Current practice of cyanoacrylate endovenous ablation: American vein and lymphatic society position statement.

BACKGROUND: Cyanoacrylate endovenous ablation and closure of incompetent saphenous veins have become increasingly utilized since its approval for use in the United States in 2015. This increase in usage necessitates a societal update to guide treatment and ensure optimal and consistent patient outcomes. METHOD: The American Vein and Lymphatic Society convened an expert panel to write an updated Position Statement with explanations and recommendations for the appropriate use of cyanoacrylate endovenous ablation for patients with venous insufficiency. RESULT: A Position Statement was produced by the expert panel with recommendations for appropriate use, treatment technique, outcomes review, and potential adverse events. Their recommendations were reviewed, edited, and approved by the Guidelines Committee of the Society. CONCLUSION: This societal Position Statement provides a useful document for reference for physicians and venous specialists to assist in the appropriate use of cyanoacrylate endovenous ablation in the treatment of patients with venous insufficiency.

P2Y12 inhibitor monotherapy is associated with superior outcomes as compared with aspirin monotherapy in chronic limb-threatening ischemia.

OBJECTIVE: Antiplatelet therapy is recommended in patients with peripheral arterial disease to reduce cardiovascular risk and improve outcomes. However, issues including the drug of choice and use of dual antiplatelet therapy (DAPT) vs monotherapy remain unclear. This study aims to compare the impact of aspirin (ASA) monotherapy, P2Y12 monotherapy, and DAPT on limb salvage (LS), amputation-free survival (AFS), and overall survival (OS) in patients undergoing lower extremity peripheral endovascular intervention (PVI) for chronic limb-threatening ischemia (CLTI). METHODS: The Vascular Quality Initiative PVI registry was used to identify index procedures completed for CLTI between March 1, 2010 and September 30, 2017. Patients were categorized by antiplatelet use at the time of last follow-up. Patients not on antiplatelet therapy were compared with ASA, P2Y12 monotherapy, and DAPT. Propensity score-matched samples were created for direct ASA vs P2Y12 and P2Y12 vs DAPT comparisons; veracity was confirmed by χ2 and Hosmer-Lemeshow tests. Kaplan-Meier and Cox regression were performed for OS, AFS, and LS. RESULTS: A total of 12,433 index PVI were completed for CLTI in 11,503 subjects in the pre-matched sample. Antiplatelet use at follow-up was: 12% none, 31% ASA, 14% P2Y12, and 43% DAPT. Median follow-up was 1389 days. P2Y12 monotherapy was associated with improved outcomes as compared with ASA monotherapy, OS (87.8% vs 85.5%l P = .026; Cox hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.68-0.98; P = .03), AFS (79.6% vs 74.8%; P < .001; Cox HR, 0.75; 95% CI, 0.65-0.86; P < .001) and LS (89.5% vs 86.8%; P = .013; Cox HR, 0.74; 95% CI, 0.60-0.91; P = .004). P2Y12 monotherapy and DAPT had comparable OS (87.8% vs 88.9%; P = .62; Cox HR, 0.94; 95% CI, 0.77-1.14; P = .50), AFS (79.6% vs 81.5%; P = .33; Cox HR, 0.92; 95% CI, 0.78-1.07; P = .28), and LS (91.7% vs 89.4; P = .03; Cox HR, 0.80; 95% CI, 0.64-1.00; P = .06). CONCLUSIONS: P2Y12 monotherapy was associated with superior OS, AFS, and LS as compared with ASA monotherapy, and comparable OS, LS, and AFS with DAPT in patients undergoing PVI for CLTI. P2Y12 monotherapy may be considered over ASA monotherapy and DAPT in patients with CLTI, especially in patients with high bleeding risk.

National survey of vascular surgery residents and fellows on radiation exposure and safety practices.

OBJECTIVE: The objective of the present study was to evaluate radiation safety practices, radiation training, and radiation exposure among senior vascular residents and fellows in Accreditation Council for Graduate Medical Education-accredited programs across the United States. METHODS: Anonymous surveys were sent to all Accreditation Council for Graduate Medical Education program directors to be distributed to postgraduate year 4 to 7 vascular trainees for completion. The survey questions focused on program type (single vs multiple hospital site), familiarity with their radiation officer, formal radiation training, frequency of radiation feedback, use of safety equipment, and adherence to as low as reasonably achievable principles. RESULTS: A total of 95 trainees responded (27% response rate). Of the 95 trainees, 49 (51.6%) had reported they had never met their radiation safety officer, 74 (77.9%) reported they had received formal radiation safety education, 50 (53%) reported receiving feedback regarding their monthly radiation exposure, and 24 (25%) reported never having received such feedback. All the findings were more common among the multiple hospital site program respondents. CONCLUSIONS: It should be of significant concern that such a high number of trainees have been exceeding radiation exposure limits. Programs should strive to reduce radiation exposure through formal training, provision of safety equipment, modeling by attendings of adherence to as low as reasonably achievable principles, and timely feedback on radiation exposure.

Ruptured abdominal aortic aneurysm in an 11-year-old with multiple peripheral artery aneurysms.

Pediatric abdominal aortic aneurysms (AAAs) are rarely encountered in clinical practice. The combination of a pediatric AAA in a patient with multiple peripheral artery aneurysms is even more rare. We report the management of an 11-year-old boy who presented with a ruptured AAA who also had multiple peripheral arterial aneurysms. Infectious, genetic, and inflammatory workup was negative, classifying this aneurysm as congenital.

Successful treatment of a ruptured profunda femoris artery aneurysm in association with fibromuscular dysplasia.

Fibromuscular dysplasia is rarely reported in the infra-inguinal arteries. We report a case of an 86-year-old woman who presented with a ruptured profunda femoris artery aneurysm who was found to have angiographic findings of fibromuscular dysplasia in the bilateral deep femoral arteries and bilateral renal arteries. The rupture was treated successfully with a balloon-expandable covered stent.

Dermabond and Tegaderm: A Better Surgical Incision Dressing.

Surgical site infections (SSIs) are a common source of morbidity with vascular surgery incisions, especially in the groin. Single institution case series have widely varying, but high incidences of groin wound infection after open lower extremity revascularization. Optimally, a dressing that did not require changes, had low cost, and was water resistant would be optimal in these patients. We developed and validate a new dressing utilizing Dermabond (Ethibond™) and Tegaderm™ for vascular surgery incisions that could simplify and reduce postoperative SSIs. In this initial experience, we reviewed 94 patients. Of the 94 patients, 0 had signs of infection superficial or deep, dehiscence, or evidence of nonhealing. Gluing a Tegaderm to an incision using Dermabond is a novel and easy way to perform dressing that reduces wound infection, increases patient comfort, avoids dressing changes, and allows visualization of the wound.

Not all lightweight lead aprons and thyroid shields are alike.

OBJECTIVE: With the explosion of minimally invasive surgery, the use of fluoroscopy has significantly increased. Concurrently, there has been a demand for lighter weight aprons. The industry answered this call with the development of lightweight aprons. Our goal was to see whether lighter weight garments provide reduced protection. METHODS: Dry laboratory testing was performed in a standard X-ray room, using a standard fluoroscopy table and standard acrylic blocks. A commercial-grade pressurized ion chamber survey meter (Ludlum Model 9DP; Ludlum Measurements, Inc, Sweetwater, Tex) was used to detect gamma rays and X-rays above 25 keV. Nonlead aprons from several manufacturers were tested for scatter radiation penetration above the table at a fixed distance (3 feet) and compared with two standard 0.5-mm lead aprons of different manufacturers. RESULTS: Scatter measurements were made at 60 kVp and 70 kVp for pure lead (0.5 mm), mixed, and nonlead protective garments. Scatter penetration for the nonlead blends and barium aprons was 292% and 258%, respectively, at 60 kVp compared with the pure lead apron. At the higher beam quality of 70 kVp, the scatter penetration was 214% and 233% for the blend and barium aprons, respectively, compared with the pure lead apron. Our measurements demonstrate a noticeable difference in scatter reduction between pure lead and nonlead garments. Pure barium aprons and nonlead aprons from certain companies demonstrated scatter penetration that is inconsistent with the 0.5 mm of lead equivalence as claimed on the label. In addition, there was an incidental finding of a handful of lightweight aprons with significant tears along the seams, leaving large gaps in protection. Our study also demonstrates that several companies rate their lightweight garments as 0.5 mm lead equivalent, when actually only a small area on the chest and abdomen where the garment overlapped was 0.5 mm, leaving the rest of the garment with half the protection at 0.25 mm. CONCLUSIONS: Our reliance on protective lead garments to shield us from the biologic effects of radiation exposure and the inferiority of some lightweight garments necessitate a streamlining of the testing methods and transparency in data reporting by manufacturers.

Surgical residents' interpretation of diagnostic radiologic imaging in the traumatically injured patient.

BACKGROUND: Senior surgical residents are of paramount importance in directing further therapeutic modalities based on their interpretation of critical diagnostic imaging. We propose that senior surgical residents are proficient with interpreting radiologic imaging studies in the trauma patient. METHODS: A prospective cohort study was performed comparing surgery resident interpretations of computed tomography (CT) scans of the head, maxillofacial bones, spine (cervical, thoracic, lumbar), chest, abdomen, pelvis, and chest X-rays versus final radiologists' reports at a Level II trauma center from September 2014 to May 2015. A Cohen κ coefficient and a statistical analysis of variance testing were used to make multiple comparisons of the data. RESULTS: There were 951 trauma alerts activated in the period stated. Of these, 860 met our age inclusion criteria (age, > 18 years). There were 204 images included with an overall accuracy of 81.3%. Residents were more than 70% successful interpreting seven of nine categories. They achieved an accuracy of 84.6%, 62.5%, and 75% in the cervical, thoracic, and lumbar spine categories, respectively. Forty-one of 50 CT scans of the head were interpreted correctly. Maxillofacial CT scans proved to be the weakest category, with only 50% read accurately. In regard to CT scans of the abdomen and pelvis, 80% proficiency was achieved. Abdominal x-rays were read correctly in all instances and chest x-rays 83.3%. On κ analysis, there was an overall moderate agreement between the two groups with K = 0.449, and an overall p less than 0.0005 (Table 1). A perfect agreement existed with abdominal x-rays. CONCLUSION: Senior surgical residents are capable of interpreting critical images obtained in the trauma setting. When discordance existed with attending radiologists' interpretation, it did not change the clinical outcome or result in any critically missed findings. LEVEL OF EVIDENCE: Therapeutic/Care Management study, Level IV.

Modified Staple Aneurysmorrhaphy for Treating Arteriovenous Fistula-Related Venous Aneurysms.

Autogenous arteriovenous fistulas (AVFs) are the preferred access for hemodialysis. AVF occasionally develop venous aneurysms, and we report a modified staple aneurysmorrhaphy technique for treatment. Briefly, the lateral wall of the venous aneurysm is dissected and a longitudinal staple resection performed. Adjunct procedures include inflow banding and outflow venous angioplasty with possible stenting. In this initial experience, 20 aneurysms were resected in 17 patients. The average AVF age at time of repair was 5.8 years. Sixteen of 17 AVF remained patent, and there were no recurrences or mortalities. One patient had a loss of thrill intraoperatively after stapling and was successfully treated with cephalic vein embolectomy. All AVF were cannulated for dialysis immediately following the procedure. The average follow-up period was 12.5 months. Given the benefits of uninterrupted fistula use and avoidance of temporary catheter placement, this technique is a promising therapy for arteriovenous fistula related venous aneurysms.

Appendicitis Presenting Concurrently with Cecal Arteriovenous Malformation in a Child.

Acute appendicitis is a commonly diagnosed surgical problem in the pediatric population. Arterio-venous malformations (AVM) of the colonic tract are rarely reported in the pediatric literature. A 13-year old boy who presented with acute appendicitis with concurrent cecal AVM is reported in whom appendectomy was done. Later on radiological investigations AVM was confirmed.

Production of membrane proteins for NMR studies using the condensed single protein (cSPP) production system.

In the Single Protein Production (SPP) method, all E. coli cellular mRNAs are eliminated by the induction of MazF, an ACA-specific mRNA interferase. When an mRNA for a membrane protein, engineered to have no ACA sequences without altering its amino acid sequence, is induced in the MazF-induced cells, E. coli is converted into a bioreactor producing only the targeted membrane protein. Here we demonstrate that three prokaryotic inner membrane proteins, two prokaryotic outer membrane proteins, and one human virus membrane protein can be produced at very high levels, and assembled in appropriate membrane fractions. The condensed SPP (cSPP) system was used to selectively produce isotope-enriched membrane proteins for NMR studies in up to 150-fold condensed culture without affecting protein yields, providing more than 99% cost saving for isotopes. As a novel application of the cSPP system for studies of membrane proteins prior to purification we also demonstrate, for the first time, fast detergent screening by microcoil NMR and well-resolved NMR spectra of several targeted integral membrane proteins obtained without purification.