Carotid Duplex Poorly Predicts Stroke Risk During Transcatheter Aortic Valve Replacement.

INTRODUCTION: Patients undergoing surgical aortic valve replacement, in isolation or with concomitant coronary artery bypass grafting, have historically been screened for carotid artery disease prior to surgery. Over the past decade, transcatheter aortic valve replacement (TAVR) has incrementally become the predominant technique for the treatment of severe aortic stenosis. The relationship between internal carotid artery stenosis (ICAS) and risk of periprocedural stroke in the TAVR population is uncertain. We sought to evaluate our institution's outcomes with the TAVR procedure and the association with preoperative carotid duplex scan (CDS) results. METHODS: A retrospective review of a single institution TAVR registry over a 5-year period was performed. All patients with pre-operative carotid imaging were included. Outcomes included in-hospital, 30-day, and 1-year stroke and all-cause mortality rates. The diagnosis of post-operative stroke was based on neurological exam and confirmed by radiologic imaging. Standard statistical analysis was performed. RESULTS: A total of 436 patients met inclusion criteria. The prevalence of ICAS >50% was 18.3% and 70-99% stenosis was 4.8%. The in-hospital stroke and mortality rates were 2.3% and 1.2%, respectively. The cumulative 30-day and 1- year stroke rates were 3.7% and 6%, respectively. All were ischemic in nature. Bilateral infarcts were identified in 46.2% of stroke patients and 11.5% had an ipsilateral ICAS >50%. A large majority of stroke patients (23, 88.5%) had an ipsilateral ICAS of <50%. Less than 0.5% of patients had ICAS >70% and subsequently had an ipsilateral stroke within 30 days of procedure. CONCLUSIONS: The preoperative CDS identified carotid lesions that met criteria for elective repair in only 4.8% of patients. Of these, 9.5% suffered a stroke in the first 30 days after surgery. Over 90% of patients who had a stroke had less than 70% stenosis present in either carotid artery and there was no correlation between degree of ICAS and risk of stroke during the follow-up period. Routine CDS prior to TAVR does not predict in-hospital or 30-day stroke. As TAVR programs evolve, expand, and proliferate across the country, routine preoperative CDS is unlikely to determine the need for pre-operative carotid revascularization or predict stroke risk.

Attracting the Best Students to a Surgical Career.

The predicted shortage of surgeons in the future workforce is already occurring in rural areas and is expected to worsen. US allopathic medical school graduates have been losing interest in surgery for the past 40 years. The residency match remains unaffected because of foreign and osteopathic applicants. Negative myths regarding surgeon training, lifestyle, and personality persist among medical students, proving to be a powerful deterrent to students who might consider a surgical career. Proven strategies for making surgery more attractive to students are not always used and can be as simple as getting early exposure to students before clinical rotations.

Left renal vein transposition for posterior Nutcracker syndrome.

Nutcracker syndrome (NCS) is a rare cause of pelvic venous congestion syndrome and is secondary to either compression of the left renal vein in its normal anatomic position by the superior mesenteric artery and aorta or less commonly when the left renal vein is in a retroaortic position, compressed between the aorta and the spine. We herein present a unique case of NCS in a female patient with a history of chronic pelvic pain and venous congestion. We also review the literature and discuss the diagnostic modalities, differential diagnosis, and various open surgical and endovascular options for NCS.

Facial Fractures After Geriatric Ground-Level Falls Are a Marker of Functional Decline and Warrant Trauma Center Admission.

Ground-level falls (GLFs) are a frequent source of injury in the geriatric population. Facial fractures (FFs) are one subsequent injury that can occur and may be an important marker of functional decline. We conducted a retrospective analysis over a 6-year period of patients 65 years and older sustaining one or more FFs due to a GLF (n = 28). Demographics, comorbidities, FF patterns, concomitant injuries, procedures, and outcomes were analyzed. The mean age was 80.0 ± 8.2 years, 64% were male, 12 patients (43%) were on oral anticoagulants prior to injury, and mean injury severity score was 8.3 ± 7.0. Five patients (18%) had LeFort fractures (1 with LeFort I, 4 with LeFort II), and 5 (18%) had isolated mandible fractures (2 were bilateral). Nearly half of all patients suffered neurological injury (concussion: 18%, intracranial hemorrhage: 29%). Average hospital length of stay (LOS) was 4.0 ± 2.9 days. Eight patients (29%) required intensive care unit (ICU) admission with an average ICU-LOS of 2.8 ± 1.2 days. Surgical management was required in 4 patients (14%). More than half of the patients returned home (54%), 25% were discharged to a skilled nursing facility, 4% to rehabilitation, 7% to hospice, and 7% expired. Nearly one-third of patients required discharge to a higher level of care facility than their location prior to injury. GLF-induced FFs are often associated with significant injuries and serve as an indicator of functional decline. These injuries warrant trauma center admission for comprehensive evaluation and management.