Psoas Muscle Area Predicts All-Cause Mortality After Endovascular and Open Aortic Aneurysm Repair.

OBJECTIVE: Psoas muscle area (PMA) is a validated surrogate for muscle mass that can be easily measured from a clinical CT scan. This study sought to determine whether PMA was associated with post-operative mortality after endovascular or open aortic aneurysm repair. METHODS: A retrospective review was undertaken of patients who underwent elective endovascular or open aortic aneurysm repair between 2010 and 2015 at a tertiary vascular center in Montreal, Quebec, Canada. Pre-operative CT scan images were analyzed with the CoreSlicer.com software tool to measure PMA at the axial level of the L4 vertebrae. Measurements were made by two independent observers blinded to clinical data. The primary endpoint was all-cause mortality. RESULTS: The cohort consisted of 149 patients with a mean age of 75.6 ± 8.8 years. The mean PMA was 24.0 ± 5.8 cm2 in males, and 14.3 ± 3.1 cm2 in females. There were 31 deaths over a mean follow-up of 22.4 months. After adjusting for age, sex, revised cardiac risk index, and surgical approach, Cox regression revealed a graded association between PMA and all-cause mortality with a hazard ratio of 0.86 per cm2 (95% CI 0.79-0.93). Addition of PMA to the model with the clinical covariates resulted in an improvement in C-statistic from 0.57 to 0.67, and BIC from 307 to 301 (with lower BIC values preferred). CONCLUSIONS: PMA is independently associated with all-cause mortality after elective endovascular and open aortic aneurysm repair, and may be integrated into the pre-operative risk assessment to optimize care in high-risk frail patients.

Association of ultrasonic texture and echodensity features between sides in patients with bilateral carotid atherosclerosis.

OBJECTIVES: Our objective was to estimate the correlation of echodensity and textural features, using ultrasound and digital image analysis, between plaques in patients with bilateral carotid stenosis. DESIGN: Cross-sectional observational study. METHODS: Patients undergoing carotid endarterectomy were recruited from Vascular Surgery at the Royal Victoria and Jewish General hospitals in Montreal, Canada. Bilateral pre-operative carotid ultrasound and digital image analysis was performed to extract echodensity and textural features using a commercially available Plaque Texture Analysis software (LifeQMedical Ltd). Principal component analysis (PCA) was performed. Partial correlation coefficients for PCA and individual imaging variables between surgical and contralateral plaques were calculated with adjustment for age, sex, contralateral stenosis, and statin use. RESULTS: In the whole group (n = 104), the six identified PCA variables and 42/50 individual imaging variables were moderately correlated (r = .211-.641). Correlations between sides were increased in patients with ≥50% contralateral stenosis and symptomatic patients. CONCLUSION: Textural and echodensity features of carotid plaques were similar between two sides in patients with bilateral stenosis, supporting the notion that plaque instability is determined by systemic factors. Patients with unstable features of one plaque should perhaps be monitored more closely or treated more aggressively for their contralateral stenosis, particularly if this is hemodynamically significant.

Treatment of aortic arch aneurysms with a modular transfemoral multibranched stent graft: initial experience.

OBJECTIVES: To present initial experience with a new modular transfemoral multibranched stent graft for treating aortic arch aneurysms. METHODS: Six patients, considered high risk for open surgery, were treated with custom made branched stent grafts. All patients had a staged left carotid subclavian bypass before the endovascular procedure. Each branched graft had a 12 mm side branch for the innominate artery and an 8 mm side branch for the left common carotid artery. RESULTS: Four patients out of six had uneventful placement of the prostheses, with successful exclusion of their aneurysms. One patient developed a type I endoleak that was managed successfully with coiling and gluing of the aneurysm sac. In one patient, cannulation of the innominate branch was unsuccessful and an extra-anatomic bypass was necessary to perfuse the right carotid and vertebral arteries. This patient developed a stroke, while one more suffered a right cerebellar infarct. CONCLUSION: We have demonstrated the technical feasibility of a modular transfemoral branched stent graft for treatment of aortic arch aneurysms. The method is relatively safe based on initial experience. More cases and long-term follow up are necessary to evaluate the efficacy and safety of this new device.

Early vascular complications after endovascular repair of aortoiliac aneurysms.

The purpose of this study was to estimate the frequency of and review the treatment options for intraoperative endograft access-related vascular complications and early postoperative vascular complications of endovascular repair for aortoiliac aneuryms (EVAR). Between February 1998 and April 2000, 53 patients (46 males, 7 females) with aneurysms of the abdominal aorta (AAA) and iliac arteries were treated with endovascular grafts (48 AAA, and 5 iliac aneurysms). All procedures were performed using open exposure of the femoral arteries. One patient with an AAA was converted to open repair (primary technical success, 98.1%). We recorded the need for adjunctive vascular procedures or intervention to the access arteries (iliofemoral) or the endograft because of thrombosis or distal embolization. Events were classified as either intraoperative, early postoperative (< 30 postoperative days), or late postoperative. Their etiology and treatment were recorded. The results were compared to those from other series reported in the literature and to published registry data. From our results we concluded that the need for adjunctive vascular procedures to the iliofemoral arteries at the time of EVAR is significant. These procedures are necessary to either repair damage to the access arteries from the delivery system or provide a conduit for graft delivery in cases where the access arteries are inadequate. Early postoperative vascular complications are due to technical factors resulting in residual graft limb stenoses. Both intraoperative and early postoperative vascular complications after EVAR are more common in female patients. These complications can be effectively treated with a variety of open surgical and transfemoral endovascular techniques.

Incidence of major venous and renal anomalies relevant to aortoiliac surgery as demonstrated by computed tomography.

Preoperative knowledge of the presence of major venous anomalies facilitates the safe performance of aortic surgery. The purpose of the study was to estimate the incidence, as detected by abdominal and pelvic computed tomography (CT), of major venous and renal anomalies related to the abdominal aorta in an adult population. A total of 1822 intravenous contrast-enhanced abdominal and pelvic CT scans done in 1822 patients at two university teaching hospitals were randomly selected and prospectively reviewed (between June 1999 and March 2000) to identify major venous and renal anomalies associated with the abdominal aorta and iliac arteries. An interpreting staff radiologist then indicated on adata sheet whether any of the following anomalies were present or absent: (1) retroaortic left renal vein, (2) circumaortic left renal vein, (3) left-sided inferior vena cava (IVC) without situs inversus, (4) left-sided IVC with situs inversus, (5) duplicate IVC, (6) preaortic confluence of the iliac veins, or (7) horseshoe kidney. The CT scans reviewed had been performed for a wide variety of indications. Thirty-four scans were excluded from the study because either the anomalies we were looking for could not be assessed for technical reasons or the patient had a previous left nephrectomy and therefore assessment of the left renal vein was impossible. From this analysis we found that in an adult population, the prevalence of major venous and renal anomalies related to the abdominal aortaand iliac arteries and detected by CT scan was 5.65%. Prior to aortic surgery, preoperative knowledge of the presence of such anomalies helps with operative planning and may reduce the risk of major venous hemorrhage associated with these anomalies.

Ureteropelvic urinary extravasation due to iliac artery aneurysm.

We report a case of left-sided hydronephrosis and ureteropelvic urinary extravasation due to a large left iliac artery aneurysm. Urinoma was diagnosed preoperatively by contrast-enhanced computed tomography. The patient was successfully treated by percutaneous nephrostomy and ureteral double J stent placement followed by staged operative repair.

Lower extremity vascular reconstruction and endovascular surgery without preoperative angiography.

BACKGROUND: Recent studies have shown the feasibility of performing lower extremity revascularization based on noninvasive vascular studies alone. METHODS: We undertook a prospective study of patients with lower extremity ischemia who underwent revascularization without preoperative angiography. Preoperative evaluation was done with noninvasive studies including segmental pressures, ankle arm index, duplex scan, and selective use of magnetic resonance angiography. Intraoperative angiography and intra-arterial pressure measurements were used prior to revascularization. Standard patency analysis and follow-up examination were performed. RESULTS: In all, 47 patients underwent 65 procedures (27 iliac, 38 infrainguinal) over a 3-year period. Intraoperative angiography and operative findings correlated with the noninvasive studies. There was one immediate failure, and life table analysis demonstrated primary patency rates of 92% for iliac reconstruction (29 months) and 82% for infrainguinal reconstruction (40 months). CONCLUSION: Preoperative evaluation for lower extremity revascularization utilizing only noninvasive vascular testing gives satisfactory results and is a safe and potentially durable alternative to routine preoperative angiography in most cases.

Continued change in the distribution of colorectal carcinoma.

BACKGROUND: The aim of this study was to determine whether the previously reported shift in carcinoma from the left colon to the right colon has progressed. METHODS: The charts of 2169 patients admitted to one institution between 1979 and 1994 with a diagnosis of colorectal carcinoma were reviewed retrospectively. The study was divided into four equal intervals. The large bowel was divided into five regions: right, transverse, left, sigmoid and rectum. RESULTS: Right-sided lesions increased from 20.6 to 29.9 per cent (P = 0.001) and rectal lesions decreased from 22.0 to 11.3 per cent (P = 0.0002) from the first to the fourth study interval. The frequency of transverse, left and sigmoid colon lesions remained relatively constant. CONCLUSION: The continuing trend of increased incidence of right-sided lesions and decreased incidence of rectal lesions was documented. Any screening examination for carcinoma requires total examination of the colon.

Incidence and patterns of recurrence following curative resection for colorectal carcinoma.

PURPOSE: This study was designed to determine incidence and patterns of recurrence after curative resection of colorectal carcinoma and to determine which variables are significant in predicting outcome. METHOD: A retrospective review of 524 patients operated on by one surgeon from 1975 to 1992 was conducted. Variables recorded included age, gender, location, gross morphology, histology, stage of each primary and evidence of perforation and direct extension at time of original operation. Overall survival and pattern of recurrence were documented. RESULTS: Overall recurrence rate was 27.9 percent. Anastomotic recurrence rate was 11.7 percent. Anastomotic recurrences were higher for rectal than colon lesions (20.3 vs. 6.2 percent; P = 0.001). Distant metastases developed in 14.4 percent of patients, 13.9 percent for colon carcinoma and 15.5 percent for rectal carcinoma. Average time for anastomotic recurrence was 16.2 months vs. 22.9 months for distant disease. T1,2,N0,M0 lesions had a 17.6 percent recurrence rate, T3,N0,M0 was 23.4 percent, and T1,2,3,N1,M0 was 43.7 percent (P = .001). Patients who did not undergo any intervention after diagnosis of recurrence survived an average of 28 months. Those who received palliative treatment survived an average of 39 months. Twenty-four percent of patients had reresection for cure, and 47 percent of these patients were alive at a mean of 80 months; those who died of their disease did so at an average of 53 months. Positive predictive factors for recurrence include site of lesion (rectum vs. colon), stage, invasion of contiguous organs, and presence of perforation. Age, gender, degree of differentiation, mucin secretion, and gross morphology were not found to be predictive factors in this study. CONCLUSIONS: Recurrence after resection for rectal carcinoma is higher than after colon carcinoma. In those patients in whom reresection is possible, up to 50 percent may have long-term survival. Understanding patterns of recurrence and features that predispose to them may guide the physician in aggressive but more selective adjuvant therapy and recommendations for targeted surveillance in follow-up.

Transluminal balloon angioplasty, stents, and atherectomy.

Arterial bypass grafting for occlusive disease is still considered the gold standard in the treatment of arterial occlusive disease. However, less invasive methods are available for select patients. Percutaneous balloon angioplasty has been shown to be effective in focal iliac artery stenosis, with patency rates of 50% to 90% at 5 years. Patency rates for femoropopliteal lesions are generally less than 50% at 2 years. Complications seen with balloon angioplasty often can be treated with arterial stents. Stents can be categorized into balloon-expandable, which provide a rigid scaffold to support the artery, self-expanding, which exert radial force to resist external compression, and thermal expanding stents, which allow for the use of a smaller introducer sheath. Another treatment option is atherectomy, in which the offending lesion is removed instead of fracturing and dilating the lumen. Although overall initial results of atherectomy have not been favorable, short lesions with eccentric atheroma or intimal hyperplasia, such as those seen in dialysis access fistulas or vein graft stenoses, may respond well.

Results of local excision for rectal carcinoma.

OBJECTIVE: To determine the results peranal excision for rectal carcinoma. DESIGN: Retrospective case series. SETTING: A university-affiliated hospital. PATIENTS: Of 178 patients who presented for curative resection of rectal carcinoma between 1975 and 1993, 19 (10.7%) were deemed suitable for local excision. There were 10 men and 9 women with a mean age of 71.2 years. The follow-up ranged from 13 to 184 months. INTERVENTION: Peranal excision. MAIN OUTCOME MEASURES: Histologic differentiation, gross morphology, depth of invasion and size of the carcinoma, adequacy of margins of excision, complications of operation, rates of recurrence, results of salvage therapy and 5-year survival. RESULTS: There were no intraoperative complications. Postoperative complications included urinary retention (one patient) and bleeding (one patient). There were five local recurrences (26%). Salvage operations were performed in three (60%) patients and were successful in two of them. The 5-year cancer-specific survival rate was 82%. The recurrence rate was higher in patients with inadequate margins of excision and ulcerative lesions. Neither size nor grade of the carcinoma correlated with recurrence. CONCLUSIONS: Local excision of rectal carcinoma can be performed successfully in selected patients. Diligent follow-up is required, because up to 60% of local recurrences can be treated successfully.