Tomas D. Martin

Esophageal Perforation in Adults: Aggressive, Conservative Treatment Lowers Morbidity and Mortality

Objective:To evaluate the outcome of aggressive conservative therapy in patients with esophageal perforation. Summary Background Data:The treatment of esophageal perforation remains controversial with a bias toward early primary repair, resection, and/or proximal diversion. This review evaluates an alternate approach with a bias toward aggressive drainage of fluid collections and frequent CT and gastographin UGI examinations to evaluate progress. Methods:From 1992 to 2004, 47 patients with esophageal perforation (10 proximal, 37 thoracic) were treated (18 patients early [<24 hours], 29 late). There were 31 male and 16 females (ages 18–90 years). The etiology was iatrogenic (25), spontaneous (14), trauma (3), dissecting thoracic aneurysm (3), and 1 each following a Stretta procedure and Blakemore tube placement. Results:Six of 10 cervical perforations underwent surgery (3 primary repair, 3 abscess drainage). Nine of 10 perforations healed at discharge. In 37 thoracic perforations, 2 underwent primary repair (1 iatrogenic, 1 spontaneous) and 4 underwent limited thoracotomy. Thirty-4 patients (4 cervical, 28 thoracic) underwent nonoperative treatment. Thirteen of the 14 patients with spontaneous perforation (thoracic) underwent initial nonoperative care. Overall mortality was 4.2% (2 of 47 patients). These deaths represent 2 of 37 thoracic perforations (5.4%). There were no deaths in the 34 patients treated nonoperatively. Esophageal healing occurred in 43 of 45 surviving patients (96%). Subsequent operations included colon interposition in 2, esophagectomy for malignancy in 3, and esophagectomy for benign stricture in 2. Conclusions:Aggressive treatment of sepsis and control of esophageal leaks leak lowers mortality and morbidity, allow esophageal healing, and avoid major surgery in most patients.

Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR).

PURPOSE To determine the clinical and anatomical risk factors for cerebrovascular accidents (CVA) in patients undergoing thoracic endovascular aortic repair (TEVAR). METHODS Between September 2000 and December 2006, 196 patients (135 men; mean age 68.6+/-13.5 years, range 17-92) underwent TEVAR for a variety of aortic pathologies. The majority (156, 79.6%) were treated with the TAG stent-graft. Demographics, pathologies, intraoperative procedure-related measures, device usage, and postoperative outcomes were assessed. CVA was defined as a new focal or global neurological (motor or sensory) deficit lasting >48 hours associated with acute intracranial abnormalities on computed tomography or magnetic resonance brain imaging. Spinal cord ischemia was excluded. In a subset of patients with planned left subclavian artery (LSA) coverage and an incomplete circle of Willis or a dominant left vertebral artery, prophylactic carotid-subclavian bypasses were performed. RESULTS Nine (4.6%) patients suffered a CVA. Factors not predictive of a CVA on univariate analysis included aortic pathology, urgency of repair, ASA classification, type of anesthesia, blood loss, procedure time, and device used. Proximal extent of repair (with or without extra-anatomical revascularization) was significantly associated with a higher incidence of strokes (zones 0-2 versus 3-4, p=0.025). Five (55.6%) patients with a CVA had documented intraoperative hypotension (systolic blood pressure<80 mmHg). Additionally, while 2 patients had hemispheric infarcts, 5 had acute posterior circulation infarcts involving the cerebellum and brainstem; a single patient had both anterior and posterior circulation infarcts. Seven of the CVA patients had proximal coverage of the thoracic aorta in zones 0-2; of these, 6 had posterior circulation infarcts. Selective LSA revascularization based on preoperative cerebrovascular imaging resulted in lower rates of CVA (6.4% to 2.3%, p=0.30) and posterior circulation infarcts (5.5% to 1.2%, p=0.13). CONCLUSION Proximal extent of repair may serve as a surrogate marker for greater severity of degenerative disease of the aortic arch. Avoidance of intraoperative hypotension and preservation of antegrade vertebral perfusion may be important in prevention of posterior circulation strokes.

The relationship between visceral ischemia, proinflammatory cytokines, and organ injury in patients undergoing thoracoabdominal aortic aneurysm repair.

ObjectivesPlasma proinflammatory, anti-inflammatory cytokine, and soluble tumor necrosis factor (TNF) receptor concentrations were examined in hospitalized patients after abdominal and thoracoabdominal aortic aneurysm (TAAA) repair, with and without left atrial femoral bypass. Changes in plasma cytokine concentrations were related to the duration of visceral ischemia and the frequency rate of postoperative, single, or multiple system organ dysfunction (MSOD). DesignProspective, observational study. SettingTwo academic referral centers in the United States and The Netherlands. PatientsWe included 16 patients undergoing TAAA repair without left atrial femoral bypass, 12 patients undergoing TAAA repair with left atrial femoral bypass, and nine patients undergoing infrarenal aortic aneurysm repair. Measurements and Main ResultsTimed, arterial blood sampling for proinflammatory and anti-inflammatory cytokine and soluble TNF receptor concentrations (p55 and p75), and prospective assessment of postoperative single and MSOD. Plasma appearance of TNF-&agr;, interleukin (IL)-6, IL-8, and IL-10 peaked 1 to 4 hrs after TAAA repair, and concentrations were significantly elevated compared with infrarenal abdominal aortic aneurysm repair (p < .05). Left atrial femoral bypass significantly reduced the duration of visceral ischemia (p < .05) and the systemic TNF-&agr;, p75, and IL-10 responses (p < .05). Plasma TNF-&agr; concentrations >150 pg/mL were more common in patients with extended visceral ischemia times (>40 mins). Additionally, patients with early peak TNF-&agr; concentrations >150 pg/mL and IL-6 levels >1,000 pg/mL developed MSOD more frequently than patients without these elevated plasma cytokine levels (both p < .05). ConclusionsThoracoabdominal aortic aneurysm repair results in the increased plasma appearance of TNF-&agr;, IL-6, IL-8, IL-10, and shed TNF receptors. The frequency and magnitude of postoperative organ dysfunction after TAAA repair is associated with an increased concentration of the cytokines, TNF-&agr;, and IL-6 and the increased plasma levels of these cytokines appear to require extended visceral ischemia times.

Management of Combined Pancreatoduodenal Injuries

From 1969 to 1985, 129 patients with combined pancreatoduodenal injuries were treated at one urban trauma center. A total of 104 patients (80.6%) had penetrating wounds, and multiple visceral and vascular injuries were usually associated with the pancreatoduodenal injury. Primary repair or resection of one or both organs coupled with pyloric exclusion and gastrojejunostomy (68 patients) and drainage was used in 79 patients (61.2%) in the entire study and in 59% (36 of 61) of all patients treated since 1976. Simple primary repair of one or both organs and drainage was performed in 31 patients (24%), whereas the remaining 19 patients (14.8%) had pancreatoduodenectomies (13 patients) or no repair before exsanguination (six patients). Major pancreatoduodenal complications occurring in the 108 patients surviving more than 48 hours included pancreatic fistulas (25.9%), intra-abdominal abscess formation (16.6%), and duodenal fistulas (6.5%). The overall mortality rate for the study was 29.5% (38 of 129). The acute mortality rate with these injuries will remain high secondary to injuries to associated organs and vascular structures. The morbidity and late mortality rates related to the moderate to severe pancreatoduodenal injury itself can be decreased by the addition of pyloric exclusion and gastrojejunostomy to the primary repairs.

Extent of Aortic Coverage and Incidence of Spinal Cord Ischemia After Thoracic Endovascular Aneurysm Repair

BACKGROUND Risk factors for spinal cord ischemia (SCI) after thoracic endovascular aneurysm repair (TEVAR) remain unclear. Aortic coverage was examined as a risk factor for SCI using quantitative three-dimensional computed tomography angiography (CTA) analysis. METHODS The medical records, radiographic imaging studies, and a prospectively maintained database of all TEVAR procedures performed during a 7-year period were retrospectively reviewed. Preoperative anatomic dimensions and postoperative graft path lengths were measured from CTAs using curved planar and orthogonal multiplanar reformations along centerline paths. SCI was defined as transient or permanent lower extremity neurologic deficit without associated intracerebral hemispheric events. RESULTS Of 326 TEVAR cases, 241 patients (74%) had satisfactory imaging. Thirty-three (10%) had SCI. These patients were older (72.7 +/- 10.6 vs 64.7 +/- 15.8 years, p = 0.005) and had longer intraoperative procedure times (137 +/- 65 vs 113 +/- 68 minutes, p = 0.05). Despite similar total lengths of native thoracic aorta (295.0 +/- 36.3 vs 283.1 +/- 39.8 mm, p = 0.17), patients with permanent SCI had a greater absolute (260.5 +/- 40.9 vs 195.8 +/- 81.6 mm, p = 0.002) and proportionate (88.8% +/- 12.1% vs 67.6% +/- 24.0%, p = 0.001) length of aortic coverage. The average length of uncovered aorta proximal to the celiac artery in patients with SCI was 17.3 +/- 21.8 mm vs 63.1 +/- 62.9 mm in patients without SCI (p = 0.0006). Neither the patency of the hypogastric arteries nor left subclavian artery was associated with SCI. CONCLUSIONS The extent and distal location (relative to the celiac artery) of aortic coverage were associated with an increased risk of SCI. Prophylactic measures for spinal cord protection should be considered in patients whose thoracic aortas require extensive coverage.

The impact of renal fusion and ectopia on aortic surgery

This article is concerned with observations in 17 patients with renal fusion and ectopic abnormalities: horseshoe kidney in 13 patients, crossed ectopia with fusion in two, pancake kidney in one, and pelvic kidney in one. Three patients had occlusive disease, one may have had renal artery occlusion, and 13 had aneurysms--three thoracoabdominal and 10 infrarenal. Rupture of aneurysm had occurred in one patient at each level and six patients had had one or more previous attempts at aneurysmal removal. Diagnosis and evaluation were made with the aid of intravenous pyelography, retrograde pyelography, CT scanning, and at operation (three patients). Three patients had two normally located right and left renal arteries. Twelve patients had one to three additional aberrant arteries arising from the aorta and iliac arteries. One patients renal blood supply arose from multiple aberrant arteries. Ureters crossed the midline in two patients. Treatment of occlusive disease consisted of endarterectomy in one patient and percutaneous transluminal angioplasty in two. Aneurysms were treated by graft replacement with retroperitoneal exposure in seven patients and transabdominal exposure in six. One patient was treated medically. Renal isthmus division was employed in only two patients and involved accessory arteries were reattached to the grafts in all cases. Death from myocardial infarction occurred in two patients (12%). Eleven patients subjected to operation were alive 6 months to 14 years later.

Early outcomes after endovascular management of acute, complicated type B aortic dissection

OBJECTIVES Surgical management of acute, complicated type B aortic dissection is associated with significant morbidity and mortality. This study examined the feasibility and safety of endovascular treatment of this pathology. METHODS We reviewed a prospectively maintained thoracic endovascular database and medical records at a single institution from 2005 to 2007. The study group comprised of acute, complicated type B dissections, defined as duration of symptoms <or=14 days and involving either false lumen rupture, malperfusion, intractable pain, or uncontrolled hypertension. All repairs were performed using the TAG device (W. L. Gore and Associates, Flagstaff, Ariz). Select 30-day or in-hospital outcomes were reported. RESULTS Of the 216 thoracic endovascular aortic aneurysm repairs performed during the study period, 33 (15%) were for acute, complicated type B dissections. There were eight women (24%). The mean age was 61 +/- 15 years. The average duration of symptoms was 2.9 +/- 4.1 (median, 1) days. The indications for repair included rupture in 15 patients (46%) and mesenteric/renal/lower extremity malperfusion in 11 (33%). Mean fluoroscopy time and contrast volume were 30 +/- 16 minutes and 176 +/- 55 mL, respectively. Eight (73%) of 11 patients with malperfusion required branch vessel stenting. The 30-day in-hospital mortality was 21% (7 of 33). Causes of death included cardiac arrest in 3, progressive multisystem organ failure in 2, rupture in 1 and unknown in 1. At least one major complication occurred in 76% of the patients, including respiratory failure in 11 (33%), permanent spinal cord ischemia in 5 (15%), renal failure requiring dialysis in 4 (12%), and stroke in 4 (12%). The mean postoperative length of stay was 17.2 +/- 16.5 days, and only 14 (42%) were discharged to home. CONCLUSIONS Emergency endovascular repair of acute, complicated type B dissection is associated with significant mortality and morbidity. The overall role of this therapy in the treatment of this lethal problem should be better defined and compared with other surgical or interventional options before being generally adopted.

Exogenously administered interleukin-10 decreases pulmonary neutrophil infiltration in a tumor necrosis factor–dependent murine model of acute visceral ischemia

INTRODUCTION Visceral ischemia and reperfusion associated with thoracoabdominal aortic aneurysm (TAAA) repair results in lung injury, which appears to be mediated in part by proinflammatory cytokines. The purpose of this study was to determine the effect of exogenous administration of the antiinflammatory cytokine, recombinant human IL-10 (rhIL-10), on proinflammatory cytokine production (IL-6 and TNF alpha) and pulmonary neutrophil infiltration after acute visceral ischemia-reperfusion. METHODS Two hours before 25 minutes of supraceliac aortic occlusion, 80 C57BL/6 mice (20 to 22 g) received an intraperitoneal injection of rhIL-10 (0.2 microgram [n = 20], 2 micrograms [n = 20], 5 micrograms [n = 25], or 20 micrograms [n = 15]), and 16 mice received murine anti-IL-10 IgM 200 micrograms. Twenty-five additional mice underwent visceral ischemia-reperfusion without treatment (controls), and 16 mice underwent laparotomy without aortic occlusion (sham). RESULTS Pretreatment with exogenous rhIL-10 resulted in significant reductions in lung neutrophil infiltration with 0.2 microgram, 2 micrograms, and 5 micrograms per mouse of rhIL-10 compared with lung neutrophil levels in control mice that underwent acute visceral ischemia-reperfusion alone (p < 0.05). In addition, serum TNF alpha was detected in 50% of control mice and in 75% of mice that received murine anti-IL-10, but in none of the mice that received rhIL-10 (2 micrograms per mouse) or the mice that underwent sham operative procedures (p < 0.05 by chi 2 analysis). CONCLUSION Exogenous IL-10 limits pulmonary neutrophil recruitment and the appearance of TNF alpha in this model of visceral ischemia-reperfusion injury. Thus the use of exogenous IL-10 may offer a novel therapeutic approach to decrease the complications that are associated with TAAA repair.

Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration

BACKGROUND The Food and Drug Administration has approved devices for endovascular management of thoracic endovascular aortic aneurysm repair (TEVAR); however, limited data exist describing the outcomes of TEVAR for aneurysms attributable to chronic type B aortic dissection (cTBAD). This study was undertaken to determine the results of endovascular treatment of cTBAD with aneurysmal degeneration. METHODS A retrospective analysis of all patients treated for cTBAD with aneurysmal degeneration at the University of Florida from 2004 to 2011 was performed. Computed tomograms with centerline reconstruction were analyzed to determine change in aortic diameter, relative proportions of aortic treatment lengths, and false lumen perfusion status. Reintervention and mortality were estimated using life-tables. Cox regression analysis was completed to predict mortality. RESULTS Eighty patients underwent TEVAR for aneurysm due to cTBAD (mean age [± standard deviation], 60 ± 13 years [male, 87.5%; n = 70]; median follow-up, 26 [range, 1-74] months). Median time from diagnosis of TBAD to TEVAR was 16 (range, 1-72) months. Prior aortic root/arch replacement had been performed in 29% (n = 23) at a median interval of 28.5 (range, 0.5-312) months. Mean preoperative aneurysm diameter was 62.0 ± 9.9 mm. In 75% (n = 60) of cases, coverage was proximal to zone 3, and 24% (n = 19) underwent carotid-subclavian bypass or other arch debranching procedure. Spinal drains were used in 78% (pre-op 71%, n = 57; post-op 6%, n = 5). Length of stay was 6.5 ± 4.7 days with a composite morbidity of 26% and in-hospital mortality of 2.5% (n = 2). Overall neurologic event rate was 17% (spinal cord ischemia 10% [n = 8], with a permanent deficit observed in 6.2% [n = 5]; stroke 7.5%). Aneurysm diameter reduced or stabilized in 65%. The false lumen thrombosed completely within the thoracic aorta in 52%, and reintervention within the treated aortic segment was required in 16% (n = 13).One- and 3-year freedom from reintervention (with 95% confidence interval [CI]) was 80% (range, 68%-88%) and 70% (range, 57%-80%), respectively. Survival at 1 and 5 years was 89% (range, 80%-94%) and 70% (range, 55%-81%) and was not significantly different among patients requiring reintervention or experiencing favorable aortic remodeling. Multivariable analysis identified coronary artery disease (hazard ratio [HR], 6.4; 95% CI, 2.3-17.7; P < .005), prior infrarenal aortic surgery (HR, 8.6; 95% CI, 2.3-31.7; P = .001), and congestive heart failure (HR, 11.9; 95% CI, 1.9-73.8; P = .008) as independent risk factors for mortality. Hyperlipidemia was found to be protective (HR, 0.2; 95% CI, 0.05-0.6; P = .004). No significant difference in predictors of mortality were found between patients who underwent reintervention vs those who did not (P = .2). CONCLUSIONS TEVAR for cTBAD with aneurysmal degeneration can be performed safely but spinal cord ischemia rates may be higher than previously reported. Liberal use of procedural adjuncts to reduce this complication, such as spinal drainage, is recommended. Reintervention is common, but long-term survival does not appear to be impacted by remediation.

Spinal cord ischemia after TEVAR in patients with abdominal aortic aneurysms

OBJECTIVE To examine the incidence of and the anatomic factors that may contribute to spinal cord ischemia (SCI) in patients with a history of abdominal aortic aneurysms (AAA) after thoracic endovascular aortic repair (TEVAR). METHODS The medical records, computed tomography (CT) angiograms, and a prospectively maintained clinical database of all TEVAR patients at a single institution between 2000 and 2007 were reviewed. Select preoperative demographics, thoracoabdominal aortoiliac anatomy, intraoperative procedural variables, and postoperative outcomes were examined. Univariate and multivariate analyses were performed and odds ratio estimates were reported with 95% confidence intervals. RESULTS Of the 261 patients who underwent TEVAR, 27 developed SCI (10%). Thirteen (48%) of these 27 patients were completely reversed with spinal drainage, and 14 (52%) were permanent. Patients with SCI tended to be older (P = .006), male (P = .049), and required more emergent procedures (P = .051) performed under general anesthesia (P = .004). Interestingly, while prior AAA repair (50/261, 19%) alone was not associated with SCI (P = .44), a history of either repaired or unrepaired AAA (101/261, 39%) was a predictor of SCI on multivariate analysis (odds ratio [OR] = 4.35 [1.43, 14.3], P = .10), independent of thoracic aortic coverage (P = .001) and lumbar artery patency (P = .008), both of which were also associated with SCI. CONCLUSION Although the causes of SCI after TEVAR are multifactorial, abdominal aortic anatomy appears to be associated with development of this complication. Patients with either prior AAA repair or those with unrepaired AAA appear to be at increased risk for SCI.