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Background: Mesenteric metastases from small-bowel neuroendocrine tumors (SBNETs) present a surgical challenge due to encasement of mesenteric vessels. In this study, we evaluate the feasibility and safety of a new, hybrid surgical approach to these mesenteric masses, EndoVascular Occlusion and Tumor Excision (EVOTE).Methods: From 2014 to 2018, 13 patients underwent the EVOTE procedure after being referred to our institution for primary SBNETs with "unresectable" mesenteric metastases. During stage 1 of the hybrid EVOTE procedure, angiographic evaluation of the mesenteric mass is performed. If adequate collateralization is demonstrated, the encased mesenteric vessel(s) is embolized. Mass excision is performed the following day during stage 2 of the EVOTE procedure.Results: Preoperative embolization was successful in 86% of cases; 2 cases were aborted for persistent abdominal pain following occlusion testing. Complete surgical excision of the mesenteric mass was achieved in 86% of cases. The 30-day overall morbidity and mortality rate was 29% and 0%, respectively. There was one local recurrence at 31.8 months post-op; this patient underwent a repeat EVOTE procedure with successful complete excision.Discussion: EVOTE represents a new technique that aids in preoperative planning and surgical resection of SBNETs with mesenteric metastases. [ABSTRACT FROM AUTHOR]

When is a director or officer personally liable in tort to a party who is not the corporation he or she serves? In Canada, there is no clear answer. The law is marked by division both within and between appellate courts, resulting in judgments that are hard to reconcile and verge on arbitrary. This is likely attributable to the mistaken belief that there is a tension between personal liability and corporate personality, as well as the disputed relationship between common law and statutory obligations. To address these challenges, most Canadian courts have followed a threshold corporate law analysis, which seeks to categorize the allegations as either corporate or personal. When applied, this approach often results in directors and officers having immunity with respect to torts they committed in pursuit of the corporation's interests. Such immunity, however, has no basis in law. Canada's business corporations statutes do not limit the liability of directors and officers, and implicitly contemplate their exposure to tort claims. Accordingly, I propose that directors and officers ought to be personally liable when they are implicated in facts that give rise to a cause of action in tort, regardless of whether their actions may be considered authorized by, or in the interests of, the corporation. This approach is conceptually simpler and more respectful of legislative intent, while posing no serious policy concerns. This is because ordinary tort law principles are sufficiently robust to bar improper personal claims, such as those that do not implicate the director or officer, those that are inconsistent with the expectations of the parties, or those that conflict with statutory obligations or remedies. [ABSTRACT FROM AUTHOR]

A green synthesis method for the preparation of polyglycidol in buffer with a high degree of control is presented. Polymerizations were conducted in phosphate buffered saline (PBS) of varying pH 3.8, 6.0, and 8.0 and deionized water at temperatures of 60, 80, and 100 °C. Taking advantage of the catalytic reactivity between water and glycidol afforded a novel green polymerization technique for the facile synthesis of polyglycidol systems with semibranched architectures with a degree of branching (DB) of 0.24, which situates the polymers between purely linear (DB = 0) and hyperbranched (DB = 0.56-0.63) systems. This method sidesteps the strenuous polymerization conditions required for most polyglycidol structures and provides well-controlled and reproducible species with a high degree of linearity and narrow polydispersities of 1.1-1.2 via the first green and nonexothermic synthesis of polyglycidol. [ABSTRACT FROM AUTHOR]

In this study, sub and supercritical CO 2 are used as effective solvents to impregnate hydrogen peroxide (H 2 O 2 ) into cellulose acetate (CA) non-woven mats. As much as 25 wt% H 2 O 2 can be impregnated at operating conditions of 25–45 °C and 1200 psig. Thermal gravimetric analysis shows that H 2 O 2 -loaded CA mats lose more than 60% of available H 2 O 2 when quickly heated to 37 °C and held at this temperature for 60 min. However, in comparison, pure H 2 O 2 –H 2 O (50:50 w/w) solution evaporates 100% within 15 min at this same temperature. Shelf-life studies show that H 2 O 2 -loaded CA mats lose ∼50% and ∼100% of available H 2 O 2 in 30 days, when stored at 2–8 °C and 20–23 °C, respectively. H 2 O 2 slowly diffuses and subsequently evaporates from the CA mat at a rate determined by the diffusion of H 2 O 2 through the CA fibers. We envision applying a thin polymer coating to the CA mat to suppress diffusional losses of H 2 O 2 , thus leading to an increased product shelf-life. These mats should find use as bandages for the continuous delivery of O 2 for advanced wound care. In vitro studies presented here demonstrate that the developed bandages produce O 2 at a controlled rate for 24 h. [ABSTRACT FROM AUTHOR]

Highlights: [•] Silk fibroin aerogels are synthesized using sol–gel and supercritical CO2 technology. [•] SF aerogels are loaded with ∼21wt% of ibuprofen using supercritical CO2. [•] Greater than 99.98wt% of ibuprofen is in the amorphous form. [•] The ibuprofen release from SF aerogels occurs over a period of 6h. [•] Release of ibuprofen from SF aerogels is governed by Fickian diffusion. [Copyright &y& Elsevier]

Abstract: A simple, elegant method for the formation of a continuous stationary phase gradient for use in chromatographic separations is described. Its applicability to separation science is demonstrated using thin-layer chromatography as a test case. Gradient stationary phases were formed on activated High Performance Thin-Layer Chromatography (HP-TLC) plates using a newly developed methodology termed “controlled rate infusion”. Specifically, the SiOH groups on the activated HP-TLC plates were reacted with 3-aminopropyltriethoxysilane (APTEOS) in a time dependent fashion by using a programmable syringe pump to control the rate of APTEOS infusion into the deposition reservoir. The shape (profile) of the gradient was controlled by the rate of infusion and imaged by taking advantage of the concentration-dependent color formation reaction between amine groups and ninhydrin. The advantages of such gradients in optimizing the retention and separation of various components in different mixtures were illustrated using mixtures of (1) four weak acids and bases and (2) three widely used over-the-counter drugs. The separation of the individual components on the gradient stationary phase was clearly improved relative to those on either traditional normal-phase TLC plates or uniformly amine-modified TLC plates. Precise control over component retention and separation was also demonstrated by strategically modifying the steepness of the gradient. [Copyright &y& Elsevier]

Stem cell differentiation involves critical changes in gene expression. Identification of these should provide endpoints useful for optimizing stem cell propagation as well as potential clues about mechanisms governing stem cell maintenance. Here we describe the results of a new meta-analysis methodology applied to multiple gene expression datasets from three mouse embryonic stem cell (ESC) lines obtained at specific time points during the course of their differentiation into various lineages. We developed methods to identify genes with expression changes that correlated with the altered frequency of functionally defined, undifferentiated ESC in culture. In each dataset, we computed a novel statistical confidence measure for every gene which captured the certainty that a particular gene exhibited an expression pattern of interest within that dataset. This permitted a joint analysis of the datasets, despite the different experimental designs. Using a ranking scheme that favored genes exhibiting patterns of interest, we focused on the top 88 genes whose expression was consistently changed when ESC were induced to differentiate. Seven of these (103728_ at, 8430410A17Rik, Klf2, Nr0b1, Sox2, Tcl1, and Zfp42) showed a rapid decrease in expression concurrent with a decrease in frequency of undifferentiated cells and remained predictive when evaluated in additional maintenance and differentiating protocols. Through a novel meta-analysis, this study identifies a small set of genes whose expression is useful for identifying changes in stem cell frequencies in cultures of mouse ESC. The methods and findings have broader applicability to understanding the regulation of self-renewal of other stem cell types. [ABSTRACT FROM AUTHOR]

Several factors may limit the success of conventional operative therapy for traumatic arterial injuries. In particular, the inaccessibility of the vascular lesion, anatomic distortion, and the inherent problems associated with operating in a traumatized and often contaminated field are among these limiting factors. As a result, endovascular therapy has emerged as an important potential alternative. This paper focuses on the application of endovascular therapy to the trauma patient, based on our experience and those previously published by other groups. Injuries to the carotid, femoral, axillary/subclavian and iliac arteries, as well as to the abdominal and thoracic aorta, have been successfully managed by stent-grafting. Despite the potential benefits of this mode of therapy, its long-term utility will depend on our ability to overcome certain limitations associated with the technique, and on careful patient selection. [ABSTRACT FROM AUTHOR]

Minimally invasive techniques have greatly influenced the practice of surgery in the past two decades, especially the vascular surgical specialty. Current technological advances and refinements have allowed for the application of less invasive or percutaneous endovascular techniques to the treatment of arterial aneurysms and peripheral vascular occlusive disease. While balloon angioplasty and stenting for occlusive disease have proven successful in certain vascular beds (such as common iliac arteries), infrainguinal results are generally less impressive. This paper reviews the results of the application of covered stent-grafts to peripheral arterial occlusive disease, both at the aortoiliac and infrainguinal anatomical levels. The review includes the results of iliac artery stented graft placement utilizing a combined open surgical and endovascular technique at Mount Sinai Medical Center. [ABSTRACT FROM AUTHOR]

Focuses on paraplegia following endovascular thoracic aortic aneurysm repair. Determinants of spinal cord ischemia; Infrarenal aortic aneurysm repair.

Background: The practice of day care surgery is less embraced in many low‐middle‐income countries (LMIC), and even less for some procedures considered major such as thyroidectomy. Here we examine the safety of day care thyroidectomy at Kyabirwa Surgical Center, a stand‐alone day care surgery center in rural Eastern Uganda. Methods: This was a retrospective cohort study conducted between 2019 and 2023. All patients who had day care thyroidectomy were included. Demographics, diagnosis, investigation findings, pathology reports, and surgery outcomes were collected. Postoperative follow‐up data up to 30 days were also collected. Data were analyzed using R version 4.3.2. Results: A total of 51 patients underwent same‐day thyroidectomy, with an average age of 44.9 ± 12.1 years and 98% female. Procedures included total thyroidectomy (5, 9.8%), subtotal thyroidectomy (26, 51.0%), and lobectomy (20, 39.2%). Average size of the glands was 7.9 ± 2.21 cm. The majority 46 (90.2%) were of benign pathology. All patients were discharged by the evening of the same day. Complications encountered included hypocalcemia (1), hypertrophic scar (1), seroma (2), and transient recurrent laryngeal nerve injury (1). Overall complications rate was 9.8%. Gland size was statistically significant between patients with no complications (7.68 ± 2.06 cm) versus complications (9.90 ± 2.82, p < 0.05). Conclusion: With overall low complication rates, these findings suggest that thyroidectomy can safely be performed on a day care basis in a rural LMIC setting with suboptimal health care delivery. [ABSTRACT FROM AUTHOR]

Introduction: Improving surgical access in low- and middle-income countries is vital for the 5 billion people who lack safe surgical care. Tailoring a culturally sensitive approach to consent is essential for patient comprehension and comfort, thereby alleviating the effects of resource constraints and advancing equitable care. This study examines the consenting process for endoscopy at Kyabirwa Surgical Center in Kyabirwa, Jinja, Uganda, to assess patients' knowledge and attitudes as a potential barrier to participating in endoscopic procedures. Methods: All adult upper endoscopy (EGD) and colonoscopy patients were recruited to participate in a survey of their demographics, knowledge, and attitudes toward their procedure. All patients received a standard consultation explaining the procedure and its risks and benefits. Results: 75 patients were included; median age was 54 years and 56% (n = 42) were women. 92% (n = 69) of patients had never had an endoscopy before and 73% (n = 55) of patients were scheduled for an EGD while the remaining 27% (n = 20) were scheduled for a colonoscopy. Most patients 80% (n = 60) had a basic understanding of what an endoscopy is and 87% (n = 65) its diagnostic purpose. Few patients 15% (n = 11) knew of the most common side effects or if they would have a surgical scar 27% (n = 20). Overall, 46.7% (n = 35) of patients were moderately or severely fearful of getting an endoscopy. Additionally, 45.3% (n = 34) of patients were moderately or severely fearful of receiving anesthesia during their endoscopic procedure. Despite this fear, most patients 85.3% (n = 64) stated that they understood the benefits of the procedure either very well or extremely well. Conclusions: Most patients understood the role that an endoscopic procedure plays in their care and its potential benefits. Despite this, many patients continued to have high levels of fear associated with both the endoscopic procedure and with receiving anesthesia during their procedure. Future patient education should focus on addressing patients' fears and the risks of undergoing an endoscopy, which may improve the utilization of surgical services. [ABSTRACT FROM AUTHOR]

Background: Access to minimally invasive surgery (MIS) is limited in Sub‐Saharan African countries. In 2019, the Mount Sinai Department of Surgery in New York collaborated with local Ugandans to construct the Kyabirwa Surgical Center (KSC), an independent, replicable, self‐sustaining ambulatory surgical center in Uganda. We developed a focused MIS training program using a combination of in‐person training and supervised telementoring. We present the results of our initial MIS telementoring experience. Methods: We worked jointly with Ugandan staff to construct the KSC in the rural province of Jinja. A solar‐powered backup battery system ensured continuous power availability. Underground fiber optic cables were installed to provide stable high‐speed Internet. The local Ugandan general surgeon (JOD) underwent a mini‐fellowship in MIS and then trained extensively using the Fundamentals of Laparoscopic Surgery program. After a weeklong in‐person session to train the Ugandan OR team, JOD performed laparoscopic cases with telementoring, which was conducted remotely by surgeons in New York via audiovisual feeds from the KSC OR. Results: From October 2021 to February 2024, JOD performed 61 telementored laparoscopic operations at KSC including 37 appendectomies and 24 cholecystectomies. Feedback was provided regarding patient positioning, port placement, surgical technique, instrument use, and critical steps of the operation. There were no intra‐operative complications. Postoperatively, field medical workers visited patients at home to collect follow‐up information. Two superficial wound infections (3.3%) were reported in the short‐term follow‐up. Conclusion: Telementoring can be safely implemented to assist surgeons in previously underserved areas to provide advanced laparoscopic surgical care to the local patient population. [ABSTRACT FROM AUTHOR]

Background: New York City was the epicenter of the initial surge of the COVID-19 pandemic in the United States. Tracheostomy is a critical procedure in the care of patients with COVID-19. We hypothesized that early tracheostomy would decrease the length of time on sedation, time on mechanical ventilation, intensive care unit length of stay, and mortality. Methods: A retrospective analysis of outcomes for all patients with COVID-19 who underwent tracheostomy during the first year of the COVID-19 pandemic at the Mount Sinai Hospital in New York City, New York. All adult intensive care units at the Mount Sinai Hospital, New York. Patients/subjects: 888 patients admitted to intensive care with COVID-19. Results: All patients admitted to the intensive care unit with COVID-19 (888) from 1 March 2020 to 1 March 2021 were analyzed and separated further into those intubated (544) and those requiring tracheostomy (177). Of those receiving tracheostomy, outcomes were analyzed for early (≤12 days) or late (>12 days) tracheostomy. Demographics, medical history, laboratory values, type of oxygen and ventilatory support, and clinical outcomes were recorded and analyzed. Conclusions: Early tracheostomy resulted in reduced duration of mechanical ventilation, reduced hospital length of stay, and reduced intensive care unit length of stay in patients admitted to the intensive care unit with COVID-19. There was no effect on overall mortality. [ABSTRACT FROM AUTHOR]

Focuses on the development of minimally invasive vascular surgery or endovascular therapy. Overview of the improvements in diagnostic arteriography; Information on the minimally invasive catheter-based therapy introduced by Fogarty; Examples of therapeutic devices for the technique.

Background: There is a significant, unmet need for endoscopy services in rural Uganda. With limited diagnostic and therapeutic interventions, patients in these communities often present with advanced disease. Practicing surgeons must continually adapt to new techniques to meet the needs of their patient populations. Here, we present a remotely proctored endoscopy training program for a surgeon practicing in an area devoid of endoscopic capabilities. Methods: This was a retrospective case series conducted between February 2020 and December 2022 at Kyabirwa Surgical Center (KSC). After a 1-week in-person training camp, one surgeon performed endoscopy under guidance of a remote proctor. Patient data and outcomes were collected retrospectively. Results: The previously endoscopic naïve practicing Ugandan surgeon was remotely proctored for 139 endoscopic cases and he subsequently independently performed 167 diagnostic colonoscopies and 425 upper endoscopies. Therapeutic endoscopy was conducted under remote guidance after proficiency in diagnostic endoscopy. A total of 43 therapeutic procedures were performed, including 29 esophageal stent placements, 5 variceal bandings, and 9 foreign body retrievals. All procedures were completed without complication. Conclusion: Our center developed a remotely proctored endoscopy program that allowed for training of practicing surgeons in an area lacking endoscopic services. Despite its limitations, remotely proctored endoscopy serves as a unique but highly valuable method of expanding access to endoscopy, particularly in areas that lack adequate training opportunities. [ABSTRACT FROM AUTHOR]

Introduction: In low- and middle-income countries (LMICs), surgical care can be limited by access to pathology services. In Uganda, the pathologist-to-population ratio is less than 1 to 1 million people. The Kyabirwa Surgical Center in Jinja, Uganda, created a telepathology service in collaboration with an academic institution in New York City. This study demonstrated the feasibility and considerations of implementing a telepathology model to supplement the critical pathology needs of a low-income country. Methods: This was a retrospective, single-center study of an ambulatory surgery center with pathology capability using virtual microscopy. The remote pathologist (also known as a telepathologist) controlled the microscope and reviewed histology images transmitted across the network in real time. In addition, this study collected demographics, clinical histories, the surgeon's preliminary diagnoses, and the pathology reports from the center's electronic medical record. Results: Nikon's NIS Element Software was used as a dynamic, robotic microscopy model with a video conferencing platform for communication. An underground fiber optic cable established Internet connectivity. After a two-hour tutorial session, the lab technician and pathologist were able to proficiently use the software. The remote pathologist read (1) pathology slides with inconclusive reports from external pathology labs, and (2) tissues labeled by the surgeon as suspicious for malignancy, which belonged to patients who lacked financial means for pathology services. Between April 2021 and July 2022, tissue samples of 110 patients were examined by a telepathologist. The most common malignancies on histology were squamous cell carcinoma of the esophagus, ductal carcinoma of the breast, and colorectal adenocarcinoma. Conclusion: With the increasing availability of video conference platforms and network connections, telepathology is an emerging field that can be used by surgeons in LMICs to improve access to pathology services, confirming histological diagnosis of malignancies to ensure appropriate treatment. [ABSTRACT FROM AUTHOR]

Objective/Introduction: Increased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following EVAR in AAA patients. Methods: Patients who underwent elective EVAR between 2004 and 2018 were reviewed. Thoracic tortuosity index (TTI) was measured using 3D reconstruction software. Patients were dichotomized across the median TTI into high tortuosity [HT] (TTI >1.27, Figure1(a)) and low tortuosity [LT] (TTI ≤1.27, Figure 1(b)) groups. Perioperative complications, postoperative outcomes, and CT-based features of thoracic aortic wall degeneration (Figure 1(c)-(e)) were collected and analyzed. Results: 136 patients underwent treatment: 70 HT patients, including 54 males and 16 females (mean age: 77 years), and 66 LT patients, including 62 males and 4 females (mean age: 70 years) (age; P <.001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P =.045, P =.01). Presence of degenerative aortic wall markers was greater in HT patients (P =.045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P =.002). Frequency of AAA rupture/dissection was 4.3% for HT and 1.5% for LT (P =.339). A trend was observed in all cause 30-day mortality in the HT group (P =.061). Other perioperative complications and postoperative outcomes were similar between groups. Conclusion: High TTI was associated with older age at time of EVAR, greater prevalence of degenerative markers in the descending thoracic aortic wall, and widespread aorto-iliac dilation. While not predictive of EVAR outcomes, TTI can provide valuable information regarding aneurysm pathophysiology. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the editors discuss articles on the use of endovascular surgery in the treatment of vascular diseases.

Evaluates the efficacy of a balloon-expandable Palmaz stent common iliac artery occluder device for endovascular stent-graft repair in eighty-four patients with aortoiliac aneurysms. Description of the device; Occurrence of infrarenal aortic rupture during deployment of aortic stent; Delayed occluder device-related complications.

The article focuses on a surgical activity related to the transfemoral repair of an abdominal aortic aneurysm, that was performed on a 70-year-old woman. A Dacron prosthetic graft was sutured to a balloon-expandable metallic stent and inserted under local anesthesia through a right femoral-artery cutdown with an enlarging, tender 5.6-cm abdominal aortic aneurysm. Aortography disclosed the aneurysm and a tortuous aorta, and computed tomography identified the aneurysm and minimal mural thrombus. Figure related to the above experiment is also presented.

Abstract: Polysaccharides are biopolymers that have excellent biocompatibility and biodegradability and have been considered for a wide range of pharmaceutical and biomedical applications. In this work polysaccharide-based superabsorbent aerogels are prepared using a combination of sol-gel and supercritical fluid technology. The advantages of supercritical drying are the reduced gel shrinkage, higher porosity, and three-dimensional network of the aerogel morphology compared to the morphology obtained with conventional air or vacuum drying methods. The aerogel open-porous structure and high surface area promotes rapid water absorption into the aerogel matrix by capillary force. Aerogel structural properties are modified by using different cross-linking ions and different alginate molecular weights and the influence of the aerogel properties on water absorption capacity is presented. Scanning electron microscopy is used to characterize the aerogel surface morphology, and nitrogen adsorption/desorption measurements are used to obtain information on the aerogel surface area, pore size, and pore volume. A unique feature of alginate aerogels is that they absorb more saline compared to distilled water, which is opposite to the behavior of regular superabsorbents. A gram of alginate aerogel absorbs as much as 120g of saline (0.9wt% aq. NaCl solution) solution compared to 20g of distilled water. The results from these analytical methods highlight the improved product characteristics of the aerogels synthesized using sol–gel processing technology combined with supercritical fluid technology. [Copyright &y& Elsevier]

Aneurysms of the tibioperoneal trunk and anterior tibial artery are extremely rare. There are only a few case reports of this entity, for which the majority are secondary to prior trauma or bacteremia and endocarditis. We describe a case of spontaneous pseudoaneurysms of the right anterior tibial artery and tibioperoneal trunk. The pseudoaneurysms were thrombosed on follow-up computed tomography angiography and the patient has been asymptomatic. The patient is being treated conservatively and remains asymptomatic at 1 year of follow-up. [ABSTRACT FROM AUTHOR]

Despite improvements in diagnostic and therapeutic methods and an increased awareness of their clinical significance, abdominal aortic aneurysms (AAAs) continue to be a major source of morbidity and mortality. Endovascular repair of AAAs, initially described in 1990, offers a less-invasive alternative to conventional open repair. The technology and devices used for endovascular repair of AAAs have progressed rapidly and the approach has proven to be safe and effective in short to midterm investigations. Furthermore, several large trials have demonstrated that elective endovascular repair is associated with lower perioperative morbidity and mortality than open repair. The long-term benefits of endovascular repair relative to open repair, however, continue to be studied. In addition to elective repair, the use of endovascular repair for ruptured AAAs has been increasing, and has been shown to be associated with reduced perioperative morbidity and mortality. Advances in endovascular repair of AAAs, including the development of branched and fenestrated grafts and the use of implantable devices to measure aneurysm-sac pressures following stent-graft deployment, have further broadened the application of the technique and have enhanced postoperative monitoring. Despite these advances, endovascular repair of AAAs remains a relatively novel technique, and further long-term data need to be collected. [ABSTRACT FROM AUTHOR]

Introduction: With the aging U.S. population, peripheral vascular procedures will become increasingly common. The objective of this study is to characterize the factors associated with increased total costs after peripheral bypass surgery. Methods: Data for 34,819 patients undergoing peripheral bypass surgery in NY State were extracted using the Statewide Planning and Research Cooperative System (SPARCS) database for years 2009-2017. Patient demographics, All Patient Refined Diagnostic Related Groups (APR) severity score, mortality risk, hospital volume, and length of stay data were collected. Primary outcomes were total costs and length of stay. Data were analyzed using univariate and multivariate analysis. Results: 28.1% of peripheral bypass surgeries were performed in New York City. 7.9% of patients had extreme APR severity of illness whereas 32.0% had major APR severity of illness. 6.3% of patients had extreme risk of mortality and 1 in every 5 patients (20%) had major risk of mortality. 24.9% of patients were discharged to a facility. The mean length of stay (LOS) was 9.9 days. Patient LOS of 6-11 days was associated with +$2,791.76 total costs. Mean LOS of ≥ 12 days was associated with + $27,194.88 total costs. Multivariate analysis revealed risk factors associated with an admission listed in the fourth quartile of total costs (≥$36,694.44) for peripheral bypass surgery included NYC location (2.82, CI 2.62-3.04), emergency surgery (1.12, CI 1.03-1.22), extreme APR 2.08, 1.78-2.43, extreme risk of mortality (2.73, 2.34-3.19), emergency room visit (1.68, 1.57-1.81), discharge to a facility (1.27, CI 1.15-1.41), and LOS in the third or fourth quartile (11.09, 9.87-12.46). Conclusion: The cost of peripheral bypass surgery in New York State is influenced by a variety of factors including LOS, patient comorbidity and disease severity, an ER admission, and discharge to a facility. [ABSTRACT FROM AUTHOR]

Purpose: Surgery is the only curative therapy for carcinoid patients; however, many are unresectable due to direct involvement of the superior mesenteric artery (SMA) branches. In these patients, we sought to improve surgical outcomes via arterial skeletonization of the SMA prior to surgical resection. Materials and methods: After left radial access, the SMA was catheterized, angiography was performed, and balloon occlusion was achieved in the tumor vessel. Following balloon occlusion of the affected artery, patients were assessed for symptoms of ischemia and angiographic evidence of distal perfusion via collaterals. If patients tolerated occlusion, an endovascular plug was deployed in the affected artery; if not, the procedure was terminated. The next day, all patients underwent exploratory laparotomy and surgical resection of tumor and bowel. Results: The procedure was performed 15 times on 14 patients. 13 out of 15 procedures went to embolization, while the other 2 proceeded to surgery without plug deployment. One of the embolized patients had serious post-surgical complications, while both non-embolized patients developed complications including short bowel syndrome and ischemic colitis. Length of stay between embolized and non-embolized patients was equal, but re-admittance within 30 days was 7.7% in the embolized group and 100% in the non-embolized group. Discussion: Our initial experience demonstrates feasibility and safety of deploying plugs within branches of the SMA prior to surgical resection and improved surgical outcomes. Palpation of the plug assisted in surgical resection. We have demonstrated that pre-operative endovascular occlusion is a safe, practical procedure, which aids surgical resection of mesenteric carcinoid disease. [ABSTRACT FROM AUTHOR]

Introduction: Extracranial carotid artery aneurysms and pseudoaneurysms (ECCAs) are rare pathologies with various etiologies, presentations, and management strategies. Historically, open aneurysm resection and arterial repair have been the gold standard management of ECCAs. Our study examines the evolving experience with endovascular management of ECCAs. Methods: We performed a literature review of multiple studies on endovascular and open management of carotid artery aneurysms and pseudoaneurysms. Conclusions: Endovascular stenting is technically feasible and clinically effective for the treatment of carotid artery aneurysms and pseudoaneurysms. Further follow-up is required regarding long-term safety and efficacy. [ABSTRACT FROM AUTHOR]

Historically, the gold standard for treating acute uncomplicated type B aortic dissection (TBAD) has been aggressive medical therapy to achieve optimal heart rate and blood pressure control. However, recent data have demonstrated that a significant proportion of patients with medically managed acute uncomplicated TBAD have late aorta-related complications, such as aneurysmal degeneration, that increase mortality and often necessitate surgical intervention. In this review, the authors review existing literature on uncomplicated TBAD and highlight contemporary surgical and medical strategies to manage this condition. Looking ahead, efforts are underway to identify and characterize a high-risk subgroup of acute uncomplicated TBAD patients who may benefit from early intervention. [ABSTRACT FROM AUTHOR]

Extracranial carotid artery aneurysms located in the cervical region in close proximity to the skull are difficult to access using open surgical methods. Endovascular treatment has emerged as an alternative option for anatomically challenging internal carotid artery aneurysms. However, data comparing various endovascular techniques including stent grafting, coil embolization, double stenting, and stent-assisted coil embolization are lacking, making it difficult to determine the optimal treatment. We present a case of a patient with 2 fusiform extracranial carotid artery aneurysms treated successfully with a combination of double stenting and stent-assisted coil embolization. We also discuss technical considerations for selecting the appropriate endovascular intervention. [ABSTRACT FROM AUTHOR]

Disaster relief is an interdisciplinary field dealing with the organizational processes that help prepare for and carry out all emergency functions necessary to prevent, prepare for, respond to, and recover from emergencies and disasters caused by all hazards, whether natural, technological, or human-made. Although it is an important function of local and national governing in the developed countries, it is often wanting in resource-poor, developing countries where, increasingly, catastrophic disasters tend to occur and have the greatest adverse consequences. The devastating January 12, 2010, Haiti earthquake is a case study of the impact of an extreme cataclysm in one of the poorest and most unprepared settings imaginable. As such, it offers useful lessons that are applicable elsewhere in the developing world. Emergency preparedness includes 4 phases: mitigation or prevention, preparedness, response, and recovery. Periods of normalcy are the best times to develop disaster preparedness plans. In resource-poor countries, where dealing with the expenses of daily living is already a burden, such planning is often neglected; and, when disasters strike, it is often with great delay that the assistance from international community can be deployed. In this increasingly interconnected world, the Haiti earthquake and the important international response to it make a strong case for a more proactive intervention of the international community in all phases of emergency management in developing countries, including in mitigation and preparedness, and not just in response and recovery. Predisaster planning can maximize the results of the international assistance and decrease the human and material tolls of inevitable disasters. There should be a minimum standard of preparedness that every country has to maintain and the international assistance to achieve that. International academic medical centers interested in global health could strengthen their programs by prospectively including in them contingency planning for international relief operations. Healthcare professionals of these institutions who travel to disaster zones should rigorously prepare themselves and make provisions for collecting and reporting data, which will enrich the knowledge of this growing activity. © 2011 Mount Sinai School of Medicine [ABSTRACT FROM AUTHOR]

Objective: We evaluated the results of thoracic endovascular aneurysm repair (TEVAR) to determine what anatomic factors influenced the clinical outcomes. Methods: Preoperative computed tomography (CT) angiograms of 65 patients who underwent TEVAR were analyzed using 3-dimensional imaging. The proximal and distal neck, thoracic aneurysm, and iliac arteries were measured for angulation, diameter, length, calcification, and tortuosity. Immediate technical success and clinical success were measured. Results: Immediate technical success was achieved in 91% (59 of 65) of the patients analyzed. One patient died in the operating room during treatment of rupture. Clinical success was achieved in 83%(54 of 65) of patients at follow-up. Four patients had small endoleaks with no sac enlargement at follow-up. One patient was converted to open repair. Severe iliac calcification was found to be significant for deployment failure. The mean follow-up is 8 months (1-36 months). Conclusion: Increased iliac calcification and increased iliac tortuosity correlate with an inability to successfully deploy the device. [ABSTRACT FROM AUTHOR]

Renal artery stenosis may cause or exacerbate hypertension and renal failure. Percutaneous transluminal renal artery stent placement, increasingly the firstline therapy for ostial atherosclerotic renal artery stenosis, can be complicated by instent restenosis weeks to months after the procedure. There is currently no consensus for the treatment of in-stent restenosis. Sirolimus-eluting stents have been shown to be effective to treat in-stent restenosis in the coronary circulation. We report a case of sustained 24-month patency after repair of recurrent renal artery instent restenosis with use of a sirolimus-eluting stent. [ABSTRACT FROM AUTHOR]

Objective: We reviewed our institution's experience with carted artery pseudo-occlusion (CAPO), to investigate whether internal carted artery (ICA) end-diastolic velocity (EDV) as measured by duplex ultrasonography, was a predictor of need for further intervention. Methods: From February 2003 to January 2008, 7478 patients underwent duplex ultrasonographic evaluation of their carted arteries. Diagnosis of CAPO included the appearance of a narrow flow jet (string sign) on power doppler images, low velocities in the ICA and additional criteria listed below. Results: Ten patients (0.13%) were identified as having a CAPO. All patients were asymptomatic and had anEDV<78cm/s.Occlusion or functional occlusion was identified in nine patients on contrast imaging studies. Eight of these patients were treated medically without neurologic complication on follow-up. Two patients were treated with interventions and were asymptomatic at follow up. The mean follow up for the entire group was 12 months. Conclusions: Although this is a low volume study, there is evidence to suggest that asymptomatic patients with lowEDV in the setting of carted artery pseudo-occlusion found of duplex, may be safely managed medically. [ABSTRACT FROM AUTHOR]

Visceral artery aneurysms, although uncommon, can present with life-threatening hemorrhage. The increasing use of imaging studies has allowed for earlier identification and intervention of these aneurysms, thus avoiding the high morbidity and mortality associated with rupture. The treatment options for visceral artery aneurysms range from conventional open surgical repair to minimally invasive techniques using covered stents or embolization materials. Anatomic features and patient selection determine which treatment option would result in the most durable treatment and outcome. This article reviews our experience with the endovascular treatment of visceral artery aneurysms. [ABSTRACT FROM AUTHOR]

Objective: The clinical significance of Type 2 endoleak after endovascular repair of abdominal aortic aneurysms (AAA) remains incompletely delineated. This study describes the development of a novel canine model that allows for continuous monitoring of intraaneurysmal pressure in the setting of Type 2 endoleak. Methods: Infrarenal AAA were created in 10 mongrel dogs by implanting a prosthetic aneurysm containing an intraluminal, solid-state, strain gauge pressure transducer which is able to measure pressures in both solid and liquid media. A segment of native aorta with two or more patent side branch vessels was reimplanted into the prosthetic aneurysm using a Carrel patch. Four animals had two lumbar vessels implanted; two had two lumbar vessels and the caudal mesenteric artery implanted, and four control animals had no vessels reimplanted. Retrograde flow in the aneurysmal side branches caused a Type 2 endoleak after the aneurysm was excluded from antegrade flow by deploying a stent graft. Both systemic and intra-sac pressures were measured daily for up to 90 days after endovascular exclusion and indexed to systemic pressure. Endoleak patency and flow were assessed with digital subtraction angiography, duplex ultrasound, and cine-magnetic resonance angiography (MRA). Histological characterization of the intraaneurysmal contents was performed. Results: Before endovascular exclusion, the systolic, mean arterial, and pulse pressure within the aneurysmal sac closely matched that of the systemic circulation (systolic, 0.96 ± 0.22; mean, 0.94 ± 0.21; pulse pressure, 0.97 ± 0.22) (R value, 0.97). Endovascular exclusion in animals with no collateral side branch vessels resulted in no endoleak and significantly reduced intraaneurysmal pressure when compared to systemic pressure, with systolic, mean arterial, and pulse pressure 0.172 ± 0.05, 0.137 ± 0.05, and 0.098 ± 0.02, respectively (P < 0.001). In animals with Type 2 endoleaks, the pressures were lower than systemic pressure, but statistically significant in their difference from the control group. The systolic pressure of those with Type 2 endoleaks was 0.702 ± 0.048; mean arterial pressure was 0.784 ± 0.028, and pulse pressure was 0.406 ± 0.031 when indexed to systemic pressure (P < 0.001). Cine-MRA and Duplex ultrasound documented persistent patency of the Type 2 endoleaks throughout the study period in animals with multiple side branches. Conclusion: Intraaneurysmal pressure in the setting of Type 2 endoleaks may be accurately determined using this canine model. Intraaneurysmal pressure is maintained at a significant level in the context of this retrograde collateral perfusion, suggesting that persistent Type 2 endoleaks are of clinical significance. This model may serve to allow further evaluation and characterization of Type 2 endoleaks. [Copyright &y& Elsevier]

Minimally invasive endovascular techniques for the treatment of abdominal aortic aneurysm have significantly reduced its morbidity compared to that following standard surgical repair. Moreover, patients with extensive comorbid medical illnesses, for whom standard operative repair is contraindicated may be successfully treated using endovascular means. The full limitations and indications for use of endovascular grafts have not yet been fully defined. The effectiveness of commercially fabricated devices is currently being evaluated. This article describes the general principles of use for endovascular devices for the repair of abdominal aortic aneurysms and details the features of the devices currently in use, as well as the typical results. [ABSTRACT FROM AUTHOR]

Utilization of percutaneous interventions for arterial and venous occlusive lesions continue to increase. With the progression of the technology supporting these therapeutic measures, the results of these interventions may be expected to improve. In general, a comparison of techniques for revascularization demonstrates similar initial technical success rates for surgery and percutaneous transluminal angioplasty. Angioplasty is often associated with lower procedural morbidity and mortality rates. Conversely, surgery frequently provides greater long-term patency. Late failure of percutaneous therapies may often be treated successfully with reintervention, however. The continued accumulation of experience with PTA and stenting will ultimately define its role in the management of occlusive disease. [ABSTRACT FROM AUTHOR]

The incidence of acute cholecystitis complicating standard abdominal aortic aneurysm (AAA) repair has been reported between 0.3 and 18 per cent. This has prompted considerable debate regarding the management of cholelithiasis discovered incidentally during open aortic reconstruction. This study seeks to determine the incidence of cholelithiasis and acute cholecystitis after endovascular AAA repair and evaluate options for management. Between February 1996 and October 2001 492 patients underwent endovascular AAA repair. All the procedures were performed in the operating room under fluoroscopic guidance. Epidural (98.9%), local (0.5%), or general (1.7%) anesthesia was used during these cases. The incidence of cholelithiasis and acute cholecystitis was evaluated by CT scan and abdominal ultrasound. Serum measurements of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total and direct bilirubin, and amylase were performed and clinical assessment was conducted at 1, 6, and 12 months postoperatively and annually thereafter. The mean age of these patients was 76.6 years; 84% were male. Comorbid medical conditions were present in all patients (average 3.5 conditions/patient). Follow-up ranged from 2 to 35 months (mean 12.8 months). Endovascular stent graft deployment was successful in 486 of the 492 patients (98.8%). Six patients were converted to standard open repair because of inability to achieve successful endovascular aneurysm repair. The perioperative major morbidity rate was 14.9 per cent. Minor morbidity rate was 8.5 per cent. The perioperative mortality rate was 1.9 per cent. No deaths were related to biliary disease. Cholelithiasis was identified in 64 (13%) patients preoperatively. One of 64 patients with a prior Billroth II reconstruction for peptic ulcer disease developed jaundice 8 days after AAA repair as a result of choledocholithiasis that required surgical repair. One patient without gallstones developed acute acalculous... [ABSTRACT FROM AUTHOR]

Background. Phenotypic variation of vascular smooth muscle cells (VSMC) may result in altered biological behavior and responses. Within the vessel wall, arterial VSMC have a greater propensity to form atherosclerotic lesions as compared to venous VSMC. In this study the rates of proliferation, adhesion, and migration were compared between VSMC of atherosclerotic arterial and venous origin.Materials and methods. Human VSMC cultures were isolated from 18 infragenicular arteries at the time of below knee amputation and from 20 saphenous veins during lower extremity revascularization surgery. Cell cultures were isolated from the media of each specimen and maintained in distinct cell lines for all assays. Cells from passages 2 and 3 were assayed for their proliferative capacity using total DNA fluorescence photometry and for adhesion and migration using a modified Boyden chamber.Results. Patient age and the incidence of atherosclerotic risk factors did not vary significantly between the arterial and the venous patient groups. VSMC of atherosclerotic arterial origin demonstrated greater proliferation (arterial, 162 ± 59 absorption units, vs venous, 106 ± 56 aborption units, P < 0.001), adhesion (arterial, 74.1 ± 22.6 cells/microscopic field, vs venous, 41.3 ± 12.8 cells/microscopic field, P < 0.001) and migration (arterial, 427 ± 185 cells/microscopic field, vs venous, 119 ± 101 cells/microscopic field, P < 0.001) than VSMC of venous origin.Conclusion. Human atherosclerotic arterial VSMC exhibit significantly increased rates of proliferation, adhesion, and migration as compared to human venous VSMC. These observations of VSMC in culture are consistent with the clinical predilection for the hyperplasic responses that result in the development of atherosclerosis in the arterial wall. Possible intrinsic differences in VSMC phenotype should be considered in designing methods to limit atherosclerosis. [Copyright &y& Elsevier]

Background: We endeavored to characterize the anesthesia experience with endovascular aneurysm repair (EVAR) at a large academic medical center in the United States. Methods: A retrospective review of electronic medical records was conducted for all patients undergoing elective EVAR from 2002 to 2007 in a large academic medical center. Results: A total of 522 cases met inclusion criteria, with 4% of cases using general anesthesia (GA), 92% regional anesthesia (RA), and 4% local anesthesia (LA). There was no statistically significant difference between the groups for duration of surgery or in-hospital mortality. In-hospital length of stay was longer for GA than LA or RA. Four cases were converted to open repair. Two mortalities occurred during the perioperative period (0.4% of cases). Conclusions: The vast majority of EVAR were successfully performed under RA, involved mild blood loss, involved infrequent need for conversion to GA, and resulted in brief in-hospital length of stay and low mortality rate. [ABSTRACT FROM AUTHOR]