Faculty Bibliography

BACKGROUND:Acute limb ischemia (ALI) is challenging to treat because of high morbidity and mortality. Endovascular-first options beginning with thrombolysis are technically feasible with similar results to open surgery. We examined our experience with thrombolysis to identify patients and target conduits that are predictive of improved outcomes. METHODS:We performed a retrospective review of our institutional database of thrombolysis cases for arterial lower extremity disease. Thrombolysis was the index procedure, and any subsequent treatment was a reintervention. Conversion to open surgery perioperatively such as thromboembolectomy or bypass was considered a technical failure. Primary outcomes included primary patency, secondary patency, amputation-free survival (AFS), and survival. Secondary outcomes included conversion to open, reintervention <30 days, and amputation <30 days. Descriptive statistics and analysis of variance were performed for preoperative and intraoperative risk factors. Kaplan-Meier estimation and Cox proportional hazard models were used for primary and secondary outcomes. RESULTS:Ninety-nine patients with ALI were treated with thrombolysis from 2007 to 2017. Thrombolysis was attempted on native artery (40%), vein bypass (7%), prosthetic bypass (33%), and stent (19%). Rutherford class distribution was 50% class 1, 41% class 2a, 5% class 2b, and 3% class 3. Technical success was 70%, characterized by an all-endovascular approach, patency at 30 days, and AFS for 30 days. Primary patency at 1- and 2-years was 31% and 22%, respectively. Secondary patency at 1- and 2-years was 39% and 27%, respectively. Overall, 30% required conversion to open surgery at the time of the index procedure, 7% reintervention <30 days, 5% mortality <30 days, and 5% major amputation <30 days. Prosthetic grafts and vein bypasses had the worst primary and secondary patency (P < 0.05). Five out of 7 vein bypasses required open conversion. Thrombolysis of native arteries was most successful maintaining primary patency (P < 0.05), secondary patency (P < 0.05), and AFS (P < 0.05). Patients who had adjunctive procedures at the time of thrombolysis had a significantly greater primary patency (P < 0.05) and secondary patency (P < 0.05) but not greater AFS. CONCLUSION/CONCLUSIONS:Outcomes in thrombolysis for ALI have not significantly improved 20 years after the STILE trial. Technical success and mid-term patency rates are modest at best. Thrombolysis of vein bypasses and prosthetic grafts have poor technical success and primary patency compared with native arteries. However, aggressive adjunctive interventions during thrombolysis appear to improve primary and secondary patency.

BACKGROUND:A novel coronavirus (COVID-19) erupted in the latter part of 2019. The virus, SARS-CoV-2 can cause a range of symptoms ranging from mild through fulminant respiratory failure. Approximately 25% of hospitalized patients require admission to the intensive care unit, with the majority of those requiring mechanical ventilation. High density consolidations in the bronchial tree and in the pulmonary parenchyma have been described in the advanced phase of the disease. We noted a subset of patients who had a sudden, significant increase in peak airway, plateau and peak inspiratory pressures. Partial or complete ETT occlusion was noted to be the culprit in the majority of these patients. METHODS:With institutional IRB approval, we examined a subset of our mechanically ventilated COVID-19 patients. All of the patients were admitted to one of our COVID-19 ICUs. Each was staffed by a board certified intensivist. During multidisciplinary rounds, all arterial blood gas (ABG) results, ventilator settings and ventilator measurements are discussed and addressed. ARDSNet Protocols are employed. In patients with confirmed acute occlusion of the endotracheal tube (ETT), acute elevation in peak airway and peak inspiratory pressures are noted in conjunction with desaturation. Data was collected retrospectively and demographics, ventilatory settings and ABG results were recorded. RESULTS:Our team has observed impeded ventilation in intubated patients who are several days into the critical course. Pathologic evaluation of the removed endotracheal tube contents from one of our patients demonstrated a specimen consistent with sloughed tracheobronchial tissues and inflammatory cells in a background of dense mucin. Of 110 patients admitted to our adult COVID-19 ICUs, 28 patients required urgent exchange of their ETT. CONCLUSION:Caregivers need to be aware of this pathological finding, recognize, and to treat this aspect of the COVID-19 critical illness course, which is becoming more prevalent.

OBJECTIVE:Previous studies of men suggested that patients with varicocele may be leaner than the normal population. No such work exists in women with pelvic congestion syndrome (PCS). This study evaluated the correlation between body mass index (BMI) and PCS. METHODS:A case-control study at a single institution was performed of women who had the objective diagnosis of PCS. Data were prospectively collected for 100 consecutive patients with PCS. BMI was calculated for every patient and categorized into normal weight (BMI <25), overweight (BMI 25-29.9), and obese (BMI >30). Diagnosis of PCS was made by ultrasound and venography. Mean BMI was compared with that of the general female population of the United States from 1999 to 2002. Furthermore, analyses included comparison of patients with and without ovarian vein dilation and pelvic varices. RESULTS:; P = .036). No differences were identified for pelvic varices or reflux. CONCLUSIONS:Women with PCS are more likely to have a normal BMI with ovarian vein dilation compared with obese women, who are more frequently affected by leg varicosities.

Pelvic congestion syndrome is one of the many causes of chronic pelvic pain and is often diagnosed based on exclusion of other pathologies. Over the past decades, pelvic congestion syndrome was recognized to be a more common cause of chronic pelvic pain. Multiple diagnostic modalities including pelvic duplex ultrasonography, transvaginal ultrasonography, computed tomography, and magnetic resonance were studied. In the current literature, selective ovarian venography, an invasive imaging approach, is believed to be the gold standard for diagnosing pelvic congestion syndrome.

OBJECTIVE:The purpose of this study was to evaluate potential factors affecting patient non-compliance after endovascular aneurysm repair. METHOD/METHODS:We performed a retrospective review of patients undergoing elective or emergency endovascular repair for thoracic, abdominal aorta, or iliac artery aneurysm at a single institution from November 2007 to March 2014. Compliance to follow-up at 1, 6, and 12 months was assessed. Factors evaluated included patient demographics, size of aneurysm, distance between the patient's residence and outpatient clinic, urgency of surgery, and time of year in which the follow-up visits were scheduled. RESULTS:During the study period, 205 patients (75% male and 25% female) fulfilled the inclusion criteria. One-month mortality was 1.1% for elective procedures and 16.1% for emergency procedures (p = 0.001). Overall mortality at 12 months was 6.3% and 32.3% for elective and emergency procedures, respectively (p = 0.0002). Highest compliance was observed at 1 month, with 184 patients (93%) attending. A significant decrease was seen at 6 (n = 102, 54%) and 12 (n = 89, 48%) months. At the 12-month mark, a larger proportion of minority patients were non-compliant compared with Caucasian patients. Confounders for non-compliance were analyzed using multivariate analysis, and statistical significance was found for widowed marital status (p = 0.008), travel distance >25 miles to the outpatient clinic (p = 0.032), and emergency repair of aneurysms (p = 0.022). CONCLUSION/CONCLUSIONS:Despite emphasizing the importance of follow-up after endovascular aortic procedures, almost half of the treated patients were non-compliant. Our study identified travel distance, marital status, and urgency of surgery as factors that may affect patients' compliance to scheduled follow-up visits.

BACKGROUND:We report a case of endovascular treatment of a complex renal artery aneurysm using the Pipeline Embolization Device, a flow diverting stent which is indicated for the treatment of large and giant cerebral aneurysms. METHODS:A forty-year-old female with medically refractory hypertension and congenital agenesis of the right kidney was found to have a 2.8-cm left superior renal artery branch aneurysm. The patient was treated successfully using the Pipeline Embolization Device (Medtronic, Irvine, CA) with coil embolization of the aneurysm and of one outflow vessel. RESULTS:On 3-year follow-up, her renal function was normal, vascular imaging showed complete occlusion of the aneurysm, and physiological remodeling of the reconstructed artery and parenchymal imaging showed no evidence of renal infarction. CONCLUSION/CONCLUSIONS:Flow diverting stents are a valuable treatment option for visceral aneurysms with complex anatomy.