Treatment of a contained rupture of a splenic artery pseudoaneurysm with direct thrombin injection.

Splenic artery pseudoaneurysm is a rare and potentially fatal condition. In the present report, we describe the case of a 50-year-old woman with chronic pancreatitis who presented with worsening abdominal pain. Computed tomography demonstrated a 3.5-cm splenic artery pseudoaneurysm of the mid-splenic artery. The patient underwent attempted endovascular repair of the pseudoaneurysm that was unsuccessful. Open conversion revealed an inaccessible splenic artery due to chronic pancreatitis that resulted in dense retroperitoneal fibrosis, and repair was achieved via direct thrombin injection under ultrasound guidance of the pseudoaneurysm and splenectomy. The patient recovered well, and computed tomography at 3 days postoperatively revealed complete thrombosis of the pseudoaneurysm.

Comparison of direct oral anticoagulants and warfarin in chronic limb-threatening ischemia.

OBJECTIVE: The role of direct oral anticoagulants (DOACs) in chronic limb-threatening ischemia after revascularization is unknown. Current evidence-based guidelines do not provide clear guidance on the role of anticoagulation or the selection of anticoagulant. Current practice is highly varied and based on provider and patient preference. The purpose of this study was to measure the impact of different anticoagulants on the incidence of major adverse limb events (MALEs) after revascularization for chronic limb-threatening ischemia, major adverse cardiovascular events (MACEs), all-cause mortality, and hospitalization for major bleeding events. METHODS: This was a single-center, observational, retrospective cohort study. Subjects were eligible if they were 18 years or older; underwent endovascular or open revascularization for chronic limb-threatening ischemia, rest pain, or tissue loss; and were subsequently prescribed apixaban, rivaroxaban, or warfarin. The primary end point was the incidence of MALEs, including above-ankle amputation or major index-limb reintervention, within 1 year of index event. Secondary end points included the rate of all-cause mortality, MACEs, and incidence of International Society on Thrombosis and Haemostasis (ISTH) major bleeding. RESULTS: From January 1, 2017, to September 20, 2022, 141 patients met the inclusion and exclusion criteria and were reviewed. The median age was 67 years, with 92 patients prescribed apixaban or rivaroxaban and 49 patients prescribed warfarin. Of these, 42 patients were prescribed triple antithrombotic therapy, 88 dual antithrombotic therapy, and 13 anticoagulant monotherapy. The primary outcome of 1-year MALEs occurred in 36.7% of the warfarin group and 33.7% of the DOAC group (relative risk [RR], 1.09; 95% CI, 0.53-2.25; P = .72). Secondary outcomes of 1-year MACEs (10.2% vs 4.3%; RR, 2.35; 95% CI, 0.60-9.18; P = .18) and 1-year all-cause mortality (26.5% vs 16.3%; RR, 1.63; 95% CI, 0.70-3.78; P = .15) did not differ between the groups. The secondary safety outcome of 1-year ISTH major bleeding occurred in 16.3% of the warfarin group and 4.3% of the DOAC group (RR, 3.76; 95% CI, 1.07-13.19; P = .015). CONCLUSIONS: In patients with chronic limb-threatening ischemia who were revascularized and prescribed anticoagulation with apixaban, rivaroxaban, or warfarin on discharge, no difference in MALEs, MACEs, or all-cause mortality was found. However, 1-year admissions for ISTH major bleeding were significantly higher among patients prescribed warfarin. A randomized trial may confirm these findings.

Endovascular repair of blunt extremity arterial injury: case report.

OBJECTIVE: Surgical revascularization is the standard treatment of complex blunt traumatic extremity vascular injuries. Limb salvage may be improved with minimally invasive endovascular therapies because of the ability to perform diagnostic and therapeutic intervention simultaneously. Two cases of acute limb-threatening arterial injuries successfully treated with percutaneous endovascular therapy are reported. RESULTS: A skier suffered hemodynamic instability after shoulder reduction. An axillary arterial injury was suspected and confirmed with angiography. A covered stent successfully controlled the hemorrhage. A morbidly obese female sustained anterior dislocation of her left knee 7 years previously requiring repair. She developed recurrent knee dislocation with acute leg ischemia. Emergent fixation was performed followed by percutaneous angiography. Short segment thrombosis of the popliteal was noted. Wire recanalization of the thrombosed artery and stent placement restored 3-vessel runoff. CONCLUSION: Endovascular therapy can offer faster, easier access to the extremity vascular injury facilitating revascularization and avoiding long incisions and dissections.

Patients with depression are at increased risk for secondary cardiovascular events after lower extremity revascularization.

BACKGROUND: For patients with peripheral arterial disease (PAD), depression is associated with worse patency and recurrent symptoms in the treated leg, but its association with death or cardiovascular events in other vascular beds is unknown. OBJECTIVE: To assess the association between depression and mortality or cardiovascular events outside the affected leg after PAD revascularization. DESIGN: Retrospective cohort study. SUBJECTS: Two hundred fifty-seven consecutive patients undergoing lower extremity revascularization for symptomatic PAD at a single institution between January 2000 and May 2005 were included in this study. By protocol, patients were previously screened for depression and diagnosed by the primary care provider. MEASUREMENTS: The outcomes evaluated included a composite of death or major adverse cardiovascular events (MACE; coronary heart disease, contralateral PAD, or cerebrovascular event) as well as major outcome categories of death, coronary heart disease, contralateral PAD, or cerebrovascular events. RESULTS: At revascularization, 35.0% patients had been diagnosed with depression. Those with depression were significantly younger and more likely to use tobacco. By life-table analysis, patients with depression had significantly increased risk for death/MACE, coronary heart disease, and contralateral PAD events, but not cerebrovascular events or death. By multivariate analysis, patients with depression were at significantly increased risk for death/MACE (hazard ratio [HR] = 2.05; p < .0001), contralateral PAD (HR = 2.20; p = .009), and coronary heart disease events (HR = 2.31; p = .005) but not cerebrovascular events or death. CONCLUSIONS: Depression is common among patients undergoing revascularization for symptomatic PAD. After intervention, patients with depression are at significantly increased risk for coronary heart disease events and progression of contralateral PAD. Prospective analysis is required to confirm these results.

Is F 18 fluorodeoxyglucose positron emission tomography too sensitive for the diagnosis of vascular endograft infection?

We report a case of a false positive fluorodeoxyglucose positron emission tomography (FDG-PET) scan in a patient who presented with abdominal pain, and gastrointestinal bleeding accompanied by elevation of inflammatory markers, seven weeks after a proximal type I endoleak repair with a cuff extension. Aortoenteric fistula and endograft infection was ruled out by laparotomy. FDG-PET image may have a role in diagnosis of infection, but false positive results are possible and caution is necessary if other data are non-confirmatory.

Depression is associated with worse patency and recurrent leg symptoms after lower extremity revascularization.

OBJECTIVES: Depression is associated with worse outcomes after coronary artery bypass surgery, but its association with the results after revascularization for symptomatic peripheral arterial disease (PAD) is unknown. This study assessed the association between depression and patency, recurrent symptoms, and limb salvage after revascularization for symptomatic PAD. METHODS: Electronic medical records were retrospectively reviewed for all patients with symptomatic PAD who underwent intervention (open, endovascular, or combined) between January 2000 and October 2004. All patients were previously screened for depression, and treatment was initiated as indicated by the primary care physician or psychiatrist. Demographic data and outcomes were recorded using published guidelines. Outcomes of interest included primary patency of the revascularization (bypass graft or angioplasty/stented artery), assisted primary patency, secondary patency, recurrent symptomatic ipsilateral PAD, and major amputation. Follow-up was available for all patients (mean, 23.4 +/- 14.1 months). RESULTS: Board-certified vascular surgeons performed all interventions. At the time of intervention, 78 (36.1%) of 216 patients had been diagnosed with depression. Compared with those without depression, depressed patients were younger (64.4 vs 69.1 years; P = .001), currently using tobacco (74.4% vs 51.4%; P = .001), and less likely to have hypertension (79.5% vs 89.9%; P = .03). No other significant differences were noted for cardiovascular risk factors or prevalent comorbidities. During follow-up, 50 patients (23.1%) had failing or failed revascularizations, and 24 (11%) had amputations. Those with depression at the time of the PAD intervention, compared at 24 months with patients without depression, had significantly worse primary patency (58.2% vs 79.8%; P = .02), primary assisted patency (59.5% vs 81.5%; P = .01), and secondary patency (60.2% vs 82.2%; P = .007). They also had a significantly increased risk of recurrent symptomatic PAD (33.7% vs 20.8%; P = .03) but not major amputation (13.8% vs 10.4%; P = .73). By multivariate analysis, patients with depression were at significantly increased risk for recurrent symptomatic PAD (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.03 to 3.02; P = .04) and failure of revascularization (HR, 2.18; 95% CI, 1.22 to 3.88; P < .01), but not major amputation. CONCLUSIONS: Depression is common among patients undergoing intervention for symptomatic PAD. After intervention, patients with depression have worse outcomes for the affected leg. Prospective analysis is required to confirm these results.

The new training paradigms and the unfilled match positions of 2004: will history repeat itself?

OBJECTIVE: The new millennium has seen an increase in vascular residency vacancies. The American Board of Vascular Surgery recently proposed new training paradigms, but their impact on recruitment remains unknown. We surveyed vascular fellows regarding factors and timing of career decisions to determine an optimal strategy for recruitment. METHODS: Surveys were sent electronically to vascular residents for completion. Data were analyzed using SPSS software. Additional data were obtained from the National Resident Matching Program. RESULTS: Of the 90 fellows that responded, 84% committed to vascular surgery during residency. Of these, 18% decided during postgraduate year 1, 54% by year 2, 84% by year three, and 95% by year 4. Sixteen percent of all trainees decided in medical school. Seventy-three percent of residents performed a minimum of 20 to 50 cases before reaching a decision. Among the group deciding between years 2 to 4 of residency, there was a significant difference in the number of vascular rotations before career commitment (P = .0001). In the 2004 Match, 21% of vascular residency positions were unfilled, up from 12% in 2003, 9% in 2002, and 4% in 2001. CONCLUSIONS: Leaders in the field of vascular surgery have proposed focused training through the new paradigms. The incline in unmatched vascular residency positions over the past 4 years highlights the importance of a strategic plan to optimize recruitment. Few current trainees decided early in training about career choice, and volume appears critical to the decision process. Utilizing the current matching system (an 18-month process) and without any proactive change in recruitment, an integrated program after medical school would be reasonable for only 16% of applicants, or the 3+3 option for 54% of residents. For the new paradigms to be successful and to prevent more unfilled positions, increased medical student integration into vascular rotations and early active exposure to endovascular and open procedures during general surgical training will be necessary across the country.

Intraoperative needle localization during neck reexploration.

BACKGROUND: Recurrent cervical adenopathy can be difficult to identify intraoperatively during a neck reexploration. Although local preoperative imaging techniques are available, these are not useful in the operative theater. METHODS: We introduce an intraoperative technique of ultrasound-guided needle localization to identify and guide the resection of suspicious cervical lymphadenopathy. CONCLUSIONS: This intraoperative approach to localizing the suspicious lymph node under ultrasound-guided needle localization makes surgical extirpation of lymph node metastasis easy.

Anorexia in space and possible etiologies: an overview.

Space travelers experience a flight duration-dependent loss in weight and body mass while in a microgravity environment, despite the absence of increased energy expenditure. Anorexia in space can lead to in-flight caloric deficits of 1330 kcal per 70 kg astronaut per day in the presence of abundant food and has a critical effect on endurance and performance. Microgravity, alterations in the light-and-dark cycle, and exposure to radiation energy are the environmental stresses believed to influence appetite, food intake, and gastrointestinal function during space flight. Review of data and recent studies in rodents during microgravity showed a release of stress hormones and complex neuroendocrine and physiologic changes involving the modulation of hypothalamic activity, food intake-related hormones, and cytokines. The shift of dietary preference to carbohydrates, which occurs in astronauts, denotes a stress physiologic response and augments free-plasma tryptophan concentration in the brain, the precursor of the potent anorexic agent, serotonin (5-HT). Alterations of other neuroendocrine mediators, including corticotropin-releasing factor (CRF), coordinate the stress response, leading to a decrease in appetite and gastrointestinal function. Our laboratories used the antiorthostatic tail-suspension technique to successfully mimic some of these anorexia-related stress responses and to directly demonstrate the role of 5-HT in microgravity-related decreased food intake and delayed gastric emptying. Further rodent studies from our laboratories demonstrated the adverse effect of altered dark-and-light cycles on food intake and body weight. Radiation energy, through its documented effects on appetite, probably contributes to the decreased caloric intake by astronauts. Modulation of hypothalamic activity, 5-HT, and CRF play a critical role in anorexia related to microgravity and circadian rhythm alterations. Specific gene knockout mice (e.g., 5-HT or CRF and their respective receptors) may prove fruitful in defining the pathways by which anorexia in space occurs. An understanding of these pathophysiologic problems as they relate to appetite, food intake, gastric emptying and gastrointestinal function, sufficiently to derive successful practical solutions, may lead to a quantitative enhancement of physiologic well-being and performance status, serving as a productive countermeasure in space.