Sinan Jabori

Regrown first rib in patients with recurrent thoracic outlet syndrome.

BACKGROUND Recurrent symptoms of thoracic outlet syndrome (TOS) after first rib resection have varying etiologies. Regrowth of a first rib is a rare event. Recurrent symptoms in the presence of a regrown rib strongly suggest a causal relationship. We report our experience with recurrent symptoms of TOS and regrown first ribs. METHODS We identified patients with recurrent TOS symptoms and regrown first ribs presented between 1995 and 2012. Details regarding their presentation, evaluation, and treatment were gathered. RESULTS Eight patients (6 women and 2 men) presenting with recurrent TOS symptoms and regrown first ribs underwent 10 decompression surgeries. Prior surgeries included supraclavicular first rib resection (5), transaxillary first rib resection (5), scalenectomy (5), cervical rib resection (1). The average period between initial surgery and reoperation was 4.7 years. Average age at current presentation was 40.8 years (range 29-52). All patients (8) represented with neurogenic symptoms and 1 patient with concomitant venous TOS symptoms. Presenting symptoms included pain (8), numbness and tingling (7), weakness (6), headache (2), and venous congestion (3). Initial treatment included physical therapy in all. Preoperative assessment included chest X-rays (8), magnetic resonance imaging (7), electrodiagnostic studies (8), venography (2), and anterior scalene muscle block (2). Surgical approach included transaxillary resection of the regrown first rib (10), neurolysis of brachial plexus (10), scalenectomy (5), and lysis of subclavian vein (1). After an average follow-up of 10.8 months, resolution of symptoms included 4 complete and 4 partial. CONCLUSIONS Regrowth of the first rib is a rare event. There is a concordance between a regrown rib and TOS symptoms. Patients presenting with recurrent TOS symptoms and a regrown first rib have a high probability of improvement with resection of the regrown rib.

Is Heparin Reversal Required for the Safe Performance of Percutaneous Endovascular Aortic Aneurysm Repair

BACKGROUND Percutaneous endovascular aneurysm repair (PEVAR) can be performed with high technical success rates and low morbidity rates. Several peer-reviewed papers regarding PEVAR have routinely combined heparin reversal with protamine before sheath removal. The risks of protamine reversal are well documented and include cardiovascular collapse and anaphylaxis. The aim of this study is to review outcomes of patients who underwent PEVAR without heparin reversal. METHODS All patients who underwent percutaneous femoral artery closure after PEVAR between 2009-2012 without heparin reversal were reviewed. Only patients who underwent placement of large-bore (12- to 24-French) sheaths were included. Patient demographics, comorbidities, operative details, and complications were reported. RESULTS One hundred thirty-one common femoral arteries were repaired using the Preclose technique in 76 patients. Fifty-five patients underwent bilateral repair and 21 underwent unilateral repair. The mean age was 73.9±9.1 years. The mean heparin dose administered was 79±25.4 U/kg. The mean patient body mass index was 27.5±4.8 kg/m2. Ultrasound-guided arterial puncture was performed in all patients. Average operative times were 196.5±103.3 min, and the mean estimated blood loss was 277.6 mL. Four femoral arteries (3%) required open surgical repair after failed hemostasis with ProGlide closure (Abbott Vascular, Abbott Park, IL). Two patients required deployment of a third ProGlide device with successful closure. Two patients had small (<3 cm) groin hematomas that had resolved at the time of the postoperative computed tomography scan. No pseudoaneurysms or arteriovenous fistulas developed in our patient cohort. No early or late thrombotic complications were noted. One patient (1.3%) with a ruptured aneurysm died 48 hours after endovascular repair unrelated to femoral closure. CONCLUSIONS PEVAR may be performed with low patient morbidity after therapeutic heparinization without heparin reversal. Femoral artery repair after the removal of large-diameter sheaths using the Preclose technique can be performed in this setting with minimal rates of early and late bleeding or thrombosis.

Retroperitoneal Trapdoor Endarterectomy for Paravisceral “Coral-reef” Aortic Plaque

A 67-year-old woman presented to the emergency room with progressive claudication, chest pain, and flash-pulmonary edema. Her past medical history was significant for poorly controlled hypertension requiring multiple antihypertensive medications, renal insufficiency, and tobacco abuse. Diagnostic evaluation revealed an extensive exophytic plaque localized to the paravisceral aorta resulting in high-grade stenoses of the proximal aorta as well as the celiac, superior mesenteric, and left renal arteries. She underwent surgical revascularization through a retroperitoneal aortic exposure and trapdoor aortic endarterectomy, the technical conduct of which is described in this manuscript. The patient recovered uneventfully and experienced resolution of her claudication and pulmonary symptoms, improved blood pressure control, and normalization of her creatinine. Review of the medical literature pertaining to management of proximal occlusive disease of the abdominal aorta is discussed.

Antiplatelet therapy before, during, and after extremity revascularization

Peripheral arterial disease (PAD) is well recognized as a marker for systemic atherosclerosis. Platelets play an essential role in all stages of the disease, contributing to both thrombosis and the development of atherosclerosis. Medication regimens to optimize outcomes in both patients who are to undergo revascularization and those who will be managed without interventional therapy must address antiplatelet therapy. Given the common cardiovascular and cerebrovascular comorbidities in patients with PAD, antiplatelet therapy has the potential to decrease thromboembolic events in addition to improving patency after interventions. This clinical update reviews the current literature and recommendations for antiplatelet therapy in patients with PAD.

Transaxillary decompression of thoracic outlet syndrome patients presenting with cervical ribs

Objective: The transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach. Methods: We reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report. Results: Between 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow‐up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow‐up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit). Conclusions: This series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision. Graphical abstract: Figure. No caption available.

Recognition and Surgical Techniques for Management of Nonrecurrent Laryngeal Nerve during Carotid Endarterectomy.

The presence of a nonrecurrent laryngeal nerve (NRLN) during carotid endarterectomy (CEA) may significantly limit the exposure of the surgical field during this operation. Although its reported incidence is rare, NRLN typically overlies the carotid bifurcation and failure to recognize this anatomic variation increases the risk of NRLN injury. A retrospective chart review of all patients who underwent CEA for hemodynamically significant extracranial carotid stenosis between January 2005 and December 2014 was performed. All patients with NRLN encountered intraoperatively were identified. Clinical outcomes, surgical techniques, and complications were reviewed and reported. Four left-sided NRLN were identified and 4 were right sided. No cranial nerve deficits or injuries occurred after CEA in patients where NRLN was encountered. Two distinct surgical techniques were used to manage patients with NRLN and they are discussed in detail.

Promoting Excellence in Surgical Educational Research

Surgical education offers a rich and exciting setting for conducting educational research. Surgical educators need to understand basic concepts in educational research in order to design and conduct research studies as well as to become critical consumers of journal articles that report educational research findings. This chapter is divided into two portions. The first offers an overview of foundational concepts involved in the design of educational research studies. To that end we describe the differences between quantitative and qualitative studies and for each of them address what we believe are the five key questions: (1) What is the main purpose of the research being conducted?; (2) How is the number of research subjects determined?; (3) What are the key methods for collecting data from research subjects?; (4) How are research data analyzed?; and (5) How are research data reported? The second half of the chapter discusses in detail two published articles, one that follows the quantitative design and one that uses the qualitative research design. For each article we discuss, in a practical manner, how the five key elements apply.