Eroded GDA coil surgically managed with Roux-en-Y reconstruction.

Here, we describe the case of a 56-year-old African American male who initially presented to the emergency department with 2 days of abdominal cramping, epigastric pain, loss of consciousness, melena and hematochezia. He underwent coil embolization of his gastroduodenal artery by the interventional radiology team after it was felt he was a high risk for rebleed. The patient then returned to the hospital with 3 weeks of epigastric pain, lightheadedness and melanotic stool. An upper endoscopy revealed a metallic coil embedded into the duodenal bulb. This coil was believed to be from prior embolization to the gastroduodenal artery. The patient then underwent a laparoscopic distal gastrectomy and partial duodenectomy with antecolic antegastric Roux-en-Y reconstruction bypassing the area where erosion occurred.

Impact of regional versus general anesthesia on the clinical outcomes of patients undergoing major lower extremity amputation.

BACKGROUND: Patients undergoing major lower extremity amputation (MLEA) for peripheral arterial disease are often elderly, debilitated, and fraught with medical comorbid conditions that place them at high risk for surgical intervention. Data from lower extremity revascularization surgeries are often extrapolated to determine which anesthetic modality to use for amputations, with preference given to regional anesthesia. However, there is little evidence to support the use of one mode of anesthesia over another. We conducted this study to determine the effect of anesthetic modality on the clinical outcomes of patients undergoing above- or below-knee amputations. METHODS: This study is a retrospective review of consecutive patients who underwent MLEA at a single center between 2002-2011. The study population was divided into 2 groups based on anesthetic modality (i.e., regional vs. general anesthesia). These groups were compared based on demographics and comorbidities. Major outcomes analyzed included death, myocardial infarction (MI), and pulmonary complications. Secondary outcome measures included cardiac arrhythmias, venous thromboembolism (VTE), and duration of stay in the intensive care unit and hospital. RESULTS: Four hundred sixty-three patients were identified; 56 patients were excluded for incomplete data, leaving 407 patients in the 2 groups combined. Of these, 259 patients underwent amputation under regional anesthesia; 148 underwent amputation under general anesthesia. Patients in the regional anesthesia group were older (76.6 vs. 71.6 years; P=0.001) and had a lower body mass index (25.2 vs. 26.9 kg/m2; P=0.013). They were also less likely to be on preoperative antiplatelet therapy (aspirin or clopidogrel) or anticoagulation (27% vs. 45%; P<0.001). Regional anesthesia was associated with a lower incidence of overall postoperative pulmonary complications (15% vs. 24%; P=0.02) and postoperative arrhythmia (14% vs. 25%; P=0.001). Duration of stay in the intensive care unit (1.92 vs. 3.85 days; P=0.001) and hospital (19.4 vs 23.1 days; P=0.037) were significantly longer in the group receiving general anesthesia. No significant differences in postoperative MI (12% vs. 9%; P=not significant [NS]), VTE (5% vs. 7%; P=NS) or mortality (10% vs. 13%; P=NS) was seen between groups. Controlling for procedure, above- versus below-knee amputation did not significantly alter these results. CONCLUSIONS: Regional anesthesia for patients undergoing MLEA is associated with a lower incidence of postoperative pulmonary complications and cardiac arrhythmias. It is also associated with lower resource use. As such, regional anesthesia should likely be the favored anesthetic modality for patients undergoing MLEA.

Aortic mural thrombus in the normal or minimally atherosclerotic aorta.

BACKGROUND: Aortic mural thrombus in a nonaneurysmal minimally atherosclerotic or normal aorta is a rare clinical entity and an uncommon cause of peripheral arterial embolization. Both anticoagulation therapy and aortic surgery are commonly used as primary treatment, but there are no consensuses or clinical guidelines to outline the best management strategy for this unusual problem. This systematic review compares the outcomes of these different strategies for the treatment of aortic mural thrombus. METHODS: An extensive search of the literature was conducted, and all relevant publications were reviewed, with individual patient data pooled in this meta-analysis. The outcome variables included were persistence or recurrence of aortic thrombus, recurrence of peripheral embolization, mortality, and a composite end point of complications consisting of stroke, limb loss, and bowel resection. Chi-square test and logistic regression analysis were used to compare groups and to find any predictors of adverse outcome. RESULTS: Two hundred patients from 98 articles were considered. Of these, 112 patients received anticoagulation and 88 underwent aortic surgery as primary treatment. Smoking was more prevalent in the surgery group, but no other significant differences in demographics, comorbidities, or mode of presentation were seen between groups. The surgery group was more likely to have aortic thrombus located in the arch, but there were no differences in terms of the mobility or size of the thrombus between groups. Aortic thrombus persisted or recurred in 26.4% of the anticoagulation group and in 5.7% of the surgery group (P < 0.001). Recurrence of peripheral arterial embolization was seen in 25.7% of the anticoagulation group and 9.1% of the surgery group (P = 0.003). Mortality rates were similar at 6.2% and 5.7% for the anticoagulation group and the surgery group, respectively (P = 0.879). Complications were noted in 27% of the anticoagulation group and 17% of the surgery group (P = 0.07), and major limb amputation rates were 9% for the anticoagulation group and 2% for the surgery group (P = 0.004). Logistic regression analysis established thrombus location in the ascending aorta (odds ratio [OR]: 12.7; 95% confidence interval [CI]: 2.3-238.8) or arch (OR: 18.3; 95% CI: 2.6-376.7), mild atherosclerosis of the aortic wall (OR: 2.5; 95% CI: 1-6.4), and stroke presentation (OR: 11.8; 95% CI: 3.3-49.5) as important predictors of recurrence. CONCLUSIONS: The results of our meta-analysis seem to favor the surgical management of aortic mural thrombus in the normal or minimally diseased aorta. Anticoagulation as primary therapy is associated with a higher likelihood of recurrence, a trend toward a higher incidence of complications, and a higher incidence of limb loss. Aortic surgery should be considered as primary treatment, particularly for those patients at high risk for recurrence considered to be good operative candidates.

Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database.

INTRODUCTION: Postoperative pulmonary embolism (PE) is a leading cause of morbidity and mortality after bariatric surgery. However, the concurrent prophylactic placement of an inferior vena cava filter (CPIVCF) in patients undergoing bariatric operations remains controversial. This study used the Bariatric Outcomes Longitudinal Database (BOLD) to establish associated characters and determine outcomes of CPIVCF for patients undergoing Roux-en-Y gastric bypass (GB) and adjustable gastric banding (AB) surgeries. METHODS: We analyzed BOLD, a database of bariatric surgery patient information. GB and AB operations were categorized into open and laparoscopic approaches. Univariate logistic regressions were used to compare between non-CPIVCF and concurrent CPIVCF groups. Significant variables (P < .05) were subsequently input into multivariate regression models: CPIVCF was retained in each model. RESULTS: A total of 322 CPIVCFs (0.33%) were identified from 97,218 GB and AB operations performed between 2007 and 2010 in this retrospective registry study. Significant differences were identified in male gender (21.1% vs 31.4%; P < .001), preoperative body mass index (BMI; 44.5 ± 6.6 vs 45.3 ± 7; P < .001), and African-American race (10.5% vs 18%; P < .001) between non-CPIVCF and CPIVCF groups. The CPIVCF group had more patients with previous nonbariatric surgery (50% vs 43.6%; P = .02), a history of venous thromboembolism (VTE; 21.4% vs 3.1%; P < .001), impairment of functional status (7.8% vs 3.1%; P < .001), lower extremity edema (47.2% vs 27.1%; P < .001), obesity hypoventilation syndrome (7.1% vs 2.1%; P < .001), obstructive sleep apnea syndrome (58.1% vs 43.3%; P < .001), and pulmonary hypertension (13% vs 4.1%; P < .001). Patients in the CPIVCF group were more likely to receive GB than gastric banding (77% vs 58.1%; P < .001) and an open surgical approach (21.4% vs 4.8%; P < .001). Operative duration was longer in the CPIVCF group (119 ± 67 vs 89 ± 52 minutes; P < .001). The CPIVCF group also had a longer length of hospital stay (3 ± 2 vs 2 ± 6 days; P = .048), was associated with higher incidence of deep venous thrombosis (DVT; 0.93% vs 0.12%; P < .001), and had a higher mortality (0.31% vs 0.03%; P = .003) from PE and indeterminate causes. In multivariate analysis, male gender, African-American race, previous nonbariatric surgery, a high BMI, obesity hypoventilation syndrome, history of VTE, lower extremity edema, and pulmonary hypertension were preoperative factors associated with CPIVCF. CONCLUSIONS: CPIVCF was associated with specific clinical features, increased health care resource utilization, and a higher mortality in patients undergoing bariatric operations. Although selected patient characteristics influence surgeons to perform CPIVCF, this study was unable to establish an outcome benefit for CPIVCF.

Endovascular revascularization of symptomatic infrapopliteal arteriosclerotic occlusive disease: comparison of atherectomy and angioplasty.

The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.

Endovascular management of the popliteal artery: comparison of atherectomy and angioplasty.

PURPOSE: Symptomatic atherosclerotic disease of the popliteal artery presents challenges for endovascular therapy. We evaluated the technical success, complications, and midterm outcomes of atherectomy and angioplasty involving the popliteal segment. METHODS: We conducted a retrospective review of outcomes of popliteal artery intervention using atherectomy or angioplasty performed between 2003 and 2008. RESULTS: A total of 56 patients (36% women, age 72.8 +/- 12.2 years, 77% critical limb ischemia) underwent popliteal atherectomy (n = 18) or angioplasty (n = 38). These patients had similar clinical characteristics, TransAtlantic Intersociety Consensus (TASC)/ TASC II classification, mean lesion length, and runoff scores. We observed a trend toward higher rates of technical success defined as <30% residual stenosis after atherectomy compared to angioplasty (94% vs 71%, P = .08). While angioplasty was associated with a higher frequency of arterial dissection (23% vs 0%, P = .003), atherectomy was associated with a higher rate of thromboembolic events (22% vs 0%, P = 0.01). Adjunctive stenting was used more frequently following angioplasty compared to atherectomy (45% vs 6%, P = .005). Thrombolysis was used to treat embolization in 4 patients in the atherectomy group. The improvement in the ankle-brachial index (ABI) was similar between the 2 treatment groups. Primary patency of the popliteal artery at 3, 6, and 12 months was 94%, 88%, and 75% in the atherectomy group and 89%, 82%, and 73% in the angioplasty group (P = not significant [NS]). There were no significant differences in limb salvage and freedom from reintervention at 1 year between the atherectomy and angioplasty groups. CONCLUSIONS: Our experience with popliteal artery endovascular therapy indicates a distinct pattern of procedural complications with atherectomy compared to angioplasty but similar midterm patency, limb salvage, and freedom from intervention.