Subclavian artery reconstruction with femoral vein for ballistic injury in a 3-year-old boy.

Few descriptions of using the femoral vein as an arterial replacement exist in the pediatric surgical literature. A 3-year-old child sustained a gunshot wound to the right subclavian artery, which resulted in ischemia to the upper extremity. The left femoral vein was harvested and used to reconstruct the subclavian artery. This report highlights a rare case of subclavian artery reconstruction using a femoral vein conduit in a young child after a penetrating injury.

Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.

Routine Postoperative Cardiac Testing is Unnecessary after Carotid Endarterectomy.

BACKGROUND: Routine laboratory testing to rule out myocardial infarction (MI) after carotid endarterectomy (CEA) is common in many centers. Its use in this patient population has not been thoroughly investigated. We hypothesize that routine testing for MI in post-CEA patients is of low yield and not cost-effective. METHODS: A retrospective review of 291 consecutive CEAs from February 2011 to July 2015 was performed. Two patients were excluded: one for postoperative noncardiac death and one for preoperative MI. Patient demographics, medications, medical history, type of anesthesia, and postoperative laboratory results were reviewed. All patients had troponin-I and creatine kinase-MB levels taken postoperatively. A patient was judged to have an MI if troponin-I was greater than or equal to 0.6 ng/mL or CK-MB is >6.3 ng/mL. The incidence of postoperative MI was recorded, and a cost analysis was performed. RESULTS: The mean age was 70.2 years (range: 42-92). Of all, 59.5% were male, and 92.4% had a history of hypertension. Preoperatively, 57.4% were on beta-blocker therapy, 86.5% on aspirin, and 52.2% on both. Most (80.6%) were on preoperative statin therapy, 26.9% had a prior history of MI (37.2% within 5 years of surgery), and 56.4% of patients had a prior coronary intervention (27.6% percutaneous, 28.7% coronary artery bypass grafting, and 11% both). All patients received general anesthesia. The mean procedure time was 121.5 min (range: 62-258). The mean postoperative length of stay was 2.6 days. Eight patients (2.7%) were judged to have acute MI, one of which was symptomatic. Three of the 8 (38%) had a prior history of MI. In asymptomatic patients, the peak level of troponin-I ranges from 0.52 to 3.64 ng/mL and that of CK-MB from 11.8 to 24 ng/mL. The symptomatic patient had chest pain and bradycardia. The patient had a peak troponin-I level of 1.59 ng/mL, with a CK-MB level of 11.5 ng/mL. All patients were treated medically. The cost per troponin-I and CK-MB is $27.78 and $31.44, respectively, in our institution. We estimate that eliminating routine postoperative troponin-I and CK-MB testing in patients who underwent CEA would have saved an estimated $51,343 over the course of treatment of the studied population. CONCLUSIONS: Routine postoperative cardiac laboratory testing in asymptomatic patients after CEA increases the hospital cost. The low overall rate of postoperative MI suggests that cardiac testing is best reserved for symptomatic patients or those with clinical suspicion for MI.

Aortoiliac thrombi in inflammatory bowel disease.

Isolated arterial thrombi complicating inflammatory bowel disease occurs rarely. We encountered a case of a 28-year-old man with Crohn disease who presented with abdominal pain and severe claudication and was found to have an isolated aortoiliac thrombus. Bilateral aortoiliac thromboembolectomies were performed with successful restoration of femoral blood flow. Long-term anticoagulation therapy was instituted after an extensive hypercoagulable workup, which failed to reveal an etiology for the patient's coagulopathy. We present our case and perform an extensive literature review on this topic.

Demographic and laboratory data may predict positive temporal artery biopsy.

BACKGROUND: Temporal artery biopsy is performed in patients suspected of having giant cell arteritis. This study was conducted to evaluate clinical and laboratory criteria correlating with positive biopsy results in an effort to limit the number of negative biopsies performed. METHODS: A retrospective review was performed of patients who underwent temporal artery biopsy at two urban medical centers from 2002 to 2009. A multivariate analysis of patient demographics, clinically relevant signs and symptoms, laboratory data, and pathologic outcomes was performed. RESULTS: Temporal artery biopsy histologically confirmed giant cell arteritis in 24% of cases. The mean age of those with disease was 77.8 y and those without were 73.1 y; age was found to be statically significant (P = 0.0227); 76% were female and 24% were male; gender was not significant (P = 0.9594); 42% were Caucasian (39% had a positive temporal artery biopsy), 27% were Hispanic (17% positive), and 31% of the patients were African-American (3% positive); ethnicity was significant (P = 0.0005). The PPV of elevated ESR was 27%; sensitivity was 100%; specificity was 16%. A history of headache or visual disturbance was not predictive of a positive biopsy CONCLUSION: Fewer negative biopsy results may be achieved by screening patients with normal ESR or lower risk patients with other modalities.

Staged endovascular treatment of bilateral ruptured and intact ovarian artery aneurysms in a postmenopausal woman.

Ovarian artery aneurysms have rarely been reported in the literature, with almost all being unilateral and occurring in the peripartum period. We herein describe a unique case of a postmenopausal patient with a ruptured ovarian aneurysm and an intact contralateral aneurysm that were both successfully treated by endovascular techniques.

The effect of systemic anticoagulation in patients undergoing angioaccess surgery.

The benefit of intravenous heparin as an anticoagulant to avoid thrombotic complications during angioaccess surgery for hemodialysis is unknown. We prospectively randomized 115 consecutive patients referred to our institution for permanent hemodialysis access to receive systemic anticoagulation or no anticoagulation during angioaccess surgery. Patient demographics, comorbid conditions, procedure time, complications, and patency were recorded in accordance with standards recommended by the Society for Vascular Surgery. Of the 115 patients randomized, 58 received no anticoagulation and 57 received systemic anticoagulation with intravenous heparin. Arteriovenous fistulas were created in 84 patients and 31 arteriovenous grafts were inserted. Operative times were longer for grafts compared to fistulas, but there were no significant differences in operative times between patients receiving anticoagulation and those not (p = 0.31). Perioperative bleeding complications were more common in patients receiving heparin (p = 0.008). The primary 30-day patency was 84% for patients receiving heparin and 86% for those not (p = 0.79). The 3-month functional patency was 68% for both groups (p = 0.99). Age, gender, operative time, and incidence of bleeding complications had no impact on patency. In our experience, systemic anticoagulation for angioaccess surgery is associated with an increased incidence of bleeding complications and offers no advantage in terms of early patency.

The F11 receptor (F11R/JAM-A) in atherothrombosis: overexpression of F11R in atherosclerotic plaques.

F11R is the gene name for an adhesion protein, called the F11-receptor, aka JAM-A, which under normal physiological conditions is expressed constitutively on the surface of platelets and localized within tight junctions of endothelial cells (EC). Previous studies of the interactions between human platelets and EC suggested that F11R/JAM-A plays a crucial role in inflammatory thrombosis and atherosclerosis. The study reported here obtained in-vivo confirmation of this conclusion by investigating F11R/JAM-A protein and mRNA in patients with aortic and peripheral vascular disease and in an animal model of atherosclerosis. Molecular and immunofluorescence determinations revealed very high levels of F11R/JAM-A mRNA and F11R/JAM-A protein in atherosclerotic plaques of cardiovascular patients. Similar results were obtained with 12-week-old atherosclerosis-prone apoE-/- mice, an age in which atherosclerotic plaques are well established. Enhanced expression of the F11R/JAM-A message in cultured EC from human aortic and venous vessels was observed following exposure of the cells to cytokines. Determinations of platelet adhesion to cultured EC inflamed by combined cytokine treatment in the presence of F11R/JAM-A - antagonists provided data indicating that de novo expression of F11R/JAM-A on the luminal surface of inflamed EC has an important role in the conversion of EC to a thrombogenic surface. Further studies of these interactions under flow conditions and under in-vivo settings could provide a final proof of a causal role for F11R/JAM-A in the initiation of thrombosis. Based on our in-vitro and in-vivo studies to date, we propose that therapeutic drugs which antagonize the function of F11R/JAM-A should be tested as novel means for the prevention and treatment of atherosclerosis, heart attacks and stroke.

Enlargement of previously ligated popliteal aneurysm causing venous bypass graft occlusion.

A 72-year-old male patient presented with a thrombosed popliteal artery aneurysm measuring 15 x 8 cm 12 years following ligation and saphenous vein bypass grafting through a medial approach. The giant aneurysm, which had grown and compressed the previously functional vein bypass graft to the point of graft thrombosis, was causing a knee contracture that impeded ambulation. Resection via a posterior approach was accomplished without neurovascular compromise or the need for revascularization. This case underscores the value of aneurysm decompression in cases of large popliteal aneurysms to prevent further growth and attendant complications. Duplex surveillance of ligated popliteal aneurysms is warranted to exclude the possibility of future aneurysm expansion.

Safety of contrast venography prior to caval interruption in patients with renal insufficiency.

We undertook this study to determine whether the use of contrast venography would adversely affect renal function in patients with renal insufficiency requiring caval interruption. We conducted a retrospective review of all inferior vena cava (IVC) filters inserted at our institution over a 2-year period (January 2002 to January 2004). The indication for caval interruption, insertion technique, type of filter used, pre- and postintervention creatinine level, and the presence of diabetes and hypertension were analyzed. A total of 282 IVC filters were inserted, with 38 of them placed in patients with renal insufficiency as defined by a serum creatinine level of > 1.5 mg/dL. Contrast venography with 15 to 30 mL of iohexol (Omnipaque 300) was used in all cases, and no special measures other than proper hydration were used for renal protection. All filters were successfully deployed. The mean +/- SD preintervention creatinine level was 2.38 +/- 0.79 mg/dL. The mean +/- SD postintervention creatinine levels at 2 and 30 days were 2.26 +/- 0.45 mg/dL and 2.12 +/- 0.94 mg/dL, respectively. No patients required hemodialysis following caval interruption, and no adverse effect on renal function was noted. Contrast venography accurately delineates venous anatomy and facilitates proper caval filter placement with no apparent adverse effect on renal function. We believe contrast venography is safe even in the presence of renal insufficiency.

Abdominal aortic aneurysm causing duodenal obstruction: two case reports and review of the literature.

Obstruction of the upper gastrointestinal tract caused by an abdominal aortic aneurysm (aortoduodenal syndrome) has been rarely reported. The typical presentation includes protracted emesis in a patient with a pulsatile abdominal mass. Clinical features of weight loss, abdominal pain, and distention are present less frequently. The diagnosis is suggested by findings on computed tomography scans, and may be confirmed with upper gastrointestinal contrast material-enhanced studies or upper endoscopy. Aortic aneurysmorrhaphy is curative, and should be undertaken after gastrointestinal decompression and correction of fluid and electrolyte disturbances. We report 2 cases of abdominal aortic aneurysm producing upper gastrointestinal obstruction, and provide a review of the literature relevant to this clinical syndrome.

Giant celiac artery aneurysm with associated visceral occlusive disease.

Celiac artery aneurysms are rarely seen in clinical practice. We report an unusual case of a large celiac artery aneurysm in a patient with associated visceral occlusive disease who presented with vague abdominal pain and underwent uneventful open surgical repair.

Why insurers should reimburse for compression stockings in patients with chronic venous stasis.

BACKGROUND: Chronic venous stasis ulcers produce substantial morbidity rates and result in a significant expense to society. Fortunately, compression stockings (CS) have been found to reduce the rate of recurrence in patients with previous ulceration. Surprisingly, Medicare and other insurers do not reimburse the expense associated with CS or with patient education (Ed), which is essential to ensure compliance. METHODS: A Markov decision analysis model was used for analysis of the cost-effectiveness of a strategy of reimbursement for CS and Ed (prophylaxis) versus one that does not supply these resources in a 55-year-old patient with prior venous stasis ulceration. The mean time to ulcer recurrence (53 months with CS+Ed; 18.7 months without prophylaxis), the mean time for ulcer healing (4.6 months), the probabilities of hospitalization (12%) and amputation (0.4%) after the development of an ulcer, and quality-adjustment factors (0.80 during ulcer treatment) were derived from the literature. The cost of CS ($300/year) and Ed ($93 for initial evaluation; $58/year; $40/recurrence) and the medical cost of ulcer treatment (average cost, $1621/recurrence) were calculated from our hospital cost accounting system. RESULTS: A strategy of CS and Ed was cost saving, with 0.37 quality-adjusted life years and $5904 saved, compared with a strategy that does not provide these resources. The inclusion of loss of revenue related to absence from work in the analysis increased cost savings to $17,080 during the patient's lifetime. With sensitivity analysis, CS and Ed remained cost-effective (lifetime cost per quality-adjusted life year saved, <$60,000) if amputations and the cost of ulcer treatment were eliminated or if the cost of prophylaxis was increased to 600% of the base-case. The mean time to recurrence in patients with CS and Ed needed to be reduced from 53 months to 21.1 months before this strategy was no longer cost-effective. CONCLUSION: Prophylactic CS and Ed in patients with prior venous stasis ulceration are cost saving, even with the most conservative of assumptions. Insurers should routinely reimburse for these interventions.