Matthew J. Sideman

A novel approach to the problem of intestinal fistulization arising in patients managed with open peritoneal cavities

Open management of the peritoneal cavity is an efficacious technique for controlling fulminant intraabdominal sepsis. A significant proportion of these patients develop intestinal fistulae for which there are few good treatment options. We propose a novel technique for preventing and potentially treating intestinal fistulas that involves patching intestinal deserosalizations and fistulas with acellular dermal matrix (Alloderm) and fibrin glue. We report our experience with this technique in 2 patients who developed small bowel deserosalizations, neither of whom went on to develop fistulas. We additionally describe 1 patient who developed an intestinal fistula for whom we were able to affect closure with this technique. We propose that our method is a useful temporizing measure to prevent fistulae formation. Furthermore, we believe this technique may be a useful option for treating intestinal fistulae arising in patients managed with open abdominal wounds.

Primary and staged transposition arteriovenous fistulas.

BACKGROUND The use of catheters or prosthetic grafts for vascular access has significantly higher mortality and morbidity risks, in addition to higher costs, than arteriovenous fistulas (AVF). Many patients have a difficult access extremity due to complex medical illnesses, previous vascular access procedures, intravenous catheters, diabetes, vascular disease, female sex, age, and other complicating factors. Transposition AVFs (AVF-T) have been used for these individuals to avoid catheters and grafts. We report our experience with primary and staged basilic vein AVF-Ts and staged brachial vein AVF-Ts. METHODS From our database of consecutive vascular access operations, we reviewed patients from May 2003 to September 2006 for all upper extremity AVF-Ts. A primary AVF-T was used when the basilic vein was continuous with a minimum diameter of 4 mm and of adequate length. When the basilic vein was 2.5 to 4 mm, the procedure was staged. The proximal radial artery was used for inflow, if possible. When the basilic vein was not suitable, a radial vein or brachial vein anastomosis was performed as the first stage of a planned brachial vein AVF-T. The second stage operations of staged AVF-Ts were generally done 4 to 6 weeks after the primary AVF construction. All patients were evaluated with preoperative ultrasound imaging by the operating surgeon. RESULTS From a database of 412 consecutive vascular access patients, 78 upper extremity transposition procedures were identified. Of these, 57 patients (73.1%) were women, 44 (56.4%) were diabetic, and 46 (59.0%) had previous access surgery. Fifty-eight operations were staged procedures. The basilic vein was used in 68 AVF-T, the brachial vein in six, and cephalic vein in four. The anastomosis was based on the proximal radial artery in 60 patients. Mean follow-up was 18 months (range, 3-48 months). Primary patency, primary assisted patency, and cumulative patency were 45.7%, 93.5%, and 96.0% at 12 months and 27.6%, 86.5%, and 88.9% at 24 months, respectively. No prosthetic grafts were used in the study period. CONCLUSION Both primary and staged AVF-T procedures were successfully used in patients with difficult access extremities. AVF-Ts were durable, although many required an interventional procedure for maturation or maintenance. Cumulative (secondary) patency was 96.0% at 12 months and 88.9% at 24 months. The absence of an adequate basilic vein does not preclude the use of a staged AVF-T because the brachial vein offers a suitable alternative.

Brachial vein transposition arteriovenous fistulas for hemodialysis access

BACKGROUND An arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis, offering lower morbidity, mortality, and cost compared with grafts or catheters. Patients with a difficult access extremity have often lost all superficial veins, and even basilic veins may be obliterated. We have used brachial vein transposition AVFs (BVT-AVFs) in these challenging patients and review our experience in this report. METHODS The study reviewed consecutive patients in whom BVT-AVFs were created from September 2006 to March 2009. Most BVT-AVFs were created in staged procedures, with the second-stage transposition operations completed 4 to 6 weeks after the first-stage AVF operation. A single-stage BVT-AVF was created when the brachial vein diameter was > or =6 mm. RESULTS We identified 58 BVT-AVF procedures, comprising 41 women (71.0%), 28 diabetic patients (48.3%), and 29 (50.0%) had previous access surgery. The operation was completed in two stages in 45 operations (77.6%) and was a primary transposition in 13 patients. However, five of these were secondary AVFs with previous distal AV grafts or AVFs placed elsewhere; effectively, late staged procedures. Follow-up was a mean of 11 months (range, 2.0-31.7 months). Primary patency, primary-assisted patency, and cumulative (secondary) patency were 52.0%, 84.9%, and 92.4% at 12 months and 46.2%, 75.5%, and 92.4% at 24 months, respectively. Harvesting the brachial vein was tedious and more difficult than harvesting other superficial veins. No prosthetic grafts were used. CONCLUSION BVT-AVFs provide a suitable option for autogenous access when the basilic vein is absent in patients with difficult access extremities. Most patients required intervention for access maturation or maintenance. Most BVT-AVFs were created with staged procedures. Cumulative (secondary) patency was 92.4% at 24 months.

Endoscopic basilic vein transposition for hemodialysis access.

BACKGROUND Hemodialysis access by autogenous arteriovenous fistulas (AVFs) is generally recommended due to lower mortality, morbidity, and cost vs graft and catheter use. Many dialysis patients lack the common superficial veins used for standard AVF options and require transposition of a deep vein for autogenous dialysis access through a long open incision (open/AVF-T). These operations may require prolonged time for healing, thus extending catheter-based dialysis. We report our experience with minimally invasive techniques for creating AVF-Ts using an endoscopic procedure (endo/AVF-T). METHODS We reviewed our vascular access database of consecutive access operations to identify consecutive patients with endo/AVF-Ts. For comparison, we also reviewed the immediate preceding traditional open/AVF-T operations that we previously reported. We evaluated demographics, time to access use, and primary, assisted, and cumulative patency. RESULTS We identified 100 consecutive endo/AVF-T operations attempted, and 98 were technically successful. The analysis excluded two conversions to successful open/AVF-T. The mean age of the 98 patients in the endo/AVF-T study group was 60 years (range, 22-94 years), 59 (60.2%) were women, 48 (49.0%) were diabetic, 20 (20.4%) were obese, and 52 (53.1%) had had previous access surgery. Mean time to initial use of the access for endo/AVF-Ts was 6 weeks for primary and 12 weeks for staged transpositions. Mean follow-up was 14 months (range, 1-30 months). The 12- and 24-month cumulative patencies were 95.5% and 88.6%. The 78 traditional open/AVF-T operations from our previous report were reviewed for comparison. The mean age was 62 years (range, 18-83 years), 57 (73.1%) were women, 44 (56.4%) were diabetic, 15 (19.2%) were obese, and 46 (59.0%) had previous access surgery. Mean time to initial use of the access for open/AVF-Ts was 8 weeks for primary and 16 weeks for staged operations. Mean follow-up was 18 months (range, 3-48 months). The 12- and 24-month cumulative patencies were 96.0 and 88.9%. No grafts were used in any patient during the study period. CONCLUSION Time to access use was less with endoscopic AVF-T (P < .01) for both primary and staged operations. Primary, assisted, and cumulative patency rates were the same for open and technically successful endoscopic transpositions. Endoscopic AVF-Ts offer a viable alternative to open AVF-Ts.

Outcomes of Isolated Tibial Endovascular Interventions for Rest Pain in Patients on Dialysis

Study design: Single-center review between September 2013 and April 2015. Key findings: There were 30 patients who underwent preoperative computed tomograqphy angiography (CTA) and noncontrast enhanced magnetic resonance imaging (NC-MRI) at a maximum interval of 60 days prior to endovascular aneurysm repair (EVAR). Two expert readers (vascular radiologist and vascular surgeon) reviewed CTA images and chose the proper endograft for each patient. A vascular radiologist and a resident radiologist reviewed CTA and NCMRI examinations in a double-blind fashion. MRI sensitivity and specificity compared with CTA were 94% and 100%, respectively. CTA and NC-MRI angiographic measurements showed strong correlation, except for external iliac artery diameters. The choice of stent size was always the same between the two observers. Conclusion: Although CTA remains the gold standard, NC-MRI is a good alternative for EVAR planning such as for patients with renal impairment. Commentary: The paper suggests that NC-MRI is a suitable alternative for CTA when planning EVAR. This imaging alternative most readily applies to patients with chronic renal failure where contrast would be contraindicated. Although gadolinium-enhanced MRA has been (rarely) associated with nephrogenic systemic fibrosis in patients with renal failure, omission of contrast when performing MRI, as in this report, would avoid this complication. The biggest concern for the vascular surgeon who is not experienced interpreting MRIs is relying on a radiologist to provide accurate measurements for EVAR planning based on NC-MRI. Nonetheless, NC-MRI may prove to be a valuable alternative when planning EVAR in patients with renal impairment by avoiding the use of contrast with CTA. However, we have successfully used noncontrast-enhanced CT scans to plan EVAR in patients with renal insufficiency. My question is which study is more accurate and reliable in patients requiring complicated endovascular repairs who have underlying renal insufficiency: CT scan without contrast or MRI without contrast?

Outcomes of reintervention for recurrent symptomatic disease after tibial endovascular intervention

Objective Tibial interventions for critical limb ischemia are now commonplace. Restenosis and occlusion remain barriers to durability after intervention. The aim of this study was to examine the patient‐centered outcomes of open and endovascular reintervention for symptomatic recurrent disease after a primary isolated tibial endovascular intervention. Methods A database of patients undergoing isolated primary lower extremity tibial endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with recurrent critical ischemia (Rutherford 4 and 5) were identified. Outcomes in this cohort were analyzed, and three groups were defined: endovascular reintervention (ie, a repeated tibial or pedal endovascular intervention), bypass (bypass to a tibial or pedal vessel), and primary amputation (ie, above‐ or below‐knee amputation) on the ipsilateral leg. Patient‐oriented outcomes of clinical efficacy (absence of recurrent signs or symptoms of critical ischemia, maintenance of ambulation, and absence of major amputation), amputation‐free survival (survival without major amputation), and freedom from major adverse limb events (above‐ankle amputation of the index limb or major reintervention, such as new bypass graft or jump or interposition graft revision) were evaluated after the reintervention. Results There were 1134 patients (56% male; average age, 59 years) who underwent primary tibial intervention for critical ischemia, and 54% presented with symptomatic restenosis and occlusion. Of the 513 patients with recurrent disease, 58% presented with rest pain and the remainder with ulceration. A repeated tibial endovascular intervention was performed in 64%, open bypass in 19%, and below‐knee amputation in 17%. Bypass was employed in patients with a good target vessel, venous conduit, and good pedal runoff. Patient‐centered outcomes were better in the bypass group compared with the reintervention group (amputation‐free survival, 45% ± 9% vs 27% ± 9% [P < .01]; major adverse limb events, 50% ± 9% vs 31% ± 9% [P < .05]; clinical efficacy, 60% ± 7% vs 30% ± 9% [P < .01], mean ± standard error of the mean at 5 years). Conclusions Tibial interventions for critical ischemia are associated with a high rate of reintervention. In patients with good target vessel, venous conduit, and good pedal runoff, bypass appears more durable than repeated tibial endovascular intervention.

Outcomes of upper extremity interventions for chronic critical ischemia

Background: Critical hand ischemia owing to below‐the‐elbow atherosclerotic occlusive disease is relatively uncommon. The aim of this study was to examine the outcomes in patients presenting with critical ischemia owing to below‐the‐elbow arterial atherosclerotic disease who underwent nonoperative and operative management. Methods: A database of patients undergoing operative and nonoperative management for symptomatic below‐the‐elbow atherosclerotic disease between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (tissue loss and rest pain) were identified. Three management groups were identified: no revascularization (None), endovascular revascularization (Endo), and open revascularization by bypass (Bypass). Patients with acute embolism, active vasculitis, end‐stage renal disease, ipsilateral dialysis access complications of steal, and ipsilateral trauma were excluded. Results: One hundred eight patients (56% male; average age, 59 years) presented with symptomatic below‐the‐elbow disease: 93% presented with digital ulceration and the remainder with rest pain. Eighty‐one percent had diabetes and 41% had chronic renal insufficiency (not on dialysis). All underwent catheter‐based angiography. Fifty‐three patients (49%) had no intervention and subsequently were committed to wound care; 26 of these required no further intervention, 10 had an interval palmar sympathectomy, and 17 underwent either a phalanx or digital amputation. Thirty‐four patients (31%) underwent an endovascular intervention with a median of 1.5 vessels (ulnar, radial, or interosseous arteries) intervened on. Technical success was achieved in 29 patients (85%). Of the five technical failures, two went on to bypass, one had a focal endarterectomy and patch angioplasty, and one was treated conservatively. Ten patients in the Endo group required either a phalanx or digital amputation. Twenty‐one patients (19%) underwent a saphenous vein bypass (reversed or nonreserved) to the radial in 12 and the ulnar in 11 limbs. In follow‐up, 11 patients underwent open or endovascular intervention to maintain patency of the bypass. There were nine phalanx or digital amputations in the Bypass group. No below‐the‐elbow or above‐the‐elbow amputations were performed within 30 days. The wound healing rate without amputation was 78% (85 of 108). The predictors of wound healing were technical success of the revascularization, intact palmar arch and presence of digital run‐off. The presence of an incomplete arch and poor digital run‐off were associated with a phalanx or digital amputation. Conclusions: Upper extremity interventions for critical ischemia are associated with a high rate of success. Major amputations are rare and the many can be treated nonoperatively. In appropriately selected patients, both endovascular and open interventions have a high rate of success.

Coding for Vascular and Endovascular Surgery

Vascular coding is a complex arena. Codes for open, percutaneous, and transcatheter procedures are delineated. Discussion regarding graft placement and endovascular treatment for occlusive disease is presented. Specifics of the nuances of reconstruction, whether abdominal aorta or peripheral vessel, are elaborated for arterial disease. The treatment and coding for venous disease is described. Specific examples regarding debridement are given with some case examples. Finally, modifiers used by vascular surgeons for coding are described.

Outcomes of tibial endovascular intervention in patients with poor pedal runoff

Objective: Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine the impact of pedal runoff on patient‐centered outcomes after tibial endovascular intervention. Methods: A database of patients undergoing lower extremity endovascular interventions at a single urban academic medical center between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford 5 and 6) were identified. Preintervention angiograms were reviewed in all cases to assess pedal runoff. Each dorsalis pedis, lateral plantar, and medial plantar artery was assigned a score according to the reporting standards of the Society for Vascular Surgery (0, no stenosis >20%; 1, 21%‐49% stenosis; 2, 50%‐99% stenosis; 2.5, half or less of the vessel length occluded; 3, more than half the vessel length occluded). A foot score (dorsalis pedis + medial plantar + lateral plantar + 1) was calculated for each foot (1–10). Two runoff score groups were identified: good vs poor, <7 and ≥7, respectively. Patient‐oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation‐free survival (survival without major amputation), and freedom from major adverse limb events (above‐ankle amputation of the index limb or major reintervention [new bypass graft, jump/interposition graft revision]) were evaluated. Results: There were 1134 patients (56% male; average age, 59 years) who underwent tibial intervention for critical ischemia, with a mean of two vessels treated per patient and a mean pedal runoff score of 6 (47% had a runoff score ≥7). Overall major adverse cardiac events were equivalent at 30 days after the procedure in both groups. At 5 years, vessels with compromised runoff (score ≥7) had significantly lower ulcer healing (25% ± 3% vs 73% ± 4%, mean ± standard error of the mean [SEM]) and a lower 5‐year limb salvage rate (45% ± 6% vs 69% ± 4%, mean ± SEM) compared with those with good runoff (score <7). Patients with poor pedal runoff (score ≥7) had significantly lower clinical efficacy (23% ± 8% vs 38% ± 4%, mean ± SEM), amputation‐free survival (32% ± 6% vs 48% ± 5%, mean ± SEM), and freedom from major adverse limb events (23% ± 9% vs 41% ± 8%, mean ± SEM) at 5 years compared with patients with good runoff (score <7). Conclusions: Pedal runoff score can identify those patients who will not achieve ulcer healing and patient‐centered outcomes after tibial intervention. Defining such subgroups will allow stratification of the patients and appropriate application of interventions.

Complications and Secondary Procedures after Elective Endovascular Aortic Aneurysm Repair

Endovascular aortic aneurysm repair has revolutionized the treatment of abdominal aortic aneurysms (AAAs). Since Juan Parodi first published his experience with custom-made stent grafts in 1991, there has been an explosion of interest in endovascular aortic aneurysm repair (EVAR). Manufactured devices have continued to improve leading to decreased operative time, blood loss, ICU stay, and overall hospital stays. As the technique improved, patients previously unfit for open repair were offered EVAR as treatment of their aneurysms that otherwise would have been left to grow and, approximately half of them, rupture. The decreased morbidity and mortality associated with EVAR and its broader application to patients that are not traditional surgical candidates gives some the false sense of safety when performing these procedures. Some think that EVAR is “complication free,” but this is certainly not the case. EVAR cases are subject to many of the same complications as open AAA repairs and some that are unique to the procedure itself. It is imperative that physicians who plan on doing EVAR know the possible complications associated with this complex operation and be well versed on the secondary procedures utilized to manage them.