Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19.

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.

Case Report: A Durable Open Repair of a Rare Profunda Aneurysm.

Profunda femoris artery aneurysms (PFAAs) are rare and difficult to diagnose in the early stages of development due to location and encasement in the deep thigh musculature. We report the case of a 74-year-old male who was discovered to have a right PFAA during evaluation for progressively worsening short distance claudication. He had undergone an angioplasty of the left iliofemoral system several months ago with no improvement of his symptoms. The PFAA was diagnosed through computed tomography angiography and repaired via syndactylization of profunda femoris branches and interposition grafting with a polytetrafluoroethylene stretch graft. The imaging features are described in the article. Although PFAAs are rare clinical presentations, their development should be considered, in particular when symptoms such as progressive or unchanging claudication are present in a patient following an angioplasty of the affected iliofemoral system.

Performance Metrics in Professional Baseball Pitchers before and after Surgical Treatment for Neurogenic Thoracic Outlet Syndrome.

BACKGROUND: High-performance throwing athletes may be susceptible to the development of neurogenic thoracic outlet syndrome (NTOS). This condition can be career-threatening but the outcomes of treatment for NTOS in elite athletes have not been well characterized. The purpose of this study was to utilize objective performance metrics to evaluate the impact of surgical treatment for NTOS in Major League Baseball (MLB) pitchers. METHODS: Thirteen established MLB pitchers underwent operations for NTOS between July 2001 and July 2014. For those returning to MLB, traditional and advanced (PitchF/x) MLB performance metrics were acquired from public databases for various time-period scenarios before and after surgery, with comparisons made using paired t-tests, Wilcoxon matched-pair signed-rank tests, and Kruskal-Wallis analysis of variance. RESULTS: Ten of 13 pitchers (77%) achieved a sustained return to MLB, with a mean age of 30.2 ± 1.4 years at the time of surgery and 10.8 ± 1.5 months of postoperative rehabilitation before the return to MLB. Pre- and postoperative career data revealed no significant differences for 15 traditional pitching metrics, including earned run average (ERA), fielding independent pitching, walks plus hits per inning pitched (WHIP), walks per 9 innings, and strikeouts to walk ratio (SO/BB). There were also no significant differences between the 3 years before and the 3 years after surgical treatment. Using PitchF/x data for 72 advanced metrics and 25 different time-period scenarios, the highest number of significant relationships (n = 18) was observed for the 8 weeks before/12 weeks after scenario. In this analysis, 54 (75%) measures were unchanged (including ERA, WHIP, and SO/BB) and 14 (19%) were significantly improved, while only 4 (6%) were significantly decreased (including hard pitch maximal velocity 93.1 ± 1.0 vs. 92.5 ± 0.9 miles/hr, P = 0.047). Six pitchers remained active in MLB during the study period, while the other 4 had retired due to factors or injuries unrelated to NTOS. CONCLUSIONS: Objective performance metrics demonstrate that pitchers returning to MLB after surgery for NTOS have had capabilities equivalent to or better than before treatment. Thoracic outlet decompression coupled with an ample period of postoperative rehabilitation can provide effective treatment for professional baseball pitchers with career-threatening NTOS.

Performance and Return to Play After Surgery for Thoracic Outlet Syndrome in Professional Baseball Players: A Matched Cohort Analysis.

BACKGROUND: Thoracic outlet syndrome (TOS) remains a rare diagnosis but is being recognized as a cause of upper extremity dysfunction in professional baseball players. PURPOSE/HYPOTHESIS: The purpose was to determine performance and return-to-play (RTP) outcomes in professional baseball players after surgical treatment of TOS. The hypothesis was that there would be a high RTP rate in professional baseball players after TOS surgery with no statistical differences in performance between pitchers who had TOS surgery and matched controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All professional baseball players who underwent surgical treatment of TOS between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after surgery) for each player were recorded. Performance variables were then compared between players who underwent TOS surgery and matched controls. The matching criteria were no history of previous surgeries on affected arm, age at time of surgery, throwing side, level of play (Major or Minor League Baseball), and years of experience playing professional baseball. RESULTS: Overall, 52 players underwent surgery for TOS, of whom 46 (88%) were pitchers. The type of TOS was neurogenic in 69% and venous in 29%. One player had arterial TOS. After TOS surgery, 79% of players returned to play at the same or higher level (RTSP) by 9.5 months and played ≥3 years after surgery. No differences were found in RTSP rate based on the type of TOS. No statistical difference was found in RTP rates between major and minor league players. Pitchers had a 76% RTSP, which was similar to the natural attrition for control pitchers (P = .874). After TOS surgery, pitchers saw a decline in several performance metrics, but these declines were not different from those of control pitchers, indicating that the decline in performance after TOS surgery was no faster than is seen in healthy professional pitchers as they age. CONCLUSION: The rate of RTSP after surgery for TOS in professional baseball players was 79%. There was no difference in RTP based on the type of TOS. Pitchers who underwent surgery for TOS had no significant differences in pitching performance metrics after surgery compared with matched controls.

The role of amputation as an outcome measure in cellular therapy for critical limb ischemia: implications for clinical trial design.

BACKGROUND: Autologous bone marrow-derived stem cells have been ascribed an important therapeutic role in No-Option Critical limb Ischemia (NO-CLI). One primary endpoint for evaluating NO-CLI therapy is major amputation (AMP), which is usually combined with mortality for AMP-free survival (AFS). Only a trial which is double blinded can eliminate physician and patient bias as to the timing and reason for AMP. We examined factors influencing AMP in a prospective double-blinded pilot RCT (2:1 therapy to control) of 48 patients treated with site of service obtained bone marrow cells (BMAC) as well as a systematic review of the literature. METHODS: Cells were injected intramuscularly in the CLI limbs as either BMAC or placebo (peripheral blood). Six month AMP rates were compared between the two arms. Both patient and treating team were blinded of the assignment in follow-up examinations. A search of the literature identified 9 NO-CLI trials, the control arms of which were used to determine 6 month AMP rates and the influence of tissue loss. RESULTS: Fifteen amputations occurred during the 6 month period, 86.7% of these during the first 4 months. One amputation occurred in a Rutherford 4 patient. The difference in amputation rate between patients with rest pain (5.6%) and those with tissue loss (46.7%), irrespective of treatment group, was significant (p = 0.0029). In patients with tissue loss, treatment with BMAC demonstrated a lower amputation rate than placebo (39.1% vs. 71.4%, p = 0.1337). The Kaplan-Meier time to amputation was longer in the BMAC group than in the placebo group (p = 0.067). Projecting these results to a pivotal trial, a bootstrap simulation model showed significant difference in AFS between BMAC and placebo with a power of 95% for a sample size of 210 patients. Meta-analysis of the literature confirmed a difference in amputation rate between patients with tissue loss and rest pain. CONCLUSIONS: BMAC shows promise in improving AMP-free survival if the trends in this pilot study are validated in a larger pivotal trial. The difference in amp rate between Rutherford 4 & 5 patients suggests that these patients should be stratified in future RCTs.

Early results and lessons learned from a multicenter, randomized, double-blind trial of bone marrow aspirate concentrate in critical limb ischemia.

OBJECTIVES: Despite advances in endovascular therapies, critical limb ischemia (CLI) continues to be associated with high morbidity and mortality. Patients without direct revascularization options have the worst outcomes. We sought to explore the feasibility of conducting a definitive trial of a bone marrow-derived cellular therapy for CLI in this "no option" population. METHODS: A pilot, multicenter, prospective, randomized, double-blind, placebo-controlled trial for "no option" CLI patients was performed. The therapy consisted of bone marrow aspirate concentrate (BMAC), prepared using a point of service centrifugation technique and injected percutaneously in 40 injections to the affected limb. Patients were randomized to BMAC or sham injections (dilute blood). We are reporting the 12-week data. RESULTS: Forty-eight patients were enrolled. The mean age was 69.5 years (range, 42-93 years). Males predominated (68%). Diabetes was present in 50%. Tissue loss (Rutherford 5) was present in 30 patients (62.5%), and 18 (37.5%) had rest pain without tissue loss (Rutherford 4). Patients were deemed unsuitable for conventional revascularization based on multiple prior failed revascularization efforts (24 [50%]), poor distal targets (43 [89.6%]), and medical risk (six [12.5%]). Thirty-four patients were treated with BMAC and 14 with sham injections. There were no adverse events attributed to the injections. Renal function was not affected. Effective blinding was confirmed; blinding index of 61% to 85%. Subjective and objective outcome measures were effectively obtained with the exception of treadmill walking times, which could only be obtained at baseline and follow-up in 15 of 48 subjects. This pilot study was not powered to demonstrate statistical significance but did demonstrate favorable trends for BMAC versus control in major amputations (17.6% vs 28.6%), improved pain (44% vs 25%), improved ankle brachial index (ABI; 32.4% vs 7.1%), improved Rutherford classification (35.3% vs 14.3%), and quality-of-life scoring better for BMAC in six of eight domains. CONCLUSIONS: In this multicenter, randomized, double-blind, placebo-controlled trial of autologous bone marrow cell therapy for CLI, the therapy was well tolerated without significant adverse events. The BMAC group demonstrated trends toward improvement in amputation, pain, quality of life, Rutherford classification, and ABI when compared with controls. This pilot allowed us to identify several areas for improvement for future trials and CLI studies. These recommendations include elimination of treadmill testing, stratification by Rutherford class, and more liberal inclusion of patients with renal insufficiency. Our strongest recommendation is that CLI studies that include Rutherford 4 patients should incorporate a composite endpoint reflecting pain and quality of life.

Effects of radiation and MediPort placement on the development of thoracic outlet syndrome.

We present a patient who exemplifies the interplay of factors contributing to the development of venous-type thoracic outlet syndrome. The patient was treated with both radiation and chemotherapy for squamous cell carcinoma in the head and neck region; radiation and chemotherapy have been known to damage the vascular system. Multimodality treatment is necessary to achieve good long-term results in these complex patients.

Frequency and extent of media in the internal carotid artery in "endarterectomy" specimens.

Carotid endarterectomy has been performed now for approximately 50 years. No report, however, has described the presence of media in these "endarterectomy" specimens. From January 1997 through May 2003, 147 carotid endarterectomy specimens were examined histologically. Portions of arterial media were present in each of them. The maximal amount of circumferential media in any patient varied from>95% of the cross-sectional circumference in 55 patients (37%) to75% of the arterial circumference of the internal carotid artery contained media. The proper term for this operative procedure might better be "endomediaectomy" rather than "endarterectomy."

A novel surgical approach to symptomatic left renal vein aneurysm.

Visceral venous aneurysms are uncommon and renal vein aneurysms are among the rarest in this subset. Renal vein aneurysms are frequently asymptomatic, but patients may present with flank pain or hematuria. Complications of untreated visceral venous aneurysms include thrombus formation and, very rarely, rupture. Treatment of renal vein aneurysms ranges from watchful waiting to surgical repair. We describe a patient with renal vein aneurysm presenting with recurrent pulmonary embolus with no other identifiable source. Furthermore, we propose a novel surgical treatment with complete resection of the aneurysm and reconstruction of venous return by transposing the inferior mesenteric vein to the remaining left renal vein.

Relation of weights of intraaneurysmal thrombi to maximal right-to-left diameters of abdominal aortic aneurysms.

We determined the weight of operatively excised thrombi within abdominal aortic aneurysms (AAAs) in 42 patients aged 52 to 92 years (mean 73 +/- 9). The thrombi in the 32 men ranged in weight from 12 to 586 g (mean 162 +/- 135) and in the 10 women, from 12 to 351 g (mean 94 +/- 102). The maximal right-to-left diameter of the AAA by computed tomography immediately preoperatively in the 32 men ranged from 5.0 to 11.0 cm (mean 7.6 +/- 1.7), and in the 10 women from 4.0 to 10.5 cm (mean 6.7 +/- 1.9). The relation of the weight of the intraaneurysmal thrombus to the maximal right-to-left diameter of the AAA preoperatively was highly significant in both men (r = 0.72, p <0.001) and women (r = 0.88, p <0.001). In conclusion, the intraaneurysmal thrombi consisted virtually entirely of fibrin, indicating no evidence of organization.

Surgical repair of renal artery aneurysms.

The pathogenesis of renal artery aneurysms (RAAs) is degenerative, which eventually leads to weakening of the vessel wall and, in extreme cases, rupture. RAAs are a rare occurrence. Patients generally are asymptomatic, with a small number presenting with uncontrollable hypertension or hematuria. Most RAAs are discovered incidentally on imaging and do not pose an immediate health threat. However, the risk of rupture is an indication for prophylactic repair in certain patients. Interest in interventional radiologic procedures in the management of RAAs has recently increased; however, open repair should still be considered in select instances. In this case series, we present three patients for whom an open approach was indicated and performed.

A hybrid repair of a superior mesenteric artery pseudoaneurysm using open mesenteric bypass and endovascular exclusion.

Superior mesenteric artery (SMA) aneurysms and pseudoaneurysms are uncommonly encountered in vascular surgery practice, but they typically require repair. Historically, they have been repaired with open aneurysmorrhaphy, bypass and exclusion, or simple ligation. More recently, endovascular repair with coil embolization and stent graft exclusion have been advocated. We present a repair of an SMA pseudoaneurysm via a hybrid approach with common hepatic artery to SMA bypass, exclusion of the pseudoaneurysm with ligation of the SMA proximal to the bypass, plug occlusion of the proximal SMA, and coil embolization of the pseudoaneurysm.

Comparison of ages between men and women and their distribution across five age decades among patients undergoing carotid endarterectomy.

Analysis of 486 patients who underwent carotid endarterectomy from January 1996 to June 2002 showed similar mean ages in the 269 men and 217 women, whereas the reported mean ages at the time of abdominal aortic aneurysmal resection and at the time of coronary artery bypass grafting were usually significantly different between the 2 genders.

Weights of carotid endarterectomy specimens in patients undergoing unilateral procedures.

Analysis of 273 unilateral carotid endarterectomy specimens showed those in the men to be larger than those in the women (1.4 vs 0.96 g). A large weight variation was found. The smallest specimen weighed 0.38 g, and the largest weighed 4.2 g, a 10-fold difference; the mean weight was 1.25 g.

Comparison of weights of carotid endarterectomy specimens in the same patient among patients undergoing bilateral procedures at different times.

We analyzed weights of carotid endarterectomy specimens in 17 patients who underwent bilateral procedures. Although we assumed that both arterial systems would be the same size, the weight of the carotid endarterectomy specimens was similar in only 4 of the 17 patients; the carotid endarterectomy specimen was larger at the second operation in 5 patients and smaller at the second operation in 8 patients.

Intermediate follow-up of carotid artery stent placement.

BACKGROUND: Carotid artery stent placement (CAS) is becoming more popular among various specialties for the treatment of primary and recurrent carotid artery disease. The morbidity associated with this procedure is improving but the intermediate- and long-term follow-up remains unknown. We report our restenosis rates and follow-up associated with CAS. METHODS: Thirty-one interventions on 29 patients from May 1998 to January 2002 were reviewed. All patients have undergone serial follow-up using Doppler ultrasound at 3 and 6 months and every 6 months thereafter. Ten interventions (32%) were performed on patients with recurrent carotid artery disease and 21 (68%) on patients with primary disease. RESULTS: Five periprocedural complications occurred (transient ischemic attack, n = 3; major stroke, n = 1; immediate intrastent restenosis requiring lysis, n = 1) for a total immediate complication rate of 16%. No deaths occurred. Follow-up was achieved in all 29 patients (mean 28 months; range 20 to 46). Twenty-seven patients (29 vessels; 94%) remain asymptomatic with less than 50% stenosis. Two vessels (6%) have been found to have a critical restenosis of greater than 90%. Both patients were symptomatic from their recurrence (transient ischemic attack, n = 1; acute stroke, n = 1). Cumulative major stroke and death rate including all follow-up was 6%. CONCLUSIONS: CAS can be performed with an acceptable stroke/death rate (3%) in a properly selected patient population. In our small series of patients, the restenosis rate at a mean of 28 months after CAS is 6%.

Treatment of proximal vertebral artery disease.

Vertebral arterial disease (VAD) is a less commonly recognized and treated source of cerebrovascular ischemia compared with carotid artery disease. Patients are often referred for treatment after they have developed symptoms in the form of transient ischemic attacks or had a posterior hemispheric stroke. Traditional treatment of VAD has been surgical. More recently, endovascular treatment of VAD has been utilized. We performed a retrospective review of our institutional experience in treating VAD from 2001 to 2010. For treatment of proximal VAD, perioperative morbidity is lower for the endovascular group than for the surgical group, but six-week mortality was higher for the endovascular group. Complete resolution of symptoms occurred more frequently with surgery than with endovascular therapy. Therefore surgical reconstruction appears to be preferable to angioplasty and stenting for treatment of proximal vertebral artery occlusive disease.

Thermoregulatory catheter-associated inferior vena cava thrombus.

The use of thermoregulatory catheters (TRCs) in critically ill patients has become increasingly popular. TRCs have been shown to be effective in regulating patient body temperature with improved outcomes. Critically ill patients, especially multitrauma patients and those with femoral catheters, are at high risk for deep vein thrombosis (DVT). Among patients for whom chemical DVT prophylaxis is not an option, inferior vena cava (IVC) filters are often placed prophylactically. The development of intravascular ultrasound (IVUS) has allowed placement of IVC filters at the bedside for patients who are too ill for transport to the operating room or cardiac catheterization lab. After encountering several patients with occult DVT of the IVC during bedside IVC filter placement, we performed a retrospective review to determine the incidence of DVT or pulmonary embolus (PE) in patients who had been treated with a TRC at Baylor University Medical Center at Dallas. Since 2008, IVC filters have been deployed at the bedside with the use of IVUS at Baylor University Medical Center. During that same time period, 83 patients had a TRC placed for either intravascular warming or cooling during their resuscitation. Forty-seven out of 83 patients who had a TRC placed survived their injuries. Ten of 47 patients (21%) were diagnosed with DVT or PE, and 6 of these 10 (60%) were found to have caval thrombus. We present this case series as evidence that undiagnosed IVC thrombus associated with TRCs may be higher than previously suspected, given that 5 out of 10 patients who had IVUS of their IVC for prophylactic IVC filter placement, as well as one patient diagnosed with PE, were found to have caval thrombus.

Avoidance of lower-limb amputation by surgical implantation of autologous stem cells.

A 69-year-old Caucasian man was referred to Baylor University Medical Center at Dallas with resting lower-extremity pain and a nonhealing sore above his right ankle (Rutherford chronic ischemia stage 5 of 6) after having failed multiple attempts at revascularization. He was enrolled in a clinical research trial using adult autologous stem cells for treatment of critical limb ischemia. Autologous stem cells from the patient's pelvic bone marrow were harvested, concentrated in the operating room, and reinjected into the lower leg along the vasculature below the level of complete occlusion of the popliteal artery and around the ulcer. After 3 months, the patient had significant improvement in his ankle brachial index, which increased from 0.10 to 0.40 (normal 0.9-1.01), and early healing. After 12 months, the ulcer was fully healed. Healing of the sore has persisted for 3 years.