Like Father like Daughter: Surgical Redo Thoracoabdominal Aneurysm Repairs in a Family With Loeys-Dietz Syndrome.

Loeys Dietz Syndrome (LDS) is an autosomal dominant connective tissue disorder resulting from a mutation in the transforming growth factor beta receptor (TGFBR) family of genes. It is commonly associated with the development of aortic aneurysms and dissections. We report the successful open surgical management of thoracoabdominal aneurysms in a father and daughter with Loeys-Dietz Syndrome after failed endovascular repair. The daughter required stent graft explantation, while the stent graft remained in the father. These cases highlight the importance of early genetic testing of both patients and first-degree family members in those with a strong history of aortic disease, even when there is a lack of typical connective tissue disorder associated physical exam findings and open surgical index operations.

Staged endovascular and open surgical approach for treatment of a giant left upper back arteriovenous malformation.

We present a case of a symptomatic, giant, left upper back arteriovenous malformation that was treated through a staged endovascular and open approach. Through a series of embolizations, followed by resection, we were able to preserve the limb and upper back neurovascular supply, demonstrating an approach to preserve sensation and function and improving quality of life.

Analysis of completion intraoperative venography during first rib resection for venous thoracic outlet syndrome.

BACKGROUND: We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS). METHODS: We performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality. RESULTS: Fifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with no stenosis (group 1, 31.3%), 17 with no stenosis after angioplasty (group 2, 33.3%), 10 with residual stenosis after angioplasty (group 3, 19.7%), and 8 with complete occlusion (group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (group 1, 14 of 16; group 2, 13 of 17; group 3, 10 of 10; and group 4, 7 of 8; log-rank test, P = .5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (group 1, 16 of 16 and 9 of 9; group 2, 16 of 17 and 12 of 13; group 3, 10 of 10, 5 of 5; group 4, primary patency not obtained). There was one asymptomatic rethrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR. CONCLUSIONS: Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR.

A comprehensive analysis of leadership attributes, discrepancies, and implications for gender equity in vascular surgery.

OBJECTIVE: Well-developed leadership skills have been associated with a better understanding of health care context, increased team performance, and improved patient outcomes. Surgeons, in particular, stand to benefit from leadership development. Although studies have focused on investigating knowledge gaps and needs of surgeons in leadership roles, there is a noticeable gap in the literature concerning leadership in vascular surgery. The goal of this study was to characterize current leadership attributes of vascular surgeons and understand demographic influences on leadership patterns. METHODS: This retrospective cohort study was a descriptive analysis of vascular surgeons and their observers who took the Leadership Practices Inventory (LPI) from 2020 to 2023. The LPI is a 30-question inventory that measures the frequency of specific leadership behaviors across five practices of leadership. RESULTS: A total of 110 vascular surgeons completed the LPI. The majority of participants were White (56%) and identified as male (60%). Vascular surgeons most frequently observed the "enabling others to act" leadership practice style (8.90 ± 0.74) by all evaluators. Vascular surgeons were most frequently above the 70th percentile in the "challenge the process" leadership practice style (49%) compared with the average of other leaders worldwide. Observers rated vascular surgeons as displaying significantly more frequent leadership behaviors than vascular surgeons rated themselves in every leadership practice style (P < .01). The only demographic variable associated with a significantly increased occurrence of achieving 70th percentile across all five leadership practice styles was the male gender: a multivariable model adjusting for objective experience showed that men were at least 3.5 times more likely to be rated above the 70th percentile than women. CONCLUSIONS: Vascular surgeons under-report the frequency at which they practice leadership skills across all five leadership practice styles and should recognize their strengths of enabling others to act and challenging the process. Men are recognized as exhibiting all five leadership practices more frequently than women, regardless of current position or experience level. This observation may reflect the limited leadership positions available for women, thereby restricting their opportunities to demonstrate leadership practices as frequently or recognizably as their male counterparts.

Penumbra aspiration thrombectomy of the superior mesenteric artery for mesenteric ischemia.

Acute mesenteric ischemia from thromboembolic occlusion is a life-threatening emergency associated with a high mortality rate. Prompt diagnosis and intervention are vital to preserve viable bowel and prevent mortality. In the past decade, a shift has occurred toward minimally invasive alternatives such as endovascular therapies. We present a case of acute mesenteric ischemia from superior mesenteric artery thrombosis treated promptly with the Penumbra suction thrombectomy device (Penumbra Inc).

External iliac vein aneurysm treated via balloon-assisted aneurysmorrhaphy with a contemporary review of the literature.

Isolated external iliac vein aneurysm is exceedingly rare, not well-described in the literature, and presents several potential surgical approaches. Herein, we describe the case of a 72-year-old woman who presented with incidentally found 4.3 cm × 3.4 cm × 5.6 cm right external iliac vein aneurysm after undergoing magnetic resonance imaging for orthopedic work-up. She was treated via parallel supra- and infra-inguinal incisions and novel combination of primary aneurysmorrhaphy with intraluminal balloon mandrel-assisted closure. The patient was discharged on postoperative day two, and 6-month follow-up ultrasound showed a normal caliber vessel with normal compressibility, suggesting this technique is safe and effective for appropriately selected patients.

Coil embolization of ruptured distal renal artery pseudoaneurysm with gross hematuria and hemorrhagic shock.

Renal artery pseudoaneurysms have been infrequently reported in the literature. In the present report, we have described a case of a ruptured renal artery pseudoaneurysm requiring coil embolization. A 49-year-old man had presented to our institution with a hypertensive emergency. Computed tomography revealed a 3.4-cm right renal artery pseudoaneurysm. Nonemergent coil embolization was planned for the following day. However, he became hypotensive, exsanguinating frank blood from the urethra. An arteriogram showed extravasation of contrast into the pseudoaneurysm sac, renal pelvis, and ureter, consistent with intrarenal pseudoaneurysm rupture. We have demonstrated coil embolization as a method of repairing a ruptured renal artery pseudoaneurysm with gross hematuria.

Complications of Peripheral Cannulation Site in Obese Patients on Adult Extracorporeal Membrane Oxygenation.

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

Giant abdominal aortic aneurysms.

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

Evaluation of Endovascular Intervention for Tracheo-Innominate Artery Fistula: A Systematic Review.

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

Update of Operative Log Data for Traditional versus Integrated Vascular Training Programs.

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

False lumen embolization as a rescue technique in the setting of acute and chronic dissecting aneurysms as adjunct to thoracic endovascular aortic repair.

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

Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair.

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

Endovascular management and the risk of late failure in the treatment of ureteroarterial fistulas.

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

Functional Popliteal Artery Entrapment Syndrome: A Review of Diagnosis and Management.

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

A Quality Improvement Intervention to Improve the Efficiency of Arteriovenous Access Placement for Pre-Dialysis Inpatients.

The authors aimed to improve the rate of pre-dialysis arteriovenous (AV) access placement for hospitalized patients with advanced chronic kidney disease. The authors developed and implemented a protocol for hospitalized adult patients with an estimated glomerular filtration rate <20 mL/min to streamline the workflow for obtaining AV access. The protocol was piloted on 5 inpatient medical services over 3 months at 1 institution. Specific-Measurable-Achievable-Realistic-Timely (SMART) aims, Fishbone diagrams, Plan-Do-Study-Act cycles, and run charts were used to assess the process and outcomes of the intervention. There were 22 patients in the baseline group and 27 patients in the intervention group. Pre-dialysis AV access increased from 23% to 46%. Length of stay did not differ significantly between the baseline group (8.31 days) and the intervention group (8.4 days). Pathways can improve pre-dialysis AV access without significantly increasing length of stay.

A randomized clinical trial evaluating negative pressure therapy to decrease vascular groin incision complications.

OBJECTIVE: Vascular groin incision complications contribute significantly to patients' morbidity and rising health care costs. Negative pressure therapy over the closed incision decreases the infection rate in cardiac and orthopedic procedures. This study prospectively evaluated negative pressure therapy as a means to decrease wound complications and associated health care costs. METHODS: This was a randomized, prospective, single-institution study of 119 femoral incisions closed primarily after elective vascular surgery including both inflow (eg, aortofemoral) and outflow (eg, femoral-popliteal bypass) procedures. Incisions were categorized as high risk for wound complications on the basis of body mass index >30 kg/m2, pannus, reoperation, prosthetic graft, poor nutrition, immunosuppression, or hemoglobin A1c >8% and randomized 1:1 to standard gauze (n = 60) dressing vs negative pressure therapy (Prevena [Acelity, San Antonio, Tex], n = 59). Wound complication rate, length of stay (LOS), reoperation, readmission, and variable hospital costs were determined during 30 days. Statistical analysis was performed using χ2 test along with a two-sample unpaired t-test for continuous variables. RESULTS: There were no significant demographic differences (age, sex, risk factors for wound complication) between the two high-risk groups. In low-risk controls, the major wound complication rate was 4.8% (involving one infection in 21 incisions), resulting in a 3.8-day LOS, 4.8% reoperation, 4.8% readmission rate, and $17,599 in average variable cost. For high-risk controls, there was a significant increase in major wound complications to 25% (including all 12 infections in 60 incisions), LOS (10.6 days), reoperation (18.3%), readmission (16.7%), and costs ($36,537). Finally, negative pressure therapy significantly reduced major wound complications to 8.5% (including five of six infections in 59 incisions; P < .001), reoperation (8.5%; P < .05), and readmission (6.8%; P < .04) but not LOS (10.6 days). The average variable cost was reduced ($30,492), yielding an average savings of $6045 per patient (P = .11). CONCLUSIONS: This study suggests that negative pressure therapy significantly reduces the major wound complication, reoperation, and readmission rates for patients at high risk for groin wound complications. Furthermore, this therapy may lead to a reduction in hospital costs. Negative pressure therapy for all groin incisions considered at high risk for wound complications is recommended.

A rare case of Clostridium septicum aortitis with colon adenocarcinoma.

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

Symptomatic compression of right iliac vein after right iliac artery stent placement.

Right lower extremity edema can be a presenting symptom of iliocaval compression syndrome, even in the absence of deep vein thrombosis. It has been reported in idiopathic and rarely, iatrogenic, cases secondary to variant anatomy, arterial stents, and bony hardware. Classically seen in the more confined left common iliac vein as May-Thurner syndrome, it is rare on the right side. We report an unusual case of acute right common iliac vein compression after right iliac stent placement leading to symptomatic right leg edema. Venous stenting resulted in resolution of symptoms at the 6-month follow-up.