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Subclavian artery aneurysms (SAAs) are historically rare peripheral aneurysm. However, it can be associated with serious life-threatening complications including rupture, thrombosis, and embolism. The majority of such aneurysms are found incidentally. Historically, SAA have been repaired via an open approach. Increasing case reports demonstrate successful management of SAAs with endovascular repair. The present report describes a case of incidentally discovered large proximal saccular subclavian aneurysm with suspected remote traumatic etiology with a successful endovascular repair. [ABSTRACT FROM AUTHOR]

Objective This review was conducted to evaluate the types of endovascular procedures that can be performed via brachial artery access, evaluate the access success rate, and determine the incidence of technical complications. Methods A retrospective 10-year record review at a tertiary facility from January 1, 2005, through June 30, 2015, was completed. Patients who underwent attempted brachial artery access were eligible for review. Outcomes intended to be evaluated included ability to access the vessel, reach an identified lesion, and perform an indicated procedure, while describing the incidence and type of complications that occurred to clarify the utility and safety of brachial artery access. Results The review included 265 access cases in 179 patients. The access success rate was 98.9%. Intervention was performed in 223 cases (84.2%). Angioplasty was the most common intervention (59%, [154 cases]), with stents, atherectomy, coiling, and percutaneous thrombectomy having also been performed. Complications included hematoma (2.3%) and pseudoaneurysm (1.5%). Complications requiring intervention occurred in 1.9% of procedures. Interventions were performed on all major vessels as distal as the dorsalis pedis. Sheath sizes ranged from 4F to 7F. Intervention was performed on bilateral lower extremities in 38 cases (14.5%). A femoral bypass graft was present in 141 patients (53%) as the main indication for brachial artery access. Conclusions Brachial access is a reliable and effective option for treatment of peripheral vascular disease and should be considered when femoral access is difficult or contraindicated and when a bypass graft is present in the femoral region. In addition, bilateral lesions may be approached easily through one brachial artery access site, making this approach advantageous when bilateral lesions are expected. The complication rate is similar to femoral access and can be minimized with ultrasound-guided access distally over the humerus, micropuncture access, and a dedicated postprocedure “hold team.” [ABSTRACT FROM AUTHOR]

Atherosclerotic axillary artery aneurysms are rare. We report a case of a ninety six year old female who presented with a pulsatile left breast mass causing her intractable pain. She was diagnosed with a massive axillary artery aneurysm which was treated with and endovascular aneurysm repair for palliation of her symptoms. [ABSTRACT FROM AUTHOR]

This study assessed the effectiveness of a 12-week, institution-based, supervised exercise rehabilitation program with atherogenic risk factor modification in improving cardiovascular profile, ambulatory function, and quality of life of patients with peripheral arterial disease (PAD) by comparing pre- and postprogram measurements. Participants were prospectively enrolled. Cardiovascular profile variables, ambulatory function tests, and quality of life questionnaires were evaluated. Of 101 institution-based program participants, 69 completed the 12-session minimum and 47 completed a postprogram evaluation. Mean postprogram results were significantly different from preprogram results, corresponding to improvement, for the following variables: triglyceride levels (p  =  .036), both function tests (p < .001 for both), four of five Walking Impairment Questionnaire measurements, and Intermittent Claudication Questionnaire score (p  = .001). This supervised exercise program improved the cardiovascular profiles, ambulatory function, and quality of life of PAD patients completing the program and is a viable adjunct to drug therapy and surgical intervention. [ABSTRACT FROM AUTHOR]

A young adult man with Klippel-Trénaunay syndrome presented to our pain management service with complaints of severe lower extremity neuropathic pain (pain scale 8 of 10 on the left and 4 of 10 on the right). The pain in his left leg was so severe that he wanted to undergo a left lower extremity amputation. The patient declined chronic use of narcotic medications for pain relief, believing that this would interfere with his educational and lifestyle pursuits. After a complete evaluation for possible sources of pain, we performed a trial placement of a spinal cord stimulator at the T9 level, which relieved his pain. We then placed a stimulator at the T10 level. At 1 year postimplantation, he was pain free (pain scale 1 of 10 bilaterally) and was able to function normally without narcotic support. We believe this to be the first use of a spinal cord stimulator for lower extremity pain resulting from Klippel-Trénaunay syndrome. We also discuss the clinical evaluation and treatment of a Klippel-Trénaunay syndrome patient with chronic pain. [ABSTRACT FROM AUTHOR]

Peripheral arterial pseudoaneurysm, while relatively rare, are encountered by most vascular specialists. This review evaluates the epidemiology, diagnosis, natural history, and treatment of pseudoaneurysm in the peripheral arteries. Most of this review concentrates on iatrogenic peripheral pseudoaneurysms, but pseudoaneurysms of other etiologies will also be discussed.

Reports regarding the management of ruptured abdominal aortic aneurysm with aorto-caval fistula (ACF) outline various treatment options and high mortality rates associated with this condition. This case illustrates a patient with a large ACF secondary to a prior rupture into the inferior vena cava with a delayed presentation. Because of preexisting conditions and severe metabolic sequelae of the ACF, palliative care was considered by the medical team. Minimally invasive endovascular techniques and prompt treatment resulted in a successful outcome with complete resolution of physiologic and metabolic abnormalities., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Inadvertent arterial puncture is a well-established complication of central venous catheter insertion. The carotid artery is the most frequently injured artery involved with injury to the subclavian artery and vertebral artery being much less common. When these injuries do occur, they are often treated with open surgical repair or endovascular, with stent-graft placement or embolization. Repair of acute vertebral artery injury with endovascular stent-graft repair has not been well represented in the literature to date. The present report discusses the successful treatment of concomitant injuries to the left subclavian and left vertebral arteries from acute iatrogenic puncture with endovascular stent-graft placement., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Duplex ultrasonography (DUS) is a safe, noninvasive method for imaging vasculature when compared with conventional angiography. Our goal is to assess the accuracy of DUS compared with angiography of the lower extremities. We reviewed a total of 373 lesions in 278 patients from July 2005 through June 2010. Patients underwent DUS followed by angiography within 30 days. Peak systolic velocities (PSV) were stratified into one of four categories and compared with the angiographic findings. Seventy-five chronic total occlusions were found. Of the remaining 298 lesions, a significant relationship was found between PSV and degree of angiographic stenosis (p < 0.001). DUS was found to demonstrate a sensitivity of 79.7%, specificity of 79.2%, positive predictive value of 88.2%, and negative predictive value of 66.7% for lesions ≥ 70%. The 66.7% of the false-negative lesions with the lowest velocities were below the knee joint. DUS of the lower extremities is accurate in determining the degree of stenosis ranging from mild-to-severe disease. Some limitation may exist in estimating the degree of stenosis below the knee.

Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique for varicose vein removal that addresses some limitations of traditional procedures. The study objective was to analyze perioperative and follow-up outcomes after TIPP and present modifications gleaned over 9 years of performing the technique. Four hundred and thirty-one patients who underwent TIPP performed between June 2002 and April 2011 were included in this retrospective review. Descriptive statistics were used to describe demographic, treatment, and outcome data. The mean procedure time was 20.2 minutes. The majority (50.5%) of cases involved 10 to 20 incisions. No significant varicosities were reported at a follow-up of 12 weeks. Postoperative complications included 2 (0.5%) deep vein thromboses, 8 (1.9%) cellulitis episodes, 16 (3.7%) hemosiderin staining cases, 2 (0.5%) abscesses, and 2 (0.5%) cases of excessive or hypertrophic scarring. All but one patient reported good outcomes and were satisfied with the procedure. With proper training and experience, TIPP with a lower oscillation frequency and secondary tumescence results in good outcome and high patient satisfaction.

Background: Upper-extremity arterial injuries are relatively uncommon, but they may significantly impact patient outcome. Management of these injuries was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome., Methods: Upper-extremity trauma patients presenting with arterial injury between January 2005 and July 2010 were included in this retrospective review. Descriptive statistics were used to describe demographic, injury, treatment, and outcome data. These variables also were compared between blunt and penetrating arterial injuries and between proximal and distal arterial injuries., Results: During a 5.6-year period, 135 patients with 159 upper-extremity arterial injuries were admitted, yielding an incidence of 0.74% among trauma admissions. The majority of patients (78.5%) suffered concomitant upper-extremity injuries. The most common injury mechanism was laceration by glass (26.4%). Arterial injuries were categorized into 116 penetrating (73.0%) and 43 blunt (27.0%) mechanisms. Arterial distribution involved was as follows: 13 axillary (8.2%), 40 brachial (25.2%), 52 radial (32.7%), 51 ulnar (32.1%), and 3 other (1.9%). The types of arterial injuries were as follows: 69 transection (43.4%), 68 laceration (42.8%), 16 occlusion (10.1%), 3 avulsion (1.9%), and 3 entrapment (1.9%). One patient (0.7%) required a primary above-elbow amputation. The majority of injuries (96.8%) receiving vascular management underwent surgical intervention--76 primary repair (49.7%), 41 ligation (26.8%), 31 bypass (20.3%), and 5 endovascular (3.3%). Conservative treatment was the primary strategy for five arterial injuries (3.3%). Of the patients receiving vascular intervention, three (2.2%) required major and three (2.2%) required minor amputations during hospitalization and no patients expired., Conclusion: The current multidisciplinary team management approach with prompt surgical management resulted in successful outcomes after upper-extremity arterial injuries. No outcome differences between penetrating and blunt or between proximal and distal arterial injuries were calculated. This management approach will continue to be used., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Limb amputation is a life-changing event that signifies long-term physical, social, psychological, and environmental change. Spiritual well-being in patients plays a significant role in coping and may affect outcomes of patients with limb loss. The objective of this study was to describe the role of spirituality in individuals with limb amputation and to determine whether spirituality is related to the quality of life (QOL) in this sample. Study participants were recruited through prosthetists, physicians, amputee support groups, the Amputee Coalition of America, and amputee listserv discussion groups in the United States and Canada. Participants completed questionnaires containing measures of satisfaction with life, general health, mobility, and social integration. A quantitative descriptive research design was used to examine the relationships between existential spirituality (belief that one's life is meaningful or has purpose) and religious spirituality and QOL among individuals with limb amputation. A prospective study of 108 patients with a history of limb amputation was performed. The study population consisted of 66.3% males and 33.7% females. Most patients were Caucasian (96.2%). Of the 108 participants, 86 (79.6%) were 41 years of age or older with a mean of 18 years since amputation. The most frequent cause of amputation was trauma (55.6%) and the most common location of amputation was below-the-knee (49.1%). Existential spirituality, female gender, and age above 50 years related to higher QOL in patients with a history of limb amputation. The findings of this research confirmed that amputees use spirituality to cope with limb amputation. Existential spirituality was a significant predictor of satisfaction with life, general health, and social integration.

In this study we demonstrate that ultrasound (US)-guided injection of thrombin is a safe and effective way to treat iatrogenic pseudoaneurysms as a new treatment modality at a 650-bed urban community hospital. We included retrospective chart review of patients who were treated for iatrogenic pseudoaneurysms from January 2004 to June 2010 at a single institution. All patients' pseudoaneurysms were treated using US-guided thrombin injection. This study demonstrated an overall success rate of 97.1% in treating iatrogenic pseudoaneurysms in 33 of 34 patients. One patient underwent open surgical repair. No mortality or complications were noted. The study was successful in demonstrating that the US-guided injection of thrombin is an efficacious way to treat iatrogenic pseudoaneurysms and can be safely implemented as a new treatment modality by appropriately trained vascular surgeons. A review of different techniques is included. An algorithm for the treatment of iatrogenic pseudoaneurysms is proposed from this study.

The purpose of this study was to evaluate the use of prostaglandin E1 (PGE1) as a renal protective medication for patients exposed to contrast agents, as well as to demonstrate the safety, efficacy, and low side-effect profile of PGE1. A prospective, randomized, double-blind study was designed to compare combination of intravenous sodium bicarbonate, normal saline, and oral PGE1 200 μg versus the combination and placebo for renal protection from contrast agents. All patients receiving nonionic contrast during their interventional procedure were eligible for enrollment. Creatinine levels were recorded before and after the administration of contrast and renal protective medications. Contrast-induced nephrotoxicity (CIN) was defined as an increase of 0.5 mg/dL or greater in creatinine level, or an increase of 25% or more above baseline. Age, gender, total amount of contrast used, and incidence of renal failure requiring dialysis were recorded. We conducted the study on 41 patients. Of these, 20 patients received PGE1 and 21 received the placebo. The study group comprised 29 males and 12 females. Diabetes mellitus occurred in 41.5% of the cases (including 40% of PGE1 and 43% of placebo patients). Average contrast use was 77.2 mL (range, 15 to 200 mL). Mean age of the groups was 67.2 years. Average baseline creatinine level was 1.17. The differences between the groups were not statistically significant. CIN by definition occurred in one patient, who received the placebo. Incidence of new onset renal failure requiring dialysis was zero. Postcontrast change in creatinine level for the study was 0.11. There was a change in the creatinine level of 0.161 in the PGE1 group and 0.061 in the placebo group; an improvement of 0.10. PGE1 was not effective in significantly altering postcreatinine levels (p = 0.176). None of the patients enrolled in the study suffered any side effects from taking the PGE1 tablet. Although preliminary, this study shows that the addition of PGE1 for the prevention of CIN is well-tolerated by patients and is a safe modality. Additional studies are required to evaluate efficacy.

An applicant shortage for vascular surgery (VS) residencies exists despite an increase in available training positions created to meet the growing demands for vascular surgeons. After 3 years of practice as an American Board of Surgery (ABS)-certified/board-eligible general surgeon, the author of this study attended an accredited 1-year VS training fellowship and received an ABS certificate of Added Qualifications in VS. The purpose of this review was to investigate the implications completing a vascular fellowship has had on VS procedure patterns, vascular procedure competency, clinical practice, career, and lifestyle with the aim of attracting trainees to the field of VS. The author's operative logs were reviewed retrospectively to summarize vascular procedures performed before and after the vascular fellowship. Statistical analysis was performed comparing the types and volume of vascular procedures before and after the vascular fellowship. Changes in professional career and personal life also were examined. The author performed 401 vascular procedures during 2.8 years as a general surgeon. In the first 3.4 years after the vascular fellowship, vascular procedure volume increased to 1563. The mean number of vascular procedures performed per year increased from 143.2 as a general surgeon to 459.7 as a vascular surgeon. The three major differences in vascular procedures occurring after the vascular fellowship were (1) a threefold increase in the number of vascular procedures performed, (2) a shift from major open to venous and endovascular procedures, and (3) an increase in case complexity. Specializing in VS also has resulted in increased career opportunities, more career satisfaction, a direct financial benefit, and more flexibility for lifestyle and family. Because of these positive changes, the author encourages medical students and residents interested in VS to explore the specialty early, seek vascular surgeons to serve as mentors, and enter one of the new VS pathways as early as possible in their career., (Copyright 2008 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Blunt cerebrovascular injuries (BCVI) in trauma patients are rare but potentially devastating injuries, particularly if the diagnosis is delayed. Conventional angiography (CA) has been the screening and diagnostic modality of choice for identifying BCVI. With the advent of high-resolution computed tomography (CT), CT angiography has become a common modality for the screening of BCVI. A liberalized screening approach has suggested that cerebrovascular injuries are missed in many patients; however, no standard BCVI screening protocol exists. Early diagnosis of the BCVI can prevent long-term sequelae., Methods: In this prospective study, all patients received a CT angiogram (16-slice or 64-slice) at the time of injury assessment and followed 24 hours to 48 hours later with CA of the cerebrovasculature., Results: A total of 158 patients were enrolled in the study. CA identified 32 injuries to the cerebrovasculature in 27 patients; CT detected only 13 true injuries (40.6%) in 12 patients. Of the 32 injuries, 11 were carotid artery injuries and 21 were of the vertebral artery. Seventy-four patients were screened with the 16-slice CT scanner with an overall sensitivity of 29%, and 84 patients were screened with the 64-slice CT scanner with an overall sensitivity of 54%. The combined specificity and sensitivity of 16- and 64-slice CT in detecting BCVI were 0.97 (95% confidence interval: 0.92-0.99) and 0.41 (95% confidence interval: 0.22-0.61), respectively., Conclusion: Neither 16- nor 64-slice CT angiography is as accurate as CA as a screening tool for BCVI.

Transilluminated powered phlebectomy (TIPP) is a promising alternative to traditional ambulatory phlebectomy procedures. This retrospective review of 339 patients represents the senior author's first consecutive series of 400 cases performed using TIPP for the treatment of varicose veins in a 6-year period. Patients were followed for 12 weeks postoperatively. Data analyzed included operative time, intraoperative complications, stab incision ranges, postoperative complications, and patient satisfaction. The mean operative time was 19.7 minutes, and 246 (61.5%) cases involved 10 to 20 incisions. Postoperative complications included an episode of symptomatic deep vein thrombosis in one (0.3%) patient, excessive or hypertrophic scarring in two (0.6%) patients, discoloration of the lower extremity skin due to hemosiderin staining in eight (2.3%) patients, and cellulitis in one (0.3%) patient. No recurrences were observed at a follow-up of 12 weeks. Three hundred thirty-eight (99.7%) patients reported good outcomes and were satisfied with the procedure. This review by an individual surgeon is beneficial in analyzing the outcomes and complications associated with TIPP, as a standard protocol was followed and an adequate volume was performed to advance past the learning curve associated with the technique. When concomitant saphenous vein incompetence is present, staged treatment of varicosities with TIPP after endovenous laser ablation is recommended. With proper training and experience, utilization of TIPP with a lower oscillation frequency and secondary tumescence results in good outcome and high patient satisfaction.

Although relatively uncommon, upper extremity arterial injuries are serious and may significantly impact the outcome of the trauma patient. Management of upper extremity arterial injuries at an urban level I trauma center was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome. Upper extremity trauma patients with arterial injury who presented between January 2005 and December 2006 were included in this retrospective review. Data collected included age, gender, race, mechanism of injury, type of injury, associated upper extremity injuries, concomitant injuries, injury severity score (ISS), diagnostic modalities employed, surgical procedures and interventions, mortality, length of stay, and discharge disposition. Statistical analysis between blunt and penetrating arterial injuries as well as between proximal and distal arterial injuries also was conducted. During a 2-year period, 28 patients with 30 upper extremity arterial injuries were admitted, yielding an incidence of 0.48%. The study population was comprised primarily of young Caucasian males, with a mean ISS of 9.0. The majority (89.3%) of patients suffered concomitant upper extremity injuries. Twenty-two nerve injuries were identified in 16 (57.1%) patients. The most common injury mechanism was cut by glass (39.3%). Arterial injuries were categorized into 18 (60.0%) penetrating and 12 (40.0%) blunt injuries. Involved artery distribution was as follows: 12 (40.0%) brachial, eight (26.7%) ulnar, seven (23.3%) radial, and three (10.0%) axillary. Over half (56.7%) of the injuries resulted from lacerations. Injuries were managed as follows: 14 (46.7%) primary repairs, eight (26.7%) ligations, six (20.0%) saphenous vein graft bypasses, and two (6.7%) endovascular procedures. Eleven (39.3%) patients required intensive care unit (ICU) admission. The overall mean length of hospitalization for these patients was 7.4 days compared to a mean length of hospitalization of 2.0 days for the 17 (44.7%) patients who did not require ICU admission. The overall limb salvage rate was 96.4% as arterial injuries were successfully repaired in 27 of 28 patients. No patients expired and all were discharged home. Equivalent demographics, mechanisms of injury, surgical management approaches, and successful hospital outcomes were demonstrated between penetrating and blunt injuries as well as between proximal and distal arterial injuries. The current management approach, including use of angiography and prompt surgical management, results in successful outcomes after upper extremity arterial injuries and will continue to be utilized.

Internal iliac artery (IIA) aneurysms present several challenges to the vascular surgeon: They are uncommon, and the often difficult repair is associated with relatively high morbidity/mortality. Bilateral internal iliac disease adds technical complications secondary to ischemic complications. In this case, a 76-year-old male with bilateral IIA aneurysms underwent staged endovascular coil embolization, resulting in exclusion of flow to the aneurysms and avoidance of ischemic postoperative complications. Angiography during the procedure verified complete bilateral IIA occlusion, which remained intact at 6-week and 1 year follow-up (computed tomography). This case illustrates successful repair of bilateral IIA using endovascular techniques.