David J. O'Connor

Incidence and characteristics of venous thromboembolic disease during pregnancy and the postnatal period: a contemporary series.

BACKGROUNDnTo evaluate the incidence and characteristics of venous thromboembolic events (VTE) associated with pregnancy in a contemporary patient series.nnnMETHODSnWe performed a retrospective review of 33,311 deliveries between June 2003 and June 2008. Patients with objective documentation of a VTE during pregnancy or the 3-month postnatal period were identified from hospital discharge International Classification of Disease Codes edition 9 codes. Diagnosis of deep venous thrombosis (DVT) was largely made by a Duplex ultrasound, whereas pulmonary embolism (PE) was diagnosed by a computerized tomographic angiography (CTA).nnnRESULTSnOf 33,311 deliveries during the study period, 74 patients (0.22%) had a VTE. There were 40 incidents of DVT (0.12%) and 37 of PE (0.11%). DVT involved the iliac veins (6), the femoral or popliteal veins (16), the infrapopliteal veins (17), and the axillary vein (1). Most (57.5%) of the DVTs involved the left lower extremity. Thirty-eight (51.6%) of the VTEs occurred in the postnatal period, and of those 33 (87%) occurred within 1 week of delivery. Most of the postnatal VTEs (68%) were seen in patients who underwent a cesarean section. Among patients with VTE during pregnancy, there were 28% in the first trimester, 25% in the second, and 47% in the third. Events were distributed among maternal age groups as follows: 26% aged 13-24, 50% aged 25-34, and 24% aged 35-54. Of the 35 patients tested for a hypercoagulable disorder, 12 were found to have a positive test result. Five (6.8%) of these 74 patients had a prior history of VTE, with two having a hypercoagulable disorder. In addition, 45 of the 74 patients were on oral contraceptive therapy or received hormonal stimulation therapy before pregnancy. Patients with a VTE during pregnancy were treated with low molecular weight or unfractionated heparin. Most postnatal patients were treated with subcutaneous low molecular weight heparin and coumadin. Six inferior vena cava filters were placed in patients with bleeding complications as a result of anticoagulation. There were no deaths during the study period.nnnCONCLUSIONSnComparing our results with historic controls (DVT: 0.04-0.14% and PE: 0.003-0.04%), the incidence of DVT in pregnancy has not changed significantly. We note, however, that the incidence of pulmonary embolus in our series is higher than previously reported. CTA has been used for the diagnosis of PE since the past decade. The increase in the rate of PE in the current series may be because of the higher sensitivity of CTA when compared with previous diagnostic modalities.

Long-Term Outcome of Inferior Vena Cava Filter Placement in Patients Undergoing Gastric Bypass

BACKGROUNDnIt has been well established that inferior vena cava (IVC) filter placement at the time of open gastric bypass (OGB) surgery in patients with a body mass index of more than 55 kg/m(2) reduces both the pulmonary embolism rate and the perioperative mortality. However, little is known about the long-term effects of IVC filter placement in this particular group of patients.nnnMETHODSnOver an 8-year period, a total of 571 morbid obese patients underwent OGB procedures, and 58 (10%) of them required placement of an IVC filter before their procedure. All IVC filters were placed percutaneously through a femoral vein approach using a portable OEC fluoroscope. Types of IVC filters used in our study included the TrapEase (n = 35), Simon-Nitinol (n = 9), Greenfield (n = 2), and Bard Recovery (n = 12).nnnRESULTSnOf the 58 patients who required an IVC placement, 56 remained free of any thromboembolic phenomena over the 8-year period (range, 1-8 years). The remaining two patients developed deep venous thrombosis. One patient was successfully treated with intravenous heparin and a 6-month course of Coumadin. She had complete resolution of her deep venous thrombosis and was incidentally noted to have a prothrombin 20210 gene mutation. The other patient, who had multiple gastric bypass complications, could not be successfully treated with intravenous heparin and thus progressed on to complete IVC thrombosis. She developed phlegmasia cerulea dolens and required bilateral above-the-knee amputations. She subsequently died 3 months after her procedures.nnnCONCLUSIONnIt appears that IVC filter placement at the time of OGB surgery is a relatively benign intervention with a maximal benefit. A note of caution should be exerted for those obese patients who have a hypercoagulable disorder and for those who have complications related to the gastric bypass. An aggressive posture, which may consist of immediate anticoagulation after their procedures (only when it is deemed safe), should be advocated in this small sub-group of morbid obese patients.

Single-incision laparoscopic-assisted right colon resection for cancer.

The authors suggest that laparoscopic right colectomy utilizing a single port may be performed with excellent cosmetic results.

Experience with a modified composite sequential bypass technique for limb-threatening ischemia

BACKGROUNDnComposite sequential femoro-popliteal-distal bypass is a valuable option for treatment of critical limb ischemia when autogenous vein is limited and an isolated popliteal or distal arterial segment exists. We report a modified technique for composite sequential bypass and the results with its use over a 14-year period.nnnMETHODSnTwenty-five modified composite sequential bypass procedures were performed on 24 patients to treat gangrene, ischemic ulceration, and severe rest pain. Vein grafts were anastomosed from blind popliteal or blind distal arterial segments above-knee (7) or below-knee (18) to a distal outflow vessel including the below-knee popliteal (1), posterior tibial (5), anterior tibial (7), or peroneal (12) artery. Polytetrafluoroethylene bypass grafts were then placed from a suitable inflow artery to the proximal hood of the vein graft.nnnRESULTSnCumulative primary patency rates were 80% at 3 years, and 65% at 5 years. The limb-salvage rate was 85% at 4 years. Occlusion of the prosthetic segment with a patent distal vein segment was recognized in two patients who presented with less severe recurrent ischemia. Limb-salvage in these patients was achieved by a secondary prosthetic graft to the patent vein graft.nnnCONCLUSIONnOur modified configuration of the prosthetic-vein anastomosis for composite sequential bypass is an alternative to the conventional procedure and may help preserve vein graft patency should the polytetrafluoroethylene graft thrombose.

Endovascular management of multiple arteriovenous fistulae following failed laser-assisted pacemaker lead extraction

A woman presented for evaluation of new-onset left arm edema after failed laser-assisted pacemaker lead extraction. Initial workup demonstrated a left subclavian artery to vein arteriovenous fistula (AVF). She underwent repair of the AVF with placement of a covered stent in the subclavian artery, however, her symptoms did not completely resolve. Investigation revealed a left common carotid artery to left innominate vein AVF, which was repaired by deploying a covered stent retrograde into the left common carotid artery. Her symptoms subsequently resolved. Multiple iatrogenic AVF can be repaired endovascularly, however, a high degree of suspicion for multiple injuries should be maintained.

TCT-805 Use of Orbital Atherectomy to Aid in Endovascular Aortic Endograft Delivery in Patients with Severe Iliac Artery Occlusive Disease

Stent grafts for repair of abdominal aortic aneurysms are continuing to evolve to lower profile designs to facilitate easier endograft delivery. Despite improvements in design, a subset of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) exist with severely calcified iliac

Adjunctive Use of Thoracic Stent Cuffs to Treat Infrarenal Aortic Necks Too Large for Standard EVAR

Objectives: To evaluate early outcomes and short-term durability of thoracic stent cuffs in patients with abdominal aortic aneurysms (AAA) and infrarenal necks too large for standard endovascular aneurysm repair (EVAR) who were symptomatic, not suitable for open surgery, and could not wait for a custom fenestrated device to be created. Methods: From July 2010 to December 2012, 13 patients with juxtaor pararenal AAA underwent endovascular repair with thoracic aortic endografts as proximal aortic cuffs in conjunction with standard EVAR devices. The patients were symptomatic and were deemed unfit for open surgery due to severe cardiopulmonary and/or renal comorbidities. All patients had infrarenal neck diameters greater than the indications for use for standard aortic endografts. Primary end points were technical success (as defined by aneurysm exclusion without endoleak), follow-up aneurysm exclusion by computed tomographic angiogram, and 30-day and longterm mortality. Results: Thirteen patients (10 men, 3 women) with a mean age of 77.1 years underwent EVAR who presented with symptomatic juxtaor pararenal abdominal aortic aneurysms. The mean aneurysm size was 7.2 cm, and the mean infrarenal aortic neck diameter was 35.5 mm measured by centerline analysis. Technical success was achieved in 100% of cases. The 30-day mortality was 8% (one of 13 patients). At a mean follow-up of 524 days, there have been no endoleaks or other aneurysm related mortalities. There was one death due to stroke at 605 days postop. Conclusions: Complex endovascular repair of juxta and pararenal AAA using thoracic stents cuffs can be safely and successfully performed in symptomatic patients medically unfit for open repair. Using thoracic stent cuffs below the visceral vessels may reduce the complexity and possibly the risk of repair when compared with fenestrated endografts. These techniques can be used for urgent and emergent cases where the wait time for fenestrated technology is prohibitive. Although our results have demonstrated short-term success, long-term durability of this technique with further evaluation is required.