Starting a Vascular Surgery Fellowship at a Rural Healthcare Center.

INTRODUCTION: In the United States, there is an anticipated critical shortage of vascular surgeons in the coming decades. The shortage is expected to be particularly pronounced in rural areas. Our institution serves a rural and underserved population in which the incidence and prevalence of cardiovascular disease continues to rise. Our institution maintains a general surgery residency and has all the required Accreditation Council for Graduate Medical Education (ACGME) rotations and educational infrastructure to support a vascular surgery fellowship. This study aims to analyze the vascular caseload at our institution to determine if we and other institutions with similar surgical volumes can support the creation of a 2-year vascular fellowship. METHODS: A single-site retrospective review of the number and type of vascular cases conducted at our institution between July 2016 and June 2021 was performed. The procedures were grouped into the following ACGME-defined categories: abdominal, cerebrovascular, complex, endovascular aneurysm repair, endovascular diagnostic or therapeutic, and peripheral. The total number and annual average for each category was obtained. Using the annual average, a 2-year estimate was calculated and compared to the ACGME minimum for each category. Our 2-year estimate was then compared to the national average for graduating vascular surgery fellows in order to generate a z-score for each category. RESULTS: In the specified period, 6100 total surgical procedures were performed by three vascular surgeons at our institution. Two thousand five hundred and seventy-eight of the 6100 procedures met at least one of the ACGME-defined category requirements. Our center greatly exceeded the requirements for each category except for abdominal. This is consistent with trends observed in most centers across the nation, which are seeing a decline in open repairs across all categories, especially in open abdominal repairs. Our center's vascular case volume shows no significant difference the national average in each ACGME category (P ≥ 0.05 for all). CONCLUSIONS: Despite our center's large vascular caseload and need for more vascular providers, there were not enough open abdominal cases performed to support the training of a vascular fellow. Given the continued decline in open aortic volume across the country, we anticipate that rural centers similar to our own will have difficulty establishing programs to train and recruit vascular surgeons. Flexibility in the abdominal category requirement or creation of open aortic fellowships may be necessary for smaller rural centers to train vascular surgeons and meet the future needs of the specialty.

Acute Brachial Artery Occlusion in an Elderly Patient With Acute Myocardial Ischemia.

We present a case of left upper extremity paresis secondary to acute brachial artery occlusion in an elderly female with active non-ST segment elevation myocardial ischemia (NSTEMI) in the setting of paroxysmal atrial fibrillation. The patient was initially suspected to have a cerebrovascular attack (CVA); however, computed tomography (CT) head was negative for acute stroke. The diagnosis was confirmed by computed tomographic angiography (CTA) of the upper extremity, confirming the diagnosis of acute left brachial artery occlusion. In evaluating a patient with concern for acute stroke with atypical presentation, it is essential to obtain a complete history and perform a rapid and thorough examination. Acute limb ischemia (ALI) should be considered in the differential diagnosis of CVA with atypical presentation.

Natural History Of an Untreated Type 1 Endoleak: A Case Report.

We present a case of giant abdominal aortic aneurysm greater than 17 cm complicated by an endoleak, demonstrating the natural history of an untreated Type 1 endoleak.

Left subclavian artery aneurysm: surgical repair via a sternal incision--a case report.

For trauma, the traditional approach to the proximal left subclavian artery is through a posterolateral thoracotomy. The purpose of this study was to evaluate the feasibility of accessing the proximal left subclavian artery through a partial sternotomy approach. Anatomical review of 52 subclavian arteries was performed on 52 randomly picked computed tomography (CT) scans of the thorax. The depth of the origin of the subclavian artery was measured from the lateral thoracic wall and from the sternum. It was noted that the distance from the sternum to the origin of the left subclavian artery was 4.71 cm as compared to the posterolateral wall, which was 8.87 cm. This is in contrast to the belief that the left subclavian artery is a posterior structure in the mediastinum. A subclavian artery aneurysm was repaired through the sternal approach and was noted to have an adequate exposure required for the procedure. This approach was necessitated owing to the fact that the patient had significant chronic obstructive pulmonary disease. From these data, the authors conclude that in elective circumstances it is easier and appropriate to use the partial sternotomy approach to access the proximal left subclavian artery, especially in patients who have reduced pulmonary function.

Recognition of a non-recurrent laryngeal nerve during carotid endarterectomy.

Cranial nerve injury during carotid endarterectomy (CEA), while infrequent, may have serious consequences. The recurrent laryngeal nerve is one of the most commonly injured cranial nerves. Fortunately, most of these injuries are temporary. Anatomic variations in the position of cranial nerves present challenges to surgeons during CEA. Although the occurrence of a non-recurrent laryngeal nerve (NRLN) is rare, proper recognition of this anatomic variation is critical in order to minimize complications. We present a case in which a NRLN was discovered intraoperatively and carefully preserved.

Acute abdominal aortic thrombosis following the Heimlich maneuver.

Complications from the Heimlich maneuver are relatively infrequent. Two fatal cases of abdominal aortic thrombosis have been reported following this technique. We report on the first patient that suffered an acute thrombosis of the abdominal aorta and survived. Prompt recognition of this complication provides the only hope of survival from this rare and catastrophic complication.