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True aneurysm formation in infrainguinal autologous vein grafts is rare. The authors report a case of a patient presenting with extensive aneurysmal degeneration of a femoropopliteal bypass vein graft 13 years after the original operation and 8 years after graft revision and thrombolysis for acute occlusion. Over a 2-year period, the vein graft aneurysm expanded from 2.7 to 4.5 cm maximal diameter. He underwent exclusion and partial resection of the vein graft aneurysm with placement of a new femoropopliteal bypass using reversed saphenous vein from the contralateral leg. Histopathologic examination of the aneurysm revealed intimal fibrosis, medial degeneration, and inflammation. This case and review of the literature suggests that true infrainguinal vein graft aneurysms occur infrequently and massive aneurysm degeneration is even more uncommon. Because of the rarity of true infrainguinal vein graft aneurysms, their etiology remains unclear. [ABSTRACT FROM AUTHOR]

Background: Endovascular aortic repair has revolutionized the management of traumatic blunt aortic injury (BAI). However, debate continues about the extent of injury requiring endovascular repair, particularly with regard to minimal aortic injury. Therefore, we conducted a retrospective observational analysis of our experience with these patients., Methods: We retrospectively reviewed all BAI presenting to an academic level I trauma center over a 10-year period (2000-2010). Images were reviewed by a radiologist and graded according to Society for Vascular Surgery guidelines (grade I-IV). Demographics, injury severity, and outcomes were recorded., Results: We identified 204 patients with BAI of the thoracic or abdominal aorta. Of these, 155 were deemed operative injuries at presentation, had grade III-IV injuries or aortic dissection, and were excluded from this analysis. The remaining 49 patients had 50 grade I-II injuries. We managed 46 grade I injuries (intimal tear or flap, 95%), and four grade II injuries (intramural hematoma, 5%) nonoperatively. Of these, 41 patients had follow-up imaging at a mean of 86 days postinjury and constitute our study cohort. Mean age was 41 years, and mean length of stay was 14 days. The majority (48 of 50, 96%) were thoracic aortic injuries and the remaining two (4%) were abdominal. On follow-up imaging, 23 of 43 (55%) had complete resolution of injury, 17 (40%) had no change in aortic injury, and two (5%) had progression of injury. Of the two patients with progression, one progressed from grade I to grade II and the other progressed from grade I to grade III (pseudoaneurysm). Mean time to progression was 16 days. Neither of the patients with injury progression required operative intervention or died during follow-up., Conclusions: Injury progression in grade I-II BAI is rare (~5%) and did not cause death in our study cohort. Given that progression to grade III injury is possible, follow-up with repeat aortic imaging is reasonable., (Copyright © 2014 Society for Vascular Surgery. All rights reserved.)

Background: The aim of this study was to examine the relationship between patient education level and 5-year mortality after major lower extremity amputation., Methods: The records of all patients who underwent above-knee or below-knee amputation at the Nashville Veterans Affairs Medical Center by the vascular surgery service between January 2000 and August 2006 were retrospectively reviewed. Formal levels of education of the study patients were recorded. Outcomes were compared between those patients who had completed high school and those who had not. Bivariate analysis using χ(2) and Student's t tests and multivariate logistic regression were performed., Results: Five-year mortality for patients who had completed high school was lower than for those who had not completed high school (62.6% vs 84.3%, P = .001), even after adjusting for important clinical factors (odds ratio for death, .377; 95% confidence interval, .164-.868; P = .022)., Conclusion: Patients with less education have increased long-term mortality after lower extremity amputation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: With the institution of the work-hour restrictions in 2003, less time may be available for surgical residents to learn operative technique and judgment. While numerous studies have evaluated the use of surgical simulation training to enhance operative skills, little is known about the quality of teaching that takes place in the operating room (OR). The purpose of this study was to assess residents' perception of faculty teaching in the OR in order to target ways to improve operative education., Methods: A request for resident participation in an online survey was sent to the Program Coordinator at all 255 ACGME-accredited general surgery residency programs., Results: A total of 148 programs (59%) participated in the survey, and anonymous responses were submitted by 998 of 4926 residents (20%). Most residents reported that attending surgeons verbalize their operative approach (55%), include residents in intraoperative decisions (61%), and offer technical advice (84%). However, few residents reported that faculty help to identify the resident's personal educational operative goals preoperatively (18%) or discuss areas of improvement with residents (37%). Of all cases scrubbed in the past year, most residents feel as though they only actually performed the procedure between 26% and 50% (29%) or between 51% and 75% (32%) of the time. However, more than half of all residents (51%) log these procedures for ACGME as primary surgeon 76%-100% of the time., Conclusions: This study demonstrates that from the residents' perspective, a number of opportunities exist to improve teaching in the OR, such as guiding residents with preoperative preparation and providing them with constructive feedback. These findings also suggest that residents may be logging cases without feeling as though they actually perform the operations., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: This investigation examined the trends for gender-based advancement in academic surgery by performing a comparative analysis of the rate of change in the percentage of medical students, surgery residents, and full professors of surgery who are women., Methods: All available Women in Medicine Annual Reports were obtained from the American Association of Medical Colleges (AAMC). The gender compositions of medical graduates, surgery residents, and full professors were plotted. Binomial and linear trendlines were calculated to estimate the year when 50% of surgery full professors would be women. Additionally, the percentage distribution of men and women at each professorial rank was determined from 1995 to 2009 using these reports to demonstrate the rate of academic advancement of each gender., Results: The slope of the line of increase for women full professors is significantly less than for female medical students and for female general surgery residents (0.36, compared with 0.75 and 0.99, respectively). This predicts that the earliest time that females will account for 50% of full professors in surgery is the year 2096. When comparing women and men in academic ranks, we find that women are much less likely than men to be full professors., Conclusions: The percentage of full professors in surgery who are women is increasing at a rate disproportionately slower than the increases in female medical students and surgery residents. The rates of increase in female medical students and surgery residents are similar. The disproportionately slow rate of increase in the number of female full professors suggests that multiple factors may be responsible for this discrepancy., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The Surgical Morbidity and Mortality conference has long been used as an opportunity for both process improvement and resident education. With recent heightened focus on creating environments of safety and on meeting the Accreditation Council for Graduate Medical Education (ACGME) General Competencies, novel approaches are required. With the understanding that the provision of medical care is an inherently multidisciplinary enterprise, we advocate the creation and use of a Multidisciplinary Morbidity and Mortality conference (MM&M) as a means to establish this culture of safety while teaching the ACGME General Competencies to surgery residents., Methods: A quarterly MM&M conference was implemented to foster communication between disciplines, provide a forum for quality improvement, and enhance patient care. All stakeholders in the perioperative enterprise attend, including the departments of surgery, anesthesia, radiology, pharmacy, nursing, environmental services, risk management, and patient services. Cases that expose system issues with potential to harm patients are discussed in an open, nonconfrontational forum. Solutions are presented and initiatives developed to improve patient outcomes. We retrospectively reviewed the topics presented since the conference's inception, grouping them into 1 of 7 categories. We then evaluated the completion of the improvement initiatives developed after discussion at the conference., Results: Over a 21-month period, 11 cases were discussed with 23 "actionable" initiatives for quality improvement. Cases were grouped by category; procedures (36.5%), process (36.5%), patient-related (9%), communication (9%), medication (9%), device (0%), and ethics (0%). All cases discussed addressed at least 4 of the 6 ACGME General Competencies., Conclusions: Like the practice of medicine, the occurrence of adverse outcomes is frequently multidisciplinary. An MM&M conference is useful in its potential to meet ACGME General Competencies, engender a culture of patient safety, and rapidly achieve quality improvement and systems health care delivery initiatives in a large academic medical center., (Copyright © 2011 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The use of social networking (SN) sites, such as Facebook and Twitter, has skyrocketed during the past 5 years, with more than 400 million current users. What was once isolated to high schools or college campuses has become increasingly ubiquitous in everyday life and across a multitude of industries. Medical centers and residency programs are not immune to this invasion. These sites present opportunities for the rapid dissemination of information from status updates, to tweets, to medical support groups, and even clinical communication between patients and providers. Although powerful, this technology also opens the door for misuse and policies for use will be necessary. We strive to begin a discourse in the surgical community in regard to maintaining professionalism while using SN sites., Results: The use of SN sites among surgical house staff and faculty has not been addressed previously. To that end, we sought to ascertain the use of the SN site Facebook at our residency program. Of 88 residents and 127 faculty, 56 (64%) and 28 (22%), respectively, have pages on Facebook. Of these, 50% are publicly accessible. Thirty-one percent of the publicly accessible pages had work-related comments posted, and of these comments, 14% referenced specific patient situations or were related to patient care., Conclusions: Given the widespread use of SN websites in our surgical community and in society as a whole, every effort should be made to guard against professional truancy. We offer a set of guidelines consistent with the Accreditation Council for Graduate Medical Education and the American College of Surgeons professionalism mandates in regard to usage of these websites. By acknowledging this need and by following these guidelines, surgeons will continue to define and uphold ethical boundaries and thus demonstrate a commitment to patient privacy and the highest levels of professionalism., (Copyright © 2010 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Transperitoneal (TP) and retroperitoneal (RP) approaches have equal efficacy in elective open abdominal aortic aneurysm (AAA) repair. The effect of open operative approach on patient-specific outcomes after AAA repair was tested., Methods: Consecutive patients undergoing open AAA repair at the Veterans Affairs Tennessee Valley Healthcare System between January 2000 and August 2008 were retrospectively reviewed. Analysis was performed to examine the effects of demographic and clinical covariates on postoperative outcomes., Results: A total of 106 patients were identified: 54 with TP approach and 52 with RP approach. Demographics and preoperative comorbidities were equivalent (p > or = 0.10), with the exception of chronic obstructive pulmonary disease which was more prevalent in the TP group (61 vs. 40%). Operative times were longer in the TP group (4.6 vs. 3.5 hours; p < 0.01); however, significantly more TP patients had reconstruction with a bifurcated graft (72 vs. 2%; p < 0.01). Postoperative nasogastric tube decompression times were shorter in the RP group (1 vs. 3 days; p < 0.01), and RP approach led to a quicker return to preoperative diet (4 vs. 6 days; p = 0.05). Patients undergoing RP repair developed fewer incisional hernias (2 vs. 15%; p = 0.03)., Conclusion: RP approach to AAA repair offers patients faster return of bowel function and is associated with fewer incisional hernias., (Copyright 2010 Annals of Vascular Surgery Inc. All rights reserved.)

Experience with carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CE) for management of carotid stenosis continues to evolve. We report the case of a 64-year-old man who was treated with bilateral CAS for stenoses, which developed 7 years following thyroidectomy, neck dissection, and radiotherapy. Although long considered an ideal alternative to CE in this clinical setting, CAS in this case was complicated by multiple episodes of recurrent stenosis in his left carotid, managed by balloon angioplasty. Severe, early recurrence in his right carotid associated with a type III stent fracture was managed by CE. Close surveillance and intervention prevented neurologic morbidity. This case, combined with emerging published experience, argues for reappraisal of the general consensus that CAS is an ideal alternative to CE for radiotherapy-associated carotid stenoses.

Purpose: General Surgery residents are increasingly pursuing fellowships. We examine whether perceived subspecialty content, dedicated services, and fellows impact fellowship choices., Methods: Specialty content was assessed through a survey linking 228 operations to 9 content areas. The presence of dedicated services and fellows and the post-residency activities of graduates 1997-2006 were collected from 2 program directors., Results: A total of 75% of residents (26 University of Mississippi, UM; 22 Vanderbilt University, VU) completed surveys. Five dedicated services and 2 fellowships at UM and VU were identical; VU had an additional 4 services and 3 fellowships. UM and VU residents similarly associated 184 operations (81%) with General Surgery. Agreement was not linked to services or fellows. A total of 44% of UM graduates and 68% of VU graduates pursued fellowships. The top choice at UM was Plastic/Hand (14%, versus 6% VU) and Oncology/Endocrine at VU (19%, versus 2% UM). Differences in specialties selected could not be linked consistently to dedicated services or fellows., Conclusion: Dedicated services and fellows appear to have little impact on fellowship specialty selection by chief residents. There may be a generic effect of dedicated services favoring fellowship versus no fellowship. Differential faculty mentoring skills may influence specific fellowship choices.

Carotid angioplasty and stenting (CAS) with embolic protection is currently accepted as treatment for patients considered to be at high risk for carotid endarterectomy (CEA). The purpose of this study was (1) to determine what proportion of patients treated with CEA would be categorized as "high" risk by currently accepted criteria, (2) to characterize preoperative angiographic findings in patients with carotid stenosis, and (3) to determine the potential technical challenges of CAS in these patients. Consecutive patients who underwent CEA from January 1999 through August 2004 prior to introduction of CAS at our institution were identified. Demographics, indications, perioperative complications, and deaths were reviewed. Published guidelines defining high risk for CEA were applied, and preoperative angiograms were examined for technical limitations to CAS. Two hundred and seventy-nine CEAs were performed in 259 patients for asymptomatic carotid occlusive disease (57%), transient ischemic attacks (35%), or stroke (8%) during the study period. Of these, 35.5% (n = 99) would have met one or more high-risk criteria. Overall risks of perioperative stroke, myocardial infarction, and death were 1.1%, 2.2%, and 0.4% (n = 279), respectively, with a combined major complication rate of 3.3%. No difference in major complication rates was observed between standard-risk and high-risk patients. Preoperative angiograms were available for review in 83.5% of CEAs (n = 233). The distribution of aortic arch configurations included types I (3.5%), IIa (39.5%), IIb (54.5%), and III (1.3%). Aortic arch anomalies were observed in 15.5% (n = 35) of angiograms. There were 77.7% (n = 181) with one or more angiographic findings that would have increased the technical difficulty of CAS, but only 17.6% had relative angiographic contraindications to CAS. A significant proportion of patients with carotid stenosis previously managed with CEA would be categorized as high risk and considered potential candidates for CAS by currently accepted criteria. Based on preoperative angiography, technically challenging factors, some of which limit the ability to perform CAS, are common and should be anticipated when planning CAS.

Ischemic injuries following percutaneous femoral artery catheterization are uncommon but have been associated with vascular closure devices (VCDs). The purpose of this study was to retrospectively compare ischemic and hemorrhagic complications of femoral artery catheterization and to identify factors associated with ischemic injuries. The operative registries of the attending vascular surgeons at one academic and two community hospitals were retrospectively reviewed to identify all complications of femoral artery catheterization requiring operative intervention. Demographic, clinical, procedural, operative, and outcome data were compared between patients who sustained ischemic and hemorrhagic complications. From January 2001 to December 2006, 95 patients required operative management of complications related to femoral artery catheterization including 40 patients who experienced ischemic (group 1) and 55 patients who experienced hemorrhagic (group 2) complications. Compared to those sustaining hemorrhagic complications, ischemic complications were more frequently associated with younger age, smoking, VCD deployment, and, when controlling for VCD use, female gender. Time to presentation was also significantly longer in patients experiencing ischemic complications. Ischemic complications are increasingly recognized following femoral artery catheterization. Vascular surgeons should anticipate a new pattern of injury following femoral artery catheterization, one that often requires complex arterial reconstruction.

Background: The impact of high-fidelity simulators as an adjunct for endovascular training of general surgery residents has not yet been defined. The purpose of this study was to evaluate general surgery resident perspectives on the value of a simulator-based endovascular training program by using various measurement tools., Methods: General surgery residents in postgraduate years 1 to 5 (n = 50) participated in a focused endovascular training course covering aortoiliac, renal, and carotid artery disease. The components of the course included didactic lecture, self-learning course material and computer training modules, hands-on exposure to endovascular instruments, and endovascular procedure simulation using a mobile SimSuite unit (Medical Simulation Corporation, Denver, CO). Course participants completed pre- and postcourse questionnaires, knowledge-based testing, and endovascular simulator metric testing., Results: Of the 50 general surgery residents who completed the precourse questionnaire and knowledge-based testing, 41 completed the entire program including the postcourse questionnaire and knowledge-based testing, and 33 completed endovascular simulation metric testing. Subjective responses from pre- and postcourse surveys highlighting the residents' perceptions of the potential role of endovascular simulation as part of general surgery residency training showed favorable responses. On completion of the course, mean knowledge-based test scores had statistically significant improvement (pretest, n = 50, 59.5% +/- 12.1% correct and posttest, n = 41, 69.1% +/- 15.4% correct [P = .003]). For metric testing of a simulated endovascular procedure (n = 33), 93.9% completed all of the defined tasks within the allotted time period (mean time, 12.2 +/- 4.36 minutes; range, 4.1-26.6 minutes; 95% confidence interval for mean 10.8-13.6 minutes)., Conclusions: Based on subjective and objective measures, general surgery residents found valuable and benefited in knowledge base from a focused simulator-based endovascular training program. Integrating endovascular simulation into general surgery resident training and its influence on resident interest in vascular specialization as a career choice holds future potential.

This study was undertaken to evaluate the evolution of operative vein approaches from combined "open" saphenous stripping-stab avulsion phlebectomy to combined "minimally invasive" endovenous ablation-transilluminated powered phlebectomy with a focus on comparing clinical outcomes. All patients undergoing a combined operative approach for concomitant saphenous vein insufficiency and associated varicose tributary veins between January 1, 1998 and December 31, 2005 were identified. Patients were stratified by operative approach into 3 groups: combined saphenous vein stripping-stab avulsion phlebectomy (STRIP-PHLEB); combined saphenous vein stripping-transilluminated phlebectomy (STRIP-TPP); and combined endovenous ablation-transilluminated phlebectomy (EVAB-TPP). Clinical volume, indications, technical details, and complications were retrospectively reviewed. Over the 8-year period, there were 72 limbs in 59 patients treated with STRIP-PHLEB, 92 limbs in 81 patients with STRIP-TPP, and 99 limbs in 76 patients with EVAB-TPP, with a time-dependent transition in operative techniques noted. There was no difference in distribution of CEAP clinical classification between groups, overall with most limbs in the C2-C4 categories (93.1%) and fewer in the C5-C6 categories (6.9%). There was no difference in overall complication rates between STRIP-PHLEB and EVAB-TPP, although the distribution of complications did shift with a trend toward more wound problems noted in procedures involving saphenous stripping (STRIP-PHLEB 5.6%, STRIP-TPP 6.5%, EVAB-TPP 2.0%; P = NS), and more hematomas in procedures involving transilluminated powered phlebectomy (STRIP-PHLEB 5.6%, STRIP-TPP 16.3%, EVAB-TPP 6.9%; P < .05; see Table 2). Complications associated with the endovenous ablation portion were low including technical inability to cannulate 1.6%, saphenous re-cannulation 2.4%, hematoma 2.4%, severe phlebitis 3.1%, venous thromboembolism 0.8%, and no wound or thermal injury problems. With the shift of combined operative vein approaches for concomitant saphenous vein insufficiency and varicose tributary veins towards "minimally invasive" techniques the overall complication rate has remained unchanged. While combined endovenous ablation-transilluminated phlebectomy offers some advantage of "less" invasiveness, this perceived benefit should be balanced against unchanged overall risk over traditional operative approaches.

Objective: To evaluate the impact of creating a new specialty vein clinic within an academic-based vascular practice on clinical volume, physician workload and financial parameters., Methods: All patients evaluated and treated for varicose vein related problems within an academic vascular surgery practice were identified from institutional billing databases. Data were stratified according to the time period prior to establishing a vein clinic (PRE-VC) (1999-2001) and after creation of a vein clinic (POST-VC) (2002-2004). Clinical volume, physician workload and financial parameters were evaluated. Comparisons were made between vein (VEIN) and overall vascular (VASC) practice trends., Results: Comparison of clinical volume, physician workload and financial parameters in both the clinic and operative settings showed larger and more rapid expansion of the VEIN practice than VASC practice between PRE-VC and POST-VC time periods (VEIN vs.VASC growth, respectively: new patient clinic volume +162 vs. +18%; clinic relative value units (RVUs) +131 vs. +1%, clinic revenue +201 vs. +44%; procedure volume +348 vs. +19%; procedure RVUs +129 vs. +11%; procedure revenue +93 vs. +10%). Comparing the beginning of PRE-VC to the end of POST-VC time periods, an increasing trend was also present for the percentage of VEIN practice accounting for the total VASC practice (%VEIN PRE-VC to POST-VC, respectively: new patient clinic volume 11.6-30.2%; clinic RVUs 3.2-48.2%; clinic revenue 17.6-31.2%; procedure volume 3.1-14.3%; procedure RVUs 2.8-9.8%; procedure revenue 3.3-11.7%)., Conclusion: Establishing a specialty vein clinic within an academic vascular practice can lead to a rapid expansion of clinical volume with associated increase in physician workload and reimbursement at a rate greater than that for the overall vascular practice.

We evaluated outcomes after carotid body tumor resection (CBR) requiring vascular reconstruction. Patients undergoing CBR at an academic medical center between 1990 and 2005 were identified. Medical records were retrospectively reviewed for clinical data, operative details, Shamblin's classification, tumor pathology, complications, and mortality. Comparisons were performed between those undergoing CBR alone and CBR requiring vascular reconstruction (CBR-VASC). Of the 71 CBRs performed in 62 patients, 16 required vascular reconstruction (23%). Although there was no difference in mean tumor size (CBR 29.1 +/- 11.9 mm, CBR-VASC 32.5 +/- 9.9 mm; p = 0.133), carotid body tumors were more commonly Shamblin's I when CBR was performed alone (CBR 53% vs. CBR-VASC 25%, p = 0.045) and Shamblin's II/III when vascular reconstruction was required (CBR 47% vs. CBR-VASC 75%, p = 0.045). There was also a significant difference in malignant tumor pathology when vascular reconstruction was required (CBR 4.4% vs. CBR-VASC 25%, p = 0.034). Cranial nerve dysfunction was higher in patients requiring vascular repair (CBR 27% vs. CBR-VASC 63%, p = 0.012), but there was no difference in baroreflex failure (CBR 7.27% vs. CBR-VASC 0%, p = 0.351), Horner's syndrome (CBR 5.5% vs. CBR-VASC 6.25%, p = 0.783), or first bite syndrome (CBR 7.27% vs. CBR-VASC 12.5%, p = 0.877). There were no perioperative strokes in either group, and one death was unrelated to operation. When required, carotid artery reconstruction at the time of CBR can be performed safely. Although cranial nerve dysfunction is more common when vascular repair is required, this is more likely related to locally advanced disease and tumor pathology rather than operative techniques.

Bedside placement of inferior vena cava filters by using either transabdominal duplex ultrasonography or intravascular ultrasonography (IVUS) has been shown to be safe and effective. We review techniques for bedside filter placement with transabdominal duplex ultrasonography, IVUS with dual venous access, and IVUS with single venous access. Transabdominal duplex ultrasonography and IVUS remain our preferred techniques for filter placement when feasible, especially in critically ill and immobilized patients.

Neoaortic reconstruction using an autogenous conduit is an increasingly accepted option for the management of aortic graft infections. However, this approach is not without technical challenges and potential graft-related problems, some of which can be solved with endovascular techniques. All patients who underwent neoaortic reconstruction with femoral-popliteal vein for aortic graft infection over a 6-year period were identified from the operative registry. Those patients requiring endovascular adjunctive therapies form the basis of this report. Of 17 cases of neoaortic reconstruction for aortic graft infection, five (29%) required endovascular adjunctive procedures. These included stent placement for graft stenosis (n = 3), stent graft placement for proximal anastomotic stenosis (n = 1), and stent graft placement for anastomotic disruption (n = 1). While two of these procedures occurred within 30 days of the original neoaortic reconstruction, three were required during late follow-up. Although there were no direct complications related to the endovascular procedures, the patient with anastomotic disruption died within 30 days of causes unrelated to the endovascular procedure. Primary patency of neoaortic reconstruction was 87% at 30 days and 61% at 3 years, with assisted primary patency increasing to 100% at 3 years after endovascular adjunctive intervention. While neoaortic reconstruction using an autogenous conduit for aortic graft infection has proven durability, it is not without potential early and late graft complications. When graft problems occur, endovascular options are an attractive alternative to reoperative open aortic procedures, especially in the setting of a vastly altered surgical field.

While contrast venography is considered the gold standard for imaging prior to inferior vena cava (IVC) filter insertion, bedside placement via transabdominal duplex ultrasound (DUS) has been recognized as a safe and effective alternative. To date, there has been no direct comparison of the efficacy of both imaging modalities for IVC filter placement. A concurrent cohort of patients who underwent IVC filter placement at a single institution over a 7-year period with either contrast venography or transabdominal DUS performed at bedside was retrospectively reviewed. Patient demographics, venous thromboembolism risk factors, indications, technical success, and procedural complications were compared. Of 439 patients initially imaged with transabdominal DUS, IVC filter placement was determined to be technically feasible in 382 patients (87%). The procedural technical success rate for IVC filter placement using transabdominal DUS when IVC visualization was adequate was 97.4% (n = 382 patients), compared to 99.7% (n = 318 patients) for contrast venography (p = 0.018). Patients undergoing IVC filter placement with transabdominal DUS more commonly required IVC filter for venous thromboembolism prophylaxis (81.1% vs. 27.8%, p < 0.001), had increased incidence of multiple traumatic injuries (28% vs. 10%, p < 0.001), and had increased risk from immobilization (91.3% vs. 34.1%, p < 0.001). Overall complication rates were 0.6% for venography and 1.8% for transabdominal DUS (p = NS). When IVC visualization was adequate, contrast venography and transabdominal duplex ultrasound both had high rates of success and a low incidence of complications. A technical success advantage was observed for contrast venography; this difference in technical success must be weighed against the bedside insertion advantage offered by DUS, which may be especially important in the immobilized or critically ill patient. Transabdominal DUS remains our preferred technique when feasible, especially when bedside placement is desired.

Filter malpositioning is a possible complication of inferior vena caval (IVC) filter insertion that may result in inadequate protection from pulmonary embolism. For nonretrievable filters, this is traditionally managed with either observation or additional filter placement. The purpose of this study is determine the incidence of filter malpositioning after bedside insertion under duplex ultrasound (DUS) or intravascular ultrasound (IVUS) guidance, and to report techniques for retrieving and repositioning IVC filters previously considered nonretrievable. All IVC filter insertions performed under DUS or IVUS guidance over an 8-year period were identified. Data regarding insertion technique, device used, and technical success were retrospectively collected. Cases of IVC filter malpositioning were determined and form the basis of this study. Technical details for IVC filter retrieval and repositioning are described. Of 486 patients undergoing DUS (n = 435) or IVUS (n = 51) guided IVC filter insertion, 12 patients (2.4%) had inadequate positioning as determined by postoperative radiography. Two of these patients had no further filter manipulation, three had a second filter placed under fluoroscopic guidance, and the most recent five had filters retrieved and repositioned under fluoroscopic guidance. Of those patients undergoing retrieval and repositioning, all five had Greenfield filters, which are not traditionally regarded as retrievable. All attempted retrievals or replacements were technically successful without additional filter-related complications. Bedside IVC filter insertion under DUS or IVUS guidance has a low incidence of filter misplacement. Although not traditionally regarded as retrievable, Greenfield filters can be safely retrieved and repositioned using advanced endovascular techniques in the event of malpositioning.

Objective: Endovascular abdominal aortic aneurysm repair (EAR) requires long-term surveillance for endoleak or increase in aneurysm diameter. We analyzed the natural history of and risk factors for endoleak development., Summary Background Data: Endoleak is a common complication of EAR that can lead to aneurysm enlargement and even rupture. Following EAR, imaging studies are used to identify leaks since patients with endoleak may require additional endovascular interventions or conversion to open repair. No criteria currently exist for cessation or reduction in frequency of screening imaging studies., Methods: Data on 220 patients undergoing EAR were retrospectively reviewed. Kaplan-Meier survival analysis and Cox proportional hazards regression were used with the end point being new endoleak development. Potential risk factors included preoperative aneurysm diameter, number of negative surveillance studies, and postoperative increase in diameter., Results: A total of 52 patients (24%) who underwent EAR had endoleak detected during postoperative follow-up, which averaged 19 months (range, 0.4-101 months). One, 6-, 12-, and 24- month endoleak-free survival was 90%, 80%, 77%, and 73%, respectively. Three leaks occurred after year 2, at postoperative months 24, 48, and 85. Increasing number of negative screening studies was negatively associated with risk for endoleak development (B = -3.122, P < 0.001), while increase in aneurysm diameter was positively associated with risk for endoleak (B = 0.072, P = 0.04)., Conclusion: Risk for endoleak declines as the number of negative postoperative scans increases, but new endoleaks are identified as late as 7 years following EAR. Reduction in screening frequency cannot be uniformly recommended at this time. Patients with documented aneurysm expansion should be monitored carefully and endoleak should be suspected.

Although bedside placement of inferior vena cava (IVC) filters by means of transabdominal duplex ultrasound is possible in most patients, those with inadequate visualization have traditionally required fluoroscopy. The purpose of this study was to assess the safety and efficacy of bedside IVC filter placement with intravascular ultrasound (IVUS) when transabdominal duplex ultrasound imaging is inadequate. Between January 1, 1999 and December 31, 2002, 256 IVC filter placements were performed (207 with transabdominal duplex ultrasound [81%], 21 with fluoroscopy [8%], and 28 with IVUS [11%]). IVC filter placement with IVUS was performed only if visualization with transabdominal duplex ultrasound was determined to be inadequate. Demographics, technical data, and outcome for patients undergoing IVC filter placement with IVUS were reviewed and form the basis of this report. Bedside IVC filter placement with IVUS was technically successful in 26 of 28 patients (93%). Post-procedure abdominal radiographs confirmed proper placement, based on bony landmarks in 24 of 26 patients (92%). Post-procedure complications included insertion site thrombosis in two patients and possible recurrent pulmonary embolism in one patient 2 months following filter placement. One patient died from causes unrelated to IVC filter placement. From these results we conclude that IVC filter placement with IVUS is technically feasible and safe. This may allow for expanded bedside IVC filter placement capabilities in patients with inadequate IVC visualization on transabdominal duplex ultrasound.

Objective: Despite well-documented good early results and benefits of endoluminal stent graft repair of abdominal aortic aneurysm (J Vasc Surg 2002;35:1137-44.)(AAA), the long-term outcome of this method of treatment remains uncertain. In particular, concern exists that late effectiveness and durability are inferior to that of open repair. To determine the incidence and causes of clinical failures of endovascular AAA repair, a 7-year experience with 362 primary AAA endografts was reviewed., Methods: Clinical failures were defined as deaths within 30 days of the procedure, conversions (early and late) to open AAA repair, AAA rupture after endoluminal treatment, or AAA sac growth of more than 5 mm in maximal diameter despite endograft repair. Endoleak status per se was not considered unless it resulted in an adverse event. If clinical problems arose but could be corrected with catheter-based therapies or limited surgical procedures, thereby maintaining the integrity of successful stent graft treatment of the AAA, such cases were considered as primary assisted success and not classified as clinical failures., Results: The average follow-up period was 1.5 years. Six deaths (1.6%) occurred after the procedure, all in elderly patients or patients at high risk. Five patients (1.4%) needed early conversion (immediate, 2 days) to open repair for access problems or technical difficulties with deployment, resulting in an implantation success rate of 98.6%. Eight patients (2.2%) underwent late conversion for a variety of problems, including AAA expansion (n = 4), endograft thrombosis (n = 1), secondary graft infection (n = 2), and rupture at 3 years (n = 1). Rupture occurred in an additional two patients for a total incidence rate of 0.8%. AAA sac growth of greater than 5 mm was observed in 20 patients (5.6%), four of whom have undergone successful catheter-based treatments to date. Overall, 39 patients (10.7%) needed catheter-based (n = 45) or limited surgical (n = 4) reinterventions for a variety of late problems that were successful in 92%., Conclusion: In our 7-year experience, one or more clinical failures of endovascular AAA repair were observed in 31 patients (8.3%). Reinterventions were necessitated in a total of 10.7% of patients but were usually successful in maintaining AAA exclusion and limiting AAA growth. These results emphasize that endovascular repair provides good results and many benefits for most properly selected patients but is not as durable as standard open repair.

Introduction: Evidence exists that an ideal bypass conduit should have a functional endothelial cell surface combined with mechanical properties similar to those of native arteries. We hypothesized that the effect of combined arterial levels of pulsatile shear stress, flow, and cyclic strain would enhance saphenous venous endothelial cell nitric oxide (NO) production, and that variations in these "ideal" conditions could impair this function. We studied NO production as a measure of endothelial function in response to different hemodynamic conditions., Methods: Human adult saphenous venous endothelial cells were cultured in 10-cm silicone tubes, similar in diameter (5 mm) and compliance (6%) to a medium-caliber peripheral artery (eg, popliteal). Tube cultures were exposed to arterial conditions: a combined pressure (120/80 mm/Hg; mean, 100 mm/Hg), flow (mean, 115 mL/min) and cyclic strain (2%), with a resultant pulsatile shear stress of 4.8 to 9.4 dyne/cm2 (mean, 7.1). Identical tube cultures were used to study variations in these conditions. Modifications of the system included a noncompliant system, a model with nonpulsatile flow, and a final group exposed to pulsatile pressure with no flow. NO levels were measured with a fluorometric nitrite assay of conditioned media collected at 0, 0.25, 0.5, 1, 2, and 4 hours. Experimental groups were compared with cells exposed to nonpulsatile, nonpressurized low flow (shear stress 0.1 dyne/cm2) and static cultures., Results: All experimental groups had greater rates of NO production than cells under static conditions (P <.05). Cells exposed to ideal conditions produced the greatest levels of NO. Independent decreases in compliance, flow, and pulsatility resulted in significantly lower rates of NO production than those in the group with these conditions intact (vs noncompliant P <.05, vs nonflow P <.05, and vs nonpulsatile P <.05)., Conclusions: Our results show that in the absence of physiologically normal pulsatility, cyclic strain, and volume flow, endothelial NO production does not reach the levels seen under ideal conditions. Pulsatile flow and compliance (producing flow with cyclic stretch) play a key role in NO production by vascular endothelium in a three-dimensional hemodynamically active model. This correlates biologically with clinical experience linking graft inflow and runoff and the mechanical properties of the conduit to long-term patency.

Nissen fundoplication is the most commonly performed surgical procedure in the management of gastroesophageal reflux disease. Esophageal and gastric perforations most commonly occur in the perioperative period and carry significant morbidity. We describe a unique case of intrathoracic gastric wrap perforation and its suspected pathophysiology almost two decades after the original procedure.

Ultrastructural studies of stunned myocardium have shown disorganization and loss of extracellular collagen and increased collagenase activity early after ischemia and reperfusion. The interplay between matrix metalloproteinase 1 (MMP-1) and tissue inhibitor of metalloproteinase 1 (TIMP-1) regulates the turnover of cardiac extracellular matrix fibrillar collagens. However, the gene expression of MMP-1 and TIMP-1 in stunned myocardium is not known. Here, we determined whether altered expression of MMP-1 and TIMP-1 occurs in globally stunned hearts. An isolated nonworking rabbit heart preparation, perfused with a bovine erythrocyte suspension in modified Krebs solution, was used. Two groups were studied: the stunned group was subjected to 20 min of normothermic global ischemia followed by 120 min of normal reperfusion (n = 8), and the control group underwent 140 min of uninterrupted perfusion (n = 7). The developed pressures at the end of reperfusion for ischemic and control hearts were 67.0 +/- 2.73 and 83.1 +/- 1.52 mm Hg (P < 0. 006) respectively. Ribonuclease protection assays of total left ventricular RNA using riboprobes for MMP-1, TIMP-1, and 18S rRNA were performed. A significant decrease (twofold, P < 0.03) in TIMP-1 gene expression was found in the stunned hearts, while MMP-1 mRNA expression was unchanged. Thus, in early stunning, the decrease in TIMP-1 expression could tip the balance favoring enhanced metalloproteinase activity, promoting collagen turnover, and initiating extracellular matrix remodeling. This may contribute to delayed recovery from myocardial stunning., (Copyright 1998 Academic Press.)

The success rate of vascular bypass procedures is limited by the development of intimal hyperplasia (IH). Hypercholesterolemia has been shown to accelerate IH in both arteries and experimental vein grafts; however the mechanism remains uncertain. Hyaluronic acid synthase (HAS-1) is a transmembrane enzyme responsible for the formation of hyaluronan; an important constituent of extracellular matrix (ECM). The integrin receptor for hyaluronan is CD-44. Both CD-44 and HAS-1 have been studied in the development of ECM of wounds but have yet to be examined in the ECM of IH within vein grafts. The purpose of this study was to determine if the expression of CD-44 and HAS-1 is increased during the early stages of IH and how cholesterol supplementation affects these genes. Forty white male New Zealand rabbits were divided into two groups: cholesterol supplemented (1% cholesterol chow) and noncholesterol supplemented. Each set of 20 rabbits was then divided into four additional groups (n = 5); a nonoperative group (control) and three operative groups that underwent a right interposition carotid bypass using jugular vein. Grafts were harvested at 3, 7, and 21 days after surgery for molecular studies and histology. Ribonuclease protection assays were performed using 32P-labeled riboprobes for HAS-1, CD-44, and 18s rRNA. Densitometric analysis is expressed as a ratio (riboprobe/rRNA). Cholesterol levels differed significantly between cholesterol supplemented and nonsupplemented groups (1419 +/- 130 mg/dl and 48 +/- 12 mg/dl) (p < 0.01). There was a significant increase in the expression of HAS-1 and CD-44 in the vein grafts compared to normal jugular vein. Cholesterol supplementation caused a further increase in CD-44 gene expression versus nonsupplemented vein grafts. These data demonstrate a role for CD-44 and HAS-1 transcription in vein graft intimal hyperplasia, which is further altered by cholesterol supplementation. Lastly, these results could explain differences seen in the development of IH with hypercholesterolemia and ultimately provide for improved therapies in alleviating this process.

The decision to use prosthetic or autogenous vein as the initial conduit for first-time vascular bypass of the lower extremity depends in part on the likelihood of subsequent need for autogenous conduit for another leg or heart bypass. The true frequency of these later events is not known. To answer this question, we analyzed a database of infrainguinal and coronary artery bypasses (CABG) performed at one institution between January 1980 and July 1995, to determine how many patients required subsequent infrainguinal bypass or CABG after their initial leg bypass. Five hundred and seventy-two infrainguinal bypasses were performed on 440 patients (mean age 63.9); average follow-up was 5.6 years. The clinical philosophy favored autogenous vein for first bypass, which was used in 84% of first operations performed during the study period while prosthetic material was used in 16%. For patients in which vein was used for the first operation, and who went on to have a second operation, the use of prosthetic conduit rose from 16% of operations to 27% (p < 0.05). The rate of subsequent CABG after leg bypass was very low, 2% at 5 years, 3% at 10 years. The cumulative probability of requiring a subsequent infrainguinal bypass was 27% at 5 years, 32% at 10 years. Of these, 46% were ipsilateral and 54% were contralateral. Considering only subsequent tibial bypasses (where vein might be considered obligatory), the cumulative 5-year rate of subsequent leg bypass was only 13%. Another bypass was most likely to occur within the first 3 years, rarely thereafter. In summary, after primary infrainguinal bypass, additional procedures using vein may arise in 1/4 to 1/3 of patients, mostly in the first 3 years. However, only 13% will definitely need vein for tibial bypass in 5 years, and subsequent CABG is uncommon.

Background: The success of vascular bypass procedures is limited by the development of intimal hyperplasia (IH). The nitric oxide (NO) precursor, L-arginine (L-ARG) significantly reduces IH in both arteries and experimental vein grafts; however, the precise mechanism has yet to be elucidated. Hyaluronan synthase-1 (HAS-1) is one of the two enzymes believed to be responsible for making hyaluronan, a key component extracellular matrix composition., Purpose: To determine how L-ARG supplementation affects the gene expression of HAS-1 in experimental vein grafts., Methods: Thirty-four male New Zealand white rabbits were divided into three groups: control (no operation, regular chow and water, n = 4); L-ARG supplemented (n = 15); and no L-ARG (n = 15). The latter two groups underwent a right interposition carotid bypass using jugular vein. Vein grafts were harvested at 7, 14, and 21 days after surgery. Ribonuclease protection assays were performed using 32P-labeled riboprobes for HAS-1 and 18S rRNA as an internal control and expressed as a ratio (HAS-1/rRNA)., Results: There was a significant rise in HAS-1 expression in the vein grafts 7 (1.57 +/- 0.5), 14 (0.7 +/- 0.2), and 21 days (2.82 +/- 0.7) after grafting compared to control (0.14 +/- 0.08) (P < 0.05). L-ARG-supplemented animals had a significant decrease in HAS-1 expression at 21 days (0.65 +/- 0.1) compared to nonsupplemented vein grafts (2.82 +/- 0.7) (P < 0.02)., Conclusions: These results demonstrate for the first time a significant rise in HAS expression in the early experimental vein grafts. Furthermore, L-ARG supplementation significantly diminishes the expression of HAS at 21 days. These results may represent a potential mechanism by which augmentation of the L-ARG/NO pathway inhibits IH in experimental vein grafts and may ultimately provide for improved therapeutic interventions in alleviating IH.

We examined the relative efficacies of different cardiac screening strategies for infrainguinal arterial bypass. The outcomes of 205 elective leg bypass procedures over a 10-year period, including myocardial infarction (MI), total cardiac complications, and mortality were tallied. Clinical risk factors popularized by Goldman and Eagle, and the results of dipyridamole thallium myocardial imaging (DThal) were recorded. The overall mortality rate was 3.4%, with a 3.4% incidence of MI and a 5.4% total cardiac complication rate. Both abnormal DThal (p = 0.011) and Goldman class II-IV (p = 0.030) were significant predictors of MI and cardiac death, but both suffered from poor specificity and positive predictive value. Because logistic regression analysis identified a correlation between angina, CHF, and an abnormal DThal, a customized screening strategy was developed to include the presence of angina, CHF and an abnormal DThal. Eighty-eight percent of patients suffering MI or death met these criteria, while only 11% of the complication-free group did. This screening strategy provided a superior sensitivity of 88%, specificity of 89%, positive predictive value of 25%, and 99% negative predictive value. A customized screening strategy (angina, CHF, abnormal DThal), developed from a 10-year experience with a single patient group, provided better predictive accuracy than any generalized screening formula.

Background: The patency of vascular reconstructive procedures is limited by the development of intimal hyperplasia (IH). Nitric oxide (NO) seems to be beneficial in abrogating this process. Currently, there is little information concerning inducible nitric oxide synthase (iNOS), the enzyme responsible for NO synthesis, and human vein grafts. The purpose of this study was to examine iNOS gene expression in human aortocoronary vein grafts (ACVG) and infrainguinal vein bypass grafts (IVG)., Methods: Nonthrombosed sections from ACVG (n = 5), IVG (n = 5), and control saphenous vein (SV; n = 4) were harvested and processed for RNA isolation. Quantitative reverse transcription-polymerase chain reaction (RT-PCR) was performed on samples using 32P radioactively end labeled primers. Glyceraldehyde-3-phosphate-dehydrogenase (GAPDH) was the internal control, and results were expressed as iNOS pmol/GAPDH pmol., Results: There was a significant increase in the iNOS gene expression in the ACVG (0.049 +/- 0.01) when compared with IVG (0.019 +/- 0.001) or normal SV (0.011 +/- 0.002; P < or = 0.05). There was no significant difference between normal vein and the infrainguinal grafts. Sequencing of a fragment of the amplified 428 bp gene product confirmed 84% homology with the available gene bank human sequence., Conclusions: This study proves that iNOS is expressed in human vein bypass grafts. Additionally, there is a significant elevation of iNOS message in human ACVGs compared with IVG or normal SV. This difference may be the result of the unique vascular beds supplied by these grafts. Ultimately, manipulation of iNOS expression may lead to therapies to alleviate IH in these grafts.

The success of coronary reconstructive procedures is limited by the high incidence of restenosis secondary to intimal hyperplasia (IH). Transforming growth factor-beta 1 (TGF-beta 1) is a growth factor which has been shown to be important in the early development of IH in arteries and peripheral vein grafts. To date, there is little information concerning the early remodeling in aortocoronary vein grafts (ACVG). The purpose of this study was to characterize the expression of TGF-beta 1 expression in early aortocoronary vein grafts. Eighteen mongrel dogs underwent aortocoronary vein bypass grafting. Vein grafts were excised at 2 hr, 4 hr, and 7 days after implantation, snap frozen, and processed for ribonuclease protection assays (RPA) using 32P-labeled riboprobes for TGF-beta 1 and 18 S rRNA. TGF-beta 1 expression was quantified by densitometric analysis of autoradiographs which were expressed as a ratio TGF-beta 1/rRNA. Representative vessel rings were also collected for histology. There was a significant rise in TGF-beta 1 expression in the 2-hr vein grafts (0.42 +/- 0.04 compared to control saphenous vein (0.21 +/- 0.05, P < 0.02). In addition, there was significant downregulation of TGF-beta 1 at 4 hr (0.28 +/- 0.05) and at 7 days (0.18 +/- 0.01) when compared to 2 hr (P < 0.05). Histological specimens showed minimal intimal hyperplasia at 7 days. These results show for the first time an acute rise in TGF-beta 1 expression in ACVG. This upregulation quickly subsides by 4 hr and gene expression approaches control values by 7 days. By understanding this temporal relationship of expression one could better target potential therapeutic modalities to attenuate IH.

The induction of transplantation tolerance is one of the primary goals following solid organ transplantation. The combination of a single dose of rapamycin (RAPA) with a short course of cyclosporine (CsA) has been shown to induce transplantation tolerance in the nonfunctional rat heterotopic cardiac transplant model. The purpose of this study was to assess this effective induction protocol in a functional renal transplant model. Male ACI (RTl(a)) and Lewis (RT1(1)) rats were used as donor and recipients respectively. Allografts received a single RAPA dose of (1.5 mg/kg) combined with CsA (10 mg/kg) 12-14 hr prior to transplantation. CsA (5 mg/kg) was given daily on days +1 - +7. Untreated Lewis to Lewis isografts served as histological controls. Chimerism, assessed in recipient skin, and intragraft interleukin (IL) 10 expression was determined utilizing PCR and RT-PCR techniques respectively. Treated animals and isografts were sacrificed 120-130 days posttransplant for functional and histological evaluation. Allografts (n=9) were functionally tolerant with serum creatinine (0.77+/-0.1 vs. 0.88+/-0.1; P=0.275), blood urea nitrogen (37.6+/-4.6 vs. 23.3+/-1.9; P=0.123), and 24 hr protein excretion (27.0+/-4.4 vs. 17.9+/-5.2; P=0.131) similar to single kidney ACI controls. Histologically, 45% (4/9) allografts were indistinguishable from isografts with no evidence of rejection, and were considered immunologically tolerant. Donor/recipient chimerism was not detected. All immunologically tolerant allografts had evidence of intragraft IL-10 expression. Rejecting allografts and isografts did not express intragraft IL-10. This study confirms the efficacy of pre-engraftment single-dose RAPA combined with CsA in inducing true immunologic tolerance in this stringent functional renal transplant model. The expression of intragraft IL-10 in tolerant recipients suggests a Th-2 shift as the mechanism of tolerance in this model.