The Risk Factors and Outcomes of Acute Kidney Injury after Thoracic Endovascular Aortic Repair

Hepatic portal venous gas complication associated with the thoracic endovascular aortic repair for aortic dissection: a case report and literature review

Aortic dissection (AD) is a serious disease with a higher mortality. The thoracic endovascular aortic repair (TEVAR) is a first line regimen for aortic dissection. Hepatic portal venous gas (HPVG) is a rare disease, and its definite mechanism is unknown. This is a rare association between the aortic and HPVG. In the present report, we present a case of thoracic aortic dissection, which was the type of Standford B by the computer tomography (CT) angiography, which implicated acute abdominal pain and abdominal distention after TEVAR and immediate abdominal CT shown hepatic portal venous gas (HPVG). The patient, who was treated with conservative treatment of gastrointestinal decompressing, fluid resuscitation, electrolyte replacement, anti-infection, anti-inflammation and anticoagulation, was recovered and discharged without abnormalities. This patient has been followed up for 5 years and has not experienced any physical discomfort related to HPVG. This is the first report that the aortic dissection patient implication with HPVG after thoracic endovascular aortic repair.

Compensation based on work relative value unit for cardiovascular surgeons in Iran: A mixed method study

BACKGROUND

Work relative value unit (wRVU) is a tool for assessing surgeons' performance, compensation, and productivity. It appears that wRVU for cardiovascular procedures does not consider complexity and its value for lengthy operations is low. The aim of the study is to determine wRVU for cardiovascular procedures in Iran according to the proposed approach.

MATTERIALS AND METHODS

This study was conducted as a mixed method in teaching hospitals in Tabriz in the period of September 2020 to December 2021. According to Hospital Information System and expert opinions, six procedures in cardiovascular surgery were included in the study. They were compared with 18 procedures in neurosurgery, orthopedics, and otorhinolaryngology in terms of the operation time and wRVU/min. Then, we calculated new wRVUs for the selected procedures based on surgeons' opinions, time measurements, and anesthetists' points of view by content analysis in qualitative and statistical analysis in quantitative parts.

RESULTS

Among the six cardiac procedures, the wRVU for five was under-estimated. The wRVU/min value ranged from 0/28 to 1/15 in the studied procedures. Findings demonstrate no significant relationship between the length of operations and the wRVU announced by the Ministry of Health and Medical Education (P value >0/05). Compared to studied procedures in four specialties, thoracoabdominal aortic aneurysm repair has the longest surgery time at 417 minutes. According to anesthesiologists, cardiovascular; orthopedics; ear, nose, and tongue; and neurosurgery specialties obtained 4/2, 2/9, 2/8, and 4, respectively, in terms of surgery duration, complexity, risk, and physical effort.

CONCLUSION

Despite policymakers' attempts to bring justice to payments, it seems that there has been little progress in paying cardiovascular surgeons. Improper payment to cardiovascular surgeons will affect the future of the workforce in this specialty. Today, the need to reconsider the wRVUs in heart specialty is felt more than before.

Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis

OBJECTIVE

We examined early (≤24 h) versus delayed (>24 h) thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), taking the aortic injury severity into consideration.

BACKGROUND

Current trauma surgery guidelines recommend delayed TEVAR following BTAI. However, this recommendation was based on small studies, and specifics regarding recommendation strategies based on aortic injury grades are lacking.

METHODS

Patients undergoing TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program between 2016 and 2019 were included and then stratified into 2 groups (early: ≤24 h vs. delayed: >24 h). In-hospital outcomes were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, comorbidities, concomitant injuries, additional procedures, and aortic injury severity based on the acute aortic syndrome (AAS) classification.

RESULTS

Overall, 1339 patients were included, of whom 1054(79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs delayed; 25% vs 32%; P =0.014), fewer early interventions for AAS grade 1 occurred, and AAS grade 3 aortic injuries often were intervened upon within 24 hours (grade 1: 28% vs 47%; grade 3: 49% vs 23%; P <0.001). After matching, the final sample included 548 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (8.8% vs 4.4%, relative risk: 2.2, 95% CI: 1.1-4.4; P =0.028), alongside a shorter length of hospital stay (5.0 vs 10 days; P =0.028), a shorter intensive care unit length of stay (4.0 vs 11 days; P <0.001) and fewer days on the ventilator (4.0 vs 6.5 days; P =0.036). Furthermore, regardless of the higher risk of acute kidney injury in the delayed group (3.3% vs 7.7%, relative risk: 0.43, 95% CI: 0.20-0.92; P =0.029), no other differences in in-hospital complications were observed between the early and delayed group.

CONCLUSION

In this propensity score-matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.

Complications and Management of the Thoracic Endovascular Aortic Repair

Endovascular treatment in thoracic aortic diseases has increased in use exponentially since Dake and colleagues first described the use of a home-made transluminal endovascular graft on 13 patients with descending thoracic aortic aneurysm at Stanford University in the early 1990s. Thoracic endovascular aneurysm repair (TEVAR) was initially developed for therapy in patients deemed unfit for open surgery. Innovations in endograft engineering design and popularization of endovascular techniques have transformed TEVAR to the predominant treatment choice in elective thoracic aortic repair. The number of TEVARs performed in the United States increased by 600% from 1998 to 2007, while the total number of thoracic aortic repairs increased by 60%. As larger multicenter trials and meta-analysis studies in the 2000s demonstrate the significant decrease in perioperative morbidity and mortality of TEVAR over open repair, TEVAR became incorporated into standard guidelines. The 2010 American consensus guidelines recommend TEVAR to be “strongly considered” when feasible for patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms. Nowadays, TEVAR is the predominant treatment for degenerative and traumatic descending thoracic aortic aneurysm repair. Although TEVAR has been shown to have decreased early morbidity and mortality compared with open surgical repair, endovascular manipulation of a diseased aorta with endovascular devices continues to have significant risks. Despite continued advancement in endovascular technique and devices since the first prospective trial examined the complications associated with TEVAR, common complications, two decades later, still include stroke, spinal cord ischemia, device failure, unintentional great vessel coverage, access site complications, and renal injury. In this article, we review common TEVAR complications with some corresponding radiographic imaging and their management.

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair

OBJECTIVE

Complex Crawford extent II thoracoabdominal aortic aneurysms (TAAAs) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. This study evaluated the outcomes and health care-associated value of this new method compared with traditional open repair over 10 years.

METHODS

A prospectively collected database was used to identify all patients with an extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, postoperative outcomes, and incidence of major adverse events (MAEs; renal failure, spinal cord ischemia, death) were compared. After adjusting for time since surgery, value was analyzed looking at quality (1/MAE) divided by cost (total health system cost). This was multiplied by a constant to set the value of open TAAA repair to 100.

RESULTS

A total of 113 consecutive patients underwent extent II TAAA repairs, of whom 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (P > .05). The hybrid group had shorter operative time (255 vs 306 minutes; P = .01), shorter postoperative length of stay (10.1 vs 13.3 days; P = .02), and reduced blood loss (1300 vs 2600 mL; P = .01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0% vs 51.1%; P = .03), there was no difference in renal failure (8.0% vs 4.5%; P = .84). The incidence of MAEs was lower in the staged hybrid group (20.0% vs 48.9%; P = .01), without a difference in hospital mortality (4.0% vs 3.4%; P = .89). Median total cost was higher in the hybrid group ($112,920 vs $72,037; P = .003). Value was improved in the hybrid group by 56% using mean cost and 178% by median cost.

CONCLUSIONS

The 20% MAE rate associated with staged hybrid repair of extent II TAAA was significantly decreased compared with open repair, with a relative reduction of >50%. Despite higher total hospital costs, staged hybrid repair had 56% to 178% higher health care-related value compared with standard open repair. In an era of increasing focus on costs and quality, staged hybrid repair of extensive TAAAs is associated with fewer complications than open TAAA repair, resulting in a good value investment from a resource utilization perspective.