Anthony Tortolani

Aortic Mural Thrombus in the Normal or Minimally Atherosclerotic Aorta

BACKGROUNDnAortic mural thrombus in a nonaneurysmal minimally atherosclerotic or normal aorta is a rare clinical entity and an uncommon cause of peripheral arterial embolization. Both anticoagulation therapy and aortic surgery are commonly used as primary treatment, but there are no consensuses or clinical guidelines to outline the best management strategy for this unusual problem. This systematic review compares the outcomes of these different strategies for the treatment of aortic mural thrombus.nnnMETHODSnAn extensive search of the literature was conducted, and all relevant publications were reviewed, with individual patient data pooled in this meta-analysis. The outcome variables included were persistence or recurrence of aortic thrombus, recurrence of peripheral embolization, mortality, and a composite end point of complications consisting of stroke, limb loss, and bowel resection. Chi-square test and logistic regression analysis were used to compare groups and to find any predictors of adverse outcome.nnnRESULTSnTwo hundred patients from 98 articles were considered. Of these, 112 patients received anticoagulation and 88 underwent aortic surgery as primary treatment. Smoking was more prevalent in the surgery group, but no other significant differences in demographics, comorbidities, or mode of presentation were seen between groups. The surgery group was more likely to have aortic thrombus located in the arch, but there were no differences in terms of the mobility or size of the thrombus between groups. Aortic thrombus persisted or recurred in 26.4% of the anticoagulation group and in 5.7% of the surgery group (P < 0.001). Recurrence of peripheral arterial embolization was seen in 25.7% of the anticoagulation group and 9.1% of the surgery group (P = 0.003). Mortality rates were similar at 6.2% and 5.7% for the anticoagulation group and the surgery group, respectively (P = 0.879). Complications were noted in 27% of the anticoagulation group and 17% of the surgery group (P = 0.07), and major limb amputation rates were 9% for the anticoagulation group and 2% for the surgery group (P = 0.004). Logistic regression analysis established thrombus location in the ascending aorta (odds ratio [OR]: 12.7; 95% confidence interval [CI]: 2.3-238.8) or arch (OR: 18.3; 95% CI: 2.6-376.7), mild atherosclerosis of the aortic wall (OR: 2.5; 95% CI: 1-6.4), and stroke presentation (OR: 11.8; 95% CI: 3.3-49.5) as important predictors of recurrence.nnnCONCLUSIONSnThe results of our meta-analysis seem to favor the surgical management of aortic mural thrombus in the normal or minimally diseased aorta. Anticoagulation as primary therapy is associated with a higher likelihood of recurrence, a trend toward a higher incidence of complications, and a higher incidence of limb loss. Aortic surgery should be considered as primary treatment, particularly for those patients at high risk for recurrence considered to be good operative candidates.

Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database

INTRODUCTIONnPostoperative pulmonary embolism (PE) is a leading cause of morbidity and mortality after bariatric surgery. However, the concurrent prophylactic placement of an inferior vena cava filter (CPIVCF) in patients undergoing bariatric operations remains controversial. This study used the Bariatric Outcomes Longitudinal Database (BOLD) to establish associated characters and determine outcomes of CPIVCF for patients undergoing Roux-en-Y gastric bypass (GB) and adjustable gastric banding (AB) surgeries.nnnMETHODSnWe analyzed BOLD, a database of bariatric surgery patient information. GB and AB operations were categorized into open and laparoscopic approaches. Univariate logistic regressions were used to compare between non-CPIVCF and concurrent CPIVCF groups. Significant variables (P < .05) were subsequently input into multivariate regression models: CPIVCF was retained in each model.nnnRESULTSnA total of 322 CPIVCFs (0.33%) were identified from 97,218 GB and AB operations performed between 2007 and 2010 in this retrospective registry study. Significant differences were identified in male gender (21.1% vs 31.4%; P < .001), preoperative body mass index (BMI; 44.5 ± 6.6 vs 45.3 ± 7; P < .001), and African-American race (10.5% vs 18%; P < .001) between non-CPIVCF and CPIVCF groups. The CPIVCF group had more patients with previous nonbariatric surgery (50% vs 43.6%; P = .02), a history of venous thromboembolism (VTE; 21.4% vs 3.1%; P < .001), impairment of functional status (7.8% vs 3.1%; P < .001), lower extremity edema (47.2% vs 27.1%; P < .001), obesity hypoventilation syndrome (7.1% vs 2.1%; P < .001), obstructive sleep apnea syndrome (58.1% vs 43.3%; P < .001), and pulmonary hypertension (13% vs 4.1%; P < .001). Patients in the CPIVCF group were more likely to receive GB than gastric banding (77% vs 58.1%; P < .001) and an open surgical approach (21.4% vs 4.8%; P < .001). Operative duration was longer in the CPIVCF group (119 ± 67 vs 89 ± 52 minutes; P < .001). The CPIVCF group also had a longer length of hospital stay (3 ± 2 vs 2 ± 6 days; P = .048), was associated with higher incidence of deep venous thrombosis (DVT; 0.93% vs 0.12%; P < .001), and had a higher mortality (0.31% vs 0.03%; P = .003) from PE and indeterminate causes. In multivariate analysis, male gender, African-American race, previous nonbariatric surgery, a high BMI, obesity hypoventilation syndrome, history of VTE, lower extremity edema, and pulmonary hypertension were preoperative factors associated with CPIVCF.nnnCONCLUSIONSnCPIVCF was associated with specific clinical features, increased health care resource utilization, and a higher mortality in patients undergoing bariatric operations. Although selected patient characteristics influence surgeons to perform CPIVCF, this study was unable to establish an outcome benefit for CPIVCF.

Prevalence of Helicobacter pylori infection in bariatric patients: a histologic assessment

BACKGROUNDnStudies on rates of Helicobacter pylori (HP) infection in morbidly obese patients awaiting bariatric surgery are conflicting because of small sample size and variability in diagnostic testing. The objective of this study was to determine the rate of biopsy-proven active HP infection in morbidly obese patients undergoing bariatric surgery.nnnMETHODSnRetrospective analysis was done on all morbidly obese patients who underwent bariatric surgery between 2001 and 2009. All patients underwent preoperative upper endoscopy with biopsy to evaluate HP status. All endoscopies and surgeries were performed by a single endoscopist and surgeon, respectively. Data were analyzed with Student t test, Pearson χ(2) test, and logistic regression for multivariate analysis.nnnRESULTSnThe 611 patients included 79 males (12.9%) and 532 females (87.1%). Mean age was 39.9 ± 10.7 years, and mean body mass index (BMI) was 47.8 ± 6.4 kg/m(2). The overall HP infection rate was 23.7%. Rate of infection did not differ between gender (22.8% in males, 23.9% in females; P = .479) or BMI (48.6 ± 6.5 kg/m(2) in HP-positive patients, 47.5 ± 6.4 kg/m(2) in HP-negative patients; P = .087). Patients with HP were older compared with those without infection (41.2 versus 38.7 years; P =.016). Hispanics had a higher prevalence of HP (OR 2.35; P = .023).nnnCONCLUSIONnIncreasing BMI is not an independent risk factor for active HP infection within the morbidly obese patient population. Need for invasive testing to detect HP infection in these patients should be re-evaluated. Other methods of detecting active HP infection should be considered as an alternative to invasive or serologic testing.

Acute Arterial Occlusion after Ultrasound-Guided Thrombin Injection of a Common Femoral Artery Pseudoaneurysm with a Wide, Short Neck

Ultrasound-guided thrombin injection (UGTI) has emerged as the preferred treatment modality for pseudoaneurysms occurring as a result of percutaneous femoral arterial interventions. UGTI is safe and effective, with few complications. Native arterial thrombosis has been rarely reported in the literature following UGTI and has usually been attributed to excessive thrombin injection. We report a case of femoral arteria thrombosis occurring following UGTI of a 4 cm postcatherization pseudoaneurysm with a wide, short neck successfully treated by surgical intervention. The large size of the neck of this pseudoaneurysm likely contributed to the development of this complication.

Comparison of conservative and operative treatment for blunt carotid injuries: Analysis of the National Trauma Data Bank

OBJECTIVESnBlunt carotid injury (BCI) is uncommon but potentially devastating. The best treatment modality for this injury remains undetermined. We conducted this study to better understand the hospital course and treatment outcomes for patients with BCI who received different interventions.nnnMETHODSnBCI and related vascular procedures were identified by ICD-9-CM codes from the National Trauma Data Bank(1) using data gathered from 2002 to 2006. Conservative and operative treatment groups were compared by variables of patient demographics, initial assessment in the emergency department (ED), hospital course, and treatment outcomes. Open surgical and endovascular interventions were further compared.nnnRESULTSnA total of 842 BCI were identified from 1,633,126 discharged blunt trauma patients (0.05%). Of these, 762 (90.5%) were treated conservatively and 80 (9.5%) received operative intervention. No differences in demographics were observed between these treatment groups. On initial assessment, no differences between conservative and operative treatment groups were noted with regard to vital signs, Glasgow coma scale, presence of drugs or alcohol in blood, or Trauma Related Injury Severity Score survival probability. Significant differences were seen in terms of the presence of a base deficit (-3.1 +/- 6.8 vs -7.6 +/- 8.3; P = .01), likelihood of a positive head computed tomography (CT) scan (58.6% vs 26.1%; P = .003), and total Injury Severity Score (29.8 +/- 13.3 vs 26.1 +/- 14.1; P = .02). Hospital course and treatment outcomes were comparable, with no differences in hospital length of stay (13.4 +/- 15.3 days vs 13.7 +/- 13.6 days; P = .86), total Functional Independence Measure (8.8 +/- 3.3 vs 9.3 +/- 3.1; P = .38), progression of original neurologic insult (7.5% vs 4.6%; P = .61) or mortality (28.1% vs 19%; P = .08). When comparing open surgical to endovascular interventions (46 open, 34 endovascular, including 3 combined), the only significant differences were in the total Injury Severity Score (22.4 +/- 12.2 vs 31.4 +/- 15.4; P = .01) and length of intensive care unit (ICU) and hospital stay (5.0 +/- 6.0 days vs 10.7 +/- 10.4 days; P = .01, and 10.3 +/- 9.2 days vs 19.3 +/- 17.7 days; P = .01). Multivariate regression analysis confirmed that neither Functional Independence Measure (FIM) nor mortality was associated with conservative or operative treatment.nnnCONCLUSIONnBCI is rare and carries a poor prognosis. Operative intervention is not associated with functional improvement or a survival advantage. This study was unable to support that less invasive endovascular treatment improves treatment outcome when compared to open surgery.

Blood transfusion and its effect on the clinical outcomes of patients undergoing major lower extremity amputation.

BACKGROUNDnPatients in need of lower extremity amputation are often debilitated and have coronary artery disease and underlying anemia. The transfusion of blood is a common practice in the perioperative management of these patients. However, blood transfusion has been reported to have a negative effect on the incidence of perioperative complications in other patient populations. We undertook this study to determine the effect of blood transfusion on the incidence of adverse postoperative events in patients undergoing major amputations.nnnMETHODSnWe conducted a retrospective review of 300 consecutive patients undergoing either above-knee or below-knee amputation over a 5-year period at our institution. The demographic variables, medical comorbidities, need for blood transfusion, and clinical outcomes were recorded. The impact of blood transfusion on clinical outcome was analyzed.nnnRESULTSnOf the 300 patients undergoing major amputation, 191 (64%) had one or more blood transfusions. The demographic variables and incidence of medical comorbidities were comparable between the two groups. Patients undergoing blood transfusion were 2.5 more likely to suffer from a postoperative cardiac arrhythmia, 12.8 times more likely to develop acute renal failure, 5.7 times more likely to have pneumonia, and 2.2 times more likely to have a urinary tract infection. Each of these adverse postoperative events was statistically more likely in the transfused group. The postoperative mortality was 13% for the transfused group and 6% for those not transfused, which was a nonsignificant difference. The intensive care unit stay and overall hospital stay were significantly longer in patients who had blood transfusions (difference of 2.1 and 5.4 days, respectively).nnnCONCLUSIONnBlood transfusion in patients undergoing major lower extremity amputation is associated with an increased incidence of adverse postoperative events and prolonged intensive care unit and hospital stays. We therefore suggest a restricted approach to blood transfusion in patients requiring major amputation.

Do pulmonary function tests improve risk stratification before cardiothoracic surgery

OBJECTIVEnTo assess the added value of pulmonary function tests (PFTs) and different classifications of chronic obstructive pulmonary disease (COPD) to the Society of Thoracic Surgeons (STS) risk model using a clinical definition of lung disease for predicting outcomes after cardiothoracic (CT) surgery.nnnMETHODSnWe evaluated consecutive patients who underwent nonemergency cardiac surgery and underwent PFTs before CT surgery. We used the STS risk model 2.73 to estimate the postoperative risk for respiratory failure (RF; defined as the need for mechanical ventilation for ≥72 hours, or reintubation), prolonged postoperative stay (PPLS; defined as >14 days), and 30-day all-cause mortality. We plotted the receiver operating characteristics curve for STS score for each adverse event, and compared the resulting area under the curve (AUC) with the AUC after adding PFT parameters and COPD classifications.nnnRESULTSnOf the 1412 patients with a calculated STS score, 751 underwent PFTs. The AUC of the STS score was 0.65 (95% confidence interval [CI], 0.55-0.74) for RF, 0.67 (95% CI, 0.6-0.74) for prolonged postoperative length of stay (PPLS), and 0.74 (95% CI, 0.6-0.87) for death. None of the PFT parameters or COPD classifications added to the predictive ability of STS for RF, PPLS, or 30-day mortality.nnnCONCLUSIONSnAdding individual PFT parameters or different COPD classifications to STS score calculated using clinically based classification of lung disease did not improve model discrimination. Thus, routine preoperative PFTS may have limited clinical utility in patients undergoing CT surgery when the STS score is readily available.

Serial Cardiac Magnetic Resonance Imaging of a Rapidly Progressing Liquefaction Necrosis of Mitral Annulus Calcification Associated With Embolic Stroke

Mitral annulus calcification (MAC) is a common finding in the elderly. A rare manifestation of MAC is liquefaction necrosis that can be mistaken for a tumor or an abscess. Because its course is most often benign, a correct diagnosis is imperative to avoid unnecessary workup or treatment.nnA 76-year-old woman with history of hypertension and dyslipidemia presented with chest pain and elevated cardiac enzymes. A coronary angiogram revealed no significant coronary artery disease.nnEchocardiogram (Figure 1) revealed a large, solid mass within the atrioventricular groove and the lateral wall of the left ventricle. There was moderate calcification of the mitral valve annulus. Computed tomography scan of the chest (Figure 2) revealed a soft tissue density inseparable from the region of the mitral valve and the left ventricular wall. Cardiac magnetic resonance (CMR) showed a large mass involving the basal lateral wall near the atrioventricular groove, extending into the left atrium (Figure 3A and 3B). The mass was slightly hyperintense on T1 (Figure 4) and hypointense on T2 imaging (Figure 5). The mass was homogenous on delayed enhancement with a bright ring (Figure 6), the characteristics were not changed with fat saturation, and it was avascular by perfusion (Figure 7). The patient was discharged from the hospital with a scheduled outpatient workup to continue.nnnnFigure 1. nEchocardiography images before and after biopsy. A , 4-chamber view performed on presentation, reveals a soft tissue mass involving the atrio-ventricular groove, the left atrium, and left ventricle. There is moderate calcification of the mitral valve. B , 4-chamber view performed after biopsy. The mass has decreased in size and appears cystic. White arrows indicate the mass.nnnnnnFigure 2. nComputed tomography image performed on first admission. This is a 5-chamber …

Endovascular treatment of a thrombosed intracardiac vena cava filter

Intracardiac migration of a vena cava filter (VCF) is a rare but potentially fatal complication. We describe a unique case of intracardiac migration of a permanent VCF with extensive thrombus propagating into the inferior vena cava and right atrium. Percutaneous thrombectomy with the AngioVac (AngioDynamics, Latham, NY) device was performed, and the permanent VCF was percutaneously removed.

Intraabdominal partitioning of the laparoscopic sleeve gastrectomy remnant optimizes the specimen extraction ergonomics and postoperative pain and is an attractive technique in teenage patients.

INTRODUCTIONnLaparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure in the pediatric population worldwide. The fear of complications, postoperative pain, and recovery remain the reservations for wider application of surgery in morbidly obese children. We present a novel technique for LSG remnant retrieval.nnnMATERIALS AND METHODSnThe patient was a 16-year old girl with a body mass index of 55 kg/m(2) and significant comorbidities who underwent LSG and liver biopsy. In the extraction technique, a specimen containing the gastric body and fundus, approximately 80% of the stomach volume, was partitioned longitudinally and intracorporeally with endoshears; subsequently, it was retrieved in one fragment via the lumen of a 15-mm port.nnnRESULTSnThe procedure time was 65 minutes (specimen extraction time was 7 minutes). Her recovery was uneventful, and she was discharged home on the second postoperative day. At the 1-, 3-, and 6-month follow-up, she has shown all the benefits of weight loss and associated improvement in metabolic parameters and quality of life, without any complications.nnnCONCLUSIONSnThis technique for gastric remnant retrieval results in minimizing postoperative pain, reducing operative costs, and minimizing the likelihood of wound infection.