Anatomic Variation of the Phrenic Nerve and Brachial Plexus Encountered during 100 Supraclavicular Decompressions for Neurogenic Thoracic Outlet Syndrome with Associated Postoperative Neurologic Complications.

BACKGROUND: The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS: A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS: In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS: Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.

Infraclavicular Thoracic Outlet Decompression Compared to Supraclavicular Thoracic Outlet Decompression for the Management of Venous Thoracic Outlet Syndrome.

BACKGROUND: The treatment of venous thoracic outlet syndrome (VTOS) requires surgical decompression often combined with catheter-directed thrombolysis and venoplasty. Surgical options include transaxillary, supraclavicular, or infraclavicular approaches to first rib resection. The optimal method, however, has yet to be defined. The purpose of this study is to compare the outcomes of patients who underwent infraclavicular versus supraclavicular surgical decompression for VTOS. METHODS: A retrospective review of patients who underwent surgical management for VTOS from December 2010 to November 2017 was performed. During the study period, supraclavicular and infraclavicular approaches were chosen according to surgeon preference. Patient demographics, pre- and postdecompression interventions, perioperative outcomes for each group of patients were analyzed. RESULTS: Thirty patients underwent surgical management of VTOS, of which 15 (50%) underwent infraclavicular decompression and 15 (50%) supraclavicular decompression. The mean age of patients was 32.1 ± 13.6 years and 80% were male. Twenty-six patients (86.7%) presented with thrombotic VTOS. Acute axillosubclavian vein thrombosis was present in 20 (76.9%) of these patients, 10 patients in each group. Subacute or chronic thrombosis was encountered in the remaining 6 (23%) patients, 2 patients in the infraclavicular group and 4 patients in the supraclavicular group. Preoperative thrombolysis was utilized in 7 (46.7%) and 6 (40%) patients in the infraclavicular and supraclavicular groups, respectively (P = 1.00). Patients without postdecompression venography were removed from analysis and included 1 patient in the infraclavicular group and 5 patients in the supraclavicular group. Initial postdecompression venogram, prior to any endovascular intervention, demonstrated a residual axillosubclavian vein stenosis of greater than 50% in 6 (42.9%) patients in the infraclavicular decompression group and 7 (70%) patients in the supraclavicular decompression group (P = 0.24). Crossing the stenosis after surgical decompression was more easily accomplished in the infraclavicular group, 14 (100%) versus 5 (50%), (P = 0.01). Following endovascular venoplasty, calculated residual stenosis greater than 50% was found in 0 (0%) and 3 (30%) patients in the infraclavicular and supraclavicular approaches, respectively (P = 0.047). Infraclavicular thoracic outlet decompression was associated with fewer patients with postoperative symptoms, 0 of 15 (0%) versus 8 of 15 (53.3%), (P = 0.0022), and infraclavicular thoracic outlet decompression demonstrated improved patency, 15 of 15 (100%) versus 8 of 15 (53.3%), (P = 0.028) at a mean combined follow-up of 8.47 ± 10.8 months. CONCLUSIONS: Infraclavicular thoracic outlet decompression for the surgical management of VTOS was associated with fewer postoperative symptoms and improved axillosubclavian vein patency compared to the supraclavicular approach. Prospective analysis is warranted to determine long-term outcomes following infraclavicular decompression.

Intraoperative duplex ultrasound criteria for performing interposition bypass in the treatment of popliteal artery entrapment syndrome.

We present a case series of 3 surgical procedures (2 patients) in which intraoperative duplex ultrasound (IDUS) was used to determine whether the chronic compression of the popliteal artery caused by popliteal artery entrapment syndrome had injured the artery to such a degree that interposition bypass was required. Patients initially underwent standard clinical evaluation including history and physical examination and noninvasive diagnostic testing including postexercise ankle-brachial indexes and angiography with evocative maneuvers before surgery. IDUS was performed. Doppler was used to calculate peak systolic velocities (PSVs) and velocity ratios (VRs) across areas of suspected injury. B-mode was used to assess arterial wall thickness (AWT) and sclerotic changes. Patients were followed in the postoperative period with surveillance duplex ultrasound (US). Three limbs (2 patients) underwent IDUS evaluation after popliteal decompression. Limb 1 demonstrated an elevated intraoperative PSV of 295 cm/sec with an elevated VR of 2.52 (295/117 cm/sec) and AWT of 1.1 mm. Interposition bypass was performed after popliteal decompression. Postoperative surveillance duplex US revealed a reduction of the PSV to 90 cm/sec. Limb 2 showed a mildly elevated intraoperative PSV of 211.5 cm/sec with a VR of 1.86 (211.5/114 cm/sec) and AWT of 0.8 mm. An interposition bypass was not performed. Limb 3 demonstrated an elevated intraoperative PSV of 300 cm/sec with an elevated VR of 2.51 (300/119.5 cm/sec) and AWT of 1.0. Interposition bypass was performed. Postoperative surveillance duplex US revealed a reduction of the PSV to 115 cm/sec. IDUS was very helpful in the operative management and intraoperative decision making process for popliteal artery entrapment. An elevated PSV of 250-275 cm/sec or greater on IDUS and a VR of 2.0 or greater, in conjunction with B-mode demonstration of arterial wall injury, was useful in identifying severely injured popliteal arterial segments. Additional prospective studies are warranted to further investigate objective criteria that indicate the need for bypass.

Endovascular treatment of bilateral carotid artery pseudoaneurysms after blunt carotid injury.

The detection of blunt carotid artery injures has improved because of more aggressive screening protocols. Initial treatment depends on multiple factors; however, controversy exists with regard to the treatment of pseudoaneurysmal degeneration, especially in this age of endovascular treatment options. Current options include anticoagulation, open surgical repair, and endovascular repair. We report a rare case of bilateral carotid artery pseudoaneurysm degeneration after bilateral carotid artery dissection caused by blunt trauma.

Use of a Viabahn stent for repair of a common carotid artery pseudoaneurysm and dissection.

Carotid procedures in the previously operated neck are both technically demanding and subject to increased rates of complications. Adding radiation to the operated field only increases these risks. The incidence of cranial nerve injury in the reoperative neck has increased. Similarly, patients with a history of radiation are at increased risk for stroke, cranial nerve injury, and wound complications. Before the endovascular era, the only option for repair of an extracranial carotid aneurysm was open operation. Recently, more experience has been gained using endovascular techniques to repair these aneurysms. We present a patient with a history of radiation and radical neck dissection who developed a pseudoaneurysm of the common carotid artery. This pseudoaneurysm was repaired successfully using a Viabhan covered stent graft.

Use of Wall stent to exclude a thrombosed inferior vena cava filter.

The use of inferior vena cava (IVC) filters has increased dramatically over the last two decades. Thrombosis of the IVC is a potentially catastrophic complication of caval filter placement, and its reported incidence ranges 3.6-11.2%, depending on filter type. We present a 69-year-old female with a history of deep vein thrombosis of the right leg. Prior to a planned spinal operation, a Gunther Tulip filter was placed (Cook Medical, Bloomington, IN). Postoperatively, the patient developed bilateral iliofemoral thrombosis that extended into the IVC filter. Several weeks passed, and after unsuccessful attempts at recanalization in the community setting, the patient was referred to our group for treatment. After an unsuccessful attempt at balloon angioplasty, two 10 x 60mm Protégé GPS stents (EV3, Plymouth, MN) were deployed in the common femoral, external, and internal iliac veins bilaterally. After an unsuccessful attempt at retrieval, the Tulip filter was excluded from the IVC using a 16 x 60mm Wall Stent (Boston Scientific, Natick, MA). Unobstructed flow was now noted from the femoral system all the way through the superior vena cava. The patient experienced immediate relief of her symptoms.

Reducing Wound Hemorrhage: Use of Bilayer Collagen Matrix in Chronic Myelogenous Leukemia.

Donor site preparation is a critical step before the application of an autologous split-thickness skin graft (STSG). Comorbidities can lead to complications and graft loss, including that due to hematoma. In this case, a bilayer collagen matrix was used as a temporary wound dressing in a 25-year-old woman with active chronic myelogenous leukemia. She presented with a bleeding diathesis and spontaneous intramuscular and intracompartmental hematomas of the right leg. She experienced ongoing high-volume blood loss from her fasciotomy wounds, requiring wound care to be performed in the operating room under general anesthesia, and requiring multiple blood and platelet transfusions. Instead of immediate STSG, a bilayer collagen matrix was placed to reduce the bleeding and further prepare the wound bed over a 9-week period while she underwent medical optimization. Once stabilized from a hematologic standpoint, STSG was performed with total graft take. Both uncontrolled chronic myelogenous leukemia and its therapy, tyrosine kinase inhibitors, have a risk of hemorrhagic and thrombotic complications. Bilayer collagen matrix serves as an adjunct in the limb salvage algorithm that can reduce transfusion needs whereas a temporary bleeding diathesis is medically corrected before the application of an autologous skin graft.

Supraclavicular Thoracic Outlet Decompression in the High-Performance Military Population.

Background: Neurogenic thoracic outlet syndrome (nTOS) is a relatively common disorder and often affects younger, physically active populations. The modern American military is a population at risk for the development of nTOS given the intense physical training requirements. The purpose of this study is to determine functional recovery in the active duty military population resulting in full, unrestricted return-to-duty status following supraclavicular thoracic outlet decompression with partial first rib resection, partial anterior scalenectomy, and brachial plexus neurolysis. Methods: This retrospective study was approved by the Institutional Review Board at Walter Reed National Military Medical Center, Bethesda, Maryland to evaluate functional recovery following the surgery management of nTOS. In accordance with the Walter Reed National Military Medical Center Institutional Review Board, patient informed consent was obtained for this study. An institutional procedural database (Walter Reed National Military Medical Center Surgery Scheduling System) was queried for consecutive patients who underwent supraclavicular thoracic outlet decompression from January 2011 to May 2015. This study involved the completion of two survey instruments: the Disabilities of the Arm, Shoulder, and Hand survey and the Cervical Brachial Symptoms Questionnaire. Patients were asked to complete the preoperative surveys and the postoperative surveys. Results: Twenty responses were obtained with a 57% (20/35) overall response rate. Due to the low sample size, results were reported as a median rather than a mean to reduce the bias of outliers. Of the 20 patients who underwent supraclavicular thoracic outlet decompression, 85% reported improved functional recovery, 10% demonstrated no improvement but maintained stable functional and symptomatic deficits, and 5% demonstrated worsening of their functional and symptomatic status. The median total preoperative Disabilities of the Arm, Shoulder, and Hand score was calculated at 112 (interquartile range [IQR] 94-122) with an overall score reduction demonstrated by the median total postoperative Disabilities of the Arm, Shoulder, and Hand score of 50 (IQR 40-71). The median total score reduction of 57 (IQR 28.5-72) represented improved clinical and functional recovery (p < 0.001). The median total preoperative Cervical Brachial Symptoms Questionnaire score was 96 (IQR 74-111) with an overall score reduction revealed by the median total postoperative Cervical Brachial Symptoms Questionnaire score of 28 (IQR 19-45). The median total score reduction of 60 (IQR 23-77) reflected significant functional recovery consistent with clinical improvement (p < 0.001). Around 89% of patients had a predecompression temporary profile secondary to physical debilitation directly related to nTOS. Following surgery, temporary profile status was reduced to 39%. Around 61% of patients were able to complete and pass their service-specific physical fitness testing. Around 56% of patients demonstrated a full return-to-duty status without limitations. Conclusion: Supraclavicular partial first rib resection, partial anterior scalenectomy, and brachial plexus neurolysis results in significant improvement in functional recovery in the military active duty patient population. Prospective studies are warranted to further characterize and define nTOS functional recovery after surgery in this population.

Surgical Repair of Abdominal Aortic and Renal Artery Aneurysms in Takayasu's Arteritis.

Takayasu's arteritis is a large vessel vasculitis that can be a challenging diagnosis to make and has a varied clinical presentation. Management largely depends on affected vessel disease severity and individual patient considerations. The diagnosis must be considered in a young patient with large vessel aneurysms. We present a case of a 30 year-old woman of Pacific Islander descent who presented to the Tripler Army medical Center Vascular Surgery Department in Honolulu, Hawai'i seeking repair of her abdominal aortic and renal artery aneurysms prior to conception. A 30 year-old Pacific Islander woman with a history of a saccular abdominal aortic aneurysm and renal artery aneurysms presented to our clinic seeking vascular surgery consultation prior to a planned pregnancy. She had a renal artery stent placed at an outside institution for hypertension. She met the diagnosis of Takayasu's arteritis by Sharma's criteria. Physical exam was significant for a palpable, pulsatile, abdominal mass and CT angiography revealed a saccular irregular-appearing infra-renal abdominal aortic aneurysm, extending to the aortic bifurcation, with a maximum diameter of 3.3 cm. A right renal artery aneurysm was also identified proximally, contiguous with the aorta, with a maximal transverse diameter of 1.7 cm. The patient underwent a supraceliac bypass to the right renal artery with a 7 mm Dacron graft, as well as excision of the right renal artery aneurysm. The abdominal aortic aneurysm was replaced using a Hemashield Dacron bifurcated 14 mm x 7 mm bypass graft. Intraoperative measurements of the renal artery aneurysm were 1.5 x 1.5 cm and the saccular appearing distal abdominal aortic aneurysm measured 3.6 x 3.3 cm. The patient was discharged from the hospital 7 days post-operatively. At 1-year follow up, CT scan of the abdominal aorta revealed the repair was without any evidence of aneurysm formation, anastomotic pseudoaneurysm formation, or areas of stenosis. She has remained normotensive with a normal serum creatinine 18 months after her repair. She has since delivered her second child. It is rare for Takayasu's arteritis to present with aneurysmal disease. It is much more common to present with stenosis or occlusion. It has yet to be proven that Takayasu's truly has a higher incidence in those of Asian descent. Takayasu's can be a difficult diagnosis to make but can be aided with the use of Sharma's criteria. Our particular patient posed unique considerations on the effects of the physiology of pregnancy on her aneurysms and repair. Managing the active phases of disease is imperative, and though medical management is first line, surgical intervention may be necessary. Surgical intervention should be performed in a quiescent period of disease if possible given that biological inflammation at the time of intervention increases the complication rate. Repair of aneurysmal disease in a young female should also be considered prior to pregnancy.

The effect of changing gamma count threshold on sentinel lymph node accuracy.

PURPOSE: Sentinel lymph node (SLN) biopsy has been increasingly accepted in many centers as an alternative to axillary lymph node dissection in the nodal staging of breast cancer. The goal of SLN biopsy is to accurately stage the axilla while minimizing postoperative morbidity. Theoretically, the continuing search for SLNs disrupts additional lymphatics and impacts on operative time. The gamma count threshold is a predefined threshold percentage of the ex vivo count of the "hottest" SLN, which when applied to each individually excised lymph node determines whether a given lymph node is the SLN or a non-SLN. The higher the threshold percentage, the less the number of lymph nodes will meet the criteria of being an SLN. This study examines the hypothesis that changing the gamma count threshold from 10% to 50% will not significantly affect accuracy or the false-negative rate. METHODS: We retrospectively reviewed the charts of patients who underwent SLN biopsy with or without completion axillary lymph node dissection from March 1995 to January 2001 at Walter Reed Army Medical Center. Data were collected on gamma counts for each SLN and histopathology of each SLN. For each SLN ex vivo gamma count, percentage of the ex vivo gamma count of the "hottest" SLN was calculated. RESULTS: The SLN identification success rate was 94% (163 out of 174 patients). On average, 2.07 SLNs were removed per patient and 58% of patients had more than 1 SLN removed (94 out of 163 patients). Only 10% had 4 or more SLNs removed (17 out of 163 patients). Sentinel lymph node metastasis was found in 21% of patients (35 of 163 patients). Of these 35 patients with positive SLNs, 8 patients had a negative "hottest" SLN when a less radioactive SLN was positive for metastasis. Changing the gamma count threshold from 10% to 50% lowers the extrapolated accuracy from 98% to 95% and increases the extrapolated false-negative rate from 8% to 21%. CONCLUSIONS: The accuracy and false-negative rate of SLN biopsy varies based on the lower limit gamma threshold. Maintaining our 10% gamma count threshold results in acceptable accuracy and false-negative rates comparable to reported literature.

Obstruction of the celiac axis resulting in a pancreaticoduodenal artery aneurysm.

A 47-year-old woman complained of abdominal pain, and a computed tomography scan indicated compressive obstruction of the celiac axis and a 4-cm retropancreatic aneurysm. An angiogram identified the aneurysmal vessel as the posterior pancreaticoduodenal artery. All foregut structures were supplied by this aneurysmal vessel. Via an open approach, the inflow and outflow of the aneurysm were ligated, and blood flow to the celiac axis was reconstructed via a bypass from the supraceliac aorta. A follow-up scan indicated complete thrombosis of the aneurysm. The patient is now symptom free. Open reconstruction of the celiac axis is mandatory when ligation of a pancreaticoduodenal aneurysm results in foregut ischemia. Ligation and reconstruction can be done safely and effectively in the elective setting.

Endovascular placement of the venous limb of a dialysis access graft using a Gore TAG introducer sheath in a patient with a difficult access.

Few situations are as vexing for vascular surgeons and their patients as the need for placement of permanent dialysis access when very few access sites remain viable. We recently encountered a patient who typifies this group. After venoplasty of the patient's right femoral and iliac veins, we placed a right superficial femoral artery to inferior vena cava 6-mm polytetrafluoroethylene graft. Under fluoroscopic guidance, we placed the venous limb of the graft directly into the inferior vena cava using a 24-French Gore thoracic aortic graft (TAG) introducer sheath. We secured the venous limb with a purse-string suture at the entrance site in the femoral vein. A standard end-to-side arterial anastomosis was performed. The access has worked without issue for over a year at this point.