Matthew E. Bennett

New predictors of complications in carotid body tumor resection

Objective: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. Methods: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi‐institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. Results: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0‐10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1‐1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0‐3500 mL). Twenty‐four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables—Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)—was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1‐cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25‐2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19‐1.92). Conclusions: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1‐cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Revision using distal inflow is a safe and effective treatment for ischemic steal syndrome and pathologic high flow after access creation

OBJECTIVE Ischemic steal syndrome (ISS) and pathologic high flow (HF) are a complications after hemodialysis access creation. Their management is complex and varied with most requiring surgical revision for correction of symptoms. Revision using distal inflow (RUDI) has been described in small series for the treatment of ISS. We present our experience with RUDI for the treatment of ISS and pathologic HF. METHODS We retrospectively reviewed consecutive patients who underwent RUDI for ISS from April, 2010 to March, 2014. Data collection included demographic characteristics, medical histories, subsequent procedures, volume flows, access usage, limb salvage, and patient survival. RESULTS We performed 29 RUDI procedures in 28 patients (16 women, 12 men). Indications for surgery were pathologic HF in 13 and ISS in 19. Ten percent had previous banding for ISS or HF. Sixty-nine percent of patients had a history of diabetes. Fifty-two percent had a history of atherosclerotic disease. Mean time to intervention from creation was 40 months (range, 6-88 months). Accesses included 1 upper arm graft and 27 brachial artery-based fistulas. Outflow included 25 cephalic veins and 3 basilic veins. Distalization targets were 19 radial arteries and 10 ulnar arteries. Mean flow reduction was 1191 mL/min. Primary assisted patency at 1 year was 74%. Secondary patency at 1 year was 87%. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 69% and partial in 31%. CONCLUSIONS RUDI is an effective and durable treatment of ISS and HF comparable with reported experiences with distal revascularization-interval ligation, proximalization of the arterial inflow, and banding. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.

Left axillary to right atrium anterior chest wall graft using bovine carotid artery conduit

Introduction: Central venous occlusive (CVO) disease involving the superior vena cava (SVC) and inferior vena cava (IVC) can occur frequently in patients with end-stage renal disease (ESRD) on chronic dialysis. Dialysis access is essential for the survival of these patients. Case description: We report a case of a chest wall graft creation using bovine carotid artery conduit in a patient who was experiencing life-threatening loss of dialysis access secondary to her SVC and IVC occlusion along with a hypercoagulable state. We did a subcutaneous anterior chest wall graft from the left axillary artery to the right atrium (RA) using a mini thoracotomy incision. Conclusions: ESRD patients with CVO pose a unique challenge. We believe our approach can provide an excellent option for dialysis access in patients with exhausted conventional access options.

Retrograde Pedal Access

Retrograde pedal access is performed for difficult to cross arterial lesions. In conjunction with traditional brachial/femoral antegrade access, it can be used for the “body floss” technique. This chapter describes indications, essential steps, and complications of these procedures. It provides a detailed template operative note for the procedure.