Open repair of a proximal left subclavian artery mycotic aneurysm with median claviculectomy.

Surgical repair of a subclavian artery mycotic aneurysm is dependent on aneurysm-specific characteristics and anatomic exposures could require sternotomy, thoracotomy, or supraclavicular incisions. Alternatively, a median claviculectomy can be used. We successfully performed a subclavian artery to axillary artery bypass with median claviculectomy in a 23-year-old man with multiple comorbidities. Postoperative Doppler ultrasound showed a patent left axillary artery with a palpable left radial artery, and the patient demonstrated full left shoulder range of motion without any significant deformities. This case suggests that a median claviculectomy can produce satisfactory outcomes in patients with subclavian artery mycotic aneurysms.

Contemporary Review to Reduce Groin Surgical Site Infections in Vascular Surgery.

Surgical site infection (SSIs) in lower extremity vascular procedures is a major contributor to patient morbidity and mortality. Despite previous advancements in preoperative and postoperative care, the surgical infection rate in vascular surgery remains high, particularly when groin incisions are involved. However, successfully targeting modifiable risk factors reduces the surgical site infection incidence in vascular surgery patients. We conducted an extensive literature review to evaluate the efficacy of various preventive strategies for groin surgical site infections. We discuss the role of preoperative showers, preoperative and postoperative antibiotics, collagen gentamicin implants, iodine impregnated drapes, types of skin incisions, negative pressure wound therapy, and prophylactic muscle flap transposition in preventing surgical site infection in the groin after vascular surgical procedures.

Arteriovenous Access superficialization: A New Technique and Review of Options.

BACKGROUND: Up to 30% of autogenous cephalic vein arteriovenous fistulas (AVFs) are too deep for reliable cannulation. Techniques to superficialize these AVFs have been described previously. This study describes a new surgical technique for AVF superficialization and provides a review of the alternative techniques. METHODS: The path of the fistula is marked using ultrasound, and transverse incisions are made along this path. The underlying tissue is separated from the dermis over this area to expose the fistula outflow vein. The mobilized vein is then elevated and "trapped" directly under the dermis by closing the superficial fascia and adipose tissue beneath it. RESULTS: Between March 2016 and February 2019, 23 patients underwent superficialization using this technique at two centers. The mean time between AVF creation and superficialization was 6.3 months, and the time to first use for hemodialysis after superficialization was 38.8 ± 27.9 days. The average presuperficialization depth was 7.1 ± 2.4 mm and average postsuperficialization depth was 3.7 ± 2.7 mm (P = 0.002). Sixteen fistulas were successfully accessed for a cannulation rate of 89%. 94.7% of fistulas remained patent at last visit, with only one thrombosed 8-10 weeks after superficialization. CONCLUSIONS: This technique appears to be both safe and effective, and results in a vein that is immediately subdermal without major contour deformity. Early outcomes are comparable to those alternative methods described in the literature.

Medial claviculectomy for the treatment of recalcitrant central venous stenosis of hemodialysis patients.

OBJECTIVE: Outflow tract stenosis is the leading cause of hemodialysis access loss. Many lesions are highly resistant to endovascular treatment, necessitating open surgical intervention. We present our experience using medial claviculectomy for treatment of recalcitrant lesions at the thoracic outlet. METHODS: We retrospectively reviewed patients who underwent medial claviculectomy for dialysis-associated venous thoracic outlet syndrome at our institution between February 2013 and February 2018. Data collection included demographics, past medical history, access history, subsequent procedures, preoperative and postoperative brachial volume flows, and access use. RESULTS: We performed 25 medial claviculectomies in 25 patients with central venous stenosis. Four patients underwent concomitant central venous bypass and were excluded from this study. Twelve accesses were created at our institution; of these, the average access age was 41.6 months (±26.7 months). All patients previously underwent multiple angioplasty attempts to treat outflow stenosis and continued to have residual symptoms and poor fistula function. Medial claviculectomy with venolysis and angioplasty were performed to treat residual outflow stenosis at the level of the subclavian vein. Twenty-one patients had residual stenosis requiring angioplasty. Six patients had subclavian rupture requiring stent graft placement. All patients reported symptom improvement and immediate use of the fistula after medial claviculectomy. Nineteen (76%) patients reported complete resolution of symptoms after the procedure. Ultimately, eight (32%) ipsilateral arteriovenous accesses were lost, and six (24%) patients died in follow-up with patent, functional fistulas. Median length of follow-up was 17 months (interquartile range, 5-28 months). The 18-month primary patency and secondary patency with regard to subclavian vein interventions were 28% (95% confidence interval, 13.8%-56.1%) and 84% (95% confidence interval, 69.7%-100%), respectively. One patient required ligation for high-output cardiac failure. One patient had contralateral brachiocephalic jailing, which was corrected with kissing brachiocephalic stents. CONCLUSIONS: Medial claviculectomy is an effective treatment of recalcitrant central venous stenosis of the thoracic outlet. Balloon angioplasty or stent or stent graft placement is often necessary after extrinsic compression is alleviated and demonstrates acceptable secondary patency rates.

Axillary Artery to Right Atrial Graft for Dialysis Access Using an Autologous Femoropopliteal Vein.

Patients with prolonged history of central venous catheters can develop central venous occlusion. We report the creation of an axillary artery to right atrial graft using the femoropopliteal vein (FPV) for dialysis access in a patient with end-stage renal disease on hemodialysis with history of central venous occlusion. The patient had previously developed steal syndrome following a right brachial artery to right atrial polytetrafluoroethylene graft requiring revision to a left axillary artery inflow which subsequently thrombosed. This is the first report of using an autologous FPV conduit to the right atrium for dialysis.

Open Removal of Penetrating Inferior Vena Cava Filter with Repair of Secondary Aortic Dissection: Case Report.

Inferior vena cava (IVC) filters are indicated for the management of venous thromboembolism in patients who are not candidates for anticoagulation, have a contraindication to anticoagulation or who have recurrent thromboembolism despite anticoagulation. As IVC filter usage has increased, there has been a corresponding increase in presentation of filter-related complications. Filter leg penetration is commonly seen although is infrequently associated with complications. But in a small percentage of patients, penetration can result in damage to adjacent structures: duodenum, lumbar spine, and rarely the aorta. We report the case of a 77-year-old man with a chronic aortoiliac dissection secondary to aortic IVC filter penetration who underwent open filter retrieval and aortic repair.

A novel device to preserve intestinal tissue ex-vivo by cold peristaltic perfusion.

In the past two decades, much advancement has been made in the area of organ procurement and preservation for the transplant of kidneys, livers, and lungs. However, small intestine preservation remains unchanged. We propose a new preservation system for intestinal grafts that has the potential to increase the viability of the organ during transport. When experimented with porcine intestine, our device resulted in superior tissue quality than tissue in standard of care.