Popliteal pseudoaneurysm in a young patient with multiple hereditary exostosis.

Multiple hereditary exostosis is an osteogenic disorder that causes outgrowths of cartilaginous bone tumors that are associated with adjacent neurovascular compressive injuries. We present the case of an adolescent male with multiple hereditary exostosis complicated by popliteal pseudoaneurysm formation who underwent excision of the osteochondroma and vein patch angioplasty repair of the artery. We highlight the rare association between this genetic disease and subsequent vascular complications and review the available literature of arterial complications of this disease.

Operative Case Volume for Vascular Integrated Residents and Fellows Following the Elective Surgery Shutdown due to COVID-19.

In response to the COVID-19 pandemic, nonemergent surgery was postponed in efforts to limit disease spread. To determine whether these changes affected vascular integrated resident (VR) and fellow (VF) operative volume, Accreditation Council for Graduate Medical Education (ACGME) case log data was reviewed. Case volume and standard deviation for each major category was for graduates of 2020 and 2021 were compared to the year prior to the pandemic, 2019. There were only 3 significant changes when comparing 2020/2021 to the prepandemic baseline of 2019, with increase in abdominal obstructive cases for VRs (8.1 in 2021 vs 5.9 in 2019, P = .021), an increase in upper extremity cases for VFs (18.9 in 2021 from 15.8 in 2019, P = .029), and a decrease in venous cases for VFs (39.6 in 2021 from 48.4 in 2019, P = .011). Postponing nonemergent surgery did not translate to significant changes in operative cases for graduating VRs and VFs.

Postamputation diagnosis of squamous cell carcinoma in a patient with lymphedema.

Chronic lymphedema is fraught with morbidity, including tissue loss. We present the case of a woman with long-standing lymphedema suffering from nonhealing ulcerations despite multiple interventions, who underwent below-knee amputation. Surgical pathology yielded a diagnosis of invasive squamous cell carcinoma. We highlight the uncommon association between lymphedema and squamous cell carcinoma, and the importance of routine pathological testing with lower extremity amputations.

Validating the Clinical Value of Temporal Artery Biopsy.

BACKGROUND: Giant cell arteritis (GCA) is a potentially devastating disease that may require treatment with high-dose steroids. Traditionally, diagnosis requires patients to meet at least 3 of 5 clinical criteria, one of which is a positive temporal artery biopsy (TAB). Vascular surgeons are often asked to perform TAB though it is not necessarily required for diagnosis or management. This study aimed to determine if TAB results altered management of patients with a concern for GCA by changing steroid use postoperatively in our health care system. METHODS: A retrospective review at a single-center tertiary care hospital was performed between 2007 and 2018. The inclusion criteria were patients greater than 18 years old with complete steroid treatment records who underwent a temporal artery biopsy due to concern for GCA. Steroid use and duration of treatment both pre- and post-operative were collected and analyzed. RESULTS: Eighty-three of 117 cases reviewed met inclusion criteria. Ninety-one percent (76) of patients had a negative biopsy. Twenty-nine percent (23) of negative biopsies met criteria for GCA prior to biopsy. Of those with a negative biopsy, steroids were continued in 68% (52) of patients after 30 days, 49% (37) after 90 days and 45% (34) after 180 days. Steroids were never started in 11% (6). One patient with a positive biopsy was discontinued on steroids due to intolerance. There was no statistically significant difference in duration of steroids between those with a positive and negative biopsy (average 610 and 787 days respectively; P = 0.682). Average follow up was 33 months. DISCUSSION: The duration of steroid use for patients with concern for GCA was not found to be altered by the performance of a TAB at our institution. Given the extremely low yield and absence of impact on steroid duration, TAB is not a useful diagnostic test at our institution. Similar reviews are recommended to determine the utility of TAB at other institutions that may differ in patient population or prescribing practices.

Temporizing stent graft for aortoenteric fistula with massive gastrointestinal hemorrhage.

OBJECTIVES: We present a case of a 59-year-old male with an actively bleeding aortoenteric fistula (AEF) that was temporized using an endovascular stent prior to staged open reconstruction. METHODS: Verbal informed consent was given by the patient's family for publication of this case report. The patient presented with pulseless electrical activity secondary to hemorrhagic shock due to a massive gastrointestinal bleed. His past surgical history included an aortobifemoral bypass (ABFB) that subsequently underwent extra-anatomic reconstruction with right axillofemoral artery bypass for right femoral infected pseudoaneurysm. Two months prior to presentation, he underwent a second revision with in-situ reconstruction for left limb graft infection. CTA now demonstrated actively bleeding AEF. He was emergently treated with endovascular stenting. Once stabilized, a two-stage revision with extra-anatomic bypass and aortic stump closure for management of his AEF was performed. RESULT: The patient was adequately stabilized using endovascular techniques followed by two-stage revision but unfortunately expired secondary to septic shock 20 days postoperatively. CONCLUSION: This case highlights the utility of endovascular stent graft to successfully obtain hemodynamic stability and optimization prior to open repair of AEFs.

Intraoperative blood pressure lability carries a higher risk of headache after carotid endarterectomy.

OBJECTIVE: Cerebral hyperperfusion syndrome (CHS) is a rare but potentially devastating complication after carotid endarterectomies (CEA). Its symptoms range from new-onset unilateral headache (HA) to intracranial hemorrhage (ICH). Risk factors for CHS in the literature to date have not yet yielded a consensus. This study examines intraoperative and postoperative blood pressure variations as potential risk factors for HA. METHODS: A single-center retrospective review at a tertiary care center from January 2010 to November 2019 was performed. Inclusion criteria were all patients undergoing CEA for symptomatic or asymptomatic carotid disease. Patients with incomplete charts were excluded. Primary endpoints were new-onset unilateral HA or postoperative ICH. Data on intraoperative and postoperative mean arterial pressure (MAP), systolic blood pressure (SBP), the mode of endarterectomy, shunt placement, and contralateral carotid status were collected. RESULTS: There were 735 patients who met the inclusion criteria: 430 patients underwent modified eversion CEA (59%) and 305 patients for patch angioplasty (42%). The incidence of HA was 19% (n = 142) in our total cohort. Of the 19% with HA, 1.5% (n = 11) demonstrated no relief with analgesics and strict blood pressure control; noncontrast head computed tomography scans were performed subsequently. One patient (0.1%) had an ipsilateral ICH. Univariate analysis demonstrated that greater intraoperative MAP peak had the highest risk for HA (odds ratio [OR], 1.014; 95% confidence interval [CI], 1.007-1.022; P = .0002), followed by intraoperative MAP variability (OR, 1.011; 95% CI,1.005-1.018; P ≤ .0008), and peak intraoperative SBP (OR, 1.01; 95% CI, 1.004-1.015; P = .0011). An unpaired Student t test identified change in intraoperative MAP (P < .005), change in the SBP (P < .005), and peak SBP (P < .001) were significantly associated with HA. Interestingly, there was no significant difference between postoperative MAP variability and HA (P = .1). The mode of endarterectomy showed no statistically significant difference in risk for developing HA (OR, 1.165; 95%; 95% CI, 0.801-1.694; P = .42). CONCLUSIONS: Greater intraoperative variability in blood pressures are significantly associated with a higher risk of HA. Adhering to stricter intraoperative blood pressure parameters and limiting blood pressure variability may be beneficial at decreasing the incidence of CHS and its complications.

Traumatic thoracolumbar projectile with concomitant vertebral body and aortic injury.

Penetrating subdiaphragmatic aortic trauma is associated with high morbidity and mortality with studies having reported a 50%-70% associated mortality. We describe a case of a patient with a subdiaphragmatic aortic injury caused by a 7.4-cm common nail that traversed through his L1 vertebral body into the aorta. His aortic injury was managed jointly with vascular surgery and neurosurgery teams.

Poly-Specialty Application Practices of Medical Students Applying to Integrated Vascular Surgery Residency.

BACKGROUND: It is not uncommon for medical students seeking surgical residencies to apply to and rank two or more surgical specialties. Level of interest in a specialty is consistently cited as one of the most important factors for program directors when evaluating applicants for 0 + 5 integrated vascular surgery (IVS) programs. The purpose of this study was to examine trends in poly-specialty application submission to IVS and poly-specialty ranking of IVS to determine the percentage of applicants to IVS residencies with vascular surgery as their true preference. METHODS: Electronic Residency Application Service (ERAS) statistics for noninternational medical graduates from 2011 to 2017 were mined for trends in poly-specialty applications between IVS and other surgical disciplines. The poly-specialty application percentage, range, and standard deviation were determined. The National Resident Match Program (NRMP) results and data from 2011 to 2018 were also used to identify those U.S. seniors who ranked IVS programs as their preferred choice, defined as ranking vascular as the only choice or the first-choice specialty. This was compared with those who ranked a specialty other than vascular surgery first but had vascular surgery listed on their rank list. These data were also collected for applicants to orthopedic surgery, neurosurgery, otolaryngology, obstetrics and gynecology, integrated cardiothoracic surgery, and integrated plastic surgery. RESULTS: Between 2011 and 2017, applicants who submitted ERAS applications to IVS most often poly-specialty applied to IVS and general surgery (87%) followed by IVS and the following: preliminary surgery (71%), plastic surgery (22%), orthopedic surgery (19%), neurosurgery (17%), otolaryngology (16%), obstetrics and gynecology (12%), and urology (3%). The percentage of the applicant pool submitting rank lists with multiple specialties fell over the study period from 94% in 2011 to 67% in 2018. Between 2011 and 2018, an average of 14% of IVS applicants (n = 463), who submitted rank lists to the NRMP, ranked a specialty other than vascular as their true preference (range 7-23 SD 5). Only integrated cardiothoracic surgery had a higher percentage of applicants listing a different specialty as their true preference at 25% (range 18-36 SD 7). Nearly all (97-99%) applicants to orthopedic surgery, neurosurgery, otolaryngology, obstetrics and gynecology, and plastic surgery applied to that specialty as their true preference. CONCLUSIONS: IVS residency applicants were most likely to apply for poly-specialty via the ERAS to general surgery and IVS. Compared to the other surgical specialties, those who submitted rank lists to the NRMP listing integrated cardiothoracic and IVS had the highest likelihood of ranking another specialty higher. Care must be taken when evaluating applications to IVS residencies to determine the applicant's level of interest in vascular surgery as a career.

Taking the Lead: A Case Report of a Leiomyoma Causing Duodeno-Duodenal Intussusception and Review of Literature.

Background: Duodenal masses are rare entities and symptomatic presentation generally is due to abdominal pain or the presence of gastrointestinal bleeding. A number of published case reports in the literature have detailed various neoplasms that have caused an intussusception isolated to the duodenum. This is a particularly unusual phenomenon due to the location and fixation of this portion of the proximal small bowel to the retroperitoneum. We present here a case of duodeno-duodenal intussusception secondary to a leiomyoma. Case: A 65-year-old Caucasian male presented with intermittent bloody stools and syncope over a 9-month period secondary to a duodenal leiomyoma causing intussusception, which was treated through a pancreaticoduodenectomy. Conclusion: Intussusception of the duodenum is an uncommon entity and the diagnosis of a leiomyoma should be considered in the setting of a potential mass in the small intestine.

Neoadjuvant Chemotherapy and Appleby Procedure for Pancreatic Acinar Cell Carcinoma: A Case Report.

Background: Acinar cell carcinoma is a rare form of pancreatic cancer, accounting for 1-2% of all cases of exocrine pancreatic neoplasms in adults. Due to its rarity, no randomized controlled trials have been performed to determine the optimal treatment options. As such, high-quality case reports and case series are needed to help guide clinicians in the management of this deadly disease. Case Presentation: A 56-year-old Caucasian male presenting with abdominal pain and weight loss was diagnosed with stage III acinar cell carcinoma of the pancreatic body with celiac axis involvement. Although initially deemed unresectable, the patient responded favorably to nine cycles of 5-fluorouracil-based neoadjuvant chemotherapy. The tumor was successfully resected through distal pancreatectomy with en bloc splenectomy and en bloc celiac artery resection (Appleby procedure). Final pathology analysis showed negative resection margins and complete chemotherapeutic response within the pancreas, with residual tumor cells detected in only a single peripancreatic lymph node. Conclusion: 5-fluorouracil-based chemotherapy may be a promising option for the neoadjuvant treatment of locally unresectable acinar cell carcinoma. With sufficient expertise, negative surgical resection margins are possible even with vascular involvement. Due to the generally poor prognosis associated with acinar cell carcinoma, such aggressive treatment measures are warranted.