Unstable Carotid Artery Thrombus in a Patient With COVID-19 Infection.

We present a case of an unvaccinated, 43-year-old African American female patient with COVID-19 infection and clinical evidence of a left hemispheric stroke. A non-occlusive thrombus with a radiographic target lesion was identified on computed tomography angiography (CTA). A multi-disciplinary discussion regarding concern for embolization was provided due to its unstable nature, as well as evidence of recent stroke. Given her acute COVID-19 infection, symptomatology, and radiographic findings, it was concluded that the etiology of her stroke appeared most consistent with a hypercoagulable-related embolism rather than an atheroembolic event. The patient underwent left carotid artery thrombectomy with bovine patch angioplasty. Operative findings included: left carotid thrombus, minimal plaque after evacuation of the thrombus, and a small proximal internal carotid artery diameter. Given concern for stenosis with primary repair a bovine pericardial patch angioplasty was performed. We present a paradigm for extracranial carotid thrombectomy with therapeutic anticoagulation for COVID-related spontaneous arterial thrombosis.

Hybrid Paraclavicular Decompression for Venous Thoracic Outlet Syndrome with Primary Endovascular Reconstruction.

BACKGROUND: Venous thoracic outlet syndrome (vTOS) is characterized by severe stenosis and potential thrombosis of the axillary-subclavian vein (effort thrombosis) with significant effects on patient mobility, quality of life, and risks associated with possible anticoagulation. Treatment goals are aimed at symptomatic improvement and freedom from recurrent thrombosis. To date, there exist no clear protocols or recommendations on surgical approach that result in optimal outcomes. We highlight our institution's experience with a systematized, paraclavicular approach with intraoperative balloon angioplasty only, if needed. METHODS: This was a retrospective case series identifying 33 patients that underwent thoracic outlet decompression for vTOS from 2014 to 2021 via paraclavicular approach at Trinity Health Ann Arbor. Demographics, presenting symptoms, perioperative details, and follow-up details describing symptomatic improvement and imaging surveillance were obtained. RESULTS: The average age of our patients was 37 years with the most common presenting symptoms of pain and swelling (91%). The average time from diagnosis to thrombolysis for effort thrombosis was 4 days, with an average time to operative intervention of 46 days. All patients underwent a paraclavicular approach with full first rib resection, anterior and middle scalenectomy, subclavian vein venolysis, and intraoperative venogram. Of these, 20 (61%) underwent endovascular balloon angioplasty, 1 required balloon with stent placement, 13 (39%) required no additional intervention, and no patients required surgical reconstruction of the subclavian-axillary vein. Duplex imaging was used to evaluate recurrence in 26 patients at an average of 6 months postop. Of these, 23 demonstrated complete patency (89%), 1 demonstrated chronic nonocclusive thrombus, and 2 demonstrated chronic occlusive thrombus. Almost all our patients (97%) had moderate or significant improvement of their symptoms. None of our patients required a subsequent operation for recurrence of symptomatic thrombosis. The mode length of anticoagulation use postoperatively was 3 months, with an average use of 4.5 months. CONCLUSIONS: A systematized surgical approach of paraclavicular decompression for venous thoracic outlet syndrome with primary endovascular balloon angioplasty carries minimal morbidity with excellent functional results and symptomatic relief.

Ten-year experience of infrainguinal bypass with endoscopic vein harvest.

OBJECTIVES: There is conflicting data comparing minimally invasive vein harvest (MIVH) using endoscopic technique and open vein harvest (OVH) in terms of bypass patency, wound infection incidence, and patient morbidity. Our institution has performed MIVH since 2003 for peripheral bypass procedures with a consistent team of specialized endoscopic vein harvesters. This study reviewed the major outcomes of MIVH infrainguinal bypass at our institution given a predominant cohort of critical limb ischemia. METHODS: We performed a 10-year, retrospective, single-institution review from January 2005 to December 2014, identifying all patients undergoing MIVH for obstructive infrainguinal disease. Primary outcomes were primary patency, operative time, intraoperative complications, surgical site infection (SSI), and freedom from amputation. RESULTS: A total of 289 patients (70% male) underwent MIVH infrainguinal bypass at an average age of 68 ± 12 years old, an obesity prevalence of 28%, and with critical limb ischemia in 81% of the patient cohort (20% rest pain, 61% tissue loss/gangrene). Ninety-four percent of patients had no intraoperative complications, 2.5% had adverse cardiac or technical complications, and 4.2% of patients required transfusion. Average operative time was 4.2 h. Femoral-popliteal TASC classification C and D constituted 80% of our patient cohort. At the last follow-up, toe pressures had increased from 30 ± 30 to 62 ± 40 mmHg (p < 0.0001). Primary bypass patency in the first 30 days was 95%. SSI incidence requiring surgical treatment was only 6%. Our median length of stay was 4.0 days, with median intravenous narcotic use of 1 day. In addition, 77% of patients returned to their baseline mobility at first follow-up (median 19 days), and 83% of patients had freedom from amputation at last follow-up (median 820 days). CONCLUSIONS: In a center with experience in MIVH and a consistent group of experienced endoscopic vein harvesters, MIVH bypass has excellent patency, low surgical site infection, short length of stay, and prompt return to baseline mobility.