Charles A. Andersen

Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysms: Disparities in outcomes from a nationwide perspective

BACKGROUND Endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) has become widely accepted in the elective setting but remains controversial for emergency repair of ruptured aneurysms (rAAA). We sought to examine the national trends in use and associated outcomes with EVAR. METHODS The Nationwide Inpatient Sample (NIS) was used to analyze all admissions for rAAA from 2001 through 2004. Nationwide temporal trends and demographics using weighted samples were evaluated. Focused univariate and multivariate analyses comparing outcomes from open repair and EVAR were done for the years 2003 and 2004. RESULTS There were 28,123 admissions for rAAA, with a stepwise decline in admissions from 2001 to 2004. Use of EVAR increased significantly from 6% of all emergency repairs in 2001 to 11% in 2004 (P < .01). Mortality for EVAR declined significantly from 43% to 29% (P < .01), but mortality with open repair showed no change (40% to 43%). From the 2003 to 2004 data set, 949 EVAR and 8982 open repairs were identified. Compared with open repair, the EVAR patients had lower mortality (31% vs 42%), shorter hospital stay (6 vs 9 days), and were more likely to be discharged to home (59% vs 37%, all P < .01). The total hospital charges for EVAR and open repair were similar (dollars 71,428 vs

Functional and survival outcomes in traumatic blunt thoracic aortic injuries: An analysis of the National Trauma Databank.

74,520, P = .59). Mortality for EVAR was significantly higher at nonteaching hospitals compared with teaching centers (55% vs 21%, P < .01) and at nonteaching centers, even exceeding that of open repair (46%). Regression modeling confirmed the overall benefits of EVAR as well as the worse outcomes at nonteaching facilities after adjusting for patient comorbidities, disease severity, and hospital or system covariates. CONCLUSIONS Endovascular repair is being increasingly used in the emergency management of ruptured AAA, with steadily decreasing mortality during the study period. Endovascular AAA repair is associated with improved mortality and outcomes compared with open repair, but results in nonteaching centers are substantially worse than those in teaching hospitals.

The effect of acute popliteal venous interruption.

OBJECTIVE Blunt thoracic aortic injury (BAI) remains a leading cause of trauma deaths, and off-label use of endovascular devices has been increasingly utilized in an effort to reduce the morbidity and mortality in this population. Utilizing a nationwide database, we determined the incidence of BAI, and analyzed both functional and survival outcomes at discharge compared with matched controls. METHODS Patients with BAI were identified by International Classification of Disease-9 codes from the National Trauma Data Bank (Version 6.2), 2000-2005. Patients were analyzed based on aortic repair, associated physiologic burden, and coexisting injuries. Control groups were matched by age, mechanism, major thoracic Abbreviated Injury Scale score (AIS >/= 3), major head AIS, and major abdominal AIS. Outcomes were assessed using the functional independence measure (FIM) score and overall mortality. FIM scores were scored from 1 (full assistance required) to 4 (fully independent) for three categories: feeding, locomotion, and expression. RESULTS During the study period, 3,114 patients with BAI were identified among 1.1 million trauma admissions for an overall incidence of 0.3%. One hundred thirteen (4%) were dead on arrival, and 599 (19%) died during triage. Of the patients surviving transport and triage (n = 2402), 29% had a concomitant major abdominal injury and 31% had a major head injury. Sixty-eight percent (1,642) underwent no repair, 28% (665) open aortic repair, and 4% (95) endovascular repair with associated mortality rates of 65%, 19%, and 18%, respectively (P < .05). Aortic repair independently improved survival when controlling for associated injuries and physiologic burden (odds ratio (OR) = 0.36; 95% confidence interval (CI), 0.24-0.54, P < .05). Compared with matched controls, BAI resulted in a higher mortality (55% vs. 15%, P < .05), and independently contributed to mortality (OR = 4.04; 95% CI, 3.53-4.63, P < .05). In addition, BAI patients were less likely to be fully independent for feeding (72% vs. 82%, P < .05), locomotion (33% vs. 55%, P < .05), and expression (80% vs 88%, P < .05). CONCLUSION This manuscript is the first to define the incidence of BAI utilizing the NTDB. Remarkably, two-thirds of patients are unable to undergo attempts at aortic repair, which portends a poor prognosis. When controlling for associated injuries, blunt aortic injury independently impacts survival and results in poor function in those surviving to discharge.

Ultrasound-Guided Access Improves Rate of Access-Related Complications for Totally Percutaneous Aortic Aneurysm Repair

Popliteal vascular trauma continues to be associated with a relatively high morbidity rate when compared to other major vascular injuries in extremities. There is continuing controversy regarding the management of popliteal venous injuries. The advocates of ligation of injured veins have postulated that there is an increased incidence in thrombophlebitis and pulmonary embolism associated with attempted venous repair. There is a paucity of valid statistics supporting either side of this controversy. Clinical experience documented in the Vietman Vascular Registry and experimental work at Walter Reed Army Institute of Research have supported our more aggressive approach for venous repair. This study evaluates the management of 110 injured popliteal veins without associated popliteal arterial trauma. Nearly an equal number were ligated and repaired. Thrombophlebitis and pulmonary embolism were not significant complications in this series. The only pulmonary embolus occurred after ligation of an injured popliteal vein. However, there was a significant increase in edema of the involved extremity following ligation, 50.9% compared to 13.2% after repair

Vascular trauma secondary to diagnostic and therapeutic procedures: laparoscopy.

Previous experience with totally percutaneous aortic aneurysm repair has identified morbid obesity and larger sheath sizes (> or =20F) as complicating factors for percutaneous access closure. We sought to evaluate the impact of ultrasound-guided femoral access on rates of technical success, conversion to open femoral repair, and access-related complications. A retrospective review of a prospectively maintained database was performed. All consecutive patients undergoing totally percutaneous closure of large-bore-sheath (>12F) access sites with a suture-mediated closure device were included. The cohort was stratified into two groups by access technique, standard percutaneous femoral access, and ultrasound-guided femoral access. Patient variables were evaluated, and outcome measures included technical success, requirement for conversion to open repair, and access-related complications. Recorded conversions only included those related to access closure technique. During the study period, 88 consecutive patients underwent percutaneous closure of 152 large-bore access sites after endovascular aneurysm repair. There was no difference in the proportion of morbidly obese patients (body mass index >35 kg/m(2)) between the two cohorts. Access-related complications were significantly reduced in the group undergoing ultrasound-guided access. Despite the lower complication profile with ultrasound guidance, 24 sites (41%) had sheath sizes > or =20F compared to only 21 sites (24%) in the standard access group (p<0.05). Evaluating conversions and technical success of percutaneous closure, a significant benefit was identified for sheath sizes > or =20F (p<0.05). Upon comparing the two cohorts, operative time continued to decrease from 154 (+/-64) to 101 (+/-56) min after the addition of ultrasound guidance for access (p<0.05). The addition of ultrasound-guided femoral access to totally percutaneous aortic aneurysm repair continues to increase the technical success rate for vessel closure and has a clinically profound impact on access-related complications. This technical adjunct appears to have the largest impact on patients requiring larger sheath sizes.

Autogenous venous interposition grafts in repair of major venous injuries.

Diagnostic and therapeutic laparoscopy are safe procedures that only rarely cause significant morbidity. However, major abdominal arterial and venous injury may occur, requiring prompt recognition and laparotomy. Direct compression will control major hemorrhage until resuscitation is complete. Vascular repair utilizing principles of proximal and distal control, good exposure, appropriate anticoagulation, and lateral suture technic should result in restoration of normal blood flow without significant sequelae.

Application of the Mangled Extremity Severity Score in a Combat Setting

1) This review of 51 former Vietnam casualties who had lower extremity venous injuries repaired using autogenous interposition venous grafts is the largest series of this type of venous repair to be reported. Nevertheless, additional information is needed, including more extensive phlebographic documentation of the current status of venous reconstructions. 2) The results of these venous repairs performed by essentially a different surgical team in every case are encouraging. Only one patient, or 2.0% of the total, developed thrombophlebitis in the postoperative period and this was transitory in nature. No patients developed pulmonary embolism. There was no edema in the postoperative period in 66.6% of the total. During the longterm followup, only six patients, or 11.8%, had residual edema. This is in marked contrast to a similar number of patients followed in the Registry who had ligation of popliteal veins following trauma with persistent edema in 50.9%. 3) Although this study remains incomplete, the favorable data should stimulate interest in performing additional repair of major lower extremity venous injuries utilizing autogenous venous grafts. Expanded experimental and clinical research is needed to define a readily available conduit of variable sizes which can be utilized successfully in reconstruction of the low-flow venous system.

Stroke associated with carotid endarterectomy

OBJECTIVE The aim of this study was to examine the Mangled Extremity Severity Score (MESS) in a combat setting. METHODS Data on extremity injuries were collected from a forward surgical team. MESS and Revised Trauma Score values were retrospectively calculated for each patient. Students t test was used to compare amputated and salvaged limbs. RESULTS A total of 60 extremities was identified in 49 patients. There were 10 major vascular repairs (20%). MESS values differed significantly for the eight amputations performed (mean MESS, 7.87 +/- 1.91) and 50 salvaged extremities (mean MESS, 2.44 +/-_ 0.438; p = 0.001). CONCLUSIONS A MESS of >7 correlated with amputation, thus validating the MESS in a combat setting. A young average patient age and high-energy injury mechanism on the battlefield leave ischemic time and shock as the most important factors in dictating whether a MESS is >7 or <7.

Noninvasive assessment of lower extremity hemodynamics in individuals with diabetes mellitus

Between 1966 and 1976, eleven strokes occurred in association with 509 carotid endarterectomies performed at Walter Reed Army Medical Center. Contralateral carotid arterial occlusion with unilateral stenosis, bilateral carotid stenoses, or multiple extracranial (with or without intracranial) stenoses were present in all patients in whom stroke developed. Preventable technical factors contributing to or directly causing stroke were identifiable in six of the eleven patients. Better appreciation of the high risks associated with the above arteriographic patterns and elimination of technical mishaps should lead to an improvement in our already respectably low stroke rate of 2.2 per cent.

The natural history of early recurrent carotid artery stenosis

The timely and accurate noninvasive assessment of peripheral arterial disease (PAD) is a critical component of a limb preservation initiative in patients with diabetes mellitus. Noninvasive vascular studies (NIVS) can be useful in screening patients with diabetes for PAD. In patients with clinical signs or symptoms, NIVS provide crucial information on the presence, location, and severity of PAD, as well as an objective assessment of the potential for primary healing of an index wound or a surgical incision. Appropriately-selected NIVS are important in the decision-making process to determine whether and what type of intervention might be most appropriate, given the clinical circumstances. Hemodynamic monitoring is likewise very important following either an endovascular procedure or a surgical bypass. Surveillance studies, usually with a combination of physiologic testing and imaging with duplex ultrasound, accurately identify recurrent disease prior to the occurrence of thrombosis, allowing targeted reintervention. NIVS can be broadly grouped into three general categories: physiologic or hemodynamic measurements; anatomic imaging; and measurements of tissue perfusion. These types of tests and suggestions for their appropriate application in patients with diabetes are reviewed.