Dustin Y. Yoon

Determining If Sex Bias Exists in Human Surgical Clinical Research.

Importance Sex is a variable that is poorly controlled for in clinical research. Objectives To determine if sex bias exists in human surgical clinical research, to determine if data are reported and analyzed using sex as an independent variable, and to identify specialties in which the greatest and least sex biases exist. Design, Setting, and Participants For this bibliometric analysis, data were abstracted from 1303 original peer-reviewed articles published from January 1, 2011, through December 31, 2012, in 5 surgery journals. Main Outcomes and Measures Study type, location, number and sex of participants, degree of sex matching of included participants, and inclusion of sex-based reporting, statistical analysis, and discussion of data. Results Of 2347 articles reviewed, 1668 (71.1%) included human participants. After excluding 365 articles, 1303 remained: 17 (1.3%) included males only, 41 (3.1%) included females only, 1020 (78.3%) included males and females, and 225 (17.3%) did not document the sex of the participants. Although female participants represent more than 50% (n = 57 688 606) of the total number (115 377 213) included, considerable variability existed with the number of male (46 111 818), female (58 805 665), and unspecified (10 459 730) participants included among the journals, between US domestic and international studies, and between single vs multicenter studies. For articles included in the study, 38.1% (497 of 1303) reported these data by sex, 33.2% (432 of 1303) analyzed these data by sex, and 22.9% (299 of 1303) included a discussion of sex-based results. Sex matching of the included participants in the research overall was poor, with 45.2% (589 of 1303) of the studies matching the inclusion of both sexes by 50%. During analysis of the different surgical specialties, a wide variation in sex-based inclusion, matching, and data reporting existed, with colorectal surgery having the best matching of male and female participants and cardiac surgery having the worst. Conclusions and Relevance Sex bias exists in human surgical clinical research. Few studies included men and women equally, less than one-third performed data analysis by sex, and there was wide variation in inclusion and matching of the sexes among the specialties and the journals reviewed. Because clinical research is the foundation for evidence-based medicine, it is imperative that this disparity be addressed so that therapies benefit both sexes.

Inadvertent Arterial Placement of Central Venous Catheters: Diagnostic and Therapeutic Strategies.

BACKGROUND Central venous catheterization (CVC) is among the most ubiquitous medical procedures. Inadvertent arterial placement of the catheter presents a challenging dilemma to the interventionalist. Treatment options include: removal and manual compression, off-label use of percutaneous closure devices and/or stent grafts, and open surgical removal. Potential sequelae include bleeding, thrombosis, stroke, limb ischemia, neurologic deficit, and death. Our aim is to evaluate the use of open and endovascular techniques for the management of iatrogenic carotid, subclavian, and brachiocephalic arterial injuries related to inadvertent arterial CVC placement. METHODS Retrospective chart review revealed 13 patients with iatrogenic arterial injuries related to inadvertent arterial CVC placement over a 5-year period at Northwestern Memorial Hospital using Current Procedural Terminology codes and interventional radiology and vascular databases. Presenting features, radiographic diagnosis, therapeutic maneuvers, and outcomes were reviewed. RESULTS Endovascular therapy was instituted in 10 cases with 3 requiring an adjunctive open procedure. In the endovascular therapy group, stent grafts were used in 5 patients and 4 patients were managed with percutaneous closure devices. In 1 patient, multiple embolization procedures were performed in an attempt to close a large innominate artery arteriovenous fistula (AVFs) that ultimately required sternotomy and surgical ligation for complete closure. Primary open repair was carried out in 3 patients. Two patients developed embolic stroke before therapy and removal, with 1 death reported at 36-month follow-up. Overall success rate with a single intervention was 100% (4 of 4) with closure devices, 80% (4 of 5) covered stents, 0% (0 of 1) with embolization, and 100% (3 of 3) with open intervention. Overall complication rate was 7% (1 of 13) requiring further open, invasive intervention. CONCLUSIONS Management of carotid, subclavian, and brachiocephalic arterial injuries from attempted jugular or subclavian venous cannulation can be challenging. The risk of embolic phenomenon associated with arterial catheterization, and the noncompressible anatomic location at the base of the neck frequently prevent simple removal. We use a strategy of immediate computed tomography or magnetic resonance to facilitate the most appropriate therapy. Endovascular treatment with covered stent grants, percutaneous closure devices, and embolization offer good results when selected appropriately based on imaging evaluation. However, more complex cases with associated pseudoaneurysms and/or AVFs with larger catheters may require definitive open repair.

Right-sided aortic arch with isolated left subclavian artery leading to subclavian steal syndrome

A 47 year-old man presented to the clinic with a 2-year history of intermittent headaches, dizziness, blurry vision, and hearing loss in his left ear. Although symptoms were increasing in frequency, they were not precipitated by any upper extremity effort. Physical examination revealed a normal neuromotor response and equal pulses and blood pressures in both arms. The patient gave written consent for publication of all details of his case, including the radiologic images. Computed tomography angiography demonstrated a right-sided aortic arch (RAA; A) with unconventional origins of the great vessels: the left common carotid, the right common carotid, and right subclavian arteries. The origin of the left subclavian artery (LSA) was congenitally atretic and reconstituted just proximal to the left vertebral artery (B). The lower attenuation of contrast in the LSA and vertebral arteries compared with the arch vessels suggested a subclavian steal phenomenon, later confirmed by retrograde flow in the left vertebral artery on ultrasound imaging. The isolated LSA (ILSA; C) showed prominent left inferior thyroid collateralization to the thyrocervical trunk (Cover). All of these findings were consistent with an RAA with ILSA.

Appropriate Endpoints for Chronic Limb Ischemia

Due to dramatic advances in endovascular techinques, multiple approaches to the treatment of chronic limb ischemia (CLI) are widely available to a variety of specialists. Although most of these techinques are often succesful in restoring flow to the ischemic extremity, it is unclear if this immediate success translates into long-lasting wound healing, limb salvage and retrun to a pr-morbid level of activity.Traditionally, the “success” of vascular interventions has been measured solely in terms of immediate technical success, patency, freedom from further revascularization, limb salvage and mortality. Outcomes research in CLI is entering a new phase where patient-oriented outcomes are replacing traditional lesion-oriented outcomes.

Postprandial Abdominal Pain.

An active man in his early 80s presented to the hospital with a 6-month history of cramping epigastric abdominal pain that occurred 30 minutes after eating solid food and was associated with nausea and vomiting. His medical history was significant for atrial fibrillation and a history of an open abdominal aortic aneurysm repair. Review of systems revealed a 9-kg weight loss. A recent esophagogastroduodenoscopy was unremarkable, but prior colonoscopy showed focal colitis that was treated with antibiotics. Physical examination revealed he was in sinus rhythm. He had no abdominal tenderness but had an abdominal bruit. Laboratory examination results were unremarkable. Mesenteric duplex ultrasonography showed the following: celiac artery velocity of 394 cm/s on inspiration (Figure, A) and 608 cm/s on expiration (Figure, B), superior mesenteric artery (SMA) velocity of 380 cm/s, and an occluded inferior mesenteric artery. Subsequent angiography corroborated findings. Inspiration A Expiration B

Elderly Man With 1-Month History of Flank and Abdominal Pain

An elderly man presented to the emergency department with a 1-month history of new-onset, persistent lower abdominal and flank pain. The pain was sharp and constant with intermittent radiation to the back and associated anorexia with a 10-kgweight loss.Hedidnot reportanypreviousabdominal surgery.Thepatientstated that he had not had any procedures with intravascular instrumentation in the past year, dental cleanings, intravenous drug use, cutaneousabscesses, or recent trauma.Physical examination revealedhewas afebrile and in normal sinus rhythm; there was minimal epigastric abdominal tendernesswithoutsignsofperitonitisandnopalpablemasses. Femoral pulses were palpable and symmetric. Laboratory examination revealed mild anemia (hematocrit, 35% [to convert to a proportion of 1.0, multiply by 0.01]), no leukocytosis, and an elevated erythrocyte sedimentation rate (71 mm/h). Blood and urine cultures were negative for organisms. A computed tomographic (CT) angiogram showed asymmetric attenuation surrounding the infrarenal aorta (Figure 1). On comparison, a CT scan that was performed 6 months before presentation had identified no aneurysmal disease. Quiz at jamasurgery.com Axial view A Coronal reconstruction B