Jean E. Starr

Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms

PURPOSE To determine whether gender distinction influence the cardiac risk or survival rates associated with surgical treatment of infrarenal abdominal aortic aneurysms (AAAs). METHODS From 1983 to 1988, graft replacement of intact AAAs was performed in 490 men (84%) and in 92 women (16%) who had no history of myocardial revascularization before the discovery of their AAAs. Patients of both genders were comparable with respect to mean age (68 years) and the prevalence of coronary artery disease (CAD) by standard clinical criteria (men, 73%; women, 65%). Preoperative coronary angiography was obtained in 471 of the 582 patients (men, 81%; women, 80%) during this particular study period. Preliminary coronary bypass was warranted on the basis of existing indications in 111 (24%) of these 471 patients (men, 25%; women, 18%), including 104 (31%) of the 337 who had clinical indications of CAD (men, 32%; women, 26%) but only 7 (5.2%) of the 134 who did not (men, 6%; women, 4%). Follow-up data were collected during a mean interval of 53 months (men, 54 months; women, 48 months) and were analyzed by Kaplan-Meier survival analysis and Cox proportional hazards models. RESULTS Twenty-nine perioperative deaths (5.0%) occurred in conjunction with AAA repair (men, 5.1%; women, 4.3%), and 126 early and late deaths have occurred (men, 22%; women, 22%). Survival rates for the series were found to correlate with age (p < 0.001), the serum creatinine level (p < 0.001), and the coronary angiographic classification (p < 0.001). No significant differences were identified between the gender cohorts. The cardiac mortality rate for AAA resection was only 1.8% in the 111 patients who had preliminary coronary bypass, but five additional perioperative deaths (4.5%) related to renal failure or sepsis occurred in this group. However, 5-year survival rates for patients receiving preliminary bypass (men, 82%; women, 75%) were closely comparable with those for patients found to have only mild to moderate CAD by angiography (men, 86%; women, 82%). CONCLUSION We conclude that men and women with AAAs have similar cardiac risks and survival rates associated with surgical treatment. Our results also illustrate that the potential benefit of coronary intervention for severe CAD in patients of either gender must be considered in the context of long-term outcome and the early mortality rate of AAA repair.

Superficial venous thrombosis of the lower extremities: analysis of risk factors, and recurrence and role of anticoagulation

Superficial venous thrombosis (SVT) of the lower extremities is a common ailment seen in outpatient offices of vascular medicine and surgery practices. This study of 60 consecutive outpatients was carried out to examine the incidence of concomitant deep venous thrombosis (DVT), risk factors associated with SVT, recurrence of SVT and=or new DVT, and the role of anticoagulant therapy in the prevention of recurrence. Concomitant SVT and DVT (13%) were significantly less likely to be present in patients with varicose veins as compared to patients without varicose veins (p < 0.04) and more likely to be present in patients with a previous history of DVT (p < 0.02). Fifteen patients (25%) developed either recurrent SVT or new DVT, with two patients developing both SVT and DVT. The absence of varicose veins and the presence of a hypercoagulable condition (n = 12) appeared to influence the development of new DVT but not the recurrence of SVT. Recurrent SVT was much more likely in patients with thrombosis of the tributaries (p < 0.0008). New DVT was seen significantly less frequently in patients on anticoagulants (p < 0.02).

Abdominal aortic aneurysms in women

Abdominal aortic aneurysms have an incidence that is approximately four to six times higher in men than in women. However, the incidence in women also rises with older age, although starting later in life than in men. There are also sex differences in the risk of rupture and in outcomes after endovascular and open abdominal aortic aneurysm repair. Various explanations have been proposed. Women historically have been under-represented in clinical trials to evaluate the differences between the sexes. We present a review of current recommendations and recent literature to help identify some of these differences.

The EPIC Nitinol Stent System in the Treatment of Iliac Artery Lesions: One-Year Results From the ORION Clinical Trial

Purpose To report the 1-year results of a pivotal study for a new-generation nitinol stent for the treatment of iliac atherosclerotic lesions. Methods The ORION trial ( ClinicalTrials.gov identifier NCT00896337) was a single-arm, non-randomized, prospective, multicenter clinical trial that enrolled 125 patients (81 men; mean age 61.1±9.3 years) implanted with the EPIC self-expanding nitinol stent system in 166 de novo or restenotic iliac artery lesions ≤13 cm long. The primary endpoint was the 9-month major adverse event rate [i.e., device- or procedure-related death within 30 days, myocardial infarction during the index hospitalization, target vessel revascularization (TVR), or index limb amputation]. Follow-up occurred at hospital discharge and at 1, 9, and 12 months. An independent core laboratory evaluated ultrasound results at 1, 9, and 12 months. Results The primary endpoint met the prespecified performance goal, with only 3.4% (4/117) of patients experiencing a major adverse event by 9 months (p<0.0001). By 12 months, 6 (5.4%) of 111 patients had TVR; none had an index limb amputation. The ankle-brachial index, Walking Impairment Questionnaire, and Rutherford classifications all showed sustained improvements through 12 months. Primary patency was 94.4% with comparable results for lesions classified as complex (TASC II C/D 95.5%) or non-complex (TASC II A/B 95.0%). Conclusion The EPIC stent system demonstrated safety and effectiveness through 12 months, including improvements for complex lesions. The EPIC stent is a viable alternative to surgery for patients with either complex or non-complex lesions.

Diseases of the thoracic aorta in women

Women have now equaled or surpassed men in the number of cardiovascular deaths per year in published statistics. In 2006, according to the National Center for Health Statistics and the Center for Disease Control, cardiovascular disease was the cause of death in 428,906 women (35% of all deaths in women) and in 394,840 men (33% of all deaths in men). Of those numbers, it was estimated that 5506 women (0.4% of all deaths in women) and 7732 men (0.6%) died because of aortic aneurysm or dissection. Currently, aortic disease ranks as the 19th leading cause of death with reported increases in incidence. Historically, aortic disease is thought to affect men more frequently than women with a varying reported gender ratio. Gender bias has long been implicated as an important factor, but often overlooked, in the analysis and interpretation of cardiovascular diseases outcome, in part, because of the under-representation of women in clinical trials and studies. In this section, we provide an up-to-date review of the epidemiology and management of common diseases of the thoracic aorta, focusing on the differences and similarities in women and men.

Endograft Infection Presenting as a Ruptured Aortic Aneurysm

Aortic endograft procedures have become commonplace. Fortunately, infection of endografts remains rare, with an incidence <0.5%. Infection results from contamination at the time of implantation, by seeding the graft from a remote infection, or contiguous infection. We describe a case of late infection after endovascular aortic repair resulting in rupture of the aneurysm sac, followed by a brief review of endograft infections. In a review of the endograft literature, only one other article describes rupture of an aneurysm after endograft due to infection. This case highlights the importance of a thorough endograft evaluation in any patient with abdominal complaints.

Essentials of negotiating for employment in a changing environment

Evolving changes in health care in the United States are causing new graduates and self-employed physicians to consider employment with large groups and health systems. Familiarity with the principles, proper conduct, and mechanics of negotiating an employment agreement will be important for vascular surgeons making such a decision. The various components of compensation packages and contract language need to be critically evaluated. To facilitate an understanding of the complexities involved in employment contracts, strategies to avoid making negotiating mistakes are discussed.

Ultrasound-Guided Thrombin Injection Is a Safe and Effective Treatment for Femoral Artery Pseudoaneurysm in the Morbidly Obese

Introduction: Ultrasound-guided thrombin injection (UGTI) is a well-established practice for the treatment of femoral artery pseudoaneurysm. This procedure is highly successful but dependent on appropriate pseudoaneurysm anatomy and adequate ultrasound visualization. Morbid obesity can present a significant technical challenge due to increased groin adiposity, resulting in poor visualization of critical structures needed to safely perform the procedure. We aim to evaluate the safety and efficacy of UGTI to treat femoral artery pseudoaneurysm in the morbidly obese. Methods: This is a retrospective cohort study in which all patients who underwent UGTI at The Ohio State University Ross Heart Hospital from 2009 to 2014 were analyzed for patient characteristics and stratified by body mass index (BMI). Patients with BMI ≥ 35 were considered morbidly obese and were compared to patients with a BMI < 35. Outcome was failed treatment resulting in residual pseudoaneurysm. Results: Our cohort consisted of 54 patients who underwent thrombin injection. There were 41 nonmorbidly obese and 13 morbidly obese patients. Mean age was 64.5 years. The cohort was 44.4% male. There were 6 failures, of which 1 underwent successful repeat injection and 5 underwent open surgical repair. There was no statistically significant difference in failure between nonmorbidly obese and morbidly obese patients (9.8% vs 15.4%, P = .45). There were no embolic/thrombotic complications. Conclusion: Ultrasound-guided thrombin injection is a safe and effective therapy in the morbidly obese for the treatment of femoral artery pseudoaneurysm. In the hands of experienced sonographers and surgeons with adequate visualization of the pseudoaneurysm sac, UGTI should remain a standard therapy in the morbidly obese.

Mesenchymal tumour of the inferior vena cava

Abstract The aim of this work was to study the associations between weather conditions and the occurrence of type B acute aortic dissections (ABAD). This study was a retrospective review of all ABAD cases between January 1st, 2006 and December 31st, 2015. Using a time-series design and distributed lag non-linear models (DLNM), we estimated the relative risk (RR) of ABAD presentation associated with mean daily temperatures, including cumulative RR for a 28-day period, and RR for individual daily lags through 28 days. A total of 213 patients were admitted with ABAD. A significant association was found between the daily maximal temperature and the number of hospital admissions for ABAD. The lower the maximal temperature, the higher the incidence of ABAD (P = 0.044). Furthermore, the onset of ABAD was higher in winter than in summer and autumn (P = 0.009 and P = 0.001). Based on a time-series analysis, this study showed that the associations between mean daily temperature and ABAD presentation were not monotonic. Compared to the centered temperature at 8°C, the cumulative 28-day (lag 0 to lag 27) RR was significantly elevated at - 20 °C and - 19 °C for ABAD (RR = 1.39; 95%CI: 1.02, 1.98 and RR = 1.36; 95%CI: 1.02, 1.98). At the extreme low temperature (- 17.7 °C) in Shenyang, the cumulative 14-day (lag 0 to 13 day) and 21-day (lag 0 to 20 day) RR were remarkably increased for ABAD (RRlag14-day = 1.34; 95%CI: 1.08, 1.40 and RRlag21-day = 1.06; 95%CI: 1.06, 1.23). For the extreme high temperature, however, no particular finding was detected regarding acute and prolonged effects on ABAD. In general, low ambient temperature was significantly associated with ABAD presentations in comparison with high temperature. The effects of cold were delayed by two weeks and persisted for a few days.

Can the Anesthesiologist Use the Radial Artery for Monitoring After Transradial Artery Catheterization

The use of transradial coronary angiography and intervention is growing because of its advantages over the femoral approach. However, the small size of the radial artery can contribute to complications. We present a case of an in situ access complication of transradial coronary artery catheterization. It is important for the anesthesiologist to know about the short-term and long-term consequences of this intervention, which could lead to narrowing of the artery even beyond the site of puncture. Understanding these changes could help anesthesiologists make better decisions about using the radial artery for monitoring after transradial coronary artery catheterization procedures.