Cassius Iyad Ochoa Chaar

Intussusception of the appendix: comprehensive review of the literature

BACKGROUND Intussusception of the appendix is a rare disease that constitutes a diagnostic challenge to the surgeon. The literature on this condition is limited to case reports. The demographics, presentation, and treatment remain debatable in the absence of a comprehensive review of the literature. DATA SOURCES This article reports a case of a 40-year-old woman who presented with intussusception of the appendix caused by endometriosis. A comprehensive review of the English literature in PubMed was performed. The trends in incidence, sex predilection, presentation, and treatment of appendiceal intussusception were derived based on the reports of 191 patients. COMMENTS The incidence was more common in adults (76%) than in children (24%). Female patients (72%) were 2 times more affected in adults than in children, whereas male patients (58%) seem to be more affected in the pediatric population. Intussusception of the appendix has most commonly a chronic presentation (63%). Endometriosis (33%) and inflammation (76%) were the most common pathologic findings in adults and children, respectively. Only 49% of patients were treated by simple appendectomy; 49% patients underwent partial colectomy; and 2% of patients had their appendixes endoscopically removed.

Delayed open conversions after endovascular abdominal aortic aneurysm repair

OBJECTIVE Secondary interventions after endovascular aneurysm repair (EVAR) remain a concern. Most are simple catheter-based procedures, but in some instances, open conversions (OCs) are required and carry a worse outcome. We reviewed our experience to characterize these OCs. METHODS A retrospective review was conducted of all patients who underwent an OC after a previous EVAR for an aneurysm-related indication from 2001 to 2010. Clinical outcomes are reported. RESULTS Data were reviewed for 44 patients (77% men) with a mean age of 74 years (range, 55-90 years). The average time from EVAR to the first OC was 45 months (range, 2-190 months). In six patients (14%), the initial EVAR was at another institution. The endografts used were Ancure in 16, Excluder in 13, AneuRx in eight, Zenith in three, Lifepath in one, Renu in one, and undetermined in two. Twenty-two patients had previously undergone a total of 32 endovascular reinterventions before their index OC. Indications for OC were aneurysm expansion in 28 (64%), rupture in 12 (27%), and infection in four (9%). The endograft was preserved in situ in 10 patients (23%). Explantation was partial in 18 (41%) or complete in 16 (36%). Endograft preservation was used for type II endoleak in all but one patient by selective ligation of the culprit arteries (lumbar in four, inferior mesenteric artery in five, and middle sacral in one). Proximal neck banding was performed in one type Ia endoleak. Overall morbidity was 55%, and mortality was 18%. No deaths occurred in a subgroup of patients who underwent endograft preservation with selective ligation of culprit vessels for type II endoleak. Intraoperative complications included bowel injury in two, bleeding in two, splenectomy in one, and ureteral injury in one. At a mean follow-up of 20 months, two patients underwent additional procedures after the index OC: one after endograft preservation and one after partial explantation. None of the patients who underwent elective OC with endograft preservation required subsequent endograft explantation. CONCLUSIONS Most OCs after EVAR are associated with significant morbidity and mortality, except when electively treating an isolated type II endoleak with ligation of branches and preservation of the endograft.

Expanding the role of endovenous laser therapy: results in large diameter saphenous, small saphenous, and anterior accessory veins.

BACKGROUND Endovenous laser therapy (EVLT) is an accepted form of axial vein ablation for symptomatic venous reflux but there is debate regarding its efficacy and complication rates in large veins (≥1 cm). In addition, its role in the treatment of small saphenous veins (SSVs) and anterior accessory veins (AAVs) has not been well characterized either. METHODS A retrospective review of patients undergoing EVLT on the great saphenous vein (GSV), SSV, or AAV between August 2007 and May 2009 was conducted. A total of 885 limbs were reviewed. In all, 153 patients were excluded because of incomplete information. Gender, age, vein size, operative details, ultrasound, and clinical follow-up results were recorded. Veins that measured <1 cm in diameter were considered small, whereas those that measured ≥1 cm at any point were considered to be large. RESULTS A total of 732 ablations were reviewed, involving 175 men and 557 women (76.1%). Average follow-up with duplex ultrasound was 3 weeks, and all patients underwent at least one postprocedural ultrasound. In all, 565 (77.3%) GSVs, 113 (15.5%) SSVs, and 53 (7.3%) AAVs were treated. A total of 88 ablations were performed on veins measuring ≥ 1 cm, 12% of all treated veins. In all, 82 GSVs, three SSVs, and three AAVs measured >1 cm, and GSVs comprised 93.2% of treated large veins (p ≤ 0.001 vs. entire cohort). For active ulceration, 4.9% of small vein and 9.1% of large vein treatments were performed (p = 0.11). An average of 2,983 J (range: 250-7,922) was used for each ablation, with veins measuring ≥ 1 cm being treated with significantly more energy (3,733 vs. 2,876 J, p < 0.001). Complications occurred in 7.61% of small vein ablations and 7.95% of large vein ablations (p = 0.91). This included failure in 3.4% of small vein and 4.5% of large vein ablations (p = 0.59). In addition, two deep vein thromboses (0.4%) occurred, both in GSVs. The most common complication was failure of closure, occurring in 1.6% of GSVs, 8.8% SSVs, and 13.2% AAVs (p < 0.001). Overall, the GSV was more likely to have successful closure (p ≤ 0.001) and fewer complications (p = 0.005) than SSV or AAV. CONCLUSIONS Complication rates and closure rates are not significantly different for veins of diameter ≥ 1 cm and smaller veins. Although more energy is used, this has not translated into higher complication rates, thus making EVLT safe and effective for large vein closure. Significantly higher failure and complication rates were seen in SSV and AAV treatment as compared with GSV treatment.

Consequences of hypogastric artery ligation, embolization, or coverage.

OBJECTIVE Interruption of the hypogastric artery by ligation, embolization, or coverage frequently results in ischemic complications. The aim of this study was to compare the rate and risk factors for the development of ischemic complications after interruption of the hypogastric artery in obstetrics and gynecology (OBG), vascular surgery, oncology, and trauma patients. METHODS MEDLINE, Ovid, and Scopus were searched for articles containing data of patients who underwent interruption of the hypogastric artery. Based on the indication, details of the procedure, and complications developed, data were categorized and a systematic review was done to evaluate any significant differences. RESULTS A total of 394 patients (median age, 48.5 years) from 124 papers were included in the study; 31% of the study population was male and 69% was female. Indication for interruption was OBG related in 53.3%, vascular surgery related in 25.1%, oncology related in 17.5%, and trauma related in 4.1% of patients. Overall ischemic complication rate was 22.6%, comprising buttock claudication in 12.2%, buttock necrosis in 4.8%, erectile dysfunction in 2.7%, spinal cord ischemia in 4.0%, colonic ischemia in 2.5%, and bladder necrosis in 0.8%. Complications were fewer in patients younger than the median age of 48.5 years (12.8%) compared with those older than the median age (36.3%; P < .01), women compared with men (13.1% vs 41.7%; P < .01), OBG patients compared with vascular surgery patients (9.5% vs 37.4%; P < .01), patients after ligation compared with embolization (9.4% vs 31.0%; P < .01), and proximal interruption compared with distal interruption (19.6% vs 51.4%; P < .01). No significant difference in complications was seen after bilateral interruption compared with unilateral interruption (20.6% vs 27.1%; P > .05). Similarly, no significant difference in complication rate was seen with the type of embolization material used. Among OBG patients, ligations resulted in fewer complications compared with embolization (4.1% vs 16.7%; P < .01). Among vascular surgery patients, bilateral embolization resulted in a higher rate of complications compared with bilateral ligation (83.3% vs 30.5%; P < .01). Among oncology patients, fewer complications were seen after proximal interruption compared with distal interruption (25.5% vs 75%; P = .01). No significant differences in outcome were seen with regard to gender, laterality, and material used for embolization when patients were compared within each specialty. CONCLUSIONS Interruption of the hypogastric artery is relatively safe in young and OBG patients compared with vascular surgery and oncology patients. Ligation of the hypogastric arteries is preferred to embolization, and proximal embolization should be preferred to distal embolization to decrease the risk of ischemic complications. Randomized controlled trials with larger sample size are needed to definitively elucidate clear risk factors for development of complications after hypogastric artery interruption.

Endovascular aneurysm repair is associated with less malnutrition than open abdominal aortic aneurysm repair

BACKGROUND Patients undergoing abdominal aortic aneurysm (AAA) repair have high rates of postoperative malnutrition. We examined whether endovascular aneurysm repair (EVAR) is associated with reduced postoperative malnutrition compared with open AAA repair. METHODS The records of patients undergoing AAA repair in the Veterans Affairs (VA) Connecticut Healthcare System were reviewed. Primary outcomes were 30-day morbidity, lengths of hospitalization and intensive care unit stay, duration of intubation, and nutritional risk index scores. RESULTS Sixty-two patients were included (open repair, 37; EVAR, 25). Nutritional parameters were comparable between groups before surgery. Patients treated with EVAR had improved postoperative nutritional profiles as determined by albumin level (3.7 +/- .08 vs 3.2 +/- .12; P = .003), and nutritional risk index (97.9 +/- 1.3 vs 88.9 +/- 1.8; P = .0006), compared with patients treated with open repair. CONCLUSIONS Patients undergoing EVAR developed significantly less postoperative malnutrition compared with those having open repair. EVAR may be a strategy to avoid malnutrition and improve outcomes in patients at risk for malnutrition after undergoing AAA repair.

Impact of endovascular options on lower extremity revascularization in young patients

OBJECTIVE This study assessed outcomes of revascularization strategies in young patients with premature arterial disease. METHODS Lower extremity revascularization outcomes from 2000 to 2008 were retrospectively compared among consecutive patients with comparable indications and procedures: age <50 years (group A) at the time of revascularization, 51 to 60 years (group B), and >60 years (control group C). Patency, limb salvage, and survival by limb or patient level were assessed by Kaplan-Meier and Cox proportional hazards analyses. RESULTS A total of 409 limbs in 298 patients were treated: 44% for claudication and 56% for critical limb ischemia (CLI). Group A patients were more likely to be smokers and have a hypercoagulable state but less likely to have diabetes and renal failure. Treatment indications were comparable among groups, and procedures were equally distributed between open surgical and endovascular interventions. Two perioperative deaths occurred in group C (2%). Mean follow-up was 29 months, and 16% of claudicant patients in group A progressed to CLI (B, 3%; C, 2%; P < .001). Overall, 2-year primary, primary assisted, and secondary patency were significantly lower in group A (50.5%, 65.2%, 68.2%; P = .045) vs B (65.7%, 81.4%, 86.8%; P = .01) and C (57.9%, 78.9%, 83.9%; P < .001). Claudicant patients in group A had an unexpectedly low 2-year freedom from major amputation after intervention of only 90%. Results were more comparable across groups for CLI. The 2-year freedom from reintervention was similar (A, 81.0%; B, 78.9%; C, 83.5%), irrespective of the indication for intervention (P = .60). Younger patients had a significantly higher 3-year survival (A, 89.5%; B, 85.3%) compared with patients aged >60 years (C, 71.4%; P = .005). The 2-year freedom from major amputation rate was significantly lower in claudicant patients in group A vs C undergoing endovascular revascularization (P = .002), but not in patients treated with open revascularization (P = .40). Predictors of loss of primary patency included age <50 years (P = .003), endovascular revascularization (P = .005), and progression from claudication to CLI (P < .001). Age <50 years was also an independent predictor of limb loss vs age >60 years (P = .05). CONCLUSIONS Endovascular options are commonly being used in young patients, especially those with claudication, but patency rates and outcomes remain very poor.

Distal embolization during lower extremity endovascular interventions

Objective: Distal embolization (DE) during peripheral arterial endovascular interventions is a well‐known complication that is poorly studied. The goal of this study was to determine the incidence, risk factors, and effect of DE on the outcomes of lower extremity endovascular interventions (LEIs). Methods: All LEIs between 2010 and 2014 in the Vascular Study Group of New England (VSGNE) database were reviewed. Patient characteristics were analyzed to determine predictors of DE. LEIs involving the superficial femoral artery (SFA) were reviewed to assess the effect of type of treatment on DE. The outcomes examined were loss of patency, limb loss, and mortality after LEI involving the SFA. A multivariable regression was used to determine predictors of DE. Results: There were 10,875 procedures. The incidence of DE was 17.3 per 1000 procedures, and 68% required treatment (57% endovascular, 11% open surgery). DE was more common in patients treated for critical limb ischemia compared with claudication (relative risk [RR], 2.06; 95% confidence interval [CI], 1.24‐3.45; P = .006) and for emergency interventions compared with elective (RR, 2.98; 95% CI, 1.22‐7.30; P = .017). DE increased with the number of arteries treated (P < .0001) and with the length of occlusion (P < .0001). The SFA was the most commonly treated artery (4751 [43.7%]). In comparison with atherectomy and balloon angioplasty, stenting alone (RR, 0.36; 95% CI, 0.17‐0.73; P = .005), balloon angioplasty alone (RR, 0.23; 95% CI, 0.13‐0.41; P < .0001), and combined stenting and balloon angioplasty (RR, 0.29; 95% CI, 0.17‐0.49; P < .0001) were associated with a significantly lower risk of DE. DE was not significantly associated with loss of patency, major amputation, or mortality. Conclusions: The incidence of DE during LEIs is 1% to 2% in the VSGNE database, and most patients are treated with additional endovascular interventions. The incidence increases in patients with critical limb ischemia and with the use of atherectomy.

Percutaneous endovascular aneurysm repair in morbidly obese patients

Objective: Endovascular aneurysm repair (EVAR) with percutaneous femoral access (PEVAR) has several potential advantages. Morbidly obese (MO) patients present unique anatomical challenges and have not been specifically studied. This study examines the trends in the use of PEVAR and its surgical outcomes compared with open femoral cutdown (CEVAR) in MO patients. Methods: The American College of Surgeons National Surgical Quality Improvement Program files for the years 2005 to 2013 were reviewed. The study included all MO patients (body mass index [BMI] ≥40 kg/m2) undergoing EVAR. Patients were categorized as having CEVAR if they had any one of 11 selected Current Procedural Terminology (American Medical Association, Chicago, Ill) codes describing an open femoral procedure. The PEVAR group included any remaining patients who had only codes for EVAR and endovascular procedures. Linear correlation was used to evaluate temporal trends in the use of PEVAR among MO patients. Baseline comorbidities and surgical outcomes were compared between the PEVAR and CEVAR groups using χ2 tests or t‐tests. Results: There were 833 MO patients (470 CEVAR and 363 PEVAR) constituting 3.0% of all patients undergoing EVAR. The use of PEVAR in MO patients significantly increased from 27.3% of total EVARs in the years 2005 to 2006 to 48.6% in 2013 (P = .039). The two groups had similar baseline characteristics, including age, BMI, comorbidities, and emergency procedures, except for history of severe chronic obstructive pulmonary disease (29.6% CEVAR vs 22.6% PEVAR; P = .024). PEVAR patients had shorter duration of anesthesia (244 vs 260 minutes; P = .048) and shorter total operation time (158 vs 174 minutes; P = .002). PEVAR patients had significantly decreased wound complications (5.5% vs 9.4%; P = .039). There was a trend towards PEVAR patients being more likely to be discharged home than to a facility (93.6% vs 87.8%; P = .060). There was no difference in any other complication or mortality. A subgroup analysis of 109 superobese patients with BMI ≥50 kg/mg2 (59 CEVAR and 50 PEVAR) demonstrated no significant differences in outcomes between groups. Conclusions: PEVAR is increasingly used in MO patients and decreases operating time and rates of wound infection compared with CEVAR. The advantages of PEVAR seem to be lost in the superobese patients.

Whole-exome sequencing in evaluation of patients with venous thromboembolism

Genetics play a significant role in venous thromboembolism (VTE), yet current clinical laboratory-based testing identifies a known heritable thrombophilia (factor V Leiden, prothrombin gene mutation G20210A, or a deficiency of protein C, protein S, or antithrombin) in only a minority of VTE patients. We hypothesized that a substantial number of VTE patients could have lesser-known thrombophilia mutations. To test this hypothesis, we performed whole-exome sequencing (WES) in 64 patients with VTE, focusing our analysis on a novel 55-gene extended thrombophilia panel that we compiled. Our extended thrombophilia panel identified a probable disease-causing genetic variant or variant of unknown significance in 39 of 64 study patients (60.9%), compared with 6 of 237 control patients without VTE (2.5%) (P < .0001). Clinical laboratory-based thrombophilia testing identified a heritable thrombophilia in only 14 of 54 study patients (25.9%). The majority of WES variants were either associated with thrombosis based on prior reports in the literature or predicted to affect protein structure based on protein modeling performed as part of this study. Variants were found in major thrombophilia genes, various SERPIN genes, and highly conserved areas of other genes with established or potential roles in coagulation or fibrinolysis. Ten patients (15.6%) had >1 variant. Sanger sequencing performed in family members of 4 study patients with and without VTE showed generally concordant results with thrombotic history. WES and extended thrombophilia testing are promising tools for improving our understanding of VTE pathogenesis and identifying inherited thrombophilias.

The Hidden Lesion

A 24-year-old woman presented to the ED with pain in the left leg. She had been training for a 5-km race when, 2 days before presentation, she had crampy pain in her left leg, extending to the left lower abdomen and buttock, plus leg swelling and exertional dyspnea.