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PC086 Endovascular Interventions in the Management of Postpartum Hemorrhage due to Placenta Accreta
162S
Journal of Vascular Surgery
Abstracts
June Supplement 2017 endovascular options should both be considered. The complication rate is not insignificant; therefore, careful patient selection is necessary. Author Disclosures: A. J. Brownstein: Nothing to disclose; J. Elefteriades: Nothing to disclose; Y. Erben: Nothing to disclose; Y. Li: Nothing to disclose; H. Mojibian: Nothing to disclose; S. Rajaee: Nothing to disclose; J. Rizzo: Nothing to disclose; B. Ziganshin: Nothing to disclose.
PC086. Fig. Splanchnic aneurysm (SAA) patients (mean growth rate ¼ 0.064 6 0.18 cm/y).
management, post-operative complications and follow-up data were collected. Results: A total of 125 patients (77 men [62%]) with 138 SAA were identified. The mean age was 66 years (range, 25-94 years). On CT, 56 (45%) had previously diagnosed/concomitant aneurysms elsewhere. There were 30 patients (22%) who underwent operative repair (OR). The rest were monitored with serial scans without operative intervention (NOR). All patients who presented with severe abdominal pain (n ¼ 11 [44%]) underwent OR. Five patients presented with a ruptured SAA (3.6%; range, 2.3-5.0 cm), for which all underwent OR except one. Other indications for repair included large size in 7, rapid growth in 2, other open abdominal surgical procedures in 2, multiple aneurysms in 1, and desire to pursue fertility treatment in 1. The mean overall vessel diameter was 1.76 6 0.83 cm. The diameter of OR and NOR was 2.41 6 1.23 cm and 1.58 6 0.56 cm, respectively (P ¼ .00001). Operative repair included 14 (56%) endovascular embolizations and 11 (44%) open abdominal operations. Two patients after embolization underwent abdominal operation for hematoma and splenectomy. Open repairs included bypasses in 6, splenectomy in 2, resection in 2, and plication in 1. Two patients had postoperative acute kidney injury that resolved and one died of multisystem organ failure. One bypass occluded without sequelae. The overall complication rate was 20% (6 of 30). Mean follow-up was 50 6 42 months for NOR, without any adverse events related to SAA, including 10 patients with SAA >2.0 cm. On multivariate regression analysis, a history of smoking (P ¼ .04) and male gender (P ¼ .02) were inversely related to growth rates. The mean growth rate for SAA was 0.064 6 0.18 cm/y (Fig). Conclusions: It seems reasonable to follow asymptomatic patients with a SAA <2.0 cm because of their slow growth rate (0.064 6 0.18 cm/y) and because in our series, the smallest ruptured SAA was 2.3 cm in diameter. However, when intervention is needed, open and
Endovascular Interventions in the Management of Postpartum Hemorrhage due to Placenta Accreta Marguerite Hoyler,1 Jordan R. Stern,2 Nicholas Morrissey2. 1Columbia University Medical Center, New York, NY; 2New York Presbyterian Hospital, New York, NY Objectives: Placenta accreta, an abnormal placental adherence to the myometrium, is a major risk factor for massive postpartum hemorrhage (PPH). Placenta accreta-induced PPH can be life-threatening, requiring multiple transfusions and emergency hysterectomy. There are reports describing favorable outcomes using endovascular techniques to limit PPH, although this has not been widely reported in the vascular surgical literature. Most interventions are directed at the internal iliac or uterine artery, with the goal of reducing flow in the peripartum and postpartum period and mitigating placental hemorrhage and the need for hysterectomy. Here we describe our experience with a superselective approach aimed at controlling the placental artery. Methods: A retrospective, single-institution review was performed of all cases of concurrent endovascular intervention at the time of scheduled caesarean section. Bilateral, percutaneous groin access was used to select the bilateral placental arteries. During delivery, balloon occlusion of the internal iliac artery with or without superselective coil embolization of the placental artery was performed. Sheaths and catheters were removed at the completion of the procedure. Results: Seven patients were identified, with a mean age of 36.7 years and 35 weeks’ gestation (Table). Three patients underwent balloon occlusion only; two (67%) required emergency hysterectomy secondary to hemorrhage. Four patients underwent occlusion plus coil embolization; three (75%) were able to delay hysterectomy to an elective setting. Mean blood loss was 2100 mL. There were no complications related to access site or pelvic ischemia. Conclusions: This series suggests that vascular surgeons can be valuable to the multidisciplinary approach to women at high risk of PPH. Superselective embolization of the placental arteries appears to be
Table. Endovascular interventions and outcomes in patients at high risk of postpartum hemorrhage Patient
Age GA Total pregnancies/ (years) (weeks) prior C-sections
PMH
Procedure
DVT, PFO, CVA 2a Bilateral IIA balloon tamponade
EBL (mL)
Blood products
Hysterectomy
2500
2 U PRBC
Emergent
1
36
33
8/5
2
42
34
5/3
.
Bilateral IIA balloon tamponade
1000
4 U PRBC
.
3
38
34
4/2
.
Bilateral IIA balloon tamponade; placental artery coil embolization
1000
.
.
4
30
37
3/1
.
Bilateral IIA balloon tamponade; placental artery coil embolization
1200
.
Elective, deferred
5
36
36
3/1
.
Bilateral IIA balloon tamponade
7000
10 U PRBC 10 U FFP 2d plt
Emergentb
6
37
35
4/3
.
Bilateral IIA balloon tamponade; placental artery coil embolization
1000
.
Elective, deferred
7
38
36
3/2
.
Bilateral IIA balloon tamponade; placental artery coil embolization
1000
.
Elective, deferred
C-section, Caesarean section; CVA, cerebrovascular accident; DVT, deep vein thrombosis; EBL, estimated blood loss; FFP, fresh frozen plasma; GA, gestational age; IIA, internal iliac artery; PFO, patent foramen ovale; PMH, past medical history; PRBC, packed red blood cells. a Patient on therapeutic anticoagulation. b Caesarean section complicated by cystotomy 2.
Journal of Vascular Surgery
Abstracts
163S
Volume 65, Number 6S more effective than hypogastric balloon occlusion alone and may reduce the risk of pelvic ischemia. Author Disclosures: M. Hoyler: Nothing to disclose; N. Morrissey: Nothing to disclose; J. R. Stern: Nothing to disclose.
Author Disclosures: H. Boyd: Nothing to disclose; T. Drossos: Nothing to disclose; K. Long: Nothing to disclose; G. Mak: Nothing to disclose; S. O’Brien: Nothing to disclose; C. L. Skelly: Nothing to disclose; C. Speaker: Nothing to disclose; C. Stiles-Shields: Nothing to disclose.
PC090. PC088.
Use of Google Glass in Education of Vascular Surgery
The Impact of Psychological Comorbidities on Patient-Reported Outcomes in Adults With MALS Christopher L. Skelly, Colleen Stiles-Shields, Kira Long, Grace Mak, Christopher Speaker, Hope Boyd, Setareh O’Brien, Tina Drossos. University of Chicago, Chicago, ill Objectives: Median arcuate ligament syndrome (MALS) remains a challenging vascular problem to treat, in part because the symptoms overlap with many other gastrointestinal (GI) diagnoses as well as chronic abdominal pain. In our previous work, we have demonstrated that children (aged <17 years) with MALS have similar psychosocial profiles to children with other GI disorders resulting in chronic abdominal pain. The goal of this study was to outline the psychosocial profile of adults presenting with MALS, to define the patient-reported outcomes of surgery, and to determine whether psychologic comorbidities impact these outcomes. Specifically, we tested four separate hypotheses: (1) adults with MALS have psychiatric comorbidities; (2) surgery does not ameliorate these comorbidities; (3) presurgical mood symptoms would significantly impact postsurgical outcomes; and (4) quality of life (QOL) would improve overall following surgery. Methods: Patients aged >18 years were sequentially enrolled in a prospective Institutional Review Board-approved observational trial. Fiftyone patients completed psychologic and QOL assessments before and 6 months after laparoscopic release of the artery. Descriptive analyses, t-tests, and linear regressions were conducted to characterize the sample, compare hemodynamic, psychosocial, and QOL items, and determine the predictive impact of symptoms. Results: The mean follow-up for the cohort was 19.3 months. Surgery significantly improved hemodynamics in the entire cohort (peak systolic velocity, celiac/aortic ratio, respiratory variation; P < .005). Psychiatric diagnoses were common in this cohort, with 14 of 51 (27.5%) meeting criteria for a psychiatric diagnosis. There was no evidence to suggest significant differences in the number of psychiatric diagnoses between presurgical and postsurgical evaluations (P ¼ .8). Having a psychiatric diagnosis at the presurgical evaluation predicted significantly lower postsurgical physical QOL (b ¼ 0.349, P ¼ .02), work QOL (b ¼ 0.367, P ¼ .01), psychosocial QOL (b ¼ 0.309, P ¼ .04), and overall QOL (b ¼ 0.373, P ¼ .01). Finally, patient-reported QOL improved following surgery (Table). Conclusions: Surgery overwhelmingly improves patient-reported QOL in patients undergoing surgery for MALS. However, psychiatric diagnoses are common in adult patients with MALS and predict worse patient-reported outcomes. This leads us to further hypothesize that treatment of psychological disorders before surgery may improve patient reported outcomes.
Muhammad Nadeem,1 Sonya Noor2. 1State University of New York, Buffalo, NY; 2Buffalo Endovascular and Vascular Surgical Associates, Buffalo, NY Objectives: The aim of this pilot study was to describe the role of Google Glass (GG) in teaching remote surgeons sitting out of hospital. Methods: We did five cases in Gates Vascular Institute by teaching remote surgeons. During the procedure, we not only taught them but also answered their questions. Results: There was no difference in standard operating time. All procedures were completed on almost same standardized procedure time. We had to face some audio problems which were fixed during the procedure. Vascular procedures are very microprocedures, so during the procedure it is very difficult for others to see them clearly. But GG assists us a lot regarding the microprocedure. All the remote surgeons watched live procedures clearly. Conclusions: Thus by using GG, surgeons not only watch procedures obviously but they also do not need to come and stand along the operating surgeon to watch the procedure. It demands more studies to see the role of GG in vascular surgery. Author Disclosures: M. Nadeem: Nothing to disclose; S. Noor: Nothing to disclose.
PC092. Prospective Validation of High-Fidelity Simulation of Endovascular Aortic Aneurysm Repair Using 3D Printed Aortic Model and Fluid Pump Giuliano de A. Sandri, Gustavo Oderich, Jane Matsumoto, Jonathan Morris, Amy E. Alexander, Ramoncito David, Randall R. DeMartino, David Arch. Mayo Clinic, Rochester, Minn Objectives: This study investigated the feasibility of endovascular aortic aneurysm repair (EVAR) training using high-fidelity simulation with a
Table. Preoperative and postoperative quality of life (QOL) scoresa PedsQL domain Physical Emotion
Pre-op
Post-op
P
57.0 (18.7)
73.9 (18.8)
<.001
71.8 (16.8)
79.4 (18.6)
.04
Social
84.0 (13.5)
90.8 (13.4)
.02
Work
63.8 (21.4)
79.5 (18.3)
<.001
Psychosocial
72.7 (13.9)
83.4 (13.4)
<.001
Total
67.8 (14.6)
80.3 (13.7)
<.001
PedsQL, Pediatric Quality of Life Inventory-Young Adult. a 0 to 100; 0 ¼ lowest, 100 ¼ highest; n ¼ 51.
Fig. Schematic illustration of the simulation instruments, demonstrating the aortic three-dimensional printed model over the operative table and connected to the pump. All copyrights reserved to Mayo Clinic.
Journal of Vascular Surgery
Abstracts
June Supplement 2017 endovascular options should both be considered. The complication rate is not insignificant; therefore, careful patient selection is necessary. Author Disclosures: A. J. Brownstein: Nothing to disclose; J. Elefteriades: Nothing to disclose; Y. Erben: Nothing to disclose; Y. Li: Nothing to disclose; H. Mojibian: Nothing to disclose; S. Rajaee: Nothing to disclose; J. Rizzo: Nothing to disclose; B. Ziganshin: Nothing to disclose.
PC086. Fig. Splanchnic aneurysm (SAA) patients (mean growth rate ¼ 0.064 6 0.18 cm/y).
management, post-operative complications and follow-up data were collected. Results: A total of 125 patients (77 men [62%]) with 138 SAA were identified. The mean age was 66 years (range, 25-94 years). On CT, 56 (45%) had previously diagnosed/concomitant aneurysms elsewhere. There were 30 patients (22%) who underwent operative repair (OR). The rest were monitored with serial scans without operative intervention (NOR). All patients who presented with severe abdominal pain (n ¼ 11 [44%]) underwent OR. Five patients presented with a ruptured SAA (3.6%; range, 2.3-5.0 cm), for which all underwent OR except one. Other indications for repair included large size in 7, rapid growth in 2, other open abdominal surgical procedures in 2, multiple aneurysms in 1, and desire to pursue fertility treatment in 1. The mean overall vessel diameter was 1.76 6 0.83 cm. The diameter of OR and NOR was 2.41 6 1.23 cm and 1.58 6 0.56 cm, respectively (P ¼ .00001). Operative repair included 14 (56%) endovascular embolizations and 11 (44%) open abdominal operations. Two patients after embolization underwent abdominal operation for hematoma and splenectomy. Open repairs included bypasses in 6, splenectomy in 2, resection in 2, and plication in 1. Two patients had postoperative acute kidney injury that resolved and one died of multisystem organ failure. One bypass occluded without sequelae. The overall complication rate was 20% (6 of 30). Mean follow-up was 50 6 42 months for NOR, without any adverse events related to SAA, including 10 patients with SAA >2.0 cm. On multivariate regression analysis, a history of smoking (P ¼ .04) and male gender (P ¼ .02) were inversely related to growth rates. The mean growth rate for SAA was 0.064 6 0.18 cm/y (Fig). Conclusions: It seems reasonable to follow asymptomatic patients with a SAA <2.0 cm because of their slow growth rate (0.064 6 0.18 cm/y) and because in our series, the smallest ruptured SAA was 2.3 cm in diameter. However, when intervention is needed, open and
Endovascular Interventions in the Management of Postpartum Hemorrhage due to Placenta Accreta Marguerite Hoyler,1 Jordan R. Stern,2 Nicholas Morrissey2. 1Columbia University Medical Center, New York, NY; 2New York Presbyterian Hospital, New York, NY Objectives: Placenta accreta, an abnormal placental adherence to the myometrium, is a major risk factor for massive postpartum hemorrhage (PPH). Placenta accreta-induced PPH can be life-threatening, requiring multiple transfusions and emergency hysterectomy. There are reports describing favorable outcomes using endovascular techniques to limit PPH, although this has not been widely reported in the vascular surgical literature. Most interventions are directed at the internal iliac or uterine artery, with the goal of reducing flow in the peripartum and postpartum period and mitigating placental hemorrhage and the need for hysterectomy. Here we describe our experience with a superselective approach aimed at controlling the placental artery. Methods: A retrospective, single-institution review was performed of all cases of concurrent endovascular intervention at the time of scheduled caesarean section. Bilateral, percutaneous groin access was used to select the bilateral placental arteries. During delivery, balloon occlusion of the internal iliac artery with or without superselective coil embolization of the placental artery was performed. Sheaths and catheters were removed at the completion of the procedure. Results: Seven patients were identified, with a mean age of 36.7 years and 35 weeks’ gestation (Table). Three patients underwent balloon occlusion only; two (67%) required emergency hysterectomy secondary to hemorrhage. Four patients underwent occlusion plus coil embolization; three (75%) were able to delay hysterectomy to an elective setting. Mean blood loss was 2100 mL. There were no complications related to access site or pelvic ischemia. Conclusions: This series suggests that vascular surgeons can be valuable to the multidisciplinary approach to women at high risk of PPH. Superselective embolization of the placental arteries appears to be
Table. Endovascular interventions and outcomes in patients at high risk of postpartum hemorrhage Patient
Age GA Total pregnancies/ (years) (weeks) prior C-sections
PMH
Procedure
DVT, PFO, CVA 2a Bilateral IIA balloon tamponade
EBL (mL)
Blood products
Hysterectomy
2500
2 U PRBC
Emergent
1
36
33
8/5
2
42
34
5/3
.
Bilateral IIA balloon tamponade
1000
4 U PRBC
.
3
38
34
4/2
.
Bilateral IIA balloon tamponade; placental artery coil embolization
1000
.
.
4
30
37
3/1
.
Bilateral IIA balloon tamponade; placental artery coil embolization
1200
.
Elective, deferred
5
36
36
3/1
.
Bilateral IIA balloon tamponade
7000
10 U PRBC 10 U FFP 2d plt
Emergentb
6
37
35
4/3
.
Bilateral IIA balloon tamponade; placental artery coil embolization
1000
.
Elective, deferred
7
38
36
3/2
.
Bilateral IIA balloon tamponade; placental artery coil embolization
1000
.
Elective, deferred
C-section, Caesarean section; CVA, cerebrovascular accident; DVT, deep vein thrombosis; EBL, estimated blood loss; FFP, fresh frozen plasma; GA, gestational age; IIA, internal iliac artery; PFO, patent foramen ovale; PMH, past medical history; PRBC, packed red blood cells. a Patient on therapeutic anticoagulation. b Caesarean section complicated by cystotomy 2.
Journal of Vascular Surgery
Abstracts
163S
Volume 65, Number 6S more effective than hypogastric balloon occlusion alone and may reduce the risk of pelvic ischemia. Author Disclosures: M. Hoyler: Nothing to disclose; N. Morrissey: Nothing to disclose; J. R. Stern: Nothing to disclose.
Author Disclosures: H. Boyd: Nothing to disclose; T. Drossos: Nothing to disclose; K. Long: Nothing to disclose; G. Mak: Nothing to disclose; S. O’Brien: Nothing to disclose; C. L. Skelly: Nothing to disclose; C. Speaker: Nothing to disclose; C. Stiles-Shields: Nothing to disclose.
PC090. PC088.
Use of Google Glass in Education of Vascular Surgery
The Impact of Psychological Comorbidities on Patient-Reported Outcomes in Adults With MALS Christopher L. Skelly, Colleen Stiles-Shields, Kira Long, Grace Mak, Christopher Speaker, Hope Boyd, Setareh O’Brien, Tina Drossos. University of Chicago, Chicago, ill Objectives: Median arcuate ligament syndrome (MALS) remains a challenging vascular problem to treat, in part because the symptoms overlap with many other gastrointestinal (GI) diagnoses as well as chronic abdominal pain. In our previous work, we have demonstrated that children (aged <17 years) with MALS have similar psychosocial profiles to children with other GI disorders resulting in chronic abdominal pain. The goal of this study was to outline the psychosocial profile of adults presenting with MALS, to define the patient-reported outcomes of surgery, and to determine whether psychologic comorbidities impact these outcomes. Specifically, we tested four separate hypotheses: (1) adults with MALS have psychiatric comorbidities; (2) surgery does not ameliorate these comorbidities; (3) presurgical mood symptoms would significantly impact postsurgical outcomes; and (4) quality of life (QOL) would improve overall following surgery. Methods: Patients aged >18 years were sequentially enrolled in a prospective Institutional Review Board-approved observational trial. Fiftyone patients completed psychologic and QOL assessments before and 6 months after laparoscopic release of the artery. Descriptive analyses, t-tests, and linear regressions were conducted to characterize the sample, compare hemodynamic, psychosocial, and QOL items, and determine the predictive impact of symptoms. Results: The mean follow-up for the cohort was 19.3 months. Surgery significantly improved hemodynamics in the entire cohort (peak systolic velocity, celiac/aortic ratio, respiratory variation; P < .005). Psychiatric diagnoses were common in this cohort, with 14 of 51 (27.5%) meeting criteria for a psychiatric diagnosis. There was no evidence to suggest significant differences in the number of psychiatric diagnoses between presurgical and postsurgical evaluations (P ¼ .8). Having a psychiatric diagnosis at the presurgical evaluation predicted significantly lower postsurgical physical QOL (b ¼ 0.349, P ¼ .02), work QOL (b ¼ 0.367, P ¼ .01), psychosocial QOL (b ¼ 0.309, P ¼ .04), and overall QOL (b ¼ 0.373, P ¼ .01). Finally, patient-reported QOL improved following surgery (Table). Conclusions: Surgery overwhelmingly improves patient-reported QOL in patients undergoing surgery for MALS. However, psychiatric diagnoses are common in adult patients with MALS and predict worse patient-reported outcomes. This leads us to further hypothesize that treatment of psychological disorders before surgery may improve patient reported outcomes.
Muhammad Nadeem,1 Sonya Noor2. 1State University of New York, Buffalo, NY; 2Buffalo Endovascular and Vascular Surgical Associates, Buffalo, NY Objectives: The aim of this pilot study was to describe the role of Google Glass (GG) in teaching remote surgeons sitting out of hospital. Methods: We did five cases in Gates Vascular Institute by teaching remote surgeons. During the procedure, we not only taught them but also answered their questions. Results: There was no difference in standard operating time. All procedures were completed on almost same standardized procedure time. We had to face some audio problems which were fixed during the procedure. Vascular procedures are very microprocedures, so during the procedure it is very difficult for others to see them clearly. But GG assists us a lot regarding the microprocedure. All the remote surgeons watched live procedures clearly. Conclusions: Thus by using GG, surgeons not only watch procedures obviously but they also do not need to come and stand along the operating surgeon to watch the procedure. It demands more studies to see the role of GG in vascular surgery. Author Disclosures: M. Nadeem: Nothing to disclose; S. Noor: Nothing to disclose.
PC092. Prospective Validation of High-Fidelity Simulation of Endovascular Aortic Aneurysm Repair Using 3D Printed Aortic Model and Fluid Pump Giuliano de A. Sandri, Gustavo Oderich, Jane Matsumoto, Jonathan Morris, Amy E. Alexander, Ramoncito David, Randall R. DeMartino, David Arch. Mayo Clinic, Rochester, Minn Objectives: This study investigated the feasibility of endovascular aortic aneurysm repair (EVAR) training using high-fidelity simulation with a
Table. Preoperative and postoperative quality of life (QOL) scoresa PedsQL domain Physical Emotion
Pre-op
Post-op
P
57.0 (18.7)
73.9 (18.8)
<.001
71.8 (16.8)
79.4 (18.6)
.04
Social
84.0 (13.5)
90.8 (13.4)
.02
Work
63.8 (21.4)
79.5 (18.3)
<.001
Psychosocial
72.7 (13.9)
83.4 (13.4)
<.001
Total
67.8 (14.6)
80.3 (13.7)
<.001
PedsQL, Pediatric Quality of Life Inventory-Young Adult. a 0 to 100; 0 ¼ lowest, 100 ¼ highest; n ¼ 51.
Fig. Schematic illustration of the simulation instruments, demonstrating the aortic three-dimensional printed model over the operative table and connected to the pump. All copyrights reserved to Mayo Clinic.