Richa Kalsi

Brain Metastasis and Response to Ado-Trastuzumab Emtansine: A Case Report and Literature Review

Despite promising preclinical studies that demonstrated the ability of lapatinib to cross the bloodebrain barrier (BBB), single-agent lapatinib only has modest central nervous system (CNS) activity. However, higher response rates were observed with the combination of lapatinib and capecitabine. Despite the relatively large molecular size of trastuzumab, results of some studies suggest that trastuzumab can cross the disrupted BBB, especially in patients with leptomeningeal carcinomatosis. Furthermore, radiation can further facilitate permeation of the BBB. The combination of trastuzumab and capecitabine providesbetter systemiccontrol comparedwith lapatiniband capecitabine, especially in trastuzumab-naive patients. The incidence of CNS progression as the first site of relapse is low in trastuzumab and lapatinib combinations. Ado-trastuzumab emtansine might also cross the BBB, but its true level of activity in the CNS is inadequately defined.

Implications of concomitant hypogastric artery embolization with endovascular repair of infrarenal abdominal aortic aneurysms

Objective: Hypogastric artery embolization (HAE) is associated with significant risk of ischemic complications. We assessed the impact of HAE on 30‐day outcomes of endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2014 to identify and to compare clinical features, operative details, and 30‐day outcomes of EVAR with those of concomitant HAE with EVAR (HAE + EVAR). Multivariate analysis was performed to determine preoperative and intraoperative factors associated with development of significant complications observed in patients with HAE + EVAR. Results: In a cohort of 5881 patients, 387 (6.6%) underwent HAE + EVAR. Compared with EVAR, a higher incidence of ischemic colitis (2.6% vs 0.9%; P = .002), renal failure requiring dialysis (2.8% vs 1%; P = .001), pneumonia (2.6% vs 1.3%; P = .039), and perioperative blood transfusion (17% vs 13%; P = .024) was noted after HAE + EVAR. Thirty‐day thromboembolic events, strokes, myocardial infarction, lower extremity ischemia, reoperation, and readmission rates were not significantly different (P > .05). Mortality at 30 days in HAE + EVAR patients was 4.1% compared with 2.5% with EVAR (P = .044). HAE was independently associated with increased risk of colonic ischemia (adjusted odds ratio, 2.98; 95% confidence interval, 1.44‐6.14; P = .003) and renal failure requiring dialysis (adjusted odds ratio, 2.22; 95% confidence interval, 1.09‐4.53; P = .029). However, HAE was not an independent predictor of mortality. Average length of hospital stay was 4 ± 8.5 days after HAE + EVAR vs 3.3 ± 5.9 days after EVAR (P = .001). Conclusions: Concomitant HAE with EVAR is associated with longer and more complicated hospital stays. Ischemic colitis is a rare complication of EVAR. HAE increases the risk of ischemic colitis and renal failure requiring dialysis. This study highlights the importance of hypogastric artery preservation during EVAR.

Functional status predicts major complications and death after endovascular repair of abdominal aortic aneurysms

Objective: Endovascular aneurysm repair (EVAR) is considered a lower risk option for treating abdominal aortic aneurysms and is of particular utility in patients with poor functional status who may be poor candidates for open repair. However, the specific contribution of preoperative functional status to EVAR outcomes remains poorly defined. We hypothesized that impaired functional status, based simply on the ability of patients to perform activities of daily living, is associated with worse outcomes after EVAR. Methods: Patients undergoing nonemergent EVAR for abdominal aortic aneurysm between 2010 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. The primary outcomes were 30‐day mortality and major operative and systemic complications. Secondary outcomes were inpatient length of stay, need for reoperation, and discharge disposition. Using the NSQIP‐defined preoperative functional status, patients were stratified as independent or dependent (either partial or totally dependent) and compared by univariate and multivariable analyses. Results: Of 13,432 patients undergoing EVAR between 2010 and 2014, 13,043 were independent (97%) and 389 were dependent (3%) before surgery. Dependent patients were older and more frequently minorities; had higher rates of chronic pulmonary, heart, and kidney disease; and were more likely to have an American Society of Anesthesiologists score of 4 or 5. On multivariable analysis, preoperative dependent status was an independent risk factor for operative complications (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.5‐3.9), systemic complications (OR, 2.8; 95% CI, 2.0‐3.9), and 30‐day mortality (OR, 3.4; 95% CI, 2.1‐5.6). Secondary outcomes were worse among dependent patients. Conclusions: Although EVAR is a minimally invasive procedure with substantially less physiologic stress than in open aortic repair, preoperative functional status is a critical determinant of adverse outcomes after EVAR in spite of the minimally invasive nature of the procedure. Functional status, as measured by performance of activities of daily living, can be used as a valuable marker of increased perioperative risk and may identify patients who may benefit from preoperative conditioning and specialized perioperative care.

Defining the burden, scope, and future of vascular acute care surgery

Objective The paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surgical procedures in Maryland. Methods A retrospective analysis of a statewide inpatient database was performed to identify patients undergoing noncardiac vascular procedures in Maryland from 2009 to 2013. Patients were stratified by admission acuity as elective, urgent, or emergent, with the last two groups defined as acute. The primary outcome was inpatient mortality, and secondary outcomes were critical care and hospital resource requirements. Groups were compared by univariate analyses, with multivariable analysis of mortality based on acuity level and other potential risk factors for death. Results Of 3,157,499 adult hospital admissions, 154,004 (5%) patients underwent a vascular procedure; most were acute (54% emergent, 13% urgent), whereas 33% were elective. Acute patients had higher rates of critical care morbidity and required more hospital resource utilization. Admission for acute vascular surgery was independently associated with mortality (urgent odds ratio, 2.1; emergent odds ratio, 3.0). Conclusions The majority of inpatient vascular care in Maryland is for acute vascular surgery, which is an independent risk factor for mortality. Acute vascular surgical care entails greater critical care and hospital resource utilization and—similar to emergency general surgery—may benefit from dedicated training and practice models.

Blunt multifocal aortic injury with abdominal aortic intimointimal intussusception

Blunt abdominal aortic injury is an infrequent occurrence after blunt trauma. The majority of these injuries result from deceleration forces sustained in motor vehicle collisions. Effects of these forces on the thoracic aorta are well described, but associated spinal compression or distraction can also lead to injury of the affixed abdominal aorta. We present a case of multifocal blunt thoracic and abdominal aortic injury with circumferential abdominal aortic dissection, resulting in aortoaortic intussusception associated with a thoracolumbar spinal injury. The unique diagnostic challenge and subsequent successful endovascular management of a rare nonocclusive abdominal aortic intussusception are herein discussed.

Flow Reduction–Aided Thrombin Injection for Complex Femoral Pseudoaneurysms: Case Series and Review of the Literature

BACKGROUND Peripheral pseudoaneurysms are a known complication of vascular access procedures. Complex lesions-those with short, wide necks or other complex arrangements-would conventionally require open repair, but we believe that even these lesions could be managed with an endovascular approach. METHODS Four patients with complex pseudoaneurysms were offered an open repair or thrombin injection with the use of flow-reducing balloons. RESULTS In our series of 4 patients with complex pseudoaneurysms, all were safely treated with percutaneous thrombin injection in conjunction with endovascular flow reduction. All patients recovered from their procedures without incident and are free from recurrence at follow-up. CONCLUSIONS Flow reduction-aided thrombin injection may have particular utility in complex femoral pseudoaneurysms, especially in a patient population that may not tolerate open repair. High-risk lesions may merit special consideration for this technique, and further study is warranted.

Infrainguinal wound infections in vascular surgery: An antiquated challenge without a modern solution

Surgical site infections (SSIs) have always complicated recovery after surgery, being associated with increased cost of hospitalization, length of stay, and mortality. The most significant measure to reduce the incidence of SSI was the standardization of prophylactic antibiotic administration in patients undergoing surgical procedures. Since then, countless measures have been proposed to improve rates of SSI and patient outcome, but few have been as efficacious as prophylactic antibiotics. Therefore, SSI continues to plague clinicians and patients in modern health care. This review focuses on current and future efforts at SSI control.

Chronic Type B Aortic Dissection: Endovascular and Hybrid Aortic Management

Purpose of ReviewChronic and subacute type B aortic dissection (TBAD) management has advanced drastically over the past decade. We review the major progress reported in the scientific literature.Recent FindingsSince early twenty first century, endovascular aortic repair has been on the rise for management of chronic and subacute TBAD. The technique has shown a mortality benefit in comparison to the open approach. High-risk patients who cannot tolerate open procedure and had challenging aortic anatomy benefit from hybrid approaches. More recently, total endovascular approaches are being investigated to treat these high-risk populations. With growing popularity of endovascular approach, light is casted on its shortcomings. Higher reintervention rates, endoleak prevention, subclavian artery revascularization, and spinal cord protection remain as areas of investigation.SummaryEndovascular surgery is an important addition to the repertoire of TBAD management. It remains an area of vigorous research and evolving industry.

Transcervical Carotid Artery Stenting Using a Prosthetic Arterial Conduit: Case Series of a Novel Surgical Technique

We present a series of 4 patients with carotid restenosis following carotid endarterectomy (CEA) who underwent transcervical carotid artery stenting (CAS) using a novel prosthetic conduit technique. The patients were high risk for repeat CEA (short and obese necks) and had contraindications to transfemoral CAS (bovine arch, prior dissection). CAS was thus performed via a transcervical approach with a polytetrafluoroethylene conduit anastomosed to the proximal common carotid artery. The addition of a conduit allowed stent placement via a secure, stable platform. All patients recovered from their procedure without incident and are free from restenosis at follow-up.

Continuous Flow Perfused Cadaver Model for Endovascular Training, Research, and Development

BACKGROUND Endovascular simulation employing computer, animal, and static models are common and useful adjuncts for teaching endovascular procedures and developing novel, complex endovascular techniques. Unfortunately, these models lack realistic haptic feedback and thus do not faithfully replicate many of the technical challenges associated with clinical endovascular procedures (e.g., arterial calcification, rigidity, and stenosis). We sought to develop a realistic and reproducible perfused cadaver model for endovascular training, device development, and research. METHODS Fresh frozen, elderly (age 50-80 years) male cadavers were thawed and prepared for open dissection. The entire arterial tree (ascending aorta to femoral arteries) was dissected free and major branch vessels exposed. Sheaths were placed to allow outflow from selected vessels. A Dacron conduit was sewn to the ascending aorta to generate arterial inflow, which was provided by a centrifugal pump. Aortic aneurysms were created in the descending thoracic and abdominal aorta. Digital subtraction arteriography and various endovascular interventions were performed, including stent grafts and EndoAnchors deployment. RESULTS Continuous antegrade flow was achieved in the thoracic, abdominal, iliac, and femoral segments. Open and percutaneous access at the femoral region was obtained with realistic back-bleeding and tactile feedback. Adequate, fluoroscopically documented flow was observed in both cannulated major and noncannulated smaller branches. We performed angiography with standard techniques via a pigtail catheter and contrast injector throughout the arterial system. Abdominal and thoracic endografts were deployed with appropriate angiographic guidance and realistic haptic feedback for both guidewire and stent grafts. Additional applications, including selective cannulation, aorto-iliac occlusive disease interventions, and anchor placement, were also successfully simulated. Finally, the model was used as a platform to test investigational devices. CONCLUSIONS Our pressurized cadaver flow model successfully replicated multiple aspects of advanced endovascular procedures with haptic feedback. This novel human cadaver model allows for training and device development under clinically realistic conditions.