Cerebral Hyperperfusion Syndrome Presenting As Status Epilepticus Following Carotid Endarterectomy.

Cerebral Hyperperfusion Syndrome (CHS) is a rare syndrome, commonly described as a prodrome of symptoms including a severe ipsilateral headache, focal neurological deficits, intracerebral hemorrhage, and occasionally includes seizures or encephalopathy. Our case involves a 76-year-old man who underwent a left carotid endarterectomy (CEA) for symptomatic high-grade stenosis of his left carotid artery. Post-operative day one, the patient was seen and examined in the early morning and found to be doing well, with blood pressures well-controlled and at his neurologic baseline. Three hours later, he was reported to have a sudden spike in his blood pressure and was experiencing focal motor seizures involving the right arm and face, both of which were unrelieved by anti-hypertensives and anti-seizure medications. The patient subsequently developed worsening respiratory function requiring intubation for status epilepticus. Repeat head and neck imaging with CT, CT angiography, and MRI demonstrated the known previous subacute infarct with new cerebral edema, patent carotid arteries bilaterally, and no acute infarct or intracerebral hemorrhage. While CHS is a rare syndrome with well-documented symptomatology, we present a unique case in which focal motor status epilepticus was the only presenting symptom in a patient who otherwise meets the criteria of CHS based on radiographic evidence of cerebral edema following an elective CEA.

Comprehensive Multicenter Graduate Surgical Education Initiative Incorporating Entrustable Professional Activities, Continuous Quality Improvement Cycles, and a Web-Based Platform to Enhance Teaching and Learning.

BACKGROUND: It is increasingly important for faculty to teach deliberately and provide timely, detailed, and formative feedback on surgical trainee performance. We initiated a multicenter study to improve resident evaluative processes and enhance teaching and learning behaviors while engaging residents in their education. STUDY DESIGN: Faculty from 7 US postgraduate training programs rated resident operative performances using the perioperative briefing, intraoperative teaching, debriefing model, and rated patient visits/academic performances using the entrustable professional activities model via a web-based platform. Data were centrally analyzed and iterative changes made based on participant feedback, individual preferences, and database refinements, with trends addressed using the Plan, Do, Check, Act improvement methodology. RESULTS: Participants (92 surgeons, 150 residents) submitted 3,880 assessments during July 2014 through September 2017. Evidence of preoperative briefings improved from 33.9% ± 2.5% to 95.5% ± 1.5% between April and September 2014 compared with April and September 2017 (p < 0.001). Postoperative debriefings improved from 10.6% ± 2.7% to 90.2% ± 2.5% (p < 0.001) for the same period. Meaningful self-reflection by residents improved from 28.6% to 67.4% (p < 0.001). The number of assessments received per resident during a 6-month period increased from 6.4 ± 6.2 to 13.4 ± 10.1 (p < 0.003). Surgeon-entered assessments increased from 364 initially to 685 in the final period, and the number of resident assessments increased from 308 to 445. We showed a 4-fold increase in resident observed activities being rated. CONCLUSIONS: By adopting recognized educational models with repeated Plan, Do, Check, Act cycles, we increased the quality of preoperative learning objectives, showed more frequent, detailed, and timely assessments of resident performance, and demonstrated more effective self-reflection by residents. We monitored trends, identified opportunities for improvement and successfully sustained those improvements over time, applying a team-based approach.

The endovascular management of a 3.5-cm gastroduodenal artery aneurysm presenting with gastritis and recurrent pancreatitis.

Visceral artery aneurysms (VAAs) are a rare entity. Within this subset of aneurysms, gastroduodenal artery (GDA) aneurysms represent an even more rare occurrence. We present a case report of treating GDA aneurysm on semi-elective basis followed by literature review of the clinical presentation and mainstream treatment modalities. GO is a 65-year-old male, with 6-month history of recurrent epigastric pain. He was found to have acute pancreatitis and an adjacent 3.5-cm GDA aneurysm. After conservative treatment of pancreatitis, the aneurysm was treated with coil embolization of the sac and GDA. Most VAAs are asymptomatic; GDA aneurysms tend to present clinically with epigastric pain or pancreatitis. In addition, together with pancreaticoduodenal aneurysms, GDA aneurysms warrant immediate intervention once diagnosed. Open surgical options for VAAs include aneurysm resection with or without revascularization (i.e., bypass), aneurysm ligation, or end-organ resection (i.e., splenectomy). Endovascular repair involves coil embolization with or without stent placement. While endovascular modality continues to be the first choice for stable elective VAA patients, modality of treatment for ruptured VAA or unstable patients will vary according to the patient's overall status, operator's experience, and institute capacity.

Sustained patency and clinical improvement following treatment of atherosclerotic iliac artery disease using the Assurant cobalt iliac balloon-expandable stent system.

PURPOSE: To report the outcome of the ACTIVE (Use of the Assurant Cobalt Iliac Stent System in the Treatment of Iliac Vessel Disease) study (ClinicalTrials.gov Identifier: NCT00753337), which was designed to determine the safety and effectiveness of the next-generation Assurant cobalt chromium balloon-expandable stent in symptomatic patients with iliac occlusive disease. METHODS: This prospective, multicenter, single-arm study enrolled 123 symptomatic (Fontaine class II or III) patients (69 men; mean age 65.5±10.6 years) with 159 de novo or restenotic lesions (length ≤100 mm) in the common or external iliac arteries. Objective measures of outcome were ankle or toe-brachial indexes, Fontaine class, and duplex ultrasound evaluations collected before the procedure and at 1 and 9 months. The primary endpoint of major adverse events (MAE) at 9 months was defined as device- and procedure-related death, target limb loss, or clinically-driven target lesion or target vessel revascularization (TLR/TVR). RESULTS: At 9 months, the rate of MAE was 0.8% with 1 TLR and 99.2% primary patency. There were no device- or procedure-related deaths or target limb amputations. The ankle-brachial index increased by 0.2±0.2 at 1 and 9 months. There was an improvement in the Fontaine classification of claudication for the majority of patients, accompanied by significant and sustained improvements in walking speed, distance, and stair climbing. CONCLUSION: The balloon-expandable Assurant cobalt chromium iliac stent demonstrated an excellent safety profile and sustained patency associated with marked improvements in objective and functional measures of patency.

Endograft salvage of hemodialysis accesses threatened by pseudoaneurysms.

OBJECTIVE: Currently, no formal practice guidelines exist regarding the use of endografts to exclude hemodialysis access pseudoaneurysms and prolong access lifespan in dialysis patients. We evaluated the efficacy of percutaneous endograft placement for exclusion of hemodialysis access pseudoaneurysms. METHODS: Between July 2005 and October 2009, 32 patients were prospectively evaluated. Twenty-four patients were actively enrolled in the study based upon clinical and ultrasonographic evaluation of their hemodialysis accesses. Self-expanding covered endografts were placed percutaneously to exclude access pseudoaneurysms. Patients were evaluated at 2 and 6 months to assess for graft patency, access or outflow stenosis, endoleak, or stent graft migration. RESULTS: No procedural complications resulted from these interventions. An average of 1.8 endografts was placed per patient, with patients requiring between 1 and 3 endografts to exclude pseudoaneurysms. Primary-assisted patency was 83% at completed 2-month follow-up and 54% at 6-month follow-up. At 12 months, primary-assisted patency was 50%. Eleven patients left the study before 6-month follow-up: five (21%) required explantation secondary to infection between 1 and 4 months; three (13%) were lost to follow-up; two (8%) died of unrelated causes; and 1 requested explantation citing pain from the "stent poking the vein." Mean time to explantation secondary to infection was 2.4 months. Mean duration of patency was 17.6 months with a range from 0 to 76 months. Mean duration of patency for patients who completed 6-month follow-up was 28.7 months. The longest duration of patency is 6 years 4 months, after stent fracture and subsequent placement of a new stent at 6 years 2 months. One other incident of stent fracture occurred at 36 months. Dialysis patterns were not interrupted in either patient. CONCLUSIONS: The long-term results demonstrate that endograft salvage of failing hemodialysis accesses is a viable and safe alternative to open surgical revision that excludes pseudoaneurysms while maintaining uninterrupted access patency. A larger sample size and longer follow-up are needed to support the study data.

Stent migration as a late complication following carotid angioplasty and stenting.

BACKGROUND: A 69-year-old male patient with severe asymptomatic carotid artery stenosis was treated percutaneously with implant of two self-expandable stents in the right carotid overlapped to each other by 5 mm. The 15-month follow-up colour-Doppler ultrasound (CDU) revealed a severe stenosis in the target vessel and an image suggesting migration of the distal stent. INVESTIGATIONS: Physical examination, laboratory test, CDU, carotid angiography, quantitative carotid angiography (QCA), brain computed tomography (CT). DIAGNOSIS: Migration of the distal stent associated with severe stenosis on the unsupported arterial segment. MANAGEMENT: Carotid artery angiography, QCA, antithrombotic therapy, carotid artery angioplasty and stenting (CAS).