Daniel Silverberg

Pregnancy outcome of patients following bariatric surgery as compared with obese women: a population-based study

Abstract Objective: To evaluate pregnancy outcome and rates of anemia in patients following bariatric operation in comparison with obese pregnant women. Methods: A retrospective population-based study comparing pregnancy outcome of patients following bariatric with the obese population was conducted. Multivariate logistic regression models were constructed to control for confounders. To evaluate the change in hemoglobin levels, we included women who had one pregnancy before the bariatric surgery and one following the surgery or two pregnancies for women with obesity. Results: This study included 326 women who had one pregnancy before and after a bariatric surgery and 1612 obese women who had at least two consecutive deliveries. Using a multivariable logistic regression model, controlling for confounders such as maternal age, patients following bariatric surgery had lower rates of gestational diabetes mellitus (OR 0.7; 95% CI 0.5–0.9; pu2009=u20090.49) and macrosomia (OR 0.3; 95% CI 0.2–0.5; pu2009<u20090.001) as compared with obese parturients. Women post bariatric surgery were more likely to be anemic (hemoglobinu2009<10u2009g/dL) as compared to obese parturients (48% versus 37%; OR, 1.5; 95% CI, 1.2–1.9; pu2009<u20090.001). A significant decline in hemoglobin level was noted in patients following bariatric surgery (a decline of 0.33u2009g/dL versus 0.18u2009g/dL between two consecutive pregnancies of obese women). Using another multivariable model with anemia as the outcome variable, bariatric was noted as a risk factor for anemia (adjusted ORu2009=u20091.45, 95%CI 1.13–1.86, pu2009=u20090.004). Conclusion: Women following bariatric surgery have lower risk for gestational diabetes mellitus and fetal macrosomia as compared with obese parturients. Nevertheless, bariatric surgery is a risk factor for anemia.

Long-term renin-angiotensin blocking therapy in hypertensive patients with normal aorta may attenuate the formation of abdominal aortic aneurysms.

Renin-angiotensin system (RAS) has been implicated in the pathogenesis of abdominal aortic aneurysm (AAA). Angiotensin II type 1 receptor blocker (ARB), when given with angiotensin II prevents AAA formation in mice, but found ineffective in attenuating the progression of preexisting AAA. This study was designed to evaluate the effect of chronic RAS blockers on abdominal aortic diameter in hypertensive patients without known aortic aneurysm. Consecutive hypertensive outpatients (nxa0=xa0122) were stratified according to antihypertensive therapy they received for 12xa0months or more, consisting of ARB (nxa0=xa045), angiotensin converting enzyme inhibitor (ACE-I; nxa0=xa045), or nonARB/nonACE-I (control therapy; nxa0=xa032). Abdominal ultrasonography was performed to measure maximal subrenal aortic diameter. Eighty-four patients were reexamined by ultrasonography 8xa0months later. The correlation between the different antihypertensive therapies and aortic diameter was examined. Aortic diameters were significantly smaller in ARB than in control patients in the baseline and follow-up measurements (Pxa0=xa0.004; Pxa0=xa0.0004, respectively). Risk factor adjusted covariance analysis showed significant differences between ARB or ACE-I treated groups and controls (Pxa0=xa0.006 or Pxa0=xa0.046, respectively). Ultrasound that was performed 8xa0months later showed smaller increases in mean aortic diameters of the ARB and ACE-I groups than in controls. Both ARB and ACE-I therapy attenuated expansion of nonaneurysmal abdominal aorta in humans. These results indicate that RAS blockade given before advancement of aortic medial remodeling may slow down the development of AAA.

Clostridium septicum post-endovascular aneurysm repair stent-graft infection.

Endovascular aortic aneurysm repair (EVAR) is establishing its role as a valid alternative for the treatment of abdominal aortic aneurysm. Post-EVAR graft infection is a rare and devastating complication. The incidence of post-EVAR graft infection is yet to be defined, and available data at this stage consist of case reports and small series. Possible etiologies for aortic stent-graft infection include perioperative contamination and hematogenous seeding. To the best of our knowledge, this is the first report of post-EVAR stent graft infection with Clostridium septicum. The possible mechanisms of this unusual hematogenous seeding have been discussed.

Acute limb ischemia in cancer patients: Aggressive treatment is justified

Background The outcome of cancer patients with acute limb ischemia (ALI) is not well defined. The purpose of this study is to report our experience treating patients with active malignancy who developed ALI and compare their outcome with non-cancer patients. Methods A retrospective review of patients treated for ALI between 2009 and 2012 with ALI. We identified those patients who suffered from ALI and compared the outcome of those with active malignancy to those without malignancy. Results Of 147 patients treated for ALI (122 lower extremity, 25 upper extremity), 24 (16%) were cancer patients. Mean follow-up was 9.8 months for the malignancy group and 13.4 months for the control. Perioperative mortality rates were similar among cancer and non-cancer patients (20% vs. 16%, respectively, NS). Freedom from major amputation at 30 months was similar (95% vs. 89%, NS). Long-term survival rates of cancer patients were significantly lower compared to non-cancer patients (45% vs. 77% respectively, Pu2009<u20090.05). Conclusions Treatment of ALI among cancer patients can be achieved with perioperative mortality and limb salvage rates comparable to non-cancer patients. Aggressive treatment is justified when treating cancer patients with ALI.

Endovascular Repair of Abdominal Aortic Aneurysms in the Presence of a Transplanted Kidney.

PurposeTo present our experience performing endovascular repair of abdominal aortic aneurysms in kidney transplanted patients.MethodsA retrospective review of all patients who underwent endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA) performed at our institution from 2007 to 2014. We identified all patients who had previously undergone a kidney transplant. Data collected included: comorbidities, preoperative imaging modalities, indication for surgery, stent graft configurations, pre- and postoperative renal function, perioperative complications, and survival rates.ResultsA total of 267 EVARs were performed. Six (2xa0%) had a transplanted kidney. Mean age was 74 (range, 64–82) years; five were males. Mean time from transplantation to EVAR was 7.5 (range, 2–12) years. Five underwent preoperative planning with noncontrast modalities only. Devices used included bifurcated (nxa0=xa03), aortouniiliac (nxa0=xa02), and tube (nxa0=xa01) stent grafts. Technical success was achieved in all patients. None experienced deterioration in renal function. Median follow-up was 39 (range, 6–51) months. Four patients were alive at the time of the study. Two patients expired during the period of follow-up from unrelated causes.ConclusionsEVAR is an effective modality for the management of AAAs in the coexistence of a transplanted kidney. It can be performed with minimal morbidity and mortality without harming the transplanted kidney. Special consideration should be given to device configuration to minimize damage to the renal graft.

Acute renal artery occlusion: Presentation, treatment, and outcome

OBJECTIVEnAcute renal artery occlusion is an uncommon disease requiring rapid diagnosis for prevention of kidney loss or permanent kidney damage. The purpose of this study was to identify patients with acute kidney infarction; to characterize their presentation, imaging, and treatment; and to compare the subgroup of patients who underwent catheter-directed thrombolysis (CDT) with those who were treated without intervention.nnnMETHODSnHospital records between 2005 and 2015 were queried for keywords suggestive of kidney infarction. Patients were divided into two groups: the CDT group and the noninterventional group. Data collected included demographics, comorbidities, methods of diagnosis, and time from presentation to diagnosis. For patients treated with CDT, additional data collected included details of thrombolytic therapy and follow-up studies. The two groups were compared regarding their clinical characteristics and outcome.nnnRESULTSnForty-two patients were diagnosed with acute kidney infarction; 13 (31%) were treated with CDT and 29 (69%) were treated conservatively. Median time from presentation to diagnosis was 42xa0hours in the CDT group and 32xa0hours in the untreated group. Among the CDT group, complete or partial resolution of the thrombus was seen in all patients. Two required permanent dialysis, both renal transplant patients. Median follow-up was 30xa0months (interquartile range, 2.7-46.2) in the CDT group and 13xa0months (interquartile range, 0.11-16) in the noninterventional group. Mean creatinine clearance at diagnosis and at last follow-up was 74.3 and 54.6xa0mL/min, respectively, in the CDT group (axa0decrease of 27%; Pxa0= .032) and 66.1 and 60xa0mL/min in the conservatively treated group (a decrease of 9%; Pxa0= .04). Follow-up imaging was available in nine patients treated with CDT. Mean interval from treatment to follow-up imaging was 13xa0months (range, 1-35xa0months) and consistently showed a functional but smaller treated kidney. (Mean pole-to-pole kidney length at baseline and late follow-up: 10.4xa0cm and 8.5xa0cm, respectively).nnnCONCLUSIONSnMost patients presenting with acute kidney infarction are managed conservatively. A subset of patients with complete occlusion of the renal artery undergo CDT with good angiographic results. The treated kidney is expected to decrease in size over time, and overall kidney function is expected to decrease compared with baseline. Deterioration in renal function appears to stabilize and does not continue over time. CDT for acute renal artery occlusion is a safe modalityxa0of therapy and should be attempted for the purpose of kidney salvage, even in the setting of prolonged ischemia.

The deep femoral artery, a readily available inflow vessel for lower limb revascularization: a single-center experience

The deep femoral artery (DFA) offers several advantages as an inflow vessel in lower-extremity bypasses. We report a single-center experience using the DFA as an inflow artery for lower-extremity revascularization. We reviewed all patients who underwent a lower-extremity bypass utilizing the DFA as the inflow vessel. Demographics, indications for surgery, indication for use of the DFA, type of conduits and target vessels were recorded. Follow-up data included resolution of symptoms, bypass graft patency, major amputations and survival. Over 2.5 years, 23 patients were treated with a DFA-inflow bypass. Eighteen (78%) suffered from wounds and five (22%) from rest pain. The proximal, middle and distal DFA was used in 8, 14 and 1 patients, respectively. Indications for using the DFA were limited vein conduit (16) and a hostile groin (5). All patients experienced initial resolution of their ischemic symptoms. The primary patency at two years was 93%. The survival rate was 83%. In conclusion, the DFA is an excellent and underutilized alternative inflow artery in patients requiring lower limb revascularization. It offers excellent patency rates and should be considered in patients with hostile groins or insufficient lengths of a vein conduit.

Endovascular repair of an abdominal aortic aneurysm in the presence of a hydronephrotic horseshoe kidney.

The aim of this paper is to report an unusual case of a patient with an abdominal aortic aneurysm (AAA) and a hydronephrotic horseshoe kidney (HSK) that was repaired by endovascular means. An 81-year-old male patient with a known HSK was found to have hydronephrosis and an AAA. The patients aneurysm was treated with an endovascular stent graft which required the covering of accessory renal arteries. He had an uneventful recovery with complete resolution of the hydronephrosis evident on a computed tomography scan performed seven months after the surgery. In conclusion, endovascular aneurysm repair is a feasible therapeutic option for an AAA coexisting with an HSK and may be considered as a valid alternative to open repair when concomitant hydronephrosis is present.

Hybrid revascularization of the superior mesenteric artery in a patient with acute mesenteric ischemia and an occluded aorta

A 60-year-old man with a history of chronic mesenteric ischemia and chronic aortic occlusion presented with diffuse abdominal pain. On admission he was hypotensive and acidotic. A computed tomography angiogram revealed occlusion of his entire infrarenal aorta to the femoral arteries, an occluded celiac trunk and inferior mesenteric artery (previously stented), and severe stenosis of his superior mesenteric artery (SMA; A). He underwent explorative laparotomy, during which three segments of gangrenous small bowel were resected. The rest of the small bowel appeared ischemic but viable. Endovascular attempts to recanalize the SMA were unsuccessful. Owing to his hemodynamic instability and metabolic status, we performed a hybrid procedure. Under fluoroscopy, the thrombosed aorta was punctured. A wire and catheter were introduced into the thoracic aorta. After intraluminal position was confirmed, a 14F peel-away sheath was placed. A 6-mm hybrid vascular graft (W. L. Gore and Associates, Flagstaff, Ariz) was introduced (10-cm nitinol reinforced section and a 50-cm nonringed graft). The sheath was removed and the visible end of the nitinol section, which protruded through the aorta, was secured with stitches to the aortic wall. (model, B) An 8-mm ringed polytetrafluoroethylene graft was placed over the 6-mm graft to prevent kinking and the graft was anastomosed to the SMA. The remaining bowel improved immediately. Postoperative computed tomography angiography showed the hybrid graft was patent, with filling of the SMA (C and D/Cover).

The Vanishing Giant Abdominal Aortic Aneurysm

Spontaneous sac size regression of a giant abdominal aortic aneurysm (AAA) is a rare event that has not been previously described. We report a case of an 89-year-old woman with a known 9-cm AAA, which was diagnosed in 2003. The patient had refused any kind of treatment at that time. Recent imaging studies obtained 7 years later revealed an AAA of 4 cm diameter. This is the first recorded case of significant spontaneous AAA sac shrinkage.