Conn) predicted readmission (16.2% high vs 6.2% low severity; P < .01). Initial length of stay was longer for readmitted than nonreadmitted patients (8.5 vs 6.1 days, respectively; P < .01). Intensive care unit admission during the initial hospitalization was associated with higher readmission rates in univariable analysis (18.3% with vs 9.5% without intensive care unit stay; P < .05). Discharge destination was also a strong predictor of readmission (rehabilitation, 19.2%; skilled nursing facility, 16.2%; home, 6.2%; P < .01). The effects of urgent admission, proximity to hospital, length of stay, lower extremity open procedure or amputation, and discharge destination persisted in multivariable logistic regression (P < .05). CONCLUSIONS: To reduce readmission rates effectively, institutions must identify high-risk patients. Efforts should focus on subgroups undergoing selected interventions (amputations, lower extremity revascularization), those with urgent admissions, and patients with extended hospital stays. Patients in need of postacute care upon discharge are especially prone to readmission, requiring special attention to discharge planning and coordination of postdischarge care. By focusing on subgroups at risk for readmission, preventative resources can be efficiently targeted.

Postdischarge outcomes after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Perioperative outcomes after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) have been rigorously studied; however, inpatient and postdischarge outcomes have not been separately analyzed. The objective of this study was to examine postdischarge 30-day outcomes after elective EVAR. METHODS: Patients who underwent an elective EVAR for AAA (n = 11,229) were identified from the American College of Surgeons 2005-2010 National Surgical Quality Improvement Project database. Univariable and multivariable logistic regression analyses were performed. RESULTS: The median length of hospital stay was 2 days (interquartile range, 1-3 days). Overall 30-day mortality was 1.0% (n = 117), with 31% (n = 36) of the patients dying after discharge. Overall 30-day morbidity was 10.7% (n = 1204), with 40% (n = 500) of the morbidities being postdischarge. The median time of death and complication was 9 and 3 days, respectively, after surgery. Eighty-eight percent of the wound infections (n = 205 of 234), 33% of pneumonia (n = 44 of 133), and 55% of venous thromboembolism (n = 36 of 65) were postdischarge. Multivariable analyses showed age, congestive heart failure, admission from nursing facility, postoperative pneumonia, myocardial infarction, and renal failure were independently associated with postdischarge mortality, and peripheral arterial disease, female gender, previous cardiac surgery, age, smoking, and diabetes with postdischarge morbidity (P < .05 for all). CONCLUSIONS: Patient characteristics associated with a higher risk for postdischarge adverse events after EVAR were identified. Whether improved predischarge surveillance and close postdischarge follow-up of identified high-risk patients will further improve 30-day outcomes after EVAR needs to be prospectively studied.

Early ambulation after percutaneous femoral access with use of closure devices and hemostatic agents.

BACKGROUND: Patient satisfaction after percutaneous endovascular procedures is significantly influenced by the amount of time to ambulation postprocedure. The purpose of this study was to assess the complication rates of early ambulation after use of closure devices or topical hemostatic agents for femoral access sites for endovascular procedures. METHODS: A retrospective review was performed of all patients who underwent an endovascular procedure from a femoral access site between January 2004 and March 2008. The access site was closed with an Angio-Seal, StarClose, or D-Stat Dry with pressure. Patients ambulated 2 hr postprocedure when a closure device was used and 4 hr postprocedure when a D-Stat pad was applied. Access-site bleeding complications were assessed. Sheath size, closure method, patient characteristics, and antiplatelet status were analyzed. RESULTS: A total of 245 patients with a mean age of 70 years were identified. Of these, 154 (63%) patients were treated with a D-Stat pad with pressure, Angio-Seal was used on 83 (34%), and StarClose was used on eight (3%). The overall complication rate was 5.7%. Complications increased with increasing age (p = 0.003) and use of StarClose (p = 0.0001). The D-Stat pad was associated with a decreased complication rate (p = 0.03). Sheath size did not influence the incidence of bleeding. There was no significant increase in complications in patients taking an antiplatelet agent. CONCLUSION: With a protocol using closure devices and hemostatic agents, early ambulation after percutaneous femoral access can be achieved safely with an acceptable complication rate in patients with peripheral vascular disease.