A Single-Institution Case Series of Total Endovascular Relining for Type 3 Endoleaks in Traditional Endovascular Aneurysm Repair (EVAR) Grafts with Raised Bifurcations.

BACKGROUND: The endovascular repair of infrarenal abdominal aortic aneurysms can be performed with a wide variety of devices. Many of these grafts elevate the aortic bifurcation which can limit future repairs if the graft material fails thereby creating a type III endoleak to aorto-uniliac grafts. Many manufacturers have grafts susceptible to this, but we have seen this in the Medtronic AneuRx graft. Our goal is to provide technical details and outcomes regarding a novel technique to reline these grafts while maintaining inline flow to the iliac arteries. METHODS: This was a single-institution review of patients who had endoleaks requiring intervention after a previously placed graft with an elevated aortic bifurcation. Primary outcomes included technical success defined as placement of all planned devices, resolution of type III endoleak, aneurysm size at follow-up, and requirement of reintervention. Secondary outcomes included 30-day complications, aneurysm-related mortality, and all-cause mortality. Technical details of the operation include back-table deployment of an Ovation device, modification of the deployment system tether and pre-emptive placement of an up and over 0.014″ wire. The wire is placed up and over and hung outside the contralateral gate. Once the main body is introduced above the old graft, the 0.014" is snared from the contralateral side and externalized. The main body is then able to be seated at the bifurcation as the limb is not fully deployed and then device deployment is completed per instructions for use. RESULTS: Our study consists of 4 individuals, 3 of which had an abdominal aortic aneurysm initially managed with an AneuRx endovascular aneurysm repair and 1 with a combination of Gore and Cook grafts. All 4 patients were male with an average age of 84.5 years at time of reline. All patients had at least 10 years between initial surgery and reline at our institution. Primary outcomes revealed no type 1 or 3 endoleaks at follow-up, technical success was 100% and 1 patient required reintervention for aneurysm growth and type 2 endoleak. In terms of our secondary outcomes, there was 1 postoperative complication which was cardiac dysfunction secondary to demand ischemia, aneurysm-related mortality was 0% and all-cause mortality was 25% at average follow-up of 2.44 years. CONCLUSIONS: As individuals continue to age, there are more patients who would benefit from less invasive reinterventions following endovascular aneurysm repair. Whether this is due to aortic degeneration, stent migration, or stent material damage is not always known. In this study, we present an endovascular approach to treating type III endoleak patients with a previous graft and elevated aortic bifurcation using Ovation stent grafts and found no evidence of type 1 or 3 endoleaks on follow-up imaging. This approach may allow patients with type III endoleak the option of a minimally invasive, percutaneous approach where they previously would not have had one.

Case report: Splenic artery pseudoaneurysm mimicking a bleeding marginal ulcer in a patient with gastric bypass.

INTRODUCTION: Upper gastrointestinal (GI) bleeding in patients with roux-en-Y gastric bypass can be difficult to localize. Marginal ulcers are the most common cause, but a broad differential should be maintained in cases of severe bleeding, especially since the stomach and duodenum are not easily accessible by regular upper endoscopy. PRESENTATION OF CASE: A 38-year-old female with Roux-en-Y gastric bypass presented with abdominal pain and hematochezia. Due to history of smoking and heavy use of ibuprofen, she was initially thought to have a bleeding marginal ulceration. Further investigation with computed tomographic (CT) angiography revealed a splenic artery pseudoaneurysm that had ruptured into a pancreatic pseudocyst, the gastric remnant and the peritoneum. The patient underwent successful treatment with trans-arterial embolization. DISCUSSION: Splenic artery pseudoanerysms are rare but potentially lethal if unrecognized, particularly in patients with altered foregut anatomy. Their most likely origin is a nearby pancreatic pseudocyst, which erodes into the splenic artery by direct pressure and enzymatic digestion. Bleeding inside the pseudocyst is the most feared complication, resulting in massive intraperitoneal, extraperitoneal or endoluminal hemorrhage. Surgery is particularly challenging due to intense peripancreatic inflammation. Trans-Anterial embolization is the preferred treatment modality. CONCLUSION: Marginal ulcers continue to be the most common cause of GI bleeding in patients with Roux-en-Y anatomy, although high index of suspicion for alternative diagnosis should be maintained in cases of massive hemorrhage.

Upper Extremity Access Has Worse Outcomes in F/BEVAR Using the VQI Dataset.

BACKGROUND: Physician-modified endografts and custom-manufactured devices use branched and fenestrated techniques (F/BEVAR) to repair complex aneurysms. Traditionally, many of these are deployed through a combination of upper and lower extremity access. However, with newer steerable sheaths, you can now simulate upper extremity (UEM) access from a transfemoral approach. Single-institution studies have demonstrated increased risks of access site complications and stroke when UEM access is used. This study compares outcomes after F/BEVAR in a national database between total transfemoral (TTF) access and mixed UEM access. METHODS: This study is an analysis of the Vascular Quality Initiative for all patients who underwent F/BEVAR from 2014 to 2021. Patients were stratified based on a TTF delivery of all devices versus any UEM access for deployment of target vessel stents. Primary outcomes included stroke, myocardial infarction (MI), and perioperative death. Secondary outcomes included access site hematoma, occlusion or embolization, operative time, fluoroscopy time, and technical success. Multivariable linear and logistic regression analyses were performed. RESULTS: Three thousand one hundred forty six patients underwent an F/BEVAR: 2,309 (73.4%) TTF and 837 (26.6%) UEM. Logistic regression analysis indicated a two-fold increased risk of death and MI and a three-fold increased risk of stroke in the UEM group. Furthermore, there is decreased operative time (221 vs. 297 min, P < 0.001) and fluoroscopy time (62 vs. 80 min, P < 0.001) in the TTF group and no difference in technical success between groups (96% vs. 97%, P = 0.159). Finally, there was a decrease in access site hematoma 2.54% vs. 4.31% (P = 0.013), access site occlusion 0.61% vs. 1.91% (P = 0.001), and extremity embolization 2.17% vs. 3.58% (P = 0.026) in the TTF versus UEM group. CONCLUSIONS: This study using Vascular Quality Initiative data demonstrates that patients who undergo an F/BEVAR using UEM access have an increased risk of perioperative MI, death, and stroke compared to TTF access.

Cumulative summation analysis of learning curve for robotic-assisted hiatal hernia repairs.

BACKGROUND: Robotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of general surgery. We aimed to evaluate the learning curve for RALS procedures involving repair of hiatal hernias. METHODS: A series of robotic-assisted hiatal hernia (HH) repairs were performed between 2013 and 2017 by a surgeon at a single institution. Data were entered into a retrospective database. Patient demographics and intraoperative parameters including console time (CT), surgery time (ST), and total operative time (OT) were examined and abstracted for learning curve analysis using the cumulative sum (CUSUM) method. Assessment of perioperative and post-operative outcomes were calculated using descriptive statistics. RESULTS: The average age of the patients was 57.4 years, average BMI was 29.9 kg/m2, median American Society of Anesthesiologists (ASA) classification was 2, and average Charlson Comorbidity Index (CCI) score was 2.8. The series had a mean CT of 132.6 min, mean ST of 145.1 min, and mean OT of 197.4 min. The CUSUM learning curve for CT was best approximated as a third-order polynomial consisting of three unique phases: the initial training phase (case 1-40), the improvement phase (case 41-85), and the mastery phase (case 86 onwards). There was no significant difference in perioperative complications between the phases. Short-term clinical outcomes were comparable with national standards and did not correlate significantly with operative experience. CONCLUSIONS: The three phases identified with CUSUM analysis represented characteristic stages of the learning curve for robotic hiatal hernia procedures. Our data suggest the training phase is achieved after 40 cases and a high level of mastery is achieved after approximately 85 cases. Thus, the CUSUM method serves as a useful tool for objectively evaluating practical skills for surgeons and can ultimately help establish milestones that assess surgical competency during robotic surgery training.

A single center's 15-year experience with palliative limb care for chronic limb threatening ischemia in frail patients.

OBJECTIVE: Our institution's multidisciplinary Prevention of Amputation in Veterans Everywhere (PAVE) program allocates veterans with critical limb threatening ischemia (CLTI) to immediate revascularization, conservative care, primary amputation, or palliative limb care according to previously reported criteria. These four groups align with the approaches outlined by the global guidelines for the management of CLTI. In the present study, we have delineated the natural history of the palliative limb care group of patients and quantified the procedural risks and outcomes. METHODS: Veterans prospectively enrolled into the palliative limb cohort of our PAVE program from January 2005 to January 2020 were analyzed. The primary outcome was mortality. The secondary outcomes included overall and limb-related readmissions, limb loss, and wound healing. The clinical frailty scale (CFS) score was calculated, and the 5-year expected mortality was estimated using the Veterans Affairs Quality Enhancement Research Initiative tool. Regression analysis was performed to establish associations among the following variables: mortality, wound, ischemia, and foot infection (WIfI) score, CFS score, overall admissions, and limb-related admissions. RESULTS: The PAVE program enrolled 1158 limbs during 15 years. Of the 1158 limbs, 157 (13.5%) in 145 patients were allocated to the palliative limb care group. The overall mortality of the group was 88.2% (median interval, 3.5 months; range, 0-91 months). Of the 128 patients who had died, 64 (50%) had died within 3 months of enrollment. The predicted 5-year mortality for the group was 66%. The average CFS score for the group was 6.2, denoting persons moderately to severely frail. Using the CFS score, 106 patients were considered frail and 39 were considered not frail. No differences were found in mortality between the frail and nonfrail patients. However, a statistically significant difference was found in early (<3 months) mortality (56.2% vs 37.5%; P = .032). The 30-day limb-related readmission rate was 4.7%. Eventual major amputation was necessary for 18 limbs (11.5%). Wound healing occurred in 30 patients (20.6%). Regression analysis demonstrated no association between the CFS score and mortality (r = 0.55; P = .159) or between the WIfI score and mortality (r = 0.0165; P = .98). However, a significant association was found between the WIfI score and limb-related admissions (r = 0.97; P < .001). CONCLUSIONS: Frail patients with CLTI had high early mortality and a low risk of limb-related complications. They also had a low incidence of deferred primary amputation or limb-related readmissions. In our cohort, the vast majority of patients had died within a few months of enrollment without requiring an amputation. A comprehensive approach to the treatment of CLTI patients should include a palliative limb care option because a significant proportion of these patients will have limited survival and can potentially avoid unnecessary surgery and major amputation.

Arteriovenous fistula maturation: Physical exam versus flow study.

PURPOSE: The purpose of this study was to determine the utility of routine duplex flow study 4 to 6 weeks after primary AVF creation and to compare physical exam against a duplex flow study in predicting fistula maturation. A surveillance algorithm was established to evaluate the naïve fistula after primary creation. METHODS: This was a single institution retrospective review of 155 veterans with primary autogenous AVF creation from 2016 to 2018. All patients received a duplex flow study evaluation after primary creation. A comparison was made between physical exam (PE) and flow study at 4 to 6 weeks post creation. Sensitivities and specificities of physical exam and duplex flow study were compared head-to-head in predicting unassisted fistula maturation. A mature AVF was defined as a fistula that could be repetitively cannulated and provided adequate flow for dialysis. Failure of maturation was defined as an AVF that was never usable for dialysis. An abnormal duplex included thrombosis, stenosis (> 50% on gray scale imaging), inadequate vein diameter (< 4 mm), inadequate vein length or superficialization, or poor flow (< 500 ml/min). Bivariate comparisons were conducted using Pearson's χ², Fishers exact test, and Wilcoxon test depending on distribution. Significance was defined as P < 0.05. RESULTS: There were 53 patients with radiocephalic (RC) fistulas, 41 patients with brachiocephalic (BC) fistulas, and 6 patients with brachiobasilic (BB) fistulas. Of patients with a confirmed abnormal duplex ultrasound, 53% had an abnormal PE (sensitivity 53%; PPV 96.3%, P < 0.001). Of the patients with a confirmed normal duplex, 98% had a normal PE (specificity 98%; NPV 68.5%, P < 0.001). An abnormal duplex flow study had a 67% sensitivity for predicting AVF failure or need for reintervention while an abnormal physical examination had a 42% sensitivity in predicting AVF failure or need for reintervention (P < 0.001). In total, 48 fistulas needed reintervention, however only 20 (42%) were associated with an abnormal physical examination. Of those 48 reinterventions, 20 (42%) fistulas exhibited primary assisted maturation (P < 0.001). On duplex flow study alone, 32 patients had hemodynamically significant lesions necessitating reintervention, which went on to afford 9 (28%) primary assisted mature fistulas (P = 0.69). CONCLUSION: Abnormal duplex flow studies have a better sensitivity for detecting AVF failure or the need for reintervention compared to physical exam alone. An abnormal duplex correlates more with needing a reintervention to achieve maturation than physical exam. Therefore, we advocate routine use of a postoperative duplex flow study to identify potentially correctable issues and optimize fistula maturation.

True Superficial Temporal Artery Aneurysm Presenting as a Delayed Traumatic Pseudoaneurysm: A Case Report and Review of Literature.

A rare case of a true temporal artery aneurysm is presented with review of the literature.

Long-term transplant outcomes of donor hearts with left ventricular dysfunction.

OBJECTIVE: Despite small single-center reports demonstrating acceptable outcomes using donor hearts with left ventricular dysfunction, 19% of potential donor hearts are currently unused exclusively because of left ventricular dysfunction. We investigated modern long-term survival of transplanted donor hearts with left ventricular dysfunction using a large, diverse cohort. METHODS: Using the United Network for Organ Sharing database, we reviewed all adult heart transplants between January 2000 and March 2016. Baseline and postoperative characteristics and Kaplan-Meier survival curves were compared. A covariates-adjusted Cox regression model was developed to estimate post-transplant mortality. To address observed variation in patient profile across donor ejection fraction, a propensity score was built using Cox predictors as covariates in a generalized multiple linear regression model. All the variables in the original Cox model were included. For each recipient, a predicted donor ejection fraction was generated and exported as a new balancing score that was used in a subsequent Cox model. Cubic spline analysis suggested that at most 3 and perhaps no ejection fraction categories were appropriate. Therefore, in 1 Cox model we added donor ejection fraction as a grouped variable (using the spline-directed categories) and in the other as a continuous variable. RESULTS: A total of 31,712 donor hearts were transplanted during the study period. A total of 742 donor hearts were excluded for no recorded left ventricular ejection fraction, and 20 donor hearts were excluded for left ventricular ejection fraction less than 20%. Donor hearts with reduced left ventricular ejection fraction were from younger donors, more commonly male donors, and donors with lower body mass index than normal donor hearts. Recipients of donor hearts with reduced left ventricular ejection fraction were more likely to be on mechanical ventilation. Kaplan-Meier curves revealed no significant differences in recipient survival up to 15 years of follow-up (P = .694 log-rank test). Cox regression analysis showed that after adjustment for propensity variation, transplant year, and region, ejection fraction had no statistically significant impact on mortality when analyzed as a categoric or continuous variable. Left ventricular ejection fraction at approximately 1 year after transplantation was normal for all groups. CONCLUSIONS: Carefully selected donor hearts with even markedly diminished left ventricular ejection fraction can be transplanted with long-term survival equivalent to normal donor hearts and therefore should not be excluded from consideration on the basis of depressed left ventricular ejection fraction alone. Functional recovery of even the most impaired donor hearts in this study suggests that studies of left ventricular function in the setting of brain death should be interpreted cautiously.

Collaborative Management of Missile Injury to Right Ventricle and Subsequent Pulmonary Embolization.

Pulmonary embolization of a missile is a rare phenomenon. Localization after embolization can be confounding, and there is no consensus on management. This report describes a case of a gunshot wound to the chest with preoperative and initial intraoperative imaging localizing the bullet to the right ventricle but a negative intraoperative exploration of the right-sided cardiac chambers. Intraoperative fluoroscopy allowed for immediate localization of the bullet to the hilum of the left lung, with subsequent endovascular retrieval.

Case Report: De Garengeot's hernia. Appendicitis within femoral hernia. Diagnosis and surgical management.

INTRODUCTION: Abdominal wall hernias remain as one of the most common problems that the general surgeon has to treat. Although usually straightforward and easy to diagnose by the experienced hands, obstacles appear when contents of the hernia sac include organs. The presence of the appendix inside a femoral hernia (De Garengeot's hernia) is a rare entity which represents multiple challenges, both diagnostic and therapeutic. CASE PRESENTATION: We present a case of a 36-year-old female patient who originally presented to the ED with abdominal/groin pain and a new onset of right inguinal swelling. DISCUSSION: Contrary to the usual presentation, where an appendix is incidentally found during hernia repair, we were able to make the diagnosis by CT scan before surgery. This placed us on an ideal standpoint to plan the surgical management. We approached our case laparoscopic first, where a distally gangrenous appendix was reduced intraabdominally. As purulent exudates were present on hernial sac, femoral hernia repair was achieved with McVay techniche. CONCLUSION: Although rare, the finding of a strangulated appendix within a femoral hernia represents a challenge. Here we present a case that may guide the surgeon who faces a similar case in the future.