Outcomes of peripheral artery disease and polyvascular disease in patients with end-stage kidney disease.

OBJECTIVE: Patients with peripheral artery disease (PAD) and end-stage kidney disease are a high-risk population, and concomitant atherosclerosis in coronary arteries (CAD) or cerebral arteries (CVD) is common. The aim of the study was to assess long-term outcomes of PAD and the impact of coexistent CAD and CVD on outcomes. METHODS: The United States Renal Data System was used to identify patients with PAD within 6 months of incident dialysis. Four groups were formed: PAD alone, PAD with CAD, PAD with CVD, and PAD with CAD and CVD. PAD-specific outcomes (chronic limb-threatening ischemia, major amputation, percutaneous/surgical revascularization, and their composite, defined as major adverse limb events [MALE]) as well as all-cause mortality, myocardial infarction, and stroke were studied. RESULTS: The study included 106,567 patients (mean age, 71.2 years; 40.8% female) with a median follow-up of 546 days (interquartile range, 214-1096 days). Most patients had PAD and CAD (49.8%), 25.8% had PAD alone, and 19.2% had all three territories involved. MALE rate in patients with PAD was 22.3% and 35.0% at 1 and 3 years, respectively. In comparison to PAD alone, the coexistence of both CAD and CVD (ie, polyvascular disease) was associated with a higher adjusted rates of all-cause mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.24-1.31), myocardial infarction (HR, 1.78; 95% CI, 1.69-1.88), stroke (HR, 1.66; 95% CI, 1.52,1.80), and MALE (HR, 1.07; 95% CI, 1.04-1.11). CONCLUSIONS: Patients with end-stage kidney disease have a high burden of PAD with poor long-term outcomes, which worsen, in an incremental fashion, with the involvement of each additional diseased arterial bed.

Hybrid repair of acute type B dissection with aberrant right subclavian artery and bicarotid trunk.

Patients with type B aortic dissection (TBAD) often present as an emergency. Operative repair of TBAD can be indicated for selected patients in the setting of hemodynamic instability or rupture. Thoracic endovascular aortic repair of TBAD has achieved significant popularity. Variant aortic arch anatomy can present a significant clinical challenge in patients with an inadequate proximal landing zone for thoracic endovascular aortic repair. A three-stage, hybrid aortic arch debranching and endovascular repair of a ruptured TBAD in a patient with a bicarotid trunk and an aberrant right subclavian artery was successfully performed using a unique technical approach.

Vascular complications associated with percutaneous left ventricular assist device placement: A 10-year US perspective.

BACKGROUND: Over the last decade, there has been a significant increase in the use of percutaneous left ventricular assist devices(p-LVADs). p-LVADs are being increasingly used during complex coronary interventions and for acute cardiogenic shock. These large bore percutaneous devices have a higher risk of vascular complications. We examined the vascular complication rates from the use of p-LVAD in a national database. METHODS: We conducted a secondary analysis of the National In-patient Sample (NIS) dataset from 2005 till 2015. We used the ICD-9-CM procedure codes 37.68 and 37.62 for p-LVAD placement regardless of indications. We investigated common vascular complications, defining them by the validated ICD 9 CM codes. χ2 test and t test were used for categorical and continuous variables, respectively for comparison. RESULTS: A total of 31,263 p-LVAD placements were identified during the period studied. A majority of patients were male (72.68%) and 64.44% were white. The overall incidence of vascular complications was 13.53%, out of which 56% required surgical treatment. Acute limb thromboembolism and bleeding requiring transfusion accounted for 27.6% and 21.8% of all vascular complications. Occurrence of a vascular complication was associated with significantly higher in-hospital mortality (37.77% vs. 29.95%, p < .001), length of stay (22.7 vs. 12.2 days, p < .001) and cost of hospitalization ($ 161,923 vs. $ 95,547, p < .001). CONCLUSIONS: There is a high incidence of vascular complications with p-LVAD placement including need for vascular surgery. These complications are associated with a higher in-hospital, LOS and hospitalization costs. These findings should be factored into the decision-making for p-LVAD placement.

Guidewire fracture during orbital atherectomy for peripheral artery disease: Insights from the Manufacturer and User Facility Device Experience database.

BACKGROUND/OBJECTIVES: Orbital atherectomy (OA) is routinely being used for plaque modification to facilitate percutaneous revascularization in patients with peripheral arterial disease (PAD) and arterial calcification. Guidewire fracture (GWF) during OA, though anecdotally described, has not been studied in a systematic manner. We conducted a review of the Manufacturer and User Facility Device Experience (MAUDE) database to study the reports of wire fracture and its management and consequences. METHODS: We queried the MAUDE database for all events involving the current generation of the OA device: "Diamondback 360 Peripheral Orbital Atherectomy System", and "Stealth 360° Orbital PAD System". RESULTS: We identified 62 reports of GWF during OA for PAD. The superficial femoral artery was the most commonly involved atherectomy site. The wire fractured at the soft tip in a majority of cases (68%). Embolized wire fragments were left in the patient in 36 cases (58%), retrieved percutaneously in 10 cases (16%), and trapped by a stent against the arterial wall in eight cases (13%). Lastly, eight patients (13%) underwent surgery for removal of the wire fragment. CONCLUSIONS: This is the first published report to study the complication of GWF during peripheral OA. GWF is an uncommon but has significant procedural and clinical consequences. It results in a high rate of ancillary rescue procedures (including surgery) and is associated with a higher risk of arterial thrombosis and complications from wire retrieval attempts. The risk of wire fracture may be avoided with carefully adherence to the IFU.

Aortic arch replacement through a left thoracotomy for right-sided aortic arch aneurysm with complete vascular ring.

Right-sided aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum is the second most common vascular ring. Aneurysms of the arch in its retroesophageal portion are rare. The surgical repair of a retroesophageal arch aneurysm poses a significant challenge because no single approach provides access to the whole arch and all of its branches. We describe a 39-year-old patient with aneurysmal dilatation of the retroesophageal arch who presented with airway obstruction. The arch aneurysm was repaired with a staged approach. A right-sided carotid-subclavian artery bypass was performed, followed by distal ascending aorta and aortic arch replacement under hypothermic circulatory arrest through a left thoracotomy.

Endovascular intervention for pelvic congestion syndrome is justified for chronic pelvic pain relief and patient satisfaction.

OBJECTIVE: Pelvic congestion syndrome (PCS) is difficult to diagnose, poorly understood, and often confused with other causes of chronic pelvic pain. Thus, gonadal vein reflux, its relation to lower extremity venous insufficiency (LEVI), and treatment remains controversial to physicians and payors. We present our experience with endovascular PCS treatment and hypothesize that properly selected patients can realize significant improvement. METHODS: A retrospective study of patients treated for PCS at our institution from 2008 to 2012 was performed. Diagnosis was made clinically by the presence of pelvic pain, dyspareunia, and/or perineal varicosities. Clinical parameters, procedural details, and follow-up were reviewed. A questionnaire including a visual analog scale was sent to patients. RESULTS: Diagnosis was made in 15 women (mean age, 36 years; mean parity, two). All had pelvic pain, 6 had dyspareunia, 14 had perineal varicosities, and 10 had concomitant LEVI. Fourteen had gonadal vein reflux (mean diameter, 7.4 mm) and pelvic varicosities at angiography and had coiling (n = 12) and/or Amplatzer plug (St. Jude Medical, Inc, St. Paul, Minn) (n = 4). One patient had stenting of a stenotic left common iliac vein. All patients with concomitant LEVI had successful appropriate treatment. Eight patients completed the questionnaire at a mean follow-up of 4 years. The mean pelvic pain score went from 9.375 to 1.875 post-procedure (P < .0001; Student t-test). Mean dyspareunia score went from 8.875 to 1.5 (P < .0001). Mean perineal varicosity pain score went from 9.285 to 1.285 (P < .0001). Two patients had recurrence with a mean pelvic pain score of 4.5 at a mean 21 months. On a five-point Likert scale, all patients were satisfied (one) or extremely satisfied (seven) with treatment. CONCLUSIONS: Endovascular PCS treatment offers excellent pelvic pain relief and patient satisfaction. Women with pelvic pain, dyspareunia, or perineal varicosities with gonadal vein reflux and pelvic varicosities or iliac vein stenosis should not be denied treatment. A significant number may have concomitant LEVI and should be screened accordingly.

Resorbable inferior vena cava filters: trial in an in-vivo porcine model.

PURPOSE: To determine the feasibility, effects, and complications of a resorbable inferior vena cava (IVC) filter in a porcine model. MATERIALS AND METHODS: Ten handmade, dual-filtration level, resorbable IVC filters were produced and gas sterilized. A dual-filtration cone was constructed using polyglycolic acid polymer strands oriented in a staggered cone formation with the apex of the cone in a cephalad orientation in relation to the IVC. IVC fixation was accomplished using a nitinol Z-stent, which was not resorbable. Operative insertion employing a paramedian incision, infrarenal vena caval dissection, venotomy, and device insertion using an 8-F rigid sheath was performed on 10 Yorkshire-type pigs (> 50 lb). Percutaneous delivery was not performed because of cost constraints. The IVC filters were operatively removed en bloc 6 weeks after implantation, and the pigs were euthanized. The IVC specimens were subsequently analyzed grossly and using light microscopy. RESULTS: In 9 (90%) of the 10 retrieved devices, the filtration cones were completely dissolved. One device (10%) had a retained strand of filtration cone material completely incorporated into the caval wall, excluded from luminal flow. Significant inflammatory response was appreciated from the specimen histology, and significant collagen deposition was observed, especially on trichrome staining. The intima and media of 9 of 10 specimens were two to three times normal thickness. Significant reactive change was also appreciated in the pericaval lymph nodes that were taken in the specimen. One pig (10%) developed a postoperative wound infection requiring treatment. CONCLUSIONS: Resorbable IVC filters are feasible and could be used for specific patient populations. This study outlines the need for further research of bioabsorbable polymers, absorption mechanics in the vascular system, absorption times, efficacy models, and practical application.

Does participation in graduate medical education contribute to improved patient outcomes as outlined by Surgical Care Improvement Project guidelines?

BACKGROUND: Patient quality outcomes are a major focus of the health care industry. It is unknown what effect involvement in graduate medical education (GME) has on patient outcomes. The purpose of this study is to begin to examine whether GME involvement in postoperative care impacts patient quality outcomes. METHODS: The retrospective cohort included all patients who underwent a nonemergent colectomy from January 1, 2007 to January 1, 2008 at a 2-hospital system. Data collected included patient demographics, patient quality outcomes, complications, and GME involvement. Patient quality outcomes were based on compliance with the Surgical Care Improvement Project (SCIP) guidelines. RESULTS: A total of 159 nonemergent colectomies were analyzed. The GME group accounted for 116 (73%) patients. A significant difference was found in several SCIP process-based measures of quality when comparing the GME group with the non-GME group. Postoperative antibiotics were more likely to be stopped within 24 hours (p = 0.010), and preoperative heparin and postoperative deep vein thrombosis (DVT) prophylaxis were more likely to be administered (p < 0.001). Additionally, patients in the GME group showed improved quality outcomes as there were significantly fewer postoperative complications (p < 0.001) and a shorter duration of stay (p = 0.008). The use of gastrointestinal prophylaxis was more common in the non-GME group (p = 0.002). No significant differences were observed between the 2 groups in respect to age, sex, diabetes, preoperative antibiotics, antibiotics, 1 hour before surgery, postoperative antibiotics, and continuation of home beta blockade. CONCLUSIONS: GME at teaching institutions has a positive impact on patient quality outcomes. At our institution, many of the SCIP measurable outcomes had improved compliance if an attending physician participated in the GME program.

Atrial septal rupture, flail tricuspid valve, and complete heart block due to nonpenetrating chest trauma.

This is a report of a patient with an atrial septal defect with right-to-left shunting, flail tricuspid valve, and complete heart block secondary to blunt chest trauma after a motor vehicle accident. The patient surgically repaired with pericardial recreation of atrial septum, bioprosthetic tricuspid valve replacement, and pacemaker insertion. The patient had minimal problems during the hospital course and subsequently made a full postsurgical recovery.