Yana Etkin

Successful venous repair and reconstruction for oncologic resections

OBJECTIVE We report our institutional experience of various venous reconstruction methods during oncologic resections, especially examining the patency of venous reconstructions and the conduits used. METHODS All patients undergoing venous repair or reconstruction for oncologic resections between 2008 and 2014 were identified by a retrospective search of a prospectively maintained database at a single university hospital. Extent and manner of venous reconstruction and conduit or patch material were recorded. Need for intraoperative venovenous bypass or cardiopulmonary bypass was also recorded. Whereas no prescribed follow-up protocol has been instituted, patency and survival data as available were analyzed. RESULTS During the study period, 127 patients were identified. Five patients had primary ligations, without limb loss. Of the remaining 122 patients, 77 (63%) underwent primary repairs, 23 (19%) had patch repair, and 22 (18%) had bypasses. Of these, 27 (22%) were for portal vein reconstruction during a Whipple procedure, 47 (39%) were for caval repair during caval thrombectomy in the setting of renal cell cancer, and 28 (23%) were for caval repair during resection for other abdominal malignant neoplasms. Venovenous bypass was used in 16 repairs and cardiopulmonary bypass in 10. The 1-year patency rates were 100% for primary and patch repairs and 86% for bypass graft reconstructions. Occlusions were suffered only in the prosthetic grafts group. There was no limb loss or significant long-term morbidity in patients with occluded grafts. Rate of infection was 0%, and there was no evidence of an increased infection rate in prosthetic or bioprosthetic conduits or patches. Perioperative mortality was 5.5%. CONCLUSIONS Overall, venous reconstruction for oncologic resection can be done safely with very low complication rates and low perioperative mortality. Prosthetic grafts can be used for most reconstructions with no infections and good patency rates.

Trends in Endovascular Aortic Aneurysm Repair Length of Stay over a Decade at a Tertiary Academic Institution

BACKGROUND Length of stay (LOS) is used as a quality metric to reduce cost and improve value of delivery of care. We sought to analyze trends in endovascular aortic aneurysm repair (EVAR) LOS at a tertiary academic institution over the last decade. METHODS A retrospective review of prospectively collected data was performed. Infrarenal EVARs from 2001 to 2013 were divided into 3 groups: group I (2001-2004), EVARs were performed as part of clinical trials; group II (2005-2008), EVARs were referred to a tertiary referral center with the most experience with EVAR; group III (2009-2013), EVARs were referred to academic institutions in the presence of severe patient comorbidities. Trends in LOS and correlation with severity of illness (SOI) as based on All Patient Refined Diagnosis Related Groups and admission and/or disposition status were analyzed. LOS index (LOSI) at our institution was then compared with University HealthSystem Consortium (UHC) Hospitals over the past 3 years. RESULTS A total of 1,265 EVARs were performed during this time period: 325 in group I, 547 in group II, and 393 in group III. The median LOS was 4 days (inter quartile range [IQR], 2-6) vs. 3 days (IQR, 2-5) ± 0.28 vs. 4 days (IQR, 3-7), respectively (P < 0.01). Although moderate SOI was fairly constant over time (P = 0.66), major and/or extreme SOI constituted a greater proportion of patients in group I, was reduced in group II, and was again increased in group III, P < 0.01. The complication rate paralleled this pattern (group I, 15.2%; group II, 8.6%; group III, 10.4%; P = 0.02). The percentage of patients discharged to nursing home and/or rehab was 5.7% in group I, 8.2% in group II, 11.5% in group III (P = 0.03). Cases that were performed urgently and/or emergently increased over time: 11.6% in group I, 14.9% in group II, 21.6% in group III (P = 0.01). The risk-adjusted LOSI at our institution was significantly greater (1.25) when compared with UHC hospitals (0.75). CONCLUSIONS Our study suggests a relationship between time period of EVAR, SOI, complications, admission status, and LOS. Attention to these trends could be used to decrease LOS in an increasingly complex patient population.

In Patients with a Chronic Type B Dissection, Does Endovascular Treatment Reduce Long Term Complications?

Aortic dissection is a highly morbid condition. Acute type B dissection is associated with 13 % 30-day mortality and 83 % 5 year survival [1]. The management of type B dissection remains complex and challenging. Since the introduction of TEVAR technology in the 1990’s it has become a preferred method of treatment of acute and chronic type B dissections. Medical management of chronic type B dissection continues to be a gold standard therapy while the role and timing of TEVAR remains controversial. The objective of this chapter is to describe treatment options for chronic type B dissection and establish possible benefits of endovascular repair in reducing long term complications of chronic type B dissection.

IP157. Modified Banding of Fistulas for Steal Syndrome With Quantitative Data

Objectives: Venous outflow stenosis secondary to intimal hyperplasia is a common cause of dialysis access failure. Currently, treatment with angioplasty and stenting has high rates of reintervention. We evaluated the efficacy of drug-eluting balloons (DEB) on the treatment of venous outflow stenosis of arteriovenous fistulas and grafts. Methods: We prospectively followed 13 patients on hemodialysis whose dialysis access had been treated with Bard Lutonix DEB (Paclitaxel) for venous outflow stenosis. Patients were not randomized, and treatments were at the discretion of the treating physician. Postinterventional follow-up consisted of clinic visits and routine duplex ultrasound imaging. Primary end points were time to reintervention and patency of target lesion. Results: All 13 patients had venous outflow stenosis diagnosed by duplex ultrasound imaging. Eight patients had brachiocephalic fistulas (AVFs), while the other five had grafts (AVGs). All patients underwent balloon angioplasty with DEB of the venous outflow stenosis. There was a mean follow-up of 10 months. Two patients died of unrelated events during the follow-up period. Of the 11 remaining patients, six (56%) were intervention free. Of those that require reintervention, two underwent angioplasty for central venous stenosis unrelated to the initial site of DEB angioplasty. Taking this into account eight (73%) of the AVFs/ AVGs whose venous outflow were treated with DEB were patent at 10 months. Only three patients required repeat angioplasty at the initial site of DEB angioplasty. Conclusions: Our study suggests favorable results for the treatment of venous outflow stenosis in arteriovenous fistulas and grafts with DEB however larger prospective studies are warranted prior to making a definitive recommendation.

Creation of spliced vein conduit using microvascular anastomotic coupler

&NA; The single‐segment great saphenous vein continues to be a conduit of choice for lower extremity arterial bypass. In patients without an adequate continuous segment of great saphenous vein, a spliced vein graft may be used as an alternative. Creating a spliced vein conduit can be technically challenging and time consuming. We present a technique of creating a spliced vein conduit by using a microvascular anastomotic coupler.