Apostolos K. Tassiopoulos

Blunt thoracic aortic injury (BTAI) is a life-threatening condition, arising from high-energy non-penetrating trauma and it is associated with significant fatality rates. This clinical entity demands prompt evaluation and rapid and carefully-selected therapeutic approach. Thoracic endovascular aortic repair (TEVAR) represents a significant milestone in the management of this condition and has largely replaced open surgery, offering various benefits to the patients. This review aims to compare the most recent guidelines from the Society of Vascular Surgery (SVS) and the European Society of Vascular Surgery (ESVS) regarding the management of BTAI. It presents the similarities and differences, while special attention is given to areas of controversy and particularly Grade II injuries treatment.

Hostile aortic neck anatomy challenges the outcomes of endovascular abdominal aortic aneurysm repair (EVAR). Besides reverting to open surgical repair (OSR), thoughtful endograft selection and a number of advanced endovascular techniques have been suggested as potential solutions for preventing proximal seal zone complications, improving EVAR durability, and preventing aneurysm-related death. Each technique is associated with advantages and limitations and there has not been a credible direct comparison amongst them in the form of a well-designed prospective trial. The not infrequent presence of multiple hostile anatomic characteristics further complicates decision making and challenges the surgeon’s skills. This paper serves as an overview of hostile neck anatomy and its implications on EVAR. We provide a concise literature review with the purpose of outlining the treatment modalities and outcomes in this patient population.

International Press of Boston - publishers of scholarly mathematical and scientific journals and books

Objective: Examine the possible beneficial effects of early, D-dimer driven anticoagulation in preventing thrombotic complications and improving the overall outcomes of COVID-19 intubated patients.Methods: To address COVID-19 hypercoagulability, we developed a clinical protocol to escalate anticoagulation based on serum D-dimer levels. We retrospectively reviewed all our first 240 intubated patients with COVID-19. Of the 240, 195 were stratified into patients treated based on this protocol (ON-protocol, n = 91) and the control group, patients who received standard thromboprophylaxis (OFF-protocol, n = 104). All patients were admitted to the Stony Brook University Hospital intensive care units (ICUs) between February 7th, 2020 and May 17, 2020 and were otherwise treated in the same manner for all aspects of COVID-19 disease.Results: We found that the overall mortality was significantly lower ON-protocol compared to OFF-protocol (27.47 vs. 58.66%, P < 0.001). Average maximum D-dimer levels were significantly lower in the ON-protocol group (7,553 vs. 12,343 ng/mL), as was serum creatinine (2.2 vs. 2.8 mg/dL). Patients with poorly controlled D-dimer levels had higher rates of kidney dysfunction and mortality. Transfusion requirements and serious bleeding events were similar between groups. To address any possible between-group differences, we performed a propensity-matched analysis of 124 of the subjects (62 matched pairs, ON-protocol and OFF-protocol), which showed similar findings (31 vs. 57% overall mortality in the ON-protocol and OFF-protocol group, respectively).Conclusions: D-dimer-driven anticoagulation appears to be safe in patients with COVID-19 infection and is associated with improved survival.What This Paper Adds: It has been shown that hypercoagulability in patients with severe COVID-19 infection leads to thromboembolic complications and organ dysfunction. Anticoagulation has been variably administered to these patients, but it is unknown whether routine or escalated thromboprophylaxis provides a survival benefit. Our data shows that escalated D-dimer driven anticoagulation is associated with improved organ function and overall survival in intubated COVID-19 ICU patients at our institution. Importantly, we found that timely escalation of this anticoagulation is critical in preventing organ dysfunction and mortality in patients with severe COVID-19 infection.