Reconsidering gender relative to risk of rupture in the contemporary management of abdominal aortic aneurysms.

OBJECTIVE: Abdominal aortic aneurysms (AAAs) may rupture at smaller diameters in women than in men, and women may be at higher risk and have poorer outcomes in elective and emergent interventions because of age and comorbidities. Practice guidelines recommending elective AAA repair at >5.5 cm are gender neutral and may not adequately reflect increased risks in women or the potential advantages of elective lower risk endovascular procedures. METHODS: Patients with a diagnosis of AAA discharged from a single referral hospital during a 14-year period were identified for retrospective analysis. RESULTS: A total of 2121 patients with AAAs were studied, 499 women (23.5%) and 1622 men (76.5%). Women were older and had a greater incidence of hypertension, smoking, chronic obstructive pulmonary disease, dyslipidemia, and renal insufficiency. Intact AAAs in 467 women had a mean diameter of 4.4 ± 1.3 cm compared with 1538 men at 5.0 ± 1.4 cm (P < .01). The ruptured AAAs in 32 women (6.4%) had a mean diameter of 6.1 ± 1.5 cm compared with 84 men (5.2%) at 7.7 ± 1.9 cm (P < .01). Women had a twofold increased frequency of AAA rupture than men at all size intervals (P < .01). The frequency of ruptured AAAs <5.5 cm among 10 of 32 women with ruptured AAAs was 31.3%; among 7 of 84 men with ruptured AAAs, it was 8.3% (P < .01). The frequency of ruptured AAAs <5.5 cm in all 383 women with AAAs <5.5 cm was 2.6%; in 1042 men, it was 0.6% (P < .01). Of the 1211 AAA repairs, 574 (47.4%) were open aneurysm repair (OAR) and 637 (52.6%) were endovascular aneurysm repair (EVAR). Mortality after elective OAR in 475 patients of both sexes was 5.1%; for EVAR in 676 patients, mortality was 1.6% (P < .01). No differences in mortality with respect to OAR or EVAR were found between the female and male cohorts in either intact or ruptured AAAs. CONCLUSIONS: Women with AAAs are older and have a higher frequency of cardiovascular risk factors than men. Women rupture AAAs with a greater frequency than men at all size intervals and have a fourfold increased frequency of rupture at <5.5 cm. No differences in surgical mortality between women and men were found. Current practice guidelines for elective AAA operative intervention should be reconsidered and stratified by gender.

Management of late main-body aortic endograft component uncoupling and type IIIa endoleak encountered with the Endologix Powerlink and AFX platforms.

OBJECTIVE: Junctional component separation producing type IIIa endoleak after endovascular abdominal aortic aneurysm repair (EVAR) is an uncommon but serious complication requiring unanticipated reinterventions. This retrospective study analyzed main-body EVAR component uncoupling and type IIIa endoleaks encountered with Powerlink and AFX (Endologix Inc, Irvine, Calif) endografts during an 8-year period. METHODS: Type IIIa endoleaks were identified from a database of secondary interventions and clinical surveillance. Operative reports, medical records, and computed tomography studies were reviewed. Clinical and imaging characteristics were analyzed over time, and differences were compared at appropriate follow-up intervals. RESULTS: Since 2006, 701 patients underwent primary EVAR using Endologix Powerlink (352 patients, 2006-2011) or AFX (349 patients, 2011-2014) endografts. Endoleaks required 32 secondary interventions (4.6%), including type Ia in 4 patients (1 proximal extension and 3 explants); type Ib in 8 patients (all distal extensions for enlarging iliac aneurysms); type II in 1 patient (explant); type IIIa in 17 patients (2.4%), who were the subject of this report; and type IIIb in 2 patients (both EVAR relining). The 17 patients with type IIIa endoleak were an average age of 71 years, and 14 (82%) were men. The mean preoperative abdominal aortic aneurysm (AAA) diameter was 70 ± 18 mm. The repair was elective in 16 patients and an emergency in one. Ten cases were performed with Powerlink and seven with AFX. Analysis of serial computed tomography scans found significant changes in AAA diameter; renal-to-bifurcation straight-line, centerline, and greater curvature lengths; EVAR angulation; and loss of EVAR component overlap. The average time from EVAR to reintervention was 32 months. Three patients returned with a ruptured AAA and three with AAA thrombosis, and three of these patients (18%) died ≤30 days of the emergency reintervention. Secondary procedures included EVAR relining with additional bridging components in 14 patients (82%), explant in 2, and axillobifemoral bypass in 1. No new cases of endograft uncoupling have been identified in patients treated with AFX since December 2012 after adoption of revised instructions for use. CONCLUSIONS: Although a small number of secondary interventions were needed after EVAR with the Endologix Powerlink or AFX endografts, most were undertaken for late main-body component uncoupling and type IIIa endoleak, which can occur after sideways displacement of the endograft in large and angulated AAAs. Patients treated before 2013 under the old instructions for use should be evaluated for signs of impending component separation and monitored annually, noting that expected indicators of endograft failure, such as increasing AAA diameter and endoleak, may be absent.

Necrotizing soft tissue infection following a peripheral bypass.

BACKGROUND: Necrotizing soft tissue infection (NSTI), formerly referred to as necrotizing fasciitis, is a rare but serious postoperative complication. NSTI following arterial bypass is seen only once in the literature (for a coronary artery bypass) and is not mentioned following peripheral bypass. Although surgical site infections have been studied extensively, there are limited published data on postoperative NSTI and no data for NSTI following peripheral arterial bypass. CASE PRESENTATION: Here we present the first, to our knowledge, reported instance of an NSTI following a lower extremity peripheral bypass. Despite the continued function of the bypass, the patient became rapidly systemically ill with a focus at the surgical site. Because of prompt surgical debridement, the patient survived this severe infection, though did require an above the knee amputation to control the rapid spread of the disease. The patient, a native of American Samoa, was infected with organisms infrequently associated with NSTI, Morganella morganii and Aeromonas hydrophila. This article discusses the diagnosis and treatment of this rare postoperative complication, along with a brief review of the microbiology of the disease. CONCLUSIONS: NSTI is a rare but lethal postoperative complication. To our knowledge, this is the first reported case of an NSTI following an arterial peripheral bypass. This patient survived because of prompt and aggressive intervention.

Endovascular treatment of bilateral carotid artery pseudoaneurysms after blunt carotid injury.

The detection of blunt carotid artery injures has improved because of more aggressive screening protocols. Initial treatment depends on multiple factors; however, controversy exists with regard to the treatment of pseudoaneurysmal degeneration, especially in this age of endovascular treatment options. Current options include anticoagulation, open surgical repair, and endovascular repair. We report a rare case of bilateral carotid artery pseudoaneurysm degeneration after bilateral carotid artery dissection caused by blunt trauma.

Acute hepatic failure associated with arteriovenous fistulae for hemodialysis.

We present the case of a 63-year-old woman who was admitted to the intensive care unit for altered mental status and hypotension 3 weeks after creation of an arteriovenous fistula (AVF). She was found to have high-output heart failure and evidence of acute hepatic failure. High-output heart failure is a known complication of AVF creation, but hepatic failure after AVF has not been previously described. We present such a case.

Primary aortogastric fistula after nissen fundoplication: a case report and review of pertinent literature.

Aortogastric fistulas are a rare but usually fatal entity that presents as an acute gastrointestinal bleeding. The authors present the case of a 65-year-old man who had undergone a Nissen fundoplication and presented in the emergency room with syncope secondary to massive upper gastrointestinal tract bleed. Despite aggressive resuscitation and prompt operative intervention with repair of the gastric ulcer and closure of the aortic side of the fistula, he succumbed to the complications of hypovolemic shock. Overview of the pertinent literature with discussion of the most common causes of aortogastric fistulas as well as guidelines for intraoperative management are also presented.