A Novel Way to Fenestrate a Type B Dissection Flap Using Electrocautery

Thoracic endovascular repair (TEVAR) is the current therapy of choice for treating type B aortic dissections. This is accomplished by covering the entry tear that is distal to the left subclavian artery. When the dissection flap extends into the visceral vessels it is common to have a type 1b endoleak into the false lumen from the visceral aortic tears. When the supra-celiac aorta is of normal caliber, then fenestration of the dissection flap proximal to the visceral vessels and sealing this area with a TEVAR stent graft eliminates the type 1 b endoleak. Fenestration also helps when there is distal ischemia from an over-pressured false lumen. Fenestration has been described using needles to cross the septum and balloons to tear open the septum. We describe a novel way of crossing the septum using electrocautery delivered through a wire tip then fenestrating the septum using electrocautery delivered over a 1 mm area of uninsulated wire to cut the septum. The use of electrocautery creates a controlled and deliberate aortic fenestration during endovascular repair of a type B dissection. This case is a 59 year old male who presented with an enlarging thoracic aneurysm secondary to a residual type B artic dissection (Figure 1). We elected to treat this with a TEVAR. A TX2 thoracic endograft (Cook Vascular, IN) was inserted into the thoracic aorta and deployed covering the entry tear (Figure 2). We crossed from the true lumen to the false lumen using a 0.014 Confienza wire (Figure 3). We snared the wire in the false lumen and pulled the wire out through the contralateral groin. Then we scraped the insulation off 1 mm segment ofa 0.014 Astato wire. This was kinked at the area of denuded insulation. We then introduced the wire into the patient and positioned the uncovered wire over the dissection septum. Using the electrocautery, we made a 3 cm cut in the septum (Figure 4). Finally, we deployed a distal TEVAR stent landing the distal segments in the fenestration giving us a distal seal (Figure 5). Post-procedure CTA showed complete exclusion of the aneurysm with no distal endoleaks. This novel technique was adopted to help treat a type B dissection.https://scholarlycommons.henryford.com/merf2019caserpt/1122/thumbnail.jp

Primary aortoesophageal fistula from metallic bristle ingestion

Although many patients are treated for the removal of ingested foreign objects each year, ingestions that perforate the esophagus and lead to intra-abdominal complications are rare. Aortoesophageal fistulas and aortic pseudoaneurysms are deadly complications of esophageal foreign body impaction. However, the surgical approach to aortic repair from foreign object damage has not been standardized. We have described the diagnostic, open surgical, and therapeutic approach to treating a man who had accidentally ingested a 3-cm metallic bristle that lodged in his aortic wall. The patient recovered after excision of the aortic pseudoaneurysm with CryoGraft (CryoLife, Inc, Kennesaw, Ga) replacement, drainage of abscesses, and antibiotic treatment for multiple infections

Lingual Raynaud\u27s Phenomenon after Surgical and Radiotherapeutic Intervention for Oral Squamous Cell Carcinoma

Raynaud\u27s phenomenon of the tongue after radiation therapy with or without chemotherapy is an exceedingly rare complication. Symptoms are similar to Raynaud\u27s disease of other sites and involve pallor and discomfort on exposure to cold temperatures that resolve with rewarming. Presentation occurs approximately 18-24 months after radiotherapy on average and can usually be managed effectively with lifestyle modification and pharmacotherapy. Here, we present a case of lingual Raynaud\u27s following surgery and adjuvant radiation therapy in a patient with squamous cell carcinoma of the oral cavity

Efficacy of High Temporal Frequency Photoacoustic Guidance of Laser Ablation Procedures

Inaccurate placement of the ablation catheter and the inability to monitor the real-time temperature within the tissue of interest such as veins curbs the treatment efficacy of laser ablation procedures during thermal therapies. Our previous studies have validated the efficacy of photoacoustic (PA) imaging during endovenous laser ablation (EVLA) procedures. However, the PA-guided therapies suffer from low temporal resolution, due to the low pulse repetition rates of pulsed lasers, which could cause a problem during fast catheter motion and rapid temperature changes. Herein, to enhance the accuracy and sensitivity for tracking the ablation catheter tip and temperature monitoring, we proposed to develop a high frame rate (500 Hz), combined ultrasound (US), and PA-guided ablation system. The proposed PA-guided ablation system was evaluated in a set of ex vivo tissue studies. The developed system provides a 2 ms temporal resolution for tracking and monitoring the ablation catheter tip\u27s location and temperature, which is 50 times higher temporal resolution compared to the previously proposed 10 Hz system. The proposed system also provided more accurate feedback about the temperature variations during rapid temperature increments of 10°C per 250 ms. The co-registered US and PA images have an imaging resolution of about 200 μm and a field of view of 45 × 40 mm(2). Tracking the ablation catheter tip in an excised tissue layer shows higher accuracy during a relatively fast catheter motion (0.5-3 mm/s). The fast US/PA-guided ablation system will potentially enhance the outcome of ablation procedures by providing location and temperature feedback

Outcome of tracheostomy after pediatric cardiac surgery

AbstractObjectiveTo investigate the incidence, timing indications and outcome of tracheotomy in children who underwent cardiac surgeries.MethodsAll pediatric cardiac patients (under 14years of age) who underwent cardiac surgeries and required tracheotomy from November 2000 to November 2010 were reviewed. The data were collected and reviewed retrospectively.ResultsSixteen children underwent tracheotomy after cardiac surgery. Fifteen of these cases had surgery for congenital heart disease, and one had surgery for an acquired rheumatic mitral valve disease. The mean±SEMs of the durations of ventilation before and after tracheotomy were 60.4±9.8 and 14.5±4.79days respectively (P value 0.0002). The means±SEM of the lengths of ICU stay before and after tracheotomy were 63.31±10.15 and 22±5.4days respectively (P value 0.0012). After the tracheotomy 12/16 patients (75%) were weaned from their ventilators and 10/16 were discharged from the PCICU. Six patients were discharged from the hospital and 3 were successfully decannulated. The overall survival rate was 9/16 (56%).ConclusionTracheostomy shortens the duration of mechanical ventilation and facilitates discharge from the ICU. The mortality of tracheotomy patients is still significant but is mainly related to the primary cardiac disease

Impact of chylothorax on the post operative outcome after pediatric cardiovascular surgery

BackgroundChylothorax is the accumulation of chyle in the pleural cavity, usually develops after disruption of the thoracic duct along its intra-thoracic route. In the majority of cases this rupture is secondary to trauma (including cardio thoracic surgeries). Chylothorax is a potentially serious complication after cardiovascular surgeries that require early diagnosis and adequate management.MethodsA retrospective study of all cases complicated with chylothorax after pediatric cardiac surgery in King Abdulaziz Cardiac Center between January 2007 and December 2009 was conducted. The study aim to determine the risk factors, and the impact on the post operative course.ResultsWe have 1135 cases operated during the study period, 57 cases (5%) were complicated with chylothorax in the post operative period. The most common surgeries complicated with chylothorax were the single ventricle repair surgeries (Glenn-Fontan) 15 cases (27%), followed by the arch repair cases 10 cases (18%), the ventricular septal defect cases 10 cases (18%), the Atrioventricular septal defect cases 7 cases (12%), the arterial switch cases 6 cases (11%), and others 8 cases (14%). The ICU stay, the length of hospital stay and the bypass time were significantly longer in the chylothorax group, also the ventilation time, the inotropes duration and number were higher in the chylothorax group.ConclusionChylothorax after pediatric open heart surgery is not an uncommon complication, it occurs more commonly with single ventricle repair and aortic arch repair surgeries, it has a significant impact on the post operative course and post operative morbidity

Socioeconomic Status and Clinical Stage of Patients Presenting for Treatment of Chronic Venous Disease

OBJECTIVES: The association between socioeconomic status (SES) and chronic venous insufficiency has not been rigorously studied. This study aimed to determine the influence of SES on the clinical stage of patients presenting for chronic venous disease therapy. METHODS: We performed a retrospective study of a prospectively collected data from the Vascular Quality Initiative Varicose Vein Registry at our tertiary referral center. Medical records of patients who underwent therapy for chronic venous disease between January 2015 and June 2019 were queried. SES was quantified using the neighborhood deprivation index (NDI), which summarizes 8 domains of socioeconomic deprivation and is based on census tract data derived from the patients\u27 addresses at the time of the treatment. High NDI scores correspond with lower SES. The association between SES and severity of vein disease at presentation was assessed with bivariate analysis of variance and linear regression analysis. RESULTS: A total of 449 patients with complete SES and clinical-etiology-anatomy-pathophysiology (CEAP) class data were included in the study. The mean age was 58 years, 67% were female, and 60% were White. CEAP classes were distributed as follows C2, 22%; C3, 50%; C4, 15%; C5, 5%; and C6, 8%. Patients with lower SES (higher NDI score) tended to have a higher CEAP class at presentation (P \u3c 0.05). SES was not associated with history of deep venous thrombosis, use of compression therapy, or venous clinical severity score. CONCLUSIONS: At our institution, patients with more advanced venous disease tended to belong to a lower SES group. This may reflect that patient with a lower SES have a longer time to presentation due to delay in seeking medical help for venous disease

Stronger but Not Faster : Flipped Classroom Teaching Significantly Improves Resident\u27s Skills but Not Speed

Objective: Flipped classroom teaching is a nontraditional education model where instructional content is delivered outside the classroom. This constructivist approach emphasizes self-direction, active inquiry; the instructor’s role is to foster critical reflection and facilitate the application and understanding of concepts. Our objective was to study the difference in time taken and quality of patch graft angioplasty performed by residents with and without flipped teaching. Methods: The study was set in a skills simulation teaching session overseen by attending surgeons. The intervention consisted of introducing a video outlining the technical aspects of patch graft angioplasty, watched before the session. The first group (2018 postgraduate year [PGY] 1 and 2 residents) was given instructions at the time of the class without a prior educational video or resources (Figs 1 and 2). The second group (2019, 2020 PGY 1 and 2 residents) was asked to watch a 20-minute video on the technical aspects of the procedure before the class. Participants then performed a standardized patch graft closure of a 1 cm arteriotomy using a polytetrafluoroethylene patch. The groups were timed. The quality of the closure was tested by assessing the number of leaks and the quantity of leak of the patch (Fig 3). Bivariate analysis sample t-tests were used for statistical analysis. P value \u3c.05 was considered significant. Pre- and post-session surveys were conducted to assess residents’ experience. Results: Forty-two residents (PGY 1 and 2) were enrolled in the study, 15 in nonintervention group 1 and 27 in intervention group 2, compared with 7 staff vascular surgeons. The mean completion time was 26 minutes (group 1) vs 27 minutes (group 2), P ¼ .6. The staff completion time was 12 minutes, P ¼ .001. The number of major leaks (not needle holes) was 2.0 (group 1) vs 1.6 (group 2), P ¼ .007, none for staff. The total quantity of leak was 42 mL (group 1) vs 15 mL (group 2), P ¼ .0001 (Table I). There was perceived improvement in skill on analyzing pre- and post-session surveys (Table II). Conclusions: A structured educational intervention, watching a video of a procedure before the skills session, did not change the time needed to complete the skill. There was improvement in the technical outcome of the procedure defined by a decrease in the total quantity of leak. Reversed classroom teaching significantly improves resident’s skill, not speed. There was also a perceived improvement in skill by participants. This is a pilot study and further instructional outcomes are being studied

The Effect of Neutrophil-lymphocyte Ratio on 10-year Survival Outcomes Following Elective Open and EVAR Procedures

Objectives: The neutrophil-lymphocyte ratio (NLR) is a useful and inexpensive inflammatory marker associated with surgical outcomes. This study evaluates the effects of NLR on survival after elective endovascular (EVAR) and open aortic repair (OAR) of abdominal aortic aneurysm. Methods: We retrospectively reviewed patients from 1989 to 2019 who underwent elective OAR or EVAR at two separate academic centers. Baseline comorbidities were assessed. A receiver operating characteristic (ROC) curve was used to determine a cutoff point where NLR was associated with outcome. Kaplan-Meier survival analysis was used to compare survival through 10-year follow-up. Results: Overall, 437 patients (mean age, 72.0 6 10.1 years; 74.1% male) underwent 213 EVARs and 224 OARs. Median duration of follow-up was 4.55 years. The analysis of the ROC curve yielded an NLR of 3.94 with the highest specificity and sensitivity for 10-year survival. Baseline characteristics were similar between groups, except for an increased age in the group with NLR \u3e3.94 (73.5 vs 70.9 years; P ¼ .008) (Table). KaplanMeier analysis revealed that patients with NLR \u3e3.94 had decreased 10-year survival (37.2% vs 54.2%; P ¼ .0001) (Fig). By univariate analysis, NLR \u3e3.94 (P ¼ .0001), chronic obstructive pulmonary disease (P ¼ .006), and increased age (P ¼ .0001) were associated with increased mortality. On multivariable cox regression analysis, an NLR \u3e3.94 (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.19-2.40), increased age (OR, 1.05; 95% CI, 1.03-1.07), and chronic obstructive pulmonary disease (OR, 1.44; 95% CI, 1.01-2.07) were associated with increased risk of mortality. Between OAR and EVAR, no difference in late survival was noted (49.9% vs 43.5%; P ¼ .24). Conclusions: An NLR \u3e3.94 is associated with increased mortality over a 10-year follow-up period after open and endovascular aortic repair. Future studies to further understand the driving force between an elevated NLR and increased mortality are warranted

Impact Of Preoperative Hemoglobina1c In Patients Undergoing Open Distal Vascular Procedures

Objective: The purpose of this study was to evaluate if preoperative hemoglobin (Hb) A1c levels was associated with worse outcomes in patients undergoing open lower extremity (LE) revascularization. Methods: A retrospective review of a statewide vascular surgery registry was queried for all patients who underwent open infrainguinal bypass or open LE thrombectomy procedures between January 2014 and June 2021. Patients were categorized into four groups depending on whether their plasma HbA1c was ≤6%, \u3e6% to ≤8%, \u3e8% to ≤10%, and \u3e10%. Regression models were used to evaluate the association between preoperative HbA1c and postoperative major adverse limb events (MALE), major adverse cardiac events (MACE), mortality, and length of stay (LOS). Results: A total of 5388 patients were included in the study. The average age was 66 years. Sixty-six percent of the cohort were male, and 78% were white. Demographics and comorbidities were associated with the HbA1c level. Mean LOS was 7 days for HbA1c \u3c6% and 10 days for HbA1c \u3e10% (P \u3c.001). No significant association was found when looking at perioperative MALE, MACE, 30-day mortality, or 1-year mortality. On multivariate analysis, only LOS remained significantly associated with the level of HbA1c (P \u3c.001) (Table). Conclusions: Suboptimal preoperative glycemic control in patients undergoing open LE vascular procedures for ischemia is associated with an increased risk of LOS. HbA1c level was not predictive of worse perioperative MACE, MALE, or mortality in this cohort. The increased in LOS could be explained by unmeasured complications, frailty, or increased hospitalization time needed to optimize glycemic control before discharge. [Formula presented