Edmund J. Harris

Pancreatic endocrine tumors with major vascular abutment, involvement, or encasement and indication for resection.

BACKGROUND Surgery for pancreatic endocrine tumors (PETs) with blood vessel involvement is controversial. HYPOTHESIS Resection of PETs with major blood vessel involvement can be beneficial. DESIGN The combined databases of the National Institutes of Health and Stanford University hospitals were queried. MAIN OUTCOME MEASURES Operation, pathologic condition, complications, and disease-free and overall survival. RESULTS Of 273 patients with PETs, 46 (17%) had preoperative computed tomography evidence of major vascular involvement. The mean size for the primary PET was 5.0 cm. The involved major vessel was as follows: portal vein (n = 20), superior mesenteric vein or superior mesenteric artery (n = 16), inferior vena cava (n = 4), splenic vein (n = 4), and heart (n = 2). Forty-two of 46 patients had a PET removed: 12 (27%) primary only, 30 (68%) with lymph nodes, and 18 (41%) with liver metastases. PETs were removed by either enucleation (n = 7) or resection (n = 35). Resections included distal or subtotal pancreatectomy in 23, Whipple in 10, and total in 2. Eighteen patients had concomitant liver resection: 10 wedge resection and 8 anatomic resections. Nine patients had vascular reconstruction: each had reconstruction of the superior mesenteric vein and portal vein, and 1 had concomitant reconstruction of the superior mesenteric artery. There were no deaths, but 12 patients had complications. Eighteen patients (41%) were immediately disease free, and 5 recurred with follow-up, leaving 13 (30%) disease-free long term. The 10-year overall survival was 60%. Functional tumors were associated with a better overall survival (P < .001), and liver metastases decreased overall survival (P < .001). CONCLUSION These findings suggest that surgical resection of PETs with vascular abutment/invasion and nodal or distant metastases is indicated.

EVAR Deployment in Anatomically Challenging Necks Outside the IFU

OBJECTIVE Treatment of abdominal aortic aneurysms with high-risk anatomy (neck length <10-15 mm, neck angle >60°) using commercially available devices has become increasingly common with expanding institutional experience. We examined whether placement of approved devices in short angled necks provides acceptable durability at early and intermediate time points. METHODS A total of 218 patients (197 men, 21 women) at a single academic center underwent endovascular aneurysm repair (EVAR) with a commercially available device between January 2004 and December 2007. Available medical records, pre- and postoperative imaging, and clinical follow-up were retrospectively reviewed. Patients were divided into those with suitable anatomy (instructions for use, IFU) for EVAR and those with high-risk anatomic aneurysm characteristics (non-IFU). RESULTS IFU (n = 143) patients underwent repair with Excluder (40%), AneuRx (34%), and Zenith (26%) devices, whereas non-IFU (n = 75) were preferentially treated with Zenith (57%) over Excluder (25%) and AneuRx (17%). Demographics and medical comorbidities between the groups were similar. Operative mortality was 1.4% (2.1% IFU, 0% non-IFU) with mean follow-up of 35 months (range 12-72). Non-IFU patients tended to have larger sac diameters (46.7% ≥60 mm) with shorter (30.7% ≤10 mm), conical (49.3%), and more angled (68% >60°) necks (all p < .05 compared with IFU patients). Operative characteristics revealed that the non-IFU patients were more likely to be treated utilizing suprarenal fixation devices, to require placement of proximal cuffs (13.3% vs. 2.1%, p = .003), and needed increased fluoroscopy time (31 vs. 25 minutes, p = .02). Contrast dose was similar between groups (IFU = 118 mL, non-IFU = 119 mL, p = .95). There were no early or late surgical conversions. Rates of migration, endoleak, need for reintervention, sac regression, and freedom from aneurysm-related death were similar between the groups (p > .05). CONCLUSIONS EVAR may be performed safely in high-risk patients with unfavorable neck anatomy using particular commercially available endografts. In our experience, the preferential use of active suprarenal fixation and aggressive use of proximal cuffs is associated with optimal results in these settings. Mid-term outcomes are comparable with those achieved in patients with suitable anatomy using a similar range of EVAR devices. Careful and mandatory long-term follow-up will be necessary to confirm the benefit of treating these high-risk anatomic patients.

Phlegmasia complicating prophylactic percutaneous inferior vena caval interruption: A word of caution ☆ ☆☆ ★

PURPOSE The purpose of this study was to evaluate the incidence of thrombotic complications in patients with deep vein thrombosis (DVT) who were treated with percutaneous inferior vena caval interruption in place of anticoagulation. METHODS A retrospective review of all percutaneously placed inferior vena cava filters for 1 year, August 1993 through July 1994, was performed. RESULTS Thirty-three percutaneous inferior vena cava filters were placed in 32 patients. The underlying disease was pulmonary embolism in 15 (47%) and DVT in 17 (53%) patients. Of patients with pulmonary embolism, 11 had a documented DVT, and four were not evaluated for DVT. There were 14 men and 18 women, with a mean age of 63.5 years (range 24 to 93 years). Indications for vena caval interruption were recurrent pulmonary embolism with therapeutic anticoagulation (n = 2 [6%]), prophylactic insertion with documented pulmonary embolism and therapeutic anticoagulation (n = 8 [25%]), documented pulmonary embolism and absolute contraindication to anticoagulation (n = 5 [16%]), documented DVT and absolute contraindication to anticoagulation (n = 2 [6%]), prophylactic insertion with documented DVT and therapeutic anticoagulation (n = 5 [16%]), and documented DVT with relative contraindication to anticoagulation (n = 10 [31%]). Of the 32 patients with inferior vena cava filters, 17 were not given anticoagulants (7 absolute contraindications, 10 relative contraindications), and 15 were given anticoagulants. Insertion of a percutaneous inferior vena cava filter in patients who were not given anticoagulants was followed by the development of phlegmasia cerulea dolens in four patients (24%), which was bilateral in two patients; one patient eventually died. No patients treated with inferior vena cava filter and anticoagulation had development of phlegmasia. CONCLUSIONS Percutaneous inferior vena caval interruption effectively prevents pulmonary embolism in patients with DVT but does not impact the underlying thrombotic process and in fact may contribute to progressive thrombosis in patients who are not given anticoagulants. Anticoagulation with intravenous heparin in safe and effective therapy for DVT in most patients. We believe that percutaneous insertion of vena cava filters should not replace anticoagulation in routine proximal DVT, and those patients who require an inferior vena cava filter for failure of anticoagulation should continue to receive heparin to treat the primary thrombotic process. We caution that relative contraindications to anticoagulation should be carefully scrutinized before recommending vena cava interruption as a primary therapy for DVT.

The cell-saver and autologous transfusion: An underutilized resource in vascular surgery

The vascular surgeons best resource for blood transfusion is the patients own blood. It is readily available for recycling, already precisely typed and crossmatched, and without the risk of transfusion-related diseases such as hepatitis and AIDS. The relative ease, safety, and cost-effectiveness of autologous blood transfusions, intraoperative autotransfusions, and postoperative autotransfusions has been shown in our hospital experience with 320 cases and in the literature. We predict that autologous donor blood and autotransfusion will soon be widely accepted and utilized as the best and safest method of blood replacement.

Long-term results after accessory renal artery coverage during endovascular aortic aneurysm repair

OBJECTIVE Current information regarding coverage of accessory renal arteries (ARAs) during endovascular aneurysm repair (EVAR) is based on small case series with limited follow-up. This study evaluates the outcomes of ARA coverage in a large contemporary cohort. METHODS Consecutive EVAR data from January 2004 to August 2010 were collected in a prospective database at a University Hospital. Patient and aneurysm-related characteristics, imaging studies, and ARA coverage versus preservation were analyzed. Volumetric analysis of three-dimensional reconstruction computed tomography scans was used to assess renal infarction volume extent. Long-term renal function and overall technical success of aneurysm exclusion were compared. RESULTS A cohort of 426 EVARs was identified. ARAs were present in 69 patients with a mean follow-up of 27 months (range, 1 to 60 months). Forty-five ARAs were covered in 40 patients; 29 patients had intentional ARA preservation. Patient and anatomic characteristics were similar between groups except that ARA coverage patients had shorter aneurysm necks (P = .03). Renal infarctions occurred in 84% of kidneys with covered ARAs. There was no significant deterioration in long-term glomerular filtration rate when compared with patients in the control group. No difference in the rate of endoleak, secondary procedures, or the requirement for antihypertensive medications was found. CONCLUSIONS This study is the largest to date with the longest follow-up relating to ARA coverage. Contrary to previous reports, renal infarction after ARA coverage is common. Nevertheless, coverage is well tolerated based upon preservation of renal function without additional morbidity. These results support the long-term safety of ARA coverage for EVAR when necessary.

Coagulopathy associated with peritoneovenous shunting

Le Veen shunts successfully alleviated ascites in 19 of 24 patients (79 percent). Clinical clotting typical of disseminated intravenous coagulation occurred in nine of these patients (37 percent) and was fatal in seven (78 percent). Laboratory findings suggesting disseminated intravenous clotting were present in five other patients (21 percent) but were not associated with troublesome bleeding. Coagulopathy was reversed in 7 of 14 patients (50 percent), if the shunt was ligated and supportive measures were taken early in the postoperative course. Failure to recognize or take immediate action resulted in progressive disseminated intravenous clotting associated with a mortality of 50 percent (7 of 14 patients).

Avoiding coagulopathy in vascular surgery.

The possibility of coagulopathy can be minimized by attending to certain general perioperative details to avoid hypothermia, hypotension-shock, and multiple transfusions. In this paper, we present our protocol for avoiding coagulopathy in vascular surgery. In the past 1 1/2 years, we have used perioperative plasmapheresis in 204 patients undergoing cardiac or aortic peripheral vascular surgery. Autologous platelet-rich plasma is transfused at the completion of the operation after heparin reversal. Our data show an approximate 50% reduction in homologous blood product requirement. Seventy-five percent of patients having aortic surgery received no homologous blood products during their hospital stay. For those undergoing cardiac surgery, there has been about a 45% reduction in the use of homologous blood products. In our experience, autologous platelet-rich plasma not only decreases the risk of transmittable disease, but promotes hemostasis.

Value of postoperative heparin therapy in peripheral arterial thromboembolism

The experience with 359 patients with arterial thromboembolism from 1963 to 1982 has been reported. Combined operative and anticoagulant therapy appears the most beneficial form of treatment. Treatment with heparin after catheter embolectomy was associated with a decrease in mortality (7.6 percent), number of amputations (5 percent), and recurrent emboli (6 percent). Serious wound complications occurred less frequently than anticipated (8 percent). We advocate prompt arteriography and revascularization procedures to ensure long-term limb function after initial embolectomy for salvage, if the result is less than optimal or expected. Postoperative heparin seems to buy time in marginal cases, enabling secondary operations to ensure a satisfactory outcome in most patients.

Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study.

OBJECTIVE To examine the impact of major vascular resection on sarcoma resection outcomes. SUMMARY BACKGROUND DATA En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described. METHODS Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival. RESULTS From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion. CONCLUSIONS Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.

The Plasma Collection System: A New Concept in Autotransfusion

We have used the Haemonetics Cell-Saver autotransfusion technique in over 6,500 cases since 1979, salvaging more than 11,000 units of packed red blood cells. Major utilization has been in cardiac, vascular, and orthopedic cases. Coagulopathy associated with hypothermia, shock, multiple transfusions, and the autotransfusion technique, which removes clotting factors and platelets, often necessitated use of fresh-frozen plasma and platelet packs postoperatively to control bleeding and clotting problems. However, this defeats the prevention of disease transmission, transfusion reaction, and autoimmunization. Haemonetics has recently developed a plasma collection system which salvages up to 1,000 cc of platelet-rich plasma. Early experience suggests this technique will not only decrease the incidence of postoperative bleeding but further decrease the use of homologous (bank) blood and components. A step-by-step guide to the plasma collection system is discussed. The plasma collection system augments the present autotransfusion technique that conserves red blood cells, thus making complete autologous blood transfusion a reality.