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Although venous aneurysms are rare, typically asymptomatic, and most commonly found incidentally on imaging studies, patients with this pathology can develop pulmonary emboli owing to these aneurysms acting as a nidus for thrombus formation. There is no clear consensus regarding conservative management with anticoagulation vs operative intervention as the best treatment of deep venous aneurysms. We report the clinical course and surgical treatment of a patient presenting with both bilateral common femoral vein and bilateral popliteal venous aneurysms who had a known history of prior symptomatic pulmonary emboli.

Ultrasound-guided thrombin injection (UGTI) has emerged as the first-line treatment for moderately sized or persistent pseudoaneurysms (PSAs). Although rare, the most feared complication of UGTI is arterial thrombosis or embolism during the off-label injection of thrombin causing acute limb ischemia requiring emergent surgical intervention. Higher thrombin volume, rapidity of injection, and wide or short-neck PSAs are all thought to increase the risk of arterial thrombosis or embolism during this procedure. For patients with unfavorable PSA anatomy who are high-risk surgical candidates due to their medical comorbidities or active critical illness, balloon-assisted thrombin injection (BATI) has been suggested as a means to potentially reduce the risk of thrombosis or distal embolization associated with UGTI. This minimally invasive technique also decreases the risk of groin wound dehiscence or infection associated with open repair, especially in patients who are morbidly obese or have had prior groin surgery. We report a patient with a complex femoral artery PSA after endovascular intervention who was successfully treated with BATI and describe the procedure in detail.

Surgical site infection (SSIs) in lower extremity vascular procedures is a major contributor to patient morbidity and mortality. Despite previous advancements in preoperative and postoperative care, the surgical infection rate in vascular surgery remains high, particularly when groin incisions are involved. However, successfully targeting modifiable risk factors reduces the surgical site infection incidence in vascular surgery patients. We conducted an extensive literature review to evaluate the efficacy of various preventive strategies for groin surgical site infections. We discuss the role of preoperative showers, preoperative and postoperative antibiotics, collagen gentamicin implants, iodine impregnated drapes, types of skin incisions, negative pressure wound therapy, and prophylactic muscle flap transposition in preventing surgical site infection in the groin after vascular surgical procedures.

Background Central venous occlusive disease (CVOD) is a prevalent problem in patients with end-stage renal disease (ESRD) and can lead to access malfunction or ligation for symptomatic relief. The purpose of this study is to evaluate the efficacy of the TriForce® Peripheral Crossing Set (Cook Medical), a novel reinforced telescoping catheter set designed to provide additional support for crossing difficult central venous occlusions. Methods This is a single-center retrospective study from a quaternary referral center. We identified 37 patients over a 17-month period who underwent 56 attempts at endovascular recanalization for the treatment of central venous occlusion. Technical success rates, procedural data, and outcomes were compared between those undergoing recanalization using traditional wire/catheter sets versus the TriForce catheter set. Results Average age was 48 ± 2 years. Comorbidities were similar between the two cohorts and included ESRD (61%), deep venous thrombosis (30%), and May-Thurner syndrome (7%). Forty attempts were made with traditional wire/catheter sets and 16 attempts with the TriForce catheter set to treat 2.1 ± 0.2 and 1.9 ± 0.3 occluded venous segments, respectively (P = 0.74). Technical success rates were significantly higher for the group undergoing recanalization using the TriForce catheter (69% versus 38%, P = 0.04) and 4 patients were successfully recanalized using the TriForce catheter set after a failed attempt with traditional wire/catheter sets. Mean fluoroscopy time and radiation dose were 13 ± 3 min and 14,623 ± 2,775 μGy∗m2 for traditional techniques versus 30 ± 6 min and 30,408 ± 10,433 μGy∗m2 for the novel telescoping catheter set (P = 0.01 and 0.09, respectively). Freedom from reintervention at 1 year was 60% for the TriForce cohort versus 44% for the traditional wire/catheter cohort (P = 0.25). Conclusions The novel TriForce reinforced telescoping catheter set is a useful adjunct that may improve recanalization rates of CVOD compared with traditional wire/catheter sets.

Objective: In complex dialysis patients, central venous stenosis may preclude additional upper extremity access options. The Hemodialysis Reliable Outflow graft (Merit Medical Systems, Inc.) can bypass this stenosis providing patients with an additional upper extremity long-term access option. We report our experience with early-cannulation Hemodialysis Reliable Outflow grafts and compare them to traditional Hemodialysis Reliable Outflow grafts. Methods: We retrospectively reviewed all patients undergoing Hemodialysis Reliable Outflow graft placement from 1 January 2013 through 15 August 2017 at our institution and compared those undergoing placement of traditional Hemodialysis Reliable Outflow grafts and simultaneous tunneled dialysis catheter insertion to those undergoing Hemodialysis Reliable Outflow graft placement using an early-cannulation Hemodialysis Reliable Outflow graft without a tunneled dialysis catheter. Results: A total of 88 patients had 98 Hemodialysis Reliable Outflow grafts inserted throughout this time period. Of these, 61 (62%) were early-cannulation Hemodialysis Reliable Outflow grafts, while 37 (38%) were traditional Hemodialysis Reliable Outflow grafts. Primary, primary-assisted, and secondary patency rates at 1 year were higher for the traditional Hemodialysis Reliable Outflow graft cohort (53.1% vs 25.2%, p < 0.01; 70.1% vs 30.5%, p < 0.01; and 80.4% vs 55.4%, p = 0.07, respectively). There was no difference in the rate of postoperative hematoma, seroma, pseudoaneurysm formation, steal syndrome, or overall graft thrombosis between the two cohorts. Early-cannulation Hemodialysis Reliable Outflow grafts required earlier reintervention for thrombosis and earlier reintervention for any cause when compared to traditional Hemodialysis Reliable Outflow grafts (146 ± 184 days vs 417 ± 272 days, p < 0.01, and 123 ± 169 days vs 401 ± 311 days, p < 0.01, respectively). Conclusion: In complex dialysis patients, early-cannulation Hemodialysis Reliable Outflow grafts have significantly lower 1-year primary and primary-assisted patency rates and require earlier reintervention to maintain this patency compared to traditional Hemodialysis Reliable Outflow grafts.

Background Trauma remains a leading cause of morbidity and mortality worldwide. Vascular injuries are present in approximately 1% to 2% of trauma patients, with the majority of injuries occurring to the extremities. Trauma patients with vascular injuries have been shown to have increased morbidity and mortality as well as the need for increased resources compared with those without vascular injuries. This study aimed to determine predictors of poor outcomes in infrainguinal bypasses performed for traumatic arterial injury. Methods All patients admitted between September 1999 and July 2015 who underwent infrainguinal arterial bypass for trauma at a single level I trauma center were included for analysis. The primary outcome was a composite of thrombosis leading to graft abandonment, revision, amputation, or death. Data were analyzed by univariate descriptive and multiple logistic regression analyses. Long-term data were analyzed by Kaplan-Meier method. Results During the study period, 108 patients presented with and underwent infrainguinal arterial bypass for traumatic arterial injury. The cohort had a mean age of 35.8 years (16/108 female [15%]). The average Injury Severity Score was 15.2; admission glomerular filtration rate, 79.3 mL/min/1.73 m2; Mangled Extremity Severity Score (MESS), 6; and injury to operating room time, 5.1 hours. Of 108 patients, 37 (34%) had penetrating injury, 71 (66%) had blunt injury, 10 (9.3%) had diabetes mellitus, and 76 (70.4%) had a below-knee target for bypass. Univariate risk factors for poor outcome included age >40 years (odds ratio [OR], 3.27 [1.40-7.65]; P Conclusions Poor outcomes in infrainguinal bypass for trauma are significantly predicted by the MESS, with poor outcomes occurring >50% of the time when MESS is ≥9 and >75% of the time when MESS is ≥11. Whereas amputation vs revascularization is a decision that also depends on nerve and soft tissue damage and other comorbidities, the MESS helps frame the data for the clinician and can aid in decision-making. Patients and family should understand that poor outcomes are more likely when MESS is ≥9. For patients with MESS ≥11, primary amputation can be considered.

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of patients with symptomatic severe aortic stenosis considered to have prohibitive surgical risk. However, there is significant variability in methods used to size the aortic valve annulus for TAVI device selection.

Objectives This report calls attention to an unappreciated cause of both acute and chronic aortic regurgitation (AR). Background Although stenosis develops in most patients with a congenitally bicuspid aortic valve (BAV), in others with this anomaly, pure AR (no element of stenosis) develops, some in the absence of infection or other clear etiology. Methods We describe 5 men who underwent aortic valve replacement for pure AR associated with a BAV containing an anomalous cord attaching the raphe of the conjoined cusp near its free margin to the wall of the ascending aorta cephalad to the sinotubular junction. Results Three of these 5 patients had a history of progressive dyspnea, and the anomalous cord, which was intact at operation, appeared to cause chronic AR by preventing proper coaptation of the 2 aortic valve cusps. The other 2 patients heard a “pop” during physical exertion and immediately became dyspneic, and at operation, the anomalous cord was found to have ruptured. Prolapse of the conjoined aortic valve cusp toward the left ventricular cavity resulted in severe acute AR. Conclusions This variant of the purely regurgitant BAV may cause either chronic AR (when the anomalous cord does not rupture) or acute severe AR (when the cord ruptures).

Most studies concerning aortic valve structure in patients having aortic valve replacement have utilized the valve structure (unicuspid, bicuspid, tricuspid) as that called by the cardiac surgeon performing the operation. We determined valve structure of 744 operatively excised stenotic aortic valves submitted to the surgical pathology laboratory of a single hospital over a 6-year period and then compared valve structure determined by a single cardiac pathologist (WCR) with that recorded in the operative report dictated by the operating surgeon. Compared with that determined from examination of the operatively excised valve by the cardiac pathologist, valve structure determined at operation was congruous in 59% (440 of 744 patients), incongruous in 20% (152 of 744), of uncertain structure in 1% (9 of 744), and not mentioned in 19% (143 of 744). Valve structure was virtually always congruous (278 of 280 cases, 99%) in patients with 3-cuspid valves, less so with bicuspid valves (156 of 280, 56%), and infrequently so with unicuspid valves (6 of 41, 15%). In conclusion, in patients having isolated aortic valve replacement for aortic valve stenosis, the structure of the valve by the operating surgeon was similar (99%) to that described by 1 of us (WCR) when a 3-cuspid aortic valve was excised, but less so when a congenitally unicuspid (15%) or bicuspid (56%) valve was excised.

Three quinquagenarians who underwent insertion of a left ventricular assist device (LVAD) because of severe heart failure and for whom histologic examination of the left ventricular apical "core" (removed to insert the device) showed noncaseating giant cell granulomas typical of sarcoidosis are described. Later, cardiac transplantation showed widespread sarcoid granulomas in the walls of the right and left ventricles and ventricular septum in 2 patients and extensive scarring in the third patient in the absence of coronary narrowing. Previously, 11 patients who underwent cardiac transplantation because of cardiac sarcoidosis had been reported, and in 1 of these patients, diagnosis was also initially made by examination of the left ventricular core excised at the time of insertion of an LVAD. In conclusion, excision of a portion of left ventricular wall to enable insertion of a therapeutic device (LVAD) can also serve as the means of definitive diagnosis of the underlying cardiac condition.

Although a number of publications have described the natural history of patients with aortic stenosis (AS), the definition of “natural history” varies widely. Those describing a large number of patients with AS without operative therapy with necropsy findings are rare. Two hundred sixty patients >15 years of age with AS were studied at necropsy over a 50-year period by the same investigator. Of the 260 patients, the valve in 37 (14%) was congenitally unicuspid, in 123 (47%), congenitally bicuspid, and in 100 (38%), tricuspid. Aortic valve structure varied with age of death (in years; unicuspid 52 ± 17, bicuspid 63 ± 12, and tricuspid 70 ± 14 years); gender (men/women: unicuspid 95%/5%, bicuspid 78%/22%, and tricuspid 63%/37%), and frequency of calcium in the mitral valve annulus and epicardial coronary arteries. The patients with cardiac-related symptoms compared with those without were more likely to have a congenitally malformed valve (unicuspid 17% vs 12%; bicuspid 51% vs 29%; tricuspid 31% vs 60%; unadjusted p = 0.013), to die from cardiac disease (86% vs 54%; unadjusted p = 0.001), and to have larger hearts (mean cardiac weight 606 ± 138 g vs 523 ± 121 g; unadjusted p = 0.009) and a larger quantity of calcium in the aortic valve cusps. In conclusion, the length of survival in adults with AS is related to valve structure, gender, presence of cardiac-related symptoms, cardiac mass, and quantity of calcium in the aortic valve cusps.

Objectives The aim of the study is to describe gross and histological features of operatively excised portions of mitral valves in patients with mitral valve prolapse (MVP). Background Although numerous articles on MVP (myxomatous or myxoid degeneration, billowing or floppy mitral valve) have appeared, 2 virtually constant histological features have been underemphasized or overlooked: 1) the presence of superimposed fibrous tissue on both surfaces of the leaflets and surrounding many chordae tendineae; and 2) the absence of many chordae tendineae on the ventricular surfaces of the leaflets as the result of their being hidden (i.e., covered up) by the superimposed fibrous tissue. Methods We examined operatively excised portions of prolapsed posterior mitral leaflets in 37 patients having operative repair. Results Histological study of elastic-tissue stained sections disclosed that the leaflet thickening was primarily due to the superimposed fibrous tissue. All leaflets had variable increases in the spongiosa element within the leaflet itself with some disruption and/or loss of the fibrosa element and occasionally complete separation of it from the spongiosa element. Both the leaflet and chordae were separated from the superimposed fibrous tissue by their black-staining elastic membranes. Conclusions These findings demonstrate that the posterior leaflet thickening in MVP is mainly due to the superimposed fibrous tissue rather than to an increased volume of the spongiosa element of the leaflet itself. The superimposed fibrous tissue on both leaflet and chordae is likely the result of subsequent abnormal contact of the leaflets and chordae with one another. Chordal rupture (i.e., missing chordae) occurred in all 37 patients, but finding individual ruptured chords was rare.