RESUMO
BACKGROUND: We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS). METHODS: We performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality. RESULTS: Fifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with no stenosis (group 1, 31.3%), 17 with no stenosis after angioplasty (group 2, 33.3%), 10 with residual stenosis after angioplasty (group 3, 19.7%), and 8 with complete occlusion (group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (group 1, 14 of 16; group 2, 13 of 17; group 3, 10 of 10; and group 4, 7 of 8; log-rank test, P = .5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (group 1, 16 of 16 and 9 of 9; group 2, 16 of 17 and 12 of 13; group 3, 10 of 10, 5 of 5; group 4, primary patency not obtained). There was one asymptomatic rethrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR. CONCLUSIONS: Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR.
Assuntos
Flebografia , Costelas , Síndrome do Desfiladeiro Torácico , Grau de Desobstrução Vascular , Humanos , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/cirurgia , Síndrome do Desfiladeiro Torácico/fisiopatologia , Feminino , Masculino , Estudos Retrospectivos , Adulto , Costelas/cirurgia , Costelas/diagnóstico por imagem , Adulto Jovem , Resultado do Tratamento , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Fatores de Tempo , Veia Subclávia/diagnóstico por imagem , Veia Subclávia/cirurgia , Veia Axilar/diagnóstico por imagem , Veia Axilar/cirurgia , Cuidados Intraoperatórios , Valor Preditivo dos Testes , Terapia Trombolítica/efeitos adversosRESUMO
Acute mesenteric ischemia from thromboembolic occlusion is a life-threatening emergency associated with a high mortality rate. Prompt diagnosis and intervention are vital to preserve viable bowel and prevent mortality. In the past decade, a shift has occurred toward minimally invasive alternatives such as endovascular therapies. We present a case of acute mesenteric ischemia from superior mesenteric artery thrombosis treated promptly with the Penumbra suction thrombectomy device (Penumbra Inc).
RESUMO
Isolated external iliac vein aneurysm is exceedingly rare, not well-described in the literature, and presents several potential surgical approaches. Herein, we describe the case of a 72-year-old woman who presented with incidentally found 4.3 cm × 3.4 cm × 5.6 cm right external iliac vein aneurysm after undergoing magnetic resonance imaging for orthopedic work-up. She was treated via parallel supra- and infra-inguinal incisions and novel combination of primary aneurysmorrhaphy with intraluminal balloon mandrel-assisted closure. The patient was discharged on postoperative day two, and 6-month follow-up ultrasound showed a normal caliber vessel with normal compressibility, suggesting this technique is safe and effective for appropriately selected patients.
RESUMO
Renal artery pseudoaneurysms have been infrequently reported in the literature. In the present report, we have described a case of a ruptured renal artery pseudoaneurysm requiring coil embolization. A 49-year-old man had presented to our institution with a hypertensive emergency. Computed tomography revealed a 3.4-cm right renal artery pseudoaneurysm. Nonemergent coil embolization was planned for the following day. However, he became hypotensive, exsanguinating frank blood from the urethra. An arteriogram showed extravasation of contrast into the pseudoaneurysm sac, renal pelvis, and ureter, consistent with intrarenal pseudoaneurysm rupture. We have demonstrated coil embolization as a method of repairing a ruptured renal artery pseudoaneurysm with gross hematuria.
RESUMO
Endovascular aneurysm repair has dramatically changed the management of abdominal aortic aneurysms as an alternative to open repair. However, complications can occur, including stent graft migration, kinking, and occlusion, leading to compromise of the excluded aneurysm walls and acute limb ischemia. In the present report, we have described a case of migration and kinking of an abdominal aortic stent graft in the main body that led to occlusion of the abdominal aorta and bilateral acute limb ischemia. The patient required emergent explantation of the stent graft and open repair of the abdominal aneurysm with a rifampin-soaked Dacron graft, which achieved a favorable outcome.
RESUMO
Giant abdominal aortic aneurysms (AAAs) are defined as AAAs >10 to 13 cm in the maximum transverse diameter. We have described a case of a patient who had presented for open repair of an 18-cm AAA and a review of reported cases of giant AAAs >10 cm in the maximum transverse diameter. Forty cases were compiled. The average maximum AAA diameter was 14.5 ± 4.1 cm. The AAA was ruptured on presentation in 12 patients (30%). Of the 40 cases, 34 (85%) were repaired with open surgery. The reported mortality was 15%. Despite the case complexity, five endovascular repairs were attempted.
RESUMO
BACKGROUND: In 2006, the Accreditation Council for Graduate Medical Education (ACGME) approved an integrated 5-year vascular surgery residency program creating a 2-tiered system of training for vascular surgeons. The question remains if the new paradigm is equivalent to the traditional training. The true test of this may be looking at data from fully trained surgeons in their first years of practice. It is hard to obtain this data. There are surrogate methods that can be used. Operative experience of trainees is readily available as a substitute. The purpose of this study is to compare the operative experience of those graduating from the traditional (5 + 2) vascular training program with the integrated (0 + 5) program. METHODS: National operative case log data supplied by the ACGME was gathered and organized for vascular surgery residents graduating between 2013 and 2019. Mean case numbers were compared between integrated vascular residents and traditional vascular fellows (mean case numbers for vascular fellows included cases from their general surgery residencies). RESULTS: The 5 + 2 trainees performed an average of 35% more total procedures than the 0 + 5 trainees (1,662 ± 7 vs. 1,084 ± 12). The greater number of overall procedures performed by the 5 + 2 trainees was primarily realized by an increased number of abdominal (e.g., biliary, small/large intestine) cases. However, the 0 + 5 trainees performed 8% more vascular procedures (858 ± 10 vs. 794 ± 3). The greater number of vascular procedures performed by the 0 + 5 trainees was primarily realized by increased mean numbers of endovascular and venous procedure cases. CONCLUSIONS: The integrated 0 + 5 graduates performed more total vascular procedures than their 5 + 2 counterparts. The overall total operative experience remains greater for the traditional 5 + 2 graduates, given their additional 2 years of training. Further longitudinal studies will be needed to fully assess the effect of the newer integrated 0 + 5 training paradigm.
Assuntos
Educação de Pós-Graduação em Medicina , Internato e Residência , Cirurgiões/educação , Procedimentos Cirúrgicos Vasculares/educação , Carga de Trabalho , Currículo , Escolaridade , Humanos , Fatores de TempoRESUMO
Complicated type B aortic dissection (TBAD) is a life-threatening condition requiring surgical intervention. One such complication in the acute or chronic setting is aneurysmal degeneration. The dissected aortic wall is weakened, and the pressures in the false lumen are often high. In the past decade, thoracic endovascular aortic repair (TEVAR) has become the treatment of choice for TBAD. TEVAR can be complicated by lack of false lumen thrombosis, increasing the risk of death. We present three cases of TBAD with patent false lumens after TEVAR that were treated by false lumen coil embolization.
RESUMO
Ureteroarterial fistula (UAF) is a rare and life-threatening source of hematuria. A high index of suspicion is warranted for early diagnosis and timely intervention. Because of high perioperative risk and comorbidities in UAF patients, the endovascular approach has become preferred for repair. Infection can complicate this mode of therapy, and treatment with antibiotics is important. Herein we present five cases of secondary UAFs treated with stent graft alone or stent graft and embolization.
RESUMO
The authors aimed to improve the rate of pre-dialysis arteriovenous (AV) access placement for hospitalized patients with advanced chronic kidney disease. The authors developed and implemented a protocol for hospitalized adult patients with an estimated glomerular filtration rate <20 mL/min to streamline the workflow for obtaining AV access. The protocol was piloted on 5 inpatient medical services over 3 months at 1 institution. Specific-Measurable-Achievable-Realistic-Timely (SMART) aims, Fishbone diagrams, Plan-Do-Study-Act cycles, and run charts were used to assess the process and outcomes of the intervention. There were 22 patients in the baseline group and 27 patients in the intervention group. Pre-dialysis AV access increased from 23% to 46%. Length of stay did not differ significantly between the baseline group (8.31 days) and the intervention group (8.4 days). Pathways can improve pre-dialysis AV access without significantly increasing length of stay.