Hybrid Paraclavicular Decompression for Venous Thoracic Outlet Syndrome with Primary Endovascular Reconstruction.

BACKGROUND: Venous thoracic outlet syndrome (vTOS) is characterized by severe stenosis and potential thrombosis of the axillary-subclavian vein (effort thrombosis) with significant effects on patient mobility, quality of life, and risks associated with possible anticoagulation. Treatment goals are aimed at symptomatic improvement and freedom from recurrent thrombosis. To date, there exist no clear protocols or recommendations on surgical approach that result in optimal outcomes. We highlight our institution's experience with a systematized, paraclavicular approach with intraoperative balloon angioplasty only, if needed. METHODS: This was a retrospective case series identifying 33 patients that underwent thoracic outlet decompression for vTOS from 2014 to 2021 via paraclavicular approach at Trinity Health Ann Arbor. Demographics, presenting symptoms, perioperative details, and follow-up details describing symptomatic improvement and imaging surveillance were obtained. RESULTS: The average age of our patients was 37 years with the most common presenting symptoms of pain and swelling (91%). The average time from diagnosis to thrombolysis for effort thrombosis was 4 days, with an average time to operative intervention of 46 days. All patients underwent a paraclavicular approach with full first rib resection, anterior and middle scalenectomy, subclavian vein venolysis, and intraoperative venogram. Of these, 20 (61%) underwent endovascular balloon angioplasty, 1 required balloon with stent placement, 13 (39%) required no additional intervention, and no patients required surgical reconstruction of the subclavian-axillary vein. Duplex imaging was used to evaluate recurrence in 26 patients at an average of 6 months postop. Of these, 23 demonstrated complete patency (89%), 1 demonstrated chronic nonocclusive thrombus, and 2 demonstrated chronic occlusive thrombus. Almost all our patients (97%) had moderate or significant improvement of their symptoms. None of our patients required a subsequent operation for recurrence of symptomatic thrombosis. The mode length of anticoagulation use postoperatively was 3 months, with an average use of 4.5 months. CONCLUSIONS: A systematized surgical approach of paraclavicular decompression for venous thoracic outlet syndrome with primary endovascular balloon angioplasty carries minimal morbidity with excellent functional results and symptomatic relief.

Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study.

BACKGROUND: In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS: Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS: 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION: In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE: Level III, Therapeutic Care Management.

Early VTE prophylaxis in severe traumatic brain injury: A propensity score weighted EAST multicenter study.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS: A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest. RESULTS: Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSION: In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE: Therapeutic Care Management; Level III.

Interpretation of Basic Clinical Images: How Are Surgical Residents Performing Compared to Other Trainees?

BACKGROUND: During medical training students, residents, and fellows learn how to accurately interpret basic radiographic images. This skill is mostly utilized by physicians in the acute and critical care settings. It is unclear whether surgical residents' interpretation skills differ from that of other trainees. METHODS: A 30-question online quiz was developed to evaluate trainees' skills in interpreting images using various radiologic modalities. The participating cohort included (1) medical students (MS), (2) general surgery residents (GST), internal medicine residents and fellows (IMT), and radiology trainees (RT). The impact of residency specialty and level of training on performance was evaluated. RESULTS: A total of 69 postgraduate trainees and 19 MS enrolled in the online quiz. The average score was 67.6% (±16.6). GST scored higher than IMT (74.2% ± 10.7% vs. 67.9% ± 11.3%, p = 0.038); however, they were equally proficient to RT. MS had the lowest interpretation accuracy rates compared to postgraduate trainees (57.4% ± 16.8%, p < 0.001). On different radiographic modalities, junior GST performance was comparable to MS, JR-IMT, and Junior Radiology Trainees (JR-RT). On computed tomography (CT) body, GST (83.1% ± 15.7%) scored higher than IMT (70.3% ± 17.7%, p = 0.026) and MS (61.7% ± 23.4%, p < 0.001). Similar findings were demonstrated on ultrasound modality. A difference in performance was not evident for X-rays, CT head, and tubes/lines localization images. CONCLUSIONS: GST were able to correctly interpret 74.2% of basic clinical images. Although superior in the evaluation of pathologies seen on CT body and ultrasound, GST have comparable performance to other trainees in X-rays, tube/line localization images, and CT head. Integration of radiology education in surgical training may enhance performance and potentially improve patient care.

Understanding the Outcomes Measures used in Huntington Disease Pharmacological Trials: A Systematic Review.

BACKGROUND: The identification of the gene mutation causing Huntington disease has raised hopes for new treatments to ease symptoms and slow functional decline. As such, there has been a push towards designing efficient pharmacological trials (i.e., drug trials), especially with regard to selecting outcomes measures that are both brief and sensitive to changes across the course of the disease, from subtle prodromal changes, to more severe end-stage changes. OBJECTIVES: Recently, to aid in efficient development of new HD research studies, the National Institute of Neurological Disorders and Stroke (NINDS) published recommendations for measurement selection in HD. While these recommendations are helpful, many of the recommended measures have little published data in HD. As such, we conducted a systematic review of the literature to identify the most common outcomes measures used in HD clinical trials. METHODS: Major medical databases, including PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, were used to identify peer-reviewed journal articles in English from 2001 through April 2013; 151 pharmacological trials were identified. RESULTS: The majority of HD clinical trials employed clinician-reported outcomes measures (93%); patient reported outcome measures (11%) and observer reported outcome measures (3%) were used with much less frequency. CONCLUSIONS: We provide a review of the most commonly used measures across these trials, compare these measures to the clinical recommendations made by the NINDS working groups, and provide recommendations for selecting measures for future clinical trials that meet the Food and Drug Administration standards.