Giant 20 × 35 cm brachial artery pseudoaneurysm after fistulogram treated with surgical resection of pseudoaneurysm and patch angioplasty of brachial artery.

Brachial artery pseudoaneurysms are a rare entity, which can occur secondary to infectious, traumatic, or iatrogenic causes. We present a 78-year-old female with end-stage renal disease on hemodialysis via a right brachio-basilic arteriovenous fistula. She had previously undergone numerous fistulograms and endovascular interventions for right upper extremity swelling due to prolonged bleeding following dialysis. After a recent fistulogram she developed recurrent arm swelling. Duplex showed a large hematoma without any evidence of vascular flow. However, intraoperatively, she was noted to have a giant 20 × 35 cm pseudoaneurysm of the brachial artery. Therapeutic options include endovascular stenting, embolization, thrombin injection, ultrasound-guided compression, and surgery. We elected to perform resection of the large pseudoaneurysm and arteriovenous fistula ligation due to the large size. Given her end-stage renal disease status and lacking quality autogenous vein, we were able to perform a patch angioplasty repair of her brachial artery without requiring a bypass.

Endovascular salvage of occluded renal artery after >15 hours of ischemic time.

In severe cases of acute traumatic injury to the kidney, immediate intervention is necessary to avoid irreversible ischemic damage. This case involves a 24-year-old woman who presented with signs of right renal devascularization after a high-speed all-terrain vehicle accident. Due to transport from an outside hospital, there was >15-hour delay before evaluation by vascular surgery. Considering her young age, we elected to salvage this patient's kidney via percutaneous endovascular stenting to mitigate any further prolongation of renal artery occlusion and prevent long-term sequelae. After intervention, her acute kidney injury resolved, and her creatinine levels normalized. As illustrated in this case, recovery of the renal parenchyma remains a possibility despite an extended warm ischemic time, providing evidence for future young patients to be considered for renal salvage.

Endovascular Coil Embolization of an Enlarging Gastroduodenal Artery Aneurysm.

Gastroduodenal artery aneurysms are a rare type of visceral aneurysm that can lead to rupture and death. We present a 75-year-old male with history of hypertension, diabetes, and hyperlipidemia with an incidental finding of a 3.2 × 3.7 cm gastroduodenal aneurysm found on abdominal computed tomography angiography (CTA). After refusing surgical intervention, he was seen two years later and presented with an enlarged gastroduodenal aneurysm, now 5.0 × 5.1 cm, visible on a repeat abdominal CTA. Upon his continued refusal for an open surgery, we elected for endovascular repair of this GDA aneurysm via coil embolization.

Giant isolated profunda femoris artery aneurysm treated with aneurysmal ligation without profunda femoris artery revascularization.

Isolated nonruptured profunda femoris artery (PFA) aneurysms are exceedingly rare. We present the case of an 80-year-old man who initially presented with a large pulsatile mass in the right groin. Computed tomography angiography identified a giant 6-cm PFA aneurysm. This was a truly isolated PFA aneurysm without any evidence of concomitant abdominal aortic or popliteal aneurysms. Potential surgical options included reconstruction with an interposition graft, endovascular coil embolization, and aneurysmal ligation. We elected to perform aneurysmal ligation of the PFA aneurysm without revascularization given the aneurysm's massive size and patency of the superficial femoral artery.

Implementing Workplace-Based Assessments at Scale: The SIMPL Approach.

Over the past decade, medical education has shifted from a time-based approach to a competency-based approach for surgical training. This transition presents many new systemic challenges. The Society for Improving Medical Professional Learning (SIMPL) was created to respond to these challenges through coordinated collaboration across an international network of medical educators. The primary goal of the SIMPL network was to implement a workplace-based assessment and feedback platform. To date, SIMPL has developed, implemented, and sustained a platform that represents the earliest and largest effort to support workplace-based assessment at scale. The SIMPL model for collaborative improvement demonstrates a potential approach to addressing other complex systemic problems in medical education.

Cyclically bleeding trocar-site endometrioma without known history of endometriosis: case report and literature review.

Endometriosis occurrence at a laparoscopic trocar-site incision is extremely rare with only 30 previous cases published. We present a 43-year-old female with surgical history of two cesarean sections and a laparoscopic Roux-en-Y gastric bypass who presented with history of cyclical bleeding from an umbilical mass coinciding with her menstrual cycle. Ultrasound demonstrated a complex solid and cystic lesion measuring 2.5 x 1.4 x 1.4 cm. This umbilical mass was surgically resected and gross examination perioperatively demonstrated dark-colored cystic implants consistent with endometrioma. Pathology confirmed the suspected diagnosis of endometriosis. There are several noteworthy characteristics in this unique case of laparoscopic trocar-site endometrioma. Umbilical bleeding is an unusual presenting symptom that has not been previously reported. This endometrioma occurred at the umbilical laparoscopic site rather than her Pfannenstiel incision. Laparoscopic Roux-en-Y gastric bypass has not been previously associated with trocar-site endometrioma. Of note, this patient had no known history of endometriosis.