Treatment options and outcomes for caval thrombectomy and resection for renal cell carcinoma

OBJECTIVE

Advanced renal cell carcinoma (RCC) has a significant predisposition to vascular invasion. Tumor vascular invasion and thrombus are found in the renal vein and the inferior vena cava (IVC) in up to 10% to 25% of patients. This study reviewed the current status of radical nephrectomy with IVC thrombectomy for advanced RCC.

METHODS

A two-level search strategy of the literature (MEDLINE, PubMed, The Cochrane Library, and Google Scholar) for relevant articles listed between January 2000 and December 2015 was performed. The review was confined to patients with primary RCC associated with vascular invasion.

RESULTS

Untreated RCC with intravascular thrombus has a median survival of 5 months. Surgical exposure and intervention are tailored to the level of tumor thrombus. The 30-day mortality for radical nephrectomy with IVC thrombectomy is low (1.5%-10%), and the complication rates have been reported to be 18%, 20%, 26%, and 47% for IVC tumor thrombus level I, II, III, and IV disease, respectively. Disease-specific survival ranges from 40% to 60% at 5 years after nephrectomy and removal of the intravascular tumor.

CONCLUSIONS

Radical nephrectomy with IVC thrombectomy is an effective cancer control operation that can be safely performed with acceptable mortality and morbidity. Preoperative imaging coupled with perioperative surgical management of the IVC is critical to procedural success and patient outcomes.

Outcomes of reintervention for recurrent symptomatic disease after tibial endovascular intervention

OBJECTIVE

Tibial interventions for critical limb ischemia are now commonplace. Restenosis and occlusion remain barriers to durability after intervention. The aim of this study was to examine the patient-centered outcomes of open and endovascular reintervention for symptomatic recurrent disease after a primary isolated tibial endovascular intervention.

METHODS

A database of patients undergoing isolated primary lower extremity tibial endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with recurrent critical ischemia (Rutherford 4 and 5) were identified. Outcomes in this cohort were analyzed, and three groups were defined: endovascular reintervention (ie, a repeated tibial or pedal endovascular intervention), bypass (bypass to a tibial or pedal vessel), and primary amputation (ie, above- or below-knee amputation) on the ipsilateral leg. Patient-oriented outcomes of clinical efficacy (absence of recurrent signs or symptoms of critical ischemia, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (above-ankle amputation of the index limb or major reintervention, such as new bypass graft or jump or interposition graft revision) were evaluated after the reintervention.

RESULTS

There were 1134 patients (56% male; average age, 59 years) who underwent primary tibial intervention for critical ischemia, and 54% presented with symptomatic restenosis and occlusion. Of the 513 patients with recurrent disease, 58% presented with rest pain and the remainder with ulceration. A repeated tibial endovascular intervention was performed in 64%, open bypass in 19%, and below-knee amputation in 17%. Bypass was employed in patients with a good target vessel, venous conduit, and good pedal runoff. Patient-centered outcomes were better in the bypass group compared with the reintervention group (amputation-free survival, 45% ± 9% vs 27% ± 9% [P < .01]; major adverse limb events, 50% ± 9% vs 31% ± 9% [P < .05]; clinical efficacy, 60% ± 7% vs 30% ± 9% [P < .01], mean ± standard error of the mean at 5 years).

CONCLUSIONS

Tibial interventions for critical ischemia are associated with a high rate of reintervention. In patients with good target vessel, venous conduit, and good pedal runoff, bypass appears more durable than repeated tibial endovascular intervention.

Outcomes of tibial endovascular intervention in patients with poor pedal runoff

OBJECTIVE

Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine the impact of pedal runoff on patient-centered outcomes after tibial endovascular intervention.

METHODS

A database of patients undergoing lower extremity endovascular interventions at a single urban academic medical center between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford 5 and 6) were identified. Preintervention angiograms were reviewed in all cases to assess pedal runoff. Each dorsalis pedis, lateral plantar, and medial plantar artery was assigned a score according to the reporting standards of the Society for Vascular Surgery (0, no stenosis >20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, half or less of the vessel length occluded; 3, more than half the vessel length occluded). A foot score (dorsalis pedis + medial plantar + lateral plantar + 1) was calculated for each foot (1-10). Two runoff score groups were identified: good vs poor, <7 and ≥7, respectively. Patient-oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (above-ankle amputation of the index limb or major reintervention [new bypass graft, jump/interposition graft revision]) were evaluated.

RESULTS

There were 1134 patients (56% male; average age, 59 years) who underwent tibial intervention for critical ischemia, with a mean of two vessels treated per patient and a mean pedal runoff score of 6 (47% had a runoff score ≥7). Overall major adverse cardiac events were equivalent at 30 days after the procedure in both groups. At 5 years, vessels with compromised runoff (score ≥7) had significantly lower ulcer healing (25% ± 3% vs 73% ± 4%, mean ± standard error of the mean [SEM]) and a lower 5-year limb salvage rate (45% ± 6% vs 69% ± 4%, mean ± SEM) compared with those with good runoff (score <7). Patients with poor pedal runoff (score ≥7) had significantly lower clinical efficacy (23% ± 8% vs 38% ± 4%, mean ± SEM), amputation-free survival (32% ± 6% vs 48% ± 5%, mean ± SEM), and freedom from major adverse limb events (23% ± 9% vs 41% ± 8%, mean ± SEM) at 5 years compared with patients with good runoff (score <7).

CONCLUSIONS

Pedal runoff score can identify those patients who will not achieve ulcer healing and patient-centered outcomes after tibial intervention. Defining such subgroups will allow stratification of the patients and appropriate application of interventions.

Rare Presentation of a Syphilitic Aneurysm of the Infrarenal Aorta with Contained Rupture

We report, to our knowledge, the first case of a rare syphilitic infrarenal aortouniiliac aneurysm with contained rupture that presented with midepigastric abdominal pain. Review of the patient's medical history revealed untreated syphilis and poorly treated congestive heart failure. Given his comorbidities, the patient was treated with an emergent endovascular aneurysm repair. His 30-day postoperative recovery period was uneventful, and follow-up imaging revealed complete resolution of the aneurysms. Syphilitic infrarenal aortic aneurysm is currently considered a rare entity in this era of antibiotics. The present article provides a brief case report and short review of literature pertaining to syphilitic aortic aneurysms.

Outcomes of Isolated Tibial Endovascular Intervention for Rest Pain in Patients on Dialysis

BACKGROUND

Tibial interventions for critical limb ischemia are frequent in patients with end-stage renal disease (ESRD) presenting with critical ischemia. The aim of this study was to examine impact of ESRD on the patient-centered outcomes following tibial endovascular Intervention for rest pain.

METHODS

A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with rest pain (Rutherford 4) were identified. Patients with claudication (Rutherford 1 to 3) and tissue loss (Rutherford 5 and 6) were excluded. Patients were categorized by the presence or absence of ESRD. Patient-orientated outcomes of clinical efficacy (CE; absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (AFS; survival without major amputation), and freedom from major adverse limb events (MALEs; above ankle amputation of the index limb or major reintervention new bypass graft, jump/interposition graft revision) were evaluated.

RESULTS

A total of 829 patients (56% male, average age 59 years; 658 nonhemodialysis [non-HD] and 171 HD) underwent isolated tibial intervention in one leg for rest pain. Technical success was 99% with a median of 2 vessels treated per patient. There was no difference in the distribution of Trans-Atlantic Inter-Society Consensus I lesions, but both the modified Society for Vascular Surgery (SVS) runoff score and the pedal runoff score were worse in the HD group. The 30-day major adverse cardiac events and 30-day MALEs were equivalent in both groups. CE was 38 ± 9% and 19 ± 8% at 5 years for the non-HD and HD groups, respectively (P < 0.01). Overall, AFS was 45 ± 8% and 18 ± 9% at 5 years for the non-HD and HD groups, respectively (P < 0.01). Freedom from MALE was 41 ± 9% and 21 ± 8% at 5 years for the non-HD and HD groups, respectively (P < 0.01).

CONCLUSIONS

Patients with ESRD who present with rest pain have equivalent short-term outcomes to those not on dialysis but do not achieve long-term satisfactory CE and AFS after isolated tibial intervention for rest pain.