Annals of vascular surgery
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Aortoenteric fistulas (AEFs) are a rare complication of infrarenal abdominal aortic aneurysm repair. They occur in <1% of aortic grafting procedures, result from graft defects, foreign bodies, and trauma, and are associated with a high mortality rate. We report a complex AEF associated with vertebral body osteomyelitis, likely secondary to tuberculous infection. ⋯ With fluoroscopic guidance, injection of contrast in the aortic sac drainage catheter demonstrated complex fistulous communications from the aortic sac to the overlying small intestine. After a course of drainage, antibiotic therapy, and parenteral nutrition, the patient underwent a transperitoneal repair of the AEF with duodeno-duodenectomy and wide debridement of the aortic sac and Dacron graft. Pathology revealed giant cell granulomas, highly suggestive of tuberculosis.
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In response to economic and societal pressures, a new integrated model of vascular surgery training has emerged that will condense training into 5 years. These new requirements challenge educators to develop innovative training programs that produce competent surgeons despite time constraints. Surgical skills simulation is a proven effective method to teach and evaluate learners in surgery residency programs. ⋯ Our needs assessment identified vascular procedures where simulation may be beneficial to improve the skill level of vascular trainees in Southern California. With economic and logistical constraints for simulation at each individual training facility, a potential approach to this educational challenge is a regional Southern California vascular surgery skills simulation center.
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Conventional repair of aortic arch pathology is associated with significant mortality and stroke rates of 6-20% and 12%, respectively. Because endografting has excellent results for descending thoracic aortic disease, extension of thoracic endovascular repair (TEVAR) to the arch is a consideration. ⋯ TEVAR can effectively treat aortic arch pathology in high-risk patients with low morbidity and mortality. TEVAR and branch vessel revascularization techniques may be extended to the more proximal arch without increased complications compared with patients with subclavian only involvement. Stroke remains the most significant drawback of arch interventions. Indications for intervention, graft selection, and revascularization choices may all affect outcome. LSA sacrifice is associated with increased SCI and may predispose left-handed patients to symptomatic weakness.
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Comparative Study
Preoperative inpatient hospitalization and risk of perioperative infection following elective vascular procedures.
Health care-associated infections are not uncommon after elective vascular surgery and can negatively impact mortality rates and hospital resource utilization. Identification of modifiable risk factors for perioperative infection is critical for efforts aimed toward reducing their incidence. We evaluated the associations between preoperative inpatient hospitalization and perioperative surgical site infection (SSI), pneumonia, and urinary tract infection (UTI) following elective vascular surgery procedures. ⋯ Preoperative inpatient hospitalization is associated with higher rates of perioperative SSI, pneumonia, and UTI in patients undergoing elective vascular surgery procedures. Avoidance of unnecessary preoperative hospitalization has potential to reduce rates of perioperative infection, but additional research is needed to develop evidence-based management strategies when hospitalization before elective procedures is necessary.
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Comparative Study
Massive and submassive pulmonary embolism: experience with an algorithm for catheter-directed mechanical thrombectomy.
The role of catheter-directed mechanical thrombectomy (CDMT) for the treatment of massive pulmonary embolism (MPE) and submassive pulmonary embolism (SMPE) is not clearly defined. We report our experience with an algorithm for CDMT as a primary treatment in patients with MPE and SMPE. ⋯ CDMT as primary treatment of MPE and SMPE has a high rate of technical and clinical success in a high-risk patient population. Experience and strict patient selection criteria may improve therapeutic outcomes.