Fast-Track Abdominal Aortic Aneurysm Repair

The open repair of abdominal aortic aneurysm (AAA) continues to evolve with incorporation of less invasive methods for surgical exposure and the use of patient care pathways for shorter hospital stays. In a consecutive series of 30 patients with infrarenal AAA, a fast-track hospital care pathway was implemented that included the following: AAA exposure via a limited (10-15 cm) retroperitoneal incision, use of self-retaining retractor and special vascular clamps/instruments, and prosthetic graft endoaneurysmorrhaphy. Excellent anatomic exposure for graft implantation was achieved with an average operative time of 175 minutes. Use of oral metoclopromide and patient-controlled epidural analgesia resulted in patient ambulation and oral diet on postoperative day 1. Average length of hospital stay was 3.6 days (range: 3-7 days), and no patient required readmission for AAA repair-related or gastrointestinal problems. One patient died (30-day mortality rate of 3.3%) caused by delayed recognition of a splenic injury, and 1 patient sustained an intraoperative ureter injury that was repaired and stented. Although stent-graft exclusion for AAA repair has become popular, the major advantages of endovascular therapy, such as shorter ICU and hospital stays, earlier dietary feeding, and reduction in postoperative morbidity, can also be achieved by using minimal incision exposure for AAA interposition grafting combined with traditional hand-sewn vascular anastomoses. Fast-track AAA repair is applicable to the majority of patients with infrarenal AAAs, and vascular surgeons can easily master the technique of limited incision retroperitoneal exposure. This approach avoids the concerns of endovascular stent-graft durability and the mandatory vascular imaging follow-up to identify endoleak development and AAA enlargement

Carotid Endarterectomy Under Local Anesthesia: An Alternative Treatment for Carotid Stenosis

Purpose. Carotid artery stenosis accounts for approximately 10% of all ischemic strokes, causing significant morbidity and mortality. Historically the standard of care for surgical candidates for carotid stenosis was carotid endarterectomy, traditionally done under general anesthesia. As carotid stenting becomes an established less invasive modality of treatment, we investigated carotid endarterectomy under local anesthesia as an alternative option. Methods. We conducted a retrospective review of medical charts for patients undergoing carotid endarterectomy at a large community hospital from July 2007 to June 2010. 30-day postoperative myocardial infarctions and strokes were evaluated for patients undergoing carotid endarterectomy under local anesthesia, compared to carotid endarterectomy under general anesthesia. Carotid artery shunting and preoperative stroke were also evaluated as risk factors for postoperative myocardial infarction and stroke. Fisher exact tests were calculated to compare postoperative outcomes between patient groups. Results. A total of 407 carotid endarterectomies under local anesthesia and 256 carotid endarterectomies under general anesthesia were included in the analysis. Age, sex, and occurrence of preoperative stroke were similar between study groups. General anesthesia patients were more likely to receive a shunt (82% vs 11%, P\u3c.001). General anesthesia patients had higher rates of postoperative myocardial infarction (1.2% vs 0%, P=.057) and stroke (2.3% vs 0.7%, P=.095), but these differences were not statistically significant. Patients with a shunt also had non-significantly higher rate of postoperative stroke (2.3% vs 0.7%, P=.096). Conclusions. Our evidence suggests that carotid endarterectomy under local anesthesia can be an effective alternative for carotid stenosis with a possibly better safety profile than carotid endarterectomy under general anesthesia. Larger randomized studies are needed to further evaluate these complications

Carotid Endarterectomy Under Local Anesthesia: An Alternative Treatment for Carotid Stenosis

Purpose. Carotid artery stenosis accounts for approximately 10% of all ischemic strokes, causing significant morbidity and mortality. Historically the standard of care for surgical candidates for carotid stenosis was carotid endarterectomy, traditionally done under general anesthesia. As carotid stenting becomes an established less invasive modality of treatment, we investigated carotid endarterectomy under local anesthesia as an alternative option. Methods. We conducted a retrospective review of medical charts for patients undergoing carotid endarterectomy at a large community hospital from July 2007 to June 2010. 30-day postoperative myocardial infarctions and strokes were evaluated for patients undergoing carotid endarterectomy under local anesthesia, compared to carotid endarterectomy under general anesthesia. Carotid artery shunting and preoperative stroke were also evaluated as risk factors for postoperative myocardial infarction and stroke. Fisher exact tests were calculated to compare postoperative outcomes between patient groups. Results. A total of 407 carotid endarterectomies under local anesthesia and 256 carotid endarterectomies under general anesthesia were included in the analysis. Age, sex, and occurrence of preoperative stroke were similar between study groups. General anesthesia patients were more likely to receive a shunt (82% vs 11%, P\u3c.001). General anesthesia patients had higher rates of postoperative myocardial infarction (1.2% vs 0%, P=.057) and stroke (2.3% vs 0.7%, P=.095), but these differences were not statistically significant. Patients with a shunt also had non-significantly higher rate of postoperative stroke (2.3% vs 0.7%, P=.096). Conclusions. Our evidence suggests that carotid endarterectomy under local anesthesia can be an effective alternative for carotid stenosis with a possibly better safety profile than carotid endarterectomy under general anesthesia. Larger randomized studies are needed to further evaluate these complications

Hybrid Open and Endovascular Treatment of Type A and Type B Aortic Dissection with Mesenteric Malperfusion

Purpose. The objective of this report is to present a novel technical hybrid (open/endovascular) approach to mesenteric malperfusion in patients with either acute type A or acute type B aortic dissection. Case Report #1. The patient presented with a type B aortic dissection with mesenteric malperfusion. This was treated by endovascular stenting and re-capture of the true lumen of the thoracic aorta without successful reperfusion of the SMA. Immediate laparotomy with retrograde stenting of the superior mesenteric artery (SMA) proved life-saving for the patient. Case Report #2. The patient presented with a type A aortic dissection and mesenteric malperfusion of the intestines and right leg. Due to the patient’s clinical presentation and a high suspicion of severe intestinal ischemia, exploratory laparotomy instead of ascending arch repair was undertaken. We were able to improve mesenteric perfusion by accessing the SMA in a retrograde fashion. The dissecting intimal flap was fenestrated and stented. The patient eventually succumbed to the disease despite a patent SMA. Conclusion. A hybrid open and endovascular approach can be performed when one is required to visualize the intestines to evaluate its viability in a type A or type B aortic dissection

Modified “Trap Door” Approach for Thoracic Outlet Syndrome Complicated by Subclavian Artery Aneurysm

Arterial thoracic syndrome is a rare condition that usually presents in young patients with upper extremity thromboembolization. The traditional surgical approaches described are supraclavicular and transaxillary. We hereby present the case of a 46-year-old male with left arterial thoracic outlet syndrome and left subclavian artery aneurysm. We describe our technique in approaching his condition with a modified “trap door” approach

“Chimney” Graft Technique for Juxtarenal AAA Using Unibody Bifurcated Stent Graft

Juxtarenal abdominal aortic aneurysms in patients who are poor candidates for open repair present a challenge for the treating surgeon. With fenestrated aortic endografts currently not readily accessible, the alternative option would be aortic endograft using a “chimney” technique. We present a case report of an 84-year-old female who is a poor surgical candidate, presenting with symptomatic juxtarenal abdominal aortic aneurysm involving the left renal artery. Satisfactory repair was performed using an Endologix Powerlink endograft with chimney technique for the left renal artery. To our knowledge this is the second report of chimney graft using the Endologix Powerlink system

Investigation of (g−2)μ(g-2)_{\mu} anomaly in the μ\mu-specific 2HDM with Vector like leptons and the phenomenological implications

The anomalous magnetic moment of muons has been a long-standing problem in SM. The current deviation of experimental value of the $(g-2)_{\mu}$ from the standard model prediction is exactly $4.2\sigma$. Two Higgs Doublet Models can accommodate this discrepancy but such type of model naturally generate flavor changing neutral current(FCNC). To prevent this it was postulated that 2HDM without FCNC required that all fermions of a given charge couple to the same Higgs boson but the rule breaks in Muon Specific Two Higgs Doublet Model where all fermions except muon couple to one Higgs doublet and muon with the other Higgs doublet. The Muon Specific Two Higgs Doublet model explain muon anomaly with a fine tuning problem of very large $\tan\beta$ value with other parameters. We have found a simple solution of this fine tuning problem by extending this model with a vector like lepton generation which could explain the muon anomaly at low $\tan\beta$ value with a heavy pseudo scalar Higgs boson under the shadow of current experimental and theoretical constraints. Moreover, with the help of the cut based analysis and multivariate analysis methods, we have also attempted to shed some light on the potential experimental signature of vector lepton decay to the heavy Higgs boson in the LHC experiment. We have showed that a multivariate analysis can increase the vector like leptons signal significance by up to an order of magnitude than that of a cut based analysis.Comment: 24 pages and multiple figures, comments are welcom

Successful Endovascular Management of an Aortic Rupture Following Stent Placement for Severe Atherosclerotic Stenosis: A Case Report

Aortic rupture during endovascular procedures is a devastating complication that mandates expedient intervention. The present report describes a case in which endovascular treatment was used to successfully manage an aortic rupture following placement of a covered stent graft for severe infrarenal aortic stenosis. Successful management of this case was the result of the procedure being performed in an operating room under appropriate anesthesia and close hemodynamic monitoring. Bilateral common femoral arterial access and use of covered aortic stent grafts also contributed to a favourable outcome