Computerized tomography and 3-D rendering help to select surgical strategy in leiomyosarcoma of the inferior vena cava.

Leiomyosarcoma of the inferior vena cava is a rare tumor that is usually fatal. The tumor may grow very slowly or occasionally very rapidly, shows extensive local invasion, and metastasizes more frequently than previously believed. Complete surgical resection remains the only potential curative therapeutic option. The aim of this study was to report the clinical experience in the management of a patient with leiomyosarcoma. A 65-year-old woman with a history of vague abdominal pain and leg swelling underwent computed tomography which demonstrated an occlusion of the inferior vena cava. The patient received a complete excision of the tumor without reconstruction and histological analysis confirmed the diagnosis of leiomyosarcoma type 1. At 3 years, the patient is still doing well with minimal leg edema and a contrast-enhanced CT demonstrates no evidence of recurrence locally or in distant sites. Leiomyosarcoma is a rare and aggressive tumor that presents with non-specific symptoms. Computerized tomography with 3-D reconstruction is a useful tool to define the presence and entity of the collateral circulation and therefore to decide on the surgical strategy. Resection probably offers the best opportunity for long-term survival.

Work-related effort thrombosis in a millwright: a case report.

BACKGROUND: Effort thrombosis refers to axillosubclavian vein thrombosis secondary to physical activities of the upper extremity. METHODS: This report describes the clinical presentation of effort thrombosis in a millwright and reviews the literature for occupational reports of this condition. RESULTS: While there is a paucity of literature reporting an occupational association, work related physical demands on the upper extremity appears to increase the risk of axillosubclavian impingement and thrombosis in certain patients. CONCLUSION: Effort thrombosis is a rare vascular condition of the upper extremity that may be seen in workers with repetitive, forceful, or overhead arm activities.

Morphometric analysis of anatomic variables affecting endovascular stent design in patients undergoing elective and emergency repair of endovascular abdominal aortic aneurysm.

BACKGROUND: Our objective was to identify morphologic trends in elective and emergency endovascular aneurysm repair (EVAR). This work will inform hospitals with endovascular programs about the diameters and lengths of endostents that should be available to efficiently care for patients with these conditions. METHODS: We performed a retrospective review of patients undergoing elective (n = 127) and emergency (n = 17) EVAR. Using computed tomography and 3-dimensional reconstructions, we evaluated the following: diameters of the aneurysm (D3), the aorta at the superior mesenteric (D1) and renal (D2a,b,c; 3 levels) levels, the iliac arteries (D5a,b; right and left) and the aortic bifurcation (D4); lengths from the lowest renal artery to the distal aspect of the aortic neck (H1), to the aortic bifurcation (H3), to the right and left iliac bifurcations (H4a,b); and angles of the origin of the common iliac arteries on the transverse plane (A1). We used descriptive statistics of trends within groups and independent sample t tests. RESULTS: In elective and emergency aneurysm repair, D2max (26, standard deviation [SD] 3, mm v. 30.7 [SD 3] mm), D5a (16 [SD 4.7] mm v. 19.3 [SD 5] mm), D5b (15.3 [SD 4] mm v. 18.1 [SD 3.6] mm), H1 (25.6 [SD 8.6] mm v. 18 [SD 2] mm), H4a (173 [SD 22] mm v. 189.5 [SD 22] mm) and H4b (174 [SD 25] mm v. 190 [SD 14] mm) were significantly different between the 2 groups (p = 0.001, p = 0.006, p = 0.007, p < 0.001, p = 0.05 and p = 0.01, respectively). H3 (118 [SD 17] mm v. 121.5 [SD 13.5] mm) was not significantly different (p = 0.40). In elective patients, A1 identified the right common iliac more frequently anterior relative to the left common iliac (mean 23 degrees , SD 16 degrees). CONCLUSION: Significant anatomic differences between elective and emergency patients will require hospitals to stock separate endovascular devices to treat abdominal aortic aneurysms in both groups.

Endovascular repair of popliteal aneurysms.

Endovascular repair is an established modality of treatment for abdominal aortic aneurysms. It is therefore reasonable to expect its application to other less common aneurysmal conditions, including isolated iliac and popliteal artery aneurysms (PAA). There are, however, essential differences between aortic aneurysms and peripheral aneurysms: smaller arterial caliber, mobility of the arterial segment, associated occlusive disease, and devices that have not been specifically designed for peripheral applications. Due to these differences, results obtained in abdominal aortic aneurysms cannot be extrapolated to peripheral aneurysms. The attraction of the endovascular repair for PAA is its minimally invasive nature. The literature, however, provides only case reports, case series and small cohorts, and one small randomized, controlled trial. A cumulative summary of these studies provides the clinician with information upon which to base the choice of treatment on a specific patient. Endovascular repair for PAA with suitable anatomy and good run-off can be considered safe, and medium term results appear comparable with those of open repair.

The effect of thoracoabdominal aneurysm repair on quality of life.

OBJECTIVE: The objective of this study is to assess the impact of surgery on quality of life (QOL) in patients who underwent thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: This is a prospective single center cohort study using two quality of life questionnaires administered before surgery, at 6 months, and 1 year after surgery. The Illness Intrusiveness Rating Scale (IIRS) is a tool that on a 7-point Likert scale assesses the impact of disease on each of 13 domains of quality of life. The Karnofsky Activity Scale (KAS) uses a single rating to assess the impact on overall quality of life. At each visit, participants completed the IIRS and KAS. Healthy, nonaneurysmal individuals also completed the IIRS to form a control group. RESULTS: From 1998 to 2006, 297 patients underwent thoracoabdominal aneurysm repair at a tertiary care hospital. Quality of life was measured on 80 patients in total. Preoperative data was available in 45 patients (7 completed the IIRS and 3 the KAS only, and 35 both); 6-month postoperative data in 25 (1 completed the KAS only, and 24 both); and 1-year data postoperative in 35 (4 completed the IIRS and 2 the KAS only, and 29 both). Internal consistency was established for IIRS (Cronbach's alpha 0.85) and KAS (0.81). The mean preoperative IIRS score was 32.10 (SD 17.91). After surgery, there was no change at the 6-month and 1-year postoperative intervals: at 6 months, the mean IIRS score was 33.17 (SD 17.66) and at 1 year the mean was 28.09 (SD 13.61). Total IIRS in nonaneurysmal controls was 13.5 (SD 0.7). The mean preoperative Karnofsky Activity Scale score was 80.0 (SD 15.07), which corresponds to an ability to perform normal activity with effort and some signs or symptoms of disease. After surgery, there was no change as patients reported a 6-month mean score of 79.60 (SD 21.89), and a 1-year postoperative mean score of 86.94 (SD 13.94). CONCLUSIONS: Quality of life for patients undergoing TAAA repair who survive to attend follow-up in an ambulatory setting can be measured using reliable and valid instruments. Preoperatively, QOL is poor compared with healthy controls. After surgery, at 6- and 12-month follow-up, QOL seems to return to the preoperative levels. Further research is necessary to address responsiveness and sensitivity of QOL measuring tools.

Progression of internal carotid artery stenosis in patients with peripheral arterial occlusive disease.

OBJECTIVES: To study the risk factors and rate of progression of asymptomatic carotid stenosis in patients with peripheral arterial occlusive disease. METHODS: Between July 1999 and September 2003, we studied consecutive patients referred to a vascular laboratory for peripheral arterial occlusive disease who had not experienced neurologic symptoms within the previous 3 years. Carotid duplex ultrasound scan (DUS) was performed at baseline and at 6 to 12-month intervals. The internal carotid artery peak systolic velocity (PSV) was used to determine severity of carotid stenosis. Multilevel linear regression modeling (MLM) was used to identify the rate of progression and risk factors for progression. RESULTS: For 614 consecutive patients, median follow-up by DUS was 30 (2-42) months. Patients were 73 +/- 10-years-old, and 62% were men. Mean ankle-brachial index (ABI) was 0.79 +/- 0.24. The baseline prevalence of carotid stenosis >or=50% (PSV >or=125 cm/second) was 22%. During follow-up, ipsilateral amaurosis fugax, transient ischemic attacks, and strokes occurred in 3 (0.4%), 7 (1.1%), and 5 (0.8%) patients, respectively. Overall, there was little progression in carotid stenosis. Female gender, low ABI, and smoking were risk factors for progression of disease regardless of severity of carotid stenosis. Patients with >or=50% carotid stenosis were at greatest risk of progression if they continued smoking and were diabetic. Prediction models for progression of carotid stenosis given a baseline PSV and patient risk factors were constructed. CONCLUSION: There are few neurologic events in patients with asymptomatic carotid stenosis. The average rate of progression of stenosis over 2 years is not significant but greater in diabetic patients with baseline stenosis >50% who continue smoking. Rescreening by serial DUS should be limited to high-grade stenosis and follow-up performed at an interval of 1-2 years.

Anaconda endovascular limbs for the treatment of isolated iliac artery aneurysms.

The purpose of this article is to report the feasibility and preliminary results of the treatment of isolated iliac artery aneurysms (IAAs) with Anaconda limbs (Vascutek Ltd., Inchinnan, Renfrewshire, Scotland). A prospective cohort is reported of consecutive IAAs treated by two senior surgeons from May to December 2006. One or more Anaconda limbs were used, and internal iliac arteries were embolized if necessary. Twelve IAAs in 11 patients were treated. The average IAA diameter was 4.3 +/- 1.1 cm, and the average diameter of stent used was 14 +/- 2.5 mm, with an average total length of 97 +/- 25 mm. At a mean follow-up of 12 +/- 4 months, there were no graft-related complications, graft occlusions, or requirements for reintervention. Endovascular treatment for isolated IAAs under local anesthesia using Anaconda limbs is feasible, safe, and effective. However, as with all new technology, longer follow-up data are necessary.

Open versus endovascular repair of abdominal aortic aneurysm: a survey of Canadian vascular surgeons.

OBJECTIVE: The aim of this survey was to determine Canadian vascular surgeons' experience with elective endovascular aortic repair (EVAR) and traditional open repair and their interest in participating in an expertise- based randomized controlled trial (RCT) as opposed to a conventional RCT comparing these 2 procedures. METHODS: A single-page questionnaire was developed and sent by fax, email or post to all vascular surgeons in Canada. Nonresponders were recontacted on 2 additional occasions to improve the response rate. The questionnaire had 2 sections. The first inquired about current and past practice patterns, including experience in both open and endovascular techniques. The second investigated the surgeons' belief in the value of open as opposed to endovascular repair and the value of expertise-based RCT methodology; it also canvassed their interest in participating in a future trial. Definitions of expertise in open and endovascular repair were drawn from the published literature. Criteria to determine the feasibility of conducting an expertise-based RCT were established a priori. RESULTS: The questionnaire was sent to 259 surgeons who appeared in multiple vascular surgery databases, and the overall response rate was 56% (95% confidence interval [CI] 50%-62%). The mean career experience was 406 cases (standard deviation [SD] 359) for conventional open abdominal aortic aneurysm (AAA) repair and 24 cases (SD 48) for endovascular repair. Of the responding surgeons, 51% (95% CI 41%-60%) ranked conventional open repair as "probably superior." Respondents were equally interested in participating in an RCT using either expertise-based methodology (54%, 95% CI 44%-63%) or conventional design (51%, 95% CI 41%-60%). CONCLUSION: Uncertainty exists among vascular surgeons in Canada as to the role of endovascular surgery in the repair of AAA. A national RCT comparing open with endovascular repair in the elective setting is potentially feasible with either expertise-based or conventional design. Increases in the number of surgeons who are willing to participate and have expertise in EVAR, in addition to high recruitment rates among eligible patients, will be necessary to make such a trial feasible in Canada.

Preoperative intra-aortic balloon pump in patients undergoing coronary bypass surgery: a systematic review and meta-analysis.

OBJECTIVES: To assess the effectiveness of preoperative intra-aortic balloon pump (IABP) placement in high-risk patients undergoing coronary bypass surgery (CABG). The primary outcome was hospital mortality and secondary outcomes were IABP-related complications (bleeding, leg ischemia, aortic dissection). METHODS: MEDLINE, EMBASE, Cochrane registry of Controlled Trials, and reference lists of relevant articles were searched. We included randomized controlled trials (RCTs), and cohort studies that fulfilled our a priori inclusion criteria. Eligibility decisions, relevance, study validity, and data extraction were performed in duplicate using pre-specified criteria. Meta-analysis was conducted using a random effects model. RESULTS: Ten publications fulfilled our eligibility criteria, of which four were RCTs and six were cohort studies with controls. There were statistical as well as clinical heterogeneity among included studies. A total of 1034 patients received preoperative IABP and 1329 did not receive preoperative IABP. The pooled odds ratio (OR) for hospital mortality in patients treated with preoperative IABP was 0.41 (95% CI, 0.21-0.82, p = 0.01). The number needed to treat was 17. The pooled OR for hospital mortality from randomized trials was 0.18 (95% CI, 0.06-0.57, p = 0.003) and from cohort studies was 0.54 (95% CI, 0.24-1.2, p = 0.13). Overall, 3.7% (13 of 349) of patients who received preoperative IABP developed either limb ischemia or haematoma at the IABP insertion site, and most of these complications improved after discontinuation of IABP. CONCLUSION: Evidence from this meta-analysis support the use of preoperative IABP in high-risk patients to reduce hospital mortality.

Endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis.

OBJECTIVES: The perioperative mortality for people with ruptured abdominal aortic aneurysms (RAAA) has not changed for two decades. Of patients who survive long enough to undergo open repair for ruptured aneurysms, half die (48%; 95% confidence interval [CI] 46 to 50). Randomized trials have shown that endovascular aneurysm repair (EVAR) for nonruptured abdominal aortic aneurysms decreases perioperative mortality compared with open repair. EVAR may similarly benefit patients with RAAA. We aimed to summarize studies of patients undergoing EVAR for ruptured aneurysms. METHODS: Two reviewers searched Medline and EMBASE databases from 1994 to July 2006, Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, the Cochrane Central Register of Controlled Trials, Best Evidence 1994 to 2006, reference lists, clinical trial registries, and conference proceedings; we also contacted authors. All published and unpublished studies in which a group of people with ruptured aneurysms, assessed objectively by imaging, was treated with EVAR (REVAR) were eligible. We used the generic inverse variance function of the REVMAN software to pool results for death in hospital. Sensitivity analyses, using prespecified subgroups, explored heterogeneity between studies. RESULTS: Pooled mortality in 18 observational studies describing 436 people who underwent REVAR was 21% (95% CI 13 to 29); however, 90% of the heterogeneity between studies was not explained by chance alone. Surgical volume explained substantial heterogeneity. According to study-specific criteria, 47% (95% CI 39 to 55) of people with ruptured aneurysms were potentially eligible for REVAR. CONCLUSIONS: Mortality in people who underwent REVAR is lower than that in historical reports of unselected people undergoing open repair. Further investigation is needed to determine whether the difference in mortality is attributable to patient selection alone or to this new approach to treatment.

Fenestrated endovascular grafts for juxtarenal aortic aneurysms: a step by step technical approach.

Fenestrated endovascular aortic aneurysm repair is a valuable alternative for patients who are at high risk for open surgery, but have unsuitable anatomy for infrarenal endovascular repair due to a short aneurysmal neck. Recognizing that this is an evolving and complex technology, we present a step by step approach to the surgical technique that may be useful for endovascular therapist interested in the management of these complex patients.

Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms.

BACKGROUND: The study was conducted to demonstrate improved survival (30-day mortality) after the introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms (rAAA). Numerous authors have successfully demonstrated reduced mortality in patients with rAAA using endovascular techniques. Comparison of endovascular aneurysm repair (EVAR) with open repair for rAAA may be misleading, however, because EVAR cannot be performed on all patients, and selection bias may explain the superior performance of any given surgical or endovascular strategy. We developed a model to predict mortality in patients before the introduction of EVAR (preprotocol population), applied this model to predict 30-day mortality among prospective patients (postprotocol population), and compared observed vs expected results. METHODS: We assessed 126 patients with rAAA. Primary outcome was 30-day mortality. Potential confounding variables were age, sex, presurgical lowest recorded systolic blood pressure (SBP), and glomerular filtration rate (GFR). A logistic regression model incorporating significant confounders was used to evaluate changes in 30-day mortality for all patients with rAAA after introduction of the EVAR protocol. Separate logistic regressions were done to compare 30-day mortality for preprotocol vs patients receiving EVAR and preprotocol vs patients receiving postprotocol open repair. Cumulative sum (CUSUM) analysis was used to assess shifts in the performance of the rAAA program over time. RESULTS: Significant confounders were SBP, absence of SBP, and GFR. Logistic regression found evidence of lower mortality after the protocol was introduced, 17.9% vs 30.0% (odds ratio [OR], 0.385; 95% confidence interval [CI], 0.141 to 0.981; P = .046). Comparison of all open repairs (preprotocol and postprotocol) and EVAR demonstrated decreased risk for EVAR of 5.0% vs 28.3% (OR, 0.109; 95% CI, 0.013 to 0.906; P = .0084). Unstable patients (SBP

Endovascular repair of perirenal and Group IV thoracoabdominal aortic aneurysms: a case study report.

BACKGROUND: Endovascular aneurysm repair (EVAR) is an established technique used in infrarenal aneurysms. Fenestrated and branched endografts (FBEGs) are a new option for the treatment of perirenal and Group IV thoracoabdominal aortic aneurysms (TAAAs). With a case study design, the preparation, surgical technique, postoperative nursing care, and medical follow-up involved in Group IV TAAAs treated with an FBEG are discussed. METHODS: Detailed imaging with state-of-the-art computed tomography scanning is used to create a custom-made endograft in which a combination of fenestrations, scallops, and covered or uncovered stents are used for the visceral arteries. This graft can be introduced in the arterial system through the femoral artery and delivered at the level of the perivisceral abdominal aorta. Perioperative nursing care in patients undergoing FBEG draws from protocols of an established EVAR program. With these protocols, preoperative assessment and education are completed to ensure that the patient is both physically and mentally prepared for the surgery. Intraoperatively, the nursing team is instrumental in the functioning of the case: The scrub nurse assists the surgeon while other registered nurses assist with invasive monitoring and emotional support for the conscious patient. Postoperatively, patients are taken directly from the recovery room to a step-down bed where close monitoring occurs. RESULTS: The use of FBEGs to treat Group IV TAAAs reduces the acuity of patient care by avoiding a thoracotomy and major surgical dissection, thus decreasing hospital length of stay. Although long-term follow-up remains limited, durability seems to be promising, and this procedure offers a viable option to high-risk patients. Because EVAR with FBEG is a new procedure in Canada, nurses involved with every aspect of care are challenged to maintain high levels of competency by continually educating themselves in this evolving field.

Acute diastolic dysfunction in thoracoabdominal aortic aneurysm surgery.

PURPOSE: To report transesophageal echocardiographic (TEE) findings consistent with intraoperative acute diastolic dysfunction in a series of patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: A series of nine consecutive patients underwent TAAA repair with intraoperative TEE monitoring. Surgical repair was performed with the adjunct of a left atrio-femoral bypass. Invasive arterial and venous pressures were monitored. Intraoperative TEE was utilized to assess the diastolic function before, and during aortic cross clamping. Diastolic dysfunction was defined as a mitral inflow pulsed wave Doppler (E: A ratio) < 1. RESULTS: All patients demonstrated an E: A ratio > 1 (1.3 +/- 0.08) before aortic cross clamping. During cross clamp, the E: A ratio decreased to < 1 (0.75 +/- 0.05) in six of nine patients consistent with diastolic dysfunction. The three patients who did not develop E: A changes were receiving ss-blockers pre-operatively. Patients with diastolic dysfunction were treated with nitroglycerin infusions, which resulted in restoration of their E: A ratios > 1 (1.2 +/- 0.09). Three of the patients with intraoperative diastolic dysfunction developed postoperative myocardial infarction. CONCLUSIONS: Chronic diastolic dysfunction is a well-known entity. This report describes acute diastolic dysfunction, which was observed frequently in patients undergoing TAAA during aortic cross clamp. Further research is required to confirm this phenomenon and determine its possible association with increased postoperative cardiac morbidity.