A minimally invasive approach to the infected aorta with novel endovascular use of biocomposite antibiotic material.

We have presented the case of a symptomatic, primarily infected aortic pseudoaneurysm treated with endovascular stent graft exclusion and adjunctive use of a long-acting biocomposite antibiotic material injected directly into the pseudoaneurysm sac. We have described preparation of the biocomposite antibiotic material and the catheter-directed delivery technique in detail. Although the use of long-acting antibiotic materials such as antibiotic beads has been well described when performing open surgery in an infected field, the application of these materials in endovascular procedures has been less certain. The techniques we have described have the potential to promote field sterilization in a minimally invasive manner for patients with aortic infections who could be poor candidates for open surgery.

Attitudes Regarding Pregnancy Among Vascular Surgery Trainees and Program Directors Based on a Survey of Vascular Residents, Vascular Fellows, and the Association of Program Directors in Vascular Surgery.

Introduction: We conducted a survey of vascular surgery (VS) trainees and program directors (PDs) to examine differing attitudes regarding pregnancy, starting a family, and work-life balance. Methods: A 20 question survey was e-mailed to VS residents (0+5), fellows (5+2) and PDs using Survey Monkey Inc. (San Mateo, California). Results: The survey was sent to 781 participants (608 VS trainees, 173 PDs) with a similar response rate among residents [39% (133/343)), fellows [37% (98/265)], and PDs [38% (65/173)]. Of the 296 total respondents, most were male [61% (181)] and ≤40 years old [81% (240)]. VS trainees and PDs believed their work load or scheduling-coverage issues significantly increased when a trainee or peer was pregnant [PDs = 73% (38/52); fellows = 66% (59/89); residents = 54% (38/71), 13 PDs, 7 fellows and 59 residents had never worked with a pregnant peer or trainee]. Male respondents overall were significantly more likely than females to opine that a pregnant vascular trainee or attending was less capable of performing her job while pregnant [28% (50/179) vs.16% (18/110); P = .024). Women overall reported each of the following factors more commonly than men as reasons for delaying childbearing: impairing professional advancement [42% (42/99) vs 14% (23/165); P < .001], limited time to devote to children [60% (59/99) vs 39% (64/165); P = .001], not wanting to burden peers or associates [36% (36/99) vs 13% (22/165); P < .001), extra stress [67% (66/99) vs 30% (50/165); P < .001], perceived negative view of peers and program directors towards pregnancy [29% (29/99) vs 1% (2/165); P < .001], and encouragement not to have children from peers or attending [15% (15/99) vs 2% (3/165); P < .001). More females than males overall regret their career choice in VS as it relates to starting a family [22% (24/107) vs. 12%; 21/170); P = .028]. When asked about the major barriers for female vascular surgeons who wanted to become pregnant, PDs cited an unsupportive home environment more than trainees [37% (24/65) vs 22% (51/231); P = .015], whereas trainees cited safety concerns affecting the pregnancy, such as radiation, more than PDs [71% (164/231) vs 43% (28/65); P < .001] Conclusions: There are significant differences in views toward pregnancy among males and females and among trainees and PDs overall. Contrasting gender-based perceptions of the impact of pregnancy on vascular training need to be addressed before adequate solutions to the challenge of work-life balance can be achieved. Significant opportunities exist for trainees and PDs to address these knowledge gaps.

Management of Pancreaticoduodenal Artery Aneurysms Based on a Single-Institution Experience.

OBJECTIVES: Pancreaticoduodenal artery aneurysms (PDAAs) are rare and have a high propensity for rupture. Historically, management of PDAAs included surgical reconstruction but has evolved with advances in endovascular therapy. We report our experience with management of PDAAs during the last 30 years. METHODS: We retrospectively reviewed our prospectively maintained registry between January 1, 1992 - March 30, 2020. RESULTS: We identified 8 patients with PDAAs: 4 with associated celiac artery occlusive disease and 4 without identifiable etiologies. Four patients were treated with surgical resection of the PDAAs: 2 intact aneurysms underwent concomitant revascularization (superior mesenteric artery-to-hepatic artery Dacron bypass; supra celiac aorta-to-hepatic artery Dacron bypass) and 2 (1 intact, 1 rupture) underwent ligation alone. Four patients were treated with coil embolization of the PDAA: 2 with concomitant stent-graft exclusion of the aneurysm (1 non-rupture, 1 rupture) and 2 without adjunctive measures (intact). There were no deaths nor any significant procedure-related morbidity. CONCLUSION: Our large single-center experience shows that PDAAs can be successfully treated by open or endovascular intervention with selective revascularization.

The Utility of Duplex Ultrasonography Surveillance in Identifying Failing Aortobifemoral Grafts.

OBJECTIVE: The Society for Vascular Surgery stated there are a lack of studies describing long-term surveillance for aortobifemoral (AoBF) bypasses. Our goal was to investigate the value of DU studies as a surveillance tool for AoBF bypasses. METHODS: We retrospectively identified patients in our prospectively maintained database who underwent AoBF bypasses between 1995-2018. Surveillance was performed routinely with DU post-operatively, every 6 months for 1 year, and then annually. We considered "abnormal" DU findings to include peri-graft fluid, pseudoaneurysm or, peak systolic velocities (PSVs) > 350 cm/sec or PSV ratio > 3.5 anywhere from the proximal aortic to distal femoral anastomosis. If abnormalities were identified patients underwent intervention or shorter surveillance intervals. RESULTS: Of 153 AoBF bypasses, 60 patients with 120 graft limbs fulfilled our post-operative surveillance protocol with a mean follow-up of 4.0 years (0.5-24 years). "Normal" DU surveillance studies were documented throughout follow-up in 112 (93%) limbs. Of these, 2 (1.7%) developed acute limb occlusion. Eight (6.7%) limbs had "abnormal" DU findings: 5 failing grafts with focal elevated PSVs, 2 with peri-graft fluid leading to a diagnosis of an infected graft, and 1 with a pseudoaneurysm (PSA). Contrast arteriography or CT-angiography confirmed > 75% diameter stenosis, fluid or PSA in all 8 limbs. Graft revision (5 endovascular, 2 surgical) was performed in 7 of the 8 limbs initially or after 2 successive "abnormal" DU studies within 6 weeks of each other; 1 patient refused intervention. Without surveillance, urgent or emergent treatment might have proved necessary in 7.5% (7 + 2 = 9/120) of cases instead of only 1.7% (2/120) of cases. CONCLUSION: Vascular surgeons should adopt DU as a useful surveillance tool to identify AoBF bypasses that are failing or have other problems not identified clinically. Persistence of "abnormal" DU findings should prompt operative or endovascular intervention.

Co-Operative Vascular Intervention Disease (COVID) Team of Greater Philadelphia.

We established the Co-Operative Vascular Intervention Disease (COVID) Team of Greater Philadelphia because national guidelines may not apply to different geographic areas of the United States owing to varying penetrance of the virus. On April 10, 2020, a 10-question survey regarding issues and strategies dealing with COVID-19 was e-mailed to 58 vascular surgeons (VSs) in the Greater Philadelphia area. Fifty-four VSs in 18 surgical groups covering 28 hospitals responded. All groups accepted transfers because of continued availability of intensive care unit beds. Thirteen groups were asked to "redeploy" if the need arose to function outside of the usual duties of a VS. None imposed age restrictions regarding older VSs continuing clinical hospital work. The majority restricted noninvasive vascular laboratory studies to those studies for which findings might mandate intervention within 2 or 3 weeks, restricted dialysis access operations to urgent revisions of arteriovenous fistulas or grafts that were failing or had ulcerations, converted from in-person to telemedicine clinic interactions, and experienced moderate-severe anxiety or fear about personal COVID-19 exposure in the hospital. The majority of VSs in the Philadelphia area dramatically adjusted their clinical practices before the COVID-19 crisis reached peak levels experienced in other metropolitan areas.

Nutcracker Syndrome as an Unusual Cause of Postprandial Pain.

Nutcracker syndrome is a rare entity in which compression of the left renal vein (LRV), usually by the overlying superior mesenteric artery (SMA), results in renal venous congestion and reflux in the left ovarian vein (LOV). Patients may present with hematuria, left flank pain, dyspareunia, and vaginal or abdominal wall varicose veins. We report a patient with nutcracker syndrome who presented atypically with left flank pain that was exacerbated in the postprandial state. We hypothesize that the physiologic dilation of the SMA after oral intake caused increased LRV compression at that site and augmented lateral LRV distention. The patient had no evidence of SMA syndrome or chronic mesenteric insufficiency. Her symptoms resolved after we performed an LOV to inferior vena cava transposition.