Chronic compartment syndrome secondary to venous hypertension: fasciectomy for symptom relief.

Chronic compartment syndrome (CCS) from venous hypertension following lower leg deep venous thrombosis or severe venous insufficiency is rare and often difficult to diagnose. Although ileocaval stenting and thrombolysis have improved claudication symptoms related to outflow venous disease, chronic calf claudication from distal vein thrombosis and venous insufficiency have historically been managed with rest, compression, and elevation. Often, conservative options give inadequate symptom relief and active individuals are rarely compliant. We report the presentation, workup, and treatment with fasciectomy for lower leg CCS secondary to venous hypertension. Fasciotomy and fasciectomy have been used for atypical claudication secondary to classic overuse CCS with symptom relief for many individuals. This case illustrates the recognition of claudication induced by CCS secondary to venous insufficiency and an approach to treatment with fasciectomy with a promising outcome.

Foot claudication with plantar flexion as a result of dorsalis pedis artery impingement in an Irish dancer.

Dorsalis pedis artery impingement is an extremely rare cause of foot claudication, with a single case reported in the literature. In this report, we describe the case of a 17-year-old female Irish dancer who presented with intermittent bilateral foot pain and discoloration during active plantar flexion.

Functional popliteal artery entrapment syndrome: A poorly understood and often missed diagnosis that is frequently mistreated.

OBJECTIVES: Functional popliteal artery entrapment syndrome (FPAES) is an uncommon overuse injury in young physically active adults manifest by neuromuscular symptoms (gastroc/soleus cramping, plantar paresthesias). It is commonly confused with chronic recurrent exertional compartment syndrome (CRECS). This study evaluated the diagnostic testing, mechanism of injury, and treatment differences between FPAES and CRECS. METHODS: Between 1987 and 2007, 854 patients (557 women, 297 men; mean age, 28.5 years) were surgically treated for the diagnosis of CRECS or FPAES, or both. Compartment pressures were measured in all patients who had anterior lateral or posterior superficial calf symptoms (normal pressure or=25 mm Hg), and fasciectomy was performed for CRECS under local anesthesia (anterior lateral, 508; posterior superficial, 191; distal deep posterior, 101). The result of stress plethysmography was positive in 139 (18%), but they were asymptomatic. Forty-three patients (27 women, 16 men; mean age, 26.6 years) had positive stress plethysmography, appropriate FPAES symptoms, and normal compartment pressures. MRA/MRI in all 43 demonstrated normal musculotendinous anatomy and lateral neurovascular compression with plantar flexion. Under general anesthesia, all had excision of the soleal band, with relief from symptoms. In 19 of the 43 FPAES patients (44%), CRECS releases were done before or after FPAES surgery. Follow-up ranged from 12 to 240 months. CONCLUSION: FPAES and CRECS occur in the same population with similar symptoms but require different treatment.

Outcomes after endarterectomy for chronic mesenteric ischemia.

OBJECTIVES: A retrospective study was performed to identify optimal factors affecting outcomes after open revascularization for chronic mesenteric ischemia. METHODS: All patients who underwent open surgery for chronic mesenteric ischemia from 1987 to 2006 were reviewed. Patients with acute mesenteric ischemia or median arcuate ligament syndrome were excluded. Mortality, recurrent stenosis, and symptomatic recurrence were analyzed using logistic regression, and univariate and multivariate analysis. RESULTS: We identified 80 patients (69% women, 31% men). Mean age was 64 years (range, 31-86 years). Acute-on-chronic symptoms were present in 26%. Presenting symptoms included postprandial pain (91%), weight loss (69%), and food fear and diarrhea (25%). Preoperative imaging demonstrated severe (>70%) stenosis of the superior mesenteric artery in 75 patients (24 occluded), the celiac axis in 63 (20 occluded), and the inferior mesenteric artery in 53 (20 occluded). Multivessel disease was present in 72 patients (90%), and 40 (50%) underwent multivessel reconstruction. Revascularization was achieved by endarterectomy in 37 patients, mesenteric bypass in 29, and combined procedures in 14. Concurrent aortic reconstruction was required in 13 patients (16%). Three hospital deaths occurred (3.8%). Mean follow-up was 3.8 years (range, 0-17.2 years). One- and 5-year survival was 92.2% and 64.5%. Mortality was associated with age (P = .019) and renal insufficiency (P = .007), but not by clinical presentation. Symptom-free survival was 89.7% and 82.1% at 1 and 5 years, respectively. Symptoms requiring reintervention occurred in nine patients (11%) at a mean of 29 months (range, 5-127 months). Multivariate analysis showed that freedom from recurrent symptoms correlated with endarterectomy for revascularization (5.2% vs 27.6%; hazard ratio, 0.20; 95% confidence interval, 0.04-0.92; P = .02). CONCLUSION: For open surgical candidates, endarterectomy appears to provide the most durable long-term symptom relief in patients with chronic mesenteric ischemia.

Vertebral artery embolic protection via ipsilateral brachial approach during left subclavian artery angioplasty and stenting--a case report.

The purpose of this report is to explore angioplasty and stenting with cerebral embolic protection as a salvage procedure for a compromised carotid-subclavian bypass in the presence of antegrade vertebral artery flow. A 76-year-old woman with a carotid-subclavian bypass presented with graft infection. Failure of medical therapy to treat the infection prompted surgical removal of the graft. The native subclavian artery was still patent, but a severe complex proximal stenosis was present with antegrade flow into the left vertebral artery. Angioplasty and stenting of the subclavian artery was performed with cerebral protection achieved by positioning a FilterWire EX in the left vertebral artery via the left brachial artery approach. Deployment of a filter device in the vertebral artery via the brachial or radial approach can provide embolic protection without interfering with the subclavian artery stenting. The successful treatment of the subclavian artery enabled the complete removal of the infected graft without need for major vascular reconstruction.

Diagnosis and management of chronic compartment syndrome.

BACKGROUND: This article describes the diagnosis and management of chronic compartment syndrome and functional popliteal entrapment syndrome, unusual causes for claudication in young adults. METHODS: A total of 276 patients (<50 years old) with isolated muscle cramping, swelling, and plantar paresthesia were routinely evaluated with compartment pressures (normal < 15 mm Hg), stress plethysmography, and selectively evaluated with pulse volume recordings and arteriography. RESULTS: Patients were young (mean 28.4 years) with long-standing symptoms (mean 24 months), affecting 1 or both lower extremities (32% vs 68%, respectively). Of the patients, 84 were male (30%) and 192 were female (70%). Common symptoms were isolated muscle cramping (100%) or swelling (40%), and plantar paresthesia (20%). Of 436 treated compartments, 316 were anterolateral, 70 deep-posterior, and 50 superficial-posterior. Mean compartment pressure was 28 mm Hg. Resting pulse volume recordings were abnormal in 6 patients (2.5%); 82 had positive popliteal entrapment tests (30%), but symptoms were present in only 21 (9.7%). Open fasciectomy was performed in all patients with chronic compartment syndrome or functional entrapment. Local anesthesia was used in 243 (88%) and general in 33 patients (12%). Mean follow-up was 60 months. Of the 276 patients, 92% had full relief of symptoms and returned to normal daily or athletic activity. Eight percent obtained symptomatic relief, but activity was limited because of new compartment symptoms or other orthopedic injury. CONCLUSIONS: Open fasciectomy for chronic compartment and functional entrapment syndromes is effective therapy.

Endovascular aortic repair or minimal incision aortic surgery: Which procedure to choose for treatment of high-risk aneurysms?

BACKGROUND: This study evaluates use of endovascular aortic repair (EVAR) and minimal incision aortic surgery (MIAS) for treatment of high-risk patients with infrarenal aneurysms. METHODS: A retrospective review of patients treated with EVAR or MIAS between 2000 and 2002 was performed. High-risk criteria included age older than 80 years, creatinine level greater than 3.0 mg/dL, recent myocardial infarction, congestive heart failure, severe chronic obstructive pulmonary disease, hostile abdomen, or morbid obesity (body mass index greater than 30). Patient demographics, duration of stay, morbidity, and mortality were compared. Exclusionary criteria for EVAR treatment included neck less than 1.5 cm or greater than 26 mm in diameter, densely calcified iliac arteries less than 6 mm, or creatinine level greater than 3.0 mg/dL. Exclusionary criteria for MIAS included pararenal abdominal aortic aneurysm, aneurysm greater than 10 cm, and morbid obesity. RESULTS: Eighty-four patients were treated (61 EVAR, 23 MIAS). Average age for EVAR was 74 years and 72 years for MIAS. Average aneurysm size was 6 cm for both. American Society of Anesthesiologists score was 3.1 for EVAR and 3.0 for MIAS patients. Thirty-two of 61 EVAR patients (52%) had 2 risk factors, and 12 of 61 (20%) had 3 risk factors. Seven of 23 MIAS patients (30%) had 2 risk factors, and 7 had more than 3 risk factors (30%). There were 2 EVAR deaths (3%) from multiorgan failure and 1 MIAS death (4%) from myocardial infarction. Average duration of stay was 5.1 days for both EVAR and MIAS. Thirty-day morbidity was 18% for EVAR and 17% for MIAS patients. CONCLUSIONS: EVAR and MIAS are comparable for the treatment of high-risk aneurysm patients.

Mycotic carotid artery pseudoaneurysm following stenting--a case report and lessons learned.

Carotid stenting is assuming an important role in the management of carotid disease. Surgeons although hesitant to embrace catheter treatment for the management of primary carotid artery disease, are more enthusiastic regarding it's use in the treatment of recurrent stenoses. This report suggests that caution should be exercised in the selection of patients to be treated with carotid stenting for recurrent disease.

Chronic abdominal pain and upper gastrointestinal bleeding due to duodenal perforation caused by migrated inferior vena cava filter--a case report.

The authors describe an unusual case of a 41-year-old man presenting with chronic abdominal pain and gastrointestinal bleeding caused by a migrated inferior vena cava filter eroding into the duodenum.

The social media: its impact on a vascular surgery practice.

OBJECTIVES: Social media has revolutionized interpersonal communication and has become a commonly used public informational resource. This study evaluates the impact of intranet informatics on a specialty practice of vascular surgery. METHODS: Referral patterns for patients with chronic compartment syndrome (CCS) and popliteal entrapment syndrome (PAES) between 2008 and 2011 were analyzed. Demographics included referral source (physicians, nonphysicians), media resource, and case volume change. RESULTS: Prior to 2008, referrals came from local or regional sports medicine practices (100%). Since 2008 this pattern has changed; local/regional (80%), national (15%), and international (5%). Physician referrals dropped from 97% to 70%, and nonphysician referrals increased from 3% to 30%. Both CCS procedures and PAES procedures increased as remote geographic and public referrals increased. Referral change was associated with social media searches using applications such as PubMed and Google. CONCLUSION: Social media is an evolving source of medical information and patient referrals which physicians should cautiously embrace.

Effect of early plasma transfusion on mortality in patients with ruptured abdominal aortic aneurysm.

BACKGROUND: The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA). METHODS: A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage (≥10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis. RESULTS: One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P < .03) for patients transfused at a PRBC:FFP ratio ≤2:1 (HIGH FFP group) compared with those transfused at a ratio of >2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2-14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004). CONCLUSION: For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients.

Cardiovascular service line development: what is it, who benefits and is it worthwhile?

This article describes the creation and function of a cardiovascular service line in a university healthcare-based system. In 2001, an organizational structure (service line) was created to establish accountability between vascular surgeons, cardiologists and hospital administrators. The purpose of this merger was to provide focused, efficient care of cardiovascular patients at a reduced cost. Performance measures included clinical volume change, market share, length of stay, patient satisfaction and hospital margins. Between 2000 and 2006, annual patient volumes increased from 28,140 to 38,182 patients per year (36% increase). Endovascular case volumes increased from 730 to 1591 per year. Between 2003 and 2006, the average length of stay dropped from 7.7 to 5.5 days. Hospital margins increased from an average of 2.8 to 8%. This service line has improved efficiency and care of heart and vascular patients with decreased length of stay and hospital cost.

Product line development: a strategy for clinical success in academic centers.

OBJECTIVE: Academic medical centers, which have traditionally been relatively inefficient, have increasing difficulty in meeting the missions of patient care, teaching, and research in a progressively competitive medical marketplace. One strategy for improved efficiency in patient care while keeping quality high is utilization of a product line matrix. This study addresses the outcome of utilizing a product line strategy consisting of 3 service lines during the past 5 years at the University of Wisconsin Hospital and Clinics (UWHC). METHODS: Service lines in heart and vascular surgery, oncology, and pediatrics have been organized since 2001, and report directly to hospital leadership as a product line. Service line leadership consists of a combination of medical leaders plus representatives of hospital administration, and service lines are allowed direct access to resources for program development, marketing, and resource allocation. Measurements of patient numbers, market share, length of stay, net margin, and patient satisfaction have been gathered and compared with the preproduct line era. RESULTS: In the 3 service lines, UWHC has seen variable but steady growth in patient numbers, enhanced market share, positive net margins, and improved patient satisfaction during the period of measurement. During this same period, the insurance milieu has resulted in consistent downward pressure on reimbursement, which has been offset by improved patient care efficiency as measured by length of stay, enhanced preferred provider status, and gains in market share. Scorecard measures of quality are also being developed and show enhanced teaching and research opportunities for students and trainees as well as improved Press Ganey patient satisfaction scores. CONCLUSIONS: At UWHC, the development of a product line matrix consisting of 3 service lines has resulted in more patient care efficiency, enhanced patient satisfaction, improved margin for the hospital, and enlargement of teaching and research opportunities. The key to successful implementation of the product line concept is a close working relationship between the hospital administration and service line medical leadership.

Effectiveness of intensive medical therapy in type B aortic dissection: a single-center experience.

OBJECTIVE: Although the mainstay of managing acute descending thoracic aortic dissection (ADTAD) remains medical, certain patients will require emergency surgery for complications of rupture or ischemia. This study evaluates factors that affect outcome and determines which patients previously treated surgically would have been eligible for endovascular repair. METHODS: A single-institution retrospective study was conducted of patients who presented with clinical signs of ADTAD that was confirmed by magnetic resonance angiography (MRA) or computed tomography (CT). All patients were admitted to the intensive care unit (ICU) and medically managed to maintain systolic blood pressure<120 mm Hg and heart rate<70 beats/min. Two treatment groups were identified: group 1 received medical treatment only; group 2 received medical treatment plus emergency surgery. Patient demographic and clinical data were correlated with 30-day group mortality and morbidity and need for emergency surgery. The MRA and CT scan images of group 2 were retrospectively reviewed to determine if currently available endovascular treatment could have been done. The Fisher exact test was used to compare between the groups, and P<.05 was considered significant. RESULTS: Between 1991 and 2005, 83 patients (55 men) were treated for ADTAD. The mean age was 67 years (range, 38 to 85). Sixty-eight patients (82%) had hypertension, three (3.6%) had Marfan syndrome, and 51 (62%) were smokers. Twenty-five (32%) of the patients were receiving beta-blocker therapy before the onset of their symptoms. Back pain was the most common initial symptom (72.2%). Emergency surgery was required in 19 patients (23%): 12 for rupture or impending rupture, four for mesenteric ischemia, and three for lower extremity ischemia. The need for emergency surgery was significantly higher in smokers (P=.03), in patients>70 years old (P=.035), and in patients who were not receiving beta-blocker therapy before the onset of symptoms (P=.023). The combined overall morbidity rate was 33%, and the mortality rate was 9.6%. Morbidity in group 2 was 64% and significantly higher than the 23% in group 1 (P=.00227). The mortality rate was also higher in group 2 at 31.5% compared with group 1 at 1.6% (P=.0004). Factors affecting the overall mortality included age>70 years (P=.057), previous abdominal aortic aneurysm repair (P=.018), tobacco use (P=.039), and the presence of leg pain at initial presentation (P=.013). As determined from the review of radiologic data, 11 of 13 patients with scans available for review in group 2 could have been treated with currently available endovascular grafts. CONCLUSIONS: Intensive medical therapies are effective in preventing early mortality associated with ADTAD. Predictably, the need for emergency surgery carries a high morbidity and mortality rate. Most patients in this series requiring emergency surgery could have been candidates for endovascular therapy had it been available.

Limb-salvage angioplasty in vascular surgery practice.

OBJECTIVE: To assess outcomes of percutaneous infrainguinal arterial angioplasty for treatment of chronic limb-threatening ischemia (CLI) in poor surgical candidates. METHODS: A retrospective clinical analysis of 67 consecutively treated patients (76 limbs) with CLI over a 33-month period was performed. Patients were considered poor surgical candidates because of absent distal target vessels (31 limbs), severe comorbid conditions (36 limbs), or lack of an autologous vein for distal bypass (9 limbs). Limb salvage was defined as preservation of a functional foot without the need for a prosthesis. Technical success was defined as the ability to percutaneously recanalize the arterial segment with less than 30% residual stenosis. Clinical success was healing of ulcers or minor amputation sites, resolving rest pain, or avoiding a major amputation. Successful technical and clinical outcomes were correlated with patient demographics, clinical presentation, and TransAtlantic Inter-Society Consensus arterial lesion characteristics by using the Fisher exact test. RESULTS: Seventy-six limbs were treated for rest pain (n = 12), gangrene (n = 22), or nonhealing ulcers (n = 42). There were 40 men and 27 women. The mean age was 70 years (range, 36-94 years). Lesions were located in tibial (n = 55), popliteal (n = 6), and superficial femoral (n = 15) arteries. Arterial recanalization and limb salvage was achieved in 64 (83.5%) limbs. Technical failure (n = 12) correlated with TransAtlantic Inter-Society Consensus D lesions ( P = .009) and the presence of occlusion ( P = .027). Clinical failure (major amputation, n = 12) correlated with the presence of gangrene ( P = .032) or the combination of diabetes, arterial occlusion, and gangrene ( P = .018). The single variables of age, sex, diabetes, and renal failure did not adversely affect outcomes. There was one mortality (myocardial infarction), and there were two major morbidities (femoral artery pseudoaneurysm and sepsis). CONCLUSIONS: Peripheral arterial angioplasty should be considered as an alternative to primary amputation in selected patients with CLI who are poor candidates for traditional surgical bypass.

Clinical review of patients treated for atypical claudication: a 28-year experience.

PURPOSE: This article describes patient demographic data, as well as diagnosis and treatment of symptomatic lower extremity claudication that has no apparent vascular or orthopedic cause. METHODS: A retrospective review was performed of records for 843 patients who received surgical treatment between 1975 and 2003. All patients had a detailed history, and underwent physical examination and selected noninvasive vascular testing. Noninvasive popliteal entrapment screening tests and compartment pressure measurements for isolated superficial muscle pain were routine. Duplex scanning or arteriography were used only when arteriovenous disease or popliteal entrapment syndrome was suspected. RESULTS: The study population included 549 female patients (65%) and 294 male patients (35%). Their mean age was 29 years (range, 12-71 years). The most common symptoms were isolated lower extremity muscle cramping (100%), foot paresthesia (20%), and medial tibial bone pain (1%). Causes of symptoms included chronic compartment syndrome (796 patients, 94%), functional popliteal entrapment syndrome (33 patients, 4%), and medial tibial syndrome (14 patients, 2%). Pathologic findings included overuse injury (756 patients, 89%), blunt limb trauma (60 patients, 7%), or gait anomaly (34 patients, 4%). Surgery for compartment release included fasciotomy (100 patients, 12%) or fasciectomy (696 patients, 88%). Surgery for functional popliteal entrapment included excision of the plantaris muscle and soleal band (33 patients). Medial tibial release included soleal and transverse fasciectomy, with periosteal cautery of the tibial insertions. Complete symptomatic relief was achieved in 92% of compartment release procedures, 100% of popliteal entrapment release procedures, and 80% of medial tibial release procedures. CONCLUSION: Atypical claudication represents a collection of syndromes that can be permanently and effectively treated with surgical intervention.

Arterial tumor embolism caused by metastatic melanoma: case report and literature review.

Arterial tumor embolization is a rare complication of neoplasms. This report describes a 64-year-old female with metastatic melanoma and acute arterial embolization to the left lower extremity. With surgical embolectomy, a clot was retrieved that had an atypical bland solid lead point. Pathologic examination confirmed metastatic melanoma. Further echocardiography revealed an intracardiac mass consistent with metastatic disease. The patient was seen a month later with embolization to the right middle cerebral artery.

Minimal incision aortic surgery (MIAS).

This study evaluates the clinical and economic impact of using less extensive minimal invasive aortic surgery (MIAS) for elective treatment of infrarenal aortic aneurysms (AAA) and aortoiliac occlusive disease (AIOD) in two independent surgical departments. Surgeons from two institutions conducted a prospective consecutive, nonrandomized analysis of MIAS electively performed in 80 patients. MIAS outcomes were compared with 80 consecutive elective standard open aortic procedures (40 from each institution), which were performed during the same time period. Cost analyses for MIAS and standard open repair were performed at each institution. Our results indicated that MIAS is as safe as standard open repair, is more cost-effective, and has significantly shorter hospital stays than with standard open repair.

Endoluminal repair of infrarenal AAA in the presence of aortic dissection.

PURPOSE: To report a challenging case of infrarenal abdominal aortic aneurysm (AAA) treated with a commercial stent-graft in the face of thoracoabdominal aortic dissection. CASE REPORT: A 73-year-old patient was admitted because of acute descending thoracic and abdominal aortic dissection. He was also found to have an 8-cm infrarenal AAA. After initial medical management of the acute aortic dissection, the patient underwent endoluminal AAA repair with an AneuRx stent-graft. The completion angiogram showed that the graft was deployed in the false lumen; this complication was treated with fenestration of the intimal flap, establishing flow through both lumens. The patient's recovery was uneventful, and he was discharged on the fourth postoperative day. Follow-up at 1 year with computed tomographic angiography documented a stable descending thoracic aorta with a suggestion of a type II endoleak and no change in the aneurysm volume. CONCLUSIONS: This case illustrates the feasibility of endograft repair of infrarenal AAA with a modular stent-graft in the presence of aortic dissection extending below the renal arteries.