Femoral pseudoaneurysm closure by direct access: To stick or not to stick?

Femoral artery pseudoaneurysms are usually the result of femoral artery cannulation for percutaneous cardiac or endovascular procedures. It causes compression of surrounding structures, may cause distal embolization, arteriovenous fistula formation, or might rupture. Most close spontaneously by thrombosis, and the remainder need intervention, either percutaneous or surgical repair. We describe a unique case of femoral pseudoaneurysm that was repaired percutaneously by excluding it via stenting and simultaneous closure of residual aneurysm by direct access and coil embolization.

Diagnosis and Management of a Challenging Patient: Ureteroarterial Fistula.

While uncommon, ureteral arterial fistula (UAF) should be a differential diagnosis for persistent hematuria, as management involves coordinated treatment with a multidisciplinary team. Despite various diagnostic modalities available, accuracy in diagnosis remains a challenge. We present a patient with known UAF risk factors, including chronic ureteral stent, history of radiation, and vascular procedures. Despite multiple negative imaging studies, UAF was ultimately diagnosed and successfully managed by an endovascular approach, with resolution of her hematuria.

Peripheral occlusive disease may provide the highest hospital margins despite rising costs.

OBJECTIVE: The objective of this study was to review vascular surgical financial trends in a tertiary care setting and to evaluate the impact of a vascular program within a health care system in the face of lower reimbursements and rising costs. METHODS: With use of Current Procedural Terminology codes and diagnosis-related groups, vascular categories of aortic disease, cerebrovascular disease, and peripheral occlusive disease (POCD) were identified at an academic tertiary health care center. Hospital margins were calculated for each of the defined categories by Health Quest cost accounting data cross-walked with Current Procedural Terminology codes, date of service, and admitting physician for each year from 2010 to 2012. RESULTS: All categories realized volume growth and a positive margin for the hospital. In comparison of 2010 and 2012, aortic cases showed an overall volume growth of 19%, revenue increase of 31%, and cost increase of 54%, resulting in an overall margin decrease of 7%. Cerebrovascular cases showed a 30% increase in volume growth, revenue increase of 13%, and cost increase of 5%, resulting in a margin increase of 18%. POCD cases showed overall volume growth of 35%, revenue increase of 37%, cost increase of 54%, and a margin increase of 15%. The margin for POCD exceeded the margin for aortic and cerebrovascular cases combined by 77%. CONCLUSIONS: In evaluating a vascular program's fiscal viability, volume-driven POCD was the only category producing growing hospital margins in the face of significant cost increases.

An all-inclusive and transparent view of a vascular program's direct impact on its health system.

OBJECTIVE: This study explores the fiduciary advantage of a Vascular Surgery program to an academic, tertiary care hospital. METHODS: This is a retrospective review of hospital (HealthQuest) and physician (IDX) billing databases from April 2009 to September 2010. We identified all patients interacting with Vascular Surgery (VS) to provide an overview of global finances. Patients introduced solely by VS were identified to minimize confounding of the downstream effect. Outcome measures obtained were revenue, average and total gross margin, relative value unit production, and service utilization. RESULTS: A total of 552 cases were identified demonstrating $13 million in revenue. This translated into a gross margin of $5 million. Examined per surgeon, VS was the most profitable, producing $1.6 million. Lower extremity amputation had the highest average gross margin at $34,000. Notably, $8 million in direct cost is among the highest in the health system. A total of 137 cases unique to VS generated $5 million in total revenue. This patient subset made use of up to 29 physician specialty services. General Medicine and Radiology were the most frequently utilized. CONCLUSION: The overall profitability of a comprehensive vascular program is tremendously positive. This study verifies that new vascular-specific referrals are a significant catalyst for revenue.

Thoracoscopic total parietal pleurectomy for primary spontaneous pneumothorax.

Although the management of spontaneous pneumothorax through a thoracotomy traditionally included apical pleurectomy, thoracoscopic treatment of this problem does not generally include pleurectomy. Thoracoscopy in fact allows excellent exposure to perform total parietal pleurectomy, and we hypothesize that including total pleurectomy will reduce recurrences. We describe here the technique of thoracoscopic total parietal pleurectomy and the early outcomes afterward.

Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans.

BACKGROUND: The combination of complete diaphragm inactivity and mechanical ventilation (for more than 18 hours) elicits disuse atrophy of myofibers in animals. We hypothesized that the same may also occur in the human diaphragm. METHODS: We obtained biopsy specimens from the costal diaphragms of 14 brain-dead organ donors before organ harvest (case subjects) and compared them with intraoperative biopsy specimens from the diaphragms of 8 patients who were undergoing surgery for either benign lesions or localized lung cancer (control subjects). Case subjects had diaphragmatic inactivity and underwent mechanical ventilation for 18 to 69 hours; among control subjects diaphragmatic inactivity and mechanical ventilation were limited to 2 to 3 hours. We carried out histologic, biochemical, and gene-expression studies on these specimens. RESULTS: As compared with diaphragm-biopsy specimens from controls, specimens from case subjects showed decreased cross-sectional areas of slow-twitch and fast-twitch fibers of 57% (P=0.001) and 53% (P=0.01), respectively, decreased glutathione concentration of 23% (P=0.01), increased active caspase-3 expression of 100% (P=0.05), a 200% higher ratio of atrogin-1 messenger RNA (mRNA) transcripts to MBD4 (a housekeeping gene) (P=0.002), and a 590% higher ratio of MuRF-1 mRNA transcripts to MBD4 (P=0.001). CONCLUSIONS: The combination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragm myofibers. These findings are consistent with increased diaphragmatic proteolysis during inactivity.

Relationship between race and mortality and morbidity after valve replacement surgery.

BACKGROUND: Previous studies have shown that black race is an independent predictor of increased operative mortality after coronary artery bypass surgery. Given the higher incidence of hypertension and hypertension-associated left ventricular hypertrophy in blacks, we hypothesized that black race might be associated with increased risk of mortality and morbidity after aortic valve replacement (AVR) or mitral valve replacement (MVR). We could not identify a previous study that used a multivariable model to evaluate the association between race and operative mortality after AVR or MVR. METHODS AND RESULTS: The Society of Thoracic Surgeons National Cardiac Database was used for a retrospective review of 3137 black and 46,249 white patients who underwent MVR alone or AVR alone from 1999 through 2002. Multivariate logistic regression was used to assess the association between race and mortality and 6 other adverse outcomes (stroke, renal failure, prolonged ventilation, prolonged postoperative stay, sternal infection, and bleeding) after adjustment for covariates. Unadjusted operative mortality for MVR only was 5.60% for blacks versus 6.18% for whites (OR 0.90 [95% CI 0.71 to 1.14]) and 4.60% for blacks versus 3.62% for whites for AVR only (OR 1.28 [95% CI 1.02 to 1.62]). After adjustment for other risk factors, black race was not a significant predictor of operative mortality after AVR or MVR; however, black race was associated with an increased risk of several complications: prolonged ventilation after AVR or MVR, postoperative stay >14 days after AVR or MVR, reoperation for bleeding after AVR, and postoperative renal failure after MVR. There was no significant association between race and the risk of stroke or deep sternal wound infection for either AVR or MVR. CONCLUSIONS: In contrast to previously published results that defined race as an independent risk factor for operative mortality after coronary artery bypass surgery, race does not appear to be a significant predictor of operative mortality after isolated AVR or MVR; however, there is evidence of an association between race and certain complications.