Endovascular repair of a Bacillus Calmette-Guerin mycotic aortic aneurysm

Bacillus Calmette-Guérin (BCG) is an attenuated form of Mycobacterium bovis used for intravesical treatment of bladder carcinoma. Aortic infection has been rare. In the present report, we have described the case of a patient with an infrarenal mycotic aortic pseudoaneurysm and para-aortic abscess after intravesical bacillus Calmette-Guérin and cystectomy. Sampling of the abscess demonstrated acid-fast bacilli. Given the hostile anatomy of the abdomen, he was offered endovascular aortic repair. A thoracic endograft was used to cover the lesion. The patient was discharged on postoperative day 2 without incident. He was seen at 1 and 6 months with resolution of his pseudoaneurysm found on the imaging studies. The technique shows promise for stabilizing such lesions with close surveillance.

Racial Disparities in the Risk for Thromboembolic Events in COVID-19 Patients during the Height of the SARS-CoV-2 Pandemic and Impact on Outcomes

Background

The primary objective of this study is to assess the risk of thromboembolic events (TEs) in hospitalized patients with coronavirus disease 2019 (COVID-19) and study the impact of TEs on hospital course and mortality risk during the initial height of the severe acute respiratory syndrome coronavirus-2 pandemic.

Methods

A retrospective review of all adult inpatients (≥ 18 years old) with COVID-19 infection at a single academic institution from March 15, 2020 to July 1, 2020 was performed. Collected data included patient demographics, comorbidities, hospital admission type, TEs, laboratory values, use of anticoagulants/antiplatelet agents, hospital length of stay, and in-hospital mortality. A logistic regression was used to estimate associations between risk factors and TEs.

Results

A total of 826 inpatients with COVID-19 were identified. Of these, 56% were male, average age was 60.9 years, and race/ethnicity was reported as Hispanic in 51%, non-Hispanic Black in 25%, and non-Hispanic White in 18%. A total of 98 TEs were documented in 87 patients (10.5%). Hypertension, coronary artery disease, and chronic limb threatening ischemia were associated with an increased incidence of thromboembolism (P < 0.05). Hispanic patients had higher incidence of thromboembolism compared to White non-Hispanic patients (odds ratio {[OR] confidence interval [CI]}: 2.237 [1.053, 4.754], P = 0.036). As D-dimer increased, the odds of TE increased by 5.2% (OR [CI]: 1.052 [1.027, 1.077], P < 0.001). Patients with TEs had longer hospital stay (median 13 vs. 6 days, P < 0.001), higher likelihood of intensive care unit admission (63% vs. 33%, P < 0.001), and higher in-hospital mortality (28% vs. 16%, P = 0.006). Arterial TEs were associated with higher in-hospital mortality than venous TEs (37% vs. 15%, P = 0.027).

Conclusions

During the initial height of the severe acute respiratory syndrome coronavirus-2 pandemic, TEs were relatively frequent in hospitalized patients with COVID-19. Racial disparities were seen with an increased proportion of minority patients admitted with respect to percentages seen in the general population. There was also a significantly increased incidence of TEs in Hispanic patients. TEs were associated with significantly longer hospital stay and higher in-hospital mortality. Patients with arterial TEs fared worse with significantly higher mortality than those with venous events. Inconsistencies in anticoagulation management early in the pandemic may have contributed to poor outcomes and more contemporary management outcomes need to be investigated.

Malignancy Does not Affect Outcomes of Pharmacomechanical Thrombolysis in Acute Symptomatic Iliofemoral Deep Vein Thrombosis

BACKGROUND

Cancer patients demonstrate increased risk for venous thromboembolism (VTE), VTE recurrence, and anticoagulation-associated bleeding. Pharmacomechanical thrombolysis (PMT) aand thrombectomy improves venous patency, venous valve function, and quality of life in patients with acute iliofemoral deep vein thrombosis (DVT). It remains unknown whether pharmacomechanical thrombolysis can be used safely in patients with active cancer. We hypothesized that perioperative and short-term outcomes of pharmacomechanical iliofemoral DVT thrombolysis would not differ between patients with cancer and those without cancer.

METHODS

A retrospective chart review of consecutive patients with symptomatic iliofemoral DVT undergoing PMT by AngioJet Power Pulse spray and thrombectomy at a single tertiary care university institution between December 2013 and December 2016 was performed. Outcomes between patients with cancer and without cancer were compared.

RESULTS

We identified 22 limbs in 18 consecutive patients: 6 patients (7 limbs) with cancer and 12 patients (15 limbs) without cancer. Between these groups, the mean age was 60.5 ± 4.3 vs. 53.8 ± 26.8 years, respectively (P = 0.5593), and females comprised 66.7% vs. 25.0%, respectively (P = 0.0878). No significant difference in inferior vena cava (IVC) involvement between the groups (57.1% vs. 53.3%, P = 0.8676) was noted. Grade II (50-94% lysis) and III (95% complete lysis) thrombus lysis with restoration of venous patency was achieved in both the groups. Overnight catheter-directed thrombolysis (CDT) was rarely used. Notably, stenting was more frequently employed in cancer patients than in those without cancer (57.1% vs. 13.3%, P = 0.0316). The mean duration of follow-up was 3.42 ± 4.41 months for the cancer group and 4.50 ± 2.43 months for the noncancer group (P = 0.5060). Overall outcomes were excellent as no patient in both the groups experienced recurrent DVT, major bleeding, or postthrombotic syndrome. There was no mortality associated with the endovascular thrombolysis procedures.

CONCLUSIONS

The results of our study suggest that the presence of malignancy does not affect short-term outcomes of endovascular thrombolytic therapy in symptomatic DVT. Further follow-up is needed to evaluate long-term outcomes.

Carotid Body Tumor Resection: Just as Safe without Preoperative Embolization

BACKGROUND

Carotid body tumors (CBTs) are rare entities for which surgical resection remains the gold standard. Given their hypervascularity, preoperative embolization is often used; however, controversy exists over whether a benefit is associated. Proponents of embolization argue that it minimizes blood loss and complications. Critics argue that cost and stroke outweigh benefits. This study aimed to investigate the impact of embolization on outcomes following CBT resection.

METHODS

Patients undergoing CBT resection were identified using the Healthcare Cost and Utilization Project State Inpatient Database for 5 states between 2006 and 2013. Patients were divided into 2 groups: carotid body tumor resection alone (CBTR) and carotid body tumor resection with preoperative arterial embolization (CBETR). Descriptive statistics were calculated using arithmetic means with standard deviations for continuous variables and proportions for categorical variables. Patients were propensity score matched on the basis of sex, age, race, insurance, and comorbidity prior to analysis. Risk-adjusted odds of mortality, stroke, nerve injury, blood loss, and length of stay (LOS) were calculated using mixed-effects regression models with fixed effects for age, race, sex, and comorbidities.

RESULTS

A total of 547 patients were identified. Of these, 472 patients underwent CBTR and 75 underwent CBETR. Mean age was 54.7 ± 16 years. Mean number of days between embolization and resection was 0.65 ± 0.72 days (range 0-3). When compared with CBTR, there were no significant differences in mortality for CBETR (1.35% vs. 0%, P = 0.316), cranial nerve injury (2.7% vs. 0%, P = 0.48), and blood loss (2.7% vs. 6.8%, P = 0.245). Following risk adjustment, CBETR increased the odds of prolonged LOS (odds ratio 5.3, 95% confidence interval 2.1-13.3).

CONCLUSIONS

CBT resection is a relatively rare procedure. The utility of preoperative tumor embolization has been questioned. This study demonstrates no benefit of preoperative tumor embolization.

Atypical Presentation of a Type 2 Endoleak following Emergency Open Repair of a Ruptured Abdominal Aortic Aneurysm

Background

An endoleak is a common complication following EVAR. Specifically, a Type 2 endoleak occurs because of retrograde flow from lumbar vessels outside the endograft within the aneurysm sac. Even though it is common following EVAR, it has not been identified as a complication following open ruptured abdominal aortic aneurysm (AAA) repair.

Report

A 73-year-old male underwent open repair of a ruptured AAA. Five months later, computed tomography revealed filling from a lumbar vessel mimicking a Type 2 “endoleak.” The initial ultrasound showed a single pair of lumbar vessels with aneurysm sac expansion 8 weeks later. The “endoleak” and expanding sac were treated, and the 2-year surveillance demonstrated sac shrinkage.

Discussion

Because endoleak is a complication after EVAR, this case provides a unique presentation of Type 2 “endoleak” physiology following open repair of a ruptured AAA. It is believed that it is necessary to expand the list of possible complications after open ruptured AAA repair to include “endoleaks.”

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An endoleak is a common complication observed after EVAR, but not open AAA repair.

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Type 2 endoleak after open AAA repair has a similar treatment paradigm to EVAR.

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Translumbar embolization done utilized bony landmarks without endograft as landmark.

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Endoleak is a complication of EVAR, but open AAA repair can mimic similar pathology.

Iliac Stent Migration during Thoracic Endovascular Aortic Aneurysm Repair Resulting in Functional Coarctation

Iliac arterial disease, unfavorable anatomy, and prior stenting all pose challenges to access in endovascular abdominal aortic repair (EVAR) and thoracic aortic repair (TEVAR). Iliac access injury during T/EVAR may lead to rupture, dissection, thrombosis, or distal ischemia. Some have advocated iliac stent prior to T/EVAR in patients with suboptimal iliac access. The rate of complication and iliac stent migration during subsequent T/EVAR is undocumented. This case report describes a unique instance of self-expanding iliac stent migration during TEVAR which pinched the thoracic aortic endograft causing functional aortic coarctation.

Should Age Limit the Use of Catheter-Directed Thrombolysis: Results of National Survey

OBJECTIVE

To determine whether advanced age should be a contraindication to catheter-directed thrombolysis (CDT) based on hemorrhagic complication rate.

METHODS

A survey was generated via Survey Monkey and sent out to vascular surgeons who were members of the society of vascular surgery (SVS).

RESULTS

Of the responders, 32.7% state they do not have an age limit for tissue plasminogen activator (TPA) infusion, and the remaining 29.2% of the responders use 80 years of age as their limitation. When asked why place limits on age for TPA infusion, 56.6% stated concern for intracranial hemorrhage. Major complications were access site hemorrhage (58.4%) and intracranial hemorrhage (41.6%). Chi-square analysis did not show age as a limiting factor to thrombolysis. Furthermore, when asked in which age-group complications occurred most commonly, 72.4% were less than 80.

CONCLUSION

Among vascular specialist, there seems to be no consensus on age limitations for TPA infusion. Serious complications do not seem to be age related and thus age alone should not be a contraindication for catheter-directed thrombolysis.

Aspirin usage is associated with improved prosthetic infrainguinal bypass graft patency

The American Heart Association recommends that, unless contraindicated, all patients undergoing surgical revascularization for critical limb ischemia should be placed postoperatively on antiplatelet therapy and remain on it indefinitely. The goal of this study was to evaluate if preoperative use of aspirin was associated with improved bypass grafting patency rates and limb salvage. We performed a four-year, retrospective review of one center's experience with open infra-inguinal bypass. We examined the effect pre- and postoperative usage of antiatherosclerotic agents (i.e. aspirin, statin, etc.) have on graft outcomes such as two-year secondary patency, stenosis and limb salvage via univariate Kaplan–Meir survival curve analysis and multiple regression analysis. Our cohort included 165 bypasses in individuals with multiple co-morbidities. The most frequent indication was critical limb ischemia (79%) and most bypasses crossed the knee (63%). Pre- and postoperative aspirin usage was associated with increased two-year secondary prosthetic graft patency over control (preoperative: 78% versus 44%, P < 0.002 and postoperative: 72% versus 50%, P < 0.01). Preoperative aspirin usage was associated with an improvement in the rate of amputation (odds ratio [OR] = 0.44 [95% CI 0.198–0.997]) and stenosis (OR = 0.45 [95% CI 0.217–0.956]). Medications commonly prescribed for atherosclerosis such as aspirin are associated with a significant patency benefit when administered pre- and postoperatively. In a population undergoing infrainguinal bypass with prosthetic graft for predominantly critical limb ischemia, medical optimization should include both pre- and postoperative antiatherosclerotic drug regimens.

Arterial reconstruction for atypical mycotic aneurysms

Our case involves a 67-year-old man with a  post lung transplantation status for idiopathic pulmonary fibrosis, who was initially referred to our institution for treatment of left hip septic arthritis due to Pseudallescheria boydii infection. One month following total hip arthroplasty, he noticed left upper thigh swelling with duplex imaging consistent with a 7-cm mid-superficial femoral artery aneurysm with popliteal vein compression and associated deep venous thrombosis. During operative resection, exploration of his contralateral saphenous vein showed inadequate conduit for use. Therefore, we proceeded with proximal and distal clamp control with intraoperative arterial shunting followed by cryoarterial reconstruction after complete aneurysm sac resection and debridement. Intraoperative arterial wall cultures remained negative for bacterial pathogens; however, final operative fungal cultures once again grew Pseudallescheria boydii. Our case highlights the complexity of adequate source control with effective arterial reconstruction in these immunosuppressed patient populations, particularly with fungal organisms that historically have poor therapeutic response to medical therapy alone.

Failed superficial femoral artery intervention for advanced infrainguinal occlusive disease has a significant negative impact on limb salvage

OBJECTIVE

Endovascular treatment of superficial femoral artery (SFA) lesions is a well-established practice. The repercussions of failed SFA interventions are unclear. Our goal was to review the efficacy of SFA stenting and define negative effects of its failure.

METHODS

A retrospective chart review was conducted from January 2007 to January 2010 that identified 42 limbs in 39 patients that underwent SFA stenting. Follow-up ankle-brachial index and a duplex ultrasound scan was performed at routine intervals.

RESULTS

Mean patient age was 68 years (range, 43-88 years); there were 22 men (56%) and 17 women (44%). Intervention indication was claudication in 15 patients (36%), rest pain in seven patients (17%), and tissue loss in 19 patients (45%). There were 15 patients (36%) with TransAtlantic Inter-Society Consensus (TASC) A, nine patients (21%) with TASC B, five patients (12%) with TASC C, and 13 patients (31%) with TASC D lesions. The majority of lesions intervened on were the first attempt at revascularization. Three stents (7.7%) occluded within 30 days. One-year primary, primary-assisted, and secondary patency rates were 24%, 44%, and 51%, respectively. Limb salvage was 93% during follow-up. Seventeen interventions failed (40%) at 1 year. Of these, seven patients (41%) developed claudication, seven patients (41%) developed ischemic rest pain, and three patients (18%) were asymptomatic. During follow-up, three patients (7.7%) required bypass and three patients (7.7%) major amputation, one after failed bypass. All limbs requiring bypass or amputation had TASC C/D lesions. Thirty-day and 1-year mortality was 2.6% and 10.3%, respectively.

CONCLUSIONS

Interventions performed for TASC C/D lesions are more likely to fail and more likely to lead to bypass or amputation. Interventions performed for TASC C/D lesions that fail have a negative impact on limb salvage. This should be considered when performing stenting of advanced SFA lesions.