Endovascular treatment of an isolated iliac artery aneurysm associated with segmental arterial mediolysis.

Segmental arterial mediolysis is a noninflammatory nonatherosclerotic vasculopathy of uncertain etiology characterized by dissection and/or aneurysm formation. It affects medium-to-large arteries, primarily the celiac, superior mesenteric, and renal arteries. Iliac involvement is rare, and its specific treatment has not been described. We detail a patient who presented with intrabdominal hemorrhage from a ruptured right colic artery aneurysm. He underwent transcatheter arterial embolization followed by right hemicolectomy. Histopathology confirmed the diagnosis of segmental arterial mediolysis. Endovascular treatment of a 3-cm iliac artery aneurysm was performed 18 months later. There was successful exclusion of the aneurysm demonstrated on computed tomography angiography at 10 years.

Conservative Management of Non-Infected Diabetic Foot Ulcers Achieves Reliable Wound Healing and Limb Salvage in the Setting of Mild-Moderate Ischemia.

BACKGROUND: The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system has been validated to predict wound healing among patients with critical limb threatening ischemia (CLTI). Our goal was to analyze the use of a previously reported conservative wound care approach to non-infected (foot infection score of zero), diabetic foot ulcers with mild-moderate peripheral arterial disease enrolled in a conservative tier of a multidisciplinary limb preservation program. METHODS: Veterans with CLTI and tissue loss were prospectively enrolled into our Prevention of Amputation in Veterans Everywhere (PAVE) program. All patients with wounds were stratified to a conservative approach based on perfusion evaluation and a validated pathway of care. Retrospective analysis of a prospectively maintained database was performed to evaluate all conservatively managed patients presenting without foot infection for the primary outcome of wound healing as well as secondary outcomes of time to wound healing, delayed revascularization, wound recurrence, and limb loss. RESULTS: Between January 2006 and December 2019, 1113 patients were prospectively enrolled into the PAVE program. A total of 241 limbs with 281 wounds (217 patients) were stratified to the conservative approach. Of these, 122 limbs (89 patients) met criteria of having diabetic foot wounds without infection at the time of enrollment and are analyzed in this report. Of the 122 limbs, 97 (79.5%) healed their index wound with a mean time to healing of 4.6 months (0.5-20 months). Wound recurrence ensued in 44 (45.4%) limbs, 93.2% of which healed again after recurrence. There were three (3.1%) limbs requiring major amputation in this group (one due to uncontrolled infection and two due to ischemic tissue loss). Of the 25 (20.5%) limbs that did not heal initially, four (16%) required amputation due to progressive symptoms of CLTI. CONCLUSIONS: In patients with diabetes and lower extremity wounds without infection in the setting of mild to moderate peripheral arterial disease, there appears to be an acceptable rate of index wound healing, and appropriate rate of recurrent wound healing with a low risk of limb loss. While wound recurrence is frequent, this can be successfully treated without the need for revascularization.

NCCN Guidelines® Insights: Squamous Cell Skin Cancer, Version 1.2022.

The NCCN Guidelines for Squamous Cell Skin Cancer provide recommendations for diagnostic workup, clinical stage, and treatment options for patients with cutaneous squamous cell carcinoma. The NCCN panel meets annually to discuss updates to the guidelines based on comments from panel members and the Institutional Review, as well as submissions from within NCCN and external organizations. These NCCN Guidelines Insights focus on the introduction of a new surgical recommendation terminology (peripheral and deep en face margin assessment), as well as recent updates on topical prophylaxis, immunotherapy for regional and metastatic disease, and radiation therapy.

Factors Affecting One-Year Outcomes After Major Lower Extremity Amputation in the Vascular Quality Initiative Amputation Registry.

INTRODUCTION: Major lower extremity amputation (LEA) results in significant morbidity and mortality. This study identifies factors contributing to adverse long-term outcomes after major LEA. STUDY DESIGN: Amputations in the Vascular Quality Initiative (VQI) long-term follow-up database from 2012 to 2017 were included. Multivariable logistic regression determined which significant patient factors were associated with 1-year mortality, long-term functional status, and progression to higher level amputation within 1 year. RESULTS: 3440 major LEAs were performed and a mortality rate of 19.9% was seen at 1 year. Logistic regression demonstrated that 1-year mortality was associated with post-op myocardial infarction (MI) (odds ratio (OR) 1.7, CI 1.02-2.97, P = .04), congestive heart failure (CHF) (OR 1.9, confidence interval (CI) 1.56-2.38, P < .001), hypertension (HTN) (OR 1.31, CI 1.00-1.72, P = .05), chronic obstructive pulmonary disease (COPD) (OR 1.36, CI 1.13-1.63, P < .001), and dependent functional status (OR 2.01, CI 1.67-2.41, P < .001). A decline in ambulatory status was associated with COPD (OR 1.36, CI 1.09-1.68, P = .006). Dependent functional status was protective against revision to higher level amputation (OR .18, CI .07-.45, P < .001). CONCLUSION: In the VQI, 1-year mortality after major LEA is nearly 20% and associated with HTN, CHF, COPD, dependent functional status, and post-op MI. Decreased functional status at 1 year was associated with COPD, and progression to higher level amputation was less likely in patients with dependent functional status.

A Sustainable Approach to Prepectoral Breast Reconstruction Using Meshed Acellular Dermal Matrix.

BACKGROUND: Prepectoral implant-based breast reconstruction provides an alternative to submuscular reconstruction, but the increased acellular dermal matrix (ADM) required has the potential to lead to increased costs and decreased supply of this limited-resource material. We present a method for prepectoral reconstruction utilizing skin-graft meshing techniques to increase the surface area of usable ADM. METHODS: Forty-four patients underwent this technique from February 2019 to February 2020. Patient characteristics, operative details, and outcomes, including complications and patient satisfaction utilizing the BREAST-Q, were analyzed. Cost analysis relative to projected cost of nonmeshed techniques was performed. RESULTS: There were 20 unilateral and 24 bilateral procedures, for a total of 68 breast reconstructions. Mean age was 45.9 years (32-71). Mean implant volume was 485 cm3 (265-800), and one sheet of ADM was used for each breast with an average surface area of 161 cm2. Median follow-up was 350 days (212-576). Minor complications included an infection treated with oral antibiotics. Major complications included one axillary hematoma and one delayed implant loss. One patient underwent revision for asymmetry. Mean BREAST-Q score was 47.4/60. Cost ranged from $4113 to 5025 per breast, compared with the projected $9125-18250 per breast for other techniques in the literature. CONCLUSIONS: In contrast to previously described uses of ADM in prepectoral reconstruction, meshing maximizes resource utilization by expanding the coverage of a single sheet. Early findings demonstrate minimal complications and high patient satisfaction, suggesting the approach has potential to provide the benefits of prepectoral reconstruction while responsibly preserving product availability and tempering healthcare costs.

5-Item Modified Frailty Index Predicts Outcomes After Below-Knee Amputation in the Vascular Quality Initiative Amputation Registry.

Patient frailty indices are increasingly being utilized to anticipate post-operative complications. This study explores whether a 5-factor modified frailty index (mFI-5) is associated with outcomes following below-knee amputation (BKA). All BKAs in the vascular quality initiative (VQI) amputation registry from 2012-2017 were reviewed. Preoperative frailty status was determined with the mFI-5 which assigns one point each for history of diabetes, chronic obstructive pulmonary disease or active pneumonia, congestive heart failure, hypertension, and nonindependent functional status. Outcomes included 30-day mortality, unplanned return to odds ratio (OR), post-op myocardial infarction (MI), post-op SSI, all-cause complication, revision to higher level amputation, disposition status, and prosthetic use. 2040 BKAs were performed. Logistic regression showed an increasing mFI-5 score that was associated with higher risk of combined complications (OR 1.22, confidence interval [CI] 1.07-1.38, P < .05), 30-day mortality (OR 1.60, CI 1.19-2.16, P < .05), post-op MI (OR 1.79, CI 1.30-2.45, P < .05), and failure of long-term prosthetic use (OR 1.17, CI 1.03-1.32, P < .05). In the VQI, every one-point increase in mFI-5 is associated with an increased risk of 22% for combined complications, 60% for 30-day mortality, nearly 80% for post-op MI, and 17% for failure of prosthetic use in BKA patients. The mFI-5 frailty index should be incorporated into preoperative planning and risk stratification.

X-ray crystal structure and specificity of the Toxoplasma gondii ME49 TgAPN2.

Toxoplasmosis is a parasitic disease caused by infection with Toxoplasma gondii that currently has few therapeutic options. The M1 aminopeptidase enzymes have been shown to be attractive targets for anti-parasitic agents and/or vaccine candidates, suggesting potential to re-purpose inhibitors between parasite M1 aminopeptidase targets. The M1 aminopeptidase TgAPN2 has been suggested to be a potential new drug target for toxoplasmosis. Here we investigate the structure and function of TgAPN2, a homologue of the antimalarial drug target PfA-M1, and evaluate the capacity to use inhibitors that target PfA-M1 against TgAPN2. The results show that despite a similar overall fold, the TgAPN2 has a unique substrate specificity and inhibition profile. Sequence and structure differences are investigated and show how comparative structure-activity relationships may provide a route to obtaining potent inhibitors of TgAPN2.

Immediate Carotid Endarterectomy Is Associated with Higher Risk in Symptomatic Patients.

BACKGROUND: Guidelines recommend that patients with carotid artery stenosis ≥50% (Sx-CAS) undergo carotid endarterectomy (CEA) within 14 days of symptoms. However, perioperative risks, especially stroke, may be increased when CEA is performed within 48 hours. This study seeks to more fully evaluate the effect of timing of surgery on outcomes for Sx-CAS. METHODS: All CEAs in the Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe) from 2012 to 18 were reviewed. Ipsilateral cortical or visual symptoms within 6 months defined Sx-CAS. Timing from symptom occurrence to CEA was classified as immediate (0-2 days), early (3-14 days), or delayed (>14 days). Perioperative stroke, myocardial infarction (MI), and 30-day mortality rates were compared by time to surgery. RESULTS: Of 2203 CEAs, 436 (20%) were for Sx-CAS (52% stroke, 48% transient ischemic attack). Mean time from symptoms to CEA was 28.3 days (range, 0-172; median, 14 days). Sixty-one cases (14%) were immediate, 166 (38%) early, and 209 (48%) delayed. Perioperative stroke occurred in 2.8% and stroke/MI/30-day mortality in 5.7%. Stroke rate was significantly higher in the immediate group (vs. early and delayed): 8.2%, versus 3.0%, and 0.96%, respectively (P = 0.009). Stroke/MI/30-day mortality was also higher in the immediate group: 13.1%, versus 6.0%, and 3.3%, respectively (P = 0.001). Immediate surgery was associated with greater postoperative events (P = 0.009), and logistic regression confirmed decreased risk of postoperative stroke and stroke/MI/30-day mortality in delayed surgery using immediate surgery as a reference. Wide variability existed among centers in the timing of CEA (immediate-range, 0-50%; delayed-range, 41-83%; P = 0.01). CONCLUSIONS: In the SoCal VOICe, 52% of patients undergo CEA within 2 weeks of symptoms. Increased stroke rates occur when CEA is performed within 2 days, whereas stroke and death rates are decreased at 3-14 days and beyond. These data support avoidance of immediate CEA. Opportunity exists to standardize timing of CEA for Sx-CAS among SoCal VOICe participants. Further study is required to define the role of immediate CEA.

Association between Preoperative Indications and Outcomes after Major Lower Extremity Amputation.

Despite aggressive limb salvage techniques, lower extremity amputation (LEA) is frequently performed. Major indications for LEA include ischemia and uncontrolled infection (UI). A review of the national Vascular Quality Initiative amputation registry was performed to analyze the influence of indication on outcomes after LEA. Retrospective review of the Vascular Quality Initiative LEA registry (2012-2017) identified all above- and below-knee amputations. Outcome measures included 30-day mortality, return to operating room (OR), postoperative myocardial infarctions, and postoperative SSI. Indications for surgery included ischemic rest pain, ischemic tissue loss (TL), acute limb ischemia (ALI), UI, and neuropathic TL. A total of 6701 patients met the inclusion criteria. The indications for surgery included TL (49.0%), UI (31.7%), ALI (8.0%), rest pain (6.6%), and neuropathic TL (2.3%). Patients with ALI had the highest 30-day mortality (12.0%) compared with TL (6.6%) and UI (6.4%) [P < 0.001]. The highest rate of return to OR occurred in the UI group (12.6%) [P < 0.001]. Multivariate analysis demonstrated that patients with UI have significantly higher rates of return to OR, whereas those with ALI have a 30-day mortality twice as high as other indications (both P < 0.001). These data can inform expectations after LEA based on the indications for surgery.

Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction: Case Series and Management Guidelines.

INTRODUCTION: Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery. METHODS: This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included. RESULTS: Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days. CONCLUSIONS: Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.

Types of materials for frontalis sling surgery for congenital ptosis.

BACKGROUND: Congenital ptosis is a drooping of one or both eyelids at birth, often due to poor development of the levator palpebrae superioris muscle. This can result in amblyopia, astigmatism, and ocular torticollis and therefore may necessitate surgical intervention in early childhood if visual development is compromised. Patients may have varied levels of levator function. Those with moderate to good function may elect to first attempt ptosis repair with external levator advancement or mullerectomy/Fasanella-Servat procedures. For those with poor function, those procedures are less likely to be effective, so they may undergo frontalis sling surgery, in which the tarsal plate is coupled to the frontalis muscle, so that movement of the brow and forehead result in movement of the eyelid. The optimal material to use in this surgery is unknown. OBJECTIVES: To evaluate the comparative effectiveness and safety of various materials used in frontalis sling surgery for congenital ptosis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (June 2018), Ovid MEDLINE, Ovid MEDLINE E-pub Ahead of Print, Ovid Medline In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to 20 June 2018), Embase (January 1947 to 20 June 2018), PubMed (1948 to 20 June 2018), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 20 June 2018), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 20 June 2018. SELECTION CRITERIA: We included randomized trials that compared one material to another for the treatment of congenital ptosis. DATA COLLECTION AND ANALYSIS: Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. MAIN RESULTS: We identified three randomized trials that had compared four different materials, two materials in each trial. The studies included a total of 160 participants. The surgical procedures compared were polytetrafluoroethylene (Gore-Tex), Ethibond suture, Mersilene mesh, and autogenous fascia lata.We judged all studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Because the three included studies compared different types of implants, we were unable to combine data in a meta-analysis. The limited data preclude any conclusion regarding the optimal implant for frontalis sling surgery.In terms of the primary outcome of functional success, this was defined as widening of the opening between eyelids, assessed either by grade or by millimeter measurement. Bajaj 2004 showed that 93% of the Gore-Tex group and 83% of the Ethibond group had a good or satisfactory outcome (as defined by investigators). Elsamkary 2016 reported that 78.1% of the autogenous fascia group and 61.8% of the Gore-Tex group had a very good or good outcome. Salour 2008 did not include this type of grading system; they showed that the lid fissure increased 4.0 mm ± 1.46 mm in the Mersilene group and 3.13 mm ± 1.72 mm in the fascia lata group.In terms of adverse events, Bajaj 2004, which included 15 patients per group, showed no recurrence in the Gore-Tex group and 1 in the Ethibond group; no need for removal in the Gore-Tex group and 1 in the Ethibond group; and no infections in the Gore-Tex group and 1 in the Ethibond group. Elsamkary 2016, which included 55 patients per group, had 3 recurrences in the fascia group and 6 in the Gore-Tex group; no need for removal in either group; and 1 infection in the fascia group and 2 in the Gore-Tex group. Salour 2008, which included 10 patients per group, had no recurrence, removals, or infections in either the Mersilene or the fascia group. AUTHORS' CONCLUSIONS: The three trials included in this review evaluated four materials for frontalis sling surgery. Assessment of these three studies does not allow us to identify the optimal material. Future randomized trials should be rigorously designed so as to identify the best treatment for this condition.

Merkel Cell Carcinoma, Version 1.2018, NCCN Clinical Practice Guidelines in Oncology.

This selection from the NCCN Guidelines for Merkel Cell Carcinoma (MCC) focuses on areas impacted by recently emerging data, including sections describing MCC risk factors, diagnosis, workup, follow-up, and management of advanced disease with radiation and systemic therapy. Included in these sections are discussion of the new recommendations for use of Merkel cell polyomavirus as a biomarker and new recommendations for use of checkpoint immunotherapies to treat metastatic or unresectable disease. The next update of the complete version of the NCCN Guidelines for MCC will include more detailed information about elements of pathology and addresses additional aspects of management of MCC, including surgical management of the primary tumor and draining nodal basin, radiation therapy as primary treatment, and management of recurrence.

Basal Cell Skin Cancer, Version 1.2016, NCCN Clinical Practice Guidelines in Oncology.

Basal cell carcinoma (BCC) of the skin is the most common cancer, with a higher incidence than all other malignancies combined. Although it is rare to metastasize, patients with multiple or frequently recurring BCC can suffer substantial comorbidity and be difficult to manage. Assessment of risk is a key element of management needed to inform treatment selection. The overall management of BCC primarily consists of surgical approaches, with radiation therapy as an alternate or adjuvant option. Many superficial therapies for BCC have been explored and continue to be developed, including topicals, cryosurgery, and photodynamic therapy. Two hedgehog pathway inhibitors were recently approved by the FDA for systemic treatment of advanced and metastatic BCC, and others are in development. The NCCN Guidelines for Basal Cell Skin Cancer, published in full herein, include recommendations for selecting among the various surgical approaches based on patient-, lesion-, and disease-specific factors, as well as guidance on when to use radiation therapy, superficial therapies, and hedgehog pathway inhibitors.

Anaplastic large cell lymphoma occurring in women with breast implants: analysis of 173 cases.

BACKGROUND: The first silicone breast implant was inserted in 1962. In 1997, the first case of anaplastic large cell lymphoma (ALCL) in association with a silicone breast implant was reported. The authors reviewed 37 articles in the world literature reporting on 79 patients and collected another 94 unreported cases as of the date of submission. METHODS: The world literature was reviewed. Missing clinical and laboratory information was solicited from the authors and treating physicians. As several different specialties were involved, information was not in one place. Many (but not all) authors and treating physicians were responsive, resulting in incomplete data. RESULTS: ALCL lesions first presented as late peri-implant seromas, a mass attached to the capsule, tumor erosion through the skin, in a regional node, or discovered during revision surgery. The clinical course varied widely from a single positive cytology result followed by apparent spontaneous resolution, to disseminated treatment-resistant tumor and death. There was no preference for saline or silicone fill or for cosmetic or reconstructive indications. Where implant history was known, the patient had received at least one textured-surface device. Extracapsular dissemination occurred in 18 cases; nine of those were fatal. Histochemical markers were primarily CD-30 and Alk-1. Other markers occurred at a lower frequency. Risk estimates ranged from one in 500,000 to one in 3 million women with implants. CONCLUSION: Breast implant-associated ALCL is a novel manifestation of site- and material-specific lymphoma originating in a specific scar location, presenting a wide array of diverse characteristics and suggesting a multifactorial cause.

Dermatofibrosarcoma protuberans, version 1.2014.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue tumor characterized by a relatively high risk of local recurrence and low risk of metastasis. The NCCN Guidelines for DFSP provide multidisciplinary recommendations on the management of patients with this rare disease. These NCCN Guidelines Insights highlight the addition of the Principles of Pathology section, which provides recommendations on the pathologic assessment of DFSP. Because DFSP can mimic other lesions, immunohistochemical studies are often required to establish diagnosis. Cytogenetic testing for the characteristic translocation t(17;22)(q22;q13) can also be valuable in the differential diagnosis of DFSP with other histologically similar tumors.

Merkel cell carcinoma, version 1.2014.

Merkel cell carcinoma is a rare, aggressive cutaneous tumor that combines the local recurrence rates of infiltrative nonmelanoma skin cancer with the regional and distant metastatic rates of thick melanoma. The NCCN Guidelines for Merkel Cell Carcinoma provide recommendations on the diagnosis and management of this aggressive disease based on clinical evidence and expert consensus. This version includes revisions regarding the use of PET/CT imaging and the addition of a new section on the principles of pathology to provide guidance on the analysis, interpretation, and reporting of pathology results.

Cardiopulmonary resuscitation training of family members before hospital discharge using video self-instruction: a feasibility trial.

BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) is a crucial therapy for sudden cardiac arrest (SCA), yet rates of bystander CPR are low. This is especially the case for SCA occurring in the home setting, as family members of at-risk patients are often not CPR trained. OBJECTIVE: To evaluate the feasibility of a novel hospital-based CPR education program targeted to family members of patients at increased risk for SCA. DESIGN: Prospective, multicenter, cohort study. SETTING: Inpatient wards at 3 hospitals. SUBJECTS: Family members of inpatients admitted with cardiac-related diagnoses. MEASUREMENTS AND RESULTS: Family members were offered CPR training via a proctored video-self instruction (VSI) program. After training, CPR skills and participant perspectives regarding their training experience were assessed. Surveys were conducted one month postdischarge to measure the rate of "secondary training" of other individuals by enrolled family members. At the 3 study sites, 756 subjects were offered CPR instruction; 280 agreed to training and 136 underwent instruction using the VSI program. Of these, 78 of 136 (57%) had no previous CPR training. After training, chest compression performance was generally adequate (mean compression rate 90 ± 26/minute, mean depth 37 ± 12 mm). At 1 month, 57 of 122 (47%) of subjects performed secondary training for friends or family members, with a calculated mean of 2.1 persons trained per kit distributed. CONCLUSIONS: The hospital setting offers a unique "point of capture" to provide CPR instruction to an important, undertrained population in contact with at-risk individuals.