Tadaki M. Tomita

Treatment and outcomes of aortic endograft infection

OBJECTIVE This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR). METHODS Patients diagnosed with infected aortic endografts after EVAR/TEVAR between January 1, 2004, and January 1, 2014, were reviewed using a standardized, multi-institutional database. Demographic, comorbidity, medical management, surgical, and outcomes data were included. RESULTS An aortic endograft infection was diagnosed in 206 patients (EVAR, n = 180; TEVAR, n = 26) at a mean 22 months after implant. Clinical findings at presentation included pain (66%), fever/chills (66%), and aortic fistula (27%). Ultimately, 197 patients underwent surgical management after a mean of 153 days. In situ aortic replacement was performed in 186 patients (90%) using cryopreserved allograft in 54, neoaortoiliac system in 21, prosthetic in 111 (83% soaked in antibiotic), and 11 patients underwent axillary-(bi)femoral bypass. Graft cultures were primarily polymicrobial (35%) and gram-positive (22%). Mean hospital length of stay was 23 days, with perioperative 30-day morbidity of 35% and mortality of 11%. Of the nine patients managed only medically, four of five TEVAR patients died after mean of 56 days and two of four EVAR patients died; both deaths were graft-related (mean follow-up, 4 months). Nineteen replacement grafts were explanted after a mean of 540 days and were most commonly associated with prosthetic graft material not soaked in antibiotic and extra-anatomic bypass. Mean follow-up was 21 months, with life-table survival of 70%, 65%, 61%, 56%, and 51% at 1, 2, 3, 4, and 5 years, respectively. CONCLUSIONS Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction.

Two Cases of Aortic Intimal Intussusception During Endovascular Repair of an Acute Type B Dissection

Purpose: To raise awareness of a previously undescribed complication of thoracic endovascular aortic repair (TEVAR) for aortic dissection that can lead to acute aortic occlusion and to highlight that early recognition, excision of the intimal flap, and open aortic repair can be lifesaving. Case Report: Two patients underwent TEVAR for acute type B dissections complicated by abdominal malperfusion syndrome. During stent-graft deployment, the intimal flap circumferentially detached from its origin proximally with subsequent intussusception, leading to acute aortic occlusion. Both complications were recognized intraoperatively with immediate conversion to open aortic reconstruction and intimal flap excision. The first patient required an infrarenal aortobi-iliac bypass, while the second had an open aortic fenestration and bovine pericardial patch repair of the aortotomy. Their postoperative courses were uneventful. Follow-up imaging revealed excellent stent-graft approximation without endoleak and thrombosis of the false lumen. Conclusion: Aortic intimal flap detachment and intussusception is a rare but potentially fatal complication of TEVAR for acute complicated aortic dissection. Quick diagnosis and a low threshold for conversion to open repair are critical in achieving a successful outcome.

Implications of Intraoperative Vascular Surgery Assistance for Hospitals and Vascular Surgery Trainees

Importance Vascular surgeons possess a skill set that allows them to assist nonvascular surgeons in the operating room. Existing studies on this topic are limited in their scope to specific procedures or clinical settings. Objective To describe the broad spectrum of cases that require intraoperative vascular surgery assistance. Design, Setting, and Participants A retrospective medical record review of patients undergoing nonvascular surgery procedures that required intraoperative vascular surgery assistance between January 2010 and June 2014 at a single urban academic medical center (Northwestern Memorial Hospital, Chicago, Illinois). Trauma patients and inferior vena cava filter placements were excluded. Exposures Intraoperative vascular surgery assistance stratified by need for vascular reconstruction, anatomic location, urgency of consultation, and timing of consultation. Main Outcomes and Measures A composite primary end point of death, myocardial infarction, or unplanned return to the operating room within 30 days of the index operation. Results We identified 299 patients involving 12 different surgical subspecialties that met the study criteria. The cohort included 148 men (49.5%) and had a mean (SD) age of 56.4 (15) years. Most consultations occurred preoperatively (n = 224; 74.9%; odds ratio, 0.04; 95% CI, 0.02-0.08; P < .001) and were elective (n = 212; 70.9%; odds ratio, 0.06; 95% CI, 0.03-0.12; P < .001 ). The indications for vascular surgery assistance were 156 spine exposure (52%), 43 vascular control without hemorrhage (14.4%), 43 control of hemorrhage (14.4%), and 57 vascular reconstruction (19%). Vascular repairs consisted of 13 bypasses (4.3%), 18 patch angioplasties (6.0%), and 79 primary repairs (26.4%). All procedures required open surgical exposure by the vascular surgeon. The incidence of death, myocardial infarction, or unplanned return to the operating room was 11.4% for the cohort with a mortality rate of 1.7%. Patients who required vascular repair had a higher incidence of death, myocardial infarction, or unplanned return to the operating room (17.4% vs 7.9%; P = .01). These cases resulted in an additional 1371.46 work relative value units per year. Conclusions and Relevance Vascular surgeons provide crucial operative support across multiple specialties. Although vascular reconstruction is not needed in most patients, it may be associated with increased risk of death, myocardial infarction, or unplanned return to the operating room. The high proportion of emergent cases that require vascular repair demonstrates the importance of having vascular surgeons immediately available at the hospital. To continue providing this valuable service, vascular surgery trainees need to continue to learn the full breadth of open anatomic exposures and vascular reconstruction.

IP137. Outcomes of Interfacility Transfer Patients Compared with Primarily Admitted Patients in Vascular Surgery to a Tertiary Academic Referral Center

indicated care managers identified marginally more superficial wounds in the THEM group (31.3% vs 7.1%; P 1⁄4 .175). Both groups reported an increase in the 8-Item Short Form Health Survey physical summary scores, but it was more pronounced in THEM patients (P 1⁄4 .076). THEM patients reported a significantly greater improvement in quality of life on two of the 8-Item Short Form Health Survey quality subscales (roledphysical [THEM, 8.7; control, 1.1] and roleeemotional [THEM, 6.1; control, 0.5]; both P < .05). THEM patients reported trends for higher satisfaction in terms of general satisfaction, technical quality, and accessibility for Patient Satisfaction Questionnaire Short Form survey questions (4.2 vs 3.7 [P 1⁄4 .72], 4.5 vs 4.1 [P 1⁄4 .81], and 4.2 vs 3.8 [P 1⁄4 .63]), respectively. Conclusions: THEM was technically feasible and provided significant benefit to patients in geographically disparate areas. THEM was associated with increased patient satisfaction. Additional findings suggested that THEM patients embraced telehealth technology and took advantage of increased access to health care professionals. Telehealth successfully merged remotely generated information with care manager interaction. Presently, a larger study, preferably multicenter, is warranted and under consideration.

Does EVAR Improve Outcomes or Quality of Life in Patients Unfit for Open Surgery

Endovascular aneurysm repair (EVAR) has emerged as the preferred treatment for most patients with an abdominal aortic aneurysm (AAA). A less invasive procedure, EVAR would seem to be a suitable method to treat AAAs in patients who are unfit for open surgery. However, recent studies have called into question the utility of EVAR in this patient population. Though there is a group of patients that do not benefit from EVAR because of either unacceptably high perioperative risk or poor long-term survival, this group is not well defined in the literature. Patients who have high-risk anatomy for EVAR and patients who have a decreased quality of life after EVAR may also not benefit. Ultimately, the complex decision making process to proceed with EVAR in any high-risk patient will require a frank discussion of the risks and benefits between the surgeon and the patient.

Diagnostic Approach to Chronic Critical Limb Ischemia

Critical limb ischemia (CLI), if left untreated, is associated with a high risk of limb loss (Hirsch et al., Circulation 113(11):e463–654, 2006; Abou-Zamzam et al., Ann Vasc Surg 21(4):458–463, 2007; Anderson et al., Circulation 127(13):1425–1443, 2013). Before revascularization can be performed, a thorough but efficient diagnostic approach is warranted. The diagnostic process begins with an initial clinical evaluation to assess for the presence of peripheral artery disease (PAD). Any underlying comorbidities the patient has must be identified as they will influence decisions regarding the diagnostic evaluation. CLI is manifested by rest pain and/or tissue loss of the lower extremity but is also an indicator of atherosclerotic disease in other vascular beds that increases the patient’s risk of cardiovascular events (Criqui et al., N Engl J Med 326:381–386, 1992; Caro et al., BMC Cardiovasc Disord 5:14, 2005; Fowkes et al., JAMA 300(2):197–208, 2008; Resnick et al., Circulation 109(6):733–739, 2004; Suominen et al., Eur J Vasc Endovasc Surg 39(3):316–322, 2010); this along with other comorbidities will determine the patient’s risk of revascularization. The process then proceeds to diagnostic studies to confirm the presence of PAD, localize the lesions that need treatment, and finally plan a revascularization procedure if indicated (Hirsch et al., Circulation 113(11):e463–654, 2006). With the recent explosion of treatment modalities for PAD, there has been an equal development of imaging modalities available to delineate the patient’s vascular anatomy prior to revascularization (Harris et al., AJR Am J Roentgenol 197(2):W314–W317, 2011; de Vos et al., J Vasc Surg 59(5):1315–1322 e1, 2014). Noninvasive vascular lab studies are used to determine the hemodynamic significance of the patient’s vascular lesions (Anderson et al., Circulation 127(13):1425–1443, 2013). Anatomic imaging by arterial duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), or catheter-based digital subtraction angiography (DSA) can then be used to plan a revascularization procedure (Anderson et al., Circulation 127(13):1425–1443, 2013; de Vos et al., J Vasc Surg 59(5):1315–1322 e1, 2014; Grassbaugh, J Vasc Surg 37(6):1186–1190, 2003; Collins et al., BMJ 334(7606):1257, 2007; Lowery et al., Ann Vasc Surg 21(4):443–451, 2007). The best imaging study to obtain depends on the patient’s underlying comorbidities, distribution of disease, and institution-specific imaging capabilities (first figure of this chapter).