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Background During the COVID-19 pandemic, cardiovascular patients were found to be presenting to hospitals with myocardial infarctions and cerebrovascular accidents at progressed disease states. We noticed a parallel in acute limb ischemia (ALI) patients presenting during Massachusetts’ COVID-19 State of Emergency declaration. We question whether patients developed a hesitancy to seek medical attention at hospitals due to fear of COVID-19. Our objective was to compare acuity of ALI, interventions, and limb survival in patients presenting before, during, and after a state of emergency. Methods Four timeframes were set to compare patients presenting peri-2020 COVID-19 State of Emergency and patients presenting during a pre-pandemic era at a tertiary, academic institution. A reference period from 2019, Pre-State of Emergency period, State of Emergency period, and Post-State of Emergency period were designated. Patient characteristics, interventions, and outcomes data were collected. Unpaired t-test, ANOVA, and Chi-square statistical analyses were used. Results A total of 95 patients presenting with ALI were identified. Compared to Reference group, state of emergency group had more patients presenting with Rutherford Class III, 12.9% vs 35%, and less patient presenting with Class I, 45.1% vs 0%, P = .02. State of emergency group had more delayed presentations with ≥6 hours after symptom onset, 45% vs 85%, P = .01. Above-knee amputations were performed in 20% of patients during state of emergency and 31.6% for Post-State of Emergency, vs 6.5% in the Reference group; P = .03. There was no difference in intensive care unit admission, length of stay, or mortality between patients from different groups. Conclusion During a state of emergency, ALI patients were noted to present later from symptom onset, have greater disease severity, and more likely to undergo amputations. We suspect delay in presentation and limb lost to be attributed to reluctance to seek immediate medical attention.

We report a case of a 69-year-old male who was planned for a transcatheter aortic valve replacement (TAVR) with a 26 mm Sapien 3 Valve (Edwards Lifesciences, Irvine, California) for the treatment of symptomatic severe aortic stenosis. During rapid ventricular pacing and implantation of the TAVR valve, there was a loss of pacing capture and subsequent embolization of the valve into the aortic arch. Retrieval of the embolized valve was attempted unsuccessfully using several techniques. Finally, by using a 34 mm Evolut R Valve (Medtronic, Minneapolis, Minnesota), we were able to secure the embolized valve in the transverse segment of the aortic arch without compromising the branch vessels. To our knowledge, this is the first reported case of using a valve-in-valve approach to fixate an embolized valve in the transverse aorta.

Despite recent publications indicating billowing (aneurysmal degeneration of the outer fabric material manifesting as a bulging sac of contained contrast due to weakening of the fabric material between the metal struts) as a benign finding, we present a unique case of billowing that resulted in aneurysmal rupture with the AFX2

Background Eversion endarterectomy (EE) is a well-described technique for the treatment of extracranial cerebrovascular disease. Longitudinal arteriotomy and closure with patch angioplasty is the standard for infrainguinal arterial occlusive disease in the iliofemoral segment. A potential drawback of this technique is the introduction of exogenous material into the field. We herein describe a technique of transverse femoral arteriotomy with primary closure for treatment of chronic limb ischemia involving the iliofemoral system. Methods We retrospectively evaluated all patients who underwent EE at our institution for chronic limb ischemia. Eleven patients were identified who underwent EE by a single surgeon (M.N.) at our institution from 2013 to 2014. Indications for operation included life-limiting claudication, rest pain, and tissue loss. In each case, the external iliac artery (EIA), common femoral artery (CFA), or superficial femoral artery (SFA) was divided with eversion of the proximal and distal segments and endarterectomy. Reconstruction was achieved with primary end-to-end closure. Preoperative demographics were evaluated, as well as preoperative and postoperative ankle-brachial indices and Trans-Atlantic Inter-Society Consensus (TASC) II lesion classification when available. In addition, all adjunctive procedures performed both at the time of index operation and subsequently were recorded. Clinical improvement was gauged using the recommended scale for gauging change in clinical status according to Rutherford. Results Follow-up ranged from 6 weeks to 16 months. There were no amputations, deaths, or surgical site infections. Two patients required concomitant patch angioplasty in the treated segment at the index operation. There was symptom improvement in 9 of 11 patients, with 2 requiring reintervention due to poor outflow. Conclusions In patients with arterial occlusive disease of the iliofemoral segment, EE either alone or in association with endovascular stenting or open bypass appears to be a safe and effective technique. It may obviate the need for patch closure. In our initial case series, there were no amputations, deaths, or surgical site infections. Symptoms improved in 9 of 11 patients with only 2 requiring reintervention due to recurrent symptoms during the follow-up period.

Despite recent publications indicating billowing (aneurysmal degeneration of the outer fabric material manifesting as a bulging sac of contained contrast due to weakening of the fabric material between the metal struts) as a benign finding, we present a unique case of billowing that resulted in aneurysmal rupture with the AFX2® stent graft (Endologix, Inc., Irvine, CA). AFX2® consists of an inner metallic endoskeleton with multiple metallic struts covered by a polytetrafluoroethylene graft fabric. It allows the flow of blood or contrast beyond the border of the metallic endoskeleton without evidence of endoleak or rupture secondary to the outer cover being anchored to the endoskeleton with polypropylene sutures only at the proximal and distal ends. Our report raises the concern that although billowing may be a relatively common manifestation with Endologix stent grafts, clinicians have to be diligent as the phenomenon may progress to abdominal aortic aneurysm rupture.

We present an atypical manifestation of chronic mesenteric ischemia in a patient with progressively worsening exertional abdominal pain. Imaging modalities revealed significant isolated stenosis of superior mesenteric artery (SMA). Successful angioplasty and stenting of SMA relieved patient's symptoms, thereby confirming the diagnosis of chronic mesenteric ischemia. Exertional abdominal pain may be a unique manifestation of this disease, but when it presents, clinicians should have acute clinical awareness of this diagnosis.

The association of iliac artery aneurysms with a congenital pelvic kidney is extremely rare. Although multiple techniques are well described for renal preservation with renal ectopia in the setting of aortic reconstruction, few reports exist describing techniques for renal preservation in the setting of bilateral iliac artery aneurysms. A case is presented of a middle-aged man with a 6-cm right common iliac artery aneurysm and a 3-cm left common iliac artery aneurysm and a right pelvic kidney. A double-proximal-clamp technique and temporary shunting to the pelvic kidney were used during the aneurysm repair. The technical aspects of this procedure are presented as well as a brief discussion of the various options for renal preservation with renal ectopia when repairing complex aneurysmal disease.

Improved imaging modalities and surgical techniques have dramatically changed the management of upper extremity vascular trauma, with a concomitant rise in limb salvage rate over the past 80 years. Surgical management of upper extremity vascular trauma is complex due to the close relationship between the arteries, veins, and nerves along with challenges involved in attaining appropriate surgical exposure. A close familiarity with the anatomy in conjunction with high-quality diagnostic imaging is vital for appropriate surgical planning. Due to the complexities involved in achieving open access to some of the more proximal vessels, endovascular management is gaining popularity. The use of stent grafts to repair damaged vessels may avoid the morbidity associated with median sternotomy with cervical extension and the extended dissection that is involved. Even in the presence of “hard signs” of vascular injury, endovascular techniques may facilitate damage control surgery and achieve hemostasis until a more definitive procedure can be completed. Proper coordination with trauma, orthopedic, and vascular surgery is necessary to minimize ischemia, properly debride nonviable tissue, and repair all of the involved injuries. Decompressive fasciotomy, even if prophylactic in nature, is an important component of avoiding the morbidity and mortality associated with compartment syndrome.

Screening mammography continues to play a key role in the early diagnosis of non-palpable breast cancer. Approximately 5% of patients will have lesions on their mammograms that appear neither clearly benign nor malignant. The proper management of these patients is not well defined. In this study, the mammograms of 64 women who underwent breast biopsy were reviewed. After the initial review, the mammograms were reevaluated using a personal computer driven digital conversion and enhancement system. The majority of indeterminate lesions were assigned a determinate diagnosis by enhancing the areas of abnormality through enlargement, contrast adjustment, and brightness adjustment. The radiologists were able to maintain baseline sensitivity and specificity throughout this process. In contrast, enhancement of lesions initially assigned a diagnosis of characteristically benign or malignant demonstrated no advantage over plain film mammography. These findings suggest a role for the selective use of digital mammography and enhancement techniques.

Three proximate risk factors for stroke are carotid stenosis, atrial fibrillation, and hypertension. Phase I of this prospective study was designed to establish the prevalence of these conditions among a population of health maintenance organization beneficiaries by using a rapid screening protocol in order to risk-stratify patients for appropriate management and subsequent cohort analysis. Patients at a tertiary care medical center were screened for stroke risk by using directed history, a 3-minute carotid “quick-scan” protocol, an EKG lead II rhythm strip, and bilateral arm blood pressures. Patients with any abnormal result underwent specific diagnostic consultation with vascular surgery, cardiology, or primary care. These evaluations included formal carotid duplex ultrasound, 12-lead EKG ± Holter monitor, and 5-day blood pressure check. Patients were then stratified into risk cohorts for appropriate management and future analysis of stroke incidence and outcomes. In 8 hours on a single day in October 2002, 294 patients (mean age 69) were screened. Combining history with results of screening and diagnostic tests, the overall prevalence of carotid stenosis was 6% (n= 17/294), atrial fibrillation 7% (n= 21/294), and severe hypertension 5% (n= 16/294). Fifty-nine patients (20%) screened positive for carotid stenosis by “quick-scan,” and 29% (n= 17/59) of these had confirmed stenosis (>50%) in 1 or both arteries by formal duplex. The prevalence of confirmed carotid stenosis was 37% among those screening positive for 1 artery (odds ratio [OR] 14.6; p 180/100). Overall, 82% (n= 242/294) of patients screened required additional diagnostic tests. Based on these results, 11% (n= 31/294) of patients were stratified as high risk, 64% (n= 188/294) as moderate risk, and 25% (n= 75/294) as low risk for future stroke. Rapid and efficient screening of a large population for stroke risk factors is feasible. The prevalence of undiagnosed, unsurveilled, and untreated carotid stenosis, atrial fibrillation, and severe hypertension is significant, as 75% of patients screened had 1 or more confirmed major risk factors for stroke. Phase II of this study will investigate the degree of stroke risk reduction possible with a multidisciplinary approach to early identification and aggressive treatment of these risks.

To evaluate the relationship of intraoperative duplex ultrasonography (duplex) results to neurologic outcomes and restenosis among patients undergoing carotid endarterectomy (CEA).One hundred consecutive CEAs were performed at a military medical center over 28 months. Prospectively acquired demographics, duplex results, revisions, and surgical outcomes were reviewed.Thirty-four percent (34 of 100) of sites were abnormal by completion duplex. Of these, 70% (24 of 34) were B-mode flap type defects located in the common carotid artery (CCA), internal carotid artery (ICA), or external carotid artery (ECA). Twenty-one percent of the defects (7 of 34) were technically unacceptable and immediately revised. Subsequently, 3 perioperative neurologic events occurred, 2 strokes and 1 transient ischemic attack (TIA), all among patients with an identified but unrepaired defect involving the ICA or CCA. This association of unrepaired defect with early stroke or TIA was significant (P = 0.02). No significant association (P0.05) between unrepaired defects and late ipsilateral stroke or TIA or restenosis was identified.Intraoperative duplex scanning is a useful adjunct to CEA that can identify correctable mechanical problems. Residual elevated velocities or B-mode flaps 2 mm or greater in the ICA warrant consideration for immediate repair. Findings not requiring revision include flaps2 mm, as well as isolated ECA defects. Prospectively validated duplex criteria are needed to further define which defects require immediate repair.

A 41-year-old man with human immunodeficiency virus (HIV) (CD4 count, 446/mm3) developed a protracted course of abdominal pain, weight loss, and increasing liver function tests after undergoing a metronidazole treatment regimen for Giardia enteritis. Three months later, endoscopic retrograde cholangiography (ERCP) showed dilated common and intrahepatic bile ducts and luminal irregularities of the common bile duct. Seven months after the onset of his acute diarrhea, a repeat ERCP with aspiration demonstrated many Giardia trophozoites and cysts in the bile and continued structural abnormalities consistent with cholangiopathy. A 10-day course of high-dose intravenous metronidazole did not resolve these signs or symptoms. A gallbladder ultrasound showed a thickened wall. Laparoscopic cholecystectomy led to resolution of abdominal pain and normalization of serum alkaline phosphatase over an 8-month period. Gallbladder histopathology revealed chronic cholecystitis, but no parasites were seen on hematoxylin and eosin staining or with Giardia antigen enzyme immunoassay testing of the gallbladder. The patient refused to undergo a follow-up ERCP, but a right upper quadrant ultrasound and computed tomography of the abdomen were normal.

Chronic ergot toxicity is a rare cause of lower extremity ischemia. The cornerstone of therapy in ergot toxicity is to discontinue the use of caffeine, cigarettes, and all ergot-containing medications. Although multiple different therapies have been recommended for acute toxicity, no specific treatment is uniformly recommended in chronic toxicity. We present a case of long-term ergot use for migraine headaches in a woman who had severe chronic lower extremity claudication. This case demonstrates the unique features associated with the diagnosis and management of chronic ergot toxicity. We recommend a conservative approach consisting of observation, antiplatelet agents, and the discontinuance of ergots. If symptoms progress to rest pain or gangrene, surgical treatment should be considered. (J Vasc Surg 2000;31:1245-7.)

Chronic indwelling catheters are plagued with a high rate of complications, including infection, central venous occlusion, or thrombosis. When direct access to the superior or inferior vena cava is not possible, venography may identify alternatives that might be viable with current endovascular techniques. This case report describes the successful placement of a tunneled catheter for total parenteral nutrition in the azygos arch through a small collateral vein from the left jugular vein in a patient with no other alternatives because of superior vena cava occlusion and inferior vena cava thrombophlebitis.