Phlegmasia cerulea dolens of the upper extremity treated with anticoagulation and leech therapy.

Phlegmasia cerulea dolens is a serious manifestation of venous thrombosis that has a high risk of morbidity and mortality. If not promptly treated on presentation, progressive extremity ischemia and potential gangrene can lead to emergency amputation of the affected limb. Most commonly, the lower extremities are affected, and reports of upper extremity phlegmasia are scarce. We report the successful treatment of phlegmasia cerulea dolens of the distal upper extremity using leech therapy combined with anticoagulation.

Cloud-based fusion imaging improves operative metrics during fenestrated endovascular aneurysm repair.

OBJECTIVE: Endovascular treatment of complex aortic pathology has been associated with increases in procedural-related metrics, including the operative time and radiation exposure. Three-dimensional fusion imaging technology has decreased the radiation dose and iodinated contrast use during endovascular aneurysm repair. The aim of the present study was to report our institutional experience with the use of a cloud-based fusion imaging platform during fenestrated endovascular aneurysm repair (FEVAR). METHODS: A retrospective review of a prospectively maintained aortic database was performed to identify all patients who had undergone FEVAR with commercially available devices (Zenith Fenestrated; Cook Medical Inc, Bloomington, IN) between 2013 and 2020 and all endovascular aneurysm repairs performed using Cydar EV Intelligent Maps (Cydar Medical, Cambridge, UK). The Cydar EV cohort was reviewed further to select all FEVARs performed with overlay map guidance. The patient demographic, clinical, and procedure metrics were analyzed, with a comparative analysis of FEVAR performed without and with the Cydar EV imaging platform. Patients were excluded from comparative analysis if the data were incomplete in the dataset or they had a documented history of prior open or endovascular abdominal aortic aneurysm repair. RESULTS: During the 7-year study period, 191 FEVARs had been performed. The Cydar EV imaging platform was implemented in 2018 and used in 124 complex endovascular aneurysm repairs, including 69 consecutive FEVARs. A complete dataset was available for 137 FEVARs. With exclusion to select for de novo FEVAR, a comparative analysis was performed of 53 FEVAR without and 63 with Cydar EV imaging guidance. The cohorts were similar in patient demographics, medical comorbidities, and aortic aneurysm characteristics. No significant difference was noted between the two groups for major adverse postoperative events, length of stay, or length of intensive care unit stay. The use of Cydar EV resulted in nonsignificant decreases in the mean fluoroscopy time (69.3 ± 28 minutes vs 66.2 ± 33 minutes; P = .598) and operative time (204.4 ± 64 minutes vs 186 ± 105 minutes; P = .278). A statistically significant decrease was found in the iodinated contrast volume (105 ± 44 mL vs 83 ± 32 mL; P = .005), patient radiation exposure using the dose area product (1,049,841 mGy/cm2 vs 630,990 mGy/cm2; P < .001) and cumulative air kerma levels (4518 mGy vs 3084 mGy; P = .02) for patients undergoing FEVAR with Cydar EV guidance. CONCLUSIONS: At our aortic center, we have observed a trend toward shorter operative times and significant reductions in both iodinated contrast use and radiation exposure during FEVAR using the Cydar EV intelligent maps. Intelligent map guidance improved the efficiency of complex endovascular aneurysm repair, providing a safer intervention for both patient and practitioner.

Outcomes of venous bypass combined with thoracic outlet decompression for treatment of upper extremity central venous occlusion.

BACKGROUND: Upper extremity central venous stenosis results from a variety of environmental and anatomic conditions, including venous thoracic outlet syndrome, the presence of device leads or catheters, and the turbulence created by the presence of arteriovenous fistulas or grafts. In cases of total occlusion, especially at the bony costoclavicular junction, options for endovascular treatment and open venous reconstruction are limited and bypass grafting may be needed. We describe our experience with venous bypass combined with thoracic outlet decompression in a cohort of symptomatic patients with subclavian vein occlusion. METHODS: A prospectively collected database of patients was queried for patients treated for central venous obstructive disease with venous bypass in the setting of both symptomatic venous thoracic outlet syndrome and ipsilateral arteriovenous access from July 2012 to December 2017. All but one patient presented with arm swelling and had either failed to respond to or were unsuitable for endovenous therapy. One patient desired elective removal of a venous stent because of pain and anxiety. Operative procedures were performed at the discretion of the operating surgeon. RESULTS: Fourteen patients (eight men; average age, 42 years) underwent open thoracic outlet decompression with first rib resection (n = 11) or claviculectomy (n = 4). Indication for treatment was dialysis-associated venous outlet obstruction in five, effort thrombosis (Paget-Schroetter syndrome) in seven, presence of a venous implantable cardioverter-defibrillator lead in one, and patent but painful venous stent in situ with significant anxiety. Nine patients required first interspace sternotomy for exposure of the proximal subclavian vein. One patient with acute Paget-Schroetter syndrome had been treated with preoperative thrombolysis without resolution; all others were chronically occluded. Bypass conduit was jugular vein in one, bovine carotid artery graft in two, paneled great saphenous vein in two, femoral vein in eight, and polytetrafluoroethylene in one. Mean operative time was 187 (±45) minutes, with mean estimated blood loss of 379 (±209) mL. There were two early graft thromboses that were revised with jugular venous turndown and femoral vein bypass, respectively. All patients experienced immediate symptom relief. Morbidity included two graft thromboses, two instances of wound dehiscence, two operative site hematomas, non-ST elevation myocardial infarction, vein harvest site infection, polytetrafluoroethylene graft infection, and phrenic nerve injury. At a mean follow-up of 357 (±303) days, primary assisted patency and secondary patency for the entire cohort were 71.4% and 85.7%, respectively, with 100% primary assisted patency among those with femoral vein conduit. At last follow-up, 13 of the 14 living patients (93%) remained symptom free. CONCLUSIONS: In our experience, venous bypass combined with thoracic outlet decompression achieves symptomatic relief in approximately 90% of patients with symptomatic upper extremity central venous occlusion, with morbidity limited to the perioperative period.

Defining a Leader-Characteristics That Distinguish a Chair of Surgery.

BACKGROUND: Chair of the Department of Surgery, sometimes known as the Chief, holds a title that has significant historical connotations. Our goal was to assess a group of objectively measurable characteristics that unify these individuals as a group. METHODS: Utilizing publicly available data for all US teaching hospitals, demographic information was accumulated for the named chiefs/chairs of surgery. Information collected included location of their program, their medical/surgical training history, their surgical specialty, previous chair/chief titles held, and academic productivity. RESULTS: Of the 259 programs listed, data were available on 244 individuals who were trained in 19 different specialties. The top three specialties of these practitioners are General Surgery (40, 16.3%), Surgical Oncology (38, 15.5%), and Vascular Surgery (33, 13.5%). There were only 14 female chairs (5.7%) and only one chair with a doctor of osteopathic medicine degree. The majority (62.3%) had been a previous chief of a surgical subdivision with only 26% having been a previous chair/chief of the surgical department. The average chair had 72 peer-reviewed manuscripts with 28 published book chapters. Chair's at academic institutions with university affiliation had a significantly higher number of peer-reviewed manuscripts (P < 0.0001) as well as were more likely to be trained at academic institutions (P = 0.013). CONCLUSIONS: There are no set characteristics that define the Chair of a Department of Surgery. By understanding a group of baseline characteristics that unify these surgical leaders, young faculty and trainees with leadership aspirations may begin to understand what is necessary to fill these roles in the future.

Management of Aortoiliac Aneurysms with Atypical Renal Artery Anatomy.

BACKGROUND: Renal artery anomalies occur at a rate of 1-2% and present a challenge to vascular surgeons performing aortic surgery. We describe adjuncts used to manage such anatomic variants. METHODS: A single surgeon registry of all abdominal aortic aneurysms repaired in an academic center was retrospectively reviewed. Patients with prior renal transplants, congenital pelvic kidneys, or horseshoe kidneys were included. Open repair was reserved for patients with no endovascular or hybrid repair options. RESULTS: Over an 8-year period, 18 patients were identified (renal transplant n = 9, horseshoe kidney n = 3, congenital pelvic kidney n = 6). All transplant patients were treated with endovascular repair. Four required cross-femoral bypasses, 1 for retrograde allograft perfusion after aorto-uni-iliac (AUI) procedure to the contralateral external iliac artery and 3 for contralateral limb perfusion after endograft extension into iliac artery ipsilateral to allograft. Three transplant patients required carotid access due to severe iliofemoral occlusive disease or allograft origin off the internal iliac artery. Two horseshoe kidney patients underwent open repair with direct reimplantation of accessory renal arteries, whereas 1 underwent endovascular repair with exclusion of an isthmus branch. Of the congenital single/pelvic kidney cohort, 2 underwent open repair with renal reimplantation, 2 underwent endovascular aneurysm repair, 1 was treated with AUI and cross-femoral bypass, and one was treated with a staged iliorenal bypass and subsequent fenestrated endovascular repair. Intravascular ultrasound was used to minimize contrast use in patients with chronic renal insufficiency (Cr > 1.5 mg/dL, n = 6). Over a mean follow-up of 31 months (range, 1-110), there were no aortic deaths or reintervention, no decline in renal function (measured by serum creatinine and glomerular filtration rate), and 100% patency of the preserved renal arteries. CONCLUSIONS: Atypical renal anatomy should not preclude repair of aortic aneurysms. Repair of such aneurysms is safe and achieves good long-term outcomes with the use of the described techniques.