The patient, a 47 year old woman, was referred for syncope, but it was much worse than that. Excessive stress, standing, and thinking hard were described as causes of her syncope. Frequent headaches and lethargy lead to inability to keep a job. Several MVA’s resulted in revocation of her driver’s license. Added to that was a two to three pack a day cigarette habit. Her cardiac workup was negative, but it was noted that her carotid duplex was notable for a left ICA occlusion and left vertebral occlusion. Blood pressure in both arms was in the 70’s systolic while in her better thigh it was 90’s. She had an open right carotid system but the flows in the common carotid were attenuated. CTA of the arch revealed severe arch disease affecting the origins of her great vessels. The innominate artery was severely diseased to its bifurcation with a small <2mm channel of flow. She had a dominant right vertebral artery that was patent, and the right ICA had moderate disease at its origin. This was in 2009, and I entertained intervention, but wasn’t all that confident that kissing stents into the innominate was all that great of an option even though there are reports of innominate interventions in the literature. I had the opportunity to perform a handful of great vessel reconstruction with Ken Cherry during my fellowship and felt that this was an ideal case for an innominate endarterectomy.
This is one of those rare and infrequent cases from vascular surgery history. The exposures is one of the grand vistas of vascular surgery. The arch, thankfully, was only calcified at the origins of the vessel and clamped well. The endarterectomy was not that much different from an aortoiliac endarterectomy with a fibrocalcific plaque and was extended onto the common carotid while the origin plaque of the subclavian was plucked cleanly. The phrenic and vagus nerves were protected. The patient was centrally hypertensive as found by a long femoral arterial line and was kept that way for the duration of the clamp. A bovine pericardial patch was applied and the sternum was closed over a mediastinal chest tube.
The recovery was impressive for the patient’s immediately improved state of consciousness, lack of lethargy, and improved cognition. She was herself impressed enough to quit smoking during that admission for good. Her right brachial cuff pressure now correlated well. She went home POD 5. When I last saw her 2 years later, she was employed and symptom free with continued patency of her repair, consistent with the earlier reports of this operation (Cherry et al. J Vasc Surg; 989;9:718-14).
The December Journal Club was held last week with excellent attendance. The winner of the best presentation prize was Dr. Francisco Vargas who critiqued the CaVent trial. Many thanks to Leo Godlewski of Hanger Orthotics for sponsoring the club’s evening.
The score sheets had a misprint in the scaling factor. The scaling factor is highest for the substance of the critique (x3) and the next highest is the presentation substance (x2). Scoring was corrected for this.
To emphasize the importance of an in-depth understanding of the paper being presented and to keep the journal articles topical, the rules are being modified. First, the selected journal has to come from the past two years. The second modification is that every presentation has to end with a table of related or similar papers and their conclusions or results. These should be a listing of landmark papers or first of its kind papers, and the discussant should be prepared to comment on them. If there are too many papers, the discussant should be prepared to discuss a few landmark papers on the topic or discuss a meta-analysis or Cochrane review article on the topic.
The presented paper should be graded on the following scale:
Level 1 – High Quality – Randomized controlled trials with high power. Meta-analyses of multiple RCT’s.
Level 2 – Moderate Quality – Evidence from one well designed experiment. RCT’s with low power. Prospective cohort study.
Level 3 – Low Quality – Evidence obtained from well-designed, quasi-experimental studies such as non-randomized, controlled, single-group, pre-post, cohort, time, or matched case-control series.
Level 4 – Very Low Quality – Evidence from well-designed, non-experimental studies such as comparative and correlational descriptive and case studies. Evidence from case reports and clinical examples. Expert opinion.
Also, in the critique, a recommendation should be made and this recommendation also graded with the following scale:
A
The USPSTF recommends the service. There is high certainty that the net benefit is substantial.
Offer or provide this service.
B
The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
Offer or provide this service.
C
The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.
Offer or provide this service for selected patients depending on individual circumstances.
D
The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
Discourage the use of this service.
I
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.
This was removed during a laparoscopic median arcuate ligament release. It was a hard white band compressed under the ligament and itself compressing the celiac axis. During the release, I grabbed a piece of these fibers and sent it for pathology under the preliminary diagnosis of celiac plexus, and it was. Described as “typical for a peripheral nerve…mostly Schwann cell nuclei in between nerve fiber.” Other micrographs in the specimen had ganglionic fibers but our pathologist wasn’t able to locate it. This is an important piece of the pathoanatomy because I believe that this is the nidus of the pain associated with median arcuate ligament syndrome, not a regional ischemia that can only occur if the celiac axis is an end artery, which can really only happen after a major exenteration like a Whipple procedure.
The patient was sent to my clinic with the diagnosis of a saccular thoracic aortic aneurysm of 5x10mm. He is a 78 year old man who was working at restoring a vintage John Deere tractor when he developed chest pain. He underwent a cardiopulmonary workup which included a CT which showed a 5x10mm saccular aneurysm of the inner curve of his aortic arch opposite the origin of the left subclavian artery. This same CT showed no pulmonary embolism. His past medical history is significant for hypertension and he has never had surgery. His only hospitalization was in 1962 when he had a head-on collision which caused rib and collar bone fractures -he was the driver and he bent the steering column.
His examination was normal. He had had a complete cardiac workup including a stress test which was also normal. He persisted on having this intermittent midsternal chest pain.
CTA images: above and below. The CT shows a small area of contrast fill consistent with a focal 5x10mm saccular aneurysm of the inner curve of the aortic arch.
My impression is this is a residual saccular aneurysm of the thoracic aorta in the ligamentum arteriosum, related to the head on collision from time of the Kennedy administration. The injuries and the steering column damage suggest significant transfer of energy. It may have been the cause of his pain. We discussed surveillance with medical therapy (to include anti-inflammatories for any tractor lifting injuries) versus TEVAR. Ultimately we chose TEVAR.
This entry was posted on my old Medscape Blog, The Pipes Are Calling, with great comments and a poll. The poll results show a majority favoring medical therapy and watching. The only problem was that this patient was still having chest pain without a good explanation -pulmonary embolism and coronary artery disease were ruled out. The patient also lived two hours away from a hospital and would be lifting old tractors and their parts because that is what old farmers in Iowa do for fun –they also never truly retire. I think it also shows a general skepticism of surgical solutions –this feeling is based on historical bias with open surgery rather than contemporary results using percutaneous techniques.
The saccular aneurysm is an inherently unstable one as the angles on the surface of the aorta caused by a sac create areas of focused high wall stress. Rupture is usually fatal and the mortality rates for emergency surgery exceed 50%.
The other consideration was the relative risks of intervention have decreased with endovascular technique. Where mortality and morbidity of open repair on the proximal thoracic aorta ranged from 5 to 10%, with endovascular techniques, these fall to under 2-5%. I have been placing these thoracic endografts percutaneously and have had good results with low complication rates.
I performed percutaneous TEVAR of this saccular aortic aneurysm. The patient recovered well and went home after two days. Two years later, his CTA (below) shows complete resolution of the saccular aortic aneurysm. His chest pain never recurred.
Maybe it’s the way the the bilateral dorsal aortas resolve into an asymmetric arch, but there is asymmetry in the carotid arteries which lets me look at a lateral carotid arteriogram and reliably predict which carotid artery it is. Image I is the usual conformation of the right ICA takeoff which may be tucked ,medially and posteriorly toward the pharynx. Image II is the typical forked appearance of the left ICA, and because it is longer and the plaque usually ends at the bend, this makes an eversion easier on that side. I began noticing this when I was on the CVRx trial applying stimulator leads on the carotids.
From my archives, the CTA illustrates two points. First, tunneling can be done without taking down much of the retroperitoneum. This lesson came to me after taking a course in laparoscopic aortic surgery with Dr. Dion in Quebec City. The old BARD-IMPRA tunnelers with their bullet tips -the short gently curved one, is particularly well suited for tunneling from the groin to the aorta -if you have a hand on the retroperitoneal pelvis, it is very straightforward to guide the tunneler to the proper location. The other point is that the graft is applied proximally end to side with a leftward orientation. This combined with dissection of the retroperitoneum with a large Ligasure or harmonic scalpel lets you avoid the problem of having no tissues to close over the graft. You take down the retroperitoneum with a cuff of tissue of about 5cm from the duodeum. Normally, this can be bloody but with the energy devices, it is not. This provides excellent graft coverage. You just have to mind the IMV which may or may not have to be taken down. End to side is preferred because you preserve endovascular options, but in this case, the anastomosis was done end to end.
April 30, 2009 11:33 PM
Aortic Bypass for occlusive disease
The patient arrived with the history of severe claudication. He was a middle
age smoker whose job required walking several miles a day. This became
increasingly difficult until he was clearly limping at short distances. He was
also developing cramps in his legs at night, worse in his left leg.
On examining him, he had no pulses in his left leg from the groin down.
The pulse volume recordings (PVR’s, red lines) on the left clearly
demonstrate normal flows in his right leg with sharp upstrokes, dicrotic
notch, and shallow diastolic relaxation. The left leg had attenuated flows on
the pulse volume recordings with dampened, gradual series of mounds.
The flow was flat at the metatarsal level (foot). His ankle brachial index
( BI) on the right leg was 0.75 which was mildly depressed. The ABI on his
left leg was 0.43 which was severely depressed.
CT was performed (above left) showing that his left iliac system was
occluded. This is due to atherosclerosis which is a systemic disease. This
kind of blockage can occur in any organ, but it was most severe in this
patient’s leg. His right common iliac artery also had moderate plaque.
He underwent an aorto-right iliac and left femoral artery bypass with a
bifurcated graft (above right). This greatly improved flows in his left leg, with
his BI improving to 1.05 from 0.43. The PVR’s also reflect this improved
flow. The right leg, surprisingly, also had an improvement despite not
having a severe stenosis in his common iliac artery. The fact is, the
common iliac artery, but being heavily diseased over the length of the
artery, offered a hemodynamically significant stenosis despite being patent.
His BI on the right improved from 0.75 to 1.03.
The operation was done with minimal invasiveness in mind. The CT
allowed for planning of the abdominal incision directly over the part of the
aorta requiring operation. The groin incision on the left was created
obliquely as to avoid crossing the groin crease -which I believe increases
the chances for tension on the wound and subsequent infection. The graft was tunneled without mobilizing the sigmoid colon directly up to the bifurcation using an IMPRA tunneler -by placing the hand in the pelvis, the
tunneler can be felt and guided in the correct trajectory. The graft was a
Gelsoft Plus graft soaked in Rifampin. This antibiotic bonds to the gelatin in
the graft giving protection against indolent bacterial infections for about 3-6
months after the procedure -this is helpful especially with groin incisions. The operation took 2.5 hours and the patient went home within a few days.
The patient is now walking without pain and will be returning to work. He
has also successfully quit smoking which has a significant impact on his
risks of future heart attack, stroke, or peripheral vascular complication. His
relative youth (in his fifties) required that we give him a repair that would
give him the best chance at maintaining patency for many years. The aortic
bypass graft for occlusive disease has a proven track record with patency
measured in decades.
Using TeraRecon for planning minimally invasive aortic surgery
Terarecon, Vitrea, Osirix, all allow for visualization of three dimensional CT data. The 3DVR (virtual reality) view, is often overlooked, but is an important feature of Terarecon. It is a synthesis of the axial data and does for you what you tried to do in your head back in the days of cut axial film -that is reconstruct a three dimensional picture from 2 dimensional sections. This is a moderate risk patient, 65 years of age, with a 5.8cm AAA. The top image shows the standard 3DVR perspective with the surgeon standing on the patient’s left. By adjusting the levels, you can bring in the organs (not shown), and then the muscles (panel below).
You can then bring in the skin by manipulating the “window levels” -in TeraRecon this is done by pressing both left and right mouse buttons. This allowed me to plan the location of a skin incision (measuring 15cm) for a minimally invasive AAA repair.
While 15cm hardly qualifies as a mini-laparotomy, it is less than half the length of a “stem to stern” laparotomy.
Dr. Jon Cohen et al. reviewed their experience with laparoscopic versus minilaparotomy averaging 8-10cm in length, and found that OR time, fluid given, and length of stay was superior in mini-laparotomy compared to open and laparoscopic assisted repair (ref).
I would say that learning curve probably accounted for the difficulties with laparoscopic-assisted. In this patient the tube graft AAA took 2.5hrs, and patient was extubated post op and went home in 4 days. TeraRecon made short work of planning out the location of incision and was predictive of the viewing perspectives.
Addendum 11/30/2014
Using the 3DVR perspectives in thoracoabdominal aortic aneurysms is indispensable for planning retroperitoneal thoracoabdominal exposures, and I will post an example.
From my case files, this was a case which I performed in 2010 and published in a prior blog.
CCx: Patient is a 56 year old man with complaints of pain in right leg with walking short distances and discomfort in the foot at night.
HPI: The patient has had cramps in his right calf with walking about a block for over a year, but over the past three months, he has developed pain with walking less than half a block which is incapacitating. He has developed pain at night which wakes him and he has taken to sleeping with his right foot dangling off the edge of the bed. This has resulted in some swelling of that leg which makes it doubly uncomfortable to wear shoes. He works as a manager at a local big box store and walks constantly. He used to smoke but quit last week. He feels this has worsened the pain.
Past Medical History: Hypertension, dyslipidemia, acid reflux
Pulse volume recordings notable for moderately diminished signals right high thigh cuff.
CTA: Moderate atherosclerosis of infrarenal abdominal aorta and its bifurcation with severe plaque of the right common iliac artery and occlusion of the external iliac artery. There was reconstitution of the common femoral artery on the right via collaterals. The left common iliac artery was affected by a moderate (50-75%) stenosis due to low density plaque.
Impression: PVD with rest pain of right leg due to severe aortoiliac occlusive disease and occlusion of right external iliac artery.
Plan: After discussing treatment options, we decided to try a right external iliac artery remote endarterectomy with angioplasty and stenting of his common iliac disease. This was chosen over aorto-bifemoral bypass because he had limited time off from work and work did require that he lift more than 20 pounds.
Up and Over Wire during remote endarterectomy ensures wire access if rupture occurs.
Operation:
Remote endarterectomy of right external iliac artery with aortography, bilateral common iliac artery angioplasty and stenting.
This operation was done via a single right groin exposure and percutaneous access of the left groin. The common femoral artery had severe posterior plaque which was the starting point of the endarterectomy. Up and over access of the right external iliac artery was achieved and a wire was passed across the occluded external iliac artery and into the right femoral system. With clamping of the common femoral artery, the wire was brought out and controlled with a Fogarty clamp -this allowed for excellent stabilization and control and possible emergent balloon occlusion in the case of a perforation.
A Vollmer ring dissector was sent over wire and plaque up the external iliac artery under fluoroscopy and dissection was stopped at the iliac bifurcation which was heavily plaqued. A Moll Ring cutting device (LeMaitre) was used to transect the plaque which was removed.
The right and left common iliac arteries were stented with self expanding nitinol covered stents and post-dilated. I chose this as I have had occlusions occur in the setting of diffuse TASC C disease with low density plaque -I suspect that thrombus propogates across open cells like weeds growing through chicken wire. The stents on the right were extended across the iliac bifurcation.
A completion angiogram is here to the right. The common femoral artery was repaired with a patch angioplasty (bovine pericardial patch, LeMaitre).
The groin was closed and the patient recovered and was discharged in a few days with excellent palpable pulses on the right and improved pulses on the left. He was without symptoms of claudication or rest pain in the right leg.
Discussion:
Remote endarterectomy allows for removal of plaque via a single groin incision, obviating the need for an abdominal exposure required in an aorto-bifemoral bypass. This minimally invasive technique is associated with a low complication rate and earlier return to full work status because the abdominal incision is avoided.
Smeets et al [reference] reviewed with 7 year experience with 48 patients and had a technical success rate of 88%. One patient died due to a myocardial infarction within 30 days of the operation. The complication rate was low. 6 patients required coversion (retroperitoneal flank exposure) for additional arteriotomy (3 patients) and bypass (3 patients). The primary and assisted patencies shown to the right were acceptable with a secondary patency of 94% at 3 years.
These cases require more surveillance than an aortobifemoral bypass. Intimal hyperplasia does occur in random loci in the SFA remote endarterectomy and this should apply to the external iliac artery. I chose the title because the external iliac artery biologically behaves like the superficial femoral artery in relation to endovascular patencies and not like the common iliac artery or aorta -probably because it shares a common embryology with the SFA, not the CIA. It is a troublesome artery that is often overlooked by vascular surgeons when femorofemoral bypass is performed for occlusive disease -the supplying external iliac artery though patent is usually diseased and has a small lumen. With a fem-fem bypass, both legs are supplied often through an artery with the caliber of a child’s drink straw. I have seen the donor leg become symptomatic through what is termed steal, but in fact reflects the hemodynamic inadequacies of a diseased external iliac artery.
I feel that 5mm is the minimal lumen caliber for an external iliac artery, and a 4mm lumen in an adult will clearly show a hemodynamic effect particularly after exercise or application of vasodilators in the endo suite. Stenting an occluded external iliac artery though technically feasible even in this case is not a durable solution in my experience. This operation allowed the patient to return to work without an extended convalescence.
I think removing the plaque offers advantages over stenting to the inguinal ligament. The common iliac stents have superior potency to external iliac artery stents and moving the stent point to the CIA and not stenting the EIA in my experience has better long term potency.
The patient is a baby who had undergone cardiac catheterization prior to repair of tetralogy of Fallot. Postoperatively he developed acute limb ischemia and was found to have an occlusion of his left common femoral artery. This was unusual, as typically, these babies tolerate catheterization and a high rate of CFA occlusion without ill effect. Usually treatment with heparin for a period of time is sufficient. In this child, there was clearly severe ischemia. What was different about this child was that his mother and her two siblings suffered from severe Raynaud’s disease, suggesting in this baby, vasospasm played a role. The foot was cold and not moving, and there were no signals from the groin down. The baby was taken to the OR for a CFA exploration and thrombectomy, as I felt the likelihood of infarction in this baby was high. The common femoral artery was exposed via an oblique incision and it was about 2mm in diameter, translucent, and very elastic. There was thrombus and I performed a longitudinal arteriotomy. There was minimal thrombus and a gossamer dissection flap. Inflow was easily established. There was no backbleeding.
Repairing the artery was initially not straightforward. The available nearby vein was even smaller for lack of blood flow and in spasm, and primarily repairing it was not a good option. There is literature describing patch angioplasty, but I felt there had to be a faster, better solution that did not require 8x magnification. Then it struck me that the artery was so pliable that it was every easy to mobilize a length of it from under the ligament.
My inspiration was the Heineken-Mikulicz pyloroplasty.
Once the laterally oriented stay sutures were in, interrupted (always) 8-0 sutures created a nice repair. The blood flow was high resistance, but the outcome was immediate. The baby had had over two days of ischemia, and I did go ahead and perform fasciotomies of the leg. There was dead muscle in all the compartments, but with VAC therapy, the baby healed within a few weeks, and a year later came in walking without a limp!
A Surgeon's Notes 