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Carotid Patch Rejection with Arterial Continuity: Case Report and Review of the Literature
JOURNAL OF VASCULAR SURGERY June Supplement 2015
80S Abstracts
Carotid Patch Rejection with Arterial Continuity: Case Report and Review of the Literature Andrew H. Maloney1, John S. Pfeifer2, Michael F. 1 Michael H. Nguyen3. Virginia Amendola3, Commonwealth University Health Systems, Richmond, Va; 2McGuire Veterans Administration Medical Center, Richmond, Va; 3VA Medical Center, VCU Medical Center, Richmond, Va Objectives: Patch angioplasty is now considered the current standard of care for repair after a carotid endarterectomy. Although patch placement with synthetic material does carry a risk of infection, these rates are known to be <1% in two systematic reviews. Methods: We present a case of a 69-year-old man with a medical history of right carotid endarterectomy for symptomatic 80% carotid stenosis in 2006. The procedure was uneventful, with patch angioplasty undertaken with a Dacron carotid patch and Prolene sutures. The patient represented to his primary care physician 8 years later with a 9-month history of intermittent right neck swelling, odynophagia, and fatigue. He was taken to the operating room for neck exploration and found to have a 4-cm phlegmon deep to the belly of the sternocleidomastoid. Exploration of the carotid sheath found with only a short segment of the Dacron patch associated with the carotid artery. The Dacron patch was removed by unwinding the running suture with gentle traction (Fig). The remaining aspects of the common carotid and internal carotid artery was encased in scar tissue, with no bleeding or pseudoaneurysm noted. Results: The patient was observed for a day and discharged without complication after drain removal. The patient returned in 1 month, with a carotid duplex that revealed no pseudoaneurysm, stenosis, or reformation of abscess. Our case shows that prosthetic carotid patch expulsion can occur as late as 8 years after placement and this report adds a fourth case regarding this exceedingly rare phenomenon.
Fig.
Conclusions: Vascular surgeons should be aware of the possibility of prosthetic patch extrusion in the setting of chronic surgical site symptoms and normal vascular radiographic studies. Author Disclosures: A. H. Maloney: Nothing to disclose; J. S. Pfeifer: Nothing to disclose; M. F. Amendola: Bristol-Myers Squibb, speakers bureau; M. H. Nguyen: Nothing to disclose. Dialysis Access Surgery: Does Anesthesia Type Affect Maturation and Complication Rates? Andrew Son. Kaiser Permanente, Riverside, Calif Objectives: Creation of an arteriovenous fistula (AVF) is the preferred method of establishing longterm dialysis access. There are multiple anesthetic techniques used for patients undergoing this surgery, including general endotracheal intubation (GET), laryngeal mask airway (LMA), regional anesthesia with nerve blocks, and monitored anesthesia care (MAC) with local infiltration (local/MAC). It is unclear what effect the method of anesthesia has on AVF creation success rate. Our objective was determine if anesthesia type affects success rates of AVF creation defined by complication and maturation rates. Methods: A retrospective review was performed in a single-institution, single-surgeon study of 253 patients who underwent AVF creation between January 2003 and December 2010. Patients were cross-analyzed between three anesthesia types (GET, LMA, and MAC) and AVF creation surgeries (radiocephalic, brachiocephalic, and basilic vein transposition AVF creations). No regional anesthesia was performed. Demographic data, including comorbidities and risk factors, were stratified among all categories. Analysis of variance, c2 testing, and Fisher exact P testing was performed across all anesthesia types and specific operations and measured according to success of AVF maturation and complication rates (including death within 30 days, myocardial infarction within 30 days, respiratory insufficiency, venous hypertension, wound infections, neuropathy, and vascular steal syndrome). Results: There were no significant differences in maturation rate in terms of the three anesthesia types (general, LMA, and local/MAC) for radiocephalic (P ¼ .191), brachiocephalic (P ¼ .191), and basilic vein transposition AVF creation (P ¼ .305). In addition, there were no differences in complication rates between the surgeries and the three types of anesthesia (P ¼ .557). Conclusions: Our study shows that despite anesthesia type, outcomes in terms of maturation and complication rate are not statistically different in AVF creation surgeries. The use of monitored anesthesia care with local anesthesia may improve operative efficiency and therefore may be the preferred method of anesthesia. Future studies can include cost analysis and implications for cost saving measures. Author Disclosures: A. Son: Nothing to disclose.
80S Abstracts
Carotid Patch Rejection with Arterial Continuity: Case Report and Review of the Literature Andrew H. Maloney1, John S. Pfeifer2, Michael F. 1 Michael H. Nguyen3. Virginia Amendola3, Commonwealth University Health Systems, Richmond, Va; 2McGuire Veterans Administration Medical Center, Richmond, Va; 3VA Medical Center, VCU Medical Center, Richmond, Va Objectives: Patch angioplasty is now considered the current standard of care for repair after a carotid endarterectomy. Although patch placement with synthetic material does carry a risk of infection, these rates are known to be <1% in two systematic reviews. Methods: We present a case of a 69-year-old man with a medical history of right carotid endarterectomy for symptomatic 80% carotid stenosis in 2006. The procedure was uneventful, with patch angioplasty undertaken with a Dacron carotid patch and Prolene sutures. The patient represented to his primary care physician 8 years later with a 9-month history of intermittent right neck swelling, odynophagia, and fatigue. He was taken to the operating room for neck exploration and found to have a 4-cm phlegmon deep to the belly of the sternocleidomastoid. Exploration of the carotid sheath found with only a short segment of the Dacron patch associated with the carotid artery. The Dacron patch was removed by unwinding the running suture with gentle traction (Fig). The remaining aspects of the common carotid and internal carotid artery was encased in scar tissue, with no bleeding or pseudoaneurysm noted. Results: The patient was observed for a day and discharged without complication after drain removal. The patient returned in 1 month, with a carotid duplex that revealed no pseudoaneurysm, stenosis, or reformation of abscess. Our case shows that prosthetic carotid patch expulsion can occur as late as 8 years after placement and this report adds a fourth case regarding this exceedingly rare phenomenon.
Fig.
Conclusions: Vascular surgeons should be aware of the possibility of prosthetic patch extrusion in the setting of chronic surgical site symptoms and normal vascular radiographic studies. Author Disclosures: A. H. Maloney: Nothing to disclose; J. S. Pfeifer: Nothing to disclose; M. F. Amendola: Bristol-Myers Squibb, speakers bureau; M. H. Nguyen: Nothing to disclose. Dialysis Access Surgery: Does Anesthesia Type Affect Maturation and Complication Rates? Andrew Son. Kaiser Permanente, Riverside, Calif Objectives: Creation of an arteriovenous fistula (AVF) is the preferred method of establishing longterm dialysis access. There are multiple anesthetic techniques used for patients undergoing this surgery, including general endotracheal intubation (GET), laryngeal mask airway (LMA), regional anesthesia with nerve blocks, and monitored anesthesia care (MAC) with local infiltration (local/MAC). It is unclear what effect the method of anesthesia has on AVF creation success rate. Our objective was determine if anesthesia type affects success rates of AVF creation defined by complication and maturation rates. Methods: A retrospective review was performed in a single-institution, single-surgeon study of 253 patients who underwent AVF creation between January 2003 and December 2010. Patients were cross-analyzed between three anesthesia types (GET, LMA, and MAC) and AVF creation surgeries (radiocephalic, brachiocephalic, and basilic vein transposition AVF creations). No regional anesthesia was performed. Demographic data, including comorbidities and risk factors, were stratified among all categories. Analysis of variance, c2 testing, and Fisher exact P testing was performed across all anesthesia types and specific operations and measured according to success of AVF maturation and complication rates (including death within 30 days, myocardial infarction within 30 days, respiratory insufficiency, venous hypertension, wound infections, neuropathy, and vascular steal syndrome). Results: There were no significant differences in maturation rate in terms of the three anesthesia types (general, LMA, and local/MAC) for radiocephalic (P ¼ .191), brachiocephalic (P ¼ .191), and basilic vein transposition AVF creation (P ¼ .305). In addition, there were no differences in complication rates between the surgeries and the three types of anesthesia (P ¼ .557). Conclusions: Our study shows that despite anesthesia type, outcomes in terms of maturation and complication rate are not statistically different in AVF creation surgeries. The use of monitored anesthesia care with local anesthesia may improve operative efficiency and therefore may be the preferred method of anesthesia. Future studies can include cost analysis and implications for cost saving measures. Author Disclosures: A. Son: Nothing to disclose.