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A new species of phlebotomine sand fly, Lutzomyia adamsi n. sp., is described and illustrated from specimens collected during August 1994, in Sandia, Department of Puno-Peru. According to the Oficina Nacional de Evaluacion de Recursos Naturales(ONERN 1976), this locality is situated in the life zone known as humid, mountain, low tropical forest (bh-MBT). Many areas in the northern part of Puno, mainly in the Inambari and Tambopata basins, are endemic to leishmaniasis. These areas are the continuation of others, largely known as "leishmaniasic" in the departments of Cusco and Madre de Dios. The morphological characteristics indicated that this species belongs to the genus Lutzomyia, subgenus Helcocyrtomyia Barretto, 1962

The advent of endovascular aortic surgery has led to the rise of novel techniques and devices in treating pathologies of the aorta. While endovascular surgery has been well established in the descending thoracic and abdominal aorta, the endovascular treatment of the aortic arch represents a new and exciting territory for aortic surgeons. This article will discuss the different aortic diseases amenable to endovascular treatment, currently available aortic arch stent grafts and their limitations, and the future of endovascular aortic arch therapies.

Purpose: In situ laser fenestration (LISF) was performed as a bailout procedure to ensure renal perfusion during complex aortic aneurysm repair., Case Report: A 69 year-old male patient with previous repair of abdominal aortic aneurysm who presented with increasing lower back pain and an enlarging, 6-cm, perivisceral aortic aneurysm that required urgent repair. Given potential complications and risks of redo open repair, we performed endovascular repair via deployment of a 5-vessel fenestrated physician modified stent graft (PMEG) with stent placement to the celiac, superior mesenteric, right renal, and 2 of the larger 3 left renal arteries. The renal artery planned for sacrifice was found intraoperatively to be perfusing a large portion of the kidney. Subsequently, LISF was used to cannulate and salvage perfusion to the third renal artery. Completion aortogram demonstrated patency of all renal visceral vessels with no vessel leak. Follow-up CT angiogram 1 year later demonstrated aortic graft with all visceral stents patent, no endoleak, and a reduction in residual aneurysm sac., Conclusion: Even with careful planning and design of a physician modified stent graft, in situ laser fenestration provides an option to successfully create additional stents intraoperatively in order to preserve perfusion to critical visceral organs., Clinical Impact: In situ laser fenestration will provide surgeons with a valuable intra-operative method to create additional stents when organ perfusion would otherwise be lost. As more surgeons develop this technical ability and more long-term outcomes are studied, this method has the possibility to not only be used for urgent and emergent cases but may one day be an acceptable variation to standard practice., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: There are no direct conflicts related to this publication; however, MW does receive honoraria from Cook, Medtronic, Gore, Penumbra, and Shockwave for speaking/education services.

Background: Letters of recommendation (LOR) are considered by program directors (PDs) to be an integral part of the residency application. With the conversion of United States Medical Licensing Examination (USMLE) Step 1 to a binary pass/fail outcome, LORs will likely have higher important in the application process moving forward. However, their utility in securing an interview for a particular applicant remains undetermined. This study aims to identify the applicant and LOR characteristics associated with an interview invitation., Methods: Letter writer (n = 977) characteristics were abstracted from applications (n = 264) to an individual integrated vascular surgery residency program over 2 application cycles. A validated text analysis program, Linguistic Inquiry and Word Count, was used to characterize LOR content. Applicant, letter writer, and LOR characteristics associated with an interview invitation were determined using multivariable analysis., Results: Letter writers were 70.9% vascular surgeons (VS), 23.7% PDs, and 45.4% professors. Applicants offered an interview were more likely to come from a top 50 medical school (35.2% vs 25.8%, P = 0.013) and an institution with a home vascular program (45.5% vs 34.1%, P = 0.006). Alpha Omega Alpha membership was significantly associated with interview offer (28.4%, P < 0.001). A greater proportion of letters from VS was associated with an interview offer (P < 0.001) compared with letter writers of other specialties. One or more PD letters were significantly associated with an interview offer (79.55% vs 20.45%, P = 0.008), whereas number of letters from APDs was not significantly associated with interview offer. Letters written by away institution faculty were significantly associated with interview offer (75%, P < 0.001), whereas nonclinical letters were not. Presence of one or more letters from a chair (57.95% vs 42.05%, P = 0.015) or chief (67.05% vs 32.95%, P = 0.028) was significantly associated with interview offer. Letters for applicants offered an interview had more references to research and teaching, which were more common in letters written by versus Letters written by PDs were more likely to use assertive, advertising language in favor of applicants. There were no significant applicant, letter writer, or LOR characteristics associated with a top 20 rank., Conclusions: Successful applicants were more likely to have LORs written by VS, PDs, and those of higher academic rank with references to research and teaching., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: The worst complication during cannulation of the contralateral gate during complex endovascular aortic repair is deployment of the limb extension behind the main graft body., Case Report: A patient with a 5.7 cm juxtarenal abdominal aortic aneurysm was taken to the operating room for fenestrated endovascular aortic repair and iliac branch device. Percutaneous femoral access was used to deploy a Gore Iliac Branch Endoprosthesis, followed by a physician modified Cook Alpha thoracic stent graft with four fenestrations. Next a Gore Excluder was deployed to bridge the fenestrated component to the iliac branch and native left common iliac artery creating distal seal. Due to the severe tortuosity, a buddy wire technique, using a stiff lunderquist wire, was used to cannulate the contralateral gate. Unfortunately, after cannulation, the limb was advanced over the buddy lunderquist wire instead of the luminal wire. We used a backtable modified guide catheter to provide the necessary pushability to navigate wires between the aberrantly deployed limb extension and the iliac branch device. Using through-and-through access, we then successfully deployed a parallel flared limb in the correct plane., Conclusion: Careful communication, wire marking, and attention to intraoperative flow can minimize risks of complication, but knowledge of bail out techniques remains imperative., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Carotid stenting has been demonstrated to effectively reduce the risk of stroke in appropriately selected patients. However, application of carotid artery stenting remains limited in the setting of heavily calcified disease., Case Report: We present here 3 patients, who were treated with intravascular lithotripsy of the internal and common carotid arteries. All 3 patients recovered uneventfully and have demonstrated excellent stent expansion on surveillance imaging., Conclusion: Intravascular lithotripsy is an effective adjunct for enabling stent expansion in heavily calcified lesions and can be employed for the treatment of high-risk carotid lesions that would otherwise be poor endovascular candidates., Clinical Impact: Carotid artery stenting via transfemoral or transcarotid application remains limited by heavily calcified disease. We present here the off-label use of intravascular lithotripsy as an effective adjunct for enabling stent expansion in heavily calcified lesions. There is potential for intravascular lithotripsy to expand the use of carotid stenting., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Open aortic arch repair is the gold standard in the treatment of diseases involving the ascending aorta and aortic arch. However, due to the invasive nature of open repair, high-risk patients with multiple comorbidities are often not suitable candidates for open surgical repair. While endovascular aortic repair is far less invasive, endovascular arch repair remains a difficult challenge due to the aortic arch diameter and angulation, origin of the supra-aortic arteries, and the lack of commercially available thoracic branched devices in the United States., Case Report: Here we describe palliation of a mycotic aortic arch pseudoaneurysm with a physician-modified endograft and in situ laser fenestration. Our technique allowed for rapid repair of the pseudoaneurysm with minimal physiologic disturbances and no perioperative complications in a high-risk surgical patient., Conclusion: Physician-modified endografts are feasible and may be an effective treatment option for palliation of acute aortic arch lesions in high-risk surgical patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Although reports on angioembolization (AE) show favorable results for severe hepatic trauma, information is lacking on its benefit in the management and mechanisms of injury (MOI). This study examined patient outcomes with severe hepatic injuries to determine the association of in-hospital mortality with AE. The hypothesis is that AE is associated with increased survival in severe hepatic injuries., Methods: Demographics, age, sex, MOI, shock index (SI), ≥6 units packed red blood cells (PRBCs) per hospital length of stay (LOS), intensive care unit LOS, injury severity score (ISS), and AE were collected. The primary outcome was in-hospital mortality. Patients were stratified into groups according to MOI, AE, and operative vs non-operative management. Multivariable logistic regression determined the independent association of mortality with AE vs no AE and operative vs nonoperative management and modeled the odds of mortality controlling for MOI, AE vs no AE, age and ISS groups, SI >.9, and ≥6 units PRBCs/LOS., Results: From 2013 to 2018, 2462 patients (1744 blunt; 718 penetrating) were treated for severe hepatic injuries. AE was used in only 21% of patients. Mortality rates increased with higher ISS and age. AE was associated with mortality when compared to patients who did not undergo AE. The strongest associations with mortality were ISS ≥25, transfusion ≥ 6 units PRBCs/LOS, and age ≥65 years., Conclusions: AE is underutilized in severe hepatic trauma. AE may be a valuable adjunct in the treatment of severe hepatic injuries especially in older patients and those needing exploratory laparotomy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aortic arch and descending thoracic pathology have historically remained in the realm of open surgical repair. Technology is quickly pushing to bring these under the endovascular umbrella, with lower morbidity repairs proving safe in their early experience. Much work remains particularly for acute aortic syndromes, however, to understand who is best treated medically, surgically, endovascularly, or with hybrid approaches., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The occurrence of wildfires in Indonesia is prevalent during drought seasons. Multiple toxic pollutants emitted from wildfires have deleterious effects on pregnant women. However, the evidence for these on pregnant women was underreported. The study conducted 24-h monitoring of fine particulate matter (PM 2.5 ) concentrations indoors and outdoors in 9 low-income homes in Palangka Raya during the 2019 wildfire season and 6 low-income homes during the 2019 non-wildfire season. A hundred and seventy pregnant women had their PM exposure assessed between July and October 2019 using personal monitors. It was observed that outdoor air pollutant levels were greater than those found indoors without indoor sources. The findings indicate that indoor PM 2.5 concentrations were modestly increased by 1.2 times higher than outdoor, suggesting that buildings only partially protected people from exposure during wildfires. The concentrations of PM 2.5 were found to be comparatively higher indoors in residential buildings with wood material than in brick houses. The study findings indicate that 8 out of 12 brick houses exhibited a notable RI/O 24 h of less than 1 during the wildfires, whereas all I/O 24 h ratios during the non-wildfire season were >1, suggesting the influence of indoor sources. Based on the estimation of daily PM 2.5 dose, pregnant women received around 21% of their total daily dose during sedentary activity involving cooking. The present research offers empirical support for the view that indoor air quality in low-income households is affected by a complex combination of factors, including wildfire smoke, air tightness, and occupant behaviour. Also, this situation is more likely a potential risk to pregnant women being exposed to wildfire smoke., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Acute lymphoblastic leukemia (ALL) is an aggressive bone marrow cancer with disparate outcomes. Data on patient outcomes in real world settings outside of clinical trials is limited. The current study reports on outcomes for 137 ALL patients who received an adult induction and consolidation regimen derived from the CALGB 10102 trial modified without alemtuzumab. Of the 137 patients, 32 were < 40 years old, 52 were between 40 and 59, and 53 were ≥ 60 years old. Overall, 109 (79.6%) patients achieved a complete remission (< 40: 96.1%, 40-59: 86.5%, and 62.3% ≥ 60 (p = 0.0002)). Progression free survival for the entire cohort was 13.5 months and by age was 19.8 months for less than 40, 23.4 months for 40 to 59 and 6.7 months for ≥ 60; p = 0.0002. Median survival was 22.1 months for the entire cohort (32.9 months for ages < 40, 26.6 months ages 40-59, 7.8 months ≥ 60, p < 0.001)., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Hospital resource use is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures is particularly relevant in the setting of the coronavirus disease 2019 pandemic and its impact on staffed intensive care unit (ICU) beds. We sought to evaluate the feasibility of regional anesthesia (RA) and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution., Methods: All patients undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management (anticoagulation and antiplatelet therapy, hemodynamic monitoring, neurovascular examination, nursing instructions) was standardized by use of an institutional protocol. Anesthetic modality was at the surgeon's preference. Patients were transferred to a postanesthesia care unit for 2 hours followed by the step-down unit, to a postanesthesia care unit for 4 hours followed by the floor, or alternatively transferred to the ICU. Intravenous (IV) blood pressure medications could be administered at all environments except the floor. Recovery location and length of stay were recorded., Results: A total of 83 patients underwent TCAR during the study period. The mean age 72 ± 9 years and 59% were male. Thirty-six percent were symptomatic. RA was used for 84% with none converted to general anesthesia (GA) intraoperatively. Postoperatively, 7 of the 83 patients (8%) included in this study were monitored in an ICU overnight (decided perioperatively), mostly for patients with prior neurological symptoms, but in 1 case for postoperative neurological event and in another owing to pulseless electrical activity arrest. Six patients required IV antihypertensives and eight required IV vasoactive support postoperatively. The mean length of ICU stay was 3.7 ± 5.1 days. The mean length of hospital stay for all patients was 2.4 ± 3.3 days. The length of stay for patients undergoing TCAR with GA was higher than those undergoing TCAR with RA (4.2 ± 4.9 days vs 1.4 ± 1.2 days, respectively; P = .066). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of prior stroke, and one respiratory arrest fatality in a frail patient with neck hematoma both of whom were treated under GA., Conclusions: Using perioperative care protocols, TCAR can safely be performed while avoiding both GA and an ICU stay in most patients., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Transposed brachiobasilic AV fistulas (BVT) have increasingly been performed in two stages. Published reports give conflicting results, perhaps in part as many reports of staged procedures eliminate those patients who "fail" the first stage (i.e. are lost to follow-up in addition to anatomic failure)., Methods: A prospectively maintained database was reviewed to identify all patients at two institutions who underwent the first stage of planned two-stage BVT by the senior author. Success in this context was defined as patients who eventually underwent second stage fistula creation, leaving the operating room after the second stage with a patent, transposed fistula., Results: From October 2012 to June 2020, 218 patients underwent first-stage procedures. At the first visit, 185 (85%) of fistulas were patent, 23 (11%) were occluded, 8 (4%) of patients were lost to follow-up, and 2 (1%) died. In the interval before the second operation, another eight (4%) patients were lost to follow-up, two were cancelled for medical reasons, and two declined surgery, leaving a total of 173 patients who made it to the second stage (80%). At operation, four patients were found to have unusable veins, leaving a total of 169 patients who completed both stages. If all patients who underwent first stage are included, 77% of patients entering this pathway left the OR after their second stage with patent access. If those lost to follow-up are excluded, this number increases to 84%, while if all those lost to follow-up are assumed to mature, success increases to 85%., Conclusions: Depending on results in patients lost to follow-up, between 77% and 85% of patients undergoing first stage brachiobasilic fistulae undergo successful second stage transposition. These numbers are equivalent or slightly lower than published maturation rates for single-stage BVT, so there is little margin for failure at the second stage.

Introduction: Diagnosis of LM is limited by low sensitivity of cerebrospinal fluid (CSF) cytopathology. Detecting tumor cells in CSF (CSF-TCs) might be more sensitive. We evaluated if CNSide (CNSide), a novel assay for tumor cell detection in CSF, can detect CSF-TCs better than conventional CSF cytology., Methods: We enrolled adults with metastatic breast cancer and clinical suspicion for LM to undergo lumbar puncture (LP) for CSF cytopathology and CNSide. CNSide captured CSF-TCs using a primary 10-antibody mixture, streptavidin-coated microfluidic channel, and biotinylated secondary antibodies. CSF-TCs were assessed for estrogen receptor (ER) expression by fluorescent antibody and HER2 amplification by fluorescent in situ hybridization (FISH). CSF cell-free DNA (cfDNA) was extracted for next-generation sequencing (NGS). Leptomeningeal disease was defined as positive CSF cytology and/or unequivocal MRI findings. We calculated sensitivity and specificity of CSF cytology and CNSide for the diagnosis of LM., Results: Ten patients, median age 51 years (range, 37-64), underwent diagnostic LP with CSF evaluation by cytology and CNSide. CNSide had sensitivity of 100% (95% Confidence Interval [CI], 40%-100%) and specificity of 83% (95% CI, 36%-100%) for LM. Among these patients, concordance of ER and HER2 status between CSF-TCs and metastatic biopsy were 60% and 75%, respectively. NGS of CSF cfDNA identified somatic mutations in three patients, including one with PIK3CA p.H1047L in blood and CSF., Conclusions: CNSide may be a viable platform to detect CSF-TCs, with potential use as a diagnostic tool for LM in patients with metastatic breast cancer. Additional, larger studies are warranted., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To describe the development and implementation of virtual vascular surgery rotations among 6 integrated vascular surgery programs., Design: A collaborative teleconference retrospectively discussing 6 independently developed virtual vascular surgery rotations to make a framework for future use., Setting: University of California Davis initiated a joint teleconference among the various integrated vascular surgery programs., Participants: Vascular surgery faculty and residents from 6 programs participated in the teleconferences and drafting of a framework for building a virtual vascular surgery rotation., Results: Four specific domains were identified in discussing the framework to build a virtual vascular surgery rotation: planning, development, curriculum, and feedback. Each domain has specific aspects in making a virtual rotation that has applicability to other surgical rotations that seek to do the same., Conclusion: Virtual vascular surgery rotations are feasible and important; these electives can be established and implemented successfully with appropriate planning and consideration. This work hopes to help programs navigate this new space in education by making it more transparent and highlighting potential pitfalls., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laser in situ fenestration (LISF) is an expanding technique for arch vessel revascularization in thoracic endovascular aortic repair (TEVAR). We present a single center's early and midterm outcomes using adjunctive LISF with TEVAR for treatment of various arch pathologies., Methods: 24 patients underwent TEVAR with LISF (2017-2020). Patients were evaluated by an Aortic Team consisting of cardiothoracic and vascular surgeons and were deemed unfit for open surgical repair. Informed consent emphasized the procedure's off-label nature. Thoracic stent-grafts were sized by preoperative Computed Tomography Angiogram and intraoperative Intravascular Ultrasound, with oversizing determined by pathology. Extra-anatomic debranching was performed in staged or concurrent fashion based on urgency of repair and access site options for branch fenestration. A 2.3 mm Spectranetics laser was used, with access site determined at surgeon discretion. Covered balloon expandable stent-grafts were deployed with 0-10% oversizing., Results: In 24 patients, a total of 30 fenestrations were created (LSA N = 19, LCCA N = 3, Innominate N = 7, RSA N = 1) with 1 (N = 18) or 2 (N = 6) fenestrations/patient. Indications included aneurysm (8), chronic dissection with aneurysmal degeneration (8), acute dissection (4), intramural hematoma (2), and pseudoaneurysm (2). 13 cases were elective, and 11 were emergent. Technical success was 100%. 12 patients underwent concurrent (N = 8) or staged (N = 4) extra-anatomic bypass. The major complication rate was 21%, including stroke (N = 3) and 30-day mortality (N = 2). The overall complication rate was 58%. Over a mean follow up of 261 days (15-864 days), 7 patients (32%) have required reinterventions., Conclusions: LISF for branch revascularization in TEVAR is technically feasible for treating various aortic arch pathologies, demonstrating practicality in both elective and emergent settings. With a morbidity and mortality profile that is favorable compared to that of open repair, LISF with TEVAR is a promising potential option for patients with complex arch pathology and prohibitive open surgical risk., (Copyright © 2021. Published by Elsevier Inc.)

Background: Medical education has traditionally relied on in-person-based curriculums in medical school and residency . However, due to the COVID19 pandemic, medical schools and residency programs have been forced to rapidly transition to virtual platforms for learning. Surgical education poses a particular challenge, as virtual platforms cannot adequately replace hands-on learning of surgical skills. In this review, we will discuss the various ways in which virtual learning has been employed in surgical education and how it may be used to enhance learning of medical students and residents in the future., Methods: We conducted a comprehensive literature search to identify articles published regarding medical school and surgical residency curriculum changes after COVID19., Results: Over the past year, several surgery departments have piloted programs using virtual learning modules, live online lectures and training workshops, and remote streaming into the OR to supplement more traditional in-person learning. Overall, these programs have received positive feedback from participating medical students and residents, suggesting that virtual and online tools may be helpful in supplementing surgical education. However, several programs also noted the possibility for significant disparities in learning due to variable access to internet and availability of newer technologies., Conclusion: Going forward, distance learning will play an important role in surgical education to further enhance learning of medical students and residents in a field with rapid technological advancements., Competing Interests: Conflict of InterestThe authors have no relevant financial or non-financial interests to disclose., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021.)

Background: Access site complication is the most common adverse event after endovascular intervention, and when emergent operative repair of the common femoral artery (CFA) is needed, patient morbidity can be significantly increased. The intent of this project was to identify predictors of wound events after emergent operative repair of the CFA due to an access site complication. It was hypothesized that patients discharged to a facility would benefit from an ongoing relationship with healthcare professionals as evidenced by more consistent follow-up and lower wound complication rates., Methods: Patients who had a percutaneous CFA access complication and required emergent open CFA repair at an academic medical institution between 2015 and 2018 were included, and the charts were reviewed retrospectively. Primary outcomes included wound complication and outpatient compliance with vascular surgery clinic visit. Dichotomous groups were evaluated by the chi-squared test, and continuous variables were evaluated by Student's t-test. Univariate and multivariate regression analyses were completed to assess risk factors contributing to wound event or failure of clinic follow-up., Results: Forty-four patients were identified with emergent CFA repair due to an access complication between July 2015 and June 2018. Among this population, 33% of patients had wound complications and 27% were discharged to a facility. Among those discharged to a facility, the rate of follow-up to the vascular surgeon's clinic was significantly lower than those discharged to home (40% vs. 85%, P < 0.05), and the incidence of wound complications appeared greater but did not reach statistical significance (50% vs. 27%, P = 0.11). Univariate analysis indicated that kidney disease, albumin <3 g/dL, and current smoking were predictive of wound complication, whereas on multivariate analysis, only kidney disease remained predictive (P < 0.05, odds ratio = 22). The modified frailty index (mFI) was not predictive of wound complications or compliance with follow-up. However, mFI did approach statistical significance when predicting discharge to a facility., Conclusions: Despite the availability of medical personnel to arrange transportation and provide wound care in post-acute care facilities, patients who were discharged to a facility after CFA injury requiring emergent repair experienced lower compliance with clinic follow-up and may have suffered more wound complications. Strategies to improve compliance with patient follow-up and wound healing in patients sent to post-acute care facilities are warranted., (Published by Elsevier Inc.)

In the absence of suitable cephalic vein, the brachiobasilic vein complex represents the best option for arteriovenous access. However, the basilic vein is too deep to cannulate and requires transposition to be accessible. Transposition can be performed during fistula creation (single-stage BBTx) or at a second operation after initial fistula creation (two-stage brachiobasilic transposition (BBTx)). The best approach is unknown. A PubMed search using "Basilic vein transposition" as the primary search term was performed to identify articles addressing this controversy. Meta-analysis was then performed using those papers that provided the inspected data points with student's t-test used to compare maturation and patency rates between the groups. A total of 37 manuscripts were judged of adequate quality for analysis. Based on the available data, overall maturation rates, 1-year primary patency rates, and overall complication rates seem to be equivalent between single- and two-stage BBTx, while 1-year secondary patency is greater in the two-stage group (79% vs 85%). A large prospective randomized clinical trial with clear definitions of maturity, patency, and complications is needed to definitively answer the question of whether one strategy is better than the other.

The development of the 0+5 integrated vascular training program allows training to begin after medical school and is a "new" paradigm in specialty surgery training. Whether community and academic surgeons in practice will accept this training program remains an unanswered question. My perspectives as an integrated vascular resident trainee who recently entered clinical practice provide insight on the adequacy of my training and the lessons I have learned as a vascular surgery specialist., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Subclavian vein stenosis or occlusion at the thoracic outlet is a problem associated with certain anatomic and environmental stresses (venous thoracic outlet syndrome [VTOS]), the presence of central venous catheters, and the high flows associated with arteriovenous (AV) access in the limb. We describe our experience with open and endovascular techniques for restoring patency in highly symptomatic patients., Methods: A prospectively collected database of patients was queried for patients treated for central venous obstructive disease in the setting of highly symptomatic VTOS and ipsilateral AV access from October 2011 to August 2016., Results: During the study period, 54 procedures were performed in 53 patients (68% male; mean age, 50.1 years). Indications for operation were venous outflow obstruction in patients with conventional VTOS (n = 19) or costoclavicular junction stenosis associated with ipsilateral dialysis access (n = 34). All patients had significant symptoms of swelling or pain. Eight patients underwent on-table pharmacomechanical thrombolysis for acute occlusion. All patients underwent costoclavicular junction decompression, 48 by infraclavicular first rib resection and 5 by claviculectomy; 6 patients underwent sternoclavicular rotation (Molina procedure) in addition to rib resection for further exposure. Surgical reconstruction of the vein was employed in 18 patients (33%); 9 underwent interposition grafting, 1 had jugular turndown, and 8 had patch angioplasty. The one patient undergoing two procedures suffered acute occlusion after patch repair followed by jugular turndown. Four patients underwent surgical reconstruction after thrombolysis. Endovascular procedures were performed in 36 patients (67%); 23 underwent venous angioplasty alone, and 13, all with hemodialysis access-associated stenosis, underwent stenting. Mean operative time was 135 (±63.5) minutes, and mean estimated blood loss was 238 (±261) mL. Median length of stay was 4 days. Perioperative complications were noted in 14 (26.4%) patients, including wound complications (n = 6), cardiac complications (n = 4), reocclusion (n = 3), and hemothorax requiring chest tube placement (n = 1) in a patient undergoing on-table thrombolysis. Mean follow-up was 13.6 (0.6-58.5) months. Initial clinical symptom relief was experienced in 100% of patients at the time of hospital discharge. During follow-up, 5 (9.4%) patients developed recurrent symptoms, 6 (11.3%) had reocclusion of the central system, and 16 (30.2%) required reintervention for restenosis, all but 2 in patients with ipsilateral hemodialysis access. Mean time to reintervention was 134 (±285) days., Conclusions: Given our decision-making threshold, both open and endovascular procedures are associated with relatively low morbidity and high efficacy for treatment of central venous occlusion in both symptomatic VTOS and AV access-associated subclavian vein disease. Restenosis is common in patients with a patent ipsilateral hemodialysis access., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Screening mammography reduces breast cancer mortality; however, screening recommendations, ordering, and compliance remain suboptimal and controversies regarding the value of screening persist. We evaluated the influence of screening mammography on the extent of breast cancer treatment., Methods: Patients ≥ 40 years of age diagnosed with breast cancer from September 2008 to May 2016 at a single institution were divided into two groups: those with screening 1-24 months prior to diagnosis, and those with screening at 25+ months, including patients with no prior mammography. The association between the two groups and various clinical factors were assessed using logistic regression models. Subgroup analysis was performed based on age groups., Results: Analysis included 1125 patients, 819 (73%) with screening at 1-24 months, and 306 (27%) with screening at 25+ months, including 65 (6%) who never had mammography. Overall, patients in the 25+ months group were more likely to receive chemotherapy [odds ratio (OR) 1.51, p = 0.0040], undergo mastectomy (OR 1.32, p = 0.0465), and require axillary dissection (AD; OR 1.66, p = 0.0045) than those in 1-24 months group. On subgroup analysis, patients aged 40-49 years with no prior mammography were more likely to have larger tumors (p = 0.0323) and positive nodes (OR 4.52, p = 0.0058), undergo mastectomy (OR 3.44, p = 0.0068), undergo AD (OR 4.64, p = 0.0002), and require chemotherapy (OR 2.52, p = 0.0287) than the 1-24 months group., Conclusions: Screening mammography is associated with decreased stage at diagnosis and receipt of less-extensive treatment. This was evident in all groups, including the 40-49 years age group, where controversy exists on whether screening is even necessary.

Background: Maintenance of pelvic circulation has been connected to reduced risks of ischemic colitis, buttock claudication, erectile dysfunction, and spinal cord ischemia during the treatment of extensive aortoiliac aneurysmal disease. We evaluate the mid-to-late follow-up of a cohort of patients treated using 1 preservation technique, the endovascular external iliac artery (EIA) to internal iliac artery (IIA) bypass., Methods: All patients undergoing elective retrograde EIA-IIA endovascular bypass at a single institution were retrospectively reviewed over a 10-year period from 2006 to 2016. Anatomic inclusion criteria were single or bilateral common iliac artery aneurysms with or without concomitant aortic aneurysm limiting distal landing zone for endovascular repair and an iliac bifurcation angle greater than 45°. Procedures were performed using aortouni-iliac (AUI) endografts extended to 1 EIA (with endovascular occlusion of the ipsilateral hypogastric artery), cross-femoral artery bypass, and retrograde placement of 1 of 3 types of covered stent grafts into the contralateral IIA. In the case of patients with prior open repair, AUI placement was not required. Follow-up surveillance included duplex ultrasound 1 and 6 months postoperatively and annually thereafter, with computed tomography scan (with selective contrast usage) 1 month postoperatively and annually thereafter., Results: Seventeen patients (mean age 70 years, 93% male) were treated over the period studied. Most were treated for primary disease (N = 11) while the remainder was secondary interventions following open repair (N = 4) or endovascular aneurysm repair (N = 2). Nine patients had bilateral common iliac aneurysms, one had bilateral IIA aneurysms, and the remainder had unilateral iliac aneurysmal degeneration with occluded or severely diseased ipsilateral hypogastric arteries. There was no preference for laterality (right iliac N = 8, left iliac N = 9). Retrograde bypasses were performed using Fluency stent graft (N = 1), Viabahn stent graft (N = 13), or Gore Excluder limbs (N = 3). Additional hypogastric embolization with AUI extension to the EIA (for bilateral common iliac aneurysms) was required in 6 patients. Proximal extension requiring snorkel/fenestration was present in 5 patients. Technical success was 100% with mean operative time was 168 min (range 50-300 min), and 71 cc contrast usage (range 30-115 cc). Mean preoperative iliac artery aneurysm size was 4.0 cm with iliac bifurcation angle 71° (range 51-102°). Median length of stay was 3 days (range 1-13). Over mean follow-up of 29.8 months, there were no aorta-related mortalities, 1 EIA-IIA bypass occlusion (asymptomatic), and 1 reintervention (for type II endoleak not attributed to the EIA-IIA bypass). There were no additional endoleaks and no sac growth. The incidence of bowel ischemia, paralysis, and bowel/bladder dysfunction was zero in the series., Conclusions: Retrograde endovascular EIA-IIA bypass provides a low risk, high patency option for preservation of a single hypogastric artery with resultant maintenance of pelvic circulation., (Published by Elsevier Inc.)

Background: The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. Our primary hypothesis analyzed how prehospital and in-hospital characteristics affect decision-making regarding continued life support (CLS) versus withdrawal of care (WOC). Our secondary hypothesis analyzed adherence to end-of-life decisions regarding code status, living wills, and advanced directives., Materials and Methods: We performed a retrospective review of patients with geriatric trauma at a level I and level II trauma center from January 1, 2007, to December 31, 2014. Two hundred seventy-four patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC., Results: A total of 13 269 patients with geriatric trauma were analyzed. Insurance type and injury severity score (ISS) were found to be significant predictors of WOC ( P = .013/.045). Withdrawal of care patients had shorter time to palliative consultation and those with geriatrics consultation were 16.1 times more likely to undergo CLS ( P = .026). Twenty-seven (33%) patients who underwent CLS and 31 (24%) patients who underwent WOC had a living will, advanced directive, or DNR order ( P = .93)., Conclusions: Of the many hypothesized predictors of WOC, ISS was the only tangible independent predictor of WOC. We observed an apparent disconnect between the patient's wishes via living wills or advanced directives "in a terminal condition" and fulfillment during EOL decision-making that speaks to the complex nature of EOL decisions and further supports the need for a multidisciplinary approach.

Objective: A number of adjunctive "off-the-shelf" procedures have been described to treat complex aortic diseases. Our goal was to evaluate parallel stent graft configurations and to determine an optimal formula for these procedures., Methods: This is a retrospective review of all patients at a single medical center treated with parallel stent grafts from January 2010 to September 2015. Outcomes were evaluated on the basis of parallel graft orientation, type, and main body device. Primary end points included parallel stent graft compromise and overall endovascular aneurysm repair (EVAR) compromise., Results: There were 78 patients treated with a total of 144 parallel stents for a variety of pathologic processes. There was a significant correlation between main body oversizing and snorkel compromise (P = .0195) and overall procedural complication (P = .0019) but not with endoleak rates. Patients were organized into the following oversizing groups for further analysis: 0% to 10%, 10% to 20%, and >20%. Those oversized into the 0% to 10% group had the highest rate of overall EVAR complication (73%; P = .0003). There were no significant correlations between any one particular configuration and overall procedural complication. There was also no significant correlation between total number of parallel stents employed and overall complication. Composite EVAR configuration had no significant correlation with individual snorkel compromise, endoleak, or overall EVAR or procedural complication. The configuration most prone to individual snorkel compromise and overall EVAR complication was a four-stent configuration with two stents in an antegrade position and two stents in a retrograde position (60% complication rate). The configuration most prone to endoleak was one or two stents in retrograde position (33% endoleak rate), followed by three stents in an all-antegrade position (25%). There was a significant correlation between individual stent configuration and stent compromise (P = .0385), with 31.25% of retrograde stents having any complication., Conclusions: Parallel stent grafting offers an off-the-shelf option to treat a variety of aortic diseases. There is an increased risk of parallel stent and overall EVAR compromise with <10% main body oversizing. Thirty-day mortality is increased when more than one parallel stent is placed. Antegrade configurations are preferred to any retrograde configuration, with optimal oversizing >20%., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether rehearsal using patient-specific information loaded onto an endovascular simulator prior to carotid stenting improves procedural efficiency and outcomes., Methods: Patients scheduled for carotid artery stenting who had adequate preoperative computed tomography (CT) imaging were considered for enrollment. After obtaining informed consent, patients were randomized to control versus rehearsal groups. Those in the rehearsal group had their CT scans loaded into an endovascular simulator (Angio Mentor) followed by case rehearsal by the attending on the simulator within 24 hours prior to the procedure; control patients underwent routine carotid stenting without rehearsal. Contrast usage, fluoroscopy time, and timing of procedural steps were recorded by a blinded observer during the actual case to determine benefit., Results: Fifteen patients were enrolled, with 6 patients randomized to the rehearsal group and 9 to the control. All measures showed improvement in the rehearsal group: Mean contrast volume (59.2 vs 76.9 mL), fluoroscopy time (11.4 vs 19.4 minutes), overall operative time (31.9 vs 42.5 minutes), time to common carotid sheath placement (17.0 vs 23.3 minutes), and total carotid sheath dwell time (14.9 vs 19.2 minutes) were all lower (more favorable) in the rehearsal group. The study was terminated early due to the lack of simulator access, and all P values were thus greater than .05 due to the lack of power. No strokes or other adverse events occurred in either group., Conclusion: Case-specific simulator rehearsal using patient-specific imaging prior to carotid stenting is associated with numerically less contrast usage, operative time, and radiation exposure, although this study was underpowered.

Purpose: Controversy surrounds management of lobular neoplasia (LN), [atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS)], diagnosed on core needle biopsy (CNB). Retrospective series of pure ALH and LCIS reported "upgrade" rate to DCIS or invasive cancer in 0-40%. Few reports document radiologic/pathologic correlation to exclude cases of discordance that are the likely source of most upgrades, and there is minimal data on outcomes with follow-up imaging and clinical surveillance., Methods: Cases of LN alone on CNB (2001-2014) were reviewed. CNB yielding LN with other pathologic findings for which surgery was indicated were excluded. All patients had either surgical excision or clinical follow-up with breast imaging. All cases included were subject to radiologic-pathologic correlation after biopsy., Results: 178 cases were identified out of 62213 (0.3%). 115 (65%) patients underwent surgery, and 54 (30%) patients had surveillance for > 12 months (mean = 55 months). Of the patients who underwent surgical excision, 13/115 (11%) were malignant. Eight of these 13 found malignancy at excision when CNB results were considered discordant (5 DCIS, and 3 invasive lobular carcinoma), with the remainder, 5/115 (4%), having a true pathologic upgrade: 3 DCIS, and 2 microinvasive lobular carcinoma. Among 54 patients not having excision, 12/54 (22%) underwent subsequent CNB with only 1 carcinoma found at the initial biopsy site., Conclusions: Surgical excision of LN yields a low upgrade rate when careful consideration is given to radiologic/pathologic correlation to exclude cases of discordance. Observation with interval breast imaging is a reasonable alternative for most cases.

Background: The aim of the study was to describe a single-center experience using combined extra-anatomic open arch branch revascularization with aortic arch endovascular exclusion for treatment of aberrant subclavian artery aneurysms., Methods: All patients undergoing management of aberrant subclavian aneurysms were identified from a prospective patient registry. Means of revascularization included carotid-subclavian bypass or subclavian transposition, and origin occlusion was performed by surgical ligation or endovascular embolization at surgeon discretion. Completion of aneurysm exclusion was performed using available distal arch/thoracic aortic endografts (TEVARs) using standard oversizing. Procedures were staged as appropriate based on patient condition., Results: Ten patients, 8 females and 2 males ranging from 32 to 85 years of age, were identified. Presenting symptoms were dysphagia (n = 9) and acute type B aortic dissection (n = 1). All patients required revascularization/exclusion of bilateral subclavian arteries to enable >20 mm proximal aortic fixation distal to the common carotid origins for the arch endograft. TEVAR with planned coverage of both subclavian origins extending into the proximal descending thoracic aorta was performed using transfemoral access (n = 9) or iliac conduit (n = 1) and required a single device (100-157 mm) in all cases except the aortic dissection which required total length coverage of the descending thoracic aorta. Extra-anatomic revascularization and thoracic endografting were staged by 1-2 days in most cases to minimize potential airway edema from bilateral neck exposures. Subclavian revascularization was performed by carotid-subclavian bypass using polytetrafluoroethylene (n = 17) or subclavian transposition (n = 3) with proximal occlusion using embolization with an Amplatzer II plug (n = 11) or ligation (n = 9). No major complications occurred including spinal cord ischemia, stroke, cranial nerve deficit, arm ischemia, access site complications, or wound complications. Length of stay ranged from 6 to 21 days with all patients having resolution of dysphagia on follow-up (mean 41 months). Directed imaging was available for 7 patients demonstrating the absence of endoleak, regression or stability of aneurysm size, and patency of all subclavian revascularizations., Conclusions: We present a hybrid repair technique with low operative morbidity that has shown to be durable in follow-up and to provide symptomatic relief for patients with aberrant subclavian artery aneurysms causing esophageal compression., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The aim of this study is to describe the use of a novel off-the-shelf technique to repair type III and type IV thoracoabdominal aortic aneurysms (TAAAs) in the absence of available prefabricated branched devices., Methods: All patients undergoing endovascular repair of type III and IV TAAAs using this technique were included from a prospectively maintained registry at a regional aortic referral center. The proximal bifurcated Gore C3 Excluder device is positioned in the descending thoracic aorta with the contralateral gate 2-3 cm above the celiac artery. From an axillary approach, the contralateral gate renovisceral branches are sequentially cannulated and simultaneously stented using Viabahn covered stents. In cases were the celiac artery could not be excluded, a parallel stent (snorkel) was added adjacent to the proximal endograft. All branches are simultaneously balloon dilated to ensure proximal gutter seal in the contralateral gate. Via the ipsilateral limb, the device can then be extended with a flared iliac extension and/or additional bifurcated device to obtain seal in the distal aorta (previous open repair) or common iliac arteries., Results: Eight patients (male = 6, mean 78 years of age) were treated in this manner since January 2015. All patients underwent repair using Gore C3 device with 3 (n = 5) or 4 (n = 3) renovisceral branches. The celiac artery was sacrificed in 4 patients and 1 renal artery in 1 patient. Mean fluoroscopy time was 88.7 min with a mean of 92.3 cc contrast utilized. Median length of stay was 7 days with 3 days spent in the intensive care unit. No major cardiac, respiratory, renal, neurologic, or wound complications occurred. Three patients had early endoleaks treated with additional endovascular techniques (n = 2) or open surgical ligation (n = 1) during the index hospitalization. Two late endoleaks were identified; 1 type II with stable sac size and 1 type III requiring iliac limb relining. All limbs and branches remain patent at the time of the last imaging study (mean 6.8 months)., Conclusions: We present an endovascular technique for repair of type III and IV TAAAs which appears to be both feasible and safe with good short-term outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: In January 2015, we created a multidisciplinary Aortic Center with the collaboration of Vascular Surgery, Cardiac Surgery, Interventional Radiology, Anesthesia and Hospital Administration. We report the initial success of creating a Comprehensive Aortic Center., Methods: All aortic procedures performed from January 1, 2015 until December 31, 2016 were entered into a prospectively collected database and compared with available data for 2014. Primary outcomes included the number of all aortic related procedures, transfer acceptance rate, transfer time, and proportion of elective/emergent referrals., Results: The Aortic Center included 5 vascular surgeons, 2 cardiac surgeons, and 2 interventional radiologists. Workflow processes were implemented to streamline patient transfers as well as physician and operating room notification. Total aortic volume increased significantly from 162 to 261 patients. This reflected an overall 59% (P = 0.0167) increase in all aorta-related procedures. We had a 65% overall increase in transfer requests with 156% increase in acceptance of referrals and 136% drop in transfer denials (P < 0.0001). Emergent abdominal aortic cases accounted for 17% (n = 45) of our total aortic volume in 2015. The average transfer time from request to arrival decreased from 515 to 352 min, although this change was not statistically significant. We did see a significant increase in the use of air-transfers for aortic patients (P = 0.0041). Factorial analysis showed that time for transfer was affected only by air-transfer use, regardless of the year the patient was transferred. Transfer volume and volume of aortic related procedures remained stable in 2016., Conclusions: Designation as a comprehensive Aortic Center with implementation of strategic workflow systems and a culture of "no refusal of transfers" resulted in a significant increase in aortic volume for both emergent and elective aortic cases. Case volumes increased for all specialties involved in the center. Improvements in transfer center and emergency medical services communication demonstrated a trend toward more efficient transfer times. These increases and improvements were sustainable for 2 years after this designation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: The natural history and potential morbidity of gutter endoleaks are unclear. We present our experience with intraoperative gutter endoleaks and strategies to determine which of these require intervention., Methods: This is a retrospective review of all patients treated with parallel stent grafts from January 2010 to September 2015. We reviewed all operative records and intraoperative angiograms as well as all postoperative imaging and secondary interventions. All gutter leaks were classified as low-flow/nonsac-enhancing gutter endoleaks or high-flow/sac-enhancing gutter endoleaks. Adjunctive interventions to manage the gutter leaks were noted, as were all subsequent interventions for gutter leak and endoleak management., Results: Seventy-eight patients had 144 parallel stents placed over a 5-year period with an average of 1.8 stents per patient. Twenty-eight patients (36%) had gutter endoleaks diagnosed intraoperatively. Seventeen patients had adjunctive procedures to reduce gutter leaks prior to leaving the operating room (OR). Patients selected for treatment had gutters filling early during completion angiography and/or contrast enhancement of the aneurysm sac. Twenty-two patients (28%) left the OR with low-flow/delayed/nonsac-enhancing gutter endoleaks. At 30 days, a total of 6 persistent gutter endoleaks were diagnosed on computed tomographic angiography. This gives a 73% rate of resolution for low-flow/nonaneurysm sac-enhancing endoleaks. There were 2 de novo endoleaks not detected at the index procedure diagnosed at 6-month follow-up. Of the 8 total postoperative endoleaks, 5 required additional intervention with a 100% success rate. Multivariate analysis revealed that the only significant predictor of having a postoperative endoleak is leaving the OR with an endoleak., Conclusions: Intraoperative treatment of gutter endoleaks has an acceptable rate of resolution. It does have a high rate of converting high-flow endoleaks to low-flow endoleaks. Low-flow/nonsac-enhancing gutter endoleaks have a high rate of spontaneous resolution. Intraoperative gutter endoleaks are not predictive of future aneurysm sac growth.

Objective: The objective of this study was to review the outcomes of renal artery revascularizations during open aortic aneurysm repair., Methods: Open abdominal aneurysm repairs performed from 2010 to 2015 at a single institution were reviewed, including type IV thoracoabdominal, suprarenal, and juxtarenal aneurysms. Direct renal reconstruction techniques included eversion endarterectomy, bypass, and vessel reimplantation based on the patient's anatomy. Renal loss was defined by artery occlusion., Results: The study included 125 patients; of these, 57 patients (46%) had 76 renal reconstructions (38 single, 19 bilateral) performed. Interventions included endarterectomy (n = 21), transaortic stenting (n = 2), reimplantation with (n = 25) or without (n = 17) endarterectomy, bypass (n = 4), and ligation (n = 7). Mean aneurysm size was 6.4 cm, with 23% (n = 29) urgent/emergent operations and 20% (n = 25) having had a prior open or endovascular repair. Overall complication rate was 50%, with significant increase among the group requiring renal intervention, primarily accounted for by a 33% early or late dialysis requirement compared with 16% in patients with no renal revascularization (P = .01). Overall 30-day mortality was 9%, with no difference between groups. Urgent/emergent operation (P < .001) was associated with increased 30-day mortality (24% vs 4% elective procedures), but prior open or endovascular repair (P = .4) was not. Mean follow-up was 26 months, with directed imaging out to a mean of 18 months. Renal intervention (P = .01) and urgent/emergent status (P = .04) were predictive of dialysis requirement; however, among those undergoing intervention, renal loss was not associated with an increase in dialysis requirement (P = .2). Of the directed intervention techniques, renal reimplantation with or without endarterectomy was associated with increased risk of dialysis requirement (P = .005) and renal loss (P = .04) relative to endarterectomy alone. Mean creatinine concentration on late follow-up was 1.4 mg/dL (from 1.3 mg/dL preoperatively) and was not statistically significantly different between those undergoing renal intervention (1.5 mg/dL) and those who did not (1.4 mg/dL)., Conclusions: Renal artery reconstruction at the time of open repair of paravisceral aneurysms is associated with an increased complication rate, primarily driven by occlusion of reimplanted vessels and increased dialysis requirement. As reported by others, nonelective presentation is the greatest determinant of early death or adverse outcomes., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic outlet decompression (TOD) is associated with significant postoperative pain often leading to hospital length of stay out of proportion to the risk profile of the operation. We seek to describe the improvement in hospital length of stay and patient pain control with an improved multiagent pain management regimen., Methods: We retrospectively reviewed the hospital length of stay, medication regimen/usage, operative details, and operative indications for all patients undergoing TOD from January 2012 through June 2015. During early experience, single-agent narcotic therapy was the mainstay of postoperatively pain control. Since 2014, we have adopted a regimen consisting of narcotic patient controlled analgesia, oral narcotics, and scheduled ibuprofen and valium, which is transitioned to oral narcotics/valium upon discharge. Operative approach (supraclavicular, infraclavicular, transaxial, or paraclavicular) was determined by patient anatomy and indication for procedure (neurogenic/arterial thoracic outlet syndrome or arteriovenous access dysfunction)., Results: Seventy-four patients were treated with TOD over the study period: 36 (49.3%) for neurogenic thoracic outlet syndrome, 23 (31.5%) for venous thoracic outlet syndrome, and 15 (19.2%) for arteriovenous access dysfunction. Prior to 2014, the mean length of stay was 4 days with a median pain score of 6. Since 2014, the mean length of stay was 2.6 (P = 0.04) with a median pain score of 4 (P = 0.005). There was no statistically significant difference in the indication for operation or operative approach between the two periods., Conclusions: Since adoption of a multiagent pain management regimen to include scheduled NSAIDs and benzodiazepines, we have reduced the mean pain score experienced by our patients as well as the hospital length of stay., (Copyright © 2017 Elsevier Inc. All rights reserved.)