Harry Schanzer

Rupture of surgically thrombosed abdominal aortic aneurysm

A case of late rupture of an abdominal aortic aneurysm that had been successfully treated by surgically induced thrombosis is presented. After emergency surgery consisting of ligation of the neck of the aneurysm, the patient survived and is doing well. The literature on surgically induced thrombosis of abdominal aortic aneurysm is reviewed. It is stressed that complete thrombosis of aortic aneurysm induced by distal ligation does not preclude rupture, and if patients present with symptoms of expansion or rupture, they should undergo emergency surgery.

Duplex Ultrasound Evaluation of Hemodialysis Access: A Detailed Protocol

A detailed protocol for the performance and interpretation of duplex ultrasound evaluation of hemodialysis access is described.

Infected false aneurysms of the subclavian artery: A complication in drug addicts

Two cases of infected false aneurysms of the subclavian artery in drug addicts are described. The clinical findings related to the location of these rare lesions are presented, together with an attempt to explain their pathophysiology. The signs and symptoms include a tender supraclavicular mass in an obviously septic patient associated with brachial plexus palsy, a swollen edematous arm, Horners syndrome, and hemoptysis. Because of the complexity of symptoms, delay in diagnosis is common. It is emphasized that the recognition of this constellation of symptoms should prompt the physician to perform emergency angiography followed by immediate surgery.

Experience of HeRO dialysis graft placement in a challenging population.

Objective: To assess the outcomes of the hemodialysis reliable outflow (HeRO) device in a subset of hemodialysis access-challenged patients with central venous obstruction. Methods: Retrospective analysis of a series of patients in 2 centers who underwent placement of the HeRO device between September 2009 and November 2010. Patients’ demographics, access history, HeRO patency, and number of reinterventions were analyzed. Results: Eleven patients underwent 12 HeRO implantations. The average duration of dialysis prior to HeRO placement was 5.55 ± 3.64 years. Primary and secondary patencies at 6 months and 1 year were 36.4% and 54.5% and 9.1% and 45.5%, respectively. Conclusions: In the end-stage renal disease population with central venous occlusive disease, the HeRO device offers the best long-term dialysis option when an arteriovenous fistula or graft is not possible. Close follow-up and subsequent aggressive interventions can prolong the use of the HeRO and avoid the last resort of dialysis catheters.

Inflow stenosis as a contributing factor in the etiology of AV access-induced ischemic steal

Objective To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS). Methods A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, pre-operative angiographic imaging and interventions performed were analyzed. Results A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography (14) and computed tomography angiography (3). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation (3), ligation (1) and angioplasty/stenting (1). Conclusion In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete pre-operative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.

Primary leiomyosarcoma of saphenous vein presenting as deep venous thrombosis

Only a small number of venous leiomyosarcomas have been previously reported. Of these tumors, those of saphenous origin comprise a minority of cases. A 59-year-old man presented with symptoms of deep vein thrombosis and was eventually diagnosed with primary leiomyosarcoma of great saphenous vein origin. The tumor was treated with primary resection and femoral vein reconstruction with autologous patch. Although extremely rare, saphenous leiomyosarcoma can present as deep vein thrombosis. Vascular tumors should be included in the differential diagnosis of atypical extremity swelling refractory to conventional deep vein thrombosis management.

Living-related donor nephrectomy by eleventh rib intraperitoneal extrapleural incision

Living-related kidney transplants continue to yield the best results. The two primary approaches for living-related donor nephrectomy are the intraperitoneal and extraperitoneal operations. We herein describe a series of 8 cases in which an eleventh rib intraperitoneal extrapleural incision was used for living-related donor nephrectomy. The advantages of the operation in terms of improved ability to manage vascular anomalies is described. No complication has been encountered.

Secondary Interventions After Iliac Vein Stenting for Chronic Proximal Venous Outflow Obstruction

Background: Iliac stent placement is an increasingly common procedure in the treatment of chronic proximal venous outflow obstruction (PVOO), but secondary interventions after vein stent placement remain poorly characterized. Our goals were to identify the incidence, indications, operative findings, and outcomes of secondary interventions after the primary iliac vein stent procedure in a single institution. Methods: We retrospectively reviewed the clinical history of 490 patients (42.41% male; mean age, 60.77 years [range, 18-92 years]; 93.28% follow-up with a mean follow-up of 308.59 days) who underwent iliac stent placement (Wallstent; Boston Scientific, Marlborough, Mass) for PVOO between October 2013 and June 2016. We specifically evaluated the clinical presentation, intraoperative findings, and outcomes among those patients who required a secondary intervention after an initial iliac vein stent procedure. Results: Secondary interventions after an initial stent placement were identified in 50 of 490 patients (10.2%; mean age, 61.54 years [range, 19-92 years]; 58% female [n 1⁄4 29]). Among these 50 patients, 56% (n 1⁄4 28) of secondary interventions were due to recurrence of symptoms after the initial stent surgery, 24% (n 1⁄4 12) were due to the development of new symptoms, and 20% (n 1⁄4 10) were due to persistence of symptoms. Intraoperative findings during the secondary intervention included migration of the stent (8% [n 1⁄4 4]), acute deep venous thrombosis/thrombosis (12% [n 1⁄4 6]), an additional lesion (ie, stenosis in a native iliac vein proximal or distal to the original lesion; 50% [n 1⁄4 25]), stenosis within the stent (stent stenosis without finding of thrombus or isolated, focal intrastent thrombosis; 16% [n 1⁄4 8]), impairment of flow of the contralateral vessel from the previous stent (12% [n 1⁄4 6]), and no finding (2% [n 1⁄4 1]). The types of secondary interventions were placement of a new stent (80% [n 1⁄4 40]), isolated balloon angioplasty alone (6% [n 1⁄4 3]), and catheter PMT (14% [n 1⁄4 7]). Significant symptomatic improvement was observed after the secondary intervention in 90% of patients (n 1⁄4 45); 2% (n 1⁄4 1) of patients experienced only a transient improvement, and 8% of patients (n 1⁄4 4) reported no improvement in their symptoms. Conclusions: This study establishes a secondary intervention rate of 10% after iliac vein stent placement for chronic PVOO, identifies discrete and definable intraoperative findings as targets for quality improvement, and indicates that secondary interventions after vein stent placement are associated with a good outcome.

Anatomical and clinical factors favoring the performance of saphenous ablation and microphlebectomy or sclerotherapy as a single-stage procedure.

Objective To identify the anatomical and clinical parameters that predict lack of regression of superficial varicosities after ablation of the great saphenous vein. Methods Symptomatic patients treated with endovenous ablation from August 2006 to July 2013, by a single surgeon, were included. Recorded parameters included age, sex, size, and extent of varicosities (class I–IV) (patient standing), and diameter and length (patient supine) of treated great saphenous vein. Varicose vein classification was defined as: class I ≤6 mm and localized to thigh or leg, class II ≤6 mm and present in the thigh and leg (extensive), class III >6 mm and localized to the thigh or leg, and class IV >6 mm and extensive. “Excellent” results were defined as complete resolution of varicosities, “good” results as incomplete resolution, and “poor” results as no improvement. Results A total of 267 patients and 302 consecutive limbs were included in the study. There were 175 females (65.5%), and the mean age was 54 years old (22–92). The CEAP classification was as follows: C2 (81.5%), C3 (6.3%), C4 (7.9%), C5 (2.0%), and C6 (2.3%). Great saphenous vein diameters was significantly larger in patients with C3–C6 (proximal 0.84 ± 0.25 versus 0.65 ± 0.21, p = < 0.0001, distal 0.58 ± 0.18 versus 0.44 ± 0.13, p < 0.0001) or class III–IV varicose veins (proximal 0.85 ± 0.25 versus 0.75 ± 0.27, p = 0.012, distal 0.62 ± 0.62 versus 0.50 ± 0.17, p < 0.0001). Class III–IV limbs had a “good/poor” result 69.8% of the time, as compared to 51.9% of the limbs class I–II varicose veins (p = 0.002). Conclusions Advanced chronic venous disease (C3–C6) patients have larger diameter great saphenous veins, reflecting the progressive nature of the disease. Patients with more severe varicosities regardless of CEAP class were more likely to require a secondary procedure. The severity of the varicosities may not correlate with the degree of venous disease, but it is an indication of which patients should undergo secondary procedures, possibly with a one-stage approach.

Scintigraphic detection of the loss of one kidney following en bloc transplantation of paired pediatric kidneys

Vascular occlusion of one of the transplanted kidneys represents a potential complication following en bloc transplantation of two pediatric kidneys into adults. Serial renal scans with Tc-99m DTPA, performed on a 26-year-old woman who underwent en bloc transplantation, revealed good perfusion and function of both kidneys in the early postoperative period but acute loss of perfusion and function in one kidney on the ninth postoperative day. Surgical exploration and open biopsy excluded rejection and twisting of the vascular pedicle as possible causes for the acute loss of perfusion and function in this kidney