Search

Placement of extracorporeal membrane oxygenation (ECMO) in obese patients has been challenging; however, cannulation risk in obese patients has not been clearly investigated. We therefore explored ECMO cannulation complications in this obese population. Data were reviewed from adult ECMO database from 2010 to 2019. Patients were stratified by body mass index (BMI) (normal weight [NW] [BMI 18.5-24.9], overweight [BMI 25-29.9], class I [BMI 30-34.9], class II [BMI 35-39.9], class III [BMI >40]). Patients with central cannulation were excluded from this study. Combined ECMO cannulation complications and survival data were retrospectively analyzed. There were 233 patients, 156 venoarterial (VA) ECMO patients (45 [28%] NW, 51 [33%] overweight, 37 [24%] class I, 12 [8%] class II, and 11 [7.0%] class III) and 77 venovenous (VV) ECMO patients (14 [18%] NW, 13 [17%] overweight, 17 [22%] class I, 11 [14%] class II, and 22 [29%] class III). There were significantly more cannulation site bleeds in VA class III (55%) patients compared with VA NW patients (22%), p = 0.006. There was no significant difference in cannulation site bleeding between BMI groups for VV ECMO. There was no difference in 30 day mortality, ECMO survival for all BMI groups in both VA and VV ECMO. There is significant increased risk of bleeding with peripheral VA cannulation of obese patients with BMI > 35. Cannulating surgeon should be aware of this bleeding risk in morbidly obese patient who undergo VA ECMO.

Giant abdominal aortic aneurysms (AAAs) are defined as AAAs >10 to 13 cm in the maximum transverse diameter. We have described a case of a patient who had presented for open repair of an 18-cm AAA and a review of reported cases of giant AAAs >10 cm in the maximum transverse diameter. Forty cases were compiled. The average maximum AAA diameter was 14.5 ± 4.1 cm. The AAA was ruptured on presentation in 12 patients (30%). Of the 40 cases, 34 (85%) were repaired with open surgery. The reported mortality was 15%. Despite the case complexity, five endovascular repairs were attempted.

Complicated type B aortic dissection (TBAD) is a life-threatening condition requiring surgical intervention. One such complication in the acute or chronic setting is aneurysmal degeneration. The dissected aortic wall is weakened, and the pressures in the false lumen are often high. In the past decade, thoracic endovascular aortic repair (TEVAR) has become the treatment of choice for TBAD. TEVAR can be complicated by lack of false lumen thrombosis, increasing the risk of death. We present three cases of TBAD with patent false lumens after TEVAR that were treated by false lumen coil embolization. Keywords: TEVAR, False lumen, Aortic dissection, Coil embolization, Endovascular, Dissecting aortic aneurysm

Axillary artery injury is a rare complication of blunt upper extremity trauma and is reported in the literature on only a few cases. The usual treatment is an open operation with the exclusion of the aneurysm and interposition grafting. Vascular injury in the elderly population after trauma is especially “dangerous” owing to a large cohort of these patients being on anticoagulation. For this reason, any hematoma after blunt trauma must be fully “evaluated” and a careful vascular exam must be undertaken. When the vascular injury is acute as a result of trauma, the typical interventions include an open repair either with an interposition graft or reverse saphenous vein graft. We report a case of a delayed traumatic axillary artery dissection with resultant pseudoaneurysm treated with endovascular stent-grafting.

Ureteroarterial fistula (UAF) is a rare and life-threatening source of hematuria. A high index of suspicion is warranted for early diagnosis and timely intervention. Because of high perioperative risk and comorbidities in UAF patients, the endovascular approach has become preferred for repair. Infection can complicate this mode of therapy, and treatment with antibiotics is important. Herein we present five cases of secondary UAFs treated with stent graft alone or stent graft and embolization. Keywords: Ureteroarterial fistula, Hematuria, Stent graft, Endovascular therapy

Background Functional popliteal artery entrapment syndrome (FPAES) results from hypertrophied gastrocnemius, soleus, and/or plantaris muscles, without an identifiable anatomic abnormality. Historically, FPAES has been managed with surgical myotomy or myomectomy. Herein, we review the literature to evaluate the results of surgery along with a newer treatment (botulinum toxin A injection) for this rare form of claudication. Methods A literature search in PubMed, Cochrane, and Ovid for studies reporting incidence and management of FPAES yielded 3391 publications; 2804 articles were excluded based on initially established exclusion criteria. Ultimately, data were extracted from six articles, from which the number of patients, demographic information, preoperative workup, surgical treatment details, follow-up imaging, and results of treatment were obtained. Results A total of 133 patients were studied. Mean age was 26 years; 57% were female, and noninvasive testing revealed bilateral findings in 39%. Treatment involved surgical myotomy/myomectomy (98; five studies) and botulinum toxin injection (35; two studies). Adjunctive vascular reconstruction was performed in eight of the surgical cases. Patients with FPAES who underwent surgical management were evaluated subjectively for symptomatic improvement, and some patients had duplex ultrasounds in follow-up averaging 25.6 months. Three of 98 patients (3%) had recurrent symptoms, and seven (7%) underwent revision surgical procedures. Complications in the surgical management group included seroma/hematoma (4%, 4/98) and infection (2%, 2/98). For the botulinum toxin treatment group, improvement of symptoms was achieved in 66% of patients at an average follow-up time of ten months. Most patients treated with botulinum toxin did not undergo imaging in follow-up. No complications were reported. Conclusions This review suggests FPAES may be treated successfully with surgical myotomy/myomectomy plus adjunctive vascular reconstruction if necessary. Botulinum toxin A injection may be useful as a diagnostic and therapeutic measure for FPAES.

Objective Vascular groin incision complications contribute significantly to patients' morbidity and rising health care costs. Negative pressure therapy over the closed incision decreases the infection rate in cardiac and orthopedic procedures. This study prospectively evaluated negative pressure therapy as a means to decrease wound complications and associated health care costs. Methods This was a randomized, prospective, single-institution study of 119 femoral incisions closed primarily after elective vascular surgery including both inflow (eg, aortofemoral) and outflow (eg, femoral-popliteal bypass) procedures. Incisions were categorized as high risk for wound complications on the basis of body mass index >30 kg/m2, pannus, reoperation, prosthetic graft, poor nutrition, immunosuppression, or hemoglobin A1c >8% and randomized 1:1 to standard gauze (n = 60) dressing vs negative pressure therapy (Prevena [Acelity, San Antonio, Tex], n = 59). Wound complication rate, length of stay (LOS), reoperation, readmission, and variable hospital costs were determined during 30 days. Statistical analysis was performed using χ2 test along with a two-sample unpaired t-test for continuous variables. Results There were no significant demographic differences (age, sex, risk factors for wound complication) between the two high-risk groups. In low-risk controls, the major wound complication rate was 4.8% (involving one infection in 21 incisions), resulting in a 3.8-day LOS, 4.8% reoperation, 4.8% readmission rate, and $17,599 in average variable cost. For high-risk controls, there was a significant increase in major wound complications to 25% (including all 12 infections in 60 incisions), LOS (10.6 days), reoperation (18.3%), readmission (16.7%), and costs ($36,537). Finally, negative pressure therapy significantly reduced major wound complications to 8.5% (including five of six infections in 59 incisions; P Conclusions This study suggests that negative pressure therapy significantly reduces the major wound complication, reoperation, and readmission rates for patients at high risk for groin wound complications. Furthermore, this therapy may lead to a reduction in hospital costs. Negative pressure therapy for all groin incisions considered at high risk for wound complications is recommended.

Background:While the standard of care for suspected tracheo-innominate artery fistula (TIF) necessitates sternotomy, perioperative mortality remains high. Endovascular interventions have been attempted, but reports have been anecdotal. The aim of this systematic review was to evaluate the outcomes of endovascular management of TIF by pooling the existing evidence.Methods:An electronic database search of Ovid MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Controlled Trials Register was performed to identify all studies examining endovascular treatment of TIF. Patients greater than 14 years of age who underwent endovascular intervention for TIF were included. 25 studies consisting of 27 patients met the inclusion criteria.Results:48.1% (13/27) of patients were male and median age was 39.0 [IQR 16.0, 47.5] years. Tracheostomy was present in 96.3% (26/27) of cases. Median duration from tracheostomy to TIF presentation was 2.2 months [0.5, 42.5]. On presentation, 84.6% (22/26) had tracheal hemorrhage, and 22.8% (6/27) were hemodynamically unstable. 96.3% (26/27) underwent covered stent graft placement while 1 patient (3.8%) had coil embolization. 18.5% (5/27) of patients required repeat endovascular intervention for recurrent bleeding, while 11.1% (3/27) required rescue sternotomy. Median hospital length of stay was 30 days [16.0, 46.5], and overall mortality was 29.6% (8/27) with a median follow-up time of 5 months [1.2, 11.5].Conclusion:While uncommon, endovascular treatment of TIF may be a feasible alternative to sternotomy. The approach may be useful in those who are unable to undergo surgery or are likely to have adhesions from prior chest operations.

Clostridium septicum aortitis is a rare, highly morbid condition typically accompanied by malignant disease, such as hematologic cancer or colon adenocarcinoma. Presenting symptoms commonly described include acute onset of abdominal pain, nausea, and fevers. Prompt diagnosis of infectious aortitis is critical to prevent deadly complications, such as sepsis and vascular catastrophe. The described management largely involves surgical resection of the infected aorta, debridement, and arterial revascularization through extra-anatomic bypass or aortic graft placement.

Background In 2006, the Accreditation Council for Graduate Medical Education (ACGME) approved an integrated 5-year vascular surgery residency program creating a 2-tiered system of training for vascular surgeons. The question remains if the new paradigm is equivalent to the traditional training. The true test of this may be looking at data from fully trained surgeons in their first years of practice. It is hard to obtain this data. There are surrogate methods that can be used. Operative experience of trainees is readily available as a substitute. The purpose of this study is to compare the operative experience of those graduating from the traditional (5 + 2) vascular training program with the integrated (0 + 5) program. Methods National operative case log data supplied by the ACGME was gathered and organized for vascular surgery residents graduating between 2013 and 2019. Mean case numbers were compared between integrated vascular residents and traditional vascular fellows (mean case numbers for vascular fellows included cases from their general surgery residencies). Results The 5 + 2 trainees performed an average of 35% more total procedures than the 0 + 5 trainees (1,662 ± 7 vs. 1,084 ± 12). The greater number of overall procedures performed by the 5 + 2 trainees was primarily realized by an increased number of abdominal (e.g., biliary, small/large intestine) cases. However, the 0 + 5 trainees performed 8% more vascular procedures (858 ± 10 vs. 794 ± 3). The greater number of vascular procedures performed by the 0 + 5 trainees was primarily realized by increased mean numbers of endovascular and venous procedure cases. Conclusions The integrated 0 + 5 graduates performed more total vascular procedures than their 5 + 2 counterparts. The overall total operative experience remains greater for the traditional 5 + 2 graduates, given their additional 2 years of training. Further longitudinal studies will be needed to fully assess the effect of the newer integrated 0 + 5 training paradigm.

Wound management is an important component of the care for neurosurgical patients. Improper wound management can lead to patient suffering, morbidity, increased length of stay, readmission, increased cost of care, and, in some cases, infection, sepsis, and mortality. The neurosurgeons manage the neurosurgical wounds. In contrast, pressure wounds are usually managed by a team led by the hospitalist. In this chapter, the authors outline the standards of care for management of pressure injuries prior to, during, and after neurosurgery procedures. The focus will be on the role of the hospitalist in this process. The crucial role of the collaboration among hospitalists, nursing staff, neurosurgeons, wound specialists, and general surgeons will be highlighted. The authors emphasize the role of evidence-based management in this process and propose an algorithm for the care of these wounds based on current understanding. Finally, the areas of needed research to achieve the best level of care are explored.

Objective: Mycotic rupture of the arteries is a rare but deadly disorder. Current management typically involves open surgical repair. However, endovascular repair is a potential treatment that can be used to delay open repair, especially in acutely unstable patients. A case report and review of the literature was conducted to determine whether endovascular therapy could be a destination therapy for patients with arterial rupture secondary to infection. Methods: We present the case of a 72-year-old man with a left common iliac artery aneurysm rupture secondary to Salmonella infection treated with endovascular therapy upon initial presentation. A literature review of PubMed yielded 29 patients with ruptured aortic and iliac infected aneurysms that were initially treated with endovascular repair. Results: Majority of the patients (76.7%, 23 of 30) were successfully treated with the endovascular treatment and did not require open revision. These patients were often placed on long-term antibiotics. Conclusion: The literature review supports endovascular repair with a stent graft as a temporizing measure for infected ruptured arteries in an emergent setting and, in select cases, as a destination therapy.

The authors aimed to improve the rate of pre-dialysis arteriovenous (AV) access placement for hospitalized patients with advanced chronic kidney disease. The authors developed and implemented a protocol for hospitalized adult patients with an estimated glomerular filtration rate

Background Type IIIB endoleak from material failure can lead to aneurysmal sac enlargement and latent rupture after endovascular repair of abdominal aortic aneurysm. Long-term durability of the endovascular stent graft is largely unknown, and the complication rate from device failure due to material fatigue may be underappreciated. In addition, even with advancement in imaging techniques, recognition of type IIIB endoleak can be challenging, which can lead to delay in intervention. Methods A review of the literature was performed in PubMed and Google Scholar, yielding 23 articles with 46 case reports of type IIIB endoleak from various Food and Drug Administration-approved stent grafts after endovascular repair of infrarenal abdominal aortic aneurysm. Results The most common location of type IIIB endoleak occurred in the main body (34.8%), followed by the area of the flow divider (32.6%). Sac growth was identified in 63% (29/46) of cases. Diagnosis of the endoleak occurred an average of 54.3 months after the index operation. Endovascular repair was the primary approach for elective repair of type IIIB endoleak (61.3% vs 13.3%). Perioperative mortality was higher in ruptured or symptomatic patients compared with patients undergoing elective repair (33.3% vs 6.5%). Conclusions The actual incidence of type IIIB endoleak is still lacking, and the etiology may be multifactorial. Therefore, suspicion of type IIIB endoleak requires appropriate imaging techniques and prompt intervention to reduce the perioperative mortality rate.

Objective To report the safe and effective treatment of celiac axis aneurysm (CAA) using a covered stent plus coil embolization of the gastric and splenic arteries, and to assess the results of similar cases treated using endovascular techniques. Methods Case report and PUBMED literature review (2000–2013) of cases treated using endovascular techniques. Results Successful exclusion of an enlarging CAA was performed using a covered stent placed from the origin of the axis into the common hepatic artery via a brachial approach; concomitantly, the splenic and gastric arteries were embolized. A PUBMED literature review revealed the successful endovascular treatment of CAA in 25. Stent graft exclusion was described a total of seven times: three within the axis itself, three landing in the splenic artery, and one landing in the hepatic artery. Conclusions Various methods of endovascular treatment of CAA have been reported to be safe and effective. Depending upon anatomy, this report suggests that preservation of blood flow to the hepatic artery with coil embolization of the gastric and splenic arteries is effective in treating this condition while maintaining important foregut blood flow.

Aberrant right subclavian artery is a rare anatomical finding of abnormal embryologic development of the dorsal aorta and right subclavian artery. An associated aortic outpouching, or Kommerell diverticulum, may develop at the origin of the aberrant right subclavian artery. Given historically high rates of aneurysm rupture and mortality, early repair is indicated. Successful aneurysm exclusion can be accomplished with thoracic endovascular stent grafting following open carotid-subclavian bypass, maintaining upper extremities perfusion. Such hybrid techniques offer a decrease in mortality and complication rates. Herein, we describe a successful repair of a symptomatic (dysphagia, weight loss) aberrant right subclavian artery with Kommerell diverticulum using this hybrid open-endovascular approach.

Mycotic aortic aneurysms are rare occurrences and such aneurysms associated with Streptococcus pneumoniae are seldom seen in the current antibiotic era. We present the unusual case of a 68-year-old healthy female with a Streptococcal mycotic abdominal aortic aneurysm of unknown etiology treated with antibiotics and open surgical intervention. Postoperative imaging revealed multiple new thoracic mycotic aortic aneurysms for which she was treated with thoracic endovascular aortic repair. Sequential abdominal and thoracic Streptococcal mycotic aortic aneurysms treated with a combination of open and endovascular surgery demonstrate a unique and rare case.

Endovenous ablation is a newer therapy for treating superficial veins in patients with chronic venous disease. The saphenous veins and their accessory veins can be treated. Radiofrequency and laser energy are used to ablate the veins. Accurate ultrasound mapping is needed to plan and perform these procedures. The length and the number of the veins treated are determined. The diameter of the vein, its distance from the skin, and segments with tortuosity, thrombosis, and anatomic variations are documented. During the procedure the access in the vein, and the introduction of the wire, sheath, catheter, and tumescent anesthesia are done under ultrasound guidance. The success of the procedures and the complications are monitored. In most studies, the failure rate is 10% or less at 2 years, and the prevalence of deep vein thrombosis is less than 3%. Currently, endovenous ablation has become the method of choice for treating superficial veins and it has almost replaced the traditional ligation and stripping.

Patients with a uretero-iliac artery fistula (UIAF) are at an elevated risk of life-threatening hemorrhage. Identification and treatment of the fistula may be challenging, and requires the combined expertise of a urologist and endovascular specialist. This manuscript provides a list of equipment needed and describes our technique for diagnosing and treating a UIAF.

Traumatic axonal injury (TAI) is one of the most important pathologies associated with closed head injury, and contributes to ensuing morbidity. The authors evaluated the potential role of calpains in TAI using a new model of optic nerve stretch injury in mice. Male C57BL/6 mice were anesthetized, surgically prepared, and subjected to a 2.0-mm optic nerve stretch injury (n = 34) or sham injury (n = 18). At various intervals up to 2 weeks after injury, optic nerves were examined for neurofilament proteins and calpain-mediated spectrin breakdown products using immunohistochemistry. In addition, fluorescent tracer was injected into the superior colliculi of mice 1 day before they were killed, to investigate the integrity of retrograde axonal transport to the retina. Optic nerve stretch injury resulted in persistent disruption of retrograde axonal transport by day 1, progressive accumulation and dephosphorylation of neurofilament protein in swollen and disconnected axons, and subsequent loss of neurofilament protein in degenerating axons at day 14. Calpains were transiently activated in intact axons in the first minutes to hours after stretch injury. A second stage of calpain-mediated proteolysis was observed at 4 days in axonal swellings, bulbs, and fragments. These data suggest that early calpain activation may contribute to progressive intra-axonal structural damage, whereas delayed calpain activation may be associated with axonal degeneration.

Objective As vascular surgery training paradigms evolve, one measure of success is operative experience. This study assessed the initial operative experience of those graduating from new integrated programs (0+5) vs those from the traditional programs (5+2). Methods National operative case log data supplied by the Accreditation Council for Graduate Medical Education was compiled for vascular surgical residents graduating between 2010 and 2013. Mean case numbers for the 0+5 residents were compared with those for the 5+2 residents (experience from their general surgery residency plus vascular fellowship) for total vascular operations, open vascular operations, endovascular procedures, and total operative experience. Results The 5+2 trainees performed significantly more procedures than the 0+5 trainees (mean, 1605 vs 1015); however, they performed 12% less vascular procedures (mean, 758 vs 851). No significant differences in total number of open vascular operations (mean, 404 vs 411) or specific open operations for cerebral vascular disease, aneurysm, peripheral obstruction, and access were found. The increase in vascular procedures logged by 0+5 trainees was realized by a 24% increase in endovascular procedures, mainly involving diagnostic arteriography, caval filter placement, and balloon angioplasty. No significant differences were seen in endovascular aneurysm repair (mean, 63 vs 60) and stent placement (mean, 59 vs 60). Conclusions This report summarizes the first data available for the 0+5 trainee operative experience. Compared with the traditional 5+2 trainees, the 0+5 trainees have (1) equivalent open vascular training and (2) overall superior endovascular training, although this was accounted via an increase in minor procedures. The overall operative experience remains greater for the 5+2 trainees secondary to 2 extra years of training. Further longitudinal studies will be needed to fully characterize the effect of the new 0+5 training paradigm.

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve within the tarsal tunnel. Its etiology varies, including space occupying lesions, trauma, inflammation, anatomic deformity, iatrogenic injury, and idiopathic and systemic causes. Herein, we describe a 46-year-old man who presented with left foot pain. Work up revealed a venous aneurysm impinging on the posterior tibial nerve. Following resection of the aneurysm and lysis of the nerve, his symptoms were alleviated. Review of the literature reveals an association between venous disease and tarsal tunnel syndrome; however, this report represents the first case of venous aneurysm causing symptomatic compression of the nerve.

Carotid endarterectomy (CEA) is the preferred treatment for symptomatic [1–3] and asymptomatic [4, 5] patients with high-grade extracra-nial carotid stenosis, compared with the best medical therapy. The increase in the number of CEAs done worldwide has resulted in a number of post-CEA carotid restenosis (CR) cases. Carotid artery stenting (CAS) has recently emerged as a less-invasive alternative to CEA for cerebral revascularization. Our institution [6–10], along with others [11–14], has demonstrated that CAS is technically feasible and safe in high-risk patients. Two randomized trials [14, 15] and results from the lead-in phase of the Carotid Revascularization, Endarterectomy vs. Stent Trial (CREST) [16] reported low periprocedural complication rates with CAS, indicating clinical equipoise between the two procedures. This resulted in the approval of CAS in the United States in high-risk patients with significant carotid stenosis (≥ 70%) and neurological symptoms (ipsilateral stroke, transient ischemic attack, and amaurosis fugax) [17]. Two additional randomized trials were not able to demonstrate equivalence of CAS with CEA with respect to postprocedural stroke, myocardial infarction, or death. These results notwithstanding, it is clear that the number of CAS procedures will continue to progressively increase until a more definitive answer is available from larger studies powered to assess superiority of one procedure over the other (e.g., the NIH-sponsored CREST).