Successful paraclavicular surgical decompression for recurrent venous thoracic outlet syndrome following transaxillary first rib resection in an elite athlete.

OBJECTIVES: Recurrent effort thrombosis after prior surgical intervention for venous thoracic outlet syndrome (TOS) is an uncommon problem, and there are multiple alternative surgical approaches in the management of recurrent venous TOS. METHODS: We present a case of a 23 year-old female professional athlete who presented with arm swelling, pain, and recurrent effort thrombosis after prior transaxillary rib resection. Imaging at our institution revealed subclavian vein thrombosis, confirmed with dynamic venography, as well as a remnant first rib. RESULTS: Thrombolysis of the subclavian vein and balloon angioplasty was followed by paraclavicular thoracic outlet decompression with complete first rib resection. Success was confirmed with intraoperative dynamic venography demonstrating a patent subclavian vein and resulted in complete elimination of symptoms. CONCLUSION: Additional surgical decompression with complete medial first rib resection of remnant rib, which was potentially causing compression of the subclavian vein, may be necessary to prevent recurrent venous compression and thrombosis for venous TOS.

Efficacy and utilization of intravascular ultrasound in office-based lower extremity endovascular interventions for peripheral arterial disease.

OBJECTIVES: Intravascular ultrasound (IVUS) is a uniquely objective but underutilized imaging modality in the interventional treatment of peripheral arterial disease treatment. IVUS has been shown to improve device size selection and diagnose occult pathology difficult to see with routine angiography. We hypothesize that the use of IVUS in lower extremity endovascular intervention improves accuracy in stent and balloon size selection and minimizes contrast use. METHODS: This is a retrospective case series performed at a single-institution outpatient center by two vascular surgeons from July 2016 through July 2017. We identified 94 total IVUS-assisted procedures. We collected data regarding demographics, balloon and stent size, IVUS-determined vessel diameter, pre-procedure and post-procedure ABI values, and contrast used during the procedure. An independent core laboratory was further utilized to characterize all IVUS and angiographic size vessel measurements. RESULTS: For the 94 lower extremity IVUS-assisted interventions, the average patient age was 70±9 years old, with an average contrast use of 37.1 mL of Omnipaque 300. There was substantial improvement in pre- and post-procedure ABI (0.7±0.23 to 0.94±0.21). On analysis of average intraluminal IVUS vessel diameter to balloon angioplasty used, we had a correlation in size of 0.96±0.16 in our series. Additionally, in eight instances IVUS allowed for identification of a flow-limiting dissection with subsequent stenting. CONCLUSIONS: Routine use of IVUS offers a powerful diagnostic paradigm that has the potential to significantly decrease contrast use and to improve objectivity in choosing appropriate vascular tools to maximize intra-procedural efficacy. The discovery of adverse findings not initially noticed on angiography further reinforces the value of IVUS utilization.

Prophylactic Groin Wound Vacuum-assisted Therapy in Vascular Surgery Patients at Enhanced Risk for Postoperative Wound Infection.

BACKGROUND: Vascular groin wounds have higher than expected surgical site infection (SSI) rates and some patients are at enhanced risk. The Wiseman et al. paper suggests an objective scoring system that identifies patients at enhanced risk of postdischarge SSI. We hypothesize that prophylactic groin wound vacuum-assisted closure (VAC) therapy in enhanced risk patients will decrease SSI and readmission and the Wiseman model provides potential evidence that enhanced risk patients can be objectively identified. METHODS: A single institution, retrospective analysis was conducted from January 2013 to September 2016 utilizing procedure codes to identify patients with wound VACs placed in the operating room. Two distinct groups were identified. The first was a wound complication patient group with 15 limbs (13 patients) with a groin wound VAC placed within 45 days postoperatively for groin wound complications. Eleven of these limbs had the VAC placed at readmission. The second group was a prophylactic patient group that included 8 limbs (7 patients) who received a VAC prophylactically placed in the enhanced risk wounds. These wounds were determined to be enhanced risk based on clinical criteria judged by the operating surgeon such as a large overhanging panniculus and/or one of several ongoing medical issues. We calculated a Wiseman score for all patients, determined total cost of the readmissions, and determined 30-day postsurgical SSI incidence for the prophylactic VAC group. RESULTS: Per the Wiseman scores, 9 limbs with postoperative complications were high risk and 3 limbs were moderate/high risk. Eleven limbs had a VAC placed at readmission with an average readmission cost of $8876.77. For the prophylactic group, 8 limbs were high risk with no observed postdischarge SSI in the first 30 days from surgery. The Wiseman scores showed close correlation between the retrospective high and moderate/high risk groups versus the prophylactic VAC group (31.5 ± 7.3 vs. 32 ± 5.5, P = 0.87). CONCLUSIONS: The Wiseman scores showed objective validation in the prognosis of anticipating groin wound breakdown. Our initial results suggest that prophylactic groin wound VAC placement for enhanced risk vascular surgery patients may proactively decrease wound morbidity, decrease readmission secondary to groin wound complications, and provide some cost benefit.