Charles H. McCollum

Aneurysms of the extracranial carotid artery: Twenty-one years' experience☆

Aneurysms of the extracranial carotid artery are an uncommon but potentially serious problem, usually due to rupture or thromboembolic events. Thirty-seven aneurysms of the extracranial carotid artery were seen in thirty-four patients from 1956 to 1977. The ages ranged from twenty-nine to ninety-two years, with an average of fifty-nine years. There were twenty-three males and eleven females. Nineteen (51 per cent) were false aneurysms, sixteen (44 per cent) atherosclerotic aneurysms, and two (5 per cent) posttraumatic aneurysms. All patients presented with evidence of a mass in the neck, and only five (15 per cent) had neurological symptoms related to the aneurysm. Surgery was performed on twenty-eight carotid aneurysms. Resection and patch angioplasty was employed for eighteen aneurysms, resection with graft replacement for six, and resection and ligation of the internal carotid artery for four. Postoperative neurologic deficits developed in three patients (11 per cent), and one of these died. There was one other operative death due to acute myocardial infarction (operative mortality, 7 per cent). Nonoperative treatment was employed when the patient had other associated high risk disease or a small asymptomatic aneurysm.

Factors influencing career choice among medical students interested in surgery

PURPOSE The number of applicants to general surgery programs has recently declined. We set out to determine factors that influence career choice among medical students. METHODS DESIGN survey; SETTING university medical center; PARTICIPANTS fourth-year medical students; INTERVENTION distribution and completion of the survey. PARTICIPANTS ranked 18 items coded on a Likert scale from 1 (not important) to 8 (very important). These factors were career opportunities, academic opportunities, experience on core rotation/subinternship, role model(s) in that specialty (mentors), length of training required, lifestyle during residency, work hours during residency, ability to obtain residency position, concern about loans/debt, call schedule, lifestyle after training, work hours after training, financial rewards after training, intellectual challenge, patient relationships/interaction, prestige, future patient demographics, and gender distribution in the specialty. Students were asked to provide gender, career choice, number of programs they applied to, and the number of programs at which they were interviewed. RESULTS A total of 111 of the 160 surveys distributed were returned (69%). A total of 48 of the students were men, 31 were women, and 32 did not identify their gender. Nineteen students were interested in pursuing a career in surgery or a surgical subspecialty. Factors predicting surgery as a career choice were career opportunities (p < 0.04) and prestige (p < 0.003). Lifestyle during residency (p < 0.0007), work hours during residency (p < 0.008), and quality of patient/physician relationships (p < 0.05) were all significantly negatively correlated with the choice of a surgical career. Students pursuing a surgical career applied to greater than 31 programs compared with 11 to 15 for the nonsurgical students (p < 0.0001). CONCLUSIONS Prestige and career opportunities are more important to students seeking surgical residencies. Concerns about lifestyle and work hours during residency and perceived quality of patient/physician relationships were deterrents to surgery as a career choice. These issues may need to be addressed to increase the number of applicants to surgical programs.

Aneurysms of the splanchnic arteries.

Experience with 19 surgically resected aneurysms of the splanchnic artery is reviewed. In contrast to early series and cases reported, all patients but one were operated on electively. The only death occurred in a patient with a ruptured celiac artery aneurysm. Long-term follow-up has revealed continuing good results, and the subsequent formation of a visceral artery aneurysm in another location in one patient.

Chronic traumatic aneurysms of the thoracic aorta: an analysis of 50 patients.

The records of 50 patients having thoracic aortic aneurysms and a remote history of severe chest trauma were reviewed. Time intervals between thoracic trauma and operation varied from 3 months to 32 years (average, 11.9 years). In 25 patients (50%) this interval was greater than 10 years and in six (12%) greater than 20 years. Surgical correction was accomplished with low mortality and morbidity. Detection and diagnosis of chronic traumatic thoracic aortic injuries may not become clinically evident in some cases for many years. This diagnosis should be considered in all patients with a history of severe thoracic trauma, no matter how remote.

Experience with Tracheal Resection for Traumatic Tracheal Stenosis

Ten patients with traumatic tracheal stenosis—unresponsive to conservative therapy—underwent tracheal resection. Two of the stenoses resulted from gunshot injuries, three were due to prolonged intubation, and five developed after tracheotomy. Eight of the operations were completely successful. There was one death, and one patient has had recurrent granulation tissue at the anastomotic site. The pathogenesis of tracheal stenosis, as well as its treatment—including the technical details of tracheal resection—are discussed.

Carotid Artery Pseudoaneurysm after Endovascular Stent Placement: Diagnosis and Follow-up Duplex Ultrasonography

Purpose Carotid artery pseudoaneurysm development after endarterectomy, albeit rare, has been attributed to patch deterioration. We present an unusual case of pseudoaneurysm development 1 year after stent placement for recurrent carotid artery stenosis. Case Report A 64-year-old man had transient hemiparesis develop 1 week after carotid artery endarterectomy (CEA) with patch angioplasty for monocular transient ischemic attack. Carotid angiography reviewed an intimal flap at the distal endarterectomy site, which was successfully treated with carotid stent placement. During a duplex scan 1 year later, he was found to have a symptomatic 2.5-cm pseudoaneurysm at the level of stented carotid bifurcation. This was successfully treated with a combined open and endovascular approach, which consisted of stent-graft placement by means of an open carotid exposure. Completion angiogram showed successful stent-graft exclusion of the pseudoaneurysm. A follow-up duplex scan 6 months later demonstrated diminution of pseudoaneurysm size without endoleak. Conclusion This report highlights the importance of duplex ultrasound surveillance in patients with CEA or carotid stenting, because it can accurately detect recurrent stenosis or carotid pseudoaneurysm. Moreover, a combined open and endovascular therapy using stent graft successfully treated the carotid pseudoaneurysm in our patient.

Tribute to 50 years and a look forward

Welcome to the 50th Annual Meeting and anniversary celebration of the Southwestern Surgical Congress. This is a historic meeting! Earlier this morning, highlights of the contributions of the Congress have been very eloquently presented. I think we can all agree that the scientific contributions of the Southwestern Surgical Congress during our previous 49 meetings have been significant. It seems proper and fitting as part of our 50th anniversary celebration to review some of the historical aspects of our Congress. Three previous presidents, Dr. Howard D. Cogswell in 1961, Dr. John A. Growdon in 1967, and Dr. Albert J. Kukral in 1982, presented historical aspects of the Southwestern Surgical Congress as their Presidential Address. In 1985, Dr. Claude H. Organ edited a review of the history of the Southwestern Surgical Congress from 1948 to 1985. I just received The American Journal of Surgery supplement to the March issue honoring our 50th anniversary. Our thanks to the editors, Dr. Feliciano, and Dr. Organ for a fine job. Dr. Organ has updated the history through the present. I may repeat some of his effort, but many of you may have not read it, and perhaps I can offer some additional interesting information. History is often defined in part by the individuals involved at the time. For example, in considering the history of World War II, the names Eisenhower, MacArthur, Marshall, Patton, and others come to mind. So it was with the Southwestern Surgical Congress. Much of our history involves the impact and contributions of many individuals. I intend to illustrate the history of the Southwestern Surgical Congress by noting the participation of several such individuals. Over 50 years ago, three surgeons had a particularly prominent role in the formation and organization of the Southwestern Surgical Congress. Dr. Walter G. Stuck was an orthopedic surgeon in San Antonio. He was born in 1905 and reared in Jonesboro, Arkansas. After graduating from Emory University, he completed his medical education at Washington University in St. Louis and served his internship at the University of Michigan Hospital. He served as a Fellow at the Mayo Clinic and received his Master of Science in orthopedic surgery. When he settled in San Antonio to practice, he became a leader and a talented investigator. He collaborated on pioneering work on the internal fixation of fractures and the introduction of nonactive metals, such as vitallium, into the field of orthopedics. His book, The Internal Fixation of Fractures, is considered a classic in its field. Before World War II, he had arranged for the papers from the Texas Surgical Society to be published in The Southern Surgeon, which was owned by the Southeastern Surgical Congress. During this time, he had developed many friendships with surgeons in that region. In 1947, Dr. Stuck attended the annual meeting of the Southeastern Surgical Congress in Hollywood Beach, Florida, where Dr. Frank K. Boland, Jr., of Atlanta first suggested the possibility of a sister organization in the Southwestern part of the United States. The following year, in April 1948, Dr. Stuck was a speaker at the Southeastern Surgical Congress in Miami and he visited at length with Dr. B. T. Beasley and Dr. R. L. Sanders. They emphasized the need for a regional surgical society in the southwestern part of the United States, and together they began formulating plans for a regional surgical society. Dr. Ben T. Beasley was born in 1884 in rural Georgia and was a graduate of the College of Physicians and Surgeons (Emory) in Atlanta. He practiced surgery in Atlanta with a special interest in gynecology. Dr. Beasley was a surgeon Charles H. McCollum, MD

Incidental finding during venous duplex examination: Solitary fibrous tumor or arteriovenous malformation in the left lower extremity

Purpose —Superficial varicosities surrounding a palpable mass in the posterior aspect of the left thigh were investigated during a venous duplex examination. A well-defined mass with arterial and venous feeding branches strongly suggested the presence of an arteriovenous malformation. We present an unusual case of a soft-tissue thigh mass that appeared to be an arteriovenous malformation by ultrasound and arteriography but after surgical resection was confirmed to be a benign soft tissue tumor. Case Report —A 32-year old woman presented with superficial varicosities surrounding a painful mass on the posterior aspect of her left thigh. Venous duplex exam demonstrated normal findings of the deep veins, but further investigation of the superficial varicosities revealed a 3.5-cm x 6.0-cm soft-homogenous mass with a large complex network of arterial and venous feeding branches. Arteriography confirmed a well-defined thigh mass with an arterial network feeding the mass. Surgical resection of this well-circumscribed mass was performed. Histological tissue exam revealed a benign low-grade spindle cell neoplasm with blood vessels. Conclusion —This report highlights the importance of evaluating all abnormal superficial varicosities and palpable soft-tissue masses as part of a lower extremity vascular duplex evaluation because incidental findings not diagnosed through clinical examination may be detected.

Continuous ultrasound contrast infusion as an adjunct to color duplex ultrasound in the assessment of aortic endografts

Objective —We sought to evaluate continuous ultrasound contrast infusion Optison® as an adjunct to color duplex ultrasound (CDU) in endoleak detection. Methods —Endoleak surveillance, including CDU, Optison®, and computed tomography (CTA), was performed during 18 examinations. One (3 ml) vial of Optison® was diluted in a 57-ml syringe of normal saline (total 60 ml) and administered by infusion pump at 4 ml/hr. Transverse and sagittal views were performed of the aortic aneurysm sac, endograft, and arteries outside the aneurysm sac. Primary endpoints were endograft patency, the presence or absence of endoleak, and limb dysfunction. Results —There were no adverse events related to the contrast agent. Contrast appearance through the endograft occurred after an average of 1 min using a mean of 46.8 ml of contrast infusion per patient. There were 10 enodleaks clearly identified by CDU and Optison®, i.e., 2 type I, 4 type II, and 2 type III endoleaks with an additional study suspicious for endoleak. Using CDU and CTA, we found 9 studies without endoleaks whereas with Optison®, we found 8 studies normal. Comparatively, when using CTA, we identified only 2 definitive endoleaks. Of the 9 endoleaks identified by using CDU and Optison®, 2 of the endoleaks were type I and not observed on conventional CTA and were later confirmed by arteriogram. One study was deemed negative by CDU and Optison® whereas CTA results were suspicious. Body habitus was prohibitive for definitive CDU findings in one patient. Conclusions —Using continuous ultrasound contrast infusion as an adjunct to CDU allowed for longer imaging time and more extensive evaluation of the endograft, the aneurysm sac, and the perianeurysmal arteries in these patients. Our early results demonstrate that the use of ultrasound contrast for endoleak detection is reliable and may be considered a primary surveillance modality after endovascular aortic aneurysm repair.

Percutaneous needle arteriography

Successful arterial reconstructive surgery requires exact definition of the occlusive or aneurysmal process and the condition of the distal arterial tree. To define these two parameters, it is essential that arteriography be precise, yet it must be safe and reproducible. At our institution, we continue to utilize percutaneous needle arteriography because of its safety and excellent delineation of the vascular system. The purpose of this paper is to discuss our indications, techniques, and results of percutaneous arteriography for evaluation of peripheral arterial disease. During 1975, 1,253 percutaneous arteriograms were performed under general anesthesia by the surgical team. The techniques for carotid, vertebral (retrograde brachial), and femoral arteriograms, and translumbar aortograms will be reviewed. There were no deaths and only 8 (0.7%) complications. We believe that this technique provides an excellent method for good preoperative evaluation of the arterial system of the peripheral arteries and abdominal aorta.RésuméPour être efficace, la chirurgie artérielle reconstructive exige une définition exacte des lésions occlusives ou anévrismales et de l’état de l’arbre vasculaire périphérique. Ces deux paramètres ne peuvent être précisés que par une artériographie, qui doit être à la fois parfaite, sans danger et reproductible. Dans notre institution, nous utilisons toujours l’artériographie percutanée à l’aiguille parce qu’elle est sûre et donne une excellente représentation de l’arbre vasculaire. L’article décrit nos indications, notre technique et les résultats de l’artériographie percutanée utilisée pour la mise au point des maladies vasculaires périphériques. En 1976, 1,253 artériographies percutanées ont été réalisées sous anesthésie générale par l’équipe chirurgicale. Les techniques d’artériographie carotidienne, vertébrale (humérale rétrograde), fémorale et lombaire sont décrites. Nous n’avons aucun décès et 8 (0.7%) complications seulement. Nous estimons que cette technique est excellente et donne une bonne définition préopératoire des artères périphériques et de l’aorte abdominale.