Ruptured abdominal aortic aneurysm repair in pediatric Marfan syndrome patient.

Marfan syndrome is a well-described autosomal dominant connective tissue disorder with a constellation of anatomic characteristics including aortic degeneration as a result of the spontaneous mutation of the fibrillin gene, FBN1. Whereas life-threatening dissection and ascending aneurysmal rupture have been thoroughly documented in the literature, aneurysms of the abdominal aorta and those present in the pediatric population have only rarely been reported. In this case report, we describe presentation, successful open surgical repair, and recovery of a pediatric Marfan syndrome patient with a ruptured abdominal aortic aneurysm.

Outcomes of a single-center experience with classification and treatment of endothermal heat-induced thrombosis after endovenous ablation.

OBJECTIVE: Endothermal heat-induced thrombosis (EHIT) is a known complication of endothermal venous ablation procedures. EHIT can lead to deep vein thrombosis/pulmonary embolism, which cause significant disability and, rarely, death. Other studies have evaluated risk factors for EHIT. There is an accepted grading system for EHIT, but there is no consensus on treatment type, duration, or follow-up. We retrospectively evaluated all cases of EHIT after radiofrequency ablation or endovenous laser ablation at our institution during a 7-year period, focusing on classification, treatment, and outcomes of EHIT. METHODS: The analysis included all patients aged >18 years who underwent radiofrequency ablation or endovenous laser ablation at our institution, Spectrum Health Hospital Vein Solutions (Grand Rapids, Mich), between January 1, 2008, and December 31, 2014. Electronic medical records were queried retrospectively to identify patients with EHIT during the study interval by International Classification of Diseases-Ninth Revision code. Demographic data, including age, gender, comorbidities (eg, history of deep venous thrombosis, hypercoagulable state, family history of blood clots, etc), body mass index, Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification, and use of preoperative anticoagulation were collected for each patient in the registry. Each patient had a required postoperative duplex ultrasound (US) examination within 1 to 2 weeks of the procedure. Preoperative and postoperative US imaging data and procedure-specific data were also recorded for each patient. EHIT was graded from 1 to 4 by review of the US studies. Each patient's treatment course was reviewed for type of anticoagulation, duration of treatment, follow-up imaging, and outcome. RESULTS: From 2008 to 2014, 4799 ablations were performed at Spectrum Health Hospital Vein Center, and EHIT was identified in 70 patients. At presentation, 87% of patients were asymptomatic, 10% reported pain, and 2.9% reported swelling. Patients with EHIT grades 1 or 2 were treated with daily aspirin, and most of those with grades 3 or 4 were treated with systemic anticoagulation. Repeat US imaging was performed at 1 to 2 weeks to evaluate progression. Progression was not seen in any patients treated with systemic anticoagulation (grades 3-4). Thrombus progression occurred in two patients with grades 1 or 2 EHIT treated with aspirin. A bleeding complication occurred in one patient. CONCLUSIONS: EHIT after endovenous ablation occurred in ∼1.5% of patients, which is similar to that reported in the literature. Our review shows that systemic anticoagulation is effective in the prevention of progression with a low risk of bleeding complications. Patients with EHIT grades 1 or 2 can be treated with aspirin alone with a low risk of progression (3%).

Preliminary results of Zenith Fenestrated abdominal aortic aneurysm endovascular grafts.

BACKGROUND: Patients with juxtarenal aortic aneurysms who are unfit for open repair may be considered for fenestrated endovascular repair (fenEVAR). We report our initial experience with fenEVAR. METHODS: We reviewed the data on all our patients receiving fenEVAR for juxtarenal aortic aneurysms. RESULTS: Eight patients, average age 75 years, underwent fenEVAR. Endografts were designed from details obtained from preoperative computed tomography angiography. There were 6 grafts with superior mesenteric scallops and bilateral renal fenestrations, 1 with bilateral renal scallops, and 1 with a single renal fenestration. All patients survived 30 days. There was no renal failure requiring dialysis. At 10 weeks, 1 patient died from acute intestinal ischemia and multisystem organ failure, and another died from respiratory failure. CONCLUSIONS: It is feasible to offer fenEVAR to patients who are poor candidates for open repair. However, these procedures are technically challenging. Early outcomes are less favorable than other aortic endovascular procedures.

Endovascular repair of bilateral common iliac artery aneurysms following open abdominal aortic aneurysm repair with preservation of both hypogastric arteries using commercially available stent grafts.

Endovascular treatment of aneurysmal disease has become the predominant form of repair for all aneurysms. Some areas continue to pose specific challenges to stay within the general tenets of successful repair, mainly achieving adequate seal without sacrificing other arterial pathways. Following aortic aneurysm repair, the common iliac arteries can continue to have aneurysmal degeneration. We present a case of bilateral common iliac artery aneurysms that presented 9 years after open repair of an infrarenal abdominal aortic aneurysm in conjunction with an extensive aortic dissection. These were repaired using endovascular techniques with preservation of both hypogastric arteries.

Mammographic distance as a predictor of nipple-areola complex involvement in breast cancer.

BACKGROUND: Although involvement of the nipple-areola complex (NAC) occurs in a minority of patients with breast cancer, standard skin-sparing mastectomy requires its removal. To assist in patient selection for NAC preservation we evaluated NAC involvement and correlated this with preoperatively available clinical data. METHODS: Patients with invasive breast cancer or ductal carcinoma in situ undergoing mastectomy from 1998 to 2005 were reviewed retrospectively. The NAC had been evaluated with multiple thin sections. Pathologic data including NAC involvement were analyzed. The mammographic tumor distance from the nipple was measured in 2 standard views. RESULTS: There were 302 patients enrolled, of which 10% were noted to have NAC involvement. This correlated negatively with tumor distance from the nipple (P < .05). A logistic regression equation was derived from the data, with NAC involvement as the dependent variable and distance from the nipple as the independent variable. The equation predicted involvement of the NAC when the distance was less than 4.96 cm with a sensitivity of 82% and a negative predictive value of 97%. CONCLUSIONS: A majority of patients are candidates for NAC preservation. The mammographic distance between the tumor and the nipple is independently predictive of NAC involvement and is useful as an equation variable.

Early tracheostomy versus late tracheostomy in the surgical intensive care unit.

BACKGROUND: This study's purpose was to determine if early tracheostomy (ET) of severely injured patients reduces days of ventilatory support, the frequency of ventilator-associated pneumonia (VAP), and surgical intensive care unit (SICU) length of stay (LOS). METHODS: This 2-year retrospective review included 185 SICU patients with acute injuries requiring mechanical ventilation and tracheostomy. ET was defined as 7 days or less, and late tracheostomy (LT) as more than 7 days. RESULTS: The incidence of VAP was significantly higher in the LT group, relative to the ET group (42.3% vs. 27.2%, respectively; P <.05). Acute Physiology and Chronic Health Evaluation II scores, hospital and SICU LOS, and the number of ventilator days were significantly higher in the LT group. CONCLUSIONS: In patients who required prolonged mechanical ventilation, there was significant decreased incidence of VAP, less ventilator time, and lower ICU LOS when tracheostomy was performed within 7 days after admission to the SICU.