Article of interest: Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience.

Hatchimonji JS, Chipman AM, McGreevy DT, et al. Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience. J Surg Res. 2020 Dec;256:149-155.

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Background: The aim of this study was to determine the current utilization patterns of resuscitative endovascular balloon occlusion of aorta (REBOA) for hemorrhage control in nontrauma patients.

Methods: Data on REBOA use in nontrauma emergency general surgery patients from six centers, 2014-2019, was pooled for analysis. We performed descriptive analyses using Fisher’s exact, Student’s t, chi-squared, or Mann-Whitney U tests as appropriate.

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Article of interest: Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift?

Katsargyris A, et al. Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift? J Endovasc Ther. 2013 Apr;20(2):159-69.

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Results: A total of 2465 vessels were targeted with fenestrations and 151 with chimney grafts (CG); intraoperative target vessel preservation was 98.6% and 98.0%, respectively. Cumulative 30-day mortality was 3.4%, 2.4%, and 5.3% for open surgery, F-EVAR and Ch-EVAR, respectively (p=NS). Impaired renal function was noted in 18.5%, 9.8%, and 12% following open surgery, F-EVAR, and Ch-EVAR, respectively (open vs. F-EVAR: p<0.001). New-onset dialysis was required postoperatively in 3.9%, 1.5%, and 2.1%, respectively (open vs. F-EVAR: p<0.001). Postoperative cardiac complications were noted in 11.3%, 3.7%, and 7.4%, respectively (open vs. F-EVAR: p<0.001). The incidence of ischemic stroke was 0.1% and 0.3% following open surgery and F-EVAR, but 3.2% after Ch-EVAR (open vs. Ch-EVAR: p=0.002; F-EVAR vs. Ch-EVAR: p=0.012). Early proximal type I endoleak was lower after F-EVAR compared to Ch-EVAR (4.3% vs. 10%, respectively, p=0.002).

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Surgical management of ruptured abdominal aortic aneurysms

Powell JT, Wanhainen A. Analysis of the Differences Between the ESVS 2019 and NICE 2020 Guidelines for Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg. 2020 Jul;60(1):7-15.

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See also: Surgical Grand Rounds: EVAR, FEVAR, and Open Repair: What to make of alphabet soup

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15-Year Patency and Life Expectancy After Primary Stenting Guided by Intravascular Ultrasound for Iliac Artery Lesions in Peripheral Arterial Disease

Kumakura H, et al. 15-Year Patency and Life Expectancy After Primary Stenting Guided by Intravascular Ultrasound for Iliac Artery Lesions in Peripheral Arterial Disease. JACC Cardiovasc Interv. 2015 Dec 21;8(14): 1893-901.

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Methods: EVT was performed for 507 lesions in 455 patients with PAD. The 15-year endpoints were primary, primary-assisted, and secondary patency; overall survival; freedom from major adverse cardiovascular events (MACE); and freedom from major adverse cardiovascular and limb events (MACLE).

Results: The 5-, 10-, and 15-year primary and secondary patencies were 89%, 83%, and 75%, respectively, and 92%, 91%, and 91%, respectively. There were no significant differences among TASC-II categories.

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Phlegmasia alba dolens and phlegmasia cerulea dolens

Chinsakchai K, et al. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011 Jan;45(1):5-14.

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PCD screenshot

Phlegmasia cerulea dolens (PCD) is a fulminant condition of acute massive venous thrombosis that may result in major amputation or death unless treated in an early phase. Guidelines for treatment are still not clearly documented. As a consequence, physicians might have limited knowledge of this potential life-threatening condition and its clinical course. Therefore, the purpose of this review was to analyze and summarize clinical manifestations and proposed diagnostic approach, factors that affect the outcome of PCD, and the evolution of management and therapeutic options. Underlying malignancy, pulmonary embolism, and PCD severity are the vital factors that predict the outcome of PCD. In the last decades, treatment options have remained largely unchanged. Published evidence shows that advances in minimally invasive techniques have not yet resulted in outcome improvements compared with traditional surgical thrombectomy. Treatment seems to depend on grading the severity of this condition and experience of the surgeon.

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Left subclavian artery coverage during thoracic endovascular aortic repair (TEVAR) and the risk of stroke

Swerdlow NJ, et al. Stroke rate after endovascular aortic interventions in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. 2020 Apr 2. [Epub ahead of print]

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TEVAR table

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Surgical Grand Rounds: EVAR, FEVAR, and Open Repair: What to make of alphabet soup

Presented by Amanda Fobare, MD, Chief Resident

Department of Surgery, Emory University School of Medicine

February 27, 2020


The evidence: EVAR vs. open repair for elective AAA repair: 

  • EVAR 1 – Endovascular Aneurysm Repair Trial 1 (UK)- Lancet (2005, 2016)
  • DREAM – Dutch Randomized Endovascular Aneurysm Management Trial (Netherlands & Belgium)- NEJM (2004), JVS (2017)
  • OVER – Open versus Endovascular Repair Trial (USA)- JAMA (2009), NEJM (2012)

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The surgical management of mycotic (infected) aneurysms

Razavi MK, Razavi MD. Stent-graft treatment of mycotic aneurysms: a review of the current literature. J Vasc Interv Radiol. 2008;19(6 Suppl):S51–S56.

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“Mycotic aneurysms are rare but are associated with a high risk of rupture if not treated promptly. The early mortality rate associated with traditional surgery depends on patients’ condition and can be as high as 43%. The use of stent-grafts is less invasive but the outcome is unproven in the setting of infected aneurysms. In an attempt to better elucidate the role of stent-grafts in this setting, a literature search was performed to examine 52 articles describing 91 patients with mycotic aneurysms who were treated with stent-grafts. The early mortality rate was 5.6%. Incidences of late aneurysm-related mortality and complications were 12.2% and 7.8%, respectively. The most consistent predictor of poor outcome was development of aortoenteric fistula. Although the 30-day mortality rate associated with the use of stent-grafts appears to be lower than that associated with surgery, late aneurysm-related events are frequent and warrant a more vigilant follow-up regimen than used with noninfected aneurysms.”

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Splenic artery aneurysms: Comparing open and endovascular surgical modalities

Barrionuevo P, Malas MB, Nejim B, et al. A systematic review and meta-analysis of the management of visceral artery aneurysms. J Vasc Surg. 2019;70(5):1694–1699.

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“We included 33 case series of 523 splenic artery aneurysms treated with an endovascular approach and 22 series of 252 splenic artery aneurysms treated with open surgery. Short-term and long-term mortality rates were very low and not significantly different between the two interventions. Mortality was high for ruptured aneurysms treated with an open approach, with an event rate of 0.29 (95% CI, 0.04-0.71). End-organ infarction and gastrointestinal complications rates were not significantly different between the two approaches. The need for reintervention was lower for open surgery 0.00 (95% CI, 0.00-0.11) than for the endovascular approach 0.07 (95% CI, 0.01-0.17). The risk of access site complications for the endovascular approach was low at 0.02 (95% CI, 0.00-0.09). Rates of PES and coil migration were 0.38 (95% CI, 0.04-0.79) and 0.08 (95% CI, 0.00-0.24), respectively. Data were insufficient to identify a difference in mortality based on aneurysm size.”

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Prophylactic cerebrospinal fluid drainage for thoracic endovascular aortic repair (TEVAR)

Mazzeffi M, et al. Contemporary Single-Center Experience With Prophylactic Cerebrospinal Fluid Drainage for Thoracic Endovascular Aortic Repair in Patients at High Risk for Ischemic Spinal Cord Injury. J Cardiothorac Vasc Anesth. 2018 Apr;32(2): 883-889.

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Flowchart TEVAR high risk ISCI outcomes_complications

Fig 2. Flowchart showing patient outcomes and complications in the cohort. SCI, spinal cord injury; SCPP, spinal cord perfusion pressure; TEVAR, thoracic endovascular aortic repair.

In summary, in a contemporary cohort of 102 patients undergoing TEVAR with a high risk for ischemic SCI, prophylactic CSF drainage was associated with a 2% paraplegia rate and 3.9% rate of drain-related complications. No patient with a drain-related complication had permanent injury, and only 1 patient required surgical intervention for spinal cord compression from epidural hematoma. Three patients with new paraplegia after surgery improved with targeted MAP increases and CSF drainage aimed to increase SCPP by 25%, whereas 1 patient’s symptoms never improved. These data further support the safety of prophylactic lumbar CSF drainage in patients undergoing TEVAR with a high risk for ischemic SCI.”

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