Distal Superior Mesenteric Artery Endarterectomy Remains an Excellent Option for Mesenteric Revascularization in the Endovascular Era.

BACKGROUND: Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be used. Herein, we present 2 cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. METHODS/RESULTS: Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status after placement of a proximal SMA stent and was transferred to our institution because of concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up, and radiographic imaging at 2 months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with postprandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with a stent was not successful because of flush occlusion of the SMA approximately 1 centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The postoperative course was uneventful, and at 1-month follow-up, she reported continued improvement in pain and appetite. CONCLUSIONS: SMA endarterectomy can be successfully performed on mid to distal lesions of the SMA. This operation should remain a viable option in the management of CMI.

Type B Aortic Dissection Complicated by Intimo-Intimal Intussusception and Extensive Intimal Denuding: Case Report with Long-term Follow-up.

BACKGROUND: Acute aortic dissection rarely results in circumferential dissections of the aortic intima that may lead to intimo-intimal intussusception (IIS) with complete separation from the aortic wall. Circumferential dissection may then result in distal embolization of the involved intima and media, adding considerable complexity to the management of such cases. Despite the severity of this complication, the natural history of aortic disease following extensive intimal denuding and IIS is not well documented in the literature. Here we present a case with long-term follow-up of type B aortic dissection (TBAD) complicated by IIS and embolization of the intima into the distal aorta following thoracic endovascular aortic repair. METHODS: Medical records and imaging studies were retrospectively reviewed with the approval of the Institutional Review Board. A single patient underwent repair of a TBAD that was complicated by IIS, with follow-up for 6 years. Aortic recovery was monitored with serial computerized tomography scans. RESULTS: During endovascular stent deployment, the patient's dissection progressed circumferentially, leading to distal embolization of the intima and aortic occlusion. An open transabdominal aortic exploration was performed to extract the embolized intima. Despite this severe aortic structural disruption, the patient recovered well postoperatively and exhibited favorable aortic remodeling over long-term follow-up. The denuded aorta did not rupture or develop progressive worsening aneurysmal dilation and the diameter of the involved aortic segment remained stable during follow-up. CONCLUSIONS: Acute TBADs can progress to circumferential intimal separation and IIS when managed with endovascular stenting and balloon dilation. Continued endovascular management once IIS has occurred may lead to further intimal damage, resulting in distal embolization of the intima and aortic occlusion. Thus, IIS may require conversion to open repair. However, in the event that loss of the aortic intima does occur following IIS, it is possible for the denuded aorta to recover well and remain stable with favorable remodeling over long-term follow-up.

Practice Makes Perfect: Introducing a Question Bank for ABSITE Preparation Improves Program Performance.

BACKGROUND: The American Board of Surgery In-Training Examination (ABSITE) is an important predictor of passing the Qualifying Examination and a determinant of fellowship competitiveness. OBJECTION: Study the impact of providing program-wide access to a commercially available question bank for ABSITE preparation. STUDY DESIGN: The surgery residency program purchased access to the TrueLearn question bank in 2018 A paired sample t test analysis compared the 2018 ABSITE percentage and percentile scores, prior to practice question bank access to 2019 ABSITE percentile scores. A simple linear regression analysis was calculated to predict improvement in percentage scores from 2018 to 2019 based on total number of practice questions as well as number of correct practice questions completed. Data were analyzed using SPSS. RESULTS: Among the residents utilizing practice questions with serial exam scores, the individual resident ABSITE percentage of correct questions showed a statistically significant improvement after introduction of the question bank from 2018 (mean = 68.7, standard deviation = 7.3) to 2019 (mean = 72.2, standard deviation = 7.2; t(35) = -4.529, p < 0.001). A statistically significant regression equation both linear (F(1,33) = 6.274, p = 0.017) and logarithmic (F(1,33) = 7.405, p =0.01) was found with an R2 of 0.160 and 0.183, respectively, for total number of practice questions completed, signifying that more completed practice questions correlated with a higher improvement in ABSITE percentage score. The improvement in residents' ABSITE percentage score increased by 3 ± 1 percentage point for each 100 practice questions completed from 2018 to 2019 (Figure 1). A significant regression equation was also found for improvement in percentage score among all residents (F (1,33) = 8.211, p = 0.007) with an R2 of 0.199 for the number of correct practice questions completed. CONCLUSION: Use of a commercial question bank improved overall ABSITE scores. More questions answered translated into improved performance. Percent correct on the practice questions also correlated strongly with performance. Programs seeking to improve scores may wish to provide access to a question bank.