Maureen K. Sheehan

Can Computed Tomography Scan Findings Predict “Impending” Aneurysm Rupture?

Several findings on computed tomography (CT) scans of intact aneurysms have been taken to suggest “imminent” or “impending” aneurysm rupture. Often these are identified incidentally in asymptomatic patients when an urgent operation was not planned and may even be ill advised. The authors evaluated whether these signs can truly predict short-term aneurysm rupture. A computerized medical archival system was reviewed from August 1994 to August 2004. Patients with aortic aneurysms and official CT scan reports of “impending rupture” were reviewed. CT films and reports were reviewed for aneurysm characteristics, while computerized medical records were reviewed for patient demographics, comorbidities, symptoms, documented subsequent rupture, and operative findings. Signs of “impending rupture” included the crescent sign, discontinuous circumaortic calcification, aortic bulges or blebs, aortic draping, and aortic wall irregularity. Rupture occurring within 2 weeks of the index CT was defined as supporting the “imminent” label. Forty-five patients with aortic aneurysms and CT stigmata of “impending rupture” were identified. Five patients with additional signs of suspicious leak and 1 with an infected previously repaired aneurysm were excluded. Of 39 intact aneurysms, 26 (67%) were infrarenal, 2 (5%) were suprarenal, and the remaining 11 (28%) were thoracoabdominal. The patient group had more women than expected (19/39, 49%) and larger aneurysms (mean diameter, 6.8 ±1.4 cm). Mean age was 74 years. Ten patients underwent elective repair within the first 2 weeks after the index CT scan (mean, 4 days), precluding adequate observation for early rupture. None had intraoperative signs of rupture. Early rupture: 2 of the 29 remaining patients ruptured within 72 hours of the CT scan, for a positive predictive value of 6.9%. One additional patient ruptured 7 months later after declining an early intervention. No Rupture: 26 patients were observed an average of 246 days (range, 14 days to 3 years) without evidence of rupture. Fourteen were repaired electively 2 weeks to 3 years after the index CT scan, and 12 never underwent repair, mostly because of severe associated comorbidities, and were observed a mean of 394 days without rupture. Although they should be taken seriously, CT signs of “impending rupture” alone are poor predictors of short-term aortic aneurysm rupture, and alternative terminology is needed until better predictors can be identified.

Use of endoluminal aortic stent-grafts for the repair of abdominal aortic aneurysms.

Abdominal aortic aneurysms affect approximately 1.5% of the United States population. Randomized trials recommend repair when the maximal aneurysm diameter is 5.5 cm or greater. Since the first report of this technique in 1991, endovascular repair has become the preferred method for elective therapy of AAA disease. This has been a direct result of reported decreased hospital length of stay, reduced patient recovery time and improved survival. The application of endovascular aneurysm repair (EVAR) requires a thorough understanding of aneurysm anatomy, which is critical for appropriate patient selection. In particular the surgeon must be familiar with device-related criteria for proximal fixation and distal fixation as well as access vessels size, tortuosity, and calcification which can often be the limiting factor in the application of EVAR. Although the reported results of EVAR indicate significant advantages when compared with conventional open repair, it is critical to have an understanding of the particular complications associated with EVAR. The development of endoleaks, reports of stent migration and stent fracture as well as the development of limb stenosis and/or occlusion have been reported in up to 20% of patients treated with EVAR and thus necessitate appropriate long-term surveillance protocols.

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.