Increasing disparity between Society for Vascular Surgery guidelines for infrarenal abdominal aortic aneurysm repair and real-world practice.

OBJECTIVE: The current Society for Vascular Surgery (SVS) guidelines, based on randomized controlled trials published more than a decade ago, recommend a minimum threshold diameter of 5.5 cm for infrarenal abdominal aortic aneurysm (iAAA) repair. It is unknown whether practice patterns with respect to size of repair have changed since the publication of these guidelines. We aimed to evaluate the real-world practice of vascular surgeons in our region with respect to iAAA size at the time of repair, whether this has changed over the past 12 years and if any changes were associated with the repair type, open vs endovascular. METHODS: The Vascular Study Group of New England (VSGNE) database was used to identify all patients who received iAAA repair between 2003 and 2015. The primary end point was to quantify the annual percentage of iAAAs repaired in different size categories (≥5.5 cm; <5.5 cm but ≥5.0 cm; <5.0 cm) over the study time period and by type of repair. The secondary end points were morbidity and mortality in these groups. We excluded nonelective cases (ruptured or symptomatic), patients with coexisting iliac artery aneurysms, and those missing critical data. RESULTS: A total of 5314 patients with iAAA repairs (1538 open, 3776 endovascular) were identified in the VSGNE database during the study period. In 40% (2110 of 5314) of patients, repair was performed for aneurysms <5.5 cm, with endovascular aneurysm repair (EVAR) comprising 75% (1581 of 2110) and open 25% (529 of 2110). More EVARs were performed for <5.5 cm in 2015 (46%) compared with 2003 (33%) (P < .05, n - 1 χ2) with an average increase of 1.1%/y. There was also a non-statistically significant increase in open repair of small aneurysms (0.7%/y; P = .759). Overall, 30-day mortality was 1.11% in the EVAR group (0.54% in <5.0 cm, 0.91% in ≥5.0 but <5.5 cm, and 1.55% in ≥5.5 cm), compared with 3% in the open group (2.88%, 1.79%, and 3.77%, respectively) with no significant change in mortality in either group over time. CONCLUSIONS: Despite the SVS guidelines suggesting surveillance rather than repair of iAAA <5.5 cm, an increasing proportion of repairs in the VSGNE database were performed below that threshold. The reasons for this are likely multifactorial and might include a lesser complexity and lower operative mortality for smaller aneurysms and markedly improved third- and fourth-generation stent graft technology with possibly better long-term survival. As such, it may be time to re-examine the current guidelines for iAAA repair.

Vascular interventions in head and neck cancer patients as a marker of poor survival.

OBJECTIVE: Head and neck cancer can involve the surrounding vasculature and require technically challenging vascular interventions. These interventions can be complicated by tumor invasion, history of prior surgery, and history of radiation therapy. Our aim was to examine patients with vascular interventions in association with head and neck cancer to determine outcomes and best practice. METHODS: We performed a retrospective review of cancer patients treated by head and neck surgery and vascular surgery between 2007 and 2014. Data concerning previous cancer treatment, operative details of head and neck surgery and vascular surgery, perioperative outcomes, and survival data were collected. Statistical analyses were performed using the χ2 test, Student t-test, and binomial regression. Patency and survival data were determined by Kaplan-Meier analysis. RESULTS: A total of 57 patients with head and neck cancer requiring vascular interventions were identified. Of these, 44 patients had squamous cell carcinoma, 4 had thyroid cancer, 3 had sarcoma, 2 had Merkel and basal cell carcinoma, and 1 each had a parotid tumor, paraganglioma, extrarenal rhomboid tumor, and malignant spindle cell neoplasm. The majority of the interventions (n = 36 [63%]) were performed on patients with recurrent or persistent malignancy despite prior treatment. The most common previous treatment was radiation therapy (n = 44 [77%]). Tumor resection and vascular intervention were performed concurrently in 26 patients (46%). The mean time between cancer treatment and vascular intervention was 37 months (range, 18 days-18 years). The most common indication for vascular intervention was bleeding (n = 21 [37%]), which included vessel rupture (n = 14), tumor bleeding (n = 5), and intraoperative bleeding (n = 2). The remaining indications for intervention included invasion/encasement of major vasculature (n = 25), stenosis/occlusion (n = 12), and aneurysm (n = 1). The most common intervention was stenting (n = 22 [41%]), followed by resection (n = 20 [35%]), exposure/dissection (n = 12 [22%]), bypass (n = 8 [15%]), and embolization (n = 3 [6%]). Of the 22 patients who were stented, 12 (55%) were placed electively (11 for stenosis and 1 for aneurysm) and 10 (45%) were placed emergently (6 for blowout and 4 for tumor bleeding). A total of six patients (11%) required reintervention after their index vascular procedure. There were no intraoperative mortalities. The 30-day mortality was 9% (n = 5). The 30-day stroke rate was 7% (n = 4; one s/p common carotid artery-internal carotid artery bypass and three with emergent intervention for vessel rupture). Primary patency at 1 year was 66% for stents and 71% for bypass (P = .604). Survival in those patients operated on emergently for bleeding at 1 year was 38%, with a trend toward worse survival compared with the 77% survival at 1 year for all other indications (P = .109). The overall survival in the cohort at 1 and 2 years was 62% and 44%, respectively. CONCLUSIONS: Vascular involvement in head and neck cancer is a marker for poor survival. Any intervention performed in light of mass resection, persistent disease, and previous radiation complicates management. Minimally invasive techniques can be used with emergent bleeding but the survival benefits are marginal. Vascular interventions, including reconstruction, are feasible but should be approached with adequate expectations and multidisciplinary support.

Outpatient Endovascular Tibial Artery Intervention in an Office-Based Setting Is as Safe and Effective as in a Hospital Setting.

PURPOSE: To compare outcomes of outpatient tibial artery procedures between an office endovascular center and a hospital angiography suite. METHODS: A retrospective review was conducted of 204 outpatient tibial interventions performed on 161 patients (mean age 72±11.5 years; 81 men) in either an office (n=100) or hospital (n=104) angiography suite from April 2011 through September 2013. Patients who had an existing ipsilateral bypass that was completely proximal to the tibial trifurcation were eligible, as were patients with prior proximal endovascular interventions. Exclusion criteria included previous ipsilateral bypass involving the infrapopliteal vessels, in-patient status at the time of the procedure, planned admission after the procedure, and infrapopliteal stenting. Treatment included percutaneous transluminal angioplasty (PTA) or PTA with atherectomy. Primary outcomes were unplanned admission, emergency room visits, acute complications, and patency. RESULTS: There were no significant differences in demographics or baseline Rutherford category between patients treated in an office endovascular suite vs a hospital angiography suite. Factors more prevalent in the hospital group included chronic obstructive pulmonary disease (16% vs 8%, p=0.045), renal insufficiency (37% vs 25%, p=0.017), and previous proximal bypass (12% vs 4%, p=0.045). Of the 100 office procedures, 25 involved PTA and 75 were PTA with atherectomy, while in the 104 hospital procedures, PTA was applied in 68 patients and PTA with atherectomy in 36. Thirty-day local complication rates (7% vs 11%, p=0.368), systemic complication rates (4% vs 8%, p=0.263), and mortality (1% vs 2%, p=0.596) in the office vs hospital setting were not statistically different. Unplanned postprocedure hospital admission rates for medical reasons were lower in the office group (2% vs 11%, p=0.01). Kaplan-Meier estimates of the 1-year follow-up data were better in the office group for primary patency (69% vs 53%, p=0.050), assisted primary patency (90% vs 89%, p=0.646), and amputation-free survival (89% vs 83%, p=0.476), but the differences were not statistically significant. CONCLUSION: Efficacy and safety of outpatient endovascular tibial artery interventions between office and hospital settings were similar, with lower unplanned admission rates and better patency. With appropriate patient selection, the office endovascular suite can be a safe alternative to the hospital angiography suite.

Delayed Superficial Femoral Artery Covered Stent Infection: Report of Two Cases and Review of Literature.

In recent years, endovascular procedures have become a first-line therapy for peripheral arterial disease. As a result, an increased number of patients received stent grafts to treat their persistent superficial femoral artery (SFA) lesions. Although the risk of stent-graft infection in that location exists, it is exceptionally rare. Successful management of this condition requires removal of the infected stent graft in combination with appropriate antibiotic therapy and debridement of necrotic tissue, as well as revascularization, with avoidance of prosthetic material. We describe 2 cases of infected stent grafts in the SFA that presented late after the original intervention. An 83-year-old man presented 8 years after the original operation, and a 57-year-old woman presented 2 years after the original operation. Both infected stent grafts were excised, and complete destruction of the native arterial wall was evident during exploration.

Uncomplicated Acute Type B Aortic Dissection: Selection Guidelines for TEVAR.

Traditionally, the surgical management of acute type B aortic dissections was reserved for patients with signs of malperfusion, rapid expansion, retrograde dissection or rupture. The adjunct of endovascular techniques has brought a paradigm shift, leaning towards preventing long term dissection complications. Multiple risk factors have been proposed to identify patients at risk for long term aortic complications. The patients, who are offered a prophylactic endovascular therapy for uncomplicated aortic dissection, should be selected carefully, and offered intervention by an experienced team in a high-volume center. (This is a review article based on the invited lecture of the 57th Annual Meeting of Japanese College of Angiology.).

The fate of endovascular aortic aneurysm repair after 5 years monitored with duplex ultrasound imaging.

BACKGROUND: Interventions for aortic aneurysm sac growth have been reported across multiple time points after endovascular aortic aneurysm repair (EVAR). We report the long-term outcomes of patients after EVAR monitored with duplex ultrasound (DUS) imaging with respect to the need for and type of intervention after 5 years. METHODS: We report a series of patients who were monitored with DUS imaging for a minimum of 5 years after EVAR. DUS imaging was performed in an accredited noninvasive vascular laboratory, and computed tomography angiography was only performed for abnormal DUS findings. RESULTS: There were 156 patients who underwent EVAR with follow-up >5 years (mean, 7.5 years; range, 5.1-14.5 years). Interventions for endoleak, graft limb stenosis, or thrombosis were performed in 44 patients (28%) at some time during follow-up. Of the 156 patients, 34 (22%) underwent their first intervention during the first 5 years (25 endoleaks, 9 limb stenoses, or occlusions). Four ruptures occurred, all in patients with their first intervention before 5 years. The remaining 10 patients (6%) underwent a first intervention >5 years after implantation: 3 for type I endoleak, 2 for type II endoleak with sac expansion, 2 for combined type I and II endoleaks 2 for type III endoleak, and 1 unknown type. CONCLUSIONS: Long-term follow-up of EVAR (mean, 7.5 years) revealed that approximately one in four patients will require intervention at some point during follow-up. First-time interventions were necessary in 22% of all patients in the first 5 years and in 6% of patients after 5 years, highlighting the need for continued graft surveillance beyond 5 years. All patients who had a first-time intervention after 5 years underwent an endoleak repair; none of these patients had a thrombosed limb or a rupture as a result of the endoleak.

Recurrent Vulvar Carcinoma in a Skin Graft: A Case Reiort and Review of the Literature.

In recentyears, theincidence ofvul- var carcinoma has increased over 400%, specifically in the population of young women. We present a patient with an extensive history of recurrent vulvar carcinoma in situ who underwent multiple surgi- cal procedures and subsequent reconstruction with a skin graft, who then returned with a rare recur- rence in the graft. Multiple hypotheses have been proposedto explain the recurrence ofthis type ofcar- cinoma; however, none provides a solid explanation. It has been noted that the increase in the incidence of vulvar cancer correlates with the increased incidence of HPV infection; the relationship between the two has been well-established. In conclusion, we recommend close and long-term follow-up for high-risk patients with this type of neoplasm.

Portal Vein Thrombosis After a Right Hemicolectomy: A Case Report.

The patient, a 43-year-old male, underwent uneventful laparoscopic right-sided hemicolectomy for a benign polyp, too large to be removed by colonoscopy. His postoperative course was uneventful; however, he returned 16 days after discharge with vague abdominal pain. A CT scan of his abdomen and pelvis showed extensive acute thrombus in portal, superior mesenteric, and splenic veins. After initial intravenous anticoagu- lation, follow-up imaging showed a persistent clot. The patient then underwent catheter-guided portal vein thrombolysis with tissue plasminogen activator (tPA), on postoperative day 29. He was doing well on 12-month follow-up. Portomesenteric thrombosis is a rare complication of laparoscopic surgery. It can occur even in the absence of any direct vascular trauma, as well as in delayed fashion after an initially uneventful procedure. Gold standard for treatment has not been developed and remains individualized based on the extent ofthe thrombus, the patient's clinical status, and condition of the affected bowel.

Successful Use of Orbital Atherectomy as an Adjunct in Treating Extensively Calcified Mesenteric Artery Lesions.

BACKGROUND: To describe the use of orbital technique of atherectomy as an adjunct to successful angioplasty and stent placement of the superior mesenteric artery (SMA). CASE REPORT: The technique is demonstrated in a 68-year-old man with critical SMA stenosis. The SMA was cannulated with 0.014-in wire, but the lesion was highly stenotic and densely calcified and prevented the passage of even the smallest 1.5-mm balloon. Orbital atherectomy was thus performed with a 1.25-mm CSI crown. Balloon angioplasty was then possible with a 4 mm × 2 cm balloon followed by placement of a 7 mm × 22 mm balloon-mounted stent. CONCLUSIONS: The use of atherectomy as an adjunct to angioplasty and stenting in extensive, calcified SMA lesions supports the value of this technique to avoid a much larger and morbid open procedure.

Prevention of treatment-related fluid overload reduces estimated effective cost of prothrombin complex concentrate in patients requiring rapid vitamin K antagonist reversal.

INTRODUCTION: Fresh frozen plasma (FFP) is a frequently used human blood product to reverse the effects of vitamin K antagonists. While FFP is relatively economical, its large fluid volume can lead to hospitalization complications, therefore increasing the overall cost of use. MATERIALS & METHODS: A recently published article by Sarode et al., in Circulation, described the rate of volume overload associated with FFP use for reversal of vitamin K antagonists. This condition, described as transfusion-associated circulatory overload, has a defined rate of intensive care admission, which also has a well-reported average cost. The additional monetary value of intensive care unit admission and caring for fluid overload is then compared to the cost of another product, four-factor prothrombin complex concentrates, which does not, as per the Sarode paper, result in fluid overload. RESULTS: The increased costs attributed to FFP-associated fluid overload for vitamin K antagonist reversal partly defrays the increased upfront cost of four-factor prothrombin complex concentrates. DISCUSSION: FFP is commonly used to acutely reverse the effects of vitamin K antagonists. However, its use requires significant time for infusion, may lead to fluid overload, and is not fully effective in compete anticoagulation reversal. One alternative therapy for anticoagulant reversal is use of prothrombin complex concentrates, which are rapidly infused, are not associated with fluid overload, and are effective in complete reversal of coagulation measurements. This should be considered for patients with acute bleeding emergencies.

Unusual Case of Isolated Pleural B-Cell Lymphoma.

Pleural involvement in lymphoma is rare as the initial presentation of disease in the immunocompetent patient. We describe a rare case of primary, isolated pleural B-cell lymphoma in a 75-year-old female, previously treated for adenocarcinoma of the left lung with lobectomy and chemotherapy, who presented with shortness of breath. A CT scan of the chest revealed a right-sided pleural effusion and pleural thickening. She underwent multiple nondiagnostic thoracenteses. A subsequent surgical biopsy was diagnostic of large B-cell lymphoma.

Solitary Neurofibroma with Malignant Transformation: Case Report and Review Of Literature.

Solitary neurofibromas are rare tumors associated mainly with neurofibromatosis and widely described in the literature as benign. We report a case of a 55-year-old female with no history of neurofibromatosis who presented with a slow-growing, painless lump on her torso. Pathologic evaluation of the lesion after excisional biopsy revealed high mitotic activity and increased cellularity within the lesion as well as positive S-100 stain. She was diagnosed with solitary subcutaneous neurofibroma with features of malignant peripheral nerve sheath tumor transformation. To our knowledge, no other case of a solitary neurofibroma that transformed into a malignant tumor in this location was described in the literature.

Unusual presentation and treatment of spontaneous celiac artery dissection.

The management options of an isolated celiac artery dissection include medical, open surgical, and endovascular techniques. Which strategy is chosen depends on the severity of the dissection, collateral circulation to the liver, the patient's hemodynamic status, and the surgeon's expertise. We describe an unusual case of celiac artery dissection involving splenic and hepatic arteries complicated by hemorrhage. The patient was successfully treated by coil embolization of the splenic and gastric branches. Hepatic arterial blood flow was preserved with a stent graft extending from the origin of the gastroduodenal artery to the orifice of the celiac artery.

Cervical spine injuries; an outcome analysis.

Cervical spine injury (CSI) in octogenarians continues to carry a high morbidity and mortality rate. The incidence of CSI among individuals who are below the age of 80 is declining, whereas the incidence of CSI for those 80 years and above is rising.The aim of the study was to evaluate outcomes of cervical spine injuries in octogenarians caused by different mechanisms: motor vehicle accidents, compared to a fall.Material and methods. The National Trauma Data Bank (NTDB) was queried for patients ages 80 and above, who sustained a cervical spine injury via motor vehicle collision and falls. Patient demographics, mechanism of injury, Glasgow Coma Score (GCS), injury severity score (ISS), days in Intensive Care Unit, Temperature on arrival, blood pressure on arrival, CT Scan of head results, complications, sex, and mortality.Results. Three-thousand three hundred seventy-five patients, 80 years of age and older with CSI were included in the study; fifteen percent of these octogenarians with cervical spine injuries died. It was observed that patients in the motor vehicle accident (MVA) group have 1.737 (95% CI 1.407, 2.144 p-value < 0.0001) times the odds of dying, compared to those in the fall group. Patients over the age of 80 who were in a MVA have 1.209 (95% CI 0.941, 1.554 p-value = 0.1372) times the odds of having a positive head CT, compared with people over the age of 80 who experienced a fall. Patients involved in a motor vehicle accident with associated CSI were more likely to be a younger age, have a lower GCS on arrival, have a longer length of stay in the Intensive Care Unit, and a higher ISS (p<0.05).Conclusions. Cervical spine injury in octogenarians carries a high mortality regardless of mechanism. Elderly patients who suffer cervical spine injuries in motor vehicle accidents have a lower SBP, a higher ISS and are nearly twice as likely to die as those who were injured in a fall.