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Objectives Endovascular surgery has revolutionized the treatment of aortic aneurysms; however these improvements have come at the cost of increased radiation and contrast exposure, particularly for more complex procedures. Three dimensional (3D) fusion computed tomographic (CT) imaging is a new technology that may facilitate these repairs. The purpose of this analysis was to determine the impact of utilizing intraoperative 3D fusion CT on performance of fenestrated endovascular aortic repair. Methods A review of our institutional database was performed to identify patients undergoing fenestrated/branched endovascular aortic repair (FEVAR). Subjects treated using 3D fusion CT were compared to patients treated in the immediate 12-month period prior to implementation of this technology when procedures were performed in a standard hybrid operating room without CT fusion capabilities. Primary endpoints included patient radiation exposure (air kerma area product: milliGray; mGy*cm2), fluoroscopy time (minutes; min), contrast usage (mL) and procedure time (min). Patients were grouped by number of aortic graft fenestrations revascularized with a stentgraft and operative outcomes were compared. Results A total of 72 patients (N = 41 before vs. N = 31 after 3D fusion CT implementation) underwent FEVAR from September 2012 through March 2014. For 2-vessel fenestrated endografts, there was a significant decrease in radiation exposure (3400±1900 vs. 1380±520 mGy*cm2; P=.001), fluoroscopy time (63±29 vs. 41±11min; P=.02), and contrast usage (69±16 vs. 26±8 mL; P=.0002) with intraoperative 3D fusion CT. Similarly, for combined 3 and 4-vessel FEVAR, significantly decreased radiation exposure (5400±2225 vs. 2700±1400 mGy*cm2; P<.0001), fluoroscopy time (89±36 vs 6±21min; P=.02), contrast usage (90±25 vs. 39±17mL; P<.0001), as well as procedure time (330±100 vs. 230±50min; P=.002) was noted. Estimated blood loss was significantly less (P<.0001) and length of stay had a trend (P=.07) toward being lower for all patients in the 3D CT group. Conclusions These results demonstrate that use of intraoperative 3D fusion CT imaging during FEVAR can significantly decrease radiation exposure and procedure time, as well as contrast usage, which may also decrease the overall physiologic impact of the repair.

With respect to both clinical outcome measures and subsequent resource utilization, statin therapy is associated with a beneficial effect in patients undergoing elective AAA repair. These data suggest that preoperative statin therapy should be an integral part of the risk optimization for patients undergoing AAA repair.

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Objectives Type 1a endoleak after endovascular aortic repair (EVAR) can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion (OSC), reports of complex endoluminal salvage techniques are increasing. Despite development of these endovascular remedial strategies, many patients ultimately require OSC. The purpose of this analysis was to determine outcomes of elective open conversion for type 1a endoleak and compare them to elective primary open juxtarenal aortic repair (OJAR) to determine if these concerns are warranted. Methods From 2000–12, 54 patients underwent EVAR conversion at median time of 27 months [interquartile range (IQR): 9, 55]. Indications included: endograft thrombosis (N=2, 4%), intraoperative EVAR failure (N=3, 6%), rupture (N=5, 9%), graft infection (N=6, 11%), and endoleak (All: N=38, 70%; type 1a: N=25). Because many open conversions are performed for emergent indications without endovascular options, we chose elective type 1a endoleak patients as our study group. These 25 patients were compared to an elective open juxtarenal aneurysm repair cohort matched by anatomy and comorbidities. Primary end-points were 30-day and 1-year mortality. Secondary end-points included early complications, cross-clamp time, procedure time, blood loss, and length of stay (LOS). Results Demographic and comorbidity data in the OSC and OJAR groups did not differ with the exception that OJAR patients presented with smaller aneurysm diameter and a higher rate of chronic obstructive pulmonary disease (P = .03). OSC patients more frequently underwent a non-tube graft repair [OSC, N=6 (24%) vs. OJAR, N=20 (80%); P=.0002], required longer procedure times (P=.03), and received more plasma transfusion (P=.03). The 30-day mortality was 4% in both groups (observed difference in rates = 0%, 95% CI for difference in mortality rates = [−14.0%, 14.0%], P=1). A similar rate of major complications occurred [OSC (N = 9) 36% vs. OJAR (N = 8) 32%; P = 1]. One-year survival was 83% in OSC and 91% in OJAR (observed difference = 7%, 95% CI [−15%, 29%], P=.65). Conclusions Despite many advances in EVAR technology, the need for OSC persists, and will likely become more common as older generation devices fail or providers attempt EVAR in more anatomically complex patients. Elective OSC for type 1a endoleak can be technically challenging, but is not associated with increased morbidity or mortality when compared to OJAR in appropriately selected patients. These results should be considered before pursuing complex endovascular remediation of EVAR failures.

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Safe thyroid surgery requires meticulous hemostasis. The objective of the current study is to compare the effectiveness and safety of ultrasonic dissection (UD) and electronic vessel sealing (EVS) in patients undergoing thyroidectomy. A retrospective analysis of a prospectively maintained database was performed. Between January 1, 2007 and January 25, 2008, hemostasis was achieved using EVS (LigaSure Precise, Valleylab, Boulder, CO). Since January 25, 2008, hemostasis has been achieved using UD (Harmonic Focus, Ethicon Endo-Surgery, Cincinnati, OH). Operative time, estimated blood loss, gland weight, and postoperative complications were compared. Differences were analyzed using unpaired t test and Chi square with significance assigned P < 0.05. Seventy-four patients underwent total thyroidectomy (EVS n = 59, UD n = 15). Operative time (EVS 115.0 ± 38.3 min, UD 88.0 ± 14.0 min, P = 0.012) was significantly decreased in the UD group compared with the EVS group. There were no significant differences in mean age (EVS 50.4 ± 13.9 years, UD 49.1 ± 15.6 years), gender distribution (EVS 78% female, UD 87% female), estimated blood loss (EVS 49.4 ± 44.7 mL, UD 47.0 ± 70.4 mL), and gland weight (EVS 67.4 ± 66.4 gm, UD 41.3 ± 26.6 gm). Analysis of complications, including hematoma, hypocalcemia, and recurrent laryngeal nerve palsy showed no significant difference. Based on the current analysis, ultrasonic dissection is a safe method of hemostasis for thyroid surgery. Its use decreases operative time when compared with electronic vessel sealing.