Fred W. Rushton

Emergency procedures on the descending thoracic aorta in the endovascular era

BACKGROUND Thoracic endovascular aortic repair (TEVAR), initially developed for the treatment of degenerative aneurysms of the descending thoracic aorta, has been applied to the entire spectrum of descending thoracic aortic pathology in both the elective and emergent settings. This single center study evaluates the effectiveness of TEVAR for the treatment of acute surgical emergencies involving the descending thoracic aorta, including traumatic aortic disruption (TAD), ruptured descending thoracic aneurysm (RDTA), and acute complicated Type B dissection (cTBD). METHODS A retrospective review of the medical records of all patients undergoing emergent TEVAR at the University of Mississippi Medical Center between August 2007 and November 2010 was undertaken. Patients were studied for 30-day survival, complications, type of device used for the repair, and technical aspects of the procedure. RESULTS A total of 44 patients (59% male) with an average age of 49 years (range, 16-87 years) underwent emergent TEVAR during the study period. The technical success rate was 100%, with no patient requiring emergent open surgery for conditions involving the descending thoracic aorta at our institution during the study period. The majority (73%) of the repairs were accomplished using commercially available thoracic stent grafts. Abdominal endograft proximal extension cuffs were used in 12 (38%) of the 32 patients undergoing repair of TAD. Twenty-one patients (48%) required coverage of the left subclavian artery, two (10%) of whom subsequently required subclavian artery revascularization. Procedure-related complications included two strokes, one spinal cord ischemia, one unintentional coverage of the left carotid artery, one episode of acute renal failure, and three access site injuries. One patient undergoing repair of TAD had collapse of the stent graft in the early postoperative period. He was successfully treated by placement of an additional stent graft. Seven patients (16%) died within 30 days of surgery. Three of the deaths occurred in patients who had successfully undergone repair of a TAD and died of associated injuries. CONCLUSIONS Emergent TEVAR has become the treatment of choice for acute surgical emergencies involving the descending thoracic aorta. Short-term morbidity and mortality compare favorably with historic results for emergent open surgical procedures on the descending thoracic aorta. Survival is highest in patients undergoing repair of TAD. Using current endograft technology, nearly all emergent conditions of the descending thoracic aorta can be successfully treated with TEVAR.

The Importance of the Abdominal Viscera to Peritoneal Transport During Peritoneal Dialysis in the Dog

The authors sought to evaluate the dialyzing surfaces important for peritoneal dialysis. They reasoned that the most definitive way to evaluate whether any of the gut and associated membranes contributed to trasport was to see if transport chnged when they were removed. Paired studies measuring rates of peritoneal uptake of glucose, urea, and inulin were carried out in dogs. In the morning, the animals were tested with all peritoneal membranes intact. In the afternoon, the studies were repeated after evisceration. The mass transfer coefficients (MTC ml/min)-glucose (viscera 4.4 ± 0.7, no viscera 4.9 ± 0.3)-urea (viscera 16.8 ± 2.4, no viscera 13.8 ± 1.0);-inulin (viscera 1.6 ± 0.6, no viscera 2.2 ± 0.7) were not changed nor was the amount of mass abosorbed significantly different. MTC and peritoneal absoption were unaffected by omentectomy, mesenterectomy, or evisceration. Whether these results were due to nonparticipation of these structures in peritoneal transport or other mechnisms await further studies.

Researches on the cause of burn hypermetabolism.

Researches on the Cause of Burn Hypermetabolism WILLIAM NEELY;ANTHONY PETRO;GARLAND HOLLOMAN;FRED RUSHTON;M. TURNER;JAMES HARDY; Annals of Surgery

Endovascular Repair of a Chronic Aortocaval Fistula Using a Thoracic Aortic Endoprosthesis

Penetrating abdominal trauma with injury to the aorta and vena cava usually requires emergent intervention and is frequently lethal. Formation of a chronic aortocaval fistula (ACF) is an uncommon late complication of these injuries. We report a case of an ACF presenting 17 years after a gunshot wound to the abdomen, with progressive congestive heart failure as the presenting symptom. The ACF was successfully treated with an endoprosthesis designed for the thoracic aorta.

Efficacy and Safety Results with the LifeSite Hemodialysis Access System versus the Tesio-Cath Hemodialysis Catheter at 12 Months

PURPOSE To compare the performance and safety of a fully subcutaneous vascular access device, the LifeSite hemodialysis access system, versus a tunneled hemodialysis catheter, the Tesio-Cath, at 1 year after implantation. MATERIALS AND METHODS Sixty-eight patients who required hemodialysis received implantation of the LifeSite device or a Tesio-Cath device as a part of this multicenter study. Thirty-four patients were treated in each group. The endpoints observed included blood flow rates and associated venous pressures, overall and device-related adverse events, the need for thrombolytic infusions, device-related infections (DRIs) and associated hospitalizations, and technical device survival. RESULTS During the 12-month observation period, significantly higher venous pressures were required in patients with the Tesio-Cath to achieve blood flow rates comparable with those achieved with the LifeSite device. Patients in the LifeSite group experienced a significantly lower rate of non-device-related adverse events (P < .001), device-related adverse events (P < .016), need for thrombolytic infusions (P < .002), and DRIs (P < .013) compared with patients in the Tesio-Cath group. There was a trend toward a lower number of hospital days per month for DRIs in the LifeSite group, with the rate for the Tesio-Cath group being twice that in the LifeSite group. The use of the LifeSite device was also associated with a significantly higher probability of device survival for 12 months after censoring for planned removals (P < .031). CONCLUSIONS The results of the present study demonstrate superior device performance and technical device survival, reduced complications, and the need for fewer interventions with the LifeSite hemodialysis access system compared with a standard hemodialysis catheter during a 1-year time period after implantation.

The weight of obesity in patients with lower extremity vascular injuries.

OBJECTIVE Clinical obesity is an epidemic problem in the United States. The impact of this disease upon traumatic lower extremity vascular injuries (LEVI) is as yet undefined. We hypothesized that clinical obesity adversely affects outcome in patients with traumatic LEVI. METHODS All adult patients admitted over a 5-year period with a traumatic LEVI were identified. Clinical obesity was defined as body mass index (BMI)>30. Obese and non-obese patient groups were compared for surgical management and outcome. RESULTS A total of 145 patients were identified. BMI data were available for 115 (79.3%) of these patients (obese n=47; non-obese n=68). Obese and non-obese groups were similar. Obese patients underwent more vascular repairs but the amputation rate and mortality were not significantly different. CONCLUSIONS While obese body habitus can increase the complexity of evaluation and management of patients with LEVI, we have demonstrated that equivalent outcomes to the non-obese population can be achieved for the clinically obese patient with a BMI>30. However, patients with a BMI>40 did reveal a significantly higher chance of amputation and death after LEVI. Due to the small number of patients in this subset, one should use caution when interpreting this data.

Infrarenal Origin of the Superior Mesenteric Artery: Implications in Endovascular Repair of Abdominal Aortic Aneurysm

Endovascular aneurysm repair (EVAR) has become the preferred modality for the treatment of infrarenal abdominal aortic aneurysms (AAAs). A variety of anatomic factors must be considered when planning EVAR, including the relationship of the visceral arteries to the aneurysmal segment of the aorta. This report describes 2 patients with infrarenal AAA in whom the superior mesenteric artery was the most caudal visceral vessel, originating inferior to the renal arteries.