Transcarotid Artery Revascularization for Symptomatic Retropharyngeal Internal Carotid Artery Stenosis.

Retropharyngeal internal carotid artery (ICA) is a rare, yet well-described anatomical variant that poses significant challenges to the management of carotid artery stenosis. In this case report, we discuss the treatment of symptomatic ICA stenosis with a retropharyngeal ICA using the transcarotid artery revascularization (TCAR) technique. A 70-year-old female with comorbidities presented with neurological symptoms and severe ICA stenosis. After diagnostic evaluation, TCAR was chosen for surgical intervention. The patient did well postoperatively. This case emphasizes the importance of considering TCAR when treating ICA stenosis in patients with anatomic variation of ICA location. It also supports adding anatomic variants such as retropharyngeal ICA to the list of indications for TCAR.

Expansion of WallStents® after Initial Deployment in Nonthrombotic Iliac Vein Lesions.

BACKGROUND: To determine the structural changes of Wallstents (Boston Scientific, Natick, MA) in vivo following deployment in iliac veins. METHODS: This retrospective single-center study was performed from September 2012 to April 2013 and included 100 office-based patients who underwent initial stent placement for nonthrombotic iliac vein lesions with Wallstent as well as a second procedure for stenting of the contralateral iliac vein. Measurements were obtained with marker balloons and the diameters of the stents were compared at the time of the index procedure to the secondary procedure. RESULTS: The average time between the 2 procedures was 28 days (range 3-237, SD ± 39.89). The overall average stent diameter after the index procedure was 16.38 mm (range 10.95-21.45, SD ± 2.24). The overall average stent diameter of the index stent when remeasured during the second intervention was 17.58 mm (range 12.84-24.11, SD ± 2.38, P = 0.0003), which was significantly different from the initial measurements. There was no difference when comparing changes in stent diameter by gender or laterality of procedure. However, there was a significant difference in expansion of stents when placed in the common iliac vein versus the external iliac or common femoral veins. CONCLUSIONS: This study shows that self-expanding Wallstents can continue to expand days to weeks in vivo following initial deployment. Additionally, we found that the change in diameter from initial placement to follow-up was more significant in stents placed in the proximal and middle segments of the common iliac vein. CLINICAL RELEVANCE: Wallstents are durable implants designed to last within a patient for the rest of their life, it is important to understand the structural changes occurring after their placement. This study allows for a better understanding of Wallstent dynamics in vivo.

Patient selection for arterial procedures in office-based laboratories: A systematic review.

A dramatic increase in the number of vascular procedures performed in the office-based laboratory setting has been observed since 2008, when the Centers for Medicare and Medicaid Services increased reimbursement for procedures performed in the ambulatory setting. We sought to evaluate the appropriateness of arterial intervention in the office-based laboratory and patient selection. This systematic review was conducted with a search of Google Scholar and PubMed using the following search terms: office-based lab, outpatient, angioplasty, patient selection, arterial, and appropriateness. More than 500 publications were screened and 14 publications related to the topic were selected. The existing literature that examined patient selection for intervention in the outpatient setting, rates of complications after outpatient procedures, and short-term data on the safety and efficacy of these procedures is discussed. Gaps were identified in current knowledge about the long-term outcomes of peripheral arterial interventions performed in the office-based laboratory setting, as well as existing guidelines for the management of patients with peripheral arterial disease.

In-Hospital Risk Factors for Reintervention and Amputation in Brachial Arterial Trauma.

INTRODUCTION: Brachial artery trauma is a rare but potentially devastating injury. There is little data regarding risk factors for reintervention and amputation prevention in this population, as well as anticoagulant (AC) and antiplatelet (AP) regimens and outcomes after discharge in trauma patients with vascular injuries requiring repair. This study aims to identify in-hospital risk factors for reintervention and amputation and stratify outcomes of follow-up by discharge AC or AP regimen. METHODS: The AAST Prospective Observational Vascular Injury Trial database was queried for all patients who underwent traumatic brachial arterial repair from 2013 to 2022. Patients were evaluated by need for reintervention, amputation, and outcomes at follow-up by AC or AP regimen. RESULTS: Three hundred and eleven patients required brachial repair, 28 (9%) required reoperation, and 8 (2.6%) required amputation. High injury severity score and an increased number of packed red blood cells and platelets showed a significant increase for reoperation and amputation. Damage control and shunt use were significant for the need to reoperate. Seventy-four percent (221/298) of patients were discharged with postoperative AC or AP regimens. There was no significant difference of short-term follow-up by type of AC or AP regimen. CONCLUSIONS: Damage control and temporary shunt may lead to additional operations but not an increase in amputations. However, anticoagulation intraoperatively and postoperatively does not appear to play a significant role in reducing reintervention. It also suggests that there is no increase in short-term follow-up complications with or without AC or AP therapy.

Thoracic Ultrasound for Detection of Pneumothorax Following Thoracostomy Tube Removal in Trauma Patients.

INTRODUCTION: Screening for pneumothorax (PTX) is standard practice after thoracostomy tube removal, with postpull CXR being the gold standard. However, studies have shown that point-of-care thoracic ultrasound (POCTUS) is effective at detecting PTX and may represent a viable alternative. This study aims to evaluate the safety and efficacy of POCTUS for evaluation of clinically significant postpull PTX compared with chest x-ray (CXR). METHODS: We performed a prospective, cohort study at a Level 1 trauma center between April and December 2022 comparing the ability of POCTUS to detect clinically significant postpull PTX compared with CXR. Patients with thoracostomy tube placed for PTX, hemothorax, or hemopneumothorax were included. Clinically insignificant PTX was defined as a small residual or apical PTX without associated respiratory symptoms or need for thoracostomy tube replacement while clinically significant PTX were moderate to large or associated with physiologic change. RESULTS: We included 82 patients, the most common etiology was blunt trauma (n = 57), and the indications for thoracostomy tube placement were: PTX (n = 38), hemothorax (n = 15), and hemopneumothorax (n = 14). One patient required thoracostomy tube replacement for recurrent PTX identified by both ultrasound and X-ray. Thoracic ultrasound had a sensitivity of 100%, specificity of 95%, positive predictive value of 60%, and negative predictive value of 100% for the detection of clinically significant postpull PTX. CONCLUSIONS: The use of POCTUS for the detection of clinically significant PTX after thoracostomy tube removal is a safe and effective alternative to standard CXR. This echoes similar studies and emphasizes the need for further investigation in a multicenter study.

Liver Transplantation in a Woman with Mahvash Disease.

Mahvash disease is an exceedingly rare genetic disorder of glucagon signaling characterized by hyperglucagonemia, hyperaminoacidemia, and pancreatic α-cell hyperplasia. Although there is no known definitive treatment, octreotide has been used to decrease systemic glucagon levels. We describe a woman who presented to our medical center after three episodes of small-volume hematemesis. She was found to have hyperglucagonemia and pancreatic hypertrophy with genetically confirmed Mahvash disease and also had evidence of portal hypertension (recurrent portosystemic encephalopathy and variceal hemorrhage) in the absence of cirrhosis. These findings established a diagnosis of portosinusoidal vascular disease, a presinusoidal type of portal hypertension previously known as noncirrhotic portal hypertension. Liver transplantation was followed by normalization of serum glucagon and ammonia levels, reversal of pancreatic hypertrophy, and resolution of recurrent encephalopathy and bleeding varices.

Traumatic Endograft Fracture With Subsequent Type IIIb Endoleak.

Abdominal aortic aneurysm (AAA) repair is commonly treated via endovascular aneurysm repair (EVAR). A known complication of EVAR is an endoleak: types I to IV. Type III endoleaks have been shown to have a relative risk of 8.95 for late rupture requiring prompt treatment. These endoleaks have been found to be caused by over dilation of the main body causing graft fabric distortion, fractures of metallic struts, fabric wear from chronic micromotion, fabric tears, and suture breakage. We present a case of traumatic EVAR fracture with subsequent type IIIb endoleak after blunt abdominal trauma. This highlights the need for close evaluation of endografts after abdominal trauma. These traumatic events can lead to traumatic fracture of endografts creating endoleaks that if not treated promptly can lead to rupture.

Creation of an Application to Increase Surgical Resident Operative Case Coverage.

PURPOSE: Studies have shown that the confidence of surgical residents to perform procedures after completing residency can be affected by their volume of operative experiences. Many surgical residencies span multiple hospitals with a multitude of attendings providing additional educational opportunities available via cross-coverage. This study aims to evaluate the use of a mobile application (app) for operative cross-coverage to improve surgical opportunities in a large surgical residency program and decrease the number of uncovered cases. METHODS: An app allowing for uncovered cases to be sent to all surgical residents was used starting March 2022. A survey was completed by residents pre- and postapp implementation. A retrospective chart review was conducted of all general surgery procedures at the 2 major hospital systems 4 months before and after implementation to evaluate resident case coverage. RESULTS: In the preapp survey, 71% (27/38) of residents noted cross-covering 1 or more cases a month with 90% (34/38) reporting, they were unaware of all cases available. In the postapp survey, 100% of residents reported better awareness of available cases, 97% (35/36) reported uncovered cases were more easily accessible, 100% felt the app simplified finding coverage, and 100% wanted to continue the app long-term. On retrospective review, 7210 cases were identified in the preapp and postapp period with an increased volume of cases in the postapp period. After implementation of the case coverage app, there was a significant increase in total case coverage (p = <0.001) as well as a significant increase in coverage of endoscopic (p = 0.007), laparoscopic (p = 0.025), open (p = 0.015) and robotic cases (p = <0.001). CONCLUSIONS: This study shows the impact that technological innovation can play in the education and operative experiences of surgical residents. This can be used to improve operative experiences of residents in various surgical fields in any training program throughout the country.

Body mass index does not decline during winter for the sedentary marine gastropod Crepidula fornicata.

Seasonal extremes in environmental conditions can substantially limit the growth and reproduction of animals. Sedentary marine animals are particularly susceptible to winter food limitation since they cannot relocate to more favourable conditions. In several temperate-zone bivalve species, substantial winter tissue mass declines have been documented; however, no comparable studies have been conducted on intertidal gastropods. Here, we investigate whether the suspension-feeding intertidal gastropod Crepidula fornicata also loses substantial tissue mass during the winter. We calculated body mass index (BMI) for individuals collected in New England at different times of year for 7 years to determine whether BMI declines through winter or varies seasonally. Remarkably, C. fornicata body mass did not decline significantly during winter months; indeed, a relatively poorer body condition was associated with higher seawater temperature, higher air temperature and higher chlorophyll concentration. In a laboratory experiment, we found that C. fornicata adults that were not fed for three weeks at 6°C (local winter seawater temperature) showed no detectable declines in BMI compared to field-collected individuals. Future studies should document energy budgets of C. fornicata and other sedentary marine animals at low winter seawater temperatures, and the impact of short-term elevated temperatures on those energy budgets.

Alcoholic vs. Nonalcoholic Steatohepatitis: Vascular Branching Heterogeneity on Magnetic Resonance Imaging as a Diagnostic Marker.

Background and Aims: Distinguishing alcoholic steatohepatitis (ASH) and nonalcoholic steatohepatitis (NASH) with biopsy alone is often difficult without a reliable clinical context. A novel finding on liver imaging, perivascular branching heterogeneity, has shown promise in distinguishing between these chronic liver diseases. Our study investigated the role of this finding on imaging to differentiate between ASH and NASH. The aim of this study was to determine the utility and reproducibility of this novel radiographic marker to help distinguish ASH from NASH. Methods: This was a retrospective cohort study conducted between 2016 and 2020 in patients with both liver biopsy-confirmed steatohepatitis/chronic hepatitis and abdominal magnetic resonance imaging within 13 months of each other. Two radiologists, blinded to patient clinical history and diagnosis, categorized the appearance of the liver as: 1- homogeneity, 2- mild heterogeneity, 3- moderate heterogeneity, 4- possible perivascular branching, 5- definite perivascular branching. Results: Of the 90 patients in the study, 60 were identified as NASH and 30 as ASH. The area under the curve (AUC) for both reader 1 and 2 when using the 5-point scale was 0.69 (CI: 0.56-0.82, p=0.006) and 0.72 (CI: 0.60-0.85, p=0.001), respectively. The positive predictive value (PPV) for identification of ASH when scoring 5 was 64.7% and 66.7% for reader 1 and 2, respectively. Interclass correlation coefficient was 0.74 in patients with ASH, indicating moderate reliability among both readers. Conclusions: Identification of this perivascular branching pattern on imaging is a promising novel diagnostic marker that can be used with other methods to help distinguish between ASH and NASH.

Systematic review of groin incision surgical site infection preventative measures in vascular surgery.

OBJECTIVE: Groin surgical site infections (SSIs) after open revascularization can lead to devastating consequences in patients. As a result, prevention has been crucial in minimizing the rate of SSIs. This review aims to evaluate the current body of literature regarding prevention ,techniques including prophylactic flaps, incision technique, topical antibiotic use, closed-incision negative pressure wound therapy, and adhesive drapes. METHODS: This review was conducted and reported in accordance with the PRISMA statement. A systematic review was conducted using the Google Scholar, PubMed, and Cochrane Review databases regarding the five prevention topics. The authors identified 1371 potential studies with 33 studies selected and analyzed after systematic review regarding the five preventative topics. RESULTS: The primary outcome of interest was how the rate of SSI was affected with each preventative technique. As a result, the recommendations are as follows. We suggest prophylactic flaps be considered in high-risk surgical patients undergoing open arterial exposure of the groin (Grade 2C). We suggest consideration of transverse incisions for open arterial exposure of the groin as a means of SSI prevention (Grade 2C). Given the lack of data regarding topical antibiotics no recommendation can be made regarding its use, we suggest closed-incision negative pressure wound therapy be used in groin surgical incisions at high risk for SSI (Grade 2B). Given the paucity of data regarding adhesive drapes, such as Ioban, no recommendation can be made regarding its use. CONCLUSIONS: This review highlights the effects of various preventative techniques and their potential benefit in the prevention of SSI in the groin. However, there is a glaring deficit in the available data, emphasizing the need for additional robust studies to better delineate their effectiveness and implementation into surgical practice. The use of endovascular techniques continues to increase, thus limiting the number of open arterial procedures and the potential for further studies to be conducted. To provide the high-quality studies needed to better evaluate these prevention techniques, large multi-institutional collaboration will likely be necessary to provide the appropriate number of patients to evaluate true effectiveness.

Outcomes Following Modified Broström for Chronic Lateral Ankle Instability With and Without Peroneal Tendon Exploration.

BACKGROUND: It is not known how peroneal tendon exploration influences results after modified Broström for lateral ankle instability. We propose peroneal exploration at the time of modified Broström will have similar outcomes as no peroneal exploration. METHODS: A retrospective analysis was performed of patients undergoing modified Broström with and without peroneal exploration. Foot and Ankle Outcome scores and data regarding military retention were gathered and compared. RESULTS: Seventeen patients were identified in the modified Broström only cohort and 24 in the peroneal exploration cohort. Patients had mean follow-up of 5 years in both cohorts. The mean FAOS in the modified Broström only cohort was 68 and 72 in the cohort with peroneal exploration (P = .541). When each FAOS subcategory was analyzed, no difference was identified in any subcategory. Eight of 17 patients (47%) in the modified Broström only cohort remained active duty compared with 8 of 24 patients (33%) in the modified Broström with peroneal exploration cohort (P = .518). One patient medically discharged in the modified Broström only cohort versus 6 in peroneal exploration cohort (P = .109). Overall satisfaction with the procedure was 12 of 17 (71%) in the modified Broström only cohort and 19 of 24 (79%) in the peroneal exploration cohort (P = .529). CONCLUSIONS: No significant difference was identified between patients undergoing modified Broström alone or modified Broström with peroneal exploration. There was no significant difference in return to duty, medical discharge or patient satisfaction. LEVELS OF EVIDENCE: Level III: retrospective case-control study with prospectively collected data.

Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration.

BACKGROUND AND AIMS: EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. METHODS: We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. RESULTS: Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. CONCLUSIONS: Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.

Effect of Post-splenectomy Booster Vaccine Program on Vaccination Compliance in Trauma Patients.

OBJECTIVE: In 2012, the Centers for Disease Control and Prevention (CDC) Advisory Council on Immunization Practice recommended an additional post-splenectomy booster vaccine at 8 weeks following the initial vaccine. The objective of this study was to evaluate our vaccination compliance rate and what sociodemographic factors were associated with noncompliance following this recommendation. MATERIALS AND METHODS: A retrospective review of a performance improvement database of trauma patients eligible for post-splenectomy vaccination (PSV) at a level I trauma center was carried out between 2009 and 2018. Overall and institutional compliance with PSV was compared before and after the addition of booster vaccine recommendation. Factors associated with booster noncompliance were also identified. RESULTS: A total of 257 patients were identified. PSV compliance rate in the pre-booster was 98.4%, while overall and institutional post-booster compliance rate were significantly lower at 66.9% (P ≤ .001) and 50.0% (P ≤ .001), respectively. Compared to booster institutional compliers, institutional noncompliers lived farther from the trauma center (48 vs. 86 miles, P = .02), and though not statistically significant, these patients were generally older (34.9 vs. 40.5, P = .05). DISCUSSION: PSV booster compliance is low even with the current educational materials and recommendations. Additional approaches to improve compliance rates need to be implemented, such as sending letters to the patient and their primary care providers (PCPs), collaborating with rehab/long-term acute care centers, communicating with city and county health departments and city pharmacies, or mirroring other countries and creating a national database for asplenic patients to provide complete information.

Factors that predict the need for early surgeon presence in the setting of pediatric trauma.

INTRODUCTION: Evidence based variables predicting the need for surgeon presence (NSP) on arrival of an injured child are limited. We sought to identify prehospital factors that best correlate with NSP and highest level of activation in pediatric trauma. A secondary analysis was also performed to determine whether injury severity score (ISS) was predictive of NSP in pediatric trauma. METHODS: This was a retrospective, single institution study of injured patients age ≤ 16 years delivered from scene to our Pediatric Level I trauma center between January 2016 and June 2017. 526 patients had complete data available for analysis. NSP was previously described as the presence of any of these factors: intubation, transfusion, emergent operation with the trauma team/craniotomy with the neurosurgery team, vasopressors, interventional radiology, spinal cord Injury, chest tube, emergency department thoracotomy, intracranial pressure monitor, pericardiocentesis, or death in the trauma bay. Multivariable analysis was performed with covariates of interest including scene and ED arrival vitals and interventions. RESULTS: Independent predictors of NSP and highest level of activation were GCS of ≤12 (OR 22.3), penetrating trauma (OR 5.4), and hypotension (age adjusted) (OR 10.2). We also found that ISS ≥ 16 was a poor indicator of NSP with a sensitivity of only 61%. CONCLUSION: A validated model based on these variables may be useful in predicting NSP and highest level of activation prior to arrival of pediatric trauma patients. NSP may augment assessment of over and undertriage in pediatric trauma patients as compared to the ISS/Cribari system alone. Level of evidence Level III, retrospective cohort study.

Closed Distal Dislocation of the Intermediate Cuneiform in a Complex Lisfranc Fracture-Dislocation: A Case Report.

CASE: A 21-year-old, active duty male sustained an irreducible, complex Lisfranc fracture-dislocation with distal extrusion of his intermediate cuneiform. He was treated in a staged manner with external fixator placement, followed by an extended midfoot fusion with autograft bone. At 19 months, he could perform all activities of daily living independently with minimal pain using an Intrepid Dynamic Exoskeletal Orthosis. CONCLUSIONS: Complex Lisfranc injuries are severe and often result in chronic pain and disability after operative management. To our knowledge, this is the only case report describing a Lisfranc fracture-dislocation with a distally extruded intermediate cuneiform treated with a fusion.

Removal of retrievable inferior vena cava filters before discharge: Is it associated with increased incidence of pulmonary embolism?

BACKGROUND: Severely injured trauma patients are at high risk of developing deep venous thrombosis and pulmonary emboli (PE), and may have contraindications to prophylactic or therapeutic anticoagulation. Retrievable inferior vena cava filters (rIVCFs) are used to act as a mechanical obstruction to prevent PE in high risk populations and those with deep venous thrombosis who cannot be anticoagulated. The removal rate of rIVCFs is variable in trauma centers, including our previous published rate of 50% to 89%/year. Indwelling filters carry a risk of significant morbidity and the success of retrieval decreases as the dwell time increases. We hypothesized that once patients could receive appropriate prophylactic or therapeutic anticoagulation, rIVCF could be removed before hospital discharge without impact on occurrence or recurrence of PE. METHODS: All trauma patients with rIVCF placed and removed between January 2006 and August 2018 were reviewed. We collected data from record review from admission to 6 months postfilter removal, including demographics, filter indication, filter type, dwell time, placement and removal complications, antithrombosis medications, location of venous thromboembolism, complications, and discharge disposition. Exposure of interest was timing of filter removal: before (BEF) or after hospital discharge (AFT). The outcome of interest was whether the patient had a documented PE within 6 months of filter removal. RESULTS: A total of 281 rIVCFs were placed, 218 were eligible for removal, 72.4% (158/218) were retrieved with 63% (100/158) removed before discharge. Mean filter duration was 26 days and 103 days for the before and after groups, respectively. No differences (p > 0.05) were noted in the distribution of demographic and clinical factors except for filter indication (venous thromboembolism indication, 95% in AFT vs. 74% in BEF, p = 0.0043). Postremoval PE rates were 0% BEF and 1% AFT (Fisher's exact test, p = 1.000). CONCLUSION: Our results suggest that removal of rIVCFs before discharge once patients are appropriately anticoagulated is a safe strategy to improve retrieval rates. LEVEL OF EVIDENCE: Therapeutic, level V.