Bailout Distal Internal Carotid Artery Stenting after Carotid Endarterectomy: Indications, Technique, and Outcomes.

BACKGROUND: Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. METHODS: We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. RESULTS: Six patients were identified during the study period. All were male with an age range of 63 to 82 years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2 days (range 1-7 days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17 months. CONCLUSIONS: Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.

Female sex is associated with reintervention and mortality following elective endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Although sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes have been increasingly reported, the determination of contributing factors has not reached a consensus. We investigated the disparities in sex-specific outcomes after elective EVAR at our institution and evaluated the factors that might predispose women to increased morbidity and mortality. METHODS: We performed a retrospective medical record review of all patients who had undergone elective EVAR from 2011 to 2020 at a suburban tertiary care center. The primary outcomes were 5-year survival and freedom from reintervention. The Fisher exact test, t tests, and Kaplan-Meier analysis using the rank-log test were used to investigate the associations between sex and outcomes. A multivariable Cox proportional hazard model controlling for age and common comorbidities evaluated the effect of sex on survival and freedom from reintervention. RESULTS: A total of 273 patients had undergone elective EVAR during the study period, including 68 women (25%) and 205 men (75%). The women were older on average than were than the men (76 years vs 73 years; P ≤ .01) and were more likely to have chronic obstructive pulmonary disease (38% vs 23%; P = .01), require home oxygen therapy (9% vs 2%; P = .04), or dialysis preoperatively (4% vs 0%; P = .02). The distribution of other common vascular comorbidities was similar between the sexes. The 30-day readmission rate was greater for the women than for the men (18% vs 8%; P = .02). The women had had significantly lower survival at 5 years (48% ± 7.9% vs 65% ± 4.3%; P < .01) and significantly lower 1-year (women, 89% ± 4.1%; vs men, 94% ± 1.7%; P = .01) and 5-year (women, 69% ± 8.9%; vs men, 84% ± 3.3%; P = .02) freedom from reintervention. On multivariable analysis, female sex (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.1-2.9), congestive heart failure (HR, 2.2; 95% CI, 1.2-3.9), and older age (HR, 1.1; 95% CI, 1.0-1.1) were associated with 5-year mortality. Female sex remained as the only variable with a statistically significant association with 5-year reintervention (HR, 2.4; 95% CI, 1.1-4.9). CONCLUSIONS: Female sex was associated with decreased 5-year survival and increased 1- and 5-year reintervention after elective EVAR. Data from our institution suggest that factors beyond patient age and baseline health risk likely contribute to greater surgical morbidity and mortality for women after elective EVAR.

Intraoperative Vascular Assistance: Essential to an Institution's Ability to Provide Surgical Care.

BACKGROUND: The wide breadth of vascular surgery (VS) training enables vascular surgeons to assist in nonvascular operations and rapidly respond to urgent and emergent needs for intervention. This study aims to evaluate VS secondary operative assistance and intraoperative consultations METHODS: Retrospective review of all operative interventions with a vascular surgeon as secondary surgeon between January 1, 2011 and January 31, 2020 at a single institution. Any cases with VS as primary service were excluded. Patient demographics, operative variables, and in-hospital outcomes were evaluated. RESULTS: Four hundred thirty-seven patients requiring interventions necessitating VS assistance were identified, this included elective, urgent, and emergent operative cases. One hundred thirty-one cases were urgent or emergent and 306 were elective. The median age was 58.0 years (IQR: 40-68.0). Most patients were male (237, 54.2%), White (298, 68.2%), and average BMI was 29.2 +/- 8.5 with ASA ≥4 (143, 32.7%). One hundred seventy (38.9%) cases involved intraoperative consultations, whereas, 267 (61.1%) provided advance notice of need for secondary assistance. The most common services requesting consultations were spine surgery (both orthopedic and neurosurgery) (83, 19%), cardiothoracic surgery (82, 18.8%), and surgical oncology (42, 9.6%). Vascular interventions included revascularization (108, 4.7%), hemorrhage control (94, 21.5%), and exposure (131, 30%). In-hospital mortality was 12.1%. CONCLUSIONS: With the armamentarium of open, endovascular, and hybrid interventions, vascular surgeons are prepared to respond and intervene in nonvascular cases in the event of unexpected vascular compromise, iatrogenic injury, or challenging exposure, as well as assist in planned elective operations. This study reinforces the role of VS in an institution's ability to offer safe and prompt surgical care.

Modern mortality risk stratification scores accurately and equally predict real-world postoperative mortality after ruptured abdominal aortic aneurysm.

OBJECTIVE: It is often unclear which patients presenting with a ruptured abdominal aortic aneurysm (rAAA) are likely to survive after surgery. The Harborview Medical Center (HMC), Dutch Aneurysm Score (DAS), and Vascular Study Group of New England (VSGNE) risk scores have been recent attempts at predicting mortality in this setting. We compared the prognostic value of these scoring systems for patients at our institution with rAAA. METHODS: A retrospective chart review was performed for all patients who received surgery at our institution for rAAA between January 1, 2011, and November 27, 2019. The χ2, Fisher's exact, and t-tests were used to screen preoperative variables against in-hospital mortality. HMC, DAS, and VSGNE scores were calculated for each patient and tested against in-hospital mortality. Logistic regression and receiver operating characteristic curves were used to assess performance of each scoring system. RESULTS: Sixty-four patients were identified during the study period. Fifteen patients were excluded because 4 patients chose comfort care and an additional 11 patients were missing key variables. The final cohort for analysis included 49 patients who underwent surgery, including 33 patients receiving endovascular repair and 16 patients receiving open repair. The in-hospital mortality was 37% (24% for endovascular repair vs 63% for open repair). Individual variables associated with in-hospital mortality were lowest preoperative systolic blood pressure (P = .036), creatinine greater than 2.0 mg/dL (P = .020), first recorded intraoperative pH (P = .007), and use of suprarenal aortic control (P = .025), and preoperative cardiac arrest approached significance (P = .051). Plots of the HMC and VSGNE scores vs in-hospital mortality rate produced linear relationships (R2 = 0.97 and R2 = 0.93, respectively), in which a higher score was associated with a greater likelihood of mortality. On logistic regression analysis using HMC score components, creatinine greater than 2.0 mg/dL produced a significant association with in-hospital mortality (odds ratio, 12.3; 95% confidence interval [CI], 1.1-131.7). Similar analysis using VSGNE components produced a significant association between suprarenal aortic control and in-hospital mortality (odds ratio, 5.5; 95% CI, 1.2-25.5). receiver operating characteristic curves produced an area under the curve of 0.74 (95% CI, 0.60-0.88), 0.73 (95% CI, 0.58-0.87), and 0.67 (95% CI, 0.51-0.83) for the HMC, VSGNE, and DAS, respectively. CONCLUSIONS: The HMC, VSGNE, and DAS scores performed similarly and adequately predicted in-hospital mortality after rAAA. The HMC score holds the added benefit of using preoperative variables, setting it apart as a valid prognostic indicator in the preoperative setting.

Angioleiomyoma (Vascular Leiomyoma) Presenting as a Pseudoaneurysm of the Tibialis Posterior Artery.

Reported here is the case of a 55-year-old woman presenting to a podiatry clinic with a chief complaint of left heel and ankle pain, who ultimately underwent operative excision of an angioleiomyoma adjacent to the tibialis posterior artery at the level of the medial malleolus. Accompanying this case are images from three modalities through which the defining characteristics of an angioleiomyoma can be appreciated. This case advocates for the inclusion of angioleiomyoma in the preoperative differential diagnosis of a mass presenting as a pseudoaneurysm in the lower extremity, particularly among women in the fourth to sixth decades of life.

Fin healing and regeneration in sturgeon.

Pectoral fin healing in fin spines and rays were examined in juvenile Atlantic sturgeon Acipenser oxyrinchus oxyrinchus following three different sampling techniques (n = 8-9 fish per treatment): entire leading fin spine removed, a 1-2 cm portion removed near the point of articulation, or a 1-2 cm portion removed from a secondary fin ray. Also, to determine whether antibiotic treatment influences healing, an additional group of fish (n = 8) was not given an injection of an oxytetracycline (OTC)-based antibiotic following removal of the entire leading fin spine. Following fin sampling, fish from different treatments were mixed equally between three large (4,000 I) recirculating systems and fin-ray healing and mortality were monitored over a 12 month period. To assess healing, blood samples were collected at 4 months to measure immune system responses, radiographs were taken at 4, 8 and 12 months to assess the degree of calcification in regions of damaged fins and fins were analyzed histologically at 12 months. Fish grew from a mean weight of 1.8 to 3.2 kg during the experiment and survival was near 100% in all treatments, with only one fish dying of unknown causes. Leukocyte counts, an indication of health status and survival were similar among treatments and in groups with or without antibiotic injection. Radiographs revealed mineralization took longer in fish with the entire leading fin spine removed and was the slowest near the point of articulation, presumably due to the greater structural support for the pectoral fin at this location. Histological sampling indicated spines and rays had similar healing patterns. Following injury, an orderly matrix of collagen bundles and many evenly spaced scleroblasts were present, transitioning to Sharpey fibres, with concentric layers forming lamellar bone. Healing and mineralization were characterized as periosteal osteogenesis and included embedded osteocytes surrounded by an osteoid seam. Chondroid formation was apparent in a few fractures not associated with treatments. The duration of time for external wound healing and internal mineralization of spines and rays depended on the fin treatment, with the slowest healing observed in fish with the most tissue removed, the entire leading fin spine.

Differential abundance of muscle proteome in cultured channel catfish (Ictalurus punctatus) subjected to ante-mortem stressors and its impact on fillet quality.

The effects of environmental and handling stress during catfish (Ictalurus punctatus) aquaculture were evaluated to identify the biochemical alterations they induce in the muscle proteome and their impacts on fillet quality. Temperature (25°C and 33°C) and oxygen (~2.5mg/L [L] and >5mg/L [H]) were manipulated followed by sequential socking (S) and transport (T) stress to evaluate changes in quality when fish were subjected to handling (25-H-ST; temperature-oxygen-handling), oxygen stress (25-L-ST), temperature stress (33-H-ST) and severe stress (33-L-ST). Instrumental color and texture of fillets were evaluated, and muscle proteome profile was analyzed. Fillet redness, yellowness and chroma decreased, and hue angle increased in all treatments except temperature stress (33-H-ST). Alterations in texture compared to controls were observed when oxygen levels were held high. In general, changes in the abundance of structural proteins and those involved in protein regulation and energy metabolism were identified. Rearing under hypoxic conditions demonstrated a shift in metabolism to ketogenic pathways and a suppression of the stress-induced changes as the severity of the stress increased. Increased proteolytic activity observed through the down-regulation of various structural proteins could be responsible for the alterations in color and texture.

The Effects of Sequential Environmental and Harvest Stressors on the Sensory Characteristics of Cultured Channel Catfish (Ictalurus Punctatus) Fillets.

Stress during fish culture alters physiological homeostasis and affects fillet quality. Maintenance of high-quality seafood is important to ensure the production of a marketable product. This study assessed how sequential stressors affect the sensory and quality characteristics of catfish (Ictalurus punctatus) fillets. Three stress trials were conducted where temperature (25 or 33 °C) and dissolved oxygen (DO, approximately 2.5 or >5 mg/L) were manipulated followed by socking and transport stress. After each stage of harvest (environmental stress, socking, and transport), fillet yield, consumer acceptability, descriptive evaluation, cook loss, tenderness, and pH were evaluated. Fillet yield decreased with increasing severity of environmental stress. Fillets from the severe stress treatment (33 °C, approximately 2.5 mg/L) received the highest acceptability scores (P < 0.05). Control fillets (25 °C, >5 mg/L) were the least acceptable (P < 0.05). Increased intensity of less favorable flavor attributes commonly associated with catfish resulted in the differences in acceptability among treatments. As fish progressed through the harvest event, cook loss decreased, tenderness increased, and pH increased, indicating that stress induced textural changes. The data suggest that although environmental stress results in slight changes in flavor attributes, its effects on acceptability are minor with fillets from all treatments still liked (>6 on a 9 point scale). Socking and transport were identified to positively affect textural characteristics of catfish fillets. Although the effects observed were not likely to negatively impact consumer acceptance, a strict management plan should be followed to maintain consistency in the product and avoid changes in stressors that might alter quality more drastically.