Emergent Open Repair Research Articles

Complicated Acute Type B Thoracic Aortic Dissections: Endovascular Treatment For Visceral Malperfusion And Pseudoaneurysms

Morbidity and mortality of acute type B thoracic aortic dissections remain alarmingly high. Endoluminal options are promising. A single-center 5-year review of 17 acute type B aortic dissections complicated by visceral malperfusion (11) or pseudoaneurysm formation (6) treated with endovascular intervention. Interventional techniques included endografting (15) and/or percutaneous fenestration (4). Median follow-up is 28 months (range 0-76 months). Median age was 55 years; 30-day death, stroke, and paraplegia rates were 0%, 17.6%, and 5.9%. Success reversing visceral ischemia or sealing a pseudoaneurysm was 100%. Cross-sectional imaging demonstrated that the false lumen was thrombosed in 9 patients, partially thrombosed in 6 patients. Late events include 1 delayed proximal type I endoleak, 1 delayed rupture of the thoracic aorta requiring successful emergent open surgical repair, and 2 unrelated late deaths. Endovascular approaches to type B dissections presenting with visceral malperfusion and/or pseudoaneurysm can achieve acceptable early results.

Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm

Background. The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA). Methods. A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage ($10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis. Results. One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P 2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2--14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004). Conclusion. For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients. (Surgery 2010;148:955-62.)

Endovascular aneurysm repair for ruptured abdominal aortic aneurysm: The Albany Vascular Group approach

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today, endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality compared with the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help vascular surgeons deal with not just the technical aspects of these procedures but also address some of the challenges, including the availability of preoperative computed tomography, the choice of anesthesia, the percutaneous vs femoral cutdown approach, use of aortic occlusion balloons, need for bifurcated vs aortouniiliac stent grafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.

Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm

The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA). A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage (≥10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis. One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P < .03) for patients transfused at a PRBC:FFP ratio ≤2:1 (HIGH FFP group) compared with those transfused at a ratio of >2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2-14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004). For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients.

Endovascular Repair of Thoracic Aortic Injury: Current Thoughts and Technical Considerations

Thoracic aortic traumatic injury is a highly morbid event. Mortality and paraplegia rates after emergent open repair remain high. Now, however, thoracic aortic endografting for trauma (TAET) is commonly used. It is appealing due to reduction of operative stress for the multiply injured trauma victim. This minimizing of stress and risk is secondary to avoidance of thoracotomy, single-lung ventilation, aortic cross-clamping, and the more complex anesthetic techniques required. Early and midterm results from TAET delineate improved outcomes, yet access and aortic constraints continue to challenge TAET. Questions regarding longer-term durability of endografts in younger patients remain unanswered. Broader application of TAET within endovascular programs is challenged by appropriate imaging, operating suite inventories, and the logistics and personnel required for TAET. Currently developed thoracic endograft devices are not ideal for TAET due to platform size and graft diameter. This is changing, however, as new modifications have been developed and trials are ongoing. In light of these collective factors, the management paradigm for traumatic aortic injury is beginning to favor TAET.

Graft Perforation by a Dislocated Rib Fracture After Open Thoracoabdominal Aortic Repair: Emergent Endovascular and Open Repair

To describe perforation of a Dacron aortic graft due to a post-thoracotomy dislocated rib fracture in a young Marfan patient. Six months after a successful open repair of a type II dissecting thoracoabdominal aortic aneurysm (TAAA), a 40-year-old woman with Marfan syndrome underwent elective repair of a post-thoracotomy dislocated rib fracture. During the procedure, the graft ruptured; 2 TAG stent-grafts were emergently implanted to reline the existing aortic graft. The fractured rib was then resected. The postoperative course was uneventful, without residual leak at computed tomography at 3 days. At 18 months, the patient is well, without need of further operations. Early correction of any dislocated rib fracture close to a thoracic aortic graft should be considered, especially if the graft is not wrapped by the aneurysm sac. In these patients, in-graft endovascular relining associated with repair of the rib fracture may be a feasible and effective alternative to redo thoracotomy and surgical graft repair. Prior to attempting rib resection, appropriate thoracic endografts should be on hand in case an endovascular bailout is needed.

Current management of traumatic rupture of the descending thoracic aorta.

Traumatic rupture of the descending thoracic aorta remains a leading cause of death following major blunt trauma. Management has evolved from uniformly performing emergent open repair with clamp and sew technique to include open repair with mechanical circulatory support, medical management and most recently, endovascular repair. This latter approach appears, in the short term, to be associated with perhaps better outcome, but long term data is still accruing. While an attractive option, there are specific anatomic and physiologic factors to be considered in each individual case.

An Easily Overlooked Injury: Lisfranc Fracture

We report a case of a 16-year-old male who sustained a Lisfranc (tarsal metatarsal joint) fracture after a minor fall. His emergency department (ED) presentation, clinical course, and operative repair are presented as well as a discussion of Lisfranc fractures to include historical significance. Even after minor trauma, an emergency department physician must consider the often elusive diagnosis of a Lisfranc fracture in any patient with foot pain.

Aortic Root Replacement in 372 Marfan Patients: Evolution of Operative Repair Over 30 Years

We reviewed the evolution of practice and late results of aortic root replacement (ARR) in Marfan syndrome patients at our institution. A retrospective clinical review of Marfan patients undergoing ARR at our institution was performed. Follow-up data were obtained from hospital and office records and from telephone contact with patients or their physicians. Between September 1976 and September 2006, 372 Marfan syndrome patients underwent ARR: 269 had a Bentall composite graft, 85 had valve-sparing ARR, 16 had ARR with homografts, and 2 had ARR with porcine xenografts. In the first 24 years of the study, 85% received a Bentall graft; during the last 8 years, 61% had a valve-sparing procedure. There was no operative or hospital mortality among the 327 patients who underwent elective repair; there were 2 deaths among the 45 patients (4.4%) who underwent emergent or urgent operative repair. There were 74 late deaths (70 Bentalls, 2 homograft, and 2 valve-sparing ARRs). The most frequent causes of late death were dissection or rupture of the residual aorta (10 of 74) and arrhythmia (9 of 74). Of the 85 patients who had a valve-sparing procedure, 40 had a David II remodeling operation; there was 1 late death in this group, and 5 patients required late aortic valve replacement for aortic insufficiency. A David I reimplantation procedure using the De Paulis Valsalva graft has been used exclusively since May 2002. All 44 patients in this last group have 0 to 1+ aortic insufficiency. Prophylactic surgical replacement of the ascending aorta in patients with Marfan syndrome has low operative risk and can prevent aortic catastrophe in most patients. Valve-sparing procedures, particularly using the reimplantation technique with the Valsalva graft, show promise but have not yet proven as durable as the Bentall.

Open vs. endovascular repair of isolated iliac artery aneurysms: A 12-year experience

To examine contemporary operative techniques and outcomes for repair of isolated iliac artery aneurysms. We retrospectively reviewed the charts of all patients who underwent repair of an isolated iliac artery aneurysm from February 1995 to June 2007. Mycotic aneurysms and patients with concurrent infrarenal abdominal aortic aneurysms greater than 3.5 cm in diameter were excluded from analysis. Patients with prior abdominal aortic aneurysm repair were not excluded. Fifty-six patients (96% male; mean age, 72 +/- 10 years) had either open (n = 24) or endovascular (n = 32) repair with median follow-up of 36 months. Seven patients were treated for rupture, six with open repair, and one with an endograft. Average aneurysm size for patients in the open and endovascular repair cohorts was 4.5 +/- 2.4 cm and 4.0 +/- 1.1 cm, respectively (P = .35). One episode of endograft limb thrombosis at five months was treated with catheter-directed thrombolytic therapy and stent placement. Thirty-day mortality for patients undergoing elective and emergent open repair was 1/18 (6%) and 1/6 (17%), respectively. There was no 30-day mortality for the endovascular group. Median length of stay was 10.5 days in the open group and one day in the endovascular elective group (P < .01). There was no mid-term aneurysm-related mortality in either group. Primary patency rates were similar between the open and endovascular groups at five years (100% vs. 96%, P = .07). Aneurysm sac diameter decreased in 67% (21/28) of patients that underwent endovascular repair. One patient with a Type III endoleak required relining of the endograft with a second endograft at 72 months. These data demonstrate that in appropriately selected patients, endovascular repair of isolated iliac artery aneurysms is a safe, effective alternative to open repair with mid-term follow-up. Endovascular repair is associated with a significantly reduced hospital length of stay and may be associated with decreased need for transfusion and mortality when compared with open repair.

Ventricular Septal Defect Secondary to a Unique Mechanism of Blunt Trauma

We report the case of an adolescent boy who had progressive respiratory distress and cardiovascular compromise after striking his chest against his bicycle handlebars. An echocardiogram in the emergency department revealed a large ventricular septal defect. The boy did well after emergent operative repair and subsequent replacement of a torn tricuspid valve. The characteristics of ventricular septal defects from blunt trauma are briefly discussed.

Complete Repair of Concomitant Interrupted Aortic Arch and Partial Anomalous Pulmonary Venous Connection

We report a rare case of concomitant presentation of partial anomalous pulmonary venous connection and type A interrupted aortic arch in a 4-week-old, 2.1 kg newborn. She presented in extremis and was found to have a closed ductus arteriosus with the entire left pulmonary venous return obstructed at its connection with the innominate vein. Emergent operative repair was performed in one-stage, consisting of aortic arch reconstruction and anomalous vein translocation. Postoperative recovery was unremarkable and the patient was discharged from hospital 12 days after operation.

Timing of endovascular repair of blunt traumatic thoracic aortic transections

Patients with blunt traumatic thoracic aortic transection (BTTAT) just distal to the takeoff of the left subclavian artery typically have concomitant injuries that make open emergent surgical repair highly risky. Over the past decade, endovascular repair of the injured thoracic aorta with commercially available and custom-made covered stents has developed as a viable option, with reported decreases in short-term morbidity and mortality. If active extravasation of contrast from the injured thoracic aorta is not appreciated on chest computed tomography scan, other concurrent injuries of the head, abdomen, and extremities can often be repaired with careful control of blood pressure. The timing of endovascular repair of the traumatic thoracic aortic transection, however, often comes into question, particularly with the presence of fever, pneumonia, or bacteremia. We sought to identify a time frame during which endovascular repair of BTTAT could safely be performed. Age, concomitant injuries, time from trauma to repair, type of device, and major outcomes were recorded. Over a 5-year period (January 2000 to March 2005), 51 patients presented with BTTAT. Twenty-seven (52.9%) patients with BTTAT died shortly after arrival. Of the remaining 24, 9 underwent emergent open repair, with 1 intraoperative death. Two delayed open repairs were performed. Thirteen patients with BTTAT underwent delayed endovascular repair. Successful endovascular repair of BTTAT was performed in all 13 patients, with no intraoperative deaths. Seven patients were treated with commercial devices and six with custom-made covered stents. None of the repairs was performed emergently. The timing of repair ranged from 1 day to 7 months (median, 6 days), and all patients were treated aggressively with beta-blockade before surgery. One patient was discharged from the hospital and underwent elective repair at a later date. Three patients died in the postoperative period (30 days): two from multisystem organ failure and one from iliac artery complications encountered at the time of device deployment. The remaining 10 patients were successfully discharged to a rehabilitation facility. The opportunity to successfully perform endovascular repair of BTTAT may be possible many days after the initial injury in the hemodynamically stable trauma patient.

Popliteal artery aneurysms: a comparison of outcomes in elective versus emergent repair

Objective The purpose of this study was to assess and compare outcomes of elective versus emergent operative repair of popliteal artery aneurysms. Design A retrospective analysis of a prospectively recorded vascular surgery database from June 1992 to December 2002 was performed with chart review. Main outcome measures Patient survival, limb salvage, and graft patency were evaluated. Results Fifty-one popliteal artery aneurysms were repaired in 39 patients, all male and ranging in age from 18 to 87 years (mean 67.1). Mean follow-up was 47.8 months. Repair was elective in 37 (72.5%) and emergent in 14 (27.5%) limbs, 13 with acute ischemia and one with aneurysm rupture. Thrombolytic therapy was utilized in four ischemic limbs with no suitable bypass target vessel identified on initial arteriogram. Outflow vessels included the popliteal artery in 22 (43.1%) and infrapopliteal vessels in 29 (56.9%) limbs. Cardiac morbidity and 30-day mortality rates were 0%. Overall primary patency, secondary patency, limb salvage, and actuarial survival were 95.6%, 100%, 98.0%, and 98.0% at 1 year and 85.1%, 96.9%, 98.0%, and 83.8% at 5 years, respectively. Bypass graft redo or revision was performed for stenosis in one and occlusion in four limbs. Two amputations were performed at 6 days and 63.6 months after initial aneurysm repair. No difference was noted between elective and emergent groups with regard to patency, limb salvage, or survival ( P > .26), and no association between the number of identified target vessels and limb salvage or patency was demonstrated ( P = .12). Conclusion In our experience, the outcome of the popliteal artery aneurysm repair was comparable in the emergent and elective settings. Aggressive tibial reconstruction plays a crucial role in the treatment of popliteal artery aneurysms, especially in those presenting with acute limb ischemia. Thrombolytic therapy is infrequently required in the acute setting, although it may be useful in patients with no identifiable outflow target vessel on initial arteriogram.

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.

SURGICAL TECHNIQUES: Thoracoabdominal Aorta

Patients presenting with impending rupture of a thoracoabdominal aortic aneurysm require emergency operative repair. To prevent rupture and its associated mortality, elective repair of thoracoabdominal aortic aneurysms exceeding 5.5 cm to 6.0 cm in diameter is recommended in patients with adequate physiologic reserve. Similarly, surgery should be considered for patients with smaller symptomatic aneurysms. Atypical symptoms have been associated with rupture, therefore, they require thorough evaluation. Whether the aortic conditions are caused by medial degenerative disease or chronic aortic dissection, surgical techniques allow for graft repair of thoracoabdominal aortic aneurysms with low mortality and morbidity rates. Although surgery is usually avoided in patients with acute distal aortic dissection, operative intervention is occasionally required when complications develop. Patients with acute aortic dissection complicated by impending rupture of the thoracoabdominal segment require graft repair to restore aortic integrity; although the mortality rate is acceptable, the incidence of postoperative paraplegia approaches 20% in this setting. For patients presenting with ischemic complications of acute distal aortic dissection, less-extensive surgical options have been effective in restoring perfusion. In experienced centers, overall operative survival rate following thoracoabdominal aortic surgery can exceed 92%. Retrospective data suggest that left heart bypass reduces the incidence of paraplegia following extensive thoracoabdominal aortic repairs. Although recent advances have led to improved outcomes, paraplegia continues to occur regardless of the strategy used. The prevention of spinal cord ischemia during thoracoabdominal aortic surgery, therefore, will remain a focus of controversy and investigation, just as it was more than 4 decades ago.

IS THERE A DIFFERENCE IN OUTCOME WHEN TREATING TRAUMATIC INTRAPERITONEAL BLADDER RUPTURE WITH OR WITHOUT A SUPRAPUBIC TUBE?

Purpose Primary bladder repair with a suprapubic tube is considered to be effective for managing intraperitoneal bladder injury. We compared the outcomes of suprapubic tube placement and no suprapubic tube for this injury. Materials and Methods We reviewed the charts of 31 men and 3 women with a mean age of 28.5 years who required emergency operative repair without a cystogram of traumatic bladder injury from 1992 to 1997. Patient characteristics, mechanism of injury, associated injuries, and short and long-term complications were reviewed. Results Penetrating and blunt trauma occurred in 28 (82%) and 5 (15%) patients, respectively, while 1 had spontaneous bladder rupture. After primary bladder repair the bladder was drained with a suprapubic tube in 18 cases (53%) and a urethral catheter only in 16 (47%). There were no significant differences between the 2 groups with respect to mechanism of injury, patient age, location of injury in the bladder, coexisting medical illnesses, stability in the field or emergency room, or the bladder repair technique. The 18 patients treated with a suprapubic tube had an associated injury that resulted in 2 deaths, while 13 of the 16 treated with urethral catheter drainage only had an associated injury and 1 died. Urological and nonurological complications in the suprapubic tube versus urethral catheter only group developed in 28 and 33 versus 19 and 19% of the cases, respectively (p <0.05). Followup ranged from 1 month to 4 years. No significant long-term morbidity was noted in either group. Conclusions These data indicate that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and urethral catheter drainage only versus suprapubic tube drainage.

A 26-year review of pectus deformity repairs, including simultaneous intracardiac repair

Background. We reviewed our operative experience and long-term results with repair of pectus excavatum and carinatum deformities through a vertical midline approach, including those cases with simultaneous intracardiac repair. Methods. From 1972 through 1998, 120 children underwent pectus deformity repair. Operative technique used a vertical midline incision with subperichondrial resection of deformed cartilages and an anterior sternal osteotomy. Thirty-five patients had a temporary metal bar for retrosternal support for 6 months; 85 underwent repair without a bar. Patients and parents were asked to assess the outcome after pectus repair as poor, fair, good, or excellent. Results. There were 94 male and 26 female patients (mean age, 8.4 years; range, 3 to 21 years). There were 111 cases of pectus excavatum and 9 of pectus carinatum. Fourteen children (11.5%) had an associated congenital heart defect; 9 patients had simultaneous pectus and intracardiac repair. One patient was referred for emergent open heart repair and pectus repair after attempted “Nuss” repair resulted in a perforated right atrium, perforated right ventricle, and partially disrupted tricuspid valve apparatus. There were no deaths and only one significant complication, which required a return to the operating room for bleeding. Morbidity was not higher in patients with simultaneous intracardiac repair. Long-term follow-up was established in 83% of patients. Results were classified as excellent in 64 patients (64%), good in 25 (25%), fair in 8 (8%), and poor in 3 (3%). Thirty (86%) of 35 patients with a sternal bar had excellent results versus 34 (52%) of 65 without a bar ( p = 0.004); 97% of patients who underwent repair with a sternal bar classified the result as excellent or good. Conclusions. Long-term results of pectus excavatum and carinatum repair through a vertical midline approach are excellent. Outcome with a temporary sternal bar is superior to outcome without a bar. Concomitant repair of congenital heart defects and pectus deformity may be performed successfully without additional morbidity.

Traumatic rupture of the thoracic aorta during the second trimester of pregnancy

A 36-year-old woman in the second trimester of pregnancy underwent emergent operative repair of a traumatic aortic disruption caused by a motor vehicle accident. Left atrial-to-femoral artery bypass was used to maintain fetal circulation during the cross-clamp period. Her healthy, full-term child was subsequently delivered 3 months later by normal vaginal delivery.

Cardiac stab wound resulting in a left anterior descending artery to left ventricular fistula with delayed pericardial tamponade

We describe the third known case of a traumatic left anterior descending artery to left ventricular fistula. Emergency operative repair was required on day 7 for delayed pericardial tamponade. The significant incidence of late serious sequelae with traumatic coronary artery fistulas suggests that early surgery is warranted.