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Aneurysmal extension of abdominal aortic aneurysms (AAAs) to the common iliac artery (CIA) presents a technical challenge to successful endovascular abdominal aortic aneurysm repair (EVAR). In the present study, we compared sac shrinkage and perioperative outcomes after the bell-bottom technique (BBT), internal iliac artery embolization and external iliac artery extension (EIE), and iliac branch endoprosthesis (IBE).Using the Vascular Quality Initiative database, a retrospective analysis was conducted for patients who had undergone EVAR from 2013 to 2019. The demographic, anatomic, and perioperative data were analyzed. All patients with a proximal aortic neck length 10 mm and aortic graft diameter32 mm were excluded from the analysis. The patients were subdivided into four groups according to the distal limb strategy: group 1, control group with a bilateral common iliac artery limb 20 mm; group 2, BBT with either a unilateral or bilateral limb20 mm; group 3, EIE technique; and group 4, IBE. The primary endpoint was the maximal change in the aortic diameter during follow-up. The secondary endpoints included postoperative complications and the rate of endoleak.The records for 14,455 patients who had undergone EVAR were queried and 5788 met the anatomic criteria. The average age was 73 years, and 86.3% were men. The maximal change in the aortic diameter in the control, BBT, IBE, and EIE groups was -7.2 mm, -6.1 mm, -4.6 mm, and -6.8 mm, respectively (P = .06). The differences were not statistically significant on univariate analysis at an average follow-up of 405 days. However, on multivariable analysis (P = .01), compared with the control group, the BBT and IBE groups were 18.4% (odds ratio [OR], 0.816; 95% confidence interval [CI], 0.68-0.98) and 48.0% (OR, 0.52; 95% CI, 0.33-0.82) less likely to experience aneurysmal shrinkage, respectively. In contrast, the EIE group showed no significant difference in shrinkage compared with that in the control group. Multivariable analysis of the groups also revealed that compared directly with the BBT group, the EIE group was 69.5% more likely to have experienced shrinkage in the aortic aneurysmal diameter (OR, 1.70; 95% CI, 1.05-2.75). The BBT and IBE groups had a significantly higher rate of type II endoleaks (17.63% and 16.95%, respectively; P = .03). The EIE group had a higher rate of type Ib endoleaks (1.9%) compared with the BBT (1.1%), IBE (1.7%), and control (0.3%) groups (P = .01). No differences were found between the groups in terms of postoperative myocardial infarction (P = .47) or respiratory (P = .61) or intestinal (P = .71) complications. However, the rates of limb complications and reoperation were higher in the EIE group.The present study revealed that the EIE technique was more likely to demonstrate shrinkage in the aortic aneurysmal diameter than were the BBT and IBE groups compared with the control group on multivariable analysis. The EIE technique was also more likely to result in aneurysmal sac shrinkage than was the BBT group, albeit with greater rates of limb-related complications.

Introduction : Hospitalists can be instrumental in management of inpatients with multiple comorbidities requiring complex medical care such as vascular surgery patients, as well as an expertise in health care delivery. We instituted a unique hospitalist co-management program and assessed length of stay, 30-day readmission rates and mortality, and performed an overall cost-analysis. Methods : Hospitalist co-management of vascular surgery inpatients was implemented beginning April 2019, and data was studied until March 2020. We compared this data to an eight-month period prior to implementing co-management (7/2018 – 3/2019). Patient-related outcomes that were assessed include length of stay, re-admission index, mortality index, case-mix index. Cost-analysis was performed to look at indirect and direct cost of care. Results : A total of 1,062 patients were included in the study 520 pre co-management and 542 patients were post-comanagement. Baseline case-mix index was 2.47, and post-comanagement was 2.46 (p>0.05). In terms of average length of stay (aLOS), the baseline aLOS was 5.16 days per patient, while after co-management it was significantly decreased by 1.25 days to 3.91 days (p Conclusions : Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings. The overall average variable direct cost decreased by $1,732 per patient. Conclusion : Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings.

Objective In the tide of robot-assisted minimally invasive surgery, few cases of robot-assisted pneumonectomy exist in the literature. This study evaluates the perioperative outcomes and risk factors for conversion to thoracotomy with an initial robotic approach to pneumonectomy for lung cancer. Methods This study is a single-center retrospective review of all pneumonectomies for lung cancer with an initial robotic approach between 2015 and 2019. Patients were divided into 2 groups: surgeries completed robotically and surgeries converted to thoracotomy. Patient demographics, preoperative clinical data, surgical pathology, and perioperative outcomes were compared for meaningful differences between the groups. Results Thirteen total patients underwent robotic pneumonectomy with 8 of them completed robotically and 5 converted to thoracotomy. There were no significant differences in patient characteristics between the groups. The Robotic group had a shorter operative time ( P < 0.01) and less estimated blood loss ( P = 0.02). There were more lymph nodes harvested in the Robotic group ( P = 0.08) but without statistical significance. There were 2 major complications in the Robotic group and none in the Conversion group. Neither tumor size nor stage were predictive of conversion to thoracotomy. Conversions decreased over time with a majority occurring in the first 2 years. There were no conversions for bleeding and no mortalities. Conclusions Robotic pneumonectomy for lung cancer is a safe procedure and a reasonable alternative to thoracotomy. With meticulous technique, major bleeding can be avoided and most procedures can be completed robotically. Larger studies are needed to elucidate any advantages of a robotic versus open approach.

In patients with abdominal aortic aneurysms, 10-20% has concomitant thoracic aortic pathologies. These are typically managed with staged endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) due to a perceived higher risk of spinal cord ischemia from a simultaneous intervention. We aimed to determine the outcomes of patients undergoing simultaneous EVAR and TEVAR for concomitant aneurysms.A retrospective cohort study was performed using the Vascular Quality Initiative registry from December 2003 to January 2021. Patients undergoing same day EVAR and TEVAR were included and analyzed in accordance with the Society for Vascular Surgery reporting standards. Primary outcomes were technical success and spinal cord ischemia.Simultaneous EVAR and TEVAR were performed in 25 patients. Median age was 75.0 (interquartile range [IQR], 63.0-79.0) years and 20 (80.0%) patients were male. Two (4.0%) patients were symptomatic and 4 (16.0%) presented with rupture. Median maximum infrarenal and thoracic aortic diameter was 57.0 (IQR, 52.0-65.0). Infrarenal aortic neck length was 15.0 mm (IQR, 10.0-25.0), and diameter was 27.0 mm (IQR, 24.5-30.0). Median procedure time was 185.0 min (IQR, 117.8-251.3), fluoroscopy time 32.7 min (IQR, 21.8-63.1), and contrast volume 165 mL (IQR, 115.0-207.0). There were 3 (12.0%) Type Ia endoleaks and 3 (12.0%) Type II endoleaks in EVAR's, with 1 (4.0%) Type Ia and 1 (4.0%) Type II endoleak in TEVARs. In-hospital mortality occurred in 3 (12.0%) patients (1 elective, 2 ruptures). Spinal cord ischemia occurred in 1 (4.0%) patient. This patient had a symptomatic aneurysm. Thoracic coverage extended from Zone 4 to Zone 5 and an emergent spinal drain was placed postoperatively. Symptoms were present on discharge. There was 1 (4.0%) conversion to open repair which occurred in a ruptured aneurysm. Technical success was achieved in 19 (76.0%) patients, however when excluding ruptured aneurysms, was achieved in 17 (81.0%) patients. Follow-up data was available for 19 (76.0%) patients at a median of 426.0 (IQR, 329.0-592.5) days postoperatively. A total of 3 (12.0%) patients died during the late mortality period, at a mean of 509.0 (±503.7) days. Median change in abdominal and thoracic aortic sac diameter was -1.35 mm (IQR, -11.5 to 2.5) and 8.0 (IQR, -10.5 to 12.0), respectively.Simultaneous EVAR and TEVAR for concomitant abdominal and thoracic aortic aneurysms can be performed with low rates of spinal cord ischemia. Short- and mid-term outcomes are acceptable.