Nathan T. Orr

Thoracoabdominal aortic aneurysm repair: current endovascular perspectives

Thoracoabdominal aneurysms account for roughly 3% of identified aneurysms annually in the United States. Advancements in endovascular techniques and devices have broadened their application to these complex surgical problems. This paper will focus on the current state of endovascular thoracoabdominal aneurysm repair, including specific considerations in patient selection, operative planning, and perioperative complications. Both total endovascular and hybrid options will be considered.

Cost analysis of vascular readmissions after common vascular procedures

OBJECTIVE This study analyzed readmissions and their associated hospital costs after common vascular surgeries at a single institution. METHODS Patients undergoing open or endovascular abdominal aortic aneurysm repair, aortoiliac revascularization, or infrainguinal revascularization, from 2010 through 2012, were retrospectively evaluated. We compared 30- and 90-day readmission rates and costs by procedure group, and we tabulated reasons for readmission and procedures performed during readmission. We used both American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data and patient records; as NSQIP only captures 30-day data, we retrospectively reviewed patient charts to extend the evaluation to 90 days. Analyses were performed using parametric or nonparametric methods as appropriate. RESULTS Two hundred nineteen cases were analyzed; the overall rate of index admission survivors experiencing at least one readmission within 30 days was 17% and within 90 days, 27%. Median readmission costs were

Debate: Whether an endovascular-first strategy is the optimal approach for treating acute mesenteric ischemia.

10,700, which added 39% to the median index costs of

Aortic injury from posterior rib fracture.

27,700. Over half of readmissions (55%) included an operation. The most common cause for readmission was related to wound complications, comprising approximately 30% of the entire readmission cohort. Independent drivers of readmission costs were the need for additional surgical procedures, the use of intensive care unit services, and the number of days spent in the hospital above the median. Total 90-day costs were statistically equivalent between open and endovascular procedures when including readmissions. CONCLUSIONS We found that vascular surgery readmissions occur at a rate of 17% at 30 days and 27% at 90 days. When including the costs of readmission for a wide variety of common vascular cases, there is no significant difference in total costs between endovascular and open procedures at 90 days.

Comparison of perioperative outcomes in endovascular versus open repair for juxtarenal and pararenal aortic aneurysms: A propensity-matched analysis.

Acute mesenteric ischemia continues to be a life-threatening insult in often-elderly patients with many comorbidities. Recognition and correct diagnosis can be an issue leading to delays in therapy that result in loss of bowel or life, or both. The basic surgical principals in treating acute mesenteric ischemia have long been early recognition, resuscitation, urgent revascularization, resection of necrotic bowel, and reassessment with second-look laparotomies. Endovascular techniques now offer a less invasive alternative, but whether an endovascular-first or open surgery-first approach is preferred in most patients is unclear. Our discussants will attempt to clarify these issues.

Internal Carotid Pseudoaneurysm Associated with Tortuosity after Tonsillectomy: A Case Report

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Outcomes of simultaneous laparoscopic cholecystectomy and ventral hernia repair compared to that of laparoscopic cholecystectomy alone

— see front matter # 2010 European Association for Cardio-Thoracic S doi:10.1016/j.ejcts.2010.04.016 A 43-year-old female sustained blunt trauma after amotor vehicle collision. Computed tomography (CT) angiogram revealed a displaced left fifth rib fragment impinging on the descending thoracic aorta (Figs. 1 and 2). On hospital day 3, she underwent surgery with excision of the rib fragment and direct aortic repair. She recovered well and was discharged on postoperative day 11.

Part Two: Against the Motion. An Endovascular First Strategy is not the Optimal Approach for Treating Acute Mesenteric Ischemia

Objective Endoluminal aortic aneurysm repair is suitable within certain anatomic specifications. This study aims to compare 30-day outcomes of endovascular versus open repairs for juxtarenal and pararenal aortic aneurysms (JAA/PAAs). Methods The ACS-NSQIP database was queried from 2012 to 2015 for JAA/PAA repairs. Procedures characterized as emergent were included in the study; however, failed prior repairs and ruptured aneurysms were excluded. The preoperative and perioperative patient characteristics, operative techniques, and outcome variables were compared between the open aortic repair and the endovascular aortic repair groups. Propensity scoring was performed to clinically match open aortic repair and endovascular aortic repair groups on preoperative risk and select perioperative factors that differed significantly in the unmatched groups. Outcome comparisons were then performed between matched groups. Results A total of 1005 (789 JAAs and 216 PAAs) aneurysm repairs were included in the study. Of these, there were 395 endovascular aortic repairs and 610 open aortic repairs. Propensity scoring created a matched group of 263 endovascular aortic repair and 263 open aortic repair patients. There was no statistically significant difference in 30-day mortality rates between matched endovascular aortic repair and open aortic repair patients (2.7% vs. 5.7%). The endovascular aortic repair group had a shorter ICU length of stay and overall hospital stay. The 30-day morbidity significantly favored endovascular aortic repair over open aortic repair (16% vs. 35%, p < 0.001). The main drivers of morbidity for endovascular aortic repair versus open aortic repair included return to the OR (6.8% vs. 15%, p < 0.001), rate of cardiac or respiratory failure (7.6% vs. 21%, p = 0.001), rate of renal insufficiency or failure (3.8% vs. 9.9%, p = 0.009), and rate of pneumonia (1.5% vs. 6.8%, p = 0.004). Conclusions There is no difference in mortality rates between endovascular aortic repair versus open aortic repair when repairing JAAs/PAAs. There is a significant difference in overall morbidity, and ICU and hospital length of stay favoring endovascular aortic repair over open aortic repair. This supports the expanded applicability and efficacy of endovascular repair for complex aneurysms.

Type IIIb Endoleak Associated With an Infected Thoracoabdominal Endograft.

We present a patient who was found to have an internal carotid pseudoaneurysm 3 years after tonsillectomy and chemoradiation for tonsillar cancer. Ha also had severe tortuosity of both internal carotid arteries. The lesion was in an anatomically challenging location, but an endoluminal approach was not feasible because of the extreme tortuosity. He underwent open repair with resection of the pseudoaneurysm and direct anastomosis with good results.