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Although current studies support the use of prophylactic distal perfusion catheters (DPCs) to decrease limb ischemia in patients on venoarterial extracorporeal membrane oxygenation (VA ECMO), methods for monitoring limb ischemia differ between studies. We evaluated the safety of a selective rather than prophylactic DPC strategy at a single center with a well-established protocol for limb ischemia monitoring. Distal perfusion catheters were placed selectively if there was evidence of hypoperfusion at any point until decannulation. All patients were followed daily by vascular surgery with continuous regional saturation monitoring. Of 188 patients supported with VA ECMO, there were no significant differences in baseline characteristics between patients with upfront, delayed, and no DPC. Thirty day mortality was highest in patients with an upfront DPC (56% in the upfront DPC group, 19% in the delayed DPC group, and 22% in the no-DPC group, p < 0.001). The incidence of major bleeding, fasciotomy, and amputation in the entire cohort was 3.7%, 3.7%, and 0%, respectively. With strict adherence to a protocol for limb ischemia monitoring, a selective rather than prophylactic DPC strategy is safe and may obviate the risks of an additional arterial catheter.

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PURPOSE: To evaluate the effect of iliac tortuosity on procedural metrics and outcomes of patients with complex aortic aneurysms (cAAs) undergoing repair with fenestrated/branched endografts (f/b-EVAR [endovascular aortic aneurysm repair]). MATERIAL AND METHODS: The study is a single-center, retrospective review of a prospectively maintained database of patients undergoing aneurysm repair using f/b-EVAR between the years 2013 and 2020 at our institution. Included patients had at least 1 preoperative computed tomography angiography (CTA) available for analysis. Iliac artery tortuosity index (TI) was calculated using centerline of flow imaging from a 3-dimensional work station based on the formula: (centerline iliac artery length / straight-line iliac artery length). The associations between iliac artery tortuosity and procedural metrics, including total operative time, fluoroscopy time, radiation dose, contrast volume, and estimated blood loss (EBL), were evaluated. RESULTS: During this period, 219 patients with cAAs underwent f/b-EVAR at our institution. Ninety-one patients (74% men; mean age = 75.2±7.7 years) met criteria for inclusion into the study. In this group, there were 72 (79%) juxtarenal or paravisceral aneurysms and 18 (20%) thoracoabdominal aortic aneurysms and 5 patients (5.4%) with failed previous EVAR. The average aneurysm diameter was 60.1±0.74 mm. Overall, 270 vessels were targeted, and 267 (99%) were successfully incorporated, including 25 celiac arteries, 67 superior mesenteric arteries, and 175 renal arteries. The mean total operative time was 236±83 minutes, fluoroscopy time was 87±39 minutes, contrast volume was 81±47 mL, radiation dose 3246±2207 mGy, and EBL was 290±409 mL. The average left and right TIs for all patients were 1.5±0.3 and 1.4±0.3, respectively. On multivariable analysis, the interval estimates suggest positive association between TI and procedural metrics to a certain degree. CONCLUSIONS: In the current series, we found no definitive association between iliac artery TI and procedural metrics, including operative time, contrast used, EBL, fluoroscopy time, and dose in patients undergoing cAA repair using f/b-EVAR. However, there was a trend toward association between TI and all these metrics on multivariable analysis. This potential association needs to be evaluated in a larger series. CLINICAL IMPACT: Iliac artery tortuosity should not exclude patients with complex aortic aneurysms from being offered fenestrated or branched stent graft repair. However, special considerations should be taken to mitigate the impact of access tortuosity on alignment of fenestrations with target vessels, including use of extra stiff wires, through and through access and delivering the fenestrated/branched device into another (larger) sheath such as a Gore DrySeal in patients with arteries large enough to accommodate such sheaths.

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Stenosis of left ventricular assist devices has traditionally required open operative management with device revision or replacement; however, endovascular therapy is emerging as an alternative to open surgery. Limited by the rarity of this approach, consensus is lacking regarding the optimal technique. In this publication, we present a case report of outflow graft stenosis managed with endovascular treatment and discuss technical considerations including preoperative planning, stent selection, and procedural adjuncts.

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Peripheral arterial disease (PAD) represents a major health issue that significantly impacts patient's survival and quality of life. In addition to limb-related events, patients with PAD have an increased risk of myocardial infarction, stroke, and death. However, compared with coronary and cerebrovascular disease, studies addressing optimal risk reduction modalities including antithrombotic therapies in patients with PAD have been underrepresented in the literature. This publication serves as a narrative review of existing evidence on the effectiveness of antithrombotic therapy in patients with PAD. In patients with chronic stable PAD or post-revascularization, antithrombotic therapies including single or dual antiplatelet agents, anticoagulation, or a combination of these treatments have been shown to reduce cardiovascular and limb events. This narrative review provides a summary of the available literature on the management of patients with PAD, categorized into treatment strategies for chronic, post-endovascular treatment, and post-open surgical revascularization and to discuss the antithrombotic protocol utilized at our institution while providing a rational for our treatment algorithm.

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Aortic pseudoaneurysms are rare entities caused by infection, trauma, atherosclerotic plaque rupture, or aortic instrumentation. Their natural course remains unknown; however, repair is invariably recommended. We present a case of a 71-year-old man with a history of recurrent deep venous thrombosis and pulmonary embolisms who underwent an inferior vena cava filter placement 8 years prior and was found to have a 3.6-cm contained ruptured infrarenal aortic pseudoaneurysm on imaging performed for abdominal pain. His pseudoaneurysm was excluded using a Gore Excluder Endoprosthesis. We further reviewed literature on the subject to highlight the various surgical approaches to this lethal condition.

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An aneurysm of the inferior mesenteric artery is a rarely described clinical presentation. We have presented the case of a ruptured aneurysm originating from a branch of the inferior mesenteric artery that might represent an aneurysm of the left colic artery or the arc of Riolan. Aneurysms of this anatomic location can develop secondary to mesenteric occlusive disease, alterations in mesenteric blood flow from previous operations, or connective tissue disease. In the present case, a patient with a ruptured inferior mesenteric artery branch aneurysm had presented with intra-abdominal hemorrhage, which was successfully treated with endovascular embolization.

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BACKGROUND: Direct-to-implant breast reconstruction offers the intuitive advantages of shortening the reconstructive process and reducing costs. In the authors' practice, direct-to-implant breast reconstruction has evolved from dual-plane to prepectoral implant placement. The authors sought to understand postoperative complications and aesthetic outcomes and identify differences in the dual-plane and prepectoral direct-to-implant subcohorts. METHODS: A retrospective review of a prospectively maintained database was conducted from November of 2014 to March of 2018. Postoperative complication data, reoperation, and aesthetic outcomes were reviewed. Aesthetic outcomes were evaluated by a blinded panel of practitioners using standardized photographs. RESULTS: One hundred thirty-four direct-to-implant reconstructions were performed in 81 women: 42.5 percent were dual-plane (n = 57) and 57.5 percent were prepectoral (n = 77). Statistical analysis was limited to patients with at least 1 year of follow-up. Total complications were low overall (8 percent), although the incidence of prepectoral complications [n = 1 (2 percent)] was lower than the incidence of dual-plane complications [n = 7 (12 percent)], with the difference approaching statistical significance (p = 0.07). Panel evaluation for aesthetic outcomes favored prepectoral reconstruction. Pectoralis animation deformity was completely eliminated in the prepectoral cohort. CONCLUSIONS: The authors present the largest comparative direct-to-implant series using acellular dermal matrix to date. Transition to prepectoral direct-to-implant reconstruction has not resulted in increased complications, degradation of aesthetic results, or an increase in revision procedures. Prepectoral reconstruction is a viable reconstructive option with elimination of animation deformity and potential for enhanced aesthetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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BACKGROUND: Prepectoral direct-to-implant breast reconstruction has historically been fraught with complications, including flap necrosis, implant extrusion, and capsular contracture, along with high rates of operative revisions. This may result from a number of factors, including the lack of an algorithmic approach, failure to predict postoperative migration of the implant, use of improper implants, and unsuitable patient selection. Over the past 5 years, the authors have gained significant experience in prepectoral breast reconstruction as they have transitioned their direct-to-implant technique. METHODS: Using video, technical aspects for achieving superior results are demonstrated, including suture technique, application of acellular dermal matrix, creation of the implant pocket, implant selection and placement, and postoperative dressings. Video is used to highlight technical aspects to yield consistent, predictable results using the anterior tenting technique. RESULTS: A systematic review of prepectoral direct-to-implant breast reconstruction was conducted to amalgamate the experience of the authors and others with regard to technique, material, and outcomes. CONCLUSIONS: Prepectoral direct-to-implant breast reconstruction represents a significant paradigm shift in postmastectomy breast reconstruction and warrants reconsideration. Prepectoral direct-to-implant breast reconstruction provides the potential benefits of a single-stage operation, elimination of dynamic deformity, enhanced aesthetic outcomes, and increased patient satisfaction. Although early evidence suggests an increased incidence of complications, our experience and that of others demonstrate favorable outcomes with version 2.0 of prepectoral direct-to-implant breast reconstruction. As the body of literature encompassing a modern approach to prepectoral direct-to-implant breast reconstruction grows, greater appreciation for operative technique, candidate selection, and implant choice may accelerate its adoption and mitigate past concerns.

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BACKGROUND: Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are devastating complications of surgery. Patients who undergo complex ventral hernia repair (CVHR) may be at risk for IAH and ACS. METHODS: We performed a retrospective review of 175 patients who underwent CVHR by a single surgeon. Body mass index (BMI), prior hernia repair, operative time, bladder pressure, serum creatinine, sedation, paralytic therapy, and ventilator support were reviewed. RESULTS: IAH was identified in 33 patients; 11 patients developed ACS. Paralytic therapy was employed in 29 patients for an average of 1.4 days. Elevated BMI was independently associated with an increased risk of IAH (p = 0.006) and ACS (p = 0.02). CONCLUSION: Patients who undergo CVHR are at risk of developing IAH and ACS in the postoperative period. Elevated BMI and longer operative time are independent risk factors for the development of IAH. IAH and ACS can be successfully managed with surgical critical care.

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Previous studies have investigated reconstructive decisions after mastectomy and such studies document a preference among African American women for autologous tissue-based procedures and among Latin American women for implant-based reconstructions, however, there is a paucity of studies evaluating the current relationship between ethnicity and reconstructive preferences. This institutional review provides a unique, up-to-date evaluation of an understudied urban population composed of majority ethnic minority patients and explores reconstructive trends. Consecutive breast reconstruction patients were entered into a prospectively maintained database at the University of Illinois at Chicago and affiliate hospitals between July 2010 and October 2013. Demographics and oncologic characteristics including tumor stage, pathology, BRCA status, and adjuvant treatment were reviewed, and reconstructive trends were assessed by racial group with a focus on reconstructive procedure, mastectomy volume, and implant characteristics. Statistical analysis was performed using SAS (version 9.2). One-hundred and sixty breast reconstructions were performed in 105 women; of which 50 per cent were African American, 26 per cent Hispanic, 22 per cent Caucasian, and 2 per cent Asian. Age, tumor stage, prevalence of triple negative disease, chemotherapy, and radiation treatment was comparable between groups. Rates of obesity, hypertension, and diabetes mellitus were slightly higher in African American and Hispanic cohorts, with more African American patients having one or more of these comorbidities as compared with the Caucasian and Hispanic cohorts (P = 0.047). Despite comparable positive BRCA testing rates, significant differences were seen in the percentage of bilateral mastectomy; 68 per cent African American, 48 per cent Caucasian, and 30 per cent Hispanic (P = 0.004). Hispanics predominantly underwent flap-based reconstruction (56%), while African American (74%) and Caucasian (60%) patients had a preference toward tissue expander reconstruction (P = 0.04 across all groups). African American and Hispanic presented with increased mastectomy weights and thus required higher implant volumes as compared with Caucasians that approached significance (P = 0.06 and P = 0.06). Implant size utilization followed a unimodal distribution for Caucasians, peaking at 500 cc; while African American and Hispanic demonstrated a bimodal distribution, peaking once at 550 cc and again at the max implant volume of 800 cc. This study of a large proportion of minority patients in an urban geographic setting offers an evolving understanding of breast reconstruction patterns. The data demonstrated unique findings of increased rates of bilateral implant-based reconstruction in African American women and unilateral flap-based reconstructions in Hispanic patients. Reconstructive decision-making seems to be greatly influenced by cultural and geographically driven preferences.

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Breast reconstruction is an important aspect of treatment after breast cancer. Postmastectomy reconstruction bears a significant impact on a woman's postsurgical confidence, sexuality, and overall well-being. Previous studies have inferred that women under age 40 years have unique characteristics that distinguish them from an older cohort. Identifying age-dependent trends will assist with counseling women on mastectomy and reconstruction. To identify age-dependent trends, 100 consecutive women were sampled from a prospectively maintained breast reconstruction database at an urban academic institution from June 2010 through June 2013. Women were placed into two cohorts <40 and ≥40 as well cohorts by decade (20s, 30s, 40s, 50s, and 60s). Statistical trends were reported as odds of risk per year of increasing age using logistic regression; linear regression, χ(2), and Fischer's exact were used to compare <40 and ≥40 and split cohorts for comparison. Comorbidities, tumor staging, oncologic treatment including chemotherapy and radiation, disease characteristics and genetics, and mastectomy, reconstructive and symmetry procedures were evaluated. Statistical analysis was performed using SAS software. In 100 patients of the sample study cohort, 151 reconstructions were performed. Increasing age was associated with one or more comorbidities [odds ratio (OR) = 1.07, P = 0.005], whereas younger age was associated with metastatic disease (OR = 0.88, P = 0.006), chemotherapy (OR = 0.94, P = 0.01), and radiation (OR = 0.94, P = 0.006); split cohorts demonstrated similar trends (P < 0.005). Mastectomy and reconstructive characteristics associated with younger age included bilateral mastectomy (OR = 0.94, P = 0.004), tissue expander (versus autologous flap) (OR = 0.94, P = 0.009), extra high implant type (OR = 0.94, P = 0.049), whereas increasing use of autologous flaps and contralateral mastopexy symmetry procedures (OR = 1.09, P = 0.02) were associated with an aging cohort. Increasing age was not associated with an increasing likelihood of complications (P = 0.75). Age-related factors play a role in the treatment of patients with breast cancer. Younger women typically present with more aggressive features requiring oncologic treatment including chemotherapy and radiation. Mastectomy and reconstructive choices also demonstrate age-dependent characteristics. Women in younger age groups are more likely to pursue risk-reduction procedures and implant-based strategies, whereas older women had a higher propensity for abdominal-based autologous reconstruction. In addition, preferential reconstructive strategies correlate with age-dependent archetypical features of the breast (higher profile implants in younger patients; autologous reconstruction on affected side mimicking natural ptosis, and contralateral mastopexy in older patients). These trends seem to be consistent with each increasing year of age. Age-related preferences and expectations, age-dependent body habitus and breast shape, and lifetime risk play a role in the choices pursued for mastectomy and reconstruction.

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