Early Cannulation of Bovine Carotid Artery Graft Reduces Tunneled Dialysis Catheter-Related Complications: A Comparison of Bovine Carotid Artery Graft Versus Expanded Polytetrafluoroethylene Grafts in Hemodialysis Access.

INTRODUCTION:: In patients who receive chronic hemodialysis but do not have autogenous venous conduit for a native dialysis access, nonautologous grafts serve as an alternative conduit of choice. This study compared the clinical outcome of hemodialysis access using bovine carotid artery graft (BCAG) and prosthetic polytetrafluoroethylene (PTFE) graft in patients who receive chronic hemodialysis. METHODS:: An analysis of all patients undergoing hemodialysis using either BCAG or PTFE grafts from 2010 to 2017 was performed. Clinical outcomes were analyzed including graft patency as well as associated complications related to dialysis grafts and tunneled dialysis catheter (TDC). RESULTS:: During the study period, 142 patients received BCAG and 128 patients received PTFE graft implantation for dialysis access. The mean duration from graft implantation to graft cannulation in the BCAG and PTFE group was 12.3 ± 8.5 days versus 43.5 ± 16.4, respectively ( P = .01). Bovine carotid artery graft group had a higher 2-year primary patency rate (33% vs 14%, P = .03) and assisted primary rate (57% vs 23%, P = .02) compared to the PTFE group. The 2-year secondary patency rates were similar between the 2 groups (56% vs 53%, P = .69). Complication rates in the BCAG and PTFE group was 1.69 ± 0.24 per patient-year versus 2.54 ± 0.48 per patient-year, respectively ( P = .01). Tunneled dialysis catheter-related infection was greater in the PTFE group compared to the BCAG group (10.87 ± 2.61 vs 5.69 ± 0.98 per 1000 TDC days; P = .02). Bovine carotid artery graft cohorts group required a mean of 1.69 interventions per patient-year, compared to 2.76 per patient-year for the PTFE group ( P = .03). CONCLUSIONS:: Bovine carotid artery graft permits earlier cannulation for hemodialysis access with superior primary and assisted primary patency rates compared to PTFE grafts. Patients with BCAG experienced shorter indwelling TDC duration and less TDC-related complications compared to PTFE cohorts.

A Prospective Evaluation of Duplex Ultrasound for Thoracic Outlet Syndrome in High-Performance Musicians Playing Bowed String Instruments

Thoracic outlet syndrome (TOS) is a neurovascular condition involving the upper extremity, which is known to occur in individuals who perform chronic repetitive upper extremity activities. We prospectively evaluate the incidence of TOS in high-performance musicians who played bowed string musicians. Sixty-four high-performance string instrument musicians from orchestras and professional musical bands were included in the study. Fifty-two healthy volunteers formed an age-matched control group. Bilateral upper extremity duplex scanning for subclavian vessel compression was performed in all subjects. Provocative maneuvers including Elevated Arm Stress Test (EAST) and Upper Limb Tension Test (ULTT) were performed. Abnormal ultrasound finding is defined by greater than 50% subclavian vessel compression with arm abduction, diminished venous waveforms, or arterial photoplethysmography (PPG) tracing with arm abduction. Bowed string instruments performed by musicians in our study included violin (41%), viola (33%), and cello (27%). Positive EAST or ULTT test in the musician group and control group were 44%, and 3%, respectively (p = 0.03). Abnormal ultrasound scan with vascular compression was detected in 69% of musicians, in contrast to 15% of control subjects (p = 0.03). TOS is a common phenomenon among high-performance bowed string instrumentalists. Musicians who perform bowed string instruments should be aware of this condition and its associated musculoskeletal symptoms.

Outcomes following operative management of thoracic outlet syndrome in the pediatric patients.

Objectives Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients. Methods Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed. Results Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (n = 60, 88%) or combined supraclavicular and infraclavicular incisions (n = 8, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4 ± 11.6 months. Long-term symptomatic relief was achieved in 94% of patients. Conclusions Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.

Echocardiographic assessment with right ventricular function improvement following ultrasound-accelerated catheter-directed thrombolytic therapy in submassive pulmonary embolism.

Introduction The objective of this study was to evaluate the efficacy of ultrasound-accelerated catheter-directed thrombolytic therapy in patients with submassive pulmonary embolism. Methods Clinical records of 46 patients with submassive pulmonary embolism who underwent ultrasound-accelerated catheter-directed pulmonary thrombolysis using tissue plasminogen activator, from 2007 to 2017, were analyzed. All patients experienced clinical symptoms with computed tomography evidence of pulmonary thrombus burden. Right ventricular dysfunction was present in all patients by echocardiographic finding of right ventricle-to-left ventricle ratio > 0.9. Treatment outcome, procedural complications, right ventricular pressures, and thrombus clearance were evaluated. Follow-up evaluation included echocardiographic assessment of right ventricle-to-left ventricle ratio at one month, six months, and one year. Results Technical success was achieved in all patients ( n = 46, 100%). Our patients received an average of 18.4 ± 4.7 mg of tissue plasminogen activator using ultrasound-accelerated thrombolytic catheter with an average infusion time of 16.5± 5.4 h. Clinical success was achieved in all patients (100%). Significant reduction of mean pulmonary artery pressure occurred following the treatment, which decreased from 36 ± 8 to 21 ± 5 mmHg ( p < 0.001). There were no major bleeding complications. All-cause mortality at 30 days was 0%. No patient developed recurrent pulmonary embolism during follow-up. During the follow-up period, 43 patients (93%) showed improvement of right ventricular dysfunction based on echocardiographic assessment. The right ventricle-to-left ventricle ratio decreased from 1.32 ± 0.18 to 0.91 ± 0.13 at the time of hospital discharge ( p < 0.01). The right ventricular function remained improved at 6 months and 12 months of follow-up, as right ventricle-to-left ventricle ratio were 0.92 ± 0.14 ( p < 0.01) and 0.91 ± 0.15 ( p < 0.01), respectively. Conclusion Ultrasound-accelerated catheter-directed thrombolysis is a safe and efficacious treatment for submassive pulmonary embolism. It reduces pulmonary hypertension and improves right ventricular function in patients with submassive pulmonary embolism.

Comparison of propaten heparin-bonded vascular graft with distal anastomotic patch versus autogenous saphenous vein graft in tibial artery bypass.

Introduction Heparin-bonded expanded polytetrafluoroethylene grafts (Propaten, WL Gore, Flagstaff, AZ, USA) have been shown to have superior patency compared to standard prosthetic grafts in leg bypass. This study analyzed the outcomes of Propaten grafts with distal anastomotic patch versus autogenous saphenous vein grafts in tibial artery bypass. Methods A retrospective analysis of prospective collected data was performed during a recent 15-year period. Sixty-two Propaten bypass grafts with distal anastomotic patch (Propaten group) were compared with 46 saphenous vein graft (vein group). Pertinent clinical variables including graft patency and limb salvage were analyzed. Results Both groups had similar clinical risk factors, bypass indications, and target vessel for tibial artery anastomoses. Decreased trends of operative time (196 ± 34 min vs. 287 ± 65 min, p = 0.07) and length of hospital stay (5.2 ± 2.3 days vs. 7.5 ± 3.6, p = 0.08) were noted in the Propaten group compared to the vein group. Similar primary patency rates were noted at four years between the Propaten and vein groups (85%, 71%, 64%, and 57%, vs. 87%, 78%, 67%, and 61% respectively; p = 0.97). Both groups had comparable secondary patency rates yearly in four years (the Propaten group: 84%, 76%, 74%, and 67%, respectively; the vein group: 88%, 79%, 76%, and 72%, respectively; p = 0.94). The limb salvage rates were equivalent between the Propaten and vein group at four years (84% vs. 92%, p = 0.89). Multivariate analysis showed active tobacco usage and poor run-off score as predictors for graft occlusion. Conclusions Propaten grafts with distal anastomotic patch have similar clinical outcomes compared to the saphenous vein graft in tibial artery bypass. Our data support the use of Propaten graft with distal anastomotic patch as a viable conduit of choice in patients undergoing tibial artery bypass.

Lower Extremity Bypass Using Bovine Carotid Artery Graft (Artegraft): An Analysis of 124 Cases with Long-Term Results.

INTRODUCTION: Although biological grafts have been utilized as a vascular conduit in leg bypass for many years, reports of a bovine carotid artery graft (BCAG) in lower extremity revascularization have been scarce. This study analyzed the outcome of lower leg bypass using BCAG. METHODS: A retrospective review of a prospectively collected database of all patients undergoing lower extremity bypass using BCAG from 2002 to 2017 was performed. Clinical outcomes including graft patency and limb salvage were evaluated. RESULTS: A total of 124 BCAG (Artegraft, North Brunswick, NJ) were implanted in 120 patients for lower extremity revascularization. Surgical indications included disabling claudication in 12%, rest pain in 36%, tissue loss in 48%, and infected prosthetic graft replacement in 3%. Autologous saphenous vein was either inadequate or absent in 72% of patients. BCAG was used in 46 patients (37%) who had a prior failed ipsilateral leg bypass. Distal anastomosis was performed in the above-knee popliteal artery, below-knee popliteal artery, and tibial artery in 30 cases (25%), 32 cases (26%), and 48 cases (39%), respectively. Distal anastomotic patch was created in all tibial artery to allow BCAG-tibial reconstruction. The yearly primary patency rates in 5 years were 86.5, 76.4, 72.2, 68.3, and 67.5%, respectively. The corresponding yearly secondary patency rates were 88.5, 84.7, 82.4, 78.5, and 75.6%, respectively. The limb salvage rate at one year was 83.6% and at five years was 86.2% for patients with critical limb ischemia. Multivariate analysis showed poor runoff score (P = 0.03, 95% CI, 1.3-5.3; OR, 1.6) was independently associated with graft occlusion. CONCLUSION: BCAG is an excellent vascular conduit and provides good long-term results in lower extremity bypass.

Contemporary Management of Patients with Concomitant Coronary and Carotid Artery Disease.

The ideal management of concomitant carotid and coronary artery occlusive disease remains elusive. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines among national or international clinical societies. Clinical studies show that coronary artery bypass grafting (CABG) with either staged or synchronous carotid endarterectomy (CEA) is associated with a high procedural stroke or death rate. Recent clinical studies have found carotid artery stenting (CAS) prior to CABG can lead to superior treatment outcomes in asymptomatic patients who are deemed high risk of CEA. With emerging data suggesting favorable outcome of CAS compared to CEA in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options when treating patients with concurrent carotid and coronary disease. This review examines the available clinical data on therapeutic strategies in patients with concomitant carotid and coronary artery disease. A treatment paradigm for considering CAS or CEA as well as CABG and percutaneous coronary intervention is discussed.

Sustained Thromboresistant Bioactivity with Reduced Intimal Hyperplasia of Heparin-Bonded Polytetrafluoroethylene Propaten Graft in a Chronic Canine Femoral Artery Bypass Model.

BACKGROUND: Bypass graft thrombosis remains a significant mode of failure in prosthetic graft revascularization. The purpose of this investigation was to evaluate the long-term thromboresistant effect of heparin-bonded expanded polytetrafluoroethylene (ePTFE) graft using Carmeda BioActive Surface technology in a canine model. METHODS: Bilateral femorofemoral artery bypass grafts with ePTFE grafts were performed in 25 adult grayhound dogs. In each animal, a heparin-bonded ePTFE graft (Propaten, WL Gore) was placed on one side, whereas a control nonheparin graft was placed on the contralateral side. The graft patency was assessed at 1, 6, 12, 18, and 24 months (n = 5 per group) following the bypass. Heparin bioactivity of the graft material was analyzed. The effect of intimal hyperplasia was also assessed. RESULTS: All bypass grafts were patent at 1 month. Significantly greater patency rates were noted in the Propaten group compared to the control group at 12, 18, and 24 months, which were 84%, 80%, and 80% vs. 55%, 35%, and 20%, respectively (P < 0.02). There was a significant reduction in the anastomotic neointimal area and neointimal cell proliferation in Propaten grafts compared with control grafts at all groups between 6 and 24 months (P < 0.05). Heparin bioactivity as measured by antithrombin binding assay was demonstrated in the Propaten graft between 1 and 24 months. Mean heparin activities on Propaten grafts ranged from 26.3 ± 6.4 pmol/cm2 to 18.4 ± 8.7 pmol/cm2 between 1 and 24 months, which were significantly greater than the control group (P < 0.001). Differences between mean heparin activities of explanted Propaten graft samples at the various time points were nonsignificant (P > 0.05). CONCLUSIONS: Heparin-bonded ePTFE graft provides a thromboresistant surface and reduced anastomotic intimal hyperplasia at 2 years. The stable heparin bioactivity of the Propaten graft confers an advantage in long-term graft patency.

Thromboembolic Risk of Endovascular Intervention for Lower Extremity Deep Venous Thrombosis.

BACKGROUND: This study evaluated the risk of thromboembolism during endovascular interventions in patients with symptomatic lower extremity deep vein thrombosis (DVT) METHODS: Clinical records of all patients who underwent endovascular interventions for symptomatic lower extremity DVT from 2001 to 2017 were retrospectively analyzed using a prospectively maintained database. Only patients who received an inferior vena cava (IVC) filter were included in the analysis. Trapped intrafilter thrombus was assessed for procedure-related thromboembolism. Clinical outcomes of thrombus management and thromboembolism risk were analyzed. RESULTS: A total 172 patients (mean age 57.4 years, 98 females) who underwent 174 endovascular DVT interventions were included in the analysis. Treatment strategies included thrombolytic therapy (64%), mechanical thrombectomy (n = 86%), pharmacomechanical thrombolysis (51%), balloon angioplasty (98%), and stent placement (28%). Thrombectomy device used included AngioJet (56%), Trellis (19%), and Aspire (11%). Trapped IVC filter thrombus was identified in 58 patients (38%) based on the IVC venogram. No patient developed clinically evident pulmonary embolism (PE). IVC filter retrieval was performed in 98 patients (56%, mean 11.8 months after implantation). Multivariate analysis showed that iliac vein occlusion (P = 0.04) was predictive for procedure-related thromboembolism. CONCLUSIONS: Iliac vein thrombotic occlusion is associated with an increased thromboembolic risk in DVT intervention. Retrievable IVC filter should be considered when performing percutaneous thrombectomy in patients with iliac venous occlusion to prevent PE.

Long-term outcomes of staged basilic vein transposition for hemodialysis access in children.

INTRODUCTION: Children requiring long-term hemodialysis often face significant challenges due to their young age and small-vessel caliber for arteriovenous (AV) access creation. In this study, we report our experience of staged basilic vein transposition (BVT) in pediatric patients. METHODS: All patients undergoing staged BVT at a tertiary care pediatric hospital from 2003 to 2015 were reviewed. Indications for staged BVT included inadequate cephalic conduit or failed AV fistula using cephalic vein. Pertinent clinical variables were analyzed to determine treatment outcomes. RESULTS: Forty-two children (24 males, 57%) underwent 46 staged BVT during the study period. Median age was 12.8 ± 4.8 years (range 3-18). The mean weight was 47 ± 5.1 kg (range, 13-126 kg), with four children (10%) weighing ≤20 kg. Mean operative times for initial brachiobasilic AV fistula and staged BVT were 39 ± 12 minutes and 66 ± 17 minutes, respectively. Mean follow-up period was 5.4 ± 1.8 years. Functional maturation was achieved in 93% of BVTs. Early fistula thrombosis within 30 days following BVT occurred in four patients (10%). Late BVT thrombosis occurred in 13 patients (31%). Primary patency rates at 2 years and 4 years were 78% and 72%, respectively. Secondary patency rates at 2 years and 4 years were 86% and 82%, respectively. CONCLUSIONS: Staged BVT is a durable and reliable autologous hemodialysis access in children who do not have adequate cephalic venous conduit.

Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair With Hyperbaric Oxygen and Therapeutic Hypothermia.

BACKGROUND: Neurological adverse events with spinal cord ischemia (SCI) remain one of the most feared complications in patients undergoing thoracic endovascular aortic repair (TEVAR). These patients can develop irreversible paraplegia with lifelong consequences with physical and psychological agony. CASE PRESENTATION: We herein present a patient who developed SCI with bilateral lower leg paraplegia on the third postoperative day following TEVAR. Spinal catheter was inserted for spinal fluid drainage. A hyperbaric oxygen therapy was initiated for 90 minutes for 2 days, which was followed by therapeutic hypothermia for 24 hours with a target temperature of 33°C. The patient exhibited significant neurological recovery following these treatments, and he ultimately regained full neurological function without spinal deficit. DISCUSSION: This represents the first reported case of full neurological recovery of a patient who developed complete SCI following TEVAR procedure. The neurological recovery was due in part to immediate therapeutic hypothermia and hyperbaric oxygen therapy which reversed the spinal ischemia.

Thrombolytic Therapy of Acute Massive Pulmonary Embolism Using Swan-Ganz Pulmonary Artery Catheter.

Acute massive pulmonary embolism (PE) is associated with high fatality, and catheter-directed thrombolytic therapy has been shown to be an efficacious treatment for this condition. We herein report a patient who developed acute massive PE but could not undergo the conventional catheter-directed thrombolytic therapy. A Swan-Ganz pulmonary artery catheter was placed at bedside to initiate immediate thrombolytic infusion, which resulted in dramatic clinical improvement. This report underscores a potential role of thrombolytic therapy via a transjugular pulmonary artery catheter in patients with acute massive PE who could not undergo the conventional catheter-based thrombolytic intervention.

Carotidynia in high-altitude travelers.

Background Carotidynia is characterized by focal pain and tenderness of the carotid artery without associated hemodynamic or structural abnormalities. Carotid artery pathology has also been known to occur in high altitude due to aberrant baroreceptor response in the carotid bulb. Case Presentation We herein report two cases of high altitude-related idiopathic carotidynia. The first patient was a geologist who performed oil reserve survey in the Alaska Mountain, while the second patient was hiking in a mountain trail in Peru. Both patients developed acute onset of neck pain while traveling in high-altitude mountainous ranges. Carotid imaging showed transmural inflammation surrounding the carotid artery without intraluminal stenosis. Treatment with low-dose aspirin and nonsteroidal anti-inflammatory drug were initiated, which resulted in complete resolution of their symptom. Follow-up carotid ultrasound showed complete resolution of carotid inflammatory tissue density. Discussion This represents the first report linking carotidynia to high-altitude traveling.

Comparison of ASPIRE Mechanical Thrombectomy Versus AngioJet Thrombectomy System in a Porcine Iliac Vein Thrombosis Model.

BACKGROUND: Percutaneous mechanical thrombectomy device has become an important therapeutic armamentarium in the management of venous thromboembolism. In this study, we compare the efficacy and safety profile of the AngioJet thrombectomy device and ASPIRE thrombectomy system in a porcine venous thrombosis model. METHODS: Twelve adult pigs underwent bilateral iliac venous thrombosis created by using a stent graft thrombosis model and subsequently underwent either AngioJet (n = 6) or ASPIRE mechanical thrombectomy (n = 6) 1 week later. Intravascular ultrasound (IVUS) was used to assess thrombectomy efficacy, and computed tomography was used to evaluate pulmonary embolism (PE). Hemolytic effect was measured by plasma-free hemoglobin (PfHgb). Iliac vein thrombogenicity was evaluated with radiolabeled platelet and fibrin deposition. Veins were harvested and evaluated with light microscopy and scanning electron microscopy (SEM). RESULTS: Similar thrombectomy efficacy by IVUS evaluation was noted in both groups. Significant greater PE and hemolysis were identified in the AngioJet group compared to the ASPIRE group. The AngioJet group had greater reduction in WBC and platelet compared to the ASPIRE group. No difference was found in thrombogenicity, light microscopic evaluation, or SEM. CONCLUSIONS: Both devices had similar thrombectomy efficacy and thrombogenicity response. The ASPIRE catheter incurred less PE and hemolysis compared to the AngioJet device. Vessel wall response by histological analysis and SEM was similar in both groups.

Durability of the Viabahn stent graft after axillary artery pseudoaneurysm exclusion.

Pseudoaneurysm formation caused by iatrogenic arterial injury during a regional anesthetic block is a rare complication. We report a case of a 56-year-old male patient who developed an axillary artery pseudoaneurysm caused by brachial plexus block performed for an upper extremity dialysis access operation. Successful repair of this pseudoaneurysm was achieved with endovascular stent graft exclusion. The repaired axillary artery with the stent graft remained patent after 10 years of follow-up. The successful long-term patency of this treatment and a strategy to potentially avoid this complication are discussed.

Posterior tibial artery aneurysm in a child with SMAD3 mutation.

Peripheral arterial aneurysms in children are uncommon. We report a 6-year-old boy who developed a right posterior tibial artery aneurysm with symptoms including pain and pulsatile tenderness. His genetic testing revealed a SMAD3 mutation, a condition associated with familial aortic aneurysm, early-onset of osteoarthritis, and peripheral aneurysms. The posterior tibial artery aneurysm was treated with surgical resection and primary anastomosis. The patient remained free of symptoms or aneurysm recurrence in his tibial artery 2 years later. This represents the first reported case of pediatric tibial artery aneurysm linked to a SMAD3 mutation.

Infrared thermography in the diagnosis and management of vasculitis.

Vasculitis is a clinical condition with associated diagnostic challenges due to nonspecific symptoms and lack of a confirmatory imaging modality. We report a case of a 39-year-old female patient who developed generalized malaise, lethargy, and headache. Laboratory evaluation showed elevated inflammatory markers. Conventional imaging studies including computed tomography and carotid duplex ultrasound were unremarkable. Infrared thermography revealed enhanced thermographic signals in the left carotid artery and aortic arch. Corticosteroid therapy was commenced, and the patient responded well. Follow-up infrared thermography at 6 months showed complete resolution of the thermographic pattern, and the patient remained symptom free.

Assessment of lower extremity ischemia using smartphone thermographic imaging.

Conventional diagnostic modalities for assessing arterial circulation or tissue perfusion include blood pressure measurement, ultrasound evaluation, and contrast-based angiographic assessment. An infrared thermal camera can detect infrared radiation energy from the human body, which generates a thermographic image to allow tissue perfusion analysis. We describe a smartphone-based miniature thermal imaging system that can be used as an adjunctive imaging modality to assess tissue perfusion. This smartphone-based camera device is noninvasive, simple to use, and cost-effective in assessing patients with lower extremity tissue perfusion. Assessment of patients with lower extremity arterial ischemia can be performed by a variety of diagnostic modalities, including ankle-brachial index, absolute systolic ankle or toe pressure, transcutaneous oximetry, arterial Doppler waveform, arterial duplex ultrasound, computed tomography scan, arterial angiography, and thermal imaging. We herein describe a noninvasive imaging modality using smartphone-based infrared thermography.

Thoracic outlet syndrome affecting high-performance musicians playing bowed string instruments.

Thoracic outlet syndrome, a condition due to neurovascular compression in the upper shoulder region, can be caused by chronic repetitive activity of the upper extremities. Studies have linked upper extremity musculoskeletal disorders to high-performance musicians who play bowed string instruments such as the violin or viola. We report herein a case series of five elite musicians, including three violinists and two violaists, who developed neurogenic thoracic outlet syndrome following years of intense practice. Successful surgical treatment including first rib resection, scalenectomy, and brachial plexus neurolysis was performed in all patients. All patients were able to resume their musical career following surgical treatment. Our report represents the first description of thoracic outlet syndrome in high-performance bowed string instrumentalists. Clinicians should be aware of thoracic outlet syndrome as a differential diagnosis when treating string instrumentalists with upper extremity musculoskeletal ailments.

Treatment outcomes and lessons learned from 5134 cases of outpatient office-based endovascular procedures in a vascular surgical practice.

Introduction The office-based endovascular facility has increased in number recently due in part to expedient patient experience. This study analyzed treatment outcomes of procedures performed in our office-based endovascular suite. Methods Treatment outcomes of 5134 consecutive procedures performed in our office-based endovascular suites from 2006 to 2013 were analyzed. Five sequential groups (group I-V) of 1000 consecutive interventions were compared with regard to technical success and treatment outcomes. Results Our patients included 2856 (56%) females and 2267 (44%) males. Procedures performed included diagnostic arteriogram, arterial interventions, venous interventions, dialysis access interventions, and venous catheter management, which were 1024 (19.9%), 1568 (30.6%), and 3073 (60.0%), 621(12.1%), and 354 (6.9%), respectively. The complication rates for group I, II, III, IV, and V were 3%, 1.5%, 1%, 1.1%, and 0.7%, respectively. The complication rate was higher in group I when compared to each of the remaining four groups ( p < 0.05). Nine patients (0.18%) died within the 30-day period following their procedures, and none were procedure related. Conclusions Endovascular procedure can be performed safely in an office-based facility with excellent outcomes. Lessons learned in establishing office-based endovascular suites with efforts to reduce procedural complications and optimize quality patient care are discussed.