A Brief Historical Perspective on Pulmonary Embolism.

Pulmonary embolism is a major cause of mortality worldwide. In this historical perspective, we aim to provide an overview of the rich medical history surrounding pulmonary embolism. We highlight Virchow's first steps toward understanding the pathophysiology in the 1800s. We see how those insights inspired early attempts at intervention such as surgical pulmonary embolectomy and caval ligation. Those early interventions were refined and ultimately led to the development of inferior vena cava filters, the earliest clinical applications of anticoagulation, and even apparently disparate medical advances such as the successful development of cardiopulmonary bypass. We also see how the diagnosis of pulmonary embolism has evolved from rudimentary monitoring of vitals and symptoms to the development of evermore sophisticated tests such as contrast tomography angiography and echocardiography. Finally, we discuss current approaches to diagnosis, classification, and myriad treatments including anticoagulation, thrombolysis, catheter-directed interventions, surgical embolectomy, and extracorporeal membrane oxygenation guided by Pulmonary Embolism Response Teams.

Popliteal artery aneurysm repair-A single center experience.

BACKGROUND: Popliteal artery aneurysms (PAAs) are relatively rare but are one of the most common peripheral arterial aneurysms. Open popliteal artery aneurysm repair (OPAR) has been the standard, but technological advancements have made endovascular popliteal artery aneurysm repair (EPAR) a promising alternative. The aim of this study is to compare EPAR and OPAR efficacy and outcomes over a 10-year period. METHODS: This study retrospectively reviewed 72 patient charts who were diagnosed with PAA or popliteal artery pseudoaneurysm and underwent EPAR or OPAR from 1 January 2010 to 31 December 2019. Endovascular popliteal artery aneurysm repair was used in 37 cases and OPAR in 35 cases. RESULTS: Graft patency <30 days postoperative was 100% in both EPAR and OPAR groups. Graft patency >90 days postoperative was 72.73% in the EPAR group and 82.35% in the OPAR group (p = 0.477). Graft patency >2 years postoperative was 81.25% in the EPAR group and 86.67% in the OPAR group (p = 0.682). Freedom from reoperation 30-day postoperative was 78.38% in the EPAR group and 80% in the OPAR group (p = 0.865). Freedom from amputation 30-day postoperative was 91.43% in the EPAR group and 94.29% in the OPAR group (p = 0.263). The 30-day survival rate was 94.59% in the EPAR group and 100% in the OPAR group. CONCLUSIONS: Endovascular repair represents a promising alternative for PAA repair. Our results demonstrate that EPAR has similar outcomes for asymptomatic, acutely symptomatic, and chronic symptomatic patients. Technological advancements of stent properties and refinement of surgical techniques may further improve endovascular techniques.

Diagnosis and Management of Aortic Valvular Disease in the Elderly.

Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations for prompt diagnosis and efficacious treatment. The current paradigm for aortic valve disease is based on surgical or interventional therapy. In this review, we discuss the approach to diagnosing aortic valvular disease and the different options for treatment based on the most recent evidence.

Managing Cardiovascular Risk Factors without Medications: What is the Evidence?

In this era of potent medications and interventional cardiovascular (CV) procedures, the importance of beginning with and including Therapeutic Lifestyle Changes (TLC) is frequently forgotten. A major goal of this review article is to show and emphasize that modification of CV risk with nonmedication approaches makes an essential contribution to CV risk reduction. Available information on TLC and modifiable CV risk factors was reviewed and assessed. Modifiable major CV risk factors include diabetes mellitus, hypertension, hyperlipidemia, tobacco abuse, obesity, stress, and a sedentary lifestyle. Age as a major CV risk factor is, of course, not susceptible to modification. A contribution to the control of CV risk factors can occur without the start of medications and there is proof of benefit for beginning with a non-pharmacological approach. TLC can benefit all of the major modifiable CV risk factors and there is good evidence for the additional benefit of supervised and group TLC. TLC includes physical activity, diet, and smoking cessation. Evidence for the benefits of TLC in reducing CV disease events is well established. However, medications must be added in those patients with higher CV risk to obtain maximum cholesterol reduction (lower is better for the low-density lipoprotein cholesterol) and good blood pressure control. The benefit of TLC is frequently forgotten in this era of potent medications and invasive procedures. The benefits of diet and physical activity are emphasized with supporting data. Many motivated patients can prolong their lives significantly by dedication to TLC. Therapeutic Lifestyle Change (TLC) especially encompasses increased physical activity, a healthy diet, and smoking cessation. There is extensive proof for the benefit of TLC in contributing to cardiovascular (CV) disease prevention. CV diseases have strong metabolic and inflammatory components, both of which can be improved by TLC.

Bitter Melon (Momordica charantia L.) Supplementation Has No Effect on Hypercholesterolemia and Atherosclerosis in Mice.

Bitter melon (BM; Momordica charantia L.) has been reported to ameliorate diet-induced obesity and dyslipidemia. However, the effects of BM on atherosclerosis have not been determined. This study investigated the effects of BM diet-induced atherosclerosis in LDL receptor-deficient mice. A total of 30 female mice (aged 6-8 wk) were fed a saturated fat-enriched diet. In group 1 (n = 10), mice were fed this diet alone, whereas mice in groups 2 and 3 (n = 10/group) were fed the diet supplemented with BM either 0.1% or 1% by weight. After 12 wk, body weight, plasma cholesterol, and atherosclerotic plaque areas were analyzed. No significant differences in body weight and plasma cholesterol concentrations were observed among the groups. Also, BM supplementation did not affect atherosclerosis development. In conclusion, dietary BM has no effect on plasma cholesterol concentration and atherogenesis in hypercholesterolemic mice.

Contemporary Surgical Management of Atrial Fibrillation.

Atrial fibrillation is a common arrhythmia which may cause symptoms that significantly impact quality of life and is associated with increased risk of stroke, heart failure, and sudden death. Over the past three decades many surgical techniques as well as catheter-bases procedures have been developed to treat atrial fibrillation. In this review we describe the indications, treatments, outcomes, surgical techniques, and technical advances reported in the literature.

Genetic Risk, Adherence to a Healthy Lifestyle, and Ischemic Heart Disease.

PURPOSE OF REVIEW: The purpose of this review is to investigate and discuss two aspects of coronary artery disease (CAD)-genetic risk and therapeutic lifestyle change (TLC)-both of which have key importance for patients and their care but which actually receive inadequate attention. RECENT FINDINGS: Genetic risk has generally been relegated to a broad association with the presence of one or more inherited cardiovascular (CV) risk factors such as hypercholesterolemia, family history of atherosclerosis, hypertension, and diabetes mellitus. However, the future of genetic risk is an understanding of specific genes, a genetic risk score, specific genetic loci known as selective nucleotide polymorphisms (SNPs), specific alleles, and microribonucleic acids (miRNAs). Healthy lifestyle is fashionably referred to as TLC and encompasses physical fitness, exercise, behavioral modification, diet, and stress reduction. In the past decade, aggressive treatment of cholesterol with statins has received the major emphasis for CV risk reduction. Genetics, of course, can only be modified by factors that influence epigenetics, and TLC could have an effect on genetics by this mechanism. On the other hand, each individual component of TLC has been shown to contribute to a reduction of CV risk. Although aggressive pharmaceutical approaches are now in vogue, whatever TLC can contribute, depending on the degree of individual patient adherence, should never be forgotten.

Extracorporeal membrane oxygenation as a rescue measure after thoracic surgery.

Background Extracorporeal membrane oxygenation is used for many different conditions including respiratory distress, cardiogenic shock, and trauma. In these patient groups, extracorporeal membrane oxygenation has been extensively studied. Recently, it has been used as a rescue measure in patients experiencing acute respiratory distress after thoracic surgery. The goal of our study was to examine the efficacy and cost-effectiveness of extracorporeal membrane oxygenation as a rescue measure after thoracic surgery at a single center. Methods We conducted a retrospective review of all patients who received extracorporeal membrane oxygenation after thoracic surgery at the University of Kentucky from January 9, 2012 to January 9, 2017. Eight patients were identified. Results The average time on extracorporeal membrane oxygenation was 9.125 days, and the average hospital stay was 65.125 days. Of the 8 patients placed on extracorporeal membrane oxygenation, 3 survived to discharge. Of the 3 patients who survived to discharge, 1 died within 6 months and 2 have been followed up for less than 4 months. The average total charge per patient was calculated to be $1,053,551, and the average charge per day was $16,177. The contribution margin was $109,200 per case. Conclusions Extracorporeal membrane oxygenation is a tool that saves lives in many different patient populations but it does not appear to be as effective in patients experiencing acute respiratory distress syndrome after thoracic surgery. Extracorporeal membrane oxygenation in this group also uses a tremendous amount of hospital resources.

Management Strategies for Noncardiac Surgery Following a Coronary Artery Event.

PURPOSE OF REVIEW: Coronary artery event includes acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery. Following such an event, risk of noncardiac surgery is increased. Of major concern is what can make this surgery safer? RECENT FINDINGS: High functional capacity improves cardiovascular (CV) risk; at least 4.0 metabolic equivalents (METs) on stress test are favorable. Risk scores can suggest need for further evaluation. Coronary angiography prior to surgery usually is not indicated since revascularization shows disappointing CV risk reduction results. Due to high association of peripheral arterial disease (PAD) with coronary artery disease (CAD), low ankle-brachial index (ABI) indicates increased CV risk. New perioperative beta blockade has shown disappointing benefit, but if ongoing should be continued. De novo perioperative beta blockade is for the highest CV risk patient undergoing noncardiac vascular surgery. Good evidence supports CV risk reduction from new or existing statin in the perioperative period, especially for the diabetic. Diabetics should also be on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) secondarily, during the perioperative period to decrease 30-day perioperative mortality. Optimal timing of elective noncardiac surgery following a coronary artery event appears to be 180 days with CV risk decreased by a statin and an ACEI or an ARB.

Outcomes of Carotid Endarterectomy with Primary Closure.

Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid artery stenosis, although the optimal surgical technique is debated. The literature suggests that patch angioplasty reduces complication risk, although primary closure shortens cross-clamp time and eliminates complications associated with grafts. The objective of this study was to assess the complication rate after CEA with primary closure. Retrospective review of 240 consecutive patients between 2002 and 2010. Of these patients, 70% returned for follow-up visits for at least 2 or more years. Primary closure was used in all patients. The average cross-clamp time was 18 minutes. Complications in the immediate postoperative period within 30 days were as follows: stroke (n = 3; 1.1%), transient ischemic attack (TIA; n = 4; 1.5%), myocardial infarction (MI; n = 3; 1.1%), and death (n = 1; 0.4%). Short-term follow-up revealed eight patients who were found to have significant restenosis (>80%) by carotid duplex imaging. Two to ten year postoperative complication rates were as follows: stroke (n = 7; 4.2%), TIA (n = 7; 4.2%), amaurosis fugax (n = 1; 0.6%), MI (n = 8; 4.8%), and death (n = 28; 17%). Mortality was due to stroke or heart attack (n = 2; 1.2%), cancer (n = 7; 4.2%), and unknown causes (n = 19; 11%). This study presents our experience with complications after primary closure after CEA. In our experience, CEA is a safe and effective surgical means of preventing stroke in the short term. Well-designed prospective studies are needed to confirm specific patient characteristics in which primary closure and patch angioplasty are indicated.

Video-Assisted Thoracoscopic versus Open Lobectomy: Costs and Outcomes.

OBJECTIVES: Video-assisted thoracoscopic (VATS) lobectomy is considered a promising surgical therapy for the diagnosis and treatment of non-small-cell lung carcinoma. The issue of whether VATS is superior to open thoracotomy remains controversial, however. We sought to determine whether the use of VATS lobectomy for diagnosing and treating non-small-cell lung carcinoma would improve patient outcomes at our institution. METHODS: A retrospective review of electronic and paper medical charts identified 109 consecutive operations for all patients undergoing thoracotomy or VATS lobectomy performed at the University of Kentucky Chandler Medical Center for fiscal years 2013 and 2014. Variables of interest included operative procedure (thoracotomy vs VATS) and operative findings (pathologic stage, operative time, postoperative length of stay [LOS], time spent in the intensive care unit, postoperative complications, direct cost). RESULTS: The demographic characteristics of the patients of both groups were similar in terms of sex (64.6% vs 44.3% male) and age (62.4 vs 61.6 years), but not stage, which was higher in the thoracotomy group. The overall operative procedure time (170.6 vs 196.3 minutes), postoperative LOS (5.7 vs 5.5 days), number of lymph nodes sampled (6.2 vs 7.0), and time spent in the intensive care unit (2.1 vs 2.4 days) did not vary between both groups. The average cost per procedure did not vary significantly-$14,003.61 compared with $15,588.11 for thoracotomy and VATS, respectively. CONCLUSIONS: In our study, the VATS group was associated with no reduction in postoperative LOS and a nonsignificant reduction in the amount of time spent in the intensive care unit. Postoperative perception of pain did not vary between either group. Pain perception did, however, correlate strongly with time from operation. Cost did not vary significantly between both groups, with VATS being equivalent to thoracotomy in terms of cost at our institution. In our experience, VATS is an effective, minimally invasive, and safe approach for the resection of lung nodules.

Cost analysis of iliac stenting performed in the operating room and the catheterization lab: A case-control study.

BACKGROUND: Iliac arterial stenting is performed both in the operating room (OR) and the catheterization lab (CL). To date, no analysis has compared resource utilization between these locations. METHODS: Consecutive patients (n = 105) treated at a single center were retrospectively analyzed. Patients included adults with chronic, symptomatic iliac artery stenosis with a minimum Rutherford classification (RC) of 3, treated with stents. Exclusion criteria were prior stenting, acute ischemia, or major concomitant procedures. Immediate and two-year outcomes were observed. Patient demographics, perioperative details, physician billings, and hospital costs were recorded. Multivariable regression was used to adjust costs by patient and perioperative cost drivers. RESULTS: Fifty-one procedures (49%) were performed in the OR and 54 (51%) in the CL. Mean age was 57, and 44% were female. Severe cases were more often performed in the OR (RC ≥ 4; 42% vs. 11%, P < 0.001) and were associated with increased total costs (P < 0.01). OR procedures more often utilized additional stents (stents ≥ 2; 61% vs. 46%, P = 0.214), thrombolysis (12% vs. 0%, P = 0.011), cut-down approach (8% vs. 0%, P = 0.052), and general anesthesia (80% vs. 0%, P < 0.001): these were all associated with increased costs (P < 0.05). After multivariable regression, location was not a predictor of procedure room or total costs but was associated with increased professional fees. Same-stay (5%) and post-discharge reintervention (33%) did not vary by location. CONCLUSIONS: The OR was associated with increased length of stay, more ICU admissions, and increased total costs. However, OR patients had more severe disease and therefore often required more aggressive intervention. After controlling for these differences, procedure venue per se was not associated with increased costs, but OR cases incurred increased professional fees due to dual-provider charges. Given the similar clinical results between venues, it seems reasonable to perform most stenting in the CL or utilize conscious sedation in the OR.

Antioxidants in the Practice of Medicine; What Should the Clinician Know?

Antioxidants offer protection against the damage potentially caused by free radicals, which usually involve an oxygen or nitrogen moiety, in living organisms. An antioxidant can be defined as a molecule that has the capability to inhibit the oxidation of another molecule, so, in other words, it is a reducing agent that is sufficiently stable to donate an electron to a circulating free radical and thereby result in its neutralization. Free radicals can be defined as any chemical species that has one or more mismatched electrons; these free radicals can cause a sequential reaction resulting in damage to multiple components of the organism, functioning either as an oxidant or a reductant by accepting or donating an electron, respectively. Oxidative stress can be defined as an imbalance between the production of free radicals and necessary antioxidant defenses. Therefore protection of the organism from these potentially damaging entities, when appropriate, is essential. Potential damage involves lipids, proteins, cell membranes, deoxyribonucleic acid (DNA), carbohydrates, and various enzymes, which can lead to cell death. Antioxidant protection from free radical-induced damage occurs via the donation of an electron with subsequent conversion of a free radical to a harmless chemical configuration that can no longer damage a cell and its components. Classes of antioxidants include, natural, nutrient, and supplemental. When antioxidant levels are low, there is a resultant increase in oxidative stress with a harmful increase in free radicals that can be associated with an increased risk for cardiovascular (CV) disease including atherosclerosis, various inflammatory diseases, and cancer. Major issues for the clinician to consider are what can be done to naturally increase antioxidants when deficient or when a directed increase might be beneficial such as in aging and degenerative disease, how nutrients can be altered or provided to increase antioxidant protection, and when or if to consider the use of supplements, frequently classified as alternative medicines.

Impact of Residents on Surgical Outcomes in High-Complexity Procedures.

BACKGROUND: There are different views on the effects of resident involvement on surgical outcomes. We hypothesized that resident participation in surgical care does not appreciably alter outcomes. STUDY DESIGN: We analyzed an American College of Surgeons NSQIP subset of inpatients having procedures with high complexity, including 4 surgical specialties (general surgery, cardiothoracic surgery, neurosurgery, and vascular surgery) with the highest mean work relative value units. We evaluated surgical outcomes in patients having procedures performed by the attending surgeon alone, or by the attending surgeon with assistance from at least one surgical resident (PGY1 to PGY≥6). Outcomes measures included operative mortality, composite morbidity, and failure to rescue (FTR). Propensity-score matching minimized the effects of nonrandom assignment of residents to procedures. RESULTS: In 266,411 patients, unmatched comparisons showed significantly higher operative mortality and composite morbidity rates, but decreased FTR, in operations performed with resident involvement. After propensity-score matching, there were small but significant resident-related increases in composite morbidity, but significant improvement in FTR. Senior-level resident involvement translated into improved outcomes, especially in cardiothoracic surgery procedures where >63.6% of procedures had PGY≥6 resident involvement. Resident involvement attenuated the significant worsening of operative mortality and FTR associated with multiple serious complications in individual patients. Measures of resource use increased modestly with resident involvement. CONCLUSIONS: We found substantial improvement in FTR with resident involvement, both in unmatched and propensity-matched comparisons. Senior-level resident participation seemed to attenuate, and even improve, surgical outcomes, despite slightly increased resource use. These results provide some reassurance about teaching paradigms.

Coenzyme Q-10 in Human Health: Supporting Evidence?

Coenzyme Q-10 (CoQ10) is a widely used alternative medication or dietary supplement and one of its roles is as an antioxidant. It naturally functions as a coenzyme and component of oxidative phosphorylation in mitochondria. Decreased levels have been demonstrated in diseased myocardium and in Parkinson disease. Farnesyl pyrophosphate is a critical intermediate for CoQ10 synthesis and blockage of this step may be important in statin myopathy. Deficiency of CoQ10 also has been associated with encephalomyopathy, severe infantile multisystemic disease, cerebellar ataxia, nephrotic syndrome, and isolated myopathy. Although supplementation with CoQ10 has been reported to be beneficial in treating hypertension, congestive heart failure, statin myopathy, and problems associated with chemotherapy for cancer treatement, this use of CoQ10 as a supplement has not been confirmed in randomized controlled clinical trials. Nevertheless, it appears to be a safe supplementary medication where usage in selected clinical situations may not be inappropriate. This review is an attempt to actualize the available information on CoQ10 and define its potential benefit and appropriate usage.

Carotid Endarterectomy: Current Concepts and Practice Patterns.

Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.

Current Surgical Management of Empyema Thoracis in Children: A Single-center Experience.

Empyema is a morbid complication of pneumonia in children, whose gold standard of surgical treatment technique remains undefined. Historically, treatment consisted of open thoracotomy with decortication. We evaluate the effectiveness and safety of video-assisted thoracoscopic surgery (VATS) as a surgical treatment in for empyema thoracis in a pediatric population at a single institution from 2005 to 2013. After receiving Institutional Review Board approval, we performed a retrospective chart review of children surgically treated for empyema as a complication of pneumonia from 2005 to 2013. Charts were reviewed for the type of procedure performed (VATS or open thoracotomy), comorbid conditions, preoperative status, operative outcomes, and postoperative status. A total of 112 pediatric patients were treated surgically for empyema. Surgical treatment consisted of VATS in all cases; no open thoracotomy procedures were performed. The success rate of VATS in our study was 96.4 per cent. Mean total length of stay was found to be 8.8 days, whereas postoperative length of stay was 6.3 days. Mean postoperative chest tube duration was 3.4 days. Perioperative complication rate was 11.6 per cent, with respiratory failure being the most common complication. The data from our study demonstrate that the exclusive use of VATS in children for the surgical management of all stages of empyema was safe and produced results with high efficacy. We consider VATS to be the new gold standard for surgical drainage of empyema.

Identifying Esophagectomy Patients at Risk for Predischarge Versus Postdischarge Venous Thromboembolism.

BACKGROUND: Current guidelines recommend postoperative venous thromboembolism (VTE) chemoprophylaxis for moderate-risk patients (3% rate or greater) and extended-duration chemoprophylaxis for high-risk patients (6% or greater). Large-scale studies of and recommendations for esophagectomy patients are lacking. This study was designed to evaluate the timing, rates, and predictors of postesophagectomy VTE. METHODS: Patients undergoing esophagectomies for cancer were identified from the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement database. Timing and rates of VTE (deep venous thrombosis or pulmonary embolism, or both) were calculated. Events were stratified as predischarge or postdischarge. Perioperative factors associated with 30-day rates of predischarge and postdischarge VTE were analyzed. RESULTS: Of 3,208 patients analyzed, the surgical approach was Ivor-Lewis (n = 1,131, 35.3%), transhiatal (n = 945, 29.5%), three-field (n = 587, 18.3%), thoracoabdominal (n = 364, 11.3%), and nongastric conduit reconstruction (n = 181, 5.6%). Rates were 2.0% pulmonary embolism, 3.7% deep venous thrombosis, and 5.1% VTE. Overall median length of stay was 11 days (versus 19 days, p < 0.001, if predischarge VTE). Predischarge VTE occurred on median day 9, whereas postdischarge VTE occurred on day 19 (p < 0.001). Only 17% of VTE occurred after discharge. Multivariate analysis identified being male (odds ratio [OR] 2.09, p = 0.018), white race (OR 1.93, p = 0.004), prolonged ventilation (OR 3.24, p < 0.001), and other major complications (OR 1.90, p = 0.005) as independent predictors of predischarge VTE. Older age (OR 1.06 per year, p = 0.006) and major complications (OR 3.14, p = 0.004) were independently associated with postdischarge VTE. CONCLUSIONS: Postesophagectomy VTE occurs in a clinically significant proportion of esophageal cancer patients with identifiable risk factors for predischarge and postdischarge events. Elderly patients and patients with major complications are most likely to benefit from extended-duration chemoprophylaxis.