Access To Vessels Research Articles

Safety of Percutaneous Femoral Access for Endovascular Aortic Aneurysm Repair Through Previously Surgically Exposed or Repaired Femoral Arteries

Objective: Percutaneous femoral artery access is being increasingly used in endovascular aortic repair (EVAR). The technique can be challenging in patients with previously surgically exposed or repaired femoral arteries because of excessive scar tissue. However, a successful percutaneous approach may cause less morbidity than a “re-do” open femoral approach. The aim of this study was to assess the impact of prior open surgical femoral exposure on technical success and clinical outcomes of percutaneous approach. Methods: This study retrospectively reviewed the clinical data of patients who underwent percutaneous EVAR between 2010 and 2020 at 2 major aortic centers. Patients were divided into 2 groups (with or without prior open surgical femoral access) for analysis of clinical outcomes. Only punctures with sheaths ≥12Fr were included for analysis. The access and (pre)closure techniques were similar in both institutions. Primary end points were intraoperative technical success, access-related revision, and access complications. A multivariate analysis was performed to identify determinants of conversion to open approach and femoral access complications in intact and re-do groins. Results: A total of 632 patients underwent percutaneous (complex) EVAR: 98 had prior open surgical femoral access and 534 patients underwent de novo femoral percutaneous access. A total of 1099 femoral artery punctures were performed: 149 in re-do and 950 in intact groins. The extent of endovascular repair included 159 infrarenal, 82 thoracic, 368 fenestrated/branched, and 23 iliac branch devices. No significant differences were seen in technical success (re-do 93.3% vs intact 95.3%, p=0.311), access-related surgical revision (0.7% vs 0.6%, p=0.950), and access complications (2.7% vs 4.0%, p=0.443). For the whole group, significant predictors for access complications in multivariate analyses were main access site (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.07%–5.35%; p=0.033) and increase of the procedure time per hour (OR 1.65; 95% CI 1.34%–2.04%; p<0.001), while increase in sheath-vessel ratio had a protective effect (OR 0.33; 95% CI 0.127%–0.85%; p=0.021). Surgical conversion was predicted by main access site (OR 2.32; 95% CI 1.28%–4.19%; p=0.007) and calcification of 50% to 75% of the circumference of the access vessel (OR 3.29; 95% CI 1.38%–7.86%; p=0.005). Conclusion: Within our population prior open surgical femoral artery exposure or repair had no negative impact on the technical success and clinical outcomes of percutaneous (complex) endovascular aortic aneurysm repair.

Contemporary indications for open abdominal aortic aneurysm repair in the endovascular era

ObjectiveDespite the emergence of endovascular aneurysm repair (EVAR) as the most common approach to abdominal aortic aneurysm repair, open aneurysm repair (OAR) remains an important option. This study seeks to define the indications for OAR in the EVAR era and how these indicatioxns effect outcomes. MethodsA retrospective cohort study was performed of all OAR at a single institution from 2004 to 2019. Preoperative computed tomography scans and operative records were assessed to determine the indication for OAR. These reasons were categorized into anatomical contraindications, systemic factors (connective tissue disorders, contraindication to contrast dye), and patient or surgeon preference (patients who were candidates for both EVAR and OAR). Perioperative and long-term outcomes were compared between the groups. ResultsWe included 370 patients in the analysis; 71.6% (265/370) had at least one anatomic contraindication to EVAR and 36% had two or more contraindications. The most common anatomic contraindications were short aortic neck length (51.6%), inadequate distal seal zone (19.2%), and inadequate access vessels (15.7%). The major perioperative complication rate was 18.1% and the 30-day mortality was 3.0%. No single anatomic factor was identified as a predictor of perioperative complications. Sixty-one patients (16.5%) underwent OAR based on patient or surgeon preference; these patients were younger, had lower incidences of coronary artery disease and chronic obstructive pulmonary disease, and were less likely to require suprarenal cross-clamping compared with patients who had anatomic and/or systemic contraindications to EVAR. The patient or surgeon preference group had a lower incidence of perioperative major complications (8.2% vs 20.1%; P = .034), shorter length of stay (6 days vs 8 days; P < .001) and no 30-day mortalities. The multivariable adjusted risk for 15-year mortality was lower for patient or surgeon preference patients (adjusted hazard ratio, 0.44; 95% confidence interval, 0.24-0.80; P = .007) compared with those anatomic or systemic contraindications. ConclusionsWithin a population of patients who did not meet instruction for use criteria for EVAR, no single anatomic contraindication was a marker for worse outcomes with OAR. Patients who were candidates for both aortic repair approaches but elected to undergo OAR owing to patient or surgeon preference have very low 30-day mortality and morbidity, and superior long-term survival rates compared with those patients who underwent OAR owing to anatomic and/or systemic contraindications to EVAR.

Minimally Invasive Cervical Access in Head and Neck Microvascular Surgery

Free flap reconstruction often involves extensive cervical access for microvascular anastomosis where management of pathology would otherwise not require cervical approach. This study reports a minimally invasive alternative technique. Investigators designed a prospective case series with subjects who underwent microvascular reconstruction between 2015 and 2020, using a small 2cm incision for vessel access, just below the mandible where facial artery/vein cross. Study variables were subject demographic characteristics, type and location of pathology/defect, and free flap types. Outcomes examined were flap success, postoperative facial weakness using House-Brackmann scale, and esthetic result with Visual Analog Scale. Descriptive statistics computed for study variables. Study sample was 43 subjects, mean age of 48years with 20 males and 23 females. There were a total of 43 flaps with 100% success using our technique. One subject had House-Brackmann level 2 postoperative facial weakness that resolved within 1week. Mean Visual Analog Scale score for scar satisfaction was 9.23/10, standard deviation 0.83. This minimally invasive approach represents an alternative to extensive open cervical access for microvascular anastomosis, offering minimal morbidity and excellent esthetic results.

Iliac Artery Endoconduits Should be the Preferred Adjunctive Access Procedure to Facilitate Complex Endovascular Aortic Aneurysm Repair.

Iliac artery anatomy can have a dramatic impact on the success of endovascular complex aortic aneurysm (CAA) procedures as endograft delivery systems need to be advanced and manipulated through these access vessels. The aim of this study was to evaluate the outcomes of iliac artery conduits with emphasizes on open vs endovascular conduits performed to facilitate CAA endovascular repair. All patients who had open or endovascular iliac conduits prior to endovascular CAA repair to treat thoracoabdominal, juxtarenal, or suprarenal aneurysms at the University of Colorado Hospital from January 2009 through January 2019 were included. Patients who presented with symptomatic or ruptured aortic aneurysms were excluded. Outcomes of interest included postoperative complications and mortality in patients undergoing iliac conduits. Twenty-seven patients with a total of 42 conduits were included in the study. The majority of patients (N = 15, 56%) were female and the average age was 72 ± 9years. The calculated VQI cardiac index was .6% (range, .3%-.8%). Eighteen (43%) endovascular and 24 (57%) open iliac conduits were performed during the study period. Thirty (71%) conduits were performed in a staged fashion, while 12 (29%) were performed at the same time as endovascular CAA repair. The mean time between conduit and definitive aneurysm repair surgery was 130 ± 68days in the endovascular and 107 ± 79days in the open groups (P = .87). No aneurysm rupture occurred during the staging period in either group. The median follow-up for the entire cohort was 18 ± 22months. The median length of hospital stay for patients undergoing endovascular and open ICs was 6 (ranging, 1-28days) and 7days (ranging, 3-18days), respectively. Patients undergoing open conduits had significantly more complications than those undergoing endovascular conduit (endoconduit) creation. A total of 4 (15%) patients died within 30days after aneurysm repair. Out of 23 survivors, 18 (78%) patients were discharged home, 4 (18%) patients were discharged to a skilled nursing facility, and 1 (4%) patient was discharged to an acute rehabilitation facility. No mortality difference based on type of conduit was found. Overall complication rate associated with creation of open iliac artery conduits is not negligible. Endoconduits, which carry less morbidity than open conduits, are preferred as a first-line adjunctive access procedure to facilitate complex endovascular aortic aneurysm repair.

ECM Depletion Is Required to Improve the Intratumoral Uptake of Iron Oxide Nanoparticles in Poorly Perfused Hepatocellular Carcinoma.

Improving tumor access for drug delivery is challenging, particularly in poorly perfused tumors. The availability of functional tumor blood vessels for systemic access is vital to allow drugs or imaging agents to accumulate in the tumor parenchyma. We subjected mice engineered to develop hepatocellular carcinoma (HCC), to treatment with tumor necrosis factor alpha (TNFα) conjugated to a CSG peptide (CSGRRSSKC). CSG binds to the laminin-nidogen-1 complex of the extracellular matrix (ECM) in HCC. When produced as a recombinant fusion protein, the TNFα-CSG functions as an ECM depletion agent via an immune-mediated mechanism to improve tumor perfusion. Tumor perfusion in HCC was dramatically improved after daily intravenous (i.v.) injection of 5 µg TNFα-CSG for five consecutive days. Following treatment, we assessed the tumor accessibility to accumulate an imaging agent, superparamagnetic iron-oxide nanoparticles (IO-NP). Here, we compared the passive delivery of an i.v. dose of IO-NP in HCC following ECM depletion after TNFα-CSG treatment, to the intratumoral accumulation of a comparable dose of CSG-targeted IO-NP in HCC with intact ECM. Magnetic resonance imaging (MRI) T2-weighted scans and T2 relaxation times indicate that when the tumor ECM is intact, HCC was resistant to the intratumoral uptake of IO-NP, even when the particles were tagged with CSG peptide. In contrast, pre-treatment with TNFα-CSG resulted in the highest IO-NP accumulation in tumors. These findings suggest poorly perfused HCC may be resistant to molecular-targeted imaging agents including CSG-IO-NP. We demonstrate that specific ECM depletion using TNFα-CSG improves nanoparticle delivery into poorly perfused tumors such as HCC.

Changing the peritoneal dialysis access algorithm with a precise technique of percutaneous Seldinger PD catheter placement.

In 1953, Swedish radiologist Sven Seldinger introduced a technique for blood vessel or hollow organ access using a needle, guide wire and catheter. Over the last two decades, this technique has been used for Peritoneal Dialysis (PD) catheter placement, "Seldinger PD" (SPD). To improve the safety and accuracy of SPD, ultrasound, X-ray guidance, contrast imaging and micropuncture techniques have been incorporated to a greater or lesser extent. This manuscript describes a new and rigorous technique of SPD developed at our unit and results in the first 64 cases. One of our goals was to replace emergency Central Vein Catheter Hemodialysis with "Urgent-Start" PD. We therefore sought to develop a procedure that was ultra-safe, minimally invasive and readily done on the sickest patients under Local Anesthetic. As the technique was new to our unit, and because of progressive modifications of the technique, some of the results reflect our "learning curve." In addition, 55% of the patients referred to our program had "crashed" into renal failure, 32% were deemed "unfit for General Anaesthesia" by the Anaesthetists and 53% were moderately to severely obese, resulting in a very morbid and vulnerable cohort. Despite this, we had no procedure related mortality, no organ injury and no significant bleeding. Technical success was 97% (intention-to-treat). Urgent Start PD was used in 36%; overall, 3/61 catheters placed experienced PD fluid leak. Correct catheter tip placement - in the Pelvic Pouch - was documented in all cases; significant catheter migration was seen in 18% of those with imaging follow-up, only two requiring revision. Most catheter migrations occurred early in our series before our low peritoneal puncture technique became standard. We believe this SPD technique is safe, precise, clinically and financially cost-effective and can replace other forms of PD placement in most situations.

Peripheral access size evaluation in transfemoral transcatheter aortic valve replacement.

Peripheral access vessel dimensions in the general patient population screened for transcatheter aortic valve replacement (TAVR) can offer insight into the indications for pre-TAVR computed tomography angiography (CTA) assessment. We seek to determine peripheral access vessel sizes in patients screened for TAVR and association with patient characteristics. All patients with severe, symptomatic aortic stenosis screened for TAVR at a high-volume center from April 2012 to March 2019 were retrospectively reviewed. For each patient, contrast-enhanced CTA was used to determine the minimal luminal diameters (MLDs) of the transfemoral access vessels, as measured between the inguinal ligament and the deep femoral artery for the femoral artery, and proximal to the inguinal ligament for the external and common iliac arteries, respectively. Paired and independent samples t-tests were used to compare means and regression analyses were performed to determine factors associated with MLD. A total of 1049 screened patients were included of which 826 (78.7%) underwent TAVRand 551 (52.5%) were male. The mean age was 80.6 (±9.6) years and the mean body mass index (BMI) was 26.7 (±5.9) kg/m2 . About 152 (14.5%) had peripheral vascular diseaseand 153 (14.6%) had chronic kidney disease. The mean (±2 standard deviations) MLDs of the right and left femoral arteries were 7.73 mm (4.68-10.78) and 7.68 mm (4.63-10.72), respectively. Male sex and BMI were associated with larger average femoral MLD while hyperlipidemia, hypertension, smoking, peripheral vascular disease, and coronary artery disease were inversely associated. Most patients screened for TAVR have minimum peripheral access vessel sizes exceeding the recommended minimum access route diameters of modern transcatheter heart valves. As sheath sizes decrease, clinicians must carefully judge patient individual risk factors to determine whether a pre-TAVR CTA assessing peripheral access vessel dimensions and anatomical contraindications is indicated. Larger studies and randomized controlled trials are required to compare the outcomes of TAVR with and without preoperative CTA.

Risk of Stroke with Impella Placement Is Not Associated with Access Vessel.

Objective: The Impella heart pump is an intravascular microaxial device that provides short-term mechanical circulatory support and can be placed through the femoral, axillary, or central vessels. One of the most feared complications is stroke. It is unclear if patient stroke risk varies based on access vessel. Methods: A retrospective review of consecutive patients who underwent Impella placement at an academic institution from January 1, 2007, through September 15, 2018, was performed. Four groups were compared: (1) minimally invasive Impella (femoral or axillary access), (2) minimally invasive Impella upgraded to another minimally invasive Impella, (3) minimally invasive Impella upgraded to a central Impella (ascending aorta), and (4) central Impella. Patient charts were reviewed to identify baseline characteristics. Outcome measures included length of stay, stroke, and mortality. Results: A total of 349 patients (or 407 Impellas) were identified, and the majority of the devices were inserted through a minimally invasive approach (n = 248, 60.9%), while the remainder were implanted via central access (n = 159, 39.1%). Minimally invasive Impellas were upgraded in 44 patients. The risk of stroke for the entire cohort was 10.3% (n = 36), with no difference observed in any particular group. Overall mortality was 44.4% (n = 155). Of the patients who initially received a minimally invasive Impella, those who were upgraded had higher rates of mortality (56.8% vs 39.4%, P = 0.03), postoperative dialysis (50.0% vs 27.4%, P < 0.01), and sepsis (43.2% vs 20.0%, P < 0.01). Conclusions: This study found no statistically significant difference in rates of postoperative stroke based on initial access vessel.

Non-guideline-compliant endovascular abdominal aortic aneurysm repair in women is associated with increased mortality and reintervention compared with men.

Sex-based disparities in surgical outcomes have emerged as an important focus in contemporary healthcare delivery. Likewise, the appropriate usage of endovascular abdominal aortic aneurysm repair (EVAR) in the United States remains a subject of ongoing controversy, with a significant number of U.S. EVARs failing to adhere to the Society for Vascular Surgery (SVS) clinical practice guideline (CPG) diameter thresholds. The purpose of the present study was to determine the effect of sex among patients undergoing EVAR that was not compliant with the SVS CPGs. All elective EVAR procedures for abdominal aortic aneurysms without a concomitant iliac aneurysm (≥3.0cm) in the SVS Vascular Quality Initiative were analyzed (2015-2019; n= 25,112). SVS CPG noncompliant repairs were defined as a size of<5.5cm for men and<5.0cm for women. The primary endpoint was 30-day mortality. The secondary endpoints were all-cause mortality, complications, and reintervention. Logistic regression was performed to control for surgeon- and patient-level factors. Freedom from the endpoints was determined using the Kaplan-Meier method. Noncompliant EVAR was performed in 9675 patients (38.5%). Although men were significantly more likely to undergo such procedures (90% vs 10%; odds ratio [OR], 3.1; 95% confidence interval [CI], 2.9-3.4; P< .0001), the 30-day mortality was greater for the women than the men (1.8% vs 0.5%; P= .0003). Women also experienced significantly higher rates of multiple complications, including postoperative myocardial infarction (1% vs 0.3%; P= .006), respiratory failure (1.4% vs 0.6%; P= .01), intestinal ischemia (0.7% vs 0.2%; P= .003), access vessel hematoma (3% vs 1.2%; P= .0006), and iliac access vessel injury (2.4% vs 0.8%; P< .0001). Additionally, women experienced increased overall 1-year reintervention rates (11.5% vs 5.8%; P< .0001). In the adjusted analysis, 30-day mortality and any in-hospital complication risk remained significantly greater for the women (30-day death: OR, 3.1; 95% CI, 1.6-5.8; P= .0005; in-hospital complication: OR, 1.9; 95% CI, 1.4-2.6; P< .0001). Women also experienced increased reintervention rates over time compared with men (OR, 1.5; 95% CI, 1.1-2.2; P= .02). Although men were more likely to undergo non-CPG compliant EVAR, women experienced increased short-term morbidity and 30-day mortality and higher rates of reintervention when undergoing non-CPG compliant EVAR. These unanticipated findings necessitate increased scrutiny of current U.S. sex-based EVAR practice and should caution against the use of non-CPG compliant EVAR for women.

A retrospective study of oral maxillary squamous cell carcinomas treated from 2008-2018

<b>Introduction:</b> Controversy exists regarding the management of the clinically node negative neck (cN0) in maxillary or gingival squamous cell carcinoma (MGSCC). This study reviews cN0 MGSCC patients over a 10-year period to record the method of neck management and outcome. <b>Methods:</b> Theatre and pathology records were searched for patients diagnosed and treated for site specific cN0 MGSCC from 2008-2018. The Fisher's exact test was used for comparative analysis and survival statistics calculated using the Kaplan–Meier method and log-rank test. <b>Results:</b> 15/36 of patients had an END and 21/36 underwent observation following primary surgery. Included in these 21 patients, 5 underwent vessel access for flap anastomosis with node sampling. 13/36 of patients received PORT. The total recurrence rate was 15/36; 5/15 local, 8/15 regional and 2/15 with locoregional. Regional recurrence was similar in observed patients 5/21 compared to those who had an END 3/15. 8/15 of patients with recurrence underwent salvage surgery. Salvage rates were 3/7 in patients who received PORT and 5/8 without, with success in 2/3 and 4/5 respectively. <b>Conclusions:</b> END 5- year disease specific survival (DSS) (67%) was similar to observed patients (65%) although those with vessel access had a 80% DSS (p=0.87). pT4a END patients had a higher 5- year DSS versus observation only patients (56% vs 44%) (p=0.53). Bone invasion was significant to RL (p= 0.05). There was no advantage to having an END for the N0 neck in MGSCC and control was also achieved with a ‘watch and wait' policy followed by salvage if required.

Comparison of percutaneous access and open femoral cutdown in elective endovascular aortic repair of abdominal aortic aneurysms.

Background The aim of this study was to compare postoperative outcomes of percutaneous access and femoral cutdown methods for elective bifurcated endovascular abdominal aortic aneurysm repair. Methods Between November 2013 and September 2020, a total of 152 patient (135 males, 17 females; mean age: 70.6±6, range, 57 to 87 years) who underwent endovascular repair due to infrarenal abdominal aortic aneurysm were retrospectively analyzed. According to femoral access type, the patients were grouped into two groups as the total percutaneous femoral access and open cutdown femoral access endovascular repair. Intra- and postoperative data were compared, including operative time, amount of contrast media, bleeding requiring transfusion, return to the operating room, access vessel complications, wound complications, and overall length of hospital stay. Results Eighty-seven (57.2%) femoral cutdown access repair and 65 (42.8%) percutaneous femoral access repair cases were evaluated in the study. The two groups were comparable in terms of demographic and clinical characteristics (p>0.05), except for chronic obstructive pulmonary disease which was more frequent in the percutaneous access group (p=0.014). After adjustment, age, diabetes mellitus, chronic obstructive pulmonary disease, and obesity were not predictive of percutaneous access failure. Percutaneous femoral access was observed as the only preventing factor for wound infection (odds ratio=0.166, 95% confidence interval: 0.036-0.756; p=0.021). Conclusion Although femoral access preference does not affect mortality and re-intervention rates, percutaneous endovascular repair reduces operation time, hospital stay, and wound site complications compared to femoral artery exposures.

Interventional Treatment of Access Site Complications During Transfemoral TAVI: A Single Center Experience.

Introduction: Transcatheter aortic valve implantation (TAVI) has rapidly developed over the last decade and is nowadays the treatment of choice in the elderly patients irrespective of surgical risk. The outcome of these patients is mainly determined not only by the interventional procedure itself, but also by its complications.Material and Methods: We analyzed the outcome and procedural events of transfemoral TAVI procedures performed per year at our institution. The mean age of these patients is 79.2 years and 49% are female. All the patients underwent duplex ultrasonography of the iliac arteries and inguinal vessels before the procedure and CT of the aorta and iliac arteries.Results: Transfemoral access route is associated with a number of challenges and complications, especially in the patients suffering from peripheral artery disease (PAD). The rate of vascular complications at our center was 2.76% (19/689). Typical vascular complications (VC) include bleeding and pseudoaneurysms at the puncture site, acute or subacute occlusion of the access vessel, and dissection or perforation of the iliac vessels. In addition, there is the need for primary PTA of the access pathway in the presence of additional PAD of the common femoral artery (CFA) and iliac vessels. Balloon angioplasty, implantation of covered and uncovered stents, lithoplasty, and ultrasound-guided thrombin injection are available to treat the described issues.Conclusion: Interventional therapy of access vessels can preoperatively enable the transfemoral approach and successfully treat post-operative VC in most of the cases. Training the heart team to address these issues is a key focus, and an interventional vascular specialist should be part of this team.

A 3D CAD model input pipeline for REFMUL3 full-wave FDTD 3D simulator

The use of advanced simulation has become increasingly more important in the planning, design, and assessment phases of future fusion plasma diagnostics, and in the interpretation of experimental data from existing ones. The design cycle of complex reflectometry systems, such as the ones being planned for next generation machines (IDTT and DEMO), relies heavily on the results produced by synthetic diagnostics, used for system performance evaluation and prediction, both crucial in the design process decision making. These synthetic diagnostics need realistic representations of all system components to incorporate the main effects that shape their behavior. Some of the most important elements that are required to be well modelled and integrated in simulations are the wave launcher structures, such as the waveguides, tapers, and antennas, as well as the vessel wall structures and access to the plasma. The latter are of paramount importance and are often neglected in this type of studies. Faithfully modelling them is not an easy task, especially in 3D simulations. The procedure herein proposed consists in using CAD models of a given machine, together with parameterizable models of the launcher, to produce a description suited for Finite Difference Time Domain (FDTD) 3D simulation, combining the capabilities of real-world CAD design with the power of simulation. However, CAD model geometric descriptions are incompatible with the ones used by standard FDTD codes. CAD software usually outputs models in a tessellated mesh while FDTD simulators use Volumetric Pixel (VOXEL) descriptions. To solve this interface problem, we implemented a pipeline to automatically convert complex CAD models of tokamak vessel components and wave launcher structures to the VOXEL input required by REFMUL3, a full wave 3D Maxwell FDTD parallel code. To illustrate the full procedure, a complex reflectometry synthetic diagnostic for IDTT was setup, converted and simulated. This setup includes 3 antennas recessed into the vessel wall, for thermal protection, one for transmission and reception, and two just for reception.

How Does Female Sex Affect Complex Endovascular Aortic Repair? A Single Centre Cohort Study

There is growing evidence of a female patient disadvantage in complex endovascular aortic repair using fenestrated and branched endografts (FB-EVAR) primarily related to peri-procedural events including ischaemic and access vessel complications. This study aimed to determine the impact of sex differences on treatment patterns, and in hospital outcomes in a single centre cohort. This was a retrospective cross sectional single centre cohort study of all consecutive FB-EVAR procedures provided to patients with asymptomatic pararenal and thoraco-abdominal aortic aneurysm (TAAA) between 1 January 2010 and 28 February 2021. Adjusted multivariable logistic regression models were developed using backward (Wald) elimination of variables to determine the independent impact of female sex on short term outcomes. In total, 445 patients (24.3% females, median age 73.0 years, IQR 66, 78) were included. Female patients had a smaller aneurysm diameter, less frequent coronary artery disease (29.6% vs. 44.8%, p= .007) and history of myocardial infarction (2.8% vs. 15.4%, p < .001) when compared with males. Females were more frequently treated for TAAA than males (49.1% vs. 25.2%, p < .001). The median length of post-procedural hospital stay was 10 days in females and 9 in males. In adjusted analyses, female sex was independently associated with higher mortality (odds ratio [OR] 10.135, 95% CI 2.264 - 45.369), post-procedural complications (OR 2.500, 95% CI 1.329 - 4.702), spinal cord ischaemia (OR 4.488, 95% CI 1.610 - 12.509), sepsis (OR 4.940, 95% CI 1.379 - 17.702), and acute respiratory insufficiency (OR 3.283, 95% CI 1.015 - 10.622) after pararenal aortic aneurysm repair during the hospital stay. In this analysis of consecutively treated patients, female sex was associated with increased in hospital mortality, peri-procedural complications, and spinal cord ischaemia after elective complex endovascular repair of pararenal aortic aneurysm, while no differences were revealed in the TAAA subgroup. These results suggest that sex related patient selection and peri-procedural management should be studied in future research.

Changes in Anesthesia Can Reduce Periprocedural Urinary Retention After EVAR

Enhanced recovery after surgery (ERAS) programs provide a streamlined approach for expedient postoperative care of high-volume procedures. Endovascular aortic repair (EVAR) has become standard treatment for abdominal aortic aneurysms and implementation of an early recovery program is warranted. Postoperative urinary retention (POUR) remains a problem lending to longer hospital stays and patient discomfort. We aim to demonstrate the utility of monitored anesthetic care (MAC) plus local anesthesia as a modality to minimize urinary retention following EVAR. Single-center retrospective review from January 2017 to March 2020 of all patients undergoing standard elective EVAR under general anesthesia or MAC anesthesia. Local anesthetic at vessel access sites was used in all patients under MAC. Ruptured pathology and female sex were excluded from analysis. Patient characteristics, operative details, prostate measurements, and outcomes were abstracted from the electronic medical record. Urinary retention was defined as any requirement of straight catheterization, urinary catheter replacement, or discharge with urinary catheter. Chi square tests and logistic regression were used to determine predictors associated with POUR and increased hospital length of stay. Among 138 patients who underwent EVAR, eight (5.8%) were excluded due to ruptured pathology. Of the cohort, 113 (86.9%) were male with mean age of 73 years. Excluding female patients, 63 (55.8%) male patients underwent general anesthesia and 50 (44.3%) underwent MAC. Male patients under general anesthesia were more likely to have intra-operative urinary catheter placement when compared to MAC (82.5% vs. 36%, respectively; P < 0.001). POUR was identified in 17 patients (13.1%) of the entire study population with 15 events (88.2%) occurring in males. Excluding patients who were admitted to the ICU, twenty-two (19.5%) male patients stayed past postoperative day (POD) one, of which those who developed POUR were more likely to experience compared to those without POUR (45.6% vs. 9.7%, respectively; P=0.001). On multivariable analysis, male patients who received MAC had a lower risk of developing POUR (OR 0.09, 95% CI 0.02-0.50). POUR was not associated with elective urinary catheter placement nor with pre-existing conditions such as diabetes, urinary retention, benign prostatic hypertrophy (BPH), or use of BPH medications. Additionally, neither prostate size nor volume was associated with developing POUR among male patients. MAC plus local anesthesia is associated with decreased rates of POUR after elective EVAR in male patients. ERAS pathways during elective EVAR interventions should implement MAC plus local anesthesia as an acceptable anesthetic option, where appropriate, in order to reduce urinary retention rates and subsequently decrease hospital length of stay in this patient cohort.

Emergency Intravascular Aortic and Iliac Artery Lithotripsy to Facilitate Thoracic Endovascular Aortic Repair of a Ruptured Thoracic Aortic Aneurysm: A Case Report

Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for ruptured thoracic aortic aneurysms. Poor access vessels are a relative contraindication to TEVAR. Intravascular lithotripsy (IVL) has recently been shown to be effective in treating calcified and stenotic vessels. Prior to the introduction of IVL, plaque modification techniques to increase vessel compliance and luminal diameter were limited to technically complex and risky surgical and interventional radiologic procedures. We present a case demonstrating the use of IVL in the emergency setting to treat severe atherosclerotic stenoses in the abdominal aorta and the iliac artery to facilitate TEVAR of a ruptured thoracic aortic aneurysm.

Frequency and outcome of acute coronary syndrome during the Covid-19 pandemic

IntroductionIn 2020 the Austrian government has ordered two complete lockdowns and two lockdown lights to maintain control over the infection rate of Covid-19. Several studies have analysed the frequency and outcome of patients with acute coronary syndrome (ACS) during the pandemic. Some have described a decrease in the admission rate of patients with ST-elevated-myocardial-infarction (STEMI) and no-ST-elevated-myocardial-infarction (NSTEMI), with the reasons still being discussed.PurposeThe aim of this study is to analyse possible differences in frequency, comorbidities and outcome of all STEMI and NSTEMI admissions over various lockdown (L) periods in Austria and to provide a possible explanation for the results.MethodsAnalysis of prospectively gathered data on ACS patients in our heart center in the year 2020. Patients were split into 4 groups: no lockdown (NL): n=136; duration (dur): 36 weeks (w); lockdown 1 (L1): n=24; dur: 7w; lockdown 2 (L2): n=16; dur: 2.5w; lockdown light (LL): n=22; dur: 5.5w. To account for the different durations, we divided patients by lockdown duration (n/w). End of a L was defined as re-opening of shops; in LL period schools and restaurants were closed but shops were open. To compare the different groups, age, sex, BMI, comorbidities, cardiovascular risk factors (CVRF) duration of preclinical-symptomatic phase (onset of chest pain to PCI), blood parameters, indication, vascular access (femoral/radial) and target vessel were recorded. As outcome we defined CPR, shock and in hospital death.ResultsOut of 198 patients 126 were male (63.6%) and 72 female (36.4%), with a mean age of 65±12 years. There were no statistically significant differences in age, BMI or CVRF between the 4 groups. A 50% higher number of diabetics in the LL group as compared to 25.3% in the NL group (p=0.005) was noticed. STEMI admissions from 2.2 patients/week (n/w) without L decreased to 1.4/w during L1. During L2, the frequency rate rose to 3.2/w in the LL group and admission rates to 2/w, which is almost as high as in the NL group. No differences in NSTEMI admissions between the NL (1.3/w), the L1 (1.4/w) and the LL group (1.8/w) were found. During L2 the frequency of NSTEMI patients increased to 3.2/w. We found a rise in in-hospital death rates from 4.4% without L to 9.1% during LL, though with boarder line statistical significance (p=0.05).ConclusionCompared to the NL group, our data show a decrease of STEMI and NSTEMI admissions during L1. This trend was not confirmed during L2, despite identical government's restrictions. We, thus, postulate that the decrease of ACS admissions in L1 was caused by patients' concern regarding in-hospital Covid-19 infection rather than by actual restrictions.Funding AcknowledgementType of funding sources: None.

Contemporary Indications for Open Abdominal Aortic Aneurysm Repair in the Endovascular Era

Despite the emergence of endovascular abdominal aortic aneurysm repair (EVAR) as the most common approach to repair, open aneurysm repair (OAR) remains a critical option. We sought to define the indications for OAR in the EVAR era and how these indications affect the outcomes. We performed a retrospective review of all OAR cases at a single institution from 2004 to 2020. Preoperative computed tomography scans and operative records were assessed to determine the indications for OAR. These reasons were categorized into anatomic contraindications, systemic factors (ie, connective tissue disorders, contraindication to contrast dye), and patient and/or surgeon preference (candidates for both EVAR and OAR). The perioperative and long-term outcomes were compared. A total 370 patients were included in the analysis. Of the 370 patients, 265 (71.6%) had at least one anatomic contraindication to EVAR (36% had two or more contraindications). The most common anatomic contraindications were a short aortic neck length (51.6%), an inadequate distal seal zone (19.2%), and inadequate access vessels (15.7%). The major perioperative complication rate was 18.1%, and the 30-day mortality was 3.6%. No single anatomic factor was identified as a predictor of perioperative complications. Sixty-one patients (16.5%) had undergone OAR by patient and/or surgeon preference. These patients were younger, had a lower incidence of coronary artery disease and chronic obstructive pulmonary disease, and were less likely to require suprarenal cross-clamping than were the patients who had had anatomic and/or systemic contraindications to EVAR. The patient/surgeon preference group had a lower incidence of perioperative major complications (8.2% vs 20.1%; P = .034), a shorter length of stay (6 vs 8 days; P < .001), and no 30-day mortality. The multivariable adjusted risk for 15-year mortality was lower for the patient/surgeon preference group (19.7% vs 39.5%; adjusted hazard ratio, 0.44; 95% confidence interval, 0.24-0.80; P = .007) than for the anatomic/systemic contraindications group (Table). Within a population of patients who did not meet the instructions for use criteria for EVAR, no single anatomic contraindication was a marker for worse outcomes after OAR. Patients who were candidates for both aortic repair approaches but who had elected to undergo OAR had 30-day mortality of 0% and superior perioperative morbidity and long-term survival rates.TableShort- and long-term outcomes stratified by OAR indicationVariableSurgeon/patient preference (n = 61)Anatomical/systemic contraindication (n = 309)P valueEstimated blood loss, mL1177 ± 9531656 ± 1653.060ICU LOS, days2 (1-2)2 (1-4).14Hospital LOS, days6 (6-9)8 (6-11)<.00130-day mortality0 (0)11 (3.6).22Long-term outcomes, adjusted 15-Year death12 (19.7)122 (39.5).007ICU, Intensive care unit; LOS, length of stay; OAR, open aneurysm repair.Data presented as mean ± standard deviation, median (interquartile range), or number (%). Open table in a new tab

FUN AND GAMES: DESIGNING A GAMIFIED CENTRAL VENOUS CATHETERIZATION TRAINING SIMULATOR.

Gamification, or adding elements of games to training systems, has the potential to increase learner engagement and information retention. However, the use of gamification has yet to be explored in Central Venous Catheterization (CVC) trainers which teach a commonly performed medical procedure with high incidence rates. In order to combat these errors, a Dynamic Haptic Robotic Trainer (DHRT) was developed, which focuses on vessel identification and access. A DHRT+ system is currently under development that focuses on whole procedure training (e.g. sterilization and catheter insertion), including a gamified Graphical User Interface. The goal of this paper was to (1) develop a game-like, patient-centered interface to foster personalized learning and (2) understand the perceived utility of gamification for CVC skill development with expert doctors. This paper outlines some of the potential benefits and deficits of the use of gamification in medical trainers that can be used to drive simulation design.

Polymer based endografts have improved rates of proximal aortic neck dilatation and migration

Proximal aortic neck dilatation (PND) affects a considerable proportion of patients undergoing endovascular aneurysm repair (EVAR) and is associated with increased rates of type I endoleak (EL1), migration, and reinterventions. Although there are numerous studies investigating PND following the placement of endografts that utilize self-expanding stent (SES) technology, there are few reports for patients treated with endografts that utilize polymer-filled rings. The purpose of this study is to examine PND and graft migration after EVAR with the Ovation stent graft. The study comprised patients who underwent EVAR as part of the prospective, international, multicenter Ovation stent graft trial. A clinical events committee adjudicated adverse events through 1 year, an independent imaging core laboratory analyzed imaging through 5 years, and a data safety and monitoring board provided study oversight. Neck diameter was measured at the level of the lowest renal artery. PND was defined as neck enlargement of 3 mm or more. Graft migration was defined as distal movement >10 mm or movement ≤10 mm when resulting in secondary intervention. A total of 238 patients received this device during the study period. Patients were predominantly male (81%), with a mean age of 73 ± 8 years. Median follow-up was 58 months (IQR 36-60). Almost half the patients (110 patients, 46%) had challenging anatomy; defined as outside the instructions for use (IFU) with other commercially available stent grafts. 41 patients (17.2%) had a proximal neck length <10 mm and 93 (39%) had a minimum access vessel diameter <6 mm. The technical success rate was 100%. The 1-, 3- and 5-year overall survival rates were 96.6%, 86.2% and 74.9%, respectively. The immediate postoperative proximal neck diameter ranged from 16 mm to 31 mm with a mean of 22.4 ± 3 mm. During follow-up, ten patients (4.2%) developed PND. Freedom from PND estimates at 1, 3 and 5 years were 97.7%, 96%, and 93.6%, respectively. None of the patients developed endograft migration. The use of the Ovation stent graft was associated with low rates of PND despite challenging neck anatomy in 17% of patients. No graft migration was observed. The design of this endograft may explain its superiority to SES in preventing neck dilatation and migration even in patients with challenging neck anatomy. This is important, as we continue to see significant late failures of EVAR due to proximal neck degeneration.