Victor J. Davila

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.

A multicenter experience with the surgical treatment of infected abdominal aortic endografts.

OBJECTIVE Single-center experiences with the treatment of infected endografts after endovascular aortic repair (I-EVAR) have been reported. We performed a multicenter review of the surgical care of these patients to elucidate short-term and long-term outcomes. METHODS A retrospective analysis of all EVAR explants from 1997 to 2014 at four institutions was performed. Patients with I-EVAR undergoing surgical treatment were reviewed. Data were obtained detailing preoperative demographics, and postoperative morbidity and mortality. RESULTS Thirty-six patients (30 male) were treated with endovascular graft excision and revascularization for I-EVAR with a median age of 69 years (range, 54-80 years). Average time from the initial EVAR to presentation was 589 days (range, 43-2466 days). Preoperative comorbidities included hypertension, 32 (89%); tobacco use, 31(86%); coronary artery disease, 26 (72%); hyperlipidemia, 25 (69%), peripheral artery disease, 13 (36%); cerebrovascular disease, 10 (28%); diabetes, 10 (28%); chronic obstructive pulmonary disease, 9 (25%); and chronic kidney disease, 9 (25%). The most common presenting patient characteristics were leukocytosis, 23 (63%); pain, 21 (58%); and fever, 20 (56%), which were present an average of 65 days (range, 0-514 days) before explantation. Nine different types of endograft were removed. Three patients (8%) underwent emergency explantation. Thirty-four patients (89%) underwent total graft excision, and two patients (6%) underwent partial excision. Methods of reconstruction were in situ in 27 (75%) and extra-anatomic in nine (28%). Conduits used were Dacron (DuPont, Wilmington, Del), with or without rifampin, polytetrafluoroethylene, cryopreserved allograft, and femoral vein. Forty-nine organisms grew from operative cultures. Gram-positive organisms were the most common, found in 24 (67%), including Staphylococcus in 13 (36%) and Streptococcus in six (17%). Anaerobes were cultured in 6 patients (17%), gram-negative organisms in 6 (17%), and fungus in 5 (14%). Thirty-one patients (86%) received long-term antibiotics. Early complications included acute renal failure requiring dialysis, 12 (33%); respiratory failure, 3 (8%); bleeding, 4 (11%); and sepsis, 2 (6%). Six patients required re-exploration due to hematoma, infected hematoma, lymphatic leak, bowel perforation, open abdomen at initial operation, and anastomotic bleeding. Perioperative mortality was 8% (3 of 36), and long-term mortality was 25% (9 of 36) at a mean follow-up of 569 days (range, 0-3079 days). Type of reconstruction (in situ vs extra-anatomic) or conduit type did not affect perioperative or overall mortality. CONCLUSIONS I-EVAR is a rare but potentially devastating clinical problem. Although perioperative mortality is acceptable, long-term mortality is high. The most common postoperative complication was acute renal failure requiring dialysis. Although this is the largest series of I-EVAR, further studies are needed to understand the risk factors and preventive measures.

Endovascular Retrieval of an Embolized Atrial Septal Occluder Device From the Abdominal Aorta

Patent foramen ovale (PFO) is a common heart condition in adults. Closure with a septal occluder device is a safe, well-established treatment option with excellent clinical outcomes. One rare complication of percutaneous PFO closure is embolization of the device to the heart chambers or distal vasculature. Most device migrations are recognized during or shortly after implantation. While many endovascular retrievals of migrated devices are successful, there are still a high percentage of surgical interventions performed. We report a case of a septal occluder device that embolized to the abdominal aorta and was discovered 7 days after implantation. Endovascular techniques with a snare and endobronchial forceps were used to retrieve the device safely.

Robotic-assisted left renal vein transposition as a novel surgical technique for the treatment of renal nutcracker syndrome

Renal nutcracker syndrome is an anatomic anomaly characterized by the compression of the left renal vein between the superior mesenteric artery and the aorta or between the aorta and the vertebral body. Diagnosis is often challenging. Common presenting symptoms include hematuria, abdominal pain, and pelvic congestion. Several open and endovascular techniques have been described to treat this syndrome. We report a novel surgical technique with robotic-assisted left renal vein transposition to treat a 19-year-old woman with renal nutcracker syndrome. Robotic vascular surgery can be a safe and effective therapy for this condition.

Natural History and Management Outcomes of Segmental Arterial Mediolysis

these specific diagnoses and a matching set of demographics (age, gender, race), Medicare Severity Diagnosis Related Group, admission severity of illness, and admission risk of mortality. Statistical analysis was performed using the Fisher exact test, the Pearson c statistic, Student t-test, and Cochran-Cox approximation. P < .05 was considered significant. Results: There were 77 patients treated by activation of the PERT pathway; 992 patients were included in the control group, and these patients were treated at the discretion of an attending physician without use of the algorithm from October 2013 to 2016. Both groups had similar demographics, similar distribution of risk of mortality and severity of illness, and similar average Medicare Severity Diagnosis Related Group weighting. There was no statistically significant difference in the mortality rate between the two groups. The PERT group had significantly lower intensive care unit stay and overall length of stay. No difference was seen in direct cost between the two groups. The results are summarized in the Table. There was higher utilization of interventional treatment in the PERT group (57% vs 40% for control). Conclusions: In our institution, patients with massive or submassive PE are managed by a dedicated team that implements a clinical algorithm developed by the team. This results in expedited treatment and reduced variation of care. Intensive care unit stay and overall length of stay are reduced by this approach, and the direct cost is not increased despite the use of advanced modalities of treatment. We believe that this paradigm can be of potential value in other disease entities, particularly when multiple disciplines are involved.

Outcomes of upper extremity during fenestrated-branched endovascular aortic repair

Objective Upper extremity (UE) access is frequently used during fenestrated‐branched endovascular aortic repair (F‐BEVAR) to facilitate catheterization of downgoing vessels. Limitations include risk of cerebral embolization and of UE arterial or peripheral nerve injury. The aim of this study was to assess outcomes of F‐BEVAR using UE access. Methods We reviewed the clinical data of 334 consecutive patients (74% males; mean age 75 ± 8 years) treated by F‐BEVAR for thoracoabdominal aortic aneurysms or pararenal aortic aneurysms between 2007 and 2016. Patients who underwent F‐BEVAR with an UE approach for catheterization of the renal and/or mesenteric arteries were included in the study. End points were technical success, mortality, and a composite of access‐related complications including cerebral embolization (stroke/transient ischemic attack), peripheral nerve injury, and axillary‐brachial arterial complications requiring intervention. Results There were 243 patients (73%) treated by F‐BEVAR with UE access, including 147 patients (60%) with thoracoabdominal aortic aneurysms and 96 patients (40%) with pararenal aortic aneurysms. A total of 878 renal–mesenteric arteries were incorporated by fenestrations or branches with a mean of 3.6 ± 0.8 vessels per patient. All patients had surgical exposure of the brachial artery. The left side was selected in 228 (94%) and the right side in 15 (6%). The technical success of target vessel incorporation was achieved in 99% of patients (870 of 878). Arterial closure was performed using primary repair in 213 patients (88%) or bovine patch angioplasty in 29 (12%). Patch closure was required in 13% of patients (21 of 159) treated by 10‐ to 12F sheaths and 8% (7 of 83) of those who had 7‐ to 8F sheaths (P = .19). There were six deaths (2.5%) at 30 days or within the hospital stay, none owing to access‐related complications. Major access‐related complication occurred in eight patients (3%), with no difference between the 10‐ to 12F (6 of 159 [4%]) or 7‐ to 8F sheaths (2 of 83 [2%]; P = .45). Two patients (1%) had transient median nerve neuropraxia, which resolved within 1 year. One patient (0.5%) required surgical evacuation of an access site hematoma. There were no UE arterial pseudoaneurysms, occlusions, or distal embolizations. Five patients (2%) had strokes (three minor, two major), occurring more frequently with right side (2 of 15 [13%]) as compared with left‐sided access (3 of 228 [1%]; P = .03). After a mean follow‐up of 38 ± 15 months, there were no other access‐related complications or reinterventions. Conclusions UE arterial access with surgical exposure was associated with a low rate of complications in patients treated with F‐BEVAR. Closure with patch angioplasty is frequently needed, but there were no arterial occlusions, pseudoaneurysms, or distal embolizations requiring secondary procedures. Graphical Abstract Figure. No caption available.

Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER): A Review of the Available Literature and Brief Overview of Alternate Therapies in Dialysis Associated Steal Syndrome

Dialysis associated steal syndrome (DASS) is a relatively rare but debilitating complication of arteriovenous fistulas. While mild symptoms can be observed, if severe symptoms are left untreated, DASS can result in ulcerations and limb threatening ischemia. High-flow with resultant heart failure is another documented complication following dialysis access procedures. Historically, open surgical procedures have been the mainstay of therapy for both DASS as well as high-flow. These procedures included ligation, open surgical banding, distal revascularization-interval ligation, revascularization using distal inflow, and proximal invasion of arterial inflow. While effective, open surgical procedures and general anesthesia are preferably avoided in this high-risk population. Minimally invasive limited ligation endoluminal-assisted revision (MILLER) offers both a precise as well as a minimally invasive approach to treating both dialysis associated steal syndrome as well as high-flow with resultant heart failure. MILLER is not ideal for all DASS patients, particularly those with low-flow fistulas. We aim to briefly describe the open surgical therapies as well as review both the technical aspects of the MILLER procedure and the available literature.

V3-02 TRANSPERITONEAL ROBOT ASSISTED INFERIOR VENA CAVA FILTER EXTRACTION: YOU ALREADY KNOW HOW TO DO THIS!

INTRODUCTION AND OBJECTIVES: Horseshoe kidney is a congenital anomaly in which the fused kidneys fail to ascend to their normal position. Anatomic aberrations including renal malrotation and the presence of an isthmus can make access to the posterior renal anatomy challenging. Persistent embryonic arteries combined with variations in origin, number, and size of renal arteries contribute to the increased potential of excess blood loss during surgery. Taken together, these anatomic variations make minimally invasive surgery in horseshoe kidneys technically challenging. Although minimally invasive techniques have been utilized for partial nephrectomy (PN) in horseshoe kidneys, reporting on technical modifications during robot-assisted techniques is minimal. Here, we present a case of a renal mass located in a horseshoe kidney and describe our technique for robot-assisted PN in this patient population. METHODS: A 65-year-old female presented with an incidental finding of a 5.6 cm posteriorly occurring enhancing renal mass on the left lower pole of her previously undiagnosed horseshoe kidney. Workup included a CT angiogram for further evaluation of renal vasculature. Nephrometry score was 2+1+3+P+21⁄4 8-P-H. The left moiety was fed by two renal arteries with significant distance between them, and a single renal vein inserting more distally into the inferior vena cava. The patient ultimately opted for robot-assisted PN. A fourth arm Grasping Retractor was utilized early for improved hilar retraction, and later for folding the kidney on its isthmus to create posterior access and optimal exposure during tumor enucleation. Intravenous indocyanine green (ICG) instillation was used in conjunction with near infrared fluorescence to attempt selective arterial clamping and improve intraoperative understanding of renal perfusion as well as the renal mass. RESULTS: Console time was 157 minutes with an estimated blood loss of 300 mL. Warm ischemia time was 19 minutes. The patient was discharged on post-operative day one. There were no perioperative complications. Pathology revealed a 5.7 cm oncocytoma. CONCLUSIONS: We demonstrate that using ICG and the 4th arm are technical considerations that can assist with robot-assisted PN in a horseshoe kidney, especially for posteriorly occurring tumors.

VESS17. Upper Extremity Access for Fenestrated-Branched Endovascular Aortic Repair

Objectives: Upper extremity (UE) access during fenestrated-branched endovascular aortic repair (F-BEVAR) facilitates catheterization of mesenteric arteries but carries added risk of arterial injury and neurologic complications. The aim of this study was to assess outcomes of F-BEVAR using UE access. Methods: We reviewed the clinical data of 334 consecutive patients treated by F-BEVAR (2007-2016). Patients who had procedures with UE arterial access for renal-mesenteric catheterization were included in the study. End points were technical success, mortality, stroke, peripheral nerve injury, UE arterial complications (dissection, thrombosis, hematoma requiring intervention, pseudoaneurysm, or distal embolization), and freedom from UE thrombosis or reintervention. Results: There were 243 patients (74% male; mean age, 75 6 8 years) treated for 148 thoracoabdominal and 95 pararenal aortic aneurysms using UE arterial access. A total of 838 renal-mesenteric arteries were incorporated by fenestrations or branches (3.4 6 0.3 vessels/patient). UE arterial access was performed using surgical exposure of the proximal brachial artery in 171 patients, distal brachial artery in 62, or infraclavicular axillary artery in nine. Access was left-sided in 228 patients (94%) and right-sided in 15 (6%). Large-profile sheaths (10F-12F) were used in 159 patients (66%) and smaller profile (7F-8F) in 84 (34%). Technical success of target vessel incorporation was achieved in 99% (829 of 838). Thirty-day mortality was 2.5% (6 of 243). UE arterial complications occurred in 8 patients (4%), including focal dissection in 5 (2%), and transection, in situ thrombosis or hematoma requiring surgical evacuation in 1 patient each. Flow-limiting UE arterial lesions were diagnosed intraoperatively and successfully treated by patch angioplasty in six patients and interposition vein graft in one. Two patients (1%) developed UE peripheral nerve neurapraxia. There were no pseudoaneurysms or distal embolizations. Four patients (2%) had stroke (3 minor, 1 major), which were more frequent with right-sided compared to leftsided UE arterial access (2 [13%] vs 2 [0.9%]; P < .001). Stroke was not associated with type of aortic arch, sheath profile, or presence of subclavian artery calcification or partial thrombus (P > .05). Mean follow-up was 38 6 15 months. There were no late UE arterial stenoses, thromboses, accessrelated complications, or reinterventions. Conclusions: UE arterial access using surgical exposure and largediameter sheaths was associated with low rates of complications, stroke, and peripheral nerve injuries in patients treated by F-BEVAR. Left-sided UE access was associated with lower stroke rates.

Endovascular repair of expanding thoracic aortic aneurysms in high surgical risk patients

thoracic aortic aneurysm. A computed tomography (CT) angiogram of the chest, abdomen, and pelvis was performed which showed a saccular aneurysm measuring 4.7 cm, approximately 2 cm distal to the left subclavian artery and extending for 3.5 cm. His aneurysm had expanded by 11 mm since prior evaluation. He was referred to surgery. Upon evaluation, he was deemed an appropriate candidate for endovascular repair. The preanesthetic evaluation was performed which included two‐dimensional echocardiogram that showed preserved left ventricular function.