Endovascular Salvage of Type Ia and Ib Endoleaks Using a Physician-Modified Fenestrated/Branched Endograft and an Iliac Branch Device Via Unilateral Transfemoral Arterial Access.

PURPOSE: This study aims to explore the feasibility and effectiveness of a unilateral transfemoral access endovascular salvage technique for complex abdominal aortic aneurysms with concurrent type Ia and Ib endoleaks following previous endovascular repair. CASE REPORT: A 69-year-old female with multiple comorbidities presented with an extent IV thoracoabdominal aortic aneurysm complicated by type Ia and Ib endoleaks and chronically occluded left iliac endoprosthesis after prior endovascular repair. Given the patient's medical complexities, open explant repair was deemed high risk. The case was successfully managed using a physician-modified fenestrated/branched endograft (PM-F/BEVAR) and an iliac branch device (IBD) deployed through a single percutaneous transfemoral access. CONCLUSION: The presented case demonstrates the safety and efficacy of PM-F/BEVAR with concomitant IBD deployment via unilateral transfemoral access. This innovative approach allows endovascular salvage in cases with restricted iliofemoral access and avoids the complexities associated with upper extremity or aortic arch manipulation. While acknowledging the technical challenges, this technique offers a viable alternative for salvaging failed endovascular repairs, emphasizing the importance of real-time modifications in achieving successful outcomes. Further studies and long-term follow-up are warranted to validate the broader applicability and durability of this approach in the management of complex abdominal aortic aneurysms with multiple endoleaks. CLINICAL IMPACT: Although not the conventional approach, unilateral transfemoral access can be utilized to implant either a physician-modified fenestrated aortic endograft or an iliac branch device. Such an approach avoids complicating issues related to upper extremity access. This innovative technique may be necessary when there is a failed prior EVAR in the setting of significant contralateral iliofemoral occlusive disease. Doing both procedures in the same setting to resolve a type Ia and Ib endoleak is feasible as demonstrated in this case report. Expanding the endovascular armamentarium to address EVAR failure will be increasingly useful in the future, especially given the morbidity profile of EVAR explantation.

The Effects of Clopidogrel Duration on Carotid Artery In-Stent Restenosis.

BACKGROUND: There are limited data supporting a specific duration for dual antiplatelet therapy in carotid artery stenting (CAS), and most clinical evidence is derived from studies involving coronary interventions. As a result, the appropriate duration of dual antiplatelet therapy after CAS is yet to be determined. We aimed to elucidate whether the duration of dual antiplatelet therapy played a role in the rate of carotid in-stent restenosis. METHODS: A retrospective analysis of all patients who underwent CAS at our institution over a 20-year period (1996-2016) was performed (n = 279). Patients who did not complete their follow-up duplex studies or were not discharged on clopidogrel were excluded from the study. Patients were separated into short-term (<6 weeks, n = 159) and long-term (>6 weeks, n = 112) clopidogrel users based on duration of therapy. We defined clinically significant in-stent restenosis as >50% restenosis (peak systolic velocity = 224 cm/s) in symptomatic patients and >80% restenosis (peak systolic velocity = 325 cm/s) in asymptomatic patients status-post prior CAS based on published velocity criteria. Rates of in-stent restenosis at 1-year, 2-year, and 5-year intervals were analyzed between the 2 groups using chi-squared analysis. RESULTS: Demographic information was largely similar between the 2 groups; however, short-term clopidogrel users were more likely to have a history of atrial fibrillation (9.43% vs. 1.68%, P = 0.008) and were less likely to have a history of coronary artery bypass graft (16.35% vs. 29.41%, P = 0.009), diabetes (33.34% vs. 49.58%, P = 0.006), and coronary artery disease (50.31% vs. 63.03%, P = 0.035). All patients were on long-term aspirin therapy. There was no significant difference between overall rates of in-stent restenosis between the short-term and long-term clopidogrel users (5.03% vs. 9.24%, P = 0.168) within 5 years of the index procedure. Similar results were observed when these groups were evaluated at 1-year (5.61% vs. 3%, P = 0.321), 2-year (2.02% vs. 6.59%, P = 0.072), and 5-year (2.24% vs. 3.57%, P = 0.635) follow-up. CONCLUSIONS: No statistically significant difference was observed in the rate of in-stent restenosis after CAS between short-term and long-term clopidogrel therapy. Patients in whom there is no other indication for longer duration clopidogrel therapy may be considered for shorter duration course of dual antiplatelet therapy following CAS.

Defining a Leader-Characteristics That Distinguish a Chair of Surgery.

BACKGROUND: Chair of the Department of Surgery, sometimes known as the Chief, holds a title that has significant historical connotations. Our goal was to assess a group of objectively measurable characteristics that unify these individuals as a group. METHODS: Utilizing publicly available data for all US teaching hospitals, demographic information was accumulated for the named chiefs/chairs of surgery. Information collected included location of their program, their medical/surgical training history, their surgical specialty, previous chair/chief titles held, and academic productivity. RESULTS: Of the 259 programs listed, data were available on 244 individuals who were trained in 19 different specialties. The top three specialties of these practitioners are General Surgery (40, 16.3%), Surgical Oncology (38, 15.5%), and Vascular Surgery (33, 13.5%). There were only 14 female chairs (5.7%) and only one chair with a doctor of osteopathic medicine degree. The majority (62.3%) had been a previous chief of a surgical subdivision with only 26% having been a previous chair/chief of the surgical department. The average chair had 72 peer-reviewed manuscripts with 28 published book chapters. Chair's at academic institutions with university affiliation had a significantly higher number of peer-reviewed manuscripts (P < 0.0001) as well as were more likely to be trained at academic institutions (P = 0.013). CONCLUSIONS: There are no set characteristics that define the Chair of a Department of Surgery. By understanding a group of baseline characteristics that unify these surgical leaders, young faculty and trainees with leadership aspirations may begin to understand what is necessary to fill these roles in the future.

The effects of arts-in-medicine programming on the medical-surgical work environment.

Background: Arts in medicine programs have significant impacts on patients and staff in long-term care environments, but the literature lacks evidence of effectiveness on hospital units with shorter average lengths of stay. Methods: The qualitative study used individual structured interviews to assess the impacts of arts programming on job satisfaction, stress, unit culture, support, quality of care, and patient outcomes on a short-term medical-surgical unit, and used a qualitative cross comparison grounded theory methodology to analyze data. Results: The study confirmed that arts programming can positively affect unit culture, nursing practice, and quality of care on short-stay medical-surgical units. Significant insights related to nursing practice and the art program were found, including that music can cause negative distraction for staff. Conclusions: While positive impacts of arts programming on the medical-surgical environment are clear, potential negative effects also need to be considered in the development of practice protocols for artists.