Sam Tyagi

Intrathoracic splenosis presenting as persistent chest pain

Thoracic splenosis is a rare entity resulting from splenic and diaphragmatic injury. Patients remain asymptomatic, and surgical intervention is not indicated in the majority of cases. We report a case of a 50-year-old male with a history of splenectomy due to a gunshot wound 30 years previously who presented with vague, progressively worsening chest pain. He was found to have a large intrathoracic splenosis. Unique features of our patient include the presence of symptoms, the significant interval growth of the splenic tissue, and the unprecedented size of the mass, which we believe to be the largest among those previously described.

Endovascular stent graft repair of thoracic aortic mural thrombus in a patient with polycythemia vera: A word of caution

Thoracic aortic mural thrombus (TAMT) is a rare pathology and potential source of cerebral, visceral, and peripheral emboli. We present a 62-year-old male in a hypercoagulable state due to primary polycythemia vera (PV) developed TAMT and catastrophic thromboembolisms despite aggressive medical and surgical management. The outcomes and adverse events of endovascular exclusion of TAMT in the presence of PV are unknown. We would recommend proceeding with extreme caution when performing endovascular exclusion of TAMT, as PV may be a prohibitive risk.

Laparoscopic Repair of an Intrapericardial Diaphragmatic Hernia

An isolated intrapericardial diaphragmatic hernia is very rare. Only 15 cases have been reported, 2 of which are in adults. The defect in the anterior diaphragm allows abdominal contents to enter the pericardial cavity. We report the 16th case--the third in an adult--and its laparoscopic repair.

Bovine carotid artery xenografts for hemodialysis access

Objective: Bovine carotid artery (BCA) grafts have been described as a possibly superior alternative to expanded polytetrafluoroethylene hemoaccess grafts. However, published experience remains limited, and patency rates for nonautogenous arteriovenous grafts remain unsatisfactory. We report herein the largest published experience with the current generation of BCA grafts for dialysis access and analyze subgroups to determine whether obesity, gender, or prior access surgery influences patency. Methods: We retrospectively reviewed 134 BCA grafts (Artegraft, North Brunswick, NJ) implanted for hemodialysis access in the upper extremities of 126 patients between January 2012 and May 2015. Patients had a mean of 1.8 prior access operations. Primary, primary assisted, and secondary patency rates were calculated using the Kaplan‐Meier method, and longitudinal infection risk was tabulated. Patency differences were calculated using the log‐rank method. Results: For the entire group, 1‐year primary patency was 32%, primary assisted patency was 49%, and secondary patency was 78%. Ten of 133 grafts (7%) developed infection requiring graft excision between 1 and 9 months after implantation. There was no statistical difference between men and women in primary or secondary patency (P = .88, P = .69). There was no difference in primary patency or secondary patency for patients with body mass index >30 or <30 (P = .85, P = .54). Patients who had a BCA graft as their first access attempt had a higher primary and primary assisted patency than that of patients who had the graft placed after prior access failure (P = .039, P = .024). Conclusions: This represents the largest published series of BCA grafts for arteriovenous grafts in the modern era. The primary patency of BCA grafts in this series was lower than that reported in a smaller randomized study. However, primary assisted and secondary patency were similar. Infection rates in this series appear to be somewhat lower than polytetrafluoroethylene infection rates reported in the literature. BCA grafts are a satisfactory alternative to expanded polytetrafluoroethylene for hemodialysis access, but larger controlled studies are needed to determine whether superior primary patency previously reported is a reproducible finding.

Case report: Hybrid endovascular and open surgical approach to a chronic, traumatic arteriovenous fistula.

Highlights • Chronic traumatic AVF leads to significant morbidity when allowed to progress.• Traumatic AVF may be approached with endovascaular, open, and hybrid techniques.• We describe a traumatic AVF which was left to progress for over 30 years.• Our staged, hybrid approach decreased venous hypertension and bleeding during surgery.

Low carotid stump pressure as a predictor for ischemic symptoms and as a marker for compromised cerebral reserve in octogenarians undergoing carotid endarterectomy

Background: Carotid artery occlusive disease can cause stroke by embolization, thrombosis, and hypoperfusion. The majority of strokes secondary to cervical carotid atherosclerosis are believed to be of embolic etiology. However, cerebral hypoperfusion could be an important factor in perioperative stroke. We retrospectively reviewed the stump pressure (SP) of carotid endarterectomy (CEA) of patients at Pennsylvania Hospital to identify whether physiologic perfusion differences account for differences in perioperative stroke rates, particularly in octogenarians. Methods: We conducted a retrospective review of our prospectively maintained database for CEA performed between 1992 and 2015. SP was measured and recorded for 1190 patients. A low SP was defined as systolic pressure <50 mm Hg. Shunts were used only for patients under general anesthesia with SP <50 mm Hg, for awake patients with neurologic changes with carotid clamping, and in some patients with recent stroke. Results: Symptomatic patients were more likely to have SP <50 mm Hg compared with asymptomatic patients (35.6% vs 26.2%; P = .0015). Patients having SP <50 mm Hg had a higher postoperative stroke rate compared with patients with SP >50 mm Hg (2.9% vs 0.9%; P = .0174). Octogenarians were more likely to have a lower SP compared with patients younger than 80 years (35.7% vs 27.7%; P = .0328). Symptomatic patients with low SP were at highest risk for perioperative stroke (6.4% vs 1.2%; P = .001) compared with patients without these factors. Conclusions: SP is a marker for decreased cerebrovascular reserve and along with symptomatic status identifies those at highest risk for periprocedural stroke with CEA. Whereas patients older than 80 years may benefit from carotid intervention, they are likely to be at somewhat elevated stroke risk because of higher prevalence of low SP, and shunting does not eliminate this risk.

A Novel Method for the Treatment of Bilateral Hypogastric Aneurysms Using Hybrid Polytetrafluoroethylene Graft

Open aortic aneurysm repair in the setting of bilateral hypogastric aneurysms is technically challenging. We present a novel technique for open surgical repair for bilateral hypogastric aneurysms using the Gore hybrid vascular graft (GVHG; W. L. Gore and Associates Inc, Flagstaff, Arizona). The GVHG is an expanded polytetrafluoroethylene graft with a nitinol stent at 1 end designed for hemodialysis access. The GVHG has been also been used for aortic debranching and treatment of occlusive disease. We describe the first report using GVHG to repair hypogastric aneurysms.

Duplex Surveillance After Prosthetic Infrainguinal Bypass Grafting

A major factor limiting the long-term patency of infrainguinal bypasses is the development of stenosis in the graft, inflow, or outflow arteries. It is critical to identify these lesions while the bypass graft is patent, as treatment with endovascular intervention or minor open procedures will maintain patency, avoiding thrombosis which is an outcome associated with more morbidity and decreased secondary patency. There is widespread evidence to support postoperative duplex ultrasound (DU) surveillance of infrainguinal vein grafts, but the interpretation criteria regarding surveillance of prosthetic bypass grafts are limited. In our vascular laboratory, peak systolic velocities are recorded along the graft every 10 cm, in addition to velocity measurements at both the proximal and distal anastomoses to identify stenosis and low-flow graft states. We found the sensitivity of DU was 88% for identification of the failing femorotibial bypass and 57% for femoropopliteal bypasses. The positive predictive value (correct abnormal studies/total abnormal studies) was 95% for femorotibial grafts and 65% for femoropopliteal grafts. We have concluded that DU surveillance is worthwhile following infrainguinal prosthetic bypass grafting. Criteria that we use to identify failing arterial bypass grafts include monophasic signal throughout the graft, uniform peak systolic velocities 300 cm/s, and peak systolic velocity ratio between two adjacent segments >3.5.

Variability in 2-year training programs in vascular surgery based on results of an Association of Program Directors in Vascular Surgery survey

Objective: Although a great deal of attention has recently focused on 5‐year integrated (0+5) training programs in vascular surgery, a paucity of data exists concerning variability of daily assignments in 2‐year (5+2) vascular fellowships. Methods: We polled Association of Program Directors in Vascular Surgery members with 2‐year vascular fellowships to determine the number of days in a 5‐day work week that first‐ and second‐year fellows were assigned to open vascular operations, endovascular procedures (hospital vs nonhospital facility), arterial clinic, venous clinic, noninvasive vascular laboratory (NIVL), and research. Results: Of the 103 program directors from 5+2 vascular training programs, 102 (99%) responded. The most common schedule for both first‐ and second‐year fellows was performing both open and endovascular procedures in the hospital on the same day 4 days of the week and spending time in combined artery and vein clinic 1 day of the week. Program directors developed different schedules for each year of the 2‐year fellowship in about half (55% [56]) of the programs. A small minority of programs devoted days to only open surgical cases (13% [13]), a separate venous clinic (17% [17]), or a separate arterial clinic (11% [11]) and performed endovascular procedures in a nonhospital facility (15% [15]). All but three programs had mandatory time in clinic both years. Approximately one‐third (30% [31]) of programs designated time devoted to research, whereas the others expected fellows to find time on their own. Although passing the Registered Physician in Vascular Interpretation examination is required, there was devoted time in the NIVL in only 60% (61) of programs. Conclusions: Training assignments in terms of time spent performing open and endovascular procedures and participating in clinic, the NIVL, and research varied widely among Accreditation Council for Graduate Medical Education‐accredited 5+2 vascular fellowships and did not always fulfill Accreditation Council for Graduate Medical Education guidelines. In the current era of emphasis on endovascular‐based interventions, few programs devoted days to purely open surgical procedures. Endovascular experience in a nonhospital facility (where these procedures will likely become more common in the future), outpatient venous procedures, and designated time devoted to the NIVL and research were lacking in many programs. These results provide a valid data set for the Association of Program Directors in Vascular Surgery to consider establishing guidelines for training assignments in 5+2 vascular training programs.

Thoracic Aortic Graft Infections Secondary to Propionibacterium Species Two Cases and Review of the Literature

Aortic graft infections are a rare occurrence, most commonly secondary to gram-positive organisms (Staphylococcus and Streptococcus species). We present 2 cases of thoracic aortic graft infections secondary to anaerobic bacteria, Propionibacterium species. The first case, a 40-year-old male, was found to have an anastomotic aneurysm at the distal anastomosis of a previous thoracoabdominal aneurysm repair. During the open repair of his anastomotic aneurysm, the original graft was not incorporated and cultures later speciated Propionibacterium acnes. The second case is a 44-year-old male with a history of abdominal aortic coarctation that was repaired with a thoracic aorta to aortic bifurcation graft as a child who presented with flank pain and was found on imaging to have fluid around his bypass graft. His operating room (OR) cultures also grew out Propionibacterium species. Both patients were treated with graft excision, revascularization, and long-term antibiotics. Anaerobic bacteria are a rare cause of aortic graft infections. Upon review of the literature, these are the first 2 cases of thoracic aortic graft infections secondary to Propionibacterium species. The cultures for both patients took almost a week to speciate, highlighting the importance of following cultures long term. Anaerobic bacteria should be recognized as a cause of latent graft infections.