Thomas C. Matthews

Outcomes after celiac artery coverage during thoracic endovascular aortic aneurysm repair

OBJECTIVE Coverage of celiac artery (CA) during thoracic endovascular aortic aneurysm repair (TEVAR) has been performed to extend the distal seal zone for which preliminary results and short-term follow-up have been reported. We aim to show the outcomes up to 81 months after CA coverage during TEVAR. METHODS Patients undergoing TEVAR with coverage of the CA origin from 2005 to 2013 were retrospectively analyzed. Points of analysis include indications for covering the CA, demonstration of collateral circulation between the CA and superior mesenteric artery (SMA), anatomic features of the distal landing zone, rate of reintervention, technical success, presence of clinical ischemic symptoms after the procedure, and mortality. RESULTS During the 9-year period, 366 patients underwent TEVAR, 18 (5%) of whom had CA coverage. Eleven (61%) had TEVAR with CA coverage due to a thoracic aneurysm, three (17%) had thoracic aortic dissection related to aneurysm, and four (22%) had previous TEVAR with a type Ib endoleak (EL) requiring distal coverage. Mesenteric angiography in preparation for TEVAR with CA coverage diagnosed a critical SMA stenosis in one patient that was treated with stenting before the index procedure. At the conclusion of the indicated procedure, two patients (11%) had a type Ia EL and two patients (11%) had a type Ib EL. Three of the type I ELs required reintervention. Two patients (11%) had a type II EL, both of which were managed with observation and resolved. Reintervention was required in 27% of patients. Postoperative complications included visceral ischemia in 2 (11%), weight loss in 1 (5%), spinal cord ischemia in 2 (11%), a cerebrovascular event in 1 (6%), and death in 1 (6%). The mean follow-up period was 38 months (range, 0.5-81 months). CONCLUSIONS This analysis of outcomes up to 81 months supports the suitability of covering the CA in selected patients for extending the distal landing zone to the visceral aortic level above the SMA or when alternative branch vessel treatment is unavailable. Preoperative angiographic evaluation of the mesenteric collaterals and early postoperative surveillance may limit postoperative complications. Once the CA is covered, new symptoms do not develop unless the SMA is compromised.

Analysis of emergency vascular surgery consults within a tertiary health care system

OBJECTIVE Patients with vascular disease often have multisystem atherosclerosis and multiple comorbidities requiring comprehensive interdisciplinary specialty care. Consultation is a critical component of a tertiary vascular surgery practice, but analysis of this service is under-reported in the literature. After-hours inpatient consultations and interhospital transfers are associated with urgent patient care. METHODS A retrospective analysis of vascular surgery consultations was carried out from January 1, 2013, to December 31, 2013. Consultations included inpatient services, the emergency department, surgical and medical intensive care unit, and interhospital transfers. Data analysis included number of consults, time of consultation (during hours, 0700-1859; after hours, 1900-0659), referring service, nature, and outcome of consultation. Consultations were then classified as urgent if vascular surgical intervention was required as an intraoperative consultation, within 24 hours, or during the same hospitalization. Patients without a same-hospital vascular surgical intervention were classified as nonurgent. RESULTS During a 1-year period, 823 independent consult requests of 749 patients were analyzed. It was found that 57.8% of after-hours consults resulted in urgent patient care (P = .003); 29.7% of medicine, 33.3% of medical intensive care unit, 41.9% of trauma surgery, and 60% of emergency department after-hours consultations were urgent; 73% of surgery and 79.2% of interhospital after-hours consults required urgent vascular surgical intervention. Extremity ischemia, aortic disease, and iatrogenic consults accounted for 44.8%, 20.4%, and 11.1% of after-hours consults, with 57.9%, 56.4%, and 70% requiring urgent vascular surgical intervention, respectively. CONCLUSIONS After-hours consultations are not always associated with an urgent vascular surgical intervention. Nonurgent after-hours consultations are requested more frequently from some services and may present an opportunity for education that could improve workflow of the vascular workforce.

Survival Comparison of Patients Undergoing Secondary Aortic Repair

Introduction. Infrarenal abdominal aortic aneurysm (AAA) repair warrants lifelong surveillance. Secondary aortic intervention (SAI) outcomes may be affected by the therapeutic approach. We compared short- and long-term mortality in patients who underwent SAIs after initial aortic repair, either endovascular (EVAR) or open. Methods. Patients who underwent AAA repair between 1986 and 2010 were retrospectively identified in a vascular surgery database as well as those who underwent SAIs. All-cause mortality and Kaplan-Meier survival curves were calculated. Results. We identified 149 patients who underwent either open AAA repair or EVAR followed by open or endovascular SAI. Seventy-seven patients (51.7%) underwent initial EVAR while 72 patients (48.3%) underwent open repair. Sixty (78%) initial EVAR patients underwent secondary EVAR while 17 (22%) patients had an open SAI. Initial open repair patients were evenly distributed between EVAR and open SAIs. Compared to EVAR, patients who underwent initial open repair had longer intervals between primary aortic interventions (PAIs) and SAIs. Multivariable-adjusted all-cause mortality was significantly higher for patients who underwent initial open AAA repair followed by EVAR when compared to patients who underwent endovascular PAI and SAI. Conclusion. Long-term mortality in patients with infrarenal aortic aneurysms who require SAI may be improved by an EVAR-first algorithm.

Upper Extremity Thromboembolism in a Patient With Subclavian Steal Syndrome

Subclavian steal is the physiologic process whereby blood flow through a vertebral artery is reversed at the level of the basilar artery as a means of supplying arterial inflow to the ipsilateral subclavian artery. This occurs in the setting of ipsilateral subclavian artery origin occlusion. We describe a case in which a patient with subclavian steal syndrome developed acute upper extremity ischemia secondary to thromboemboli from a chronically occluded ipsilateral subclavian stent (at the origin of the left subclavian artery). He subsequently underwent staged left upper extremity arterial thromboembolectomy followed by definitive revascularization via carotid-subclavian bypass. In addition, subclavian artery ligation proximal to the ipsilateral vertebral artery was performed. The patients sensory and motor neurologic hand function returned to baseline with restoration of symmetric upper extremity arterial occlusion pressures and pulse volume recordings. A search of the literature revealed that this was the first case report of acute thromboembolic hand ischemia in the setting of subclavian steal.