Faculty Bibliography

PURPOSE OF REVIEW: The most common and significant morbidity and mortality of vascular surgical procedures remain coronary artery disease, arrhythmia, and heart failure. Cardiac evaluation and medical optimization provide the groundwork for best medical practice in an otherwise high-risk surgical population. The goal of this study is to review the most current literature and guidelines for evaluating patients prior to vascular surgical interventions. From this, we have made our own recommendations regarding both the preoperative and perioperative management of vascular surgical patients. RECENT FINDINGS: Risk stratification using a modified Lee index may be best to assess perioperative cardiac risk. Coronary revascularization should be reserved for those patients with significant coronary disease irrespective of symptoms. beta-blockers, statins, and antiplatelet agents should be considered for all patients with peripheral vascular disease. SUMMARY: The preoperative management of vascular surgical patients requires a complete understanding of the patient's medical history as it relates to their perioperative cardiac risk. Overwhelming data support the use of medical therapy as adjunct to minimize or prevent the risk of future cardiovascular events. As vascular surgery transitions to the outpatient setting, further studies will be required to better elucidate cardiac evaluation in this patient population.

A 45-year old female referred for a large carotid body tumor resection. The tumor was encasing the internal (ICA) and external carotid arteries (ECA). She underwent angiogram and embolization of the ascending pharyngeal artery and a distal branch of the ECA using ethylene vinyl-alcohol copolymer (EVOH). Two days later, surgical resection of the tumor with regional lymph node dissection was performed along with an interposition reversed vein graft anastomosis between the mid common carotid and distal ICA. Devascularization of carotid body tumor can be performed using EVOH delivered through trans-arterial and percutaneous routes. Embolization may facilitate surgical resection and decrease blood loss but does not decrease the rate of neurological complications. Embolization can be performed by the vascular surgeon before a large carotid body tumor resection with minimal migration and or stroke risk.

With increasing carotid artery stenting (CAS) expertise and improved CAS equipment, recent trials have demonstrated better results for CAS compared with earlier studies. As a result, it may be argued that CAS is currently non-inferior to carotid endarterectomy (CEA), at least in some patient subgroups. Consequently, there have been recent calls for extending CAS indications to include average surgical risk patients with symptomatic or asymptomatic carotid stenosis. However, CAS remains a less cost-effective option than CEA. Opening the floodgates to unrestricted CAS for both symptomatic and asymptomatic carotid patients would have considerable cost implications for any health system. Appropriate patient selection and keeping to the indications are crucial to optimize CAS outcomes.

We report the case of a 78-year-old man with coronary artery disease, chronic obstructive pulmonary disease, and chronic renal insufficiency with an enlarging 6.7-cm infrarenal abdominal aortic aneurysm. He also had a 4-cm right common iliac artery aneurysm, and right external iliac artery occlusion. The patient had a history of an axillobifemoral bypass graft placed 10 years prior for aortoiliac occlusive disease. We describe the use of an infrarenal aorto-uni-iliac graft and subsequent intentional graft occlusion as an endovascular solution to treat aneurysmal disease in this sick patient. He remains asymptomatic after surgery, with demonstrated occlusion of his aneurysms.

BACKGROUND: Opiates are widely used for postoperative pain relief. Unfortunately, their side effects such as inhibited gastrointestinal motility and respiratory depression may compromise or delay postoperative recovery after laparotomy. We used paraincisional subcutaneous catheters (PSCs) and applied 0.25% ropivacaine infusion to improve pain relief and decrease postoperative morphine consumption in patients after open surgery for aortic aneurysm. METHODS: A retrospective single-center study including 58 patients treated by open surgery for aortic aneurysm between October 2006 and June 2012. Overall, 28 patients (control group) received standard postoperative pain management including opiates, and 30 patients (PSC group) were treated with paraincisional continuous local analgesia with 0.25% ropivacaine administrated via bilateral subcutaneous catheters along with additional ad libitum opiates administration, at first intravenously and then orally. RESULTS: Patients characteristics as well as perioperative and postoperative outcomes were comparable between the groups during the first 5 days after surgery. Patients of the PSC group received significantly less morphine, although the patients in both groups reported a similar pain intensity. Neither wound-healing disorder nor catheter-associated subcutaneous infection was reported. High serum concentration of ropivacaine was detected in 2 patients (6%) with end-stage renal disease, who developed temporary neurologic symptoms. Length of intensive care unit (ICU) stay was significantly shorter in the PSC group (2 [0-23] vs. 4.5 [0-32] ICU days). CONCLUSIONS: This is the first report about PSCs for analgesia after laparotomy. This case/control study shows that continuous paraincisional subcutaneous infusion of 0.25% ropivacaine after open surgery for aortic aneurysm repair is a feasible method of postoperative analgesia. This technique allows sustained pain relief with significant reduction of opiate requirement and faster recovery after surgery. Prospective randomized controlled trial is necessary for the assessment of safety and efficacy of this method.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are frequently encountered in patients treated for ruptured abdominal aortic aneurysms (rAAA) and carry a high morbidity and mortality risk. Despite these facts, IAH/ACS are still overlooked by many physicians, timely diagnosis is missed and treatment often inadequate. All staff involved in the treatment of rAAA should be aware of the risk factors predicting IAH/ACS, the profound implications and derangements on all organ systems, the clinical presentation, the appropriate measurement of intra-abdominal pressure to detect IAH/ACS and the current treatment options for these detrimental syndromes. This comprehensive review provides contemporary knowledge that should help to improve patient survival and long-term outcome.