Cost-effectiveness of one-time genetic testing to minimize lifetime adverse drug reactions.

We evaluated the cost-effectiveness of one-time pharmacogenomic testing for preventing adverse drug reactions (ADRs) over a patient's lifetime. We developed a Markov-based Monte Carlo microsimulation model to represent the ADR events in the lifetime of each patient. The base-case considered a 40-year-old patient. We measured health outcomes in life years (LYs) and quality-adjusted LYs (QALYs) and estimated costs using 2013 US$. In the base-case, one-time genetic testing had an incremental cost-effectiveness ratio (ICER) of $43,165 (95% confidence interval (CI) is ($42,769,$43,561)) per additional LY and $53,680 per additional QALY (95% CI is ($53,182,$54,179)), hence under the base-case one-time genetic testing is cost-effective. The ICER values were most sensitive to the average probability of death due to ADR, reduction in ADR rate due to genetic testing, mean ADR rate and cost of genetic testing.

New C-TAG device and overcome of compression events.

This article describes the modifications made to the TAG thoracic device (WL Gore, Flagstaff, AZ, USA) to better accommodate to anatomies seen in young trauma patients and patients with dissections. The device was initially approved and tested for degenerative thoracic aneurysms. The newer conformable-TAG (cTAG) is better able to accommodate to tight aortic arches and smaller aortic diameter with circumferential aortic wall opposition.

Endoluminal graft repair of abdominal aortic aneurysms by vascular surgeons at a nonclinical trial center.

The purpose of this study was to compare the early results and complication rates of commercially available endoluminal grafts (ELG) for abdominal aortic aneurysm (AAA) by a team of vascular surgeons at a nontrial center with those of published results from trial centers. A retrospective chart review of all patients undergoing endoluminal graft repair of AAA was made at the medical center. From October 1, 1999, to December 31, 2000, a team of vascular surgeons electively repaired AAAs in 100 patients at a regional referral center. Of these patients, 49 underwent repair with a commercially available ELG (35 AneuRx, 14 Ancure) whereas the remaining were repaired with an open operation. In the ELG group, the primary technical success rate was 100% with a 30-day mortality rate of 2.0%. The average hospital length of stay was 3.28 days with ICU stay of 1.20 days. The average operative estimated blood loss was 501 mL (100-2,500) with average transfusions of 0.49 unit packed red blood cells (prbc) (0-6). Eighty-eight percent of ELG patients left the hospital without complication. Seven patients (14%) required 11 follow-up procedures for complications including endoleak, limb or graft thrombosis, graft stenosis, distal embolization, or wound complications. Three of 26 patients (11%) with 6-month computed tomography follow-up had evidence of endoleak (2 have subsequently undergone lumbar embolization). Only 1 6-month follow-up patient had shown increased aneurysm size before endoleak treatment. A team of board-certified vascular surgeons at a nonclinical trial center can safely perform ELG for AAA with results similar to those of published series from trial centers.

Behçet's disease: endovascular management of a ruptured peripheral arterial aneurysm.

Traditionally, bypass grafts are at a high risk for thrombosis or anastomotic degeneration in patients with Behçet's disease. We report the successful deployment of a vein-covered stent across the neck of a ruptured peripheral arterial aneurysm, via a remote site access, with intermediate-term follow-up. Covered stents may represent an attractive alternative to open surgical bypass for the management of aneurysms in patients with Behçet's disease.

Mechanical thrombectomy as a first-line treatment for arterial occlusion.

The use of percutaneous mechanical thrombectomy devices to restore flow to an acutely ischemic limb is gaining popularity. Potential benefits include the minimally invasive nature of the procedure, rapid blood flow restoration, and a decrease in the dose and duration of adjunctive pharmacologic thrombolytic agents when required. A detailed description of the currently available mechanical thrombectomy devices, preclinical device evaluation, and published clinical trials for the management of acute limb-threatening ischemia are provided.

Endovascular management of visceral artery aneurysm.

PURPOSE: To retrospectively review our experience with visceral artery aneurysms (VAAs) treated with percutaneous coil embolization techniques. METHODS: Patient records were retrospectively reviewed between 1988 and 1998 for VAA cases treated with catheter-based techniques. Nine patients (5 women; mean age 64 +/- 11 years) with 12 (8 false and 4 true) VAAs were identified. The majority (67%) of these patients presented with symptoms of aneurysm rupture. The etiology of the aneurysm was iatrogenic in 4, pancreatitis in 4, and idiopathic in 4. Ten cases involved the hepatic artery; the other 2 aneurysmal arteries were the middle colic and the gastroduodenal. Selective and superselective catheter techniques were used to obtain access to the VAA. A variety of microcoils were delivered to entirely fill saccular aneurysms, whereas fusiform aneurysms were thrombosed by occluding the inflow and outflow vessels. RESULTS: Aneurysm exclusion was achieved in 9 (75%) of the 12 cases. The 3 technical failures resulted from the inability to cannulate the aneurysm neck. Coil embolization of the neck of the aneurysm sac did not result in occlusion of the native vessel, with a single exception. No procedure-related complications or deaths were noted. All patients remained symptom free during a mean follow-up of 46.0 +/- 29.6 months. CONCLUSIONS: Percutaneous transcatheter coil embolotherapy is an effective alternative to open surgery for the management of VAAs. This therapy may decrease the morbidity and mortality associated with an open surgical procedure in patients with ruptured aneurysms and pseudoaneurysms, selectively thrombosing the aneurysm while preserving flow in the native vessel.

The use of mechanical thrombectomy devices in the management of acute peripheral arterial occlusive disease.

A number of percutaneous mechanical thrombectomy devices are currently being used or undergoing clinical evaluation for the treatment of acute and chronic limb-threatening ischemia. Preliminary studies on the safety, efficacy, and device limitations have spurred an interest in percutaneous techniques for thrombus debulking as stand-alone therapy or an adjunct to pharmacologic thrombolysis. The devices have various mechanisms or combinations of mechanisms to optimize thrombus removal. Efficacy of thrombus removal is balanced by the propensity for vessel wall damage and distal embolization, especially for wall-contact devices (Arrow-Trerotola device and Cragg and Castañeda brushes). Initial experience in hemodialysis graft occlusion has subsequently moved on to peripheral arterial occlusions. Although the U.S. Food and Drug Administration has approved eight mechanical thrombectomy devices (MTDs) for use in thrombosed hemodialysis grafts, only the AngioJet LF140 is currently approved for use in peripheral arterial occlusive disease. Nevertheless, numerous clinical articles and abstracts have reported the "off-label" use of MTDs in the management of limb-threatening ischemia. A description of the eight MTDs and a review of the current literature on use of MTDs for acute peripheral arterial occlusive disease are provided.

Rheolytic thrombectomy in the management of acute and subacute limb-threatening ischemia.

PURPOSE: To evaluate the use of a percutaneous mechanical thrombectomy (PMT) catheter (AngioJet) as an initial treatment for acute (<2 weeks) and subacute (2 weeks to 4 months) arterial occlusion of the limbs. MATERIALS AND METHODS: A total of 86 (acute, n = 65; subacute, n = 21) patients were available for retrospective analysis, averaging 65 +/- 14 years of age. Outcomes assessed include initial angiographic success (failure = less than 50% luminal restoration [LR]; partial success = 50%-95% LR; success = more than 95% LR), pre- and postprocedural ankle-brachial index (ABI), device-related and systemic complications, 1-month amputation, mortality, and short-term patency. RESULTS: Angiographic success was evaluated in 83 of 86 patients (guide wire unable to traverse lesion in three patients). The procedure failed in 13 of 83 (15.6%) patients, partial success was seen in 19 of 83 patients (22.9%), and successful recanalization was noted in 51 of 83 patients (61.4%). Adjunctive thrombolysis was used in 50 of 86 patients (58%). However, thrombolysis resulted in angiographic improvement at the site of PMT in only seven of 50 of these patients (14%). Adjunctive thrombolysis was uniformly unsuccessful in patients in whom initial PMT failed. The median increase in ABI was 0.64 (95% CI: 0.43-0.81). Success was more likely in the setting of in situ thrombosis, with 61 of 68 (90%) procedures successful, compared to embolic occlusions, with nine of 15 (60%) procedures successful (P =.011). Angiographic outcome was not dependent on the duration of occlusion (acute, 51 of 62; subacute, 19 of 21; P =.35) or the conduit type (graft, 28 of 31; native vessel, 42 of 52; P =.35). An underlying stenosis was identified in 53 of the 70 patients (75.7%) with a successful PMT, and 51 of these 53 unmasked lesions were successfully treated. Follow-up data were available in 56 patients for patency assessment at a median of 3.9 months (range, 0.1-28.5 months). Patency at 6 months was 79% (95% CI: 65-92). Systemic complications occurred in 16.3% of patients, local complications were noted in 18.6%, and 1-month amputation and mortality rates were 11.6% and 9.3%, respectively. CONCLUSION: PMT offers the potential to rapidly reestablish flow to an ischemic extremity and may be the only available treatment option in patients at high risk for open surgery or with contraindications to pharmacologic thrombolysis.

Percutaneous AngioJet thrombectomy in the management of extensive deep venous thrombosis.

PURPOSE: This study was undertaken to evaluate the efficacy of a percutaneous mechanical thrombectomy (PMT) device for rapid thrombus removal following deep venous thrombosis (DVT). MATERIALS AND METHODS: Over a 37-month period, 17 patients (14 women; mean age, 41 y +/- 20) with extensive DVT were treated with initial attempts at PMT with use of the AngioJet rheolytic thrombectomy device. Sites of venous thrombosis included lower extremities in 14 patients and upper extremity and brachiocephalic veins in three. The etiology for venous thrombosis was malignancy in seven, idiopathic etiology in three, May-Thurner syndrome and immobilization in three each, and oral contraceptive use and hypercoagulable disorder in one each. The primary endpoint was venographic evidence of thrombus extraction. Perioperative complications, mortality, and recurrence-free survival were also evaluated. RESULTS: After PMT, four of 17 patients (24%) had venographic evidence of >90% thrombus removal, six of 17 (35%) had 50%-90% thrombus removal, and seven of 17 (41%) had <50% thrombus extraction. Adjunctive thrombolytic therapy was used in nine of 13 patients with <90% thrombus extraction by PMT; six patients (35%) had contraindications to pharmacologic thrombolytic therapy. An underlying lesion responsible for the occlusion was uncovered in 10 patients (59%). Significant improvement in clinical symptoms was seen in 14 of 17 patients (82%). No complications were noted directly relating to the use of the AngioJet thrombectomy catheter. None of the patients were lost to follow-up during a mean of 8.9 months +/- 5.3 (range, 2-21 months). At 4 and 11 months, recurrence-free survival rates were 81.6% and 51.8%, respectively. CONCLUSION: PMT with adjunctive thrombolytic therapy is a minimally invasive, low-risk therapeutic option in patients with extensive DVT, associated with clinical benefits including thrombus removal, patency, and relief of symptoms.

Chronic mesenteric ischemia: open surgery versus percutaneous angioplasty and stenting.

OBJECTIVE: The aim of the study was to evaluate the safety and efficacy of percutaneous angioplasty and stenting (PAS) in comparison with traditional open surgical (OS) revascularization for the treatment of chronic mesenteric ischemia. METHODS: Over a 3.5-year period, 28 patients (32 vessels) underwent PAS (balloon angioplasty alone, 5 [18%] of 28; angioplasty and stenting, 23 [82%] of 28) for symptoms of chronic mesenteric ischemia. These patients were compared with a previously published series of 85 patients (130 vessels) treated with OS (bypass grafting, 60 [71%] of 85; transaortic endarterectomy, 19 [22%] of 85; or patch angioplasty, 6 [7%] of 85). RESULTS: The PAS and OS groups were similar with respect to baseline comorbidities, duration of symptoms (median: 6.7 vs 10.5 months, P =.52), and the number of vessels involved, but the patients differed in their age at presentation (median: 72 vs 65 years, P =.005). Fewer vessels were revascularized per patient in the PAS group (1.1 +/- 0.4) compared with the OS group (1.5 +/- 0.6, P =.001). Overall, 85.7% (24/28) had one vessel and 14.3% (4/28) had two vessels revascularized in the PAS group versus 48.2% (41/85) with one-vessel and 47.1% (40/85) with two-vessel revascularization in the OS group. No difference was noted in the early in-hospital complications (median: 17.9% [PAS] vs 32.9% [OS], P =.12) or mortality rate (10.7% [PAS] vs 8.2% [OS], P =.71). A reduced length of hospital stay in the PAS patients did not attain statistical significance (median: 5 days [PAS] vs 13 days [OS], P =.08). Although the 3-year cumulative recurrent stenosis (P =.62) and mortality rate (P =.99) did not differ, the PAS treatment group had a higher incidence of recurrent symptoms (P =.001). CONCLUSION: Although the results of PAS and OS were similar with respect to morbidity, death, and recurrent stenosis, PAS was associated with a significantly higher incidence of recurrent symptoms. These findings suggest that OS should be preferentially offered to patients deemed fit for open revascularization.

Management of Acute Lower Extremity Ischemia: Treatment Strategies and Outcome.

Acute limb ischemia is a result of decreased arterial perfusion resulting in inadequate tissue perfusion. The severity of symptoms and urgency for treatment depends on the status of the collateral circulation. Therapy should be directed toward both systemic and local factors. Treatment is by open surgery, thrombolysis, or percutaneous thrombectomy. Unfortunately, none of the treatment modalities have proven to be the golden standard for limb salvage and patient survival. Review of current literature and a multimodality approach for the management of acute limb ischemia is presented in this article.

Delayed onset of ascending paralysis after thoracic aortic stent graft deployment.

Delayed spinal cord ischemia after thoracic aortic aneurysm repair is an infrequent but devastating complication. The use of stent grafts to exclude aortic aneurysms is thought to decrease the incidence of the neurologic deficit because there is no period of significant aortic occlusion. We report a case of paraplegia that progressed to quadriplegia occurring 48 hours after the apparently successful deployment of a thoracic aortic stent graft.

Systemic consequences of oxidative stress following aortic surgery correlate with the degree of antioxidant defenses.

The purpose of this study was to correlate the preoperative level of antioxidant defenses, measured by the plasma total antioxidant capacity (TAC), to the degree of postoperative systemic inflammatory response, measured by the severity of pulmonary injury following elective aortic surgery. Twenty-four patients had TAC measured preoperatively and 24 hr postoperatively. Chest radiography and arterial blood gases were obtained preoperatively and serially during the first 24 hr after surgery. Using objective radiologic criteria and blood gas analysis, the degree of pulmonary edema and pulmonary dysfunction were quantified. All patients showed evidence of pulmonary dysfunction in the first 24 hr following surgery. Fifteen of the 24 patients showed radiographic evidence of noncardiogenic pulmonary edema in the immediate postoperative period. In this group, the TAC was lower than in those without pulmonary edema immediately following surgery (p = 0.03). Preoperative TAC was associated with the degree of pulmonary edema in the postoperative period (r = -0.372, p = 0.067). These results suggest that preoperative antioxidant supplementation may favorably impact the severity of systemic inflammatory response following ischemia and reperfusion injury.

Synchronous laparoscopic vasectomy and hernia repair.

Over the last few years, general surgery has seen the use of more and more laparoscopic techniques in the management of common surgical problems. This expanded use is attributable not only to the excellent results seen with laparoscopic procedures but also to patient demand. A 48-year-old man requested a laparoscopic hernia repair with synchronous vasectomy. The technique of synchronous laparoscopic hernia repair and vasectomy is discussed, and a literature review is provided. Certain disadvantages along with the difficulty in reanastomosis after a laparoscopic vasectomy will prevent the replacement of traditional vasectomy with the laparoscopic technique.

Necrotizing esophagitis presenting as a black esophagus.

A case of necrotizing esophagitis discovered during upper endoscopy is described. An 88-year-old woman was admitted to our hospital with complaints of multiple episodes of coffee ground emesis and dysphagia over 3 months. Ischemia is proposed as the etiology of necrotizing esophagitis on the basis of the patient's significant cardiac history, her age, and low-flow state.

Microinvasive laparoscopic cholecystectomy in pediatric patients.

Although cholelithiasis is uncommon in children, its laparoscopic treatment has progressively become more popular among pediatric surgeons. This is due in part to the fact that compared with the open technique, laparoscopic treatment is less invasive as well as more cost-effective. A review of the literature indicates that it has been customary to use at least one 10-mm port to permit application of the 10-mm endoscopic clip applier for ligation of the cystic duct and artery. We report our experience with two patients in whom a laparoscopic cholecystectomy was performed by use of a 5-mm endoscopic clip applier and a 3-mm laparoscope. The application of a 5-mm clip applier obviated the need for a 10-mm port. It also saved an additional step by eliminating the exchange from the laparoscope to the 10-mm endoscopic clip applier through the 10-mm port. Furthermore, the use of a 3-mm telescope through the smallest port (<5 mm) would achieve a better cosmetic outcome.

Small-bowel perforation secondary to metastatic carcinoma of the breast.

Perforation from a solitary metastatic lesion of the small bowel is rare. We report a case of acute perforation with no evidence of metastatic disease within the abdomen. Resection of the small bowel was performed.

Acute mesenteric vein thrombosis and pancreatitis. A rare association.

This article presents a case of acute mesenteric vein thrombosis with small bowel infarction associated with pancreatitis. Although a rare occurrence, the authors suggest this diagnosis should be considered as a possible complication of pancreatic inflammation.