Timothy S. Roush

Spontaneous splanchnic dissection: Application and timing of therapeutic options

BACKGROUND Spontaneous splanchnic dissection (SSD) occurs infrequently and has a poorly defined natural history. Few studies address the application, timing, and consequences of therapeutic options. Our goal was to apply conservative (non-operative) management in the care of each patient, reserving interventions for specific indications that may be predictive of adverse outcomes. METHODS Between 2003 and 2008, 10 consecutive patients (mean age 54.7-years-old, 70.0% male) presented with 11 SSDs involving either the celiac artery (n = 6), superior mesenteric artery (n = 3), or both (n = 1). Each patient had acute, spontaneous onset of persistent abdominal pain and was diagnosed with SSD following multidetector row computed tomographic angiography (CTA). Non-operative management (anticoagulation, anti-impulse therapy, analgesics, and serial CTA examinations) was initially used in 9 patients. Endovascular (n = 2) or operative (n = 2) intervention was performed either immediately (n = 1) or following failed medical management (n = 3) in 4 patients for specific indications that included persistent symptoms (n = 3), expansion of false lumen (n = 3), and/or radiologic malperfusion (n = 3). RESULTS All patients were asymptomatic after successful non-operative management or following intervention. No morbidity occurred. Upon complete follow-up (mean 13.4 months, range, 2 to 36 months), all patients remained asymptomatic. Preservation of distal perfusion with either thrombosis or ongoing regression of false lumen was achieved in 5 patients who received only non-operative management and in 4 patients following intervention. A stable chronic dissection was present in 1 patient who had only non-operative management. CONCLUSION Successful outcomes following SSD may be achieved with either non-operative therapy alone or intervention if persistent symptoms, expansion of false lumen, and/or malperfusion occur. The unpredictable response of the false lumen to conservative management mandates close, long-term follow-up. Endovascular and operative interventions produced similar outcomes in a small number of patients with limited follow-up. Although SSD is currently perceived as rare, the increasing use of CTA may prove that the true incidence has been underestimated.

Current Status of Endovascular Aneurysm Repair: 20 Years of Learning

Parodi first introduced endovascular aneurysm repair (EVAR) in 1991 and since that time it has been shown to have a lower 30-day morbididty and mortality compared to open surgery. Anatomic constraints governed by the need for adequate access vessels, and sufficient proximal and distal landing zones, as well as the need for long-term surveillance, have been the main limitations of this technology. Anatomic factors were initially estimated to exclude 40% of patients with abdominal aortic aneurysm (AAA). The rapid extension of EVAR technology has been complimented by improved access to both high-quality imaging modalities and a variety of endografts. These developments have led EVAR to become a more practical alternative for patients with ruptured AAA. Early data in this setting is encouraging with even more profound reductions in morbidity and mortality than seen in the elective repair.

Short-term and midterm survival of ruptured abdominal aortic aneurysms in the contemporary endovascular era

Objective: Endovascular aneurysm repair (EVAR) has been shown to reduce mortality in the emergent repair of ruptured abdominal aortic aneurysms (AAAs). However, long‐term survival data for this group of patients are lacking with contemporary endovascular endografts. The purpose of this study was to evaluate both 30‐day mortality rates and 1‐year survival in patients undergoing emergent EVAR in a 43‐facility hospital system with a quaternary referral center with an established ruptured aneurysm protocol. Methods: Retrospective analysis of patients captured prospectively in an Institutional Review Board‐approved registry for patients treated emergently for AAA were reviewed between 2012 and 2017 was conducted. Primary outcome measures were 30‐day mortality and 1‐year survival for the entire group as well as for symptomatic and ruptured aneurysms. Data were analyzed using logistic regression survival curves, and a log‐rank test was performed to compare survival between open and endovascular repair. Patients were evaluated on an intent‐to‐treat basis, and outcomes were evaluated in a multivariate model. Results: A total of 249 patients were referred as part of the protocol. Of these, 102 (41%) were treated emergently. Kaplan‐Meier estimates of 30‐day and 1‐year survival were 64% and 53% for all patients, 58% and 46% for ruptured patients, and 86% and 81% for symptomatic patients. EVAR resulted in improved 30‐day survival (64% vs 31%; odds ratio, 4.0; P = .03) and 1‐year survival (40% vs 23%; odds ratio, 2.3; P = .4) over open repair. Significant predictors for 30‐day mortality included hypotension (P = .0003), blood transfusion (P < .0001), length of stay (P = .0005), extravasation (P = .01), preoperative cardiopulmonary resuscitation (P = .04), open repair (P = .007), aortouni‐iliac reconstruction (P = .008), and abdominal compartment syndrome (P = .007). Significant predictors for 1‐year mortality included advanced age (P = .04), hypotension (P = .01), blood transfusion (P = .006), extravasation (P = .03), reintubation (P = .03), and abdominal compartment syndrome (P = .03). There were no differences in outcomes based on race, gender, or outside transfer. Peripheral arterial disease (P = .04), hypertension (P = .04), coronary artery disease (P = .03), and familial history of aneurysms (P = .05) were related to increased 30‐day mortality. Peripheral arterial disease (P = .06) and coronary artery disease (P = .07) were nearly significant, with increased 1‐year mortality. Conclusions: EVAR is associated with improved survival compared with open repair in patients requiring emergent AAA repair. However, in the first year, there is a significant risk of death based on initial presentation as well as underlying comorbidities. To improve long‐term survival, aggressive medical management and medical surveillance are warranted.

Successful Repair of Acute Type B and Retrograde Type A Aortic Dissection With Kidney Ischemia

Acute dissection of thoracic aorta carries a risk of renal ischemia followed by the development of a kidney failure. The optimal surgical and nonsurgical management of these patients, timing of intervention, and the factors predicting renal recovery are not well delineated and remain controversial. We present a case of acute type B thoracic aortic dissection with left kidney ischemia. Evaluation of renal function was performed by the means of internationally accepted Risk, Injury, Failure, Loss of kidney function, End stage kidney disease and Acute Kidney Injury Network classifications for acute kidney injury, renal duplex sonography, and intravascular ultrasound that demonstrated left renal artery dissection with a flap completely compressing the true lumen. The patient underwent thoracic endovascular aortic repair and left renal artery stent and recovered well. Six months later, at the follow-up visit, retrograde type A aortic dissection was found, which was successfully repaired. Reversal of renal ischemia after aortic dissection depends on the precise assessment of renal function and prompt intervention.