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Step 1 of the United States Medical Licensing Examination (USMLE), a historically important factor in the selection of vascular surgery residents and fellows, transitioned to completely pass/fail on January 26, 2022. Due to the COVID-19 pandemic, residency and fellowship interviews were conducted virtually during the 2020-21 and 2021-22 application cycles. Given these significant changes in the evaluation of candidates for residency training, we sought to understand vascular surgery program directors' (PDs) perspectives regarding the change in step 1 scoring and use of virtual interviews as well as determine which factors will assume importance when applying to vascular surgery training programs in the future.A 26-item survey questionnaire was created using Qualtrics survey tools with questions regarding attitudes toward the change in step 1 scoring and virtual interviews, the importance of additional factors utilized by programs in selecting candidates for interviews and ranking applicants for residency/fellowship selection, and programmatic demographics. This was distributed anonymously to all vascular surgery training programs over a 2-week period using a comprehensive list of 249 unique email addresses created by cross-referencing the Accreditation Council for Graduate Medical Education list of certified vascular training programs with email addresses from individual program websites identifying current program leadership. Responses were analyzed with descriptive statistics with values listed as average Likert scale weight ± standard deviation (SD) or percentages.Sixty-eight of 249 (27.3%) program and associate PDs responded to the survey. Of which, 33.9% of respondents strongly disagreed with step 1 going completely pass/fail. In the absence of a scored USMLE step 1, letters of recommendation (average Likert scale weight ± SD, 4.43 ± 0.92), dedication to specialty (4.14 ± 1.03), and USMLE step 2 CK (4.06 ± 0.92) had the highest average scores for deciding which applicants to interview for integrated vascular surgery residency. For determining which candidates to interview for vascular surgery fellowship, letters of recommendation (4.51 ± 0.84), dedication to specialty (4.12 ± 0.90), and research (4.10 ± 0.80) had the highest average scores. For ranking residency candidates, the interviewee's perceived "fit" (4.61 ± 0.55), letters of recommendation (4.53 ± 0.76), and an overall interview experience (4.47 ± 0.62) had the highest average scores. Similarly, the factors with the highest average Likert scores for ranking fellowship candidates included the interviewee's perceived "fit" (4.69 ± 0.51), letters of recommendation (4.65 ± 0.52), and an overall interview experience (4.51 ± 0.59). The majority (72.2%) of PDs preferred in-person interviews; however, 50% of respondents were at least "somewhat satisfied" with virtual interviews during the 2021-22 application cycle as they could judge applicants' interview skills at least "moderately well." The minority (18.8%) who preferred virtual interviews most commonly noted a "reduction of the financial burden for applicants" as the reason for this preference.Most vascular surgery program and associate PDs were dissatisfied with USMLE step 1 going pass/fail with most indicating prescreening applicants using both step 1 and step 2 clinical knowledge (CK) during the residency and fellowship selection processes. In the absence of a scored step 1, the top factors for interviewing and ranking integrated vascular surgery residency and fellowship candidates included letters of recommendation, dedication to specialty, research, USMLE step 2 CK, the interviewee's perceived "fit," and overall interview experience. Though most PDs preferred face-to-face interviews, they were overall at least "somewhat satisfied" with the virtual format that took place during the 2021-22 cycle.

OBJECTIVE: Extremity venous aneurysms result in the risk of pulmonary embolism (PE) and chronic venous insufficiency. At present, owing to the rarity of these aneurysms, no consensus for their treatment has been established. The purpose of the present study was to review the presentation, natural history, and contemporary management of extremity venous aneurysms. METHODS: We performed a retrospective, multi-institutional review of all patients with extremity venous aneurysms treated from 2008 to 2018. A venous aneurysm was defined as saccular or fusiform with an aneurysm/vein ratio of >1.5. RESULTS: A total of 66 extremity aneurysms from 11 institutions were analyzed, 40 of which were in a popliteal location, 14 iliofemoral, and 12 in an upper extremity or a jugular location. The median follow-up was 27 months (range, 0–120 months). Of the 40 popliteal venous aneurysms, 8 (20%) had presented with deep vein thrombosis (DVT) or PE, 13 (33%) had presented with pain, and 19 had been discovered incidentally. The mean size of the popliteal venous aneurysms presenting with DVT or PE was larger than that of those presenting without thromboembolism (3.8 cm vs 2.5 cm; P = .003). Saccular aneurysm morphology in the lower extremity was associated with thromboembolism (30% vs 9%;P = .046) and fusiform aneurysm morphology with a thrombus burden >25% (45% vs 3%). Patients presenting with thromboembolism were more likely to have had a thrombus burden >25% in their lower extremity venous aneurysm compared with those who had presented without thromboembolism (70% vs 9%). Approximately half of all the patients underwent immediate intervention, and half were managed with observation or antithrombotic regimen. In the nonoperative cohort, three patients subsequently developed a DVT. Eight patients in the medically managed cohort went on to require surgical intervention. Of the 12 upper extremity venous aneurysms, none had presented with DVT or PE, and only 2 (17%) had presented with pain. Of the 66 patients in the entire cohort, 41 underwent surgical intervention. The most common indication was the absolute aneurysm size. Nine patients had undergone surgery because of a DVT or PE, and 11 for pain or extremity swelling. The most common surgery was aneurysmorrhaphy in 21 patients (53%), followed by excision and ligation in 14 patients (35%). Five patients (12%) had undergone interposition bypass grafting. A postoperative hematoma requiring reintervention was the most common complication, occurring in three popliteal vein repairs and one iliofemoral vein repair. None of the patients, treated either surgically or medically, had reported post-thrombotic complications during the follow-up period. CONCLUSIONS: Large lower extremity venous aneurysms and saccular aneurysms with thrombus >25% of the lumen are more likely to present with thromboembolic complications. Surgical intervention for lower extremity venous aneurysms is indicated to reduce the risk of venous thromboembolism (VTE) and the need for continued anticoagulation. Popliteal aneurysms >2.5 cm and all iliofemoral aneurysms should be considered for repair. Upper extremity aneurysms do not have a significant risk of VTE and warrant treatment primarily for symptoms other than VTE. (J Vasc Surg Venous Lymphat Disord 2022;10:1352–8.)

Objective: Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure. Methods: The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up. Results: For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval [CI], 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio [HR], 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure. Conclusions: No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.

Endovascular reinterventions are often performed after previous open or endovascular aortic procedures. We used the GREAT (Global Registry for Endovascular Aortic Treatment) database to compare the outcomes between these groups. We also compared reintervention of any type with a group of patients who had undergone primary endovascular abdominal aortic aneurysm repair (EVAR).All patients enrolled in GREAT were grouped according to a previous EVAR or open abdominal aortic procedure (OAP). Univariate analysis was performed using the χA total of 3974 subjects who had undergone EVAR with follow-up data available were included in the GREAT. Of the 3974 procedures, 196 (4.9%) were reinterventions (49 after OAP and 147 after previous EVAR). Reintervention after previous EVAR showed a trend toward a greater endoleak rate through 2 years (13.6% vs 4.1%; P = .07), although no difference was found in the occurrence of the intervention (12.2% vs 17.7%; P = .37). Reintervention after OAP resulted in higher all-cause mortality through 2 years of follow-up (32.7% vs 17.7%; P = .0.03). The predictors of mortality included prior OAP, renal insufficiency, and the use of cutdown for access. Compared with the patients who had undergone primary endovascular repair, patients in the reintervention cohort were older (75.3 years vs 73.3 years; P = .0005), had had only femoral artery access used (95.8% vs 90.3%; P .0001), and were more likely to have undergone aortic branch vessel procedures (32.3% vs 13.3%; P .0001). Both all-cause and aorta-related mortality through 2 years was higher in the reintervention group than in the primary EVAR group (21.4% vs 12.5% [P = .0003; and 4.6% vs 1% [P .0001], respectively). On multivariate analysis, the predictors of aortic-related mortality included reintervention, renal insufficiency, chronic obstructive pulmonary disease, underweight body mass index, increasing aortic diameter, and the use of brachial artery or other arterial access sites.Endovascular reintervention for aortic pathology was associated with higher mortality than was primary EVAR. Reinterventions after prior OAPs were associated with higher mortality than were prior EVARs.

Objectives Major depression is associated with increased morbidity and mortality in vascular surgery patients. The US Preventive Services Task Force and American Heart Association recommend routine depression screening for adults, especially those with cardiovascular disease. Since routine depression screening has not been implemented in most vascular surgery clinics across the nation, we sought to determine the feasibility of depression screening and understand the prevalence and predictors of depression in patients presenting to a single institution’s vascular surgery clinic over a 4 month period. Methods From June to September 2020, vascular surgery clinic patients were administered a 26-item survey that included validated scales for depression (PHQ-9), pain, frailty, alcohol dependence, and nicotine dependence. Although not validated, the Rosenberg Self-Esteem Scale was also administered. Patient charts were reviewed for demographic information and medical history. 9-digit patient zip codes were used to determine Area Deprivation Index, a measure of socioeconomic status. Univariate and multivariate analyses were performed to understand the factors associated with increased depression prevalence in the study population. Results A total of 140 (36.4%) of 385 patients met study inclusion criteria. 35.7% of them screened positive for mild to severe depression (PHQ-9 scores ≥5). On univariate analysis, major depression was significantly associated with lower socioeconomic status ( p = 0.007), higher frailty ( p < 0.001), lower self-esteem ( p < 0.001), higher daily pain ( p < 0.001), health problems that interfere with social activities ( p < 0.001), fatigue ( p < 0.001), unmarried status ( p = 0.031), and lack of primary care provider ( p = 0.048). Multivariate analyses significantly predicted higher frailty (B= 0.487, p = 0.007) and lower self-esteem (B= −0.413, p < 0.001) in patients with depression. Depression was not associated with gender, age, employment status, smoking status, alcohol use, or type of vascular disease. Coclusions More than one-third of vascular surgery clinic patients have comorbid depression. Higher frailty and lower self-esteem are significant risk factors for depression. Prevention and early identification of frailty may improve outcomes. Depression screening in vascular surgery clinics is feasible and could be useful in determining which patients may benefit from more frequent follow-up and monitoring for associated comorbidities. Vascular surgeons may play an important role in screening for depression and referring patients for psychotherapy and/or pharmacotherapy.

Background Paradoxical embolism is the translocation of a thrombus originating in the systemic venous circulation into the arterial circulation through a cardiac defect, most commonly a patent foramen ovale (PFO). PFO exists in 15–35% of the adult population. The most common manifestation is cerebrovascular accident; acute limb ischemia is much rarer. Methods A 67-year-old woman with multiple confounding risk factors for hypercoagulability presented with grade IIb left lower limb ischemia secondary to thromboembolism through a previously silent PFO. Management included urgent embolectomy, prophylactic fasciotomy, postoperative anticoagulation, and PFO closure. A systematic literature review of PFO-mediated acute limb ischemia was performed to identify the patient populations most commonly affected, the anatomic distribution of emboli, and patient management. Results Forty-three reports including 51 patients with first-time PFO-mediated paradoxical embolism were identified. Fifty-one percent were men, and the average age at presentation was 54 years. Multiple limbs were affected in 14 patients (27.5%), and a propensity for the lower limbs (72%) and left-sided circulation (82%) was noted. Deep venous thromboembolism was identified in 36 patients (71%). Immediate anticoagulation was instituted in 31 patients. Embolectomy and/or fibrinolysis were performed in 45 patients (88%). Conclusions Acute limb ischemia is a rare manifestation of PFO-mediated paradoxical embolism that requires a high index of suspicion for diagnosis. Middle-aged individuals appear to be more commonly affected, and acute limb ischemia most often occurs in the lower limbs and left-sided circulation, with the potential to affect multiple extremities simultaneously. Prompt identification and surgical embolectomy with prophylactic fasciotomy can facilitate successful outcomes. Perioperative management should include anticoagulation and may include workup with echocardiography, duplex ultrasound, and hypercoagulability testing.

Primary aortic infections are a lethal disease process, and acquired aortic graft infections are a dreaded complication of vascular surgery. Fortunately, both are quite rare. Review of the literature should be done carefully since aortitis, infected or mycotic aortic aneurysm, and aortic graft infection are distinct clinical entities. Management of these infections is based on patient factors such as pre-existing conditions, anatomic location of the infection, and need for reconstruction as well as the bacteriology of the infection. Current endovascular options may offer the ability to stabilize the patient until definitive treatment or be sufficient to treat existing infection depending on both the patient and type of infection.

The American Board of Surgery In-Training Examination (ABSITE) is used by programs to evaluate the knowledge and readiness of trainees to sit for the general surgery qualifying examination. It is often used as a tool for resident promotion and may be used by fellowship programs to evaluate candidates. Burnout has been associated with job performance and satisfaction; however, its presence and effects on surgical trainees' performance are not well studied. We sought to understand factors including burnout and study habits that may contribute to performance on the ABSITE examination.Anonymous electronic surveys were distributed to all residents at 10 surgical residency programs (n = 326). Questions included demographics as well as study habits, career interests, residency characteristics, and burnout scores using the Oldenburg Burnout Inventory, which assesses burnout because of both exhaustion and disengagement. These surveys were then linked to the individual's 2016 ABSITE and United States Medical Licensing Examination (USMLE) step 1 and 2 scores provided by the programs to determine factors associated with successful ABSITE performance.In total, 48% (n = 157) of the residents completed the survey. Of those completing the survey, 48 (31%) scored in the highest ABSITE quartile (≥75th percentile) and 109 (69%) scored less than the 75th percentile. In univariate analyses, those in the highest ABSITE quartile had significantly higher USMLE step 1 and step 2 scores (P 0.001), significantly lower burnout scores (disengagement, P 0.01; exhaustion, P 0.04), and held opinions that the ABSITE was important for improving their surgical knowledge (P 0.01). They also read more frequently to prepare for the ABSITE (P 0.001), had more disciplined study habits (P 0.001), were more likely to study at the hospital or other public settings (e.g., library, coffee shop compared with at home; P 0.04), and used active rather than passive study strategies (P 0.04). Gender, marital status, having children, and debt burden had no correlation with examination success. Backward stepwise multiple regression analysis identified the following independent predictors of ABSITE scores: study location (P 0.0001), frequency of reading (P = 0.0001), Oldenburg Burnout Inventory exhaustion (P = 0.02), and USMLE step 1 and 2 scores (P = 0.007 and 0.0001, respectively).Residents who perform higher on the ABSITE have a regular study schedule throughout the year, report less burnout because of exhaustion, study away from home, and have shown success in prior standardized tests. Further study is needed to determine the effects of burnout on clinical duties, career advancement, and satisfaction.

BackgroundAdventitial cystic disease (ACD) is an unusual arteriopathy; case reports and small series constitute the available literature regarding treatment. We sought to examine the presentation, contemporary management, and long-term outcomes using a multi-institutional database.MethodsUsing a standardized database, 14 institutions retrospectively collected demographics, comorbidities, presentation/symptoms, imaging, treatment, and follow-up data on consecutive patients treated for ACD during a 10-year period, using Society for Vascular Surgery reporting standards for limb ischemia. Univariate and multivariate analyses were performed comparing treatment methods and factors associated with recurrent intervention. Life-table analysis was performed to estimate the freedom from reintervention in comparing the various treatment modalities.ResultsForty-seven patients (32 men, 15 women; mean age, 43 years) were identified with ACD involving the popliteal artery (n = 41), radial artery (n = 3), superficial/common femoral artery (n = 2), and common femoral vein (n = 1). Lower extremity claudication was seen in 93% of ACD of the leg arteries, whereas patients with upper extremity ACD had hand or arm pain. Preoperative diagnosis was made in 88% of patients, primarily using cross-sectional imaging of the lower extremity; mean lower extremity ankle-brachial index was 0.71 in the affected limb. Forty-one patients with lower extremity ACD underwent operative repair (resection with interposition graft, 21 patients; cyst resection, 13 patients; cyst resection with bypass graft, 5 patients; cyst resection with patch, 2 patients). Two patients with upper extremity ACD underwent cyst drainage without resection or arterial reconstruction. Complications, including graft infection, thrombosis, hematoma, and wound dehiscence, occurred in 12% of patients. Mean lower extremity ankle-brachial index at 3 months postoperatively improved to 1.07 (P < .001), with an overall mean follow-up of 20 months (range, 0.33-9 years). Eight patients (18%) with lower extremity arterial ACD required reintervention (redo cyst resection, one; thrombectomy, three; redo bypass, one; balloon angioplasty, three) after a mean of 70 days with symptom relief in 88%. Lower extremity patients who underwent cyst resection and interposition or bypass graft were less likely to require reintervention (P = .04). One patient with lower extremity ACD required an above-knee amputation for extensive tissue loss.ConclusionsThis multi-institutional, contemporary experience of ACD examines the treatment and outcomes of ACD. The majority of patients can be identified preoperatively; surgical repair, consisting of cyst excision with arterial reconstruction or bypass alone, provides the best long-term symptomatic relief and reduced need for intervention to maintain patency.

Objective This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR). Methods Patients diagnosed with infected aortic endografts after EVAR/TEVAR between January 1, 2004, and January 1, 2014, were reviewed using a standardized, multi-institutional database. Demographic, comorbidity, medical management, surgical, and outcomes data were included. Results An aortic endograft infection was diagnosed in 206 patients (EVAR, n = 180; TEVAR, n = 26) at a mean 22 months after implant. Clinical findings at presentation included pain (66%), fever/chills (66%), and aortic fistula (27%). Ultimately, 197 patients underwent surgical management after a mean of 153 days. In situ aortic replacement was performed in 186 patients (90%) using cryopreserved allograft in 54, neoaortoiliac system in 21, prosthetic in 111 (83% soaked in antibiotic), and 11 patients underwent axillary-(bi)femoral bypass. Graft cultures were primarily polymicrobial (35%) and gram-positive (22%). Mean hospital length of stay was 23 days, with perioperative 30-day morbidity of 35% and mortality of 11%. Of the nine patients managed only medically, four of five TEVAR patients died after mean of 56 days and two of four EVAR patients died; both deaths were graft-related (mean follow-up, 4 months). Nineteen replacement grafts were explanted after a mean of 540 days and were most commonly associated with prosthetic graft material not soaked in antibiotic and extra-anatomic bypass. Mean follow-up was 21 months, with life-table survival of 70%, 65%, 61%, 56%, and 51% at 1, 2, 3, 4, and 5 years, respectively. Conclusions Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction.

ObjectiveThe acute technical failure of endovascular treatment of chronic total occlusions (CTOs) is most often due to the inability to re-enter the true lumen after occlusion is crossed in a subintimal plane. This study reports our initial experience with true lumen re-entry devices in the treatment of CTOs.MethodsPatients with treatment of CTOs were identified from our vascular registry. All patients in whom the Pioneer catheter or the Outback catheter were used were also identified from a prospectively maintained separate database of cases in which true lumen re-entry devices were used. We used procedural data from the prospective database and reviewed the medical records. Lesion character and location, access type, location of true lumen re-entry, stent usage, procedural times, and complications, were tabulated.ResultsFrom August 2003 to December 2004, endovascular techniques were used to treat 87 CTOs in 58 iliac and 29 superficial femoral arteries. In 24 (26%), the true lumen could not be re-entered by using standard catheter and wire techniques. The true lumen was not initially re-entered in 20 (34%) of 58 of treated iliac CTOs and four (13%) of 29 of treated superficial femoral artery CTOs (73% TASC C and D lesions). Intravascular ultrasound-guided true lumen re-entry using the Pioneer catheter (21 CTOs), or fluoroscopic-guided true lumen re-entry using the Outback catheter (3 CTOs) was successful in achieving true lumen re-entry in all cases at the location desired. Total time of re-entry catheter manipulation required to achieve re-entry was

Hostile neck anatomy remains the predominant reason that patients are denied endovascular aneurysm repair (EVAR). We reviewed our experience of EVAR with use of prophylactic adjunctive proximal balloon-expandable stents in patients with hostile neck anatomy and adjunctive proximal balloon-expandable stents in patients with type I endoleaks. Of 140 patients who underwent EVAR between 2000 and 2004, we reviewed data for 19 patients in whom we used proximal balloon-expandable stents. By high-resolution computed tomography scan or angiography, hostile neck anatomy was classified as length

Background: During prolonged laparoscopic operations with carbon dioxide (CO 2 ) pneumoperitoneum (PP), hypercapnia with significant acidosis has been reported to occur in some patients with pulmonary dysfunction. An alternate inert insufflation gas like helium (He) could avoid this problem. Methods: This prospective, IRB-approved study compared the cardiopulmonary response in 20 patients with both CO 2 and He PP. With the minute ventilation held constant, baseline arterial blood gases and ventilatory and cardiac parameters were obtained after anesthetic induction but prior to CO 2 PP. All values were repeated at 20 to 30 and 40 to 60-minute intervals after the insufflation of CO 2 PP, then again during He PP. Values were compared by a paired t test analysis. Results: Patients experienced significant hypercapnia during CO 2 PP when compared with baseline arterial blood gases, but all values returned to baseline levels during He PP. Conclusions: He PP is an effective alternative to CO 2 PP for a laparoscopic cholecystectomy avoiding CO 2 retention and subsequent acidosis. Carbon dioxide retention may be dangerous in patients with pulmonary dysfunction who undergo laparoscopy. (Gastrointest Endosc (1996;43:38-41.)

Although physiological changes during laparoscopy and thoracoscopy generally are similar to those seen during standard open procedures, these minimally invasive techniques are accompanied by some unique changes. General, regional, and local anesthesia during laparoscopy and thoracoscopy, and potential complications, are discussed. The physiological responses that are discussed include hemodynamic effects, acid-base and pulmonary effects, and hormonal effects.

Percutaneous vascular closure devices have become increasingly common in their use in both cardiac and peripheral vascular intervention. Our cases present the risk factors of repeat percutaneous vascular closure devices for subsequent infectious complications. A 43-year-old male underwent cardiac catheterization and closure with an Angio-Seal (St. Judes Medical, Inc., St. Paul, MN) device. He required a second cardiac catheterization with access gained on the same side as the previous intervention. He developed bacteremia and an infected hematoma with erosion of the femoral artery. The second case involves a 57-year-old male who underwent cardiac catheterization and closure with an Angio-Seal device. He developed a localized infection over the accessed groin site. The overall complication rate of closure devices is 2%, and 0.3% of patients have infectious complications. The high morbidity associated with these complications indicates the need to be able to identify patients who are at increased risk for these complications.

A thoracolumbar fracture in a pregnant patient is uncommon and is generally associated with relative osteoporosis of pregnancy1,2. We know of only one report that has addressed traumatic thoracolumbar fractures in pregnant women3. That study described two patients who had a flexion-distraction fracture treated in a delayed fashion, and neither of them had a neurologic deficit. We describe the treatment of a thirty-nine-year-old woman with a burst fracture of the twelfth thoracic vertebra with an incomplete spinal cord injury and a viable pregnancy. We believe this to be the first report of the surgical treatment of a traumatic fracture associated with a spinal cord injury in a pregnant woman. The patient was informed that data concerning the case would be submitted for publication, and she consented. A thirty-nine-year-old woman who was seventeen weeks pregnant fell from a standing height on the day prior to presentation after she had been consuming alcohol and marijuana. She presented to the emergency department the following day because of wrist and back pain. The medical and surgical history was notable for paranoid schizophrenia and a previous cesarean delivery. She denied taking any prescription medications or having any allergies. At the time of the initial presentation, the patient had a distal radial fracture and back pain. The back pain was not further evaluated, given the low level of trauma and the pregnant status of the patient. The distal radial fracture was reduced, and a cast was applied. She was discharged with instructions to return for follow-up of the wrist. The patient returned to the emergency department the next day with worsening back pain and new complaints of lower extremity weakness as well as urinary and fecal incontinence. At that time, a magnetic …

Radiation-induced damage to the bone, soft tissues, and vasculature represents the unfortunate consequences of radiation therapy for the treatment of malignant tumors. Complications arising from irradiation are frequently challenging to manage and may be life threatening. A case is presented of a patient with a longstanding clavicular osteoradionecrosis with an acute massive hemorrhage after rupture of the subclavian artery and subsequent management with endovascular stent placement. With over 2 years' follow-up, vascular patency was maintained with no further bleeding episodes in this surgically high-risk patient.

Peripheral arterial disease has a significant impact on the quality of a patient's life. Pain, fear of limb loss, increased inactivity, and poor lifestyle choices such as continued smoking further debilitate these patients. Surgical and endovascular procedures have affected this outcome for many but carry the added risk of procedural complications and mortality for this group of high-risk individuals. Risk factor management and medical therapy carry little risk and can also improve functional outcome for many of these patients. Despite this, there are currently only two FDA-approved medications for the treatment of claudication. This review discusses published data on the impact of walking distance with investigational pharmacotherapy.

Women with peripheral vascular disease requiring vascular operations are less well studied than their male counterparts. The surgical outcomes of female vascular patients in the Department of Veterans Affairs (VA) and private sector hospitals have not previously been compared, and their preoperative risk profile, postoperative morbidity, and mortality need to be better elucidated.Patients undergoing vascular operations at 14 private sector and 128 VA hospitals, from October 2001 through September 2004, had their preoperative characteristics, operative data, and 30-day postoperative morbidity and mortality compared, as part of the Patient Safety in Surgery (PSS) Study. Logistic regression analysis was performed to develop predictive models for morbidity and mortality, which allowed for a comparison of risk-adjusted outcomes between the two hospital groups.There were 458 vascular surgical operations performed in women in the VA, and 3,535 vascular operations were performed in women in the private sector. Eighteen of 45 preoperative comorbidities and laboratory variables differed considerably between the institutions, and 16 of 18 were adverse among the private sector patients. The unadjusted 30-day mortality rate was higher in the private sector compared with the VA (5.2% versus 2.4%, p=0.008); the unadjusted morbidity rate was higher in the private sector compared with the VA sector (23.4% versus 13.3%, p0.0001). After risk adjustment, there was no marked difference between the VA and the private sector in mortality (p=0.12), but the difference in morbidity rates remained pronounced, with an odds ratio of 0.60 for VA versus private sector (95% CI=0.44, 0.81).Compared with their VA counterparts, women undergoing vascular operations at private sector hospitals had a higher incidence of preoperative comorbidities; after risk adjustment, mortality did not differ substantially. Despite risk adjustment, the incidence of postoperative morbidity in the VA patients was considerably lower, suggesting unidentified differences in the hospital populations, their processes of care, or both.

p NTRAVENOUS MEDICATIONS providing both amnesia and relief of pain have been available since the 1930s.1 nfortunately, little was known of the hemodynamic or respiatory consequences when thiopental was universally adminisered to sailors injured during the attack on Pearl Harbor. eferences to the practice led to this agent being called the ideal method of euthanasia in war surgery.”2 Fortunately, uch has changed since this early application. Administration of anesthesia is no longer limited to the perating room. As more minimally invasive procedures have een developed, the need for adequate pain relief and conscious edation have expanded to include physician offices, ambulaory care facilities, cardiac catheterization laboratories, endosopy suites, and even intensive care units in which prolonged eriods of sedation may be required for the severely injured. ore recently, many vascular surgical procedures are now eing performed endovascularly, and the interventional radiolgy suite is now a frequent site of prolonged periods of sedaion during complicated or lengthy procedures. The level of sedation achieved during these procedures in hese various locations has been defined by the American ociety of Anesthesiologists (ASA) based on the patient’s esponses. Minimal sedation is a drug-induced state during hich a patient responds normally to verbal commands. Cogitive function and coordination may be impaired, but ventilaory and cardiovascular functions are usually not affected. oderate sedation (previously referred to as conscious sedaion) is another drug-induced state during which the patient esponds to verbal commands but may require light tactile timulation prior to responding. A patent airway and cardioascular function are maintained without assistance.3 Accurate records of the number of procedures being perormed with this type of anesthesia are difficult to obtain. It was stimated in 1999 that more than 65% of surgical procedures ere performed as outpatient procedures.4 How many of these rocedures used minimal or moderate sedation versus general nesthesia is also not known. How many procedures were erformed within a hospital setting using minimal or moderate edation is currently not reported on a national level. A recent eview of quality assurance data within the author’s own instiution documented more than 29,000 patients receiving modrate sedation outside of the operating room in the last 4 years, ith more patients receiving moderate sedation each year (Fig ).5 Approximately 25% of these patients receive procedures in he cardiac catheterization laboratory and in the interventional adiology suite during percutaneous interventions. Most published data regarding the methods for administraion of sedation outside of the operating room have been ccumulated from voluntary responses to surveys by intervenional radiologists. Nearly all surveys documented some utiliation of conscious sedation during interventions. Methods of roviding sedation differed widely depending on institutional ractice. In a survey of Belgian radiologists, the majority of iagnostic arteriograms were performed with local anesthesia nly. Many percutaneous interventions were also performed m

Background Aortic infections, even with treatment, have a high mortality and risk of recurrent infection and limb loss. Cryopreserved aortoiliac allograft (CAA) has been proposed for aortic reconstruction to improve outcomes in this high-risk population. Methods A multicenter study using a standardized database was performed at 14 of the 20 highest volume institutions that used CAA for aortic reconstruction in the setting of infection or those at high risk for prosthetic graft infection. Results Two hundred twenty patients (mean age, 65; male:female, 1.6/1) were treated since 2002 for culture positive aortic graft infection (60%), culture negative aortic graft infection (16%), enteric fistula/erosion (15%), infected pseudoaneurysm adjacent to the aortic graft (4%), and other (4%). Intraop cultures indicated infection in 66%. Distal anastomosis was to the femoral artery and iliac. Mean hospital length of stay was 24 days, and 30-day mortality was 9%. Complications occurred in 24% and included persistent sepsis (n = 17), CAA thrombosis (n = 9), CAA rupture (n = 8), recurrent CAA/aortic infection (n = 8), CAA pseudoaneurysm (n = 6), recurrence of aortoenteric fistula (n = 4), and compartment syndrome (n = 1). Patients with full graft excision had significantly better outcomes. Ten (5%) patients required allograft explant. Mean follow-up was 30 ± 3 months. Freedom from graft-related complications, graft explant, and limb loss was 80%, 88%, and 97%, respectively, at 5 years. Primary graft patency was 97% at 5 years, and patient survival was 75% at 1 year and 51% at 5 years. Conclusions This largest study of CAA indicates that CAA allows aortic reconstruction in the setting of infection or those at high risk for infection with lower early and long-term morbidity and mortality than other previously reported treatment options. Repair with CAA is associated with low rates of aneurysm formation, recurrent infection, aortic blowout, and limb loss. We believe that CAA should be considered a first line treatment of aortic infections.

In most patients, infrainguinal vein grafts are commonly performed for limb-threatening ischemia. Once limb salvage has been achieved, most clinicians agree that regular appointments with the vascular team are important to monitor graft patency. However, the timing of these appointments and what defines an adequate examination remains debatable. The following cases illustrate the natural history and interventions performed in 2 such patients. A review of the literature and a commentary on surveillance strategies is provided to elucidate the advantages and disadvantages of currently available vascular laboratory testing. Recommendations also are made for the appropriate timing of intervention to revise these grafts.

▪ Abstract Patients with carotid atherosclerotic disease present with a history of a neurologic event or with the presence of a bruit on physical examination. Recently, large randomized prospective studies have examined this group of patients to determine the optimal course of medical and surgical management. The data from these studies, together with the natural history of carotid disease and factors associated with stroke risk, are reviewed.

Objective: To determine the incidence of jaundice and hyperamylasemia in the absence of common bile duct abnormalities or clinical pancreatitis in patients undergoing cholecystectomy. Design: A continuous, prospective analysis of a consecutive case series was performed on all patients undergoing cholecystectomy. Setting: An urban, tertiary care university hospital. Patients: Adult patients with gallbladder disease. Intervention: All patients underwent cholecystectomy. Main Outcome Measures: The presence or absence of common bile duct abnormalities was evaluated by cholangiography, and pancreatitis was identified by clinical signs, imaging studies, and direct visual inspection during cholecystectomy. Results: All patients (N=1746) undergoing cholecystectomy were prospectively categorized as having chronic calculous (n=1410), acute calculous (n=217), chronic acalculous (n=70), or acute acalculous (n=49) gallbladder disease. It was uncommon for patients with chronic calculous cholecystitis to have an elevated bilirubin level with no choledocholithiasis and a normal common bile duct or to have hyperamylasemia without pancreatitis. Twenty-five percent of the patients with acute calculous cholecystitis had a serum bilirubin level between 34 and 86 μmol/L (2.0 and 5.0 mg/dL) with no common bile duct abnormality and 4% had hyperamylasemia without pancreatitis. Over one third of the patients with acute acalculous cholecystitis had an elevated bilirubin level with a normal common bile duct or an elevated amylase level without pancreatitis. Conclusion: Jaundice and hyperamylasemia can be produced by gallbladder disease alone. (Arch Surg. 1994;129:829-833)

Proximal gastric vagotomy (PGV) is an accepted operation for patients with ulcers that are refractory to medical management. Results comparable to those of standard, operative PGV have previously been demonstrated using endoscopic chemoneurolytic injection or laparoscopic laser seromyotomy in a porcine model. In this study, we evaluated several PGV techniques in regard to long-term effects on acid secretion, ulcer prophylaxis, and permanent vagal denervation in a rat model. Trans-mucosal injection of chemoneurolytic agents (cobaltous chloride, benzalkonium chloride, and phenol) and seromyotomy by CO 2 laser were performed. After 9 months, all rats received sub-serosal gastric injections of horseradish peroxidase (HRP) during laparotomy. Twenty-four hours later, an ulcerogenic dose of pentagastrin was administered sub-cutaneously. Three days after administration of HRP (to allow time for retrograde axonal transport and labeling of cells of the dorsal vagal nucleus with HRP), necropsy was performed. The pre-pyloric gastric mucosa was inspected for ulcerogenic changes, and a Congo red solution was applied to the gastric mucosa to map the acid-secreting areas. All PGV methods significantly diminished pentagastrin-induced ulceration when compared to sham controls. Benzalkonium chloride chemoneurolytic and laser methods were most effective for decreasing the size of acid-secreting areas. A reduced number of HRP-stained cells in the dorsal vagal nucleus indicated permanent denervation of vagal-gastric connections by operative and laser techniques. (Gastrointest Endosc 1994;40:316-20.)

Laparoscopic cholecystectomy (LC), which results in less postoperative pain, disability, and scarring, has become an attractive alternative method of surgical management of the ambulatory patient with gallbladder disease. The best procedure for severely ill patients who are poor operative risks but require cholecystectomy, however, is unknown since the operative morbidity and mortality of LC in this group of patients had not been studied. All patients (177) undergoing cholecystectomy at one institution were evaluated. Based on their preoperative state of health as defined by a modified acute physiologic score (APS), patients were divided into two groups; one group was defined by an APS of less than 10, indicating they were in good health, and the other had an APS greater than or equal to 10, indicating that the group had multiple risk factors, predicting an increased postoperative morbidity and mortality. Selection for either procedure, LC or open cholecystectomy (OC), was made independently of the patient's preoperative status. Patients' past medical histories; demographic, physiologic, and laboratory data; and postoperative complications were evaluated. When all cholecystectomy patients were arranged into the respective risk groups, the age and severity of illness scores (APS) between LC and OC were not statistically different. Intraoperative and postoperative complications were not significantly different when patients undergoing LC were compared to patients undergoing OC. Laparoscopic cholecystectomy was associated with decreased hospitalization when compared to patients undergoing OC. The overall mortality of the patients undergoing OC was significantly greater than those undergoing LC. LC is an acceptable surgical alternative for high-risk patients requiring cholecystectomy.

Hypercarbia with respiratory acidosis is a recognized complication of laparoscopic cholecystectomy. This study was performed to identify preoperatively those patients who may develop hypercarbia and acidosis during the procedure.Retrospective analysis of preoperative variables.Thirty-one consecutive patients underwent laparoscopic cholecystectomy at one institution who were receiving both preoperative pulmonary function tests and arterial blood gas analysis.More than 80 demographic, laboratory, and perioperative variables were entered into a univariate analysis to identify predictors of intraoperative acidosis (pH,7.35). Patient age, duration of the procedure, and preoperative blood gas values were not predictors of intraoperative acidosis. Several univariant predictors for patients experiencing carbon dioxide pneumoperitoneum-induced hypercarbia were identified; these included an elevated American Society of Anesthesiologists classification and significant decreases in forced expiratory flow at 25% of maximum, maximal forced expiratory flow, maximal voluntary ventilation, vital capacity, inspiratory capacity, and diffusing capacity of the lung for carbon monoxide.This study suggests that neither age nor preoperative arterial blood gas values are predictive of intraoperative hypercarbia and acidosis during periods of carbon dioxide pneumoperitoneum. However, preoperative pulmonary function measures of decreased flow, limited capacity, and compromised diffusion do correspond to the development of intraoperative acidosis. Preoperative evaluation with pulmonary function tests demonstrating forced expiratory volumes less than 70% of predicted values and diffusion defects less than 80% of predicted values can identify those patients who are at risk of developing hypercarbia and acidosis.

In this prospective study, minimally invasive methods of proximal gastric vagotomy (PGV) were investigated in male Sprague-Dawley rats. Completeness of vagotomy by traditional operative therapy, by laser denervation of the gastric serosa, and by subserosal or transmucosal injections of chemoneurolytic agents was evaluated with postoperative Congo red testing, ulcerogenic stimulation of the gastric mucosa, and histochemical labeling of whatever vagal fibers remained in the gastric wall. Short-term results demonstrate that successful PGV can be performed with minimally invasive methods.

• At present, there is no consensus regarding the routine use of intraoperative cholangiography during cholecystectomy. We describe a reliable technique for performing cystic duct cholangiography during laparoscopic cholecystectomy. Using this technique, we were able to cannulate the cystic duct in 97% of patients, completely visualize the biliary tree and duodenum in 93% of patients, and identify unsuspected choledocholithiasis in 3% of patients. Treatment options for the management of choledocholithiasis demonstrated by cholangiograms during laparoscopic cholecystectomy include conversion to an open cholecystectomy and common duct exploration, or endoscopic sphincterotomy and common duct stone extraction following laparoscopic cholecystectomy. (Arch Surg.1991;126:646-649)

Radiographic documentation of the rapid development of an aortic infection has not previously been reported. We report the case of a 68-year-old woman who presented with back pain. A computed tomographic(CT) scan documented a nondisplaced L1 compression fracture as well as an atherosclerotic but nonaneurysmal aorta. Two weeks after discharge, she developed left lower lobe pneumonia and was readmitted. A second CT scan was obtained because of continuous complaints of back pain. A contained rupture of the visceral aorta was now clearly visible. Emergent operation successfully repaired her aorta. The microorganisms responsible for aortic infection have changed since the widespread use of antibiotics. Patterns of aortic involvement have also evolved. The difficulty in making these diagnoses, the role of current antibiotic therapy, and the surgical options for these infections will be discussed.

Laparoscopic cholecystectomy uses carbon dioxide, a highly diffusable gas, for insufflation. With extended periods of insufflation, patient arterial carbon dioxide levels may be adversely altered. Patients were selected for laparoscopic cholecystectomy using the same criteria as for open cholecystectomy. Twenty patients (group 1) had normal preoperative cardiopulmonary status (American Society of Anesthesiologists class I), while 10 patients (group 2) had previously diagnosed cardiac or pulmonary disease (class II or III). Demographic, hemodynamic, arterial blood gas, and ventilatory data were collected before peritoneal insufflation and at intervals during surgery. Patients with preoperative cardiopulmonary disease demonstrated significant increases in arterial carbon dioxide levels and decreases in pH during carbon dioxide insufflation compared with patients without underlying disease. Results of concurrent noninvasive methods of assessing changes in partial arterial pressures of carbon dioxide (end-tidal carbon dioxide measured with mass spectrographic techniques) may be misleading and misinterpreted because changes in partial arterial pressures of carbon dioxide are typically much smaller than changes in arterial blood levels and, unlike arterial gas measurements, do not indicate the true level of arterial hypercarbia. During laparoscopic cholecystectomy, patients with chronic cardiopulmonary disease may require careful intraoperative arterial blood gas monitoring of absorbed carbon dioxide.