Peter Alden

Outcomes Related to Antiplatelet or Anticoagulation Use in Patients Undergoing Carotid Endarterectomy

BACKGROUND The number of cases involving patients undergoing vascular procedures who are prescribed clopidogrel or warfarin as treatment options continues to rise. Our aim was to examine outcomes related to antiplatelet or anticoagulation therapy in patients undergoing carotid endarterectomy (CEA). METHODS A retrospective review of 260 consecutive patients undergoing CEA. Data including patient demographics, operative details, perioperative use of aspirin (ASA), clopidogrel, or warfarin, and early and/or late outcome(s) were collected. Endpoints included postoperative morbidity and/or mortality rate(s) and bleeding complications. RESULTS The study included 152 men and 108 women (mean age = 69.3 years), with a mean follow-up of 406 days. In all, 46% of endarterectomies were for a symptomatic disease. The technique of eversion endarterectomy was applied in 126 (48.5%), Dacron-patch in 112 (43.1%), and bovine pericardial-patch in 14 (5.4%) of the cases. Among the patients, 171 were taking ASA, 50 were taking clopidogrel ± ASA, and 10 were taking warfarin (mean INR = 1.62; range, 1.2-2.1); the remaining 29 were not on any antiplatelet therapy. All patients who were on warfarin therapy underwent an eversion endarterectomy. Overall, there were 19 (7.3%) complications (12 major and seven minor). The 30-day stroke rate and stroke death rate was 0.7% and 1.1%, respectively. Patients taking clopidogrel developed more number of neck hematomas (16% vs. 1.7%, p = 0.0004) compared with patients who were on ASA alone. For patients taking clopidogrel, Dacron-patch repair resulted in more hematomas than eversion endarterectomy (35% vs. 4.2%, p = 0.012). There was no difference in the incidence of neck hematoma on the basis of endarterectomy technique in patients who were on ASA alone. The patients taking warfarin neither had a perioperative complication nor developed a neck hematoma. CONCLUSIONS In this study, clopidogrel use during CEA resulted in a significant risk for developing a neck hematoma, particularly when using a Dacron-patch. The risk of a neck hematoma in patients who were on clopidogrel was much less when an eversion endarterectomy was performed.

Hyperbaric Oxygen Treatment Outcome for Different Indications from a Single Center

BACKGROUND Hyperbaric oxygen (HBO) is used as an adjunctive therapy for a variety of indications. However, there is a lack of high-quality research evaluating HBO treatment outcomes for different indications available in the current literature. METHODS We retrospectively reviewed all patients who underwent HBO therapy at a single hyperbaric center from January 2010 to December 2013 using predetermined criteria to analyze successful, improved, or failed treatment outcomes for the following indications: chronic refractory osteomyelitis, diabetic foot ulcer, failed flap or skin graft, osteoradionecrosis, soft tissue radiation necrosis, and multiple coexisting indications. RESULTS Among the included 181 patients treated with adjunctive HBO at our center, 81.8% had either successful or improved treatment outcomes. A successful or improved outcome was observed in 82.6% of patients treated for chronic refractory osteomyelitis (n = 23), 74.1% for diabetic foot ulcer (n = 27), 75.7% for failed flap or skin graft (n = 33), 95.7% for osteoradionecrosis (n = 23), 88.1% for soft tissue radiation necrosis (n = 42), and 72.4% for multiple coexisting indications (n = 29). Among 4 patients treated for other indications, 100% of the cases were either successful or improved. CONCLUSIONS This study has provided a comprehensive outcome survey of using HBO for the previously mentioned indications at our center. It supplements the literature with more evidence to support the consideration of HBO in different indications.

Endovascular Repair of Descending Thoracic Aorta in Loeys-Dietz II Syndrome.

Loeys-Dietz syndrome (LDS) is an autosomal dominant disorder that is predominantly characterized by involvement of the aorta, manifesting as aneurysmal dilatation or aortic dissection. Patients with LDS manifest with spontaneous aneurysms and dissections of central and peripheral arterial beds. We present 2 cases of young male patients with Loeys-Dietz II aortopathy, who manifested with spontaneous intimal tear of descending thoracic aorta and contained aortic rupture. Both patients were managed by endovascular repair, with collaborative efforts of teams comprising interventional cardiologists and radiologists, and a vascular surgeon.

Arterial Embolisms and Thrombosis in Upper Extremity Ischemia

Objective: Upper extremity ischemia (UEI) is an uncommon condition that can lead to permanent disability. There is a limited understanding of the etiology, management, and outcomes of the disease. Methods: We retrospectively reviewed the charts of all patients who were diagnosed with “embolism and/or thrombosis of arteries of upper extremity” at our institution from January 2005 to December 2013. Results: Patients diagnosed with embolisms were older (P < .001), more likely to undergo thromboembolectomy (P < .001), had higher rates of hypertension (P = .001), and had longer lengths of hospital stay (P = .002). There were no significant differences in complications or mortality at 30 days and up to 1 year. Conclusion: At our center, embolism was found to be the most common etiology for UEI followed by thrombosis and stenosis. Patients presented with embolism were older, were more likely to undergo thromboembolectomy, and had higher rates of hypertension and longer hospital stays.

Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts

Objective: The objective of this study was to evaluate outcomes of patients with complex abdominal aortic aneurysms (cAAAs) treated with open repair (OR) or fenestrated/branched endovascular aneurysm repair (F/B‐EVAR) from a single center. Methods: A retrospective analysis of consecutive patients with cAAAs treated electively by OR or F/B‐EVAR between January 2010 and February 2017 was conducted. Demographics of the patients, cardiovascular risk factors, procedure time, number of vessels incorporated, radiation dose, estimated blood loss, intensive care unit (ICU) length of stay (LOS), and hospital LOS were recorded. End points included target vessel patency, aneurysm rupture, freedom from reintervention, and major adverse events (MAEs). Results: During this period, 153 patients (OR, 69; F/B‐EVAR, 84) underwent repair of cAAA. The majority were male (OR, 55; F/B‐EVAR, 64), with a mean age of 75.8 ± 7.6 years (F/B‐EVAR) and 71.2 ± 7.9 years (OR). Patients in the F/B‐EVAR group were more likely to be American Society of Anesthesiologists class 3 and 4 (60% vs 0%; P < .001) and had a higher median Society for Vascular Surgery/American Association for Vascular Surgery comorbidity severity score (15 vs 7; P < .001). A total of 235 vessels were targeted in the F/B‐EVAR group, with a technical success of 97.6%. Thirty‐one patients in the OR group required concomitant renal artery revascularization. Transfusion requirements (100% vs 1.2%), MAEs (40.6% vs 13.1%), procedure length (304 minutes vs 140 minutes), estimated blood loss (2246 mL vs 165 mL), ICU LOS (3 days vs 1 day), and hospital LOS (7 days vs 2 days) were higher (P < .001) in the OR group compared with the F/B‐EVAR group. The 30‐day mortality was 2.9% and 2.4% (P = .84) in the OR group and F/B‐EVAR group, respectively. Supraceliac clamp site was associated with increased incidence of postoperative renal insufficiency. A decrease in procedure time, contrast volume, fluoroscopy time, and fluoroscopy dose was noted in the F/B‐EVAR group with increasing experience even as case complexity increased. More patients were discharged home after F/B‐EVAR (97.6% vs 59.4%; P < .001). With a mean follow‐up of 31 months (F/B‐EVAR, 17 months; OR, 48 months), the rate of secondary intervention was 3.7% and 5.8% (P = NS) for F/B‐EVAR and OR, respectively. Freedom from branch instability and reintervention was 99% (95% confidence interval, 96.2%‐99.8%) and 96% (95% confidence interval, 87.1%‐98.6%), respectively. Conclusions: Results of this “real‐world” experience suggest that the use of F/B‐EVAR for the treatment of cAAAs in high‐risk surgical patients is safe and effective and has comparable short‐term results to those of low‐risk patients undergoing OR. Patients treated by F/B‐EVAR had shorter ICU and hospital LOS, lower MAEs, and faster convalescence. A decrease in procedure time and radiation dose was noted as experience was gained, even as complexity increased.

Diagnosis, Management, and Outcome of Aortitis at a Single Center

Background: Aortitis is a rare condition with inflammatory or infectious etiology that can be difficult to diagnose due to the highly variable clinical presentation and nonspecific symptoms. However, current literature on the diagnosis, management, and prognosis of aortitis is extremely scarce. Methods: We retrospectively reviewed all patients’ charts who were diagnosed with giant cell arteritis, Takayasu arteritis, or noninfectious aortitis presenting at a single center between January 1, 2009, and April 17, 2015. Data collected included demographics, medical history, comorbidities, laboratory and imaging data, management, and outcome. Results: Among the included 15 patients presenting with aortitis at our center, 53% were diagnosed with Takayasu arteritis, 33% with idiopathic inflammatory aortitis, and 13% with giant cell arteritis. All patients received steroid treatment, 67% received adjunctive immunosuppressants or immunomodulators, and 33% underwent interventional procedures. Based on clinical presentation and laboratory and imaging findings at the last follow-up visit for each patient, 67% showed improvement, 27% had no change in disease activity, and 7% had a progression of the disease. Conclusions: Takayasu arteritis was found to be more common than idiopathic inflammatory aortitis and giant cell arteritis among our 15 cases diagnosed with aortitis. All patients received medical therapy and 33% received interventional procedures, leading to 67% improvement of disease activity or related complications. This article also offers a comprehensive review of the diagnosis, management, and outcome of aortitis, supplementing the very limited literature on this disease.

A prospective randomized comparison of contralateral snare versus retrograde gate cannulation in endovascular aneurysm repair

Objective: The objective of this study was to compare snare vs the standard retrograde gate cannulation method during endovascular aneurysm repair to determine the most efficient technique and to evaluate whether time was affected by graft design or the surgeons experience. Methods: This was a prospective randomized study involving single‐center elective endovascular aneurysm repairs. Patients were randomized to the snare or retrograde group in a 1:1 ratio. The initial method was attempted for 15 minutes; if it was unsuccessful, the team switched to the alternative technique for an additional 15 minutes. The protocol continued until success was achieved. Data collected on demographic, anatomic, and procedural factors were analyzed for statistically significant differences. Results: A total of 101 patients were included. Average age was 75.3 years, and 82% were male; 49 patients were randomized to snare and 52 to retrograde cannulation. The groups were overall similar. Median cannulation times were 3.9 minutes for the snare and 2.7 minutes for the retrograde technique (P = .13). The snare group attempts were successful within the initial 15‐minute period in all but one patient (98% success). In the retrograde group, 5 of the 52 (10%) crossed over to snare. This difference did not reach statistical significance (P = .11). A difference was seen in the extremes of cannulation times. The surgeons experience and graft design were not found to have significant effects on cannulation times. Further analysis of the retrograde group patients with long cannulation time found a relative breakpoint at the 5‐minute mark. In those exceeding this time mark, the chance of eventual cannulation within 15 minutes dropped to 67%. In this group, median time to cannulation was 12.2 minutes for retrograde compared with 7.1 minutes for snare after crossover. Conclusions: Gate cannulation was successful using both methods with no statistical difference between the two in median time. Retrograde cannulation was found to be more likely to have short times. If cannulation by retrograde technique had not been achieved in the first 5 minutes, the chances of eventual success dropped significantly, and crossover to snare was more efficient. This finding suggests that one should consider an alternative method of gate cannulation if it has not been accomplished within this time.

The Success and Safety of Endovenous Ablation in Patients With Previous Superficial Venous Thrombosis A Retrospective Case–Control Study

Objectives: Retrospective case–control study to determine the failure and endovenous heat-induced thrombosis (EHIT) rates of endovenous ablation (EVA) in patients with a history of superficial venous thrombosis (SVT). Methods: Study and control groups each consisted of 73 patients with or without the history of SVT, who underwent EVA between June 2010 and July 2012. All patients were followed with venous duplex ultrasound. Procedural failure and EHIT rates were considered primary outcomes. Results: There was no difference in EHIT or failure rates between study and control groups (P = 1.00). There was no difference in EHIT or failure rates between patients with and without the history of venous thromboembolism (VTE), with and without the history of VTE and/or SVT, with and without the history of thrombophilia, and on and off anticoagulation for either group or the combined study population. For the combined study population, failure rate was higher in patients with a history of VTE. Conclusions: Although EVA seems to be safe and effective in patients with a history of SVT, vein access in this patient group might require multiple attempts.