The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms

“Although not directed by randomized prospective trials, general principles of management of visceral artery aneurysms do exist. Because of their potential for rupture, most visceral artery pseudoaneurysms, mycotic aneurysms, and many larger true aneurysms warrant intervention. Treatment can generally be accomplished by either open surgical or endovascular approaches. The treatment goal is to prevent aneurysm expansion and potential rupture by exclusion from the arterial circulation while maintaining necessary distal or collateral bed perfusion. Depending on the location of the aneurysm, this can be accomplished in a variety of ways. In areas of the visceral circulation with an abundance of collateral flow, for example, in the splenic artery, proximal and distal ligation of the aneurysm segment is a viable surgical option. This can also be accomplished with endovascular isolation of the aneurysmal segment, either by placement of a stent graft or by coil embolization of the proximal and distal arterial segment. The preferred treatment of an individual patient and aneurysm must be carefully based on the particular anatomy and any associated clinical conditions as well as the underlying condition of the patient. The purpose of these guidelines is to inform the diagnosis, treatment options, screening, and follow-up of visceral aneurysms based on the available published literature and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach”

Graphical Abstract
Continue reading

Laparoscopic Entry Techniques and Injuries

“Recent reports by the Australian Safety and Efficacy Register for New interventions and Procedures (ASERNIP-S) and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) concluded that insufficient evidence is available to assess the safety of the open versus closed laparoscopy in regard to major vascular and visceral injuries.” (Larobina & Nottle)

Major Vascular Injuries in Closed vs. Open Laparoscopy (Larobina & Nottle)

“Our case series shows that open laparoscopy can vastly reduce the incidence of access-related morbidity and mortality. Only a single visceral injury occurred in 5900 cases, and no major vascular injuries were reported.These figures are consistent with those of other reported series of open laparoscopy, which also show a zero rate of vascular injury and low rates of visceral injury.The literature review showed a rate of 1 injury to major retroperitoneal vessels per 2272 cases of closed laparoscopy procedures. This compares with a major vascular injury rate of 0 for the open technique. This difference is both statistically significant ( P = 0.003) and highly clinically significant.” (Larobina & Nottle)

Continue reading

Society for Vascular Surgery (SVS) Clinical Practice Guidelines on Popliteal Artery Aneurysms

“Popliteal artery aneurysms (PAAs) are the most common peripheral arterial aneurysms, defined as aneurysms outside the aortoiliac system or the brain, accounting for 70% of all peripheral arterial aneurysms. They are more common in men (95%) and tend to occur in the sixth and seventh decades of life. Few modern studies have been performed on the natural history of PAAs, and many of these were retrospective reviews of surgical patients. As such, the timing and details of PAA management remain nuanced.”

“These guidelines focus on PAA screening, indications for intervention, choice of repair strategy, management of asymptomatic and symptomatic PAAs (including those presenting with acute limb ischemia), and follow-up of both untreated and treated PAAs. They offer long-awaited evidence-based recommendations for physicians taking care of these patients.”

Continue reading

Periprocedural bridging anticoagulation

Rechenmacher SJ, Fang JC. Bridging Anticoagulation: Primum Non Nocere. J Am Coll Cardiol. 2015 Sep 22;66(12):1392-403.

Full-text for Emory users.

Conclusions: Periprocedural anticoagulation management is a common clinical dilemma with limited evidence (but 1 notable randomized trial) to guide our practices. Although bridging anticoagulation may be necessary for those patients at highest risk for TE, for most patients it produces excessive bleeding, longer length of hospital stay, and other significant morbidities, while providing no clear prevention of TE. Unfortunately, contemporary clinical practice, as noted in physician surveys, continues to favor interruption of OAC and the use of bridging anticoagulation. While awaiting the results of additional randomized trials, physicians should carefully reconsider the practice of routine bridging and whether periprocedural anticoagulation interruption is even necessary.

Central Illustration. Bridging Anticoagulation: Algorithms for Periprocedural Interrupting and Bridging Anticoagulation. Decision trees for periprocedural interruption of chronic oral anticoagulation (top) and for periprocedural bridging anticoagulation (bottom). OAC = oral anticoagulation.

Continue reading

The surgical management and outcomes of dialysis access-associated steal syndrome (DASS)

Al Shakarchi J, et al. Surgical techniques for haemodialysis access-induced distal ischaemia. J Vasc Access. 2016 Jan-Feb;17(1):40-6.

Results: Following strict inclusion/exclusion criteria by two reviewers, twenty-seven studies of surgical interventions were included and divided into subgroups for banding, DRIL, PAI and RUDI procedures. Both DRIL and banding procedures were found to have high rates of symptomatic relief. In addition, the DRIL has a significantly lower rate of early thrombosis than banding although the more recent papers seem to suggest that early thrombosis is less of a problem in banding. PAI and RUDI showed some promise but there were too few studies to be able to make any clear conclusions.

Continue reading

The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial

Vedantham S, et al.; ATTRACT Trial Investigators. Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis. N Engl J Med. 2017 Dec 7;377(23):2240-2252. Free full-text.

Summary: The ATTRACT trial sought to “determine whether pharmacomechanical thrombolysis prevents the post-thrombotic syndrome in patients with proximal deep-vein thrombosis” (p.2241). A total of 692 patients were enrolled at 56 centers in the US from December 2009 through December 2014. They were between the ages of 16 and 75, and had symptomatic proximal deep-vein thrombosis involving the femoral, common femoral, or iliac vein (p. 2241).

Continue reading