Outcomes and Indications for Thoracofemoral Bypass in the Endovascular Age: A case series and Literature Review

Introduction: Endovascular revascularization is commonplace in vascular surgery; however, thoracofemoral bypass (TFB) is optimal in particular patients. Little research focuses on TFB outcomes. This case series and literature review investigated indications, efficacy, and safety of TFB. Methods: Cases at Thomas Jefferson University Hospital (TJUH) included one male and four females (average age 57.2) from 2015-2019. Literature review yielded 124 cases from other institutions. PubMed and Scopus search using the term “thoraco femoral bypass” yielded 39 articles. Articles published before 2000 and case studies published in any year were excluded. Seven articles were selected. Primary outcomes included 30-day mortality and graft patency; secondary outcomes included complications and indications. Data was tabulated in tables and percentages were calculated. Results: One hundred and twenty-nine cases of TFB were identified. Some indications included revascularization of failed aortobifemoral bypass (31.8% of patients) and circumferential aortic calcification with or without concomitant infrarenal or mesenteric calcification (20.1%). Thirty-day mortality for all cases was 4.7%. Thirty-day mortality for TJUH patients was 0%. Graft patency for TJUH patients was 100% at six months. At publication, three of five patients had been revascularized for over one year and had patent grafts at one year. Some complications included pulmonary (12.5% of patients), major vascular reintervention (7.8% of patients) and incision site infection (4.1% of patients). Discussion: In recent years, few institutions have reported TFB outcomes. High graft patency and low 30-day mortality at TJUH and other institutions emphasize the safety and efficacy of TFB

Comparison of endovascular therapy versus medical therapy in the management of descending thoracic aortic dissection

Introduction: This retrospective review aimed to compare clinical outcomes between patients with descending aortic dissections, with and without organ malperfusion, who were managed with thoracic endovascular aortic repair (TEVAR) or best medical therapy (BMT). Methods: Thirty-eight patients diagnosed with descending aortic dissections between 2013 and 2020 were identified for analysis. Patients with dissection secondary to trauma and death unrelated to cardiothoracic pathology were excluded. Participants were divided into three groups based on their management: TEVAR (without side branch stenting), TEVAR+ (with additional branch stenting) and BMT. The primary outcome measure was length of hospital stay (LOS) and statistics were analyzed using ANOVA. Results: There was a significant difference in the LOS between the three groups (p=0.005), with TEVAR+ patients spending an average of three weeks in the hospital, compared to twelve days for patients managed with BMT and seven days for TEVAR patients. Younger age at presentation was a significant predictor of a longer LOS (p=0.008). Systolic blood pressure was significantly different (p=0.025), with TEVAR+ patients having the highest average pressures of 201, followed by TEVAR patients of 168 and BMT patients of 167. Initial diagnosis of aortic dissection with concomitant organ malperfusion (TEVAR+) was a significant predictor of LOS (p= 0.008). Discussion: TEVAR+ patients were younger, had higher systolic blood pressures and stayed significantly longer in the hospital compared to patients managed with TEVAR alone or BMT. Future studies should focus on the most efficacious treatment for this patient population who suffer from the highest morbidity amongst dissection patients

Assessing the Operative Log Data of Traditional (5+2) vs. Integrated (0+5) Vascular Training Programs

Introduction: In 2006, the Accreditation Council for Graduate Medical Education (ACGME) approved an integrated 5 year vascular surgery residency program. Operative experience can be used as a surrogate marker for success in the evolving field of vascular surgery training. Objective: The purpose of this study is to compare the operative experience of those graduating from the traditional (5+2) vascular training program with the integrated (0+5) program. Methods: National operative case log data supplied by the ACGME was gathered and organized for vascular surgery residents graduating between 2013 and 2018. Mean case numbers were compared between integrated vascular residents and traditional vascular fellows (mean case numbers for vascular fellows included cases from their general surgery residencies). Results: The 5+2 trainees performed 36% more overall procedures than the 0+5 trainees (mean, 1650 vs 1050). The greater number of overall procedures performed by the 5+2 trainees was primarily realized by an increased number of abdomen (e.g. biliary, small/large intestine) cases. However, the 5+2 trainees performed 8% less vascular procedures (mean, 786 vs 854). The greater number of vascular procedures performed by the 0+5 trainees was primarily realized by increased numbers of endovascular (e.g. endovascular peripheral obstruction) and venous (e.g. caval filter) cases. Discussion: The integrated 0+5 graduates performed more total vascular procedures than their 5+2 counterparts. The overall total operative experience remains greater for the traditional 5+2 graduates, given their additional two years of training. Further longitudinal studies will be needed to fully assess the effect of the new integrated 0+5 training paradigm

Acute occlusion of aortic endovascular aneurysm repair stent graft with bilateral limb ischemia

Endovascular aneurysm repair has dramatically changed the management of abdominal aortic aneurysms as an alternative to open repair. However, complications can occur, including stent graft migration, kinking, and occlusion, leading to compromise of the excluded aneurysm walls and acute limb ischemia. In the present report, we have described a case of migration and kinking of an abdominal aortic stent graft in the main body that led to occlusion of the abdominal aorta and bilateral acute limb ischemia. The patient required emergent explantation of the stent graft and open repair of the abdominal aneurysm with a rifampin-soaked Dacron graft, which achieved a favorable outcome

False lumen embolization as a rescue technique in the setting of acute and chronic dissecting aneurysms as adjunct to thoracic endovascular aortic repair.

Complicated type B aortic dissection (TBAD) is a life-threatening condition requiring surgical intervention. One such complication in the acute or chronic setting is aneurysmal degeneration. The dissected aortic wall is weakened, and the pressures in the false lumen are often high. In the past decade, thoracic endovascular aortic repair (TEVAR) has become the treatment of choice for TBAD. TEVAR can be complicated by lack of false lumen thrombosis, increasing the risk of death. We present three cases of TBAD with patent false lumens after TEVAR that were treated by false lumen coil embolization

Giant abdominal aortic aneurysms

Giant abdominal aortic aneurysms (AAAs) are defined as AAAs \u3e10 to 13 cm in the maximum transverse diameter. We have described a case of a patient who had presented for open repair of an 18-cm AAA and a review of reported cases of giant AAAs \u3e10 cm in the maximum transverse diameter. Forty cases were compiled. The average maximum AAA diameter was 14.5 ± 4.1 cm. The AAA was ruptured on presentation in 12 patients (30%). Of the 40 cases, 34 (85%) were repaired with open surgery. The reported mortality was 15%. Despite the case complexity, five endovascular repairs were attempted

Penumbra Aspiration Thrombectomy of the Superior Mesenteric Artery for Mesenteric Ischemia

Acute mesenteric ischemia from thromboembolic occlusion is a life-threatening emergency associated with a high mortality rate. Prompt diagnosis and intervention are vital to preserve viable bowel and prevent mortality. In the past decade, a shift has occurred toward minimally invasive alternatives such as endovascular therapies. We present a case of acute mesenteric ischemia from superior mesenteric artery thrombosis treated promptly with the Penumbra suction thrombectomy device (Penumbra Inc)

External Iliac Vein Aneurysm Treated Via Balloon-Assisted Aneurysmorrhaphy with a Contemporary Review of the Literature

Isolated external iliac vein aneurysm is exceedingly rare, not well-described in the literature, and presents several potential surgical approaches. Herein, we describe the case of a 72-year-old woman who presented with incidentally found 4.3 cm x 3.4 cm x 5.6 cm right external iliac vein aneurysm after undergoing magnetic resonance imaging for orthopedic work-up. She was treated via parallel supra- and infra-inguinal incisions and novel combination of primary aneurysmorrhaphy with intraluminal balloon mandrel-assisted closure. The patient was discharged on postoperative day two, and 6-month follow-up ultrasound showed a normal caliber vessel with normal compressibility, suggesting this technique is safe and effective for appropriately selected patients

Endovascular Intervention for Tracheo-Innominate Fistula: A Systematic Review and Meta-analysis

Introduction: Fistula formation between the trachea and the innominate artery is a life-threatening complication rarely seen with existing or previous tracheostomy. Fatal upon rupture, swift diagnosis and immediate intervention are paramount for survival. We aim to identify feasibility and outcomes of endovascular intervention for trachea-innominate fistula (TIF). Methods: Patient-level data of reported individuals above the age of 14 that underwent endovascular intervention for TIF was extracted and analyzed. Identification of 25 patients from 27 studies was accomplished by electronic database search of Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Ovid Medline, and Scopus. Survival data was evaluated by Kaplan-Meier analysis. Results: Median patient age was 39.0 years [IQR 16.0, 47.5]. Median time to TIF presentation following tracheostomy was 2.2 months [0.5, 42.5]. 84.6% (22/27) exhibited tracheal hemorrhage at presentation. Covered stent graft placement was performed in 96.3% (26/27) and coil embolization in 3.8% (1/27). Repeat endovascular intervention was necessary in 18.5% (5/27) and rescue sternotomy was required in 11.1% (3/27). Overall mortality was 29.6% (8/27) with a median follow-up time of 5 months [1.2, 11.5]. Discussion: Endovascular intervention may be an effective method of TIF repair at presentation. As an alternative to conventional surgical repair, endovascular intervention may be an appropriate method for TIF repair particularly in patients unfit for open sternotomy repair