Squamous cell carcinoma arising in a below-knee stump of a patient with chronic lymphocytic leukemia.

We report a case of localized squamous cell carcinoma arising in the ulceration at the site of a below-knee amputation in a patient with chronic lymphocytic leukemia on treatment with ibrutinib. The patient underwent local excision of the skin and soft tissue with histopathology showing a small focus of well-differentiated squamous cell carcinoma in the specimen. This case highlights the importance of clinical evaluation and histopathological review for underlying malignancy in the setting of amputation stump ulceration.

Acute limb ischemia secondary to external iliac and common femoral artery dissection in a body builder.

Spontaneous external iliac artery dissection in highly trained athletes is becoming more recognized, but the reason as to why they are occurring remains a mystery. We present a patient with acute limb ischemia secondary to arterial dissection after strenuous exercise. Imaging showed complete occlusion of the distal common iliac artery, and the patient underwent successful revascularization of the right lower extremity using a hybrid approach.

Ureteral stenosis following iliac artery stenting.

Ureteral complications after open aortoiliac reconstruction for aneurysmal and occlusive disease have been reported previously. However, ureteral complications from endovascular interventions for iliac artery disease are relatively rare. We describe a case of left ureteral stenosis resulting in hydroureteronephrosis after multiple endovascular interventions involving the left common and external iliac arteries. The intraoperative findings during robotic ureterolysis revealed significant peri-iliac fibrosis and scarring in the area of the iliac stents. This case illustrates that, although uncommon, ureteral stenosis may occur after iliac stenting owing to peristent fibrosis.

Carotid endarterectomy in patients with high plaque.

BACKGROUND: Difficult cephalad exposure during carotid endarterectomy in patients with high plaque (HP) may lead to increased incidence of complications after carotid endarterectomy. We report on our experience of carotid endarterectomy in patients with HP. METHODS: This is a retrospective review of 1,233 consecutive patients who underwent carotid endarterectomy by a single surgeon at 2 teaching hospitals between January 1989 to December 2018. Group A consisted of patients with HP (n = 100) diagnosed by computed tomography angiography of the neck in 90, catheter-based arteriography in 8, and an unexpected finding during carotid endarterectomy in 2 patients. Group B consisted of 1,133 consecutive carotid endarterectomies with plaque ending in Zone 1 non-high plaque (nHP). RESULTS: Both groups were similar in age (70.9 ± 8.7 vs 70.3 ± 9.1, P = .53). There was a preponderance of male patients in the HP group (78.0% vs 66.1%, P = .02). Associated risk factors, including coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease, and hyperlipidemia, were similar in both groups. Indications for carotid endarterectomy in HP patients include recent stroke (<8 weeks) in 15 patients (15.0%), transient ischemic attack in 23 patients (23.0%), and asymptomatic in 62 patients (62.0%). Three patients (3.0%) with HP required shunt placement compared with 10.9% in the nHP group (P = .009). Completion carotid arteriogram was performed in 6 patients. Perioperative stroke and mortality were similar in both groups. The incidence of cranial nerve injury was higher in the HP group. CONCLUSION: Most patients with HP can be diagnosed with computed tomography angiography of the neck or catheter-based arteriography. Shunt requirement in patients with HP is significantly lower than in the nHP group. Perioperative stroke and mortality in patients with HP undergoing carotid endarterectomy is similar to the nHP group; however, there is a higher incidence of permanent cranial nerve injury. Carotid artery stenting should be considered in cases in which carotid endarterectomy may be challenging, such as in patients with HP. Overall, our results demonstrate that carotid endarterectomy can be safely performed in patients with HP, however, at an increased risk of permanent cranial nerve injury.

Timing of carotid endarterectomy after recent minor to moderate stroke.

OBJECTIVE: Early carotid endartectomy is generally favored by vascular surgeons in patients after a minor to moderate stroke. Herein, we compared the results of early versus delayed carotid endartectomy in patients presenting with similar National Institutes of Health Stroke Scale findings after a recent minor to moderate stroke. METHODS: A retrospective analysis of 101 patients undergoing carotid endartectomy after a recent stroke in the distribution of the branches of the middle cerebral artery with >70% internal carotid artery stenosis from 2000 to February 2018 was performed. RESULTS: Sixty patients had carotid endartectomy within 2 weeks (group A) and 41 had carotid endartectomy within 2-8 weeks of stroke (group B). Associated factors, such as coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, nicotine abuse, chronic obstructive pulmonary disease, and renal failure, were similar in both groups. However, there was preponderance of male patients in group B (0.01). In group A, 35 patients presented with minor stroke (National Institutes of Health Stroke Scale 1-4) and 25 had a moderate stroke (National Institutes of Health Stroke Scale 5-15). In group B, 21 had a minor stroke and 20 had a moderate stroke (P = .54). Perioperative stroke occurred in 4 patients in group A and none in group B (P = .14), with perioperative stroke and death rate of 4.0%. Postoperative seizures occurred in 1 patient in group A and three in group B (P = .30). CONCLUSION: Early as well as delayed carotid endartectomy in patients with minor to moderate stroke results in a satisfactory outcome. To prevent recurrent stroke in the waiting period, early carotid endartectomy should be preferred.

Iatrogenic Major Venous Injury Is Associated with Increased Morbidity of Aortic Reconstruction.

BACKGROUND: Major venous injury during open aortic reconstruction though uncommon often result in sudden and massive blood loss resulting in increased morbidity and mortality. This study details the etiology, management, and outcome of such injuries. METHODS: A retrospective review of 945 patients (1981-2017) undergoing aortic reconstruction from 2 midsized (350 bed each) teaching hospitals was conducted. Seven hundred twenty-three patients (76.5%) underwent open abdominal aortic aneurysm (AAA) repair/iliac aneurysm repair, 222 patients (23.5%) underwent aortofemoral grafting (AFG). Patients sustaining major venous injury (sudden loss of more than 500 mL of blood) during major aortic reconstruction were studied. The number of units of packed red blood cells transfused, location of injured vessel, type of repair, postoperative morbidity, and mortality were collected in our vascular registry on a continuous basis. All patients identified with iliac vein/inferior vena cava/femoral vein injury had follow-up noninvasive venous examination of the lower extremities. RESULTS: Eighteen major venous injuries (1.9%) occurred during aortic reconstruction in 17 patients (1 patient had 2 major venous injuries): IVC (n = 4), iliac vein (n = 10), left renal vein (n = 4, this includes a posterior retroaortic renal vein injury n = 1). Of the 18 major venous injuries, 7 occurred during open AAA repair for ruptured AAA and another 9 occurred during repair of intact AAA (P = 0.001), 2 venous injuries occurred after AFG, and 1 after primary AFG (P = 0.05). Using multivariate regression analysis, periarterial inflammation had significant association with major venous injury (P < 0.001). The presence of associated iliac aneurysm with abdominal aortic aneurysm also increased the incidence of major venous injury during AAA surgery (P = 0.05). Two patients (11.8%) died, one from uncontrolled bleeding due to tear of right common iliac vein during ruptured AAA repair and second patient from disseminated intravascular complication following repair of ruptured AAA. Intraoperative transfusion requirements were 3-28 units, (median 8 units). Three of 9 (33%) surviving patients developed iliofemoral venous thrombosis following repair of iliac/femoral vein injury. CONCLUSIONS: Major venous injury during aortic reconstructions occurs more commonly during the repair of ruptured AAA and redo AFG. Following repair of iliac/femoral vein injury, surveillance for possible deep venous thrombosis by duplex imaging should be considered.

If not now, when? Prescription of evidence-based medical therapy prior to hospital discharge increases utilization at 6 months in patients with symptomatic peripheral artery disease.

We evaluated the impact of the prescription of evidence-based medical therapy (EBMT) including aspirin (ASA), beta-blockers (BB), ACE-inhibitors or angiotensin receptor blockade (ACE/ARB), and statins prior to discharge after peripheral vascular intervention (PVI) on long-term medication utilization in a large multi-specialty, multicenter quality improvement collaborative. Among patients undergoing coronary revascularization, use of the component medications of EBMT at hospital discharge is a major predictor of long-term utilization. Predictors of EBMT use after PVI are largely unknown. A total of 10,169 patients undergoing PVI between 1 January 2008 and 31 December 2011 were included. Post-PVI discharge and 6-month medication utilization in patients without contra-indications to ASA, BB, ACE/ARB, and statins were compared. ASA was prescribed at discharge to 9345 (92%) patients, BB to 7012 (69%), ACE/ARB to 6424 (63%), and statins to 8342 (82%), and all four component drugs of EBMT in 3953 (39%). Compared with patients not discharged on the appropriate medications, post-procedural use was associated (all p<0.001) with reported 6-month use: ASA (84.5% vs 39.2%), BB (82.5% vs 11.1%), ACE/ARB (78.2% vs 11.8%), statins (84.6% vs 21.8%). Multivariable analysis revealed that prescription of EBMT at the time of discharge remained strongly associated with use at 6 months for each of the individual component drugs as well as for the combination of all four EBMT medications. In conclusion, prescription of the component medications of EBMT at the time of PVI is associated with excellent utilization at 6 months, while failure to prescribe EBMT at discharge is associated with low use of these medications 6 months later. These data suggest that the time of a PVI is a therapeutic window in which to prescribe EBMT in this high-risk cohort and represents an opportunity for quality improvement.

Paraplegia after aortic and superior mesenteric artery stenting for occlusive disease.

Paraplegia after endovascular therapy for aortic and visceral artery occlusive disease is an extremely uncommon occurrence. Two cases of paraplegia after placement of an aortic covered stent for infrarenal aortic stenosis and a superior mesenteric artery stent for chronic visceral ischemia are presented. In both patients, embolization of the arterial supply to the spinal cord was the presumed cause. One patient had a slight recovery after intense physical therapy and rehabilitation. The second patient did not have any recovery from her paraplegia.

Results of iliac stenting and aortofemoral grafting for iliac artery occlusions.

OBJECTIVE: To compare long-term results of percutaneous iliac artery stenting (PCIS) with aortobifemoral (ABF) grafting for patients with symptomatic iliac artery occlusions. METHODS: A retrospective review of 229 patients (January 2000 to December 2011) with symptomatic iliac artery occlusions was performed. In 100 patients, 103 PCIS procedures were performed, and 101 patients underwent ABF grafting. Outcome data including periprocedural complications, improvement in ankle-brachial index, morbidity, and mortality were collected in a vascular registry. Kaplan-Meier estimates for patency and survival were analyzed. Univariate (Fisher exact test) and multivariate analyses of variables associated with the loss of primary patency were performed. RESULTS: Patients in the ABF grafting group were younger (60 ± 0.9 years old vs 65 ± 1.2 years old; P = .002) and more commonly had a history of nicotine abuse (97% vs 86%; P = .002), chronic obstructive pulmonary disease (85% vs 70%; P = .02), and a greater incidence of superficial femoral artery disease (45% vs 24%; P = .001). The most common presenting symptoms in both groups consisted of intermittent claudication (66% ABF vs 71% PCIS), rest pain (20% ABF vs 17% PCIS), and ulceration or gangrene of toes (14% ABF vs 15% PCIS). At 72 months, the primary patency for ABF bypass was greater than for PCIS (91% vs 73%; P = .010). Secondary patency rates were equivalent in both groups (98% ABF vs 85% PCIS). Survival in the ABF bypass group was significantly greater than in the PCIS group (76% vs 68%; P = .013). Hyperlipidemia (hazard ratio, 2.55; P = .049) and concurrent superficial femoral artery lesion (hazard ratio, 2.61; P = .026) were factors associated with the loss of primary patency for the entire cohort. The average hospital stay was 7 ± 2 days in the ABF group and 1 ± 0.3 days in the PCIS group (P = .0001). There were no periprocedural deaths in the PCIS group; there were four deaths in the ABF group (P = .058). In the PCIS group, ankle-brachial index increased from 0.66 to 0.89, and in the ABF group, ankle-brachial index increased from 0.54 to 0.98 (both groups, P < .001). CONCLUSIONS: This study demonstrates that PCIS remains a suitable, less invasive first-line therapy for iliac artery occlusions. PCIS has lower morbidity, shorter hospital length of stay, and equivalent secondary patency but inferior primary patency compared with ABF.

Transrenal fixation of endovascular stent-grafts for infrarenal aortic aneurysm repair: mid-term results.

PURPOSE: We evaluated mid-term results of a single-center consecutive series of endovascular stent-grafts implanted for aortic aneurysm repair with transrenal fixation, to determine clinical outcome, aneurysm anatomy, renal artery patency, and renal complications. METHODS: Modular stent-grafts were placed with transrenal fixation in 37 patients between November 1998 and July 2000. Follow-up evaluation included clinical examination, laboratory evaluation of serum creatine concentration, computed tomographic angiography, and renal duplex scanning. RESULTS: Thirty-seven patients underwent transrenal fixation of aortic stent-grafts as part of a Phase II US Food and Drug Administration study. Two patients subsequently underwent follow-up at institutions closer to their homes, and thus provided clinical information but no long-term renal or aneurysm morphologic data. There were no perioperative deaths. Five patients died during follow-up, at a mean of 9 months, because of myocardial infarction in 4 patients and respiratory failure in 1 patient. Thirty patients, ages 75 +/- 8 years, have been followed up for 28.5 +/- 7.2 months. Aneurysm diameter at follow-up was 5.0 +/- 0.8 cm, compared with 5.7 +/- 0.8 cm preoperatively. In 5 patients, endoleak developed during follow-up: 1 type I leak was treated with an aortic cuff, with temporary stabilization of the aneurysm and correction of the endoleak; 2 type II endoleaks were treated with translumbar coil embolization, and 1 resolved spontaneously; and 1 type III endoleak was treated with a combination of coil embolization and stent-graft extension to cover a graft defect. Preoperatively, serum creatinine concentration was normal in 23 patients, but increased persistently in 2 patients and was abnormal in 7 patients. Postoperatively, creatine concentration increased in 4 patients to greater than 20% of baseline level. Seventeen patients had no evidence of renal artery stenosis, compared with 13 patients with renal artery stenosis. Of 41 normal renal arteries, 90% remained unchanged, 1 became occluded, 3 demonstrated 60% stenosis. Nephrectomy was necessary in 1 patient because of cancer. Of 19 abnormal renal arteries, progression of disease was noted in 3 arteries. CONCLUSIONS: Transrenal fixation of aortic stent-grafts can be performed with acceptable mid-term outcome with respect to mortality, need for follow-up intervention, and aneurysm exclusion with protection from rupture. Postprocedural stenosis can develop in both normal and abnormal renal arteries. Rate of progression of disease was greater in patients with preprocedural renal dysfunction compared with patients with normal renal arteries. This is merely an observation, and may not be related to transrenal fixation. Long-term follow up is needed.

Carotid artery restenosis: an ongoing disease process.

Recurrence of carotid artery stenosis after primary endarterectomy is a well-known entity. The treatment and optimal management of the disease process, however, is a matter of ongoing debate. We retrospectively reviewed carotid endarterectomies for recurrent disease performed at a community hospital over the past 21 years to evaluate the outcome of surgical intervention. Eighty-two recurrences occurred in 1648 carotid endarterectomies. Females had a slightly higher recurrence rate as compared with males, and the majority of patients had risk factors in the form of hypertension, peripheral vascular disease, or cigarette smoking. All endarterectomies were repaired with a patch angioplasty by either a vein or a prosthetic graft. One patient died secondary to complications of coronary artery disease. None of the patients developed any postoperative neurological event or permanent nerve damage. A subgroup of 11 patients with recurrent carotid artery stenosis with contralateral occlusion underwent 14 endarterectomies with no neurological complications. In conclusion occlusive carotid disease is an ongoing phenomenon, and continued surveillance is recommended. Surgical treatment of recurrent disease is a safe option. Endarterectomies for recurrent carotid disease in the presence of contralateral occlusion can be performed safely.