Circulatory arrest for traumatic brachiocephalic artery pseudoaneurysm repair

Blunt traumatic injuries to the brachiocephalic artery require surgical management. The operative technique used depends on the location of the injury, the patient\u27s hemodynamic stability, and the surgeon\u27s experience. Perfusion strategy can facilitate vascular control of the aortic arch and branch vessels. This report presents an urgent repair of a proximal posterior blunt traumatic brachiocephalic artery injury under circulatory arrest, with an excellent outcome

Long-term survival after CABG in diabetics with aggressive risk factor management

Objectives: Diabetes is a well-established risk factor for cardiovascular disease, and diabetics have a threefold increase in risk of death from cardiovascular disease compared to non-diabetics. Following coronary artery bypass grafting, tight glycemic control improves short-term outcomes, however limited data exist for long-term outcomes. Here we examine these outcomes in diabetics using aggressive risk factor management. Methods: A retrospective review of all patients under-going coronary artery bypass between 1991 and 2000 at a single Veterans Affairs Medical Center was undertaken. 973 patients were included, 313 with diabetes and 660 without. Strict glucose control was maintained for all patients. Additional risk factor modification, including anti-platelets medications, statins, and beta blockers were also used. Survival analysis was performed. Results: The diabetic group was at higher risk, with age, BSA, and NYHA class all being greater (p \u3c 0.05). The mean follow-up time was 6.7 ± 3 years. There were 28 deaths/1000 person-years for non-diabetics, and 48 deaths/1000 person-years for diabetics. Survival rates were significantly higher for non-diabetics (72% versus 58% in the diabetic group, p \u3c 0.001). Cox proportional hazard analysis demonstrated mortality risk was 57% higher for diabetic patients (hazard ratio = 1.57; CI: 1.19 - 2.09; p = 0.002). The mortality risk in diabetics with and without prior MI was similar (HR = 0.83; CI: 0.54 - 1.28; p = 0.40). Conclusions: Diabetics undergoing coronary bypass have poorer long-term survival than non-diabetics despite perioperative glycemic control and risk factor modification. The long-term survival decrease in diabetics with history of MI is attenuated with surgical revascularization

Outcomes of recurrent laryngeal nerve injury following congenital heart surgery: A contemporary experience.

OBJECTIVE: Injury to the recurrent laryngeal nerve can lead to significant morbidity during congenital cardiac surgery. The objective is to expand on the limited understanding of the severity and recovery of this iatrogenic condition. DESIGN: A six-year retrospective review of all congenital heart operations at a single institution from January 1, 2008 to December 31, 2013 was performed. All patients with documented vocal cord paralysis on laryngoscopic examination comprised the study cohort. Evaluation of time to vocal cord recovery and need for further surgical intervention was the primary focus. RESULTS: The incidence of post-operative vocal cord paralysis was 1.1% (32 out of 3036 patients; 95% confidence interval: 0.7-1.5%). The majority were left-sided injuries (71%). Overall rate of recovery was 61% with a median time of 10 months in those who recovered, and a total follow up of 46 months. Due to feeding complications, 45% of patients required gastrostomy tube after the injury, and these patients were found to have longer duration of post-operative days of intubation (median 10 vs. 5 days, p = 0.03), ICU length of stay (50 vs. 8 days, p = 0.002), and hospital length of stay (92 vs. 41 days, p = 0.01). No pre-operative variables were identified as predictive of recovery or need for gastrostomy placement. CONCLUSION: Recurrent laryngeal nerve injury is a serious complication of congenital heart surgery that impacts post-operative morbidity, in some cases leading to a need for further intervention, in particular, gastrostomy tube placement. A prospective, multi-center study is needed to fully evaluate factors that influence severity and time to recovery

A modified activity protocol for claudication

© 2018 EDIZIONI MINERVA MEDICA. BACKGROUND: We propose the use of a monitored step tracking device, the FitBit® to supplant supervised exercise therapy (SET) programs to facilitate improvement in walking distance in veteran claudicators. METHODS: In this prospective study, we enrolled forty-nine patients with clinical evidence of lower extremity claudication in a six-month walking program. Each patient was given a FitBit® device to track daily number of steps. Patients were seen in clinic monthly to collect data and discuss walking goals. Surveys at the beginning and end of each study assessed patient perception of changes in walking distance as well as symptoms. The primary outcome was monthly distance walked. Changes over time in each outcome variables were examined using a random effects mixed model. RESULTS: In the first month, the adjusted mean number of steps per day was 3492 (95% CI: 2661-4322). By month 5, this had increased to 4502 (3636-5367) (P=0.0007). Twenty-eight patients used the tracker at least for 1 month, while 21 (43%) did not. Being bothered by symptoms was the only patient variable that was significantly associated with use of the FitBit®. Those who used the tracker tended to be younger, heavier, more active, and were more likely to have diabetes. CONCLUSIONS: In the veteran population, the use of a monitored step tracking device such as the FitBit® is a potentially effective strategy to improve walking distance in claudicators particularly in those with mild symptoms. Additional investigation is needed to determine which patients will benefit most from this walking protocol

Reoperation rates after open and endovascular abdominal aortic aneurysm repairs

© 2016 Society for Vascular Surgery Objective This study compared reoperation rates associated with open abdominal aortic aneurysm (AAA) repair (OR) outcomes vs endovascular AAA repair (EVAR). Methods A retrospective review of the Veterans Affairs Surgical Quality Improvement Project data was performed with inclusion criteria defined as all patients who underwent AAA repair from October 1, 2007, to October 1, 2013. The primary outcome was the incidence of reoperations. Reoperations included subsequent OR or EVAR procedures performed on the abdominal aorta or iliac arteries, surgical treatment of temporally related bowel obstruction, as well as treatment of abdominal or groin wound complications ≤6 months and treatment of bowel or lower limb ischemia ≤10 days. Results Of 6677 patients who underwent AAA repair, 476 (7.1%) required reoperations. OR was associated with a higher rate of reoperations overall (10.0% vs 6.3%; P \u3c.01), with most being intra-abdominal and wound complications. OR also had higher rates of bowel ischemia requiring operation (0.7% vs 0.3%; P =.01) and lower extremity ischemia (0.5% and 0.06%; P \u3c.01). Significantly more endovascular stents were placed during EVAR (2.8% vs 0.5%; P \u3c.01). Logistic regression showed EVAR is a negative predictor for reoperation after controlling for comorbidities (P \u3c.001). Conclusions The long-term burden of reoperations after OR may actually be more significant than current understanding when including all possible abdominal complications in an extended analysis. Future prospective trials should include all potential reoperations extended \u3e30 days with associated cost analysis. As surgical innovation in EVAR technology advances, complication comparisons with OR should undergo frequent re-evaluation given that endovascular indications and outcomes continue to expand and improve