Ankur Chandra

Classification of proximal endovenous closure levels and treatment algorithm

OBJECTIVESnEndovenous closure is a common method to treat saphenous vein incompetence. Despite attempts to prevent it, some patients have extension of thrombus above the ideal site of closure immediately below the epigastric vein. We have developed a classification system for the level of saphenous vein closure to guide further therapy after endovenous treatment.nnnMETHODSnA six-tier classification system was developed, based on thrombus proximity to the epigastric or femoral vein, and an algorithm for treatment, based on level of closure was applied to all patients.nnnRESULTSnFive hundred consecutive patients underwent radio-frequency ablation of the saphenous vein; it was successfully closed in 498 (99.6%) patients. Thirteen patients (2.6%) experienced thrombus bulging into the femoral vein or adherent to its wall, which was treated with anticoagulation. All of these patients had thrombus retraction to the level of the saphenofemoral junction (SFJ) in an average of 16 days with concurrent anticoagulation. No femoral deep venous thrombosis (DVT) occurred in the series. There was a significantly higher rate of proximal thrombus extension in those patients with a history of DVT and those with a great saphenous vein (GSV) diameter of >8 mm (P < .02).nnnCONCLUSIONSnA classification system for saphenous endovenous closure which extends above the epigastric vein has been helpful in guiding management. A GSV diameter at the SFJ of >8 mm and a history of DVT results in significantly higher rates of proximal thrombus extension into the femoral vein. A short course of LMWH, until clot retracts back into the saphenous vein, is therapeutic. Management of the patients with thrombus flush with the femoral vein wall still needs to be defined, but the outcome from these patients is generally benign.

Standardization is superior to traditional methods of teaching open vascular simulation

OBJECTIVESnStandardizing surgical skills teaching has been proposed as a method to rapidly attain technical competence. This study compared acquisition of vascular skills by standardized vs traditional teaching methods.nnnMETHODSnThe study randomized 18 first-year surgical residents to a standardized or traditional group. Participants were taught technical aspects of vascular anastomosis using femoral anastomosis simulation (Limbs & Things, Savannah, Ga), supplemented with factual information. One expert instructor taught a standardized anastomosis technique using the same method each time to one group over four sessions, while, similar to current vascular training, four different expert instructors each taught one session to the other (traditional) group. Knowledge and technical skill were assessed at study completion by an independent vascular expert using Objective Structured Assessment of Technical Skill (OSATS) performance metrics. Participants also provided a written evaluation of the study experience.nnnRESULTSnThe standardized group had significantly higher mean overall technical (95.7% vs 75.8%; P = .038) and global skill scores (83.4% vs 67%; P = .006). Tissue handling, efficiency of motion, overall technical skill, and flow of operation were rated significantly higher in the standardized group (mean range, 88%-96% vs 67.6%-77.6%; P < .05). The standardized group trended to better cognitive knowledge (mean, 68.8% vs 60.7%; P = .182), creation of a secure knot at the toe of the anastomosis, fashioning an appropriate arteriotomy, better double-ended suture placement at the heel of the anastomosis (100% vs 62.7%; P = .07), and accurate suture placement (70% vs 25%; P = .153). Seventy-two percent of participant evaluations suggested a preference for a standardized approach.nnnCONCLUSIONSnThis study demonstrates the feasibility of open vascular simulation to assess the effect of differing teaching methods on performance outcome. Findings from this report suggest that for simulation training, standardized may be more effective than traditional methods of teaching. Transferability of simulator-acquired skills to the clinical setting will be required before open simulation can be unequivocally recommended as a major component of resident technical skill training.

Chronic Mesenteric Ischemia: How to Select Patients for Invasive Treatment

Chronic mesenteric ischemia (CMI) remains a well-described disease process that is difficult to diagnose. Since its initial description more than a century ago, a myriad of diagnostic and treatment modalities have been applied to ameliorate the classic symptoms of postprandial abdominal pain and weight loss. It is estimated that mesenteric occlusive disease affects approximately 1% to 18% of the population, with a majority of these patients manifesting no symptoms of CMI. While associated with a small prevalence, the potential economic impact of this disease process, with the increasing age of the population and the catastrophic outcomes associated with no treatment, is significant. The primary etiology of CMI is atherosclerotic occlusive disease involving the ostia of the mesenteric arteries. Several studies have investigated the pathophysiology of the postprandial abdominal pain associated with ischemia focusing on transport mechanisms, claudication of the intestinal musculature, and ischemia of the visceral nerves. The process of diagnosing CMI involves assimilation of the presentation, typical history and physical examination findings, and results of imaging modalities. At the end of this diagnostic process, the decision to offer a patient surgical intervention is primarily based on symptomatology and results of duplex and other imaging modalities. There are specific criteria for which to offer symptomatic patients interventions. Patients who are asymptomatic do not need to undergo revascularization, which may disrupt collateral arterial circulation to the mesentery. They should be followed conservatively.

Aneurysmectomy With Arterial Reconstruction of Renal Artery Aneurysms in the Endovascular Era: A Safe, Effective Treatment for Both Aneurysm and Associated Hypertension

BACKGROUNDnRenal artery aneurysms (RAAs) represent a rare vascular pathology with an estimated incidence of <1%. Although an endovascular approach is being increasingly used to treat RAAs, we hypothesized that open surgical repair of RAA, specifically via aneurysmectomy with arterial reconstruction (AAR), is a safe, effective treatment, particularly for those with complex aneurysm anatomy.nnnMETHODSnA review was performed of all patients with RAA, identified by ICD-9 codes, from January 2003 to December 2008 seen at a tertiary care medical center. Data were collected regarding patient demographics, aneurysm characteristics, surgical repair, and outcomes, as well as follow-up care.nnnRESULTSnA total of 14 patients (10 women and 4 men; mean age, 48+/-19 years) were included, representing 15 aneurysms. Ten aneurysms underwent open repair via AAR and five were followed nonoperatively. Mean RAA size was larger for those undergoing repair (2.12 cm vs. 1.62 cm, p=0.037). Seven RAAs were repaired in situ with either patch angioplasty or primary repair; three required ex vivo reconstruction; and none underwent bypass. Average operative time was similar for repair type, with a higher blood loss with ex vivo repair. Median length of stay was 5 days (range, 4 to 14 days). Operative repair had no effect on mean systolic blood pressure or GFR. This repair, however, resulted in lower medication requirement for those with concurrent hypertension (2.7 pre vs. 1.6 post, p=0.03). There was a trend toward shorter time until oral intake for retroperitoneal approach compared with transperitoneal. Mean follow-up time was 11.6 months (range, 3 to 30 months). No incidences of rupture, death, nephrectomy, or renal failure occurred in the operative group.nnnCONCLUSIONnIn the era of endovascular repairs for RAAs, open repair, specifically via AAR, of RAAs remains a safe treatment with low associated morbidity. RAA repair resulted in a reduction in medications for those with associated hypertension. Open repair of RAAs should be the primary treatment modality for complex RAA, with specific consideration given to those with associated hypertension.

Thrombolysis for acute lower extremity deep venous thrombosis in a tertiary care setting.

BACKGROUNDnIn 2008, the Surgeon General made a Call to Action for the prevention of deep venous thrombosis (DVT), and for the first time, the 2008 American College of Chest Physicians guidelines for treatment of acute lower extremity DVT (ALE DVT) were revised to include thrombolysis as a grade 2B recommendation. Catheter-directed thrombolysis (CDT) therapy for patients with ALE DVT without contraindications can result in more complete clot dissolution than anticoagulation alone and may prevent the long-term sequelae of DVT. We sought to determine the percentage of inpatients with ALE DVT at a tertiary medical center who were candidates for CDT therapy and whether these patients were appropriately offered such treatment.nnnMETHODSnA hospital administrative database search from a tertiary medical center between January 2007 and December 2007 revealed 667 patient admissions associated with a diagnosis of DVT by International Classification of Diseases, Ninth Revision diagnosis codes (451-451.99, 453-453.99). Computerized hospital records were then searched for information regarding medical history, comorbidities, contraindications to thrombolysis, symptoms, imaging findings, and treatment.nnnRESULTSnOf the 667 patient admissions, 157 (24%) had ALE DVT, 31% had upper extremity DVT, 17% carried an old diagnosis DVT, and 28% had venous thromboses in other vessels. Of those 157 patients with ALE DVT, 60 (38%) had proximal iliofemoral or extensive femoral DVT that would be candidates for thrombolysis. Of the 60 patients, only 10 (17%) had no major contraindication thrombolysis. Of these, one was offered CDT but refused treatment, four did not receive consults for thrombolysis; five (9%) were offered CDT and were treated. However, of these 60 patients, 50 (83%) patients had severe illness and major and often multiple contraindications to thrombolysis.nnnCONCLUSIONnAlthough the majority of patients identified in the 2007 inpatient database with ALE DVT and an absence of contraindications to thrombolysis were appropriately offered CDT therapy, patients in such a tertiary inpatient setting typically have severe medical comorbidities that precluded the use of thrombolysis. Future studies assessing the expanding role of CDT in patients with ALE DVT should focus on outpatient settings or nontertiary care hospitals, where patients are likely to have fewer contraindications to thrombolytic therapy.

Angled Guidewire Delivery of Aortic Endovascular Prostheses for Angulated Landing Zones

We present a case of a 90-year-old male with suprarenal, infrarenal, and bilateral iliac aneurysms with significant interval enlargement treated with an endovascular graft. Due to severe infrarenal neck angulation, a type 1a endoleak was encountered, which was successfully treated with an aortic cuff. A novel technique of cuff deployment over an angled guidewire to accommodate the aortic angulation was used. This represents the first report in the literature of using this technique to deal with difficult, angulated landing zones.