Transverse versus Longitudinal Incisions for Femoral Artery Exposure in Treating Patients with Peripheral Vascular Disease.

BACKGROUND: This study evaluates differences in wound complication rate when transverse versus longitudinal incision is utilized to expose femoral vessels in managing patients with peripheral vascular disease. METHODS: A retrospective review from 2013 to 2015 was conducted of 150 patients undergoing 156 lower extremity revascularizations with femoral artery exposure through a groin incision. Patients were stratified into 2 groups, transverse versus longitudinal groin incision. Data were reviewed for 3 surgeons that utilize either transverse or longitudinal groin incision in patients undergoing common or iliofemoral endarterectomies, or where femoral artery was used as inflow and/or outflow vessel for limb revascularization. Each group had a comparative outcomes analysis based on incision type. The primary outcome was wound complication, defined as any wound infection, lymphocele, hematoma, dehiscence, pseudoaneurysm, or necrosis. Other outcomes studied included unplanned return to operating room for wound complication, wound vacuum therapy, and soft-tissue flap closure. Data were analyzed using 2-tailed chi-squared test and Student's t-test. RESULTS: Patients in the transverse (n = 85 cases) versus longitudinal (n = 71 cases) cohorts were similar in relation to demographics and comorbidities. Overall mean follow-up was 220 days. Patients with a transverse as compared to longitudinal incision had a significantly lower overall wound complication rate, 7% vs. 42%, respectively (P < 0.001). Furthermore, transverse incisions were associated with lower incidence of unplanned return to the operating room to manage wound complications than patients with a longitudinal incision (5% vs. 23%, respectively; P < 0.001). Transverse versus longitudinal incisions were also associated with significantly lower need for wound vacuum therapy (6% vs. 15%, respectively; P < 0.05) and muscle flap closure (0% vs. 13%, respectively; P < 0.001) for wound complications. CONCLUSIONS: Transverse groin incisions for femoral artery exposure may offer a lower risk of wound complications for open procedures as compared to a longitudinal incision. While longitudinal incisions may have higher wound complication rates, incisional approach is contingent on anatomical circumstance and treated disease pattern. Patients should undergo appropriate preoperative counseling regarding wound healing in preparation for limb revascularization.

Venous Thoracic Outlet Syndrome as a Cause of Intractable Migraines.

Thoracic outlet syndrome (TOS) refers to the compression of the neurovascular bundle within the thoracic outlet. Cases are classified by primary etiology-arterial, neurogenic, or venous. In addition to the typical symptoms of arm swelling and paresthesias, headaches have been reported as a potential symptom of TOS. In this report, we describe a patient with debilitating migraines, which were consistently preceded by unilateral arm swelling. Resolution of symptoms occurred only after thoracic outlet decompression. Patients with migraines and concomitant swelling and/or paresthesias, especially related to provocative arm maneuvers, should be considered a possible atypical presentation of TOS and evaluated in more detail.

Delayed presentation of a carotid pseudoaneurysm following penetrating neck trauma.

OBJECTIVE: Penetrating carotid trauma in a hemodynamically stable patient invariably presents with a pseudoaneurysm on initial imaging. Although extremely rare, delayed pseudoaneurysm formation has been reported. The purpose of this paper is to define this rare entity and propose a diagnostic and treatment plan. METHODS: We present a case of delayed presentation of carotid pseudoaneurysm following penetrating neck trauma. A systematic review of the literature was performed. RESULTS: A 21-year-old male presents to the trauma center after sustaining a gunshot wound to the left upper back resulting in a zone 2 hematoma and pneumothorax. Bullet fragment artifact interfered with computed tomography. Carotid angiogram was normal. The patient was discharged after 3 days. He returned to the Emergency Department 3 months later with a painful pulsatile hematoma. Computed tomography angiogram revealed a 6-cm pseudoaneurysm arising from the proximal left internal carotid artery (ICA). A left common carotid artery (CCA) to ICA bypass with reversed great saphenous vein was performed. The patient's post-operative course was uneventful, neurologic deficits improved, and he was discharged. CONCLUSION: Delayed presentation of traumatic pseudoaneurysms has been reported, although usually these cases are iatrogenic access complications in extremities. While endovascular therapies are first line for zone 1 and 3 vascular injuries, management of zone 2 injuries is still controversial. This patient was treated with a bypass due to the need to evacuate the hematoma that was exerting a mass effect in the neck.

Endovascular repair of a thoracic aortic aneurysm in pregnancy at 22 weeks of gestation.

Thoracic aortic aneurysm is a rare condition that carries a critical risk of rupture and mortality. These risks are increased during pregnancy because of a progressively hyperdynamic pattern of circulation. Simultaneously, pregnancy-imposed limitations on the use of ionized radiation and intravenous contrast agents may render conventional techniques for imaging and repair confirmation less acceptable. We describe a novel approach to intraoperative management of an endovascular repair for symptomatic thoracic saccular aneurysm in a pregnant patient, based on intravascular ultrasound and transesophageal echocardiography, with maintenance of uterine perfusion. The patient recovered well and proceeded to a normal delivery. Despite a favorable outcome in this case, further studies of perioperative management of aortic disease in pregnancy are needed.

Women derive less benefit from elective endovascular aneurysm repair than men.

BACKGROUND: Women have a lower chance of surviving elective open abdominal aortic repair. The reasons for this are not clear. Endovascular repair has clearly reduced early and midterm morbidity and mortality for patients with large abdominal aortic aneurysms (AAAs). However, most patients are male. It is unclear whether there has been any reduction in elective morbidity for females or what the extent of that reduction has been. We prospectively analyzed outcomes for elective endovascular aneurysm repair (EVAR) in women at our center and compared results with those for elective open surgery and emergent open and endovascular repair. METHODS: All patients undergoing elective and emergency AAA from 2002 to 2009 were prospectively entered into a database. Demographic details, including gender, were tabulated. Outcome measures were operative blood loss, incidence of type 1 endoleaks, length of in-hospital stay, postoperative complications, 30-day all-cause mortality, and secondary interventions during the follow-up period. Statistical analysis was performed using Fischer exact test and Student t test. A multivariate analysis was also performed. RESULTS: From 2002 to 2009, there were 2631 abdominal aortic aneurysms (AAA) open and endovascular repairs performed in our center (1698 endovascular aneurysm repairs [EVARs], 933 "open"). Males comprised 1995 (76%) of patients; females 636 (24%). There were 1592 elective EVARs (1248 male, 344 female) and 106 emergency EVARs (73 male, 33 female). Elective open repair was performed in 788 patients (579 male, 209 female) and emergency open repair in 149 (73 male, 76 female). For women, elective EVAR resulted in significantly greater mortality rates than men (3.2% vs 0.96%, P < .005). There was a greater incidence of intraoperative aortic neck or iliac artery rupture (4.1% vs 1.2% P = .002) and use of Palmaz stents for type 1 endoleaks (16.1% vs 8%, P = .0009). Mean blood loss was greater in females (327 mL vs 275 mL, P = .038). Perioperative complications were also more frequent in women: leg ischemia (3.5% vs 0.6%, P = .003) and colon ischemia requiring colectomy (0.9% vs 0.2%, P = .009). Mean hospital stay was also longer (3.7 days vs 2.2 days, P = .0001). In contrast, there were no gender differences for any of these outcome measures for elective open repair or emergency open surgery or EVAR. There was no significant difference in death rates between EVAR and open repair in women (3.2% vs 5.7%). In males, the 30-day mortality was 0.96% for elective EVAR and 4.7% for elective open surgery. Following logistic regression, female gender remains a significant risk even when the effects of aneurysm size and age are considered (odds ratio 3.4, P < .01). CONCLUSIONS: Mortality for females undergoing elective EVAR is significantly greater than for males. It is also more hazardous. Colon ischemia, native arterial rupture, and type 1 endoleaks are more frequent. Elective endovascular aneurysm repair benefits men more than women.

Staged endovascular treatment of bilateral ruptured and intact ovarian artery aneurysms in a postmenopausal woman.

Ovarian artery aneurysms have rarely been reported in the literature, with almost all being unilateral and occurring in the peripartum period. We herein describe a unique case of a postmenopausal patient with a ruptured ovarian aneurysm and an intact contralateral aneurysm that were both successfully treated by endovascular techniques.

Percutaneous treatment of a traumatic renal-caval arteriovenous fistula presenting as high output cardiac failure.

A 67-year-old dialysis-dependent man presented to the cardiology service with worsening high output cardiac failure and was found to have a harsh, right-sided abdominal bruit on examination. Of significance, he had undergone several laparotomies related to a stab wound experienced 7 years earlier. A computed tomography scan revealed right renal artery pseudoaneurysms with fistulous communication to the vena cava. Successful percutaneous coil embolization and cyanoacrylate gluing enabled fistula closure without renal infarction. Symptoms of cardiac failure ultimately resolved following treatment. Catheter-based therapies provide minimally invasive and effective strategies for treating complicated fistulas involving the renal vasculature.