International Multi-Institutional Experience with Presentation and Management of Aortic Arch Laterality in Aberrant Subclavian Artery and Kommerell's Diverticulum

BACKGROUND

Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch.

METHODS

Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions.

RESULTS

288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change.

CONCLUSIONS

In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality.

Outcome benefit of arterial duplex stent imaging after superficial femoral artery stent implantation

OBJECTIVE

In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion or symptom recurrence. Arterial duplex stent imaging (ADSI) can be used in the surveillance for recurrent stenosis; however, its uniform application is controversial. In this study, we aimed to determine, in patients undergoing SFA stent implantation, whether surveillance with ADSI yielded a better outcome than in those with only ankle-brachial index (ABI) follow-up.

METHODS

We performed a retrospective analysis of all patients undergoing SFA stent implantation for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with ADSI and those with ABI follow-up only. Life-table analysis comparing stent patency, major adverse limb events (MALEs), limb salvage, and mortality between groups was performed.

RESULTS

There were 248 patients with SFA stent implantation included, 160 in the ADSI group and 88 in the ABI group. Groups were homogeneous in clinical indications of claudication and critical limb-threatening ischemia (for ADSI, 39% and 61%; for ABI, 38% and 62%; P = .982) and TransAtlantic Inter-Society Consensus class A, B, C, and D lesions (for ADSI, 17%, 45%, 16%, and 22%; for ABI, 21%, 43%, 16%, and 20%; P = .874). Primary patency was similar between groups at 12, 36, and 56 months (ADSI, 65%, 43%, and 32%; ABI, 69%, 34%, and 34%; P = .770), whereas ADSI patients showed an improved assisted primary patency (84%, 68%, and 54%) vs ABI patients (76%, 38%, and 38%; P = .008) and secondary patency. There was greater freedom from MALEs in the ADSI group (91%, 76%, and 64%) vs the ABI group (79%, 46%, and 46%; P < .001) at 12, 36, and 56 months of follow-up. ADSI patients were more likely to undergo an endovascular procedure as their initial post-SFA stent implantation intervention (P = .001), whereas ABI patients were more likely to undergo an amputation (P < .001).

CONCLUSIONS

In SFA stent implantation, patients with ADSI follow-up demonstrate an advantage in assisted primary patency and secondary patency and are more likely to undergo an endovascular reintervention. These factors are likely to have effected a decrease in MALEs, indicating the benefit of a more universal adoption of post-SFA stent implantation follow-up ADSI.

Compression of endograft limb after translumbar embolization of a type II endoleak using n-butyl cyanoacrylate

Cyanoacrylate “glue” has been used in a variety of surgical disciplines. In vascular surgery, it has been used to seal type II endoleaks after endovascular aneurysm repair. In this case, we report a rare complication after translumbar injection of n-butyl cyanoacrylate to occlude a persistent type II endoleak. The cyanoacrylate resulted in significant compression of the right iliac graft limb with reduced distal perfusion.

Cerebrovascular injuries found in acute type B aortic dissections are associated with blood pressure derangements and poor outcome

OBJECTIVE

Cerebrovascular injury (CVI) is a recognized but underappreciated complication of acute type B aortic dissection (ATBAD). This study was performed to determine risk factors for CVI associated with ATBAD and, in particular, the possible contributory role of aggressive anti-impulse therapy.

METHODS

A retrospective review of all patients presenting to a tertiary medical center with an ATBAD between January 2003 and October 2012 was conducted. All CVIs were adjudicated by a vascular neurologist and assigned a probable cause. The initial intensity of anti-impulse therapy was defined as the difference in mean arterial pressure (ΔMAP) from presentation to subsequent admission to the intensive care unit.

RESULTS

A total of 112 patients were identified. The average age was 61 years; 64% were male, and 59% were African American. Twenty patients required operative intervention (14 thoracic endovascular aortic repairs and 6 open). CVI occurred in 13 patients (11.6%): 9 were hypoperfusion related (6 diffuse hypoxic brain injuries and 3 watershed infarcts), 2 were procedure related (both thoracic endovascular aortic repairs), 1 was an intracranial hemorrhage on presentation, and 1 was a probable embolic stroke on presentation. CVI patients had demographics and comorbidities comparable to those of the non-CVI patients. CVI was associated with operative intervention (54% vs 13%; P = .002). Thirty-day mortality was significantly higher in CVI patients (54% vs 6%; P < .001). Patients who suffered a hypoperfusion brain injury had a higher MAP on presentation to the emergency department (142 mm Hg vs 120 mm Hg; P = .034) and a significantly greater reduction in MAP (ΔMAP 49 mm Hg vs 15 mm Hg; P < .001) by the time they reached the intensive care unit compared with the non-CVI patients.

CONCLUSIONS

In our series, CVI in ATBAD is more frequent than previously reported and is associated with increased mortality. The most common causes are related to cerebral hypoperfusion. Higher MAP on presentation and greater decline in MAP are associated risk factors for hypoperfusion-related CVI. A less aggressive approach to lowering MAP in ATBAD warrants further study in an attempt to reduce CVI in ATBAD.

Survival after repair of pararenal and paravisceral abdominal aortic aneurysms

OBJECTIVE

The objective of this study was to review our 27-year clinical experience with open proximal abdominal aortic aneurysm repairs, with a focus on long-term survival.

METHODS

A retrospective cohort study was undertaken of all patients who underwent proximal abdominal aortic aneurysm repair between 1986 and 2013 at a tertiary care referral center. Demographics, operative variables, complications, and 30-day mortality were analyzed. Postoperative acute kidney injury was analyzed by the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease)/Acute Kidney Injury Network criteria. Long-term survival was assessed through review of electronic medical records and the Social Security Death Index. Associations between demographics and complications were investigated to determine predictors of long-term survival.

RESULTS

The study identified 245 patients. Mean age was 71 years (range, 38-92 years); 69% were men, and 88% were white. Aneurysm type was juxtarenal in 127 patients (52%), suprarenal in 68 patients (28%), and type IV thoracoabdominal in 50 patients (20%). In-hospital mortality was 3.3% (eight patients), and 30-day mortality was 2.9% (seven patients). At least one major complication occurred in 64% of the patients, which included the following: acute kidney injury, 60% (persistent acute kidney injury at discharge, however, was 28%, and hemodialysis at discharge was 1.6%); major pulmonary complications, 22%; myocardial infarction, 4%; visceral ischemia, 2%; and paraplegia, 0.5%. Median follow-up was 54 months. Kaplan-Meier survival estimates were 70% at 5 years and 43% at 10 years. Variables associated with poorer survival included congestive heart failure (hazard ratio [HR], 3.5; P < .001), chronic obstructive pulmonary disease (HR, 1.8; P < .002), and increased aneurysm size at presentation (HR, 1.1; P < .013). Persistent stage 3 acute kidney injury was associated with poor long-term survival.

CONCLUSIONS

Open surgical repair of proximal abdominal aortic aneurysms can be performed with low mortality. Acute kidney injury is the most frequent complication, but the need for hemodialysis at discharge is low. Long-term survival is favorable. These data should assist in establishing benchmarks for endovascular repair of complex proximal abdominal aortic aneurysms.

"I Can't Walk!" Acute Thrombosis of Descending Aorta Causing Paraplegia

A 50-year-old man presented to the emergency department (ED) with acute, bilateral lower extremity weakness and loss of sensation, as well as absent pulses bilaterally. Computed tomography angiography showed complete occlusion of the aorta below the inferior mesenteric artery, extending to the iliac bifurcations. Echocardiographic findings showed severe systolic dysfunction (ejection fraction of 15%) and cryptic cardiogenic shock in spite of stable vital signs. Prior to early operative intervention, an early goal-oriented hemodynamic strategy of shock management resulted in the resolution of motor and sensory deficits.After definitive surgical intervention, the patient was discharged neurologically intact. Acute aortic occlusion is frequently accompanied by myocardial dysfunction, which can be from mild to severe. The most severe form can even occur with normal vital signs or occult cardiogenic shock. Early detection and goal-directed preoperative hemodynamic optimization, along with surgical intervention in the ED, is required to optimize outcomes.

Vein Mapping Prior to Endovenous Catheter Ablation of the Great Saphenous Vein Predicts Risk of Endovenous Heat-Induced Thrombosis

Objective: We investigate the value of vein mapping for predicting the risk of endovenous heat-induced thrombosis (EHIT) after endovenous laser treatment (EVLT) and radiofrequency ablation (RFA) of the great saphenous vein (GSV). Methods: In all, 355 consecutive vein mappings were retrospectively analyzed. A generalized estimating equations approach to linear logistic regression was used to evaluate the variables. Results: Among the 312 vein ablation of the GSV, 10 (3.2%) developed EHIT. When comparing the group of patients who developed EHIT versus no EHIT, the mean GSV diameter was 13.05 ± 5.59 mm versus 8.39 ± 3.38 mm (odds ratio [OR]: 1.25, P = .001), the presence of valvular incompetence at the saphenofemoral junction (SFJ) was 10.71% versus 0.44% (OR: 27.75, P =.001), and 3.09% in RFA versus 3.33% in EVLT (OR: 1.09, P = .89). Conclusions: Patients with valvular insufficiency of the SFJ and a large proximal GSV diameter had a significantly higher risk of developing heat-induced thrombosis after endovenous catheter ablation.

Basilic vein transposition: what is the optimal technique?

OBJECTIVES

To compare the outcome of the one-stage basilic vein transposition (BVT) fistula with a modified, two-stage technique.

DESIGN

Retrospective case-controlled study, performed in an academic centre.

MATERIAL

A total of 173 candidates for BVT fistula (87 males, mean age 61 years).

METHODS

In one-stage BVT, the basilic vein is mobilised through a single incision, placed inside an anterolateral arm tunnel and anastomosed with the brachial artery. In two-stage procedures, the fistula-arterial anastomosis is created first, followed by the second stage, after fistula maturation several weeks later, when the basilic vein is mobilised through two skip incisions, transected near the anastomosis, placed inside an anterolateral arm tunnel and reanastomosed. Morbidity and fistula maturation rate were the main outcome measures.

RESULTS

In one-stage BVT (n=76), the incidence of venous hypertension, wound haematomas and all complications (17%, 13% and 43%, respectively) was significantly higher than in two-stage procedures (n=98) (4%, p=0.004, 3%, p=0.012 and 11%, p<0.001, respectively). Time (68 days) to fistula use was significantly decreased in one-stage BVT than in two-stage procedures (132 days, p<0.001) but failure to mature rate was equivalent (15% vs. 18%, p=0.49).

CONCLUSIONS

Our results indicate that the two-stage BVT fistula through two skip-arm incisions is superior to the established one-stage procedure in terms of less morbidity but at the cost of a second operation and longer time to access use. Further research comparing these two techniques is necessary. Until this issue is resolved, an individualised approach is suggested.

Routine HIV testing in the context of syndromic management of sexually transmitted infections: outcomes of the first phase of a training programme in Botswana

Objective:

In 2004, the Ministry of Health adopted revised protocols for the syndromic management of sexually transmitted infections (STI) that included routine HIV testing. A training programme for providers was developed on the revised protocols that featured interactive case studies and training videos. An objective of the first phase of the training programme was to test its effect on four measures of clinical practice: (1) routine HIV testing; (2) performance of physical examination; (3) risk-reduction counselling and (4) patient education.

Methods:

Clinical practice in a district where providers were trained was compared with a district without training. The measures of clinical practice were reported by 185 patients of providers who had been trained and compared with reports by 124 patients at comparison clinics.

Results:

Relative to patients at comparison clinics, a higher percentage of patients of trainees reported that the provider: (1) offered an HIV test (87% versus 29%; p<0.001); (2) conducted a physical examination (98% versus 64%; p<0.001); (3) helped them to make a plan to avoid future STI acquisition (95% versus 76%; p<0.001) and (4) provided patient-specific information about HIV risk (65% versus 32%; p<0.001). Among patients offered HIV testing, the percentage who accepted did not differ between groups (38% of 161 patients of trainees versus 50% of 36 comparison patients; p = 0.260). Overall, 33% of patients of trainees and 14% of comparison patients were tested (p<0.001).

Conclusion:

A multifaceted training programme was associated with higher rates of HIV testing, physical examination, risk-reduction counselling and better HIV risk education.

Oculomotor control in asymptomatic and recently diagnosed individuals with the genetic marker for Huntington's disease

We compared oculomotor control among individuals in the early stages of Huntington's disease (HD), with that of individuals who are presymptomatic HD gene carriers (PSGC) and nongene carriers (NGC). The oculomotor testing paradigm included both traditional tests and a novel experimental procedure to assess visual scanning. Traditional tests elicited saccades, pursuit and optokinetic nystagmus (OKN). HD patients demonstrated marked delay in the initiation of volitional saccades (anti-saccade and memory-guided saccades), a reduced number of correct volitional saccades, reduced velocity of saccades, and a decreased OKN gain. We also studied visual scanning while the participants completed the Digit Symbol Subscale of the Wechsler Adult Intelligence Survey-Revised (WAIS-R). The HD participants demonstrated an abnormal gaze strategy, which may be associated with attention and/or planning deficits. Differences between the PSGC and NGC groups were only observed for two measures: PSGC had a decreased number of memory-guided saccades and a subtle delay in the initiation of volitional saccades. Our results suggest that oculomotor measures are a sensitive biomarker in the early stage of HD and demonstrate that the combination of more traditional oculomotor tests with visual scanning tests is useful in the evaluation of visual performance.

Increasing influenza and pneumococcal immunization rates: a randomized controlled study of a senior center-based intervention

BACKGROUND

Immunizations decrease morbidity from influenza and pneumococcal infections. Immunization levels remain below desired levels despite clinic-based and public education efforts. This paper describes a randomized, controlled trial of a senior center-based program, which used peer-to-peer outreach to increase pneumococcal and influenza immunization rates among an urban senior population.

METHODS

Seniors were randomized to intervention or control groups. The intervention group received educational brochures mailed with reply cards to report immunization status, telephone calls from senior volunteers to unimmunized participants, and computerized immunization tracking. Immunization rates were obtained before and after the intervention by self-report.

RESULTS

Among participants without prior pneumococcal immunization, the pneumococcal immunization rate among the intervention group (52.0%; 95% CI = 46.6%-57.4%) was significantly higher than that of the control group (30.9%; 95% CI = 26.6%-35.2%) (rate ratio = 1.68; 95% CI = 1.40-2.03). Among those without influenza immunization in the prior year, significantly more (50.0%; 95% CI = 40.0%-60.0%) were immunized against influenza in the intervention group than in the control group (23.0%; 95% CI = 15.2%-33.3%) (rate ratio = 2.17; 95% CI = 1.42-3.31). Among those with influenza immunization in the prior year, the rate ratio was 1.04 (95% CI = 1.01-1.07).

CONCLUSIONS

The intervention increased both influenza and pneumococcal immunization rates to high levels, suggesting that further progress in increasing adult immunization coverage is possible.

Reliability and validity of medical outcome and patient satisfaction measures among injured workers in Washington State: a pretest

Several existing measures of medical outcomes and some newly constructed measures of patient satisfaction were tested for reliability and validity on a sample of 100 subjects who had suffered work-related injuries and illnesses in Washington State. Included in the measures of medical outcome were the SF-36 and the upper body mobility subscale of the Health Assessment Questionnaire. The newly constructed measures of patient satisfaction assessed areas such as satisfaction with the attending physician and with access to referrals. Also administered were assessments of job satisfaction, both prior to and since the injury, and a measure of chance health locus of control. The patient satisfaction and medical outcomes measures demonstrated good reliability and validity for use with this population. However, neither the measures of job satisfaction nor chance health locus of control were related to either patient satisfaction with medical care nor to medical outcomes.

Stability of in vitro fertilization-embryo transfer success rates from the 1989, 1990, and 1991 Clinic-Specific Outcome Assessments

OBJECTIVE

To determine if the differences in IVF-ET success rates among clinics are due to chance alone.

DESIGN

Retrospective analysis of data reported by individual clinics.

SETTING

One hundred seventy-five clinics in 1989, 192 clinics in 1990, and 208 clinics in 1991 that reported IVF-ET success rates to the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine (formerly The American Fertility Society).

PATIENTS

Women < 40 years of age with no male factor.

INTERVENTION

In vitro fertilization-ET.

MAIN OUTCOME MEASURE

Delivery rate per retrieval and delivery rate per transfer.

RESULTS

The hypothesis that the differences among IVF-ET success rates for clinics is due to chance alone can be rejected. Seven clinics were found to have pregnancy rates significantly higher than average and six clinics were found to have pregnancy rates significantly lower than average. Significant correlations were found between different years in the success rates for individual clinics but not for success as a function of the number of patients treated.

CONCLUSIONS

Success rates for a few clinics are significantly different from the average success rate, but success rates must be used with caution in selecting a clinic.

An O2-based enzyme electrode for whole blood lactate measurement under continuous flow conditions

An enzyme electrode-continuous flow system for whole blood lactate measurement has been produced using ultrafiltration membrane-entrapped lactate oxidase retained over an O2 sensor housed in a measuring chamber. Linearity was to 0.8 mmol/l. Oxalate inhibition of the enzyme necessitated the use of lithium heparin-fluoride as anticoagulant for blood samples. A continuous flow system was devised which eliminated differences in sample PO2; analysis of serum and plasma specimens showed good correlation with a routine fluorimetric method (y = 1.097x -0.494, r = 0.959 and y = 0.978x + 0.085, r = 0.952, respectively). The correlation for the enzyme electrode between whole blood and plasma lactate concentrations was y = 0.801x + 0.142, r = 0.986. The flow system should, furthermore, allow reagentless continuous in vivo extracorporeal lactate monitoring.