Denis Harkin

A systematic review and meta-analysis of abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysms

OBJECTIVE Limited data exist regarding the development of abdominal compartment syndrome (ACS) after endovascular repair of ruptured abdominal aortic aneurysms (RAAAs). We aimed to record the incidence, management, and outcome of this complication. METHODS A systematic review and meta-analysis of the English language literature was undertaken through June 2012. Articles reporting data on outcome after endovascular repair of RAAAs were identified, and information regarding ACS was sought. RESULTS Included were 39 eligible studies reporting 1134 patients. The pooled perioperative mortality was 21% (95% confidence interval [CI], 18%-24%). A total of 109 cases of ACS were recorded. There was significant within-study heterogeneity (Cochran Q = 94.1; P < .0001), and the pooled ACS rate was 8% (95% CI, 5.6%-10.8%). Only six studies accurately defined ACS, and four focused specifically on ACS. When the meta-analysis was repeated after including only studies with a definition and those focusing on ACS, the pooled rate increased to 17% (95% CI, 10%-26%) and 21% (95% CI, 13%-30%), respectively. A random-effects meta-regression analysis investigating the effect of ACS and other risk factors on mortality revealed a significant linear correlation between hemodynamic instability and death (r = 0.303) and a nonlinear (second degree polynomial) association between bifurcated endograft approach and death (R(2) = 0.348; P = .0027). However, no statistically significant association could be found between ACS and death. A further meta-regression analysis failed to identify any statistically significant predictors of ACS. Treatment included open decompression in 86 patients, percutaneous drainage in 18 (catheter only in five, combined with tissue plasminogen activator infusion in 13), and conservative measures in five. Data on outcome of ACS were only available for 76 patients; 35 of these died, for a mortality rate of 47%. CONCLUSIONS The pooled ACS rate was calculated at 8%, but this figure may be >20% with improved awareness and vigilant monitoring. Although no statistically significant association could be found between ACS and death, almost half the patients who developed ACS after endovascular repair of RAAAs were likely to die.

Successful Delayed Secondary Open Conversion After Endovascular Repair Using Partial Explantation Technique: A Single-Center Experience

BACKGROUND Endovascular aneurysm repair (EVAR) reduces the morbidity and mortality associated with abdominal aortic aneurysm repair, but in some patients endoleak or aneurysm expansion may necessitate secondary open conversion (SOC). We reviewed the outcomes after delayed SOC following EVAR in consecutive patients at a single center. METHODS We retrospectively reviewed all patients undergoing EVAR to identify a cohort undergoing delayed SOC in a single center between 1998 and 2008. We analyzed delayed SOC patients for operative indications, technique, and early outcomes. We made specific comment on the surgical techniques used, with respect to partial or total endograft explantation. RESULTS Delayed SOC was carried out in 10/285 (3.5%) consecutive patients implanted with the Zenith endograft; during this period, two further patients had SOC after initial EVAR in another center. Graft types were Zenith (n = 10), Talent (n = 1), and AneuRx (n = 1). Indications for open conversion were infected graft (n = 3), sac expansion (n = 3), type 1 endoleak (n = 2), type 2 endoleak (n = 2), juxtarenal aneurysm (n = 1), and rupture (n = 1). Explantation techniques were partial explantation with in situ replacement (n = 7), full explantation with axillobifemoral bypass (n = 3), in situ replacement (n = 1), and suturing (n = 1)Complete stent explantation was required in 4 patients with axillo-bifemoral bypass in three of them. 7 patients had partial stent explantation and one patient stent was left insitu. Postoperative morbidities included myocardial infarction (n = 1), renal dialysis (n = 1), and chest infection (n = 3). No 30-day mortality was noted, and all patients were discharged from hospital and remain well with median follow-up of 5 months (interquartile range 1.7-26.7). CONCLUSION SOC after EVAR is feasible in selected patients with low morbidity and mortality. Partial explantation with in situ replacement, in the absence of sepsis, may be the preferred revascularization option but may require long-term follow-up.

Limb occlusion after endovascular repair of an abdominal aortic aneurysm: beware the narrow distal aorta

PurposeThis case aims to highlight the need for careful scrutiny of the distal aorta during endovascular aneurysm repair (EVAR) planning to avoid potentially avoidable graft limb occlusion.Case reportWe present a case of graft limb occlusion after EVAR, unresponsive to endovascular re-intervention requiring surgical extra-anatomic revascularization, due to a narrow distal aorta causing graft impingement and collapse.ConclusionWe suggest clinicians should be aware of this potential pitfall during EVAR planning and beware the narrow distal aorta.

Upper limb deep vein thrombosis due to Langer's axillary arch

Langers axillary arch is a recognized muscular anomaly characterized by an accessory muscular band crossing the axilla that rarely causes symptoms. We describe a patient who presented with an upper limb deep vein thrombosis caused by this aberrant muscle, which we believe is the first reported case. Axillary surgery with division of the aberrant muscle relieved upper limb venous obstruction in this patient.

Testicular infarction: A rare complication of endovascular aneurysm repair treatment for aortoiliac aneurysm

Endovascular aneurysm repair (EVAR) is an established therapy to prevent rupture in large infrarenal abdominal aortic aneurysms (AAA). As experience with this therapy has grown, treatment of more challenging anatomy has led to the identification of several new procedurally related complications. We report the case of a 67-year-old man with an asymptomatic, large infrarenal AAA with an associated left common iliac artery aneurysm. Endovascular therapy for an aortoiliac aneurysm involved prior coil embolization of his left internal iliac artery to allow conventional EVAR with extension to the external iliac artery of the left graft limb, thus excluding the left iliac aneurysm. He presented 6 weeks postoperatively with onset of left-sided scrotal pain and underwent emergency orchidectomy for ischemic infarction of his left testis. The histology report confirmed that the left testis was necrotic secondary to a thrombus in the testicular artery. To our knowledge, this is the first report of testicular infarction after EVAR.

Brachial Artery Aneurysm Following Open Repair of Posttraumatic False Aneurysm and Arteriovenous Fistula

True brachial artery aneurysms remain extremely rare and are most commonly related to repetitive blunt trauma. Although operative repair of false aneurysms is well established, management of true aneurysms is varied due to their rarity. We present a true brachial artery aneurysm, in a 55-year old male, which occurred some 22-years following the repair of a posttraumatic false aneurysm. Following arterial duplex and computerised tomography, aneurysectomy with reversed interposition vein graft was performed.

Late aneurysm rupture after delayed secondary open conversion with partial explantation for failed endovascular repair

A delayed secondary open conversion (SOC) after endovascular aneurysm repair may be necessary due to a failing graft. Many surgical techniques can be performed, and one such approach is partial explantation of the graft with resuturing of a new graft to the retained components of the endograft. No guidelines exist with regards to the follow-up of retained endovascular components after a delayed SOC. The theoretical risk of endoleaks remains with retained components, and this case demonstrates the development of a type Ib endoleak after SOC leading to free flow of blood into a partially resected aneurysm sac and causing a symptomatic aneurysm rupture.

Endovascular repair of an inflammatory abdominal aortic aneurysm causing bilateral ureteric obstruction

BackgroundConventional open repair of inflammatory abdominal aortic aneurysms (IAAA) remains challenging through the presence of extensive peri-aortic inflammation and fibrosis which makes dissection and vascular control difficult with a risk of inadvertent injury to adjacent visceral structures such as the ureters, duodenum, inferior vena cava, left renal vein and sigmoid colon.MethodsWe describe a case of a 69-year-old gentleman who presented with acute renal failure due to bilateral ureteric obstruction in association with an IAAA and discuss the various management options available.Conclusion IAAAs and the associated peri-aortic inflammation and fibrosis can be successfully treated using endovascular abdominal aortic aneurysm repair with concurrent ureteric stenting.

The role of transthoracic echocardiography in embolic acute limb ischaemia

IntroductionEmbolic acute limb ischaemia (ALI) is commonly treated by re-vascularization and long-term anticoagulant therapy. Transthoracic echocardiography (TTE) is commonly used to screen for cardiac embolic source, but may not affect management.ReportWe reviewed 115 consecutive patients with embolic ALI, 61% underwent TTE, with cardiac thrombus identified in only 3%. Incidental severe abnormalities requiring further cardiological investigation were detected in 19% of patients. Inpatient TTE did not affect mortality, morbidity, amputation rate, or anticoagulation.DiscussionTransthoracic echocardiography seldom identifies a cardiac embolic source, but identifies many patients with severe incidental cardiac abnormalities, suggesting cardiology screening of these patients remains important.