Aorto-atrial fistula formation and therapy

Aorta-atrial fistulas (AAF) are a rare but complex pathological condition. These fistulas are characterised by aberrant blood flow between the aorta and either atrium. In the present manuscript, we present a comprehensive overview of the clinical characteristics, formation and treatment of this condition. A literature review was conducted using PubMed. Aorta-Atrial Fistula was used as the primary search term. The clinical presentation of AAF encompasses a wide range of signs and symptoms of heart failure including dyspnoea, chest pain, palpitations, fatigue, weakness coughing or oedema. Causes of fistulas can be congenital or acquired, whilst diagnosis is normally achieved via echocardiography or MRI. Due to the low incidence of AAF, no clinical trials have been performed in AAF patients and treatment strategies are based on expert opinion and consensus amongst the treating physicians. Uncorrected AAF may continue to impose a risk of progression to overt heart failure. The repair of an AAF can either be surgical or percutaneous. AAF is a relatively rare but very serious condition. Clinicians should consider the possibility of AAF, when a new continuous cardiac murmur occurs, especially in patients with a history of cardiac surgery or with signs of heart failure. Closure of the AAF fistula tract is generally recommended. Further studies are required to define optimal therapeutic strategies, but these are hindered by the rarity of the occurrence of this disorde

Aorto-atrial fistula formation and closure: a systematic review

Blood flow between the aorta and atrium is a rare but complex pathological condition, also known as aorto-atrial fistula (AAF). The exact incidence of this condition is unknown, as are the major precipitating factors and best treatment options. We carried out a systematic review of the available case report literature reporting AAF. We systematically reviewed literature on AAF formation and closure. Separate Medline (PubMed), EMBASE, and Cochrane database queries were performed. The following MESH headings were used: atrium, ventricle, fistula, cardiac, shunts, aortic, aorto-atrial tunnels and coronary cameral fistula. All papers were considered for analysis irrespective of their quality, or the journal in which they were published. Fistula formation from the ascending aorta to the atria occurred more often in the right atrium compared to the left. Endocarditis was the major cause of AAF formation, whilst congenital causes were responsible for nearly 12%. In a number of cases fistula formation occurred secondary to cardiac surgery, whilst chest traumas were a relatively rare cause of AAF. Correction via an open surgical approach occurred in 73.5% of cases, whilst percutaneous intervention was utilised in 10% of patients. In 74.3% of all studied cases the fistula repair was successful and patients survived the procedures. In 14.7% of the cases patients did not survive. Similar outcomes were observed between percutaneous and surgical interventions. Data from larger populations with AAF is lacking, meaning that specific data regarding incidence and prevalence does currently not exist

BLINDED VS ULTRASOUND-GUIDED CORTICOSTEROID INJECTIONS for the TREATMENT of the GREATER TROCHANTERIC PAIN SYNDROME (SDPT): A RANDOMIZED CONTROLLED TRIAL

Universidade Federal de São Paulo, Div Rheumatol, São Paulo, BrazilUniversidade Federal de São Paulo, Div Rheumatol, São Paulo, BrazilWeb of Scienc

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

ARTICULAR SONOGRAPHY in HEALTHY INDIVIDUALS: COMPARISON AMONG SMALL, MEDIUM and LARGE JOINTS

Universidade Federal de São Paulo, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilWeb of Scienc

Novel hemostatic patch achieves sutureless epicardial wound closure during complex cardiac surgery:A case report

Treatment of damaged cardiac tissue in patients with high bleeding tendency can be very challenging, damaged myocardial tissue has a high rupture risk when being sutured subsequently on-going bleeding is a major risk factor for poor clinical outcome. We present a case demonstrating the feasibility in using a novel haemostatic collagen sponge for the management of a myocardial wound. This report is the first description in cardiac surgery where Hemopatch (R) sponges are used to successfully seal a left ventricle wound. Our patient was diagnosed with endocarditis, had a low pre-operative haemoglobin count and underwent cardiac surgery for multiple valve repairs. The procedure was performed on cardiopulmonary bypass, which meant our patient had to be heparinized. Despite these major risk factors for bleeding Hemopatch (R) managed to contain bleeding and seal the wound, no sutures were needed

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

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

Impact of Preoperative Anemia in Patients Undergoing Peripheral Vascular Intervention

Objectives: Transcarotid artery revascularization (TCAR) is an emerging novel approach to carotid intervention, adopted and well-suited for high-risk patients. Our objective was to assess the outcomes of TCAR and determine its impact on the volume of carotid endarterectomy (CEA) and non-TCAR carotid artery stenting (CAS) in a single-state experience. Methods: A large statewide quality consortium registry was queried. The indications and outcomes of TCAR compared with CEA and non-TCAR CAS from January 2018 to October 2019 were reviewed. Non-TCAR CAS included transfemoral, transbrachial stenting and transcarotid stenting without the flow reversal technique. We also assessed the impact of TCAR on the trend of CEA and non-TCAR CAS performed, analyzing data from 2012 to 2019. Outcome comparisons were performed using the χ 2 and Mann-Whitney U tests, depending on the distribution of the outcomes. Results: A total of 438 TCARs were performed by 39 physicians in 16 hospitals; 60% of the patients were asymptomatic and 40% symptomatic. The TCAR indication was physiologic high risk for 369 patients (84%) and restenosis for 69 patients (16%), with most occurring after prior CEA (94%). Of the non-TCAR CAS cases, 94% were performed via transfemoral access. The patients undergoing non-TCAR CAS had the highest 30-day mortality ( P \u3c .001) and the highest incidence of 30-day new neurologic deficits ( P = .008) compared with the patients undergoing CEA and TCAR. CEA had the lowest myocardial infarction rate ( P = .015; Table). The number of TCAR procedures performed and the number of physicians and hospitals performing them increased during the 2-year period. Since the introduction of TCAR, no significant frequency decrease has occurred in the number of non-TCAR CAS or CEA cases by hospitals or physicians (Fig). However, a significant negative trend was found in the number of CEAs performed by physicians since 2012 ( P \u3c .001; Fig). Conclusions: TCAR is a safe method of carotid revascularization and is becoming an increasingly used method. TCAR has not affected the CEA hospital or physician volume since its introduction. CEA volumes and physician usage are declining, which could have future credentialing implications. In the present single-state experience, TCAR compared favorably with CEA and non-TCAR CAS might be less appealing because of its higher neurologic event rate