Spinal Cord Ischemia following Simultaneous EVAR and TEVAR for Concomitant Thoracic and Abdominal Aortic Aneurysms.

BACKGROUND: In patients with abdominal aortic aneurysms, 10-20% has concomitant thoracic aortic pathologies. These are typically managed with staged endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) due to a perceived higher risk of spinal cord ischemia from a simultaneous intervention. We aimed to determine the outcomes of patients undergoing simultaneous EVAR and TEVAR for concomitant aneurysms. METHODS: A retrospective cohort study was performed using the Vascular Quality Initiative registry from December 2003 to January 2021. Patients undergoing same day EVAR and TEVAR were included and analyzed in accordance with the Society for Vascular Surgery reporting standards. Primary outcomes were technical success and spinal cord ischemia. RESULTS: Simultaneous EVAR and TEVAR were performed in 25 patients. Median age was 75.0 (interquartile range [IQR], 63.0-79.0) years and 20 (80.0%) patients were male. Two (4.0%) patients were symptomatic and 4 (16.0%) presented with rupture. Median maximum infrarenal and thoracic aortic diameter was 57.0 (IQR, 52.0-65.0). Infrarenal aortic neck length was 15.0 mm (IQR, 10.0-25.0), and diameter was 27.0 mm (IQR, 24.5-30.0). Median procedure time was 185.0 min (IQR, 117.8-251.3), fluoroscopy time 32.7 min (IQR, 21.8-63.1), and contrast volume 165 mL (IQR, 115.0-207.0). There were 3 (12.0%) Type Ia endoleaks and 3 (12.0%) Type II endoleaks in EVAR's, with 1 (4.0%) Type Ia and 1 (4.0%) Type II endoleak in TEVARs. In-hospital mortality occurred in 3 (12.0%) patients (1 elective, 2 ruptures). Spinal cord ischemia occurred in 1 (4.0%) patient. This patient had a symptomatic aneurysm. Thoracic coverage extended from Zone 4 to Zone 5 and an emergent spinal drain was placed postoperatively. Symptoms were present on discharge. There was 1 (4.0%) conversion to open repair which occurred in a ruptured aneurysm. Technical success was achieved in 19 (76.0%) patients, however when excluding ruptured aneurysms, was achieved in 17 (81.0%) patients. Follow-up data was available for 19 (76.0%) patients at a median of 426.0 (IQR, 329.0-592.5) days postoperatively. A total of 3 (12.0%) patients died during the late mortality period, at a mean of 509.0 (±503.7) days. Median change in abdominal and thoracic aortic sac diameter was -1.35 mm (IQR, -11.5 to 2.5) and 8.0 (IQR, -10.5 to 12.0), respectively. CONCLUSIONS: Simultaneous EVAR and TEVAR for concomitant abdominal and thoracic aortic aneurysms can be performed with low rates of spinal cord ischemia. Short- and mid-term outcomes are acceptable.

Updated Analysis of the Oncology Section of the OITE from 2007 to 2019.

The Orthopaedic In-Training Exam (OITE) is administered annually to orthopedic surgery residents to assess their medical knowledge. The authors provide a comprehensive review of the orthopedic oncology portion of the exam in order to aid residents in preparation for future in-training and licensing examinations as well as to help guide oncology residency education curriculum. All of the orthopedic oncology questions on the OITE from 2007 to 2019 were reviewed. Analysis included (1) the number of oncology questions each year, (2) question topic, (3) question taxonomy (knowledge versus interpretation), (4) the type of imaging modalities (radiological, histological), (5) most commonly cited references, and (6) level of evidence. Descriptive statistics were utilized to compare means between variables. From 2007 to 2019, there was a total of 292 tumor-related questions with a mean of 22.5 tumor-related questions (range 19-28) per year. Of the questions, 54.8% pertained to malignant tumors and 45.2% to benign tumors. Assessment of question taxonomy showed that 79.8% of questions required interpretation of imaging and analysis of the information provided versus 20.2% of questions being knowledge recall type. Of the questions, 76.7% required interpretation of radiological images, pathological images, or both. Orthopaedic Knowledge Update, Journal of the American Academy of Orthopaedic Surgeons, and Journal of Bone and Joint Surgery were the three most commonly cited question sources. Only 29 (9.84%) oncology questions over the past 13 years have been supported by level I or II sources of evidence. Better understanding of the OITE make-up, question distribution, and number and style of question, reference sources can improve an orthopedic residents' performance as well as better guide educational curriculum to prepare residents in their orthopedic oncology education.