Objective: Patients undergoing intervention for acute iliofemoral deep vein thrombosis (IFDVT) with May-Thurner syndrome (MTS) typically require inpatient (IP) hospitalization for initial treatment with anticoagulation and management with pharmacomechanical thrombectomy. Direct oral anticoagulants and percutaneous mechanical thrombectomy (PMT) devices offer the opportunity for outpatient (OP) management. We describe our approach with these patients. Methods: Patients receiving intervention for acute IFDVT from January 2020 through October 2022 were retrospectively reviewed. Patients undergoing unilateral thrombectomy, venous angioplasty, and stenting for IFDVT with MTS comprised the study population and were divided into two groups: (1) patients admitted to the hospital and treated as IPs and (2) patients who underwent therapy as OPs. The two groups were compared regarding demographics, risk factors, procedural success, complications, and follow-up. Results: A total of 92 patients were treated for IFDVT with thrombectomy, angioplasty, and stenting of whom 58 comprised the IP group and 34 the OP group. All 92 patients underwent PMT using the Inari ClotTriever (Inari Medical), intravascular ultrasound, angioplasty, and stenting with 100% technical success. Three patients in the IP group required adjuvant thrombolysis. There was no difference in primary patency of the treated IFDVT segment at 12 months between the two groups (IP, 73.5%; OP, 86.7%; P 1/4 .21, log-rank test). Conclusions: Patients with acute IFDVT and MTS deemed appropriate for thrombectomy and iliac revascularization can be managed with initiation of ambulatory direct oral anticoagulant therapy and subsequent return for ambulatory PMT, angioplasty, and stenting. This approach avoids the expense of IP care and allows for effective use of resources at a time when staffing and supply chain shortages have led to inefficiencies in the provision of IP care for nonemergent conditions. (J Vasc Surg Venous Lymphat Disord 2024;12:101875.)

Testicular seminoma is rarely associated with occlusive venous thrombosis. Several investigators describe percutaneous guidewire recanalization for iliofemoral vein thrombosis; however, this technique is ill-documented for occlusion of the inferior vena cava, and even less information is available on managing pervasive iliocaval obstruction. Furthermore, there is limited data on percutaneous mechanical thrombectomy for malignancy-induced venous thrombosis. We present a case of symptomatic chronic occlusion of the inferior vena cava and iliac veins following remission for metastatic seminoma, with percutaneous intervention necessitating a unique combination of sharp wire recanalization, mechanical thrombectomy, and stenting to restore iliocaval patency.

Objective: To evaluate how access to an office-based laboratory (OBL) and ambulatory surgery center (ASC) impacted vascular care during the Coronavirus Disease 2019 (COVID-19) pandemic. Methods: Vascular procedures performed by our group during the 6-week period before COVID-19 restrictions (group 1) and in the first 6-week period during the COVID-19 restrictions (group 2) were reviewed. The number of procedures performed was categorized as hospital inpatient (HIP), hospital outpatient (HOP), OBL, ASC, and vein center (VC). The procedures were also grouped by type: aneurysm (AAA), carotid (CAR), peripheral arterial disease (PAD), amputation/wound care (AMP), vascular access (VA), deep vein thrombosis (DVT), and venous reflux (CVI). The number of healthcare provider contact points for each patient undergoing care at the HOP, OBL, and ASC were also collected and compared between groups 1 and 2. Differences between groups were determined using the two-way ANOVA. Results: There were no statistically significant differences between groups 1 and 2 for procedure location or type of procedure (p > 0.05). Patient contact with healthcare providers decreased between groups 1 and 2 for ambulatory care. However, projecting the number of contacts for patients in group 2 if they had to have ambulatory care in the HOP setting (913) compared to contacts in the OBL and ASC setting (588) was statistically significant (p < 0.05). No patient or staff member at the OBL or ASC developed COVID-19 infection because of the care received at these venues. Conclusions: The ability to provide essential care for patients in an ambulatory environment was enhanced using our OBL and ASC without compromising safety, efficacy, or transmission of the virus to patients or staff during the height of the COVID-19 pandemic and limited their contact with healthcare workers and therefore reduced the consumption of personal protective equipment by healthcare personnel.

We present here a case of an uncommon cutaneous manifestation after paclitaxel-coated balloon angioplasty. In this case, the patient underwent drug-coated balloon angioplasty for stenosis of a prior vein bypass graft. The patient subsequently developed extensive cutaneous lesions not confined to a single arterial distribution. This case represents a rare complication related to paclitaxel-eluting balloons and provides a cautionary tale as well as clinical acumen for providers in using such devices in their practice.

Background: Microembolization after carotid artery stenting (CAS) and carotid endarterectomy (CEA) has been documented and may confer risk for neurocognitive impairment. Patients undergoing stenting are known to be at higher risk for microembolization. In this prospective cohort study, we compare the microembolization rates for patients undergoing CAS and CEA and perioperative characteristics that may be associated with microembolization. Methods: Patients undergoing CAS and CEA were prospectively recruited under local institutional review board approval from an academic medical center. All patients also received 3T brain magnetic resonance imaging with a diffusion-weighted imaging sequence preoperatively and within 24 hours postoperatively to identify procedure-related new embolic lesions. Preoperative, postoperative, procedural factors, and plaque characteristics were collected. Factors were tested for statistical significance with logistic regression. Results: A total of 202 patients were enrolled in the study. There were 107 patients who underwent CAS and 95 underwent CEA. Patients undergoing CAS were more likely to have microemboli than patients undergoing CEA (78% vs 27%; P < .0001). For patients undergoing CAS, patency of the external carotid artery (odds ratio [OR], 11.4; 95% confidence interval [CI], 1.11-117.6; P = .04), lesion calcification (OR, 5.68; 95% CI, 1.12-28.79; P = .04), and lesion length (OR, 0.29; 95% CI, 0.08-1.01; P = .05) were all found to be independent risk factors for perioperative embolization. These factors did not confer increased risk to patients undergoing CEA. Conclusions: Patients undergoing CAS are at higher risk for perioperative embolization. The risk for perioperative embolization is related to the length of the lesion and calcification. Identifying the preoperative risk factors may help to guide patient selection and, thereby, reduce embolization-related neurocognitive impairment.

Background: Traumatic superior mesenteric vein (SMV) injury is rare, and the ideal treatment is controversial. We compared the outcomes of ligation versus repair of SMV injury using the National Trauma Databank. Materials and methods: All adult patients who suffered from traumatic SMV injury were identified from the National Trauma Databank (2002-2014) by International Classification of Diseases (ICD) codes. Patients were stratified by treatment modality into no repair, ligation, and surgical repair using ICD procedure codes. Patient characteristics were compared between ligation and surgical repair groups using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. Outcomes, including mortality, rates of small bowel resection, length of stay (LOS), and ventilation days were compared using logistic regression. Results: Among 952 patients with SMV injury, 192 patients (20.2%) had ligation, 428 (50%) underwent surgical repair, and 332 patients (34.9%) had neither repair nor ligation of the SMV. Overall hospital mortality was 32%. Age, gender, injury severity score (ISS), and Glasgow Coma Scale (GCS) were similar between groups that underwent ligation and surgical repair. Although the mortality rate (29.4% versus 36.5%, P = 0.20) and bowel resection rate (4% versus 3%, P = 0.12) were similar, patients who underwent repair had significantly longer hospital LOS (19.4 +/- 24.8 versus 15.2 +/- 24.4 d, P < 0.001) and ICU LOS (13 +/- 17.1 versus 9.3 +/- 11.8 d, P = 0.02) compared to ligation. Similar results were observed in multivariable analysis when adjusted for race, associated vascular injuries, and other associated injuries. Conclusions: In patients with traumatic SMV injury, surgical repair does not appear to confer a significant survival advantage over ligation and can be associated with greater LOS and ICU LOS. Ligation may be an acceptable option for management of a traumatic SMV injury, especially when surgical repair cannot be performed, without compromising patient mortality or bowel resection rates. (C) 2019 Elsevier Inc. All rights reserved.

Background: Portal vein injury is uncommon, and the optimal treatment is controversial. We compared the outcomes of ligation vs repair of portal injury using the National Trauma Data Bank. Methods: Adult patients who suffered portal injury were identified from the National Trauma Data Bank (2002-2014) by International Classification of Diseases, Ninth Revision diagnosis codes. Patients were stratified by treatment modality into no surgery, ligation, and surgical repair using International Classification of Diseases procedure codes. Outcomes including hospital mortality, bowel resection, and length of stay between ligation and surgical repair were compared by Kruskal-Wallis or Fisher exact test as appropriate. Multivariable analyses were performed with logistic regression. Results: Among 752 patients with portal vein injury, 345 patients (45.9%) underwent no surgery, 103 patients (13.7%) had ligation, and 304 (40.4%) underwent surgical repair. Overall mortality was 49%. Age, sex, Injury Severity Score, Glasgow Coma Scale score, presenting blood pressure, and heart rate were similar between groups that underwent ligation and surgical repair. The hospital mortality (59.2% vs 47.7%; P= .08), bowel resection (1.9% vs 1.0%; P= .55), and length of stay (12.5 vs 15.0 days; P = .08) were also comparable between ligation and repair in univariate analysis. In multivariable analysis, hospital mortality for surgical repair was similar to ligation (risk ratio, 0.69; 95% confidence interval, 0.41-1.16; P = .16). Conclusions: Portal vein injury is associated with significant mortality and morbidity. Surgical repair showed a trend for lower postoperative mortality than ligation, but this was not statistically significant on multivariate analysis. Repair of a traumatic portal vein injury should be attempted, but ligation is an acceptable alternative without an increase in bowel resection rates or a statistically significant increase in mortality.

This study investigated the accuracy and utility of capillary lactic acid measurements during periods of tissue ischemia and after revascularization using the StatStrip lactic acid analyzer (Nova Biomedical, Waltham, Mass). The primary objective of this study was to examine whether local capillary lactate levels are elevated in patients with critical limb ischemia. The secondary objective was to examine whether these capillary lactic acid levels decrease after surgical revascularization. Patients scheduled for elective or emergent surgery for the treatment of critical limb ischemia at Mount Sinai Beth Israel and who were willing and able to consent were included in this pilot study. The pilot study included 14 patients who received the following interventions: one emergent open embolectomy, two endovascular revascularizations for acute limb ischemia, four endovascular revascularizations for chronic limb ischemia, and one lower extremity bypass for chronic limb ischemia. Six patients were not successfully revascularized. The average preoperative capillary lactic acid level in the affected lower extremity for all patients was 5.1 mmol/L. In cases of acute limb ischemia, the average preoperative lactic acid level in the affected lower extremity was 10.5 mmol/L; in cases of chronic limb ischemia, the average preoperative lactic acid level was 2.3 mmol/L. For patients with acute limb ischemia undergoing embolectomy or endovascular revascularization, lactic acid levels in the affected lower extremity normalized within 30 minutes. All patients undergoing revascularization for chronic limb ischemia displayed a spike in capillary lactate concentration after revascularization. The average increase was 105% (range, 50%-236%) 30 minutes after revascularization, with a return to baseline observed within 3 hours. This pilot study suggests that capillary lactic acid level monitoring may offer an objective measure of tissue ischemia and revascularization. This may be especially valuable in the evaluation and management of acute limb ischemia, when rapid diagnosis and management are critical to limb salvage. We will continue this study at our institution to include 100 patients undergoing successful revascularization for acute or chronic limb ischemia.

• Chronic traumatic AVF leads to significant morbidity when allowed to progress. • Traumatic AVF may be approached with endovascaular, open, and hybrid techniques. • We describe a traumatic AVF which was left to progress for over 30 years. • Our staged, hybrid approach decreased venous hypertension and bleeding during surgery.

Groin wounds in vascular surgery remain a significant source of morbidity and cost. Infection rates as high as 30% have been reported in retrospective and prospective series. Prophylactic negative- pressure therapy has been proposed to decrease infection rates in a nonrandomized series. Here we report the preliminary results at the midpoint of a prospective randomized trial, comparing the effect of postoperative negative-pressure therapy to conventional dressings on wound occurrences.

Background: Using finger-stick capillary blood to assess lactate from the microcirculation may have utility in treating critically ill patients. Our goals were to determine how finger-stick capillary lactate correlates with arterial lactate levels in patients from the surgical intensive care unit, and to compare how capillary and arterial lactate trend over time in patients undergoing resuscitation for shock.Methods: Capillary whole blood specimens were obtained from finger-sticks using a lancet, and assessed for lactate via a handheld point-of-care device as part of an "investigational use only" study. Comparison was made to arterial blood specimens that were assessed for lactate by standard laboratory reference methods.Results: 40 patients (mean age 68, mean APACHEII 18, vasopressor use 62%) were included. The correlation between capillary and arterial lactate levels was 0.94 (p < 0.001). Capillary lactate measured slightly higher on average than paired arterial values, with a mean difference 0.99 mmol/L. In patients being resuscitated for septic and hemorrhagic shock, capillary and arterial lactate trended closely over time: rising, peaking, and falling in tandem. Clearance of capillary and arterial lactate mirrored clinical improvement, normalizing in all patients except two that expired.Conclusion: Finger-stick capillary lactate both correlates and trends closely with arterial lactate in critically ill surgical patients, undergoing resuscitation for shock. (C) 2016 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

INTRODUCTION:Primary malignant melanoma of the esophagus is a rare diagnosis with only a few hundred cases reported in the literature. Due to the aggressive nature of this disease, long-term survivors are exceedingly rare with only a handful of case reports. PRESENTATION OF CASE:We report the case of a 38 year old man who presented with chest and back pain. Workup revealed a mediastinal mass and the patient was diagnosed with primary malignant melanoma of the esophagus and treated with radical resection. Despite the poor prognosis associated with primary malignant melanoma of the esophagus, he remains disease free for over 7 years. DISCUSSION:Initially primary malignant melanoma of the esophagus was a controversial diagnosis until the demonstration of normal melanocytes in healthy patients. It is an aggressive disease that is nearly uniformly fatal. Review of the literature shows that treatment with radical surgical resection extends prognosis by months while treatment with adjuvant chemotherapy is controversial. CONCLUSION:Primary malignant melanoma of the esophagus is a rare and aggressive disease that should be treated with surgical resection when feasible. We report the rare case of a long term survivor over 7 years since diagnosis.

Indocyanine green fluorescence angiography (ICGA) was used to measure perfusion dynamics of the foot in patients with critical limb ischemia undergoing open and endovascular procedures. We correlated the measured perfusion dynamics with clinical outcomes. ICGA was used to measure perfusion dynamics before and after revascularization in patients with critical limb ischemia. ICGA of the foot provides an objective, quantifiable measurement of inflow and outflow of blood in the foot (Fig 1). The total fluorescence curves were fitted to a logistical equation and maximum intensity, maximum ingress rate, time to maximum intensity, and time to half-maximum intensity were calculated. Patients were followed up for clinical correlation for a minimum of 6 months and divided into two groups, those whose wounds healed vs freedom from a major adverse limb event. The mean increase in flow after revascularization was 25% (range, 6%-55%), time to maximum intensity decreased by an average of 13 seconds (range, 1.1-25 seconds), time to half-maximum intensity decreased by an average of 4 seconds (range, 0-8.5 seconds), and maximum ingress rate increased by an average of 11% (range, –23% to 38%). When comparing the patients who had successful vs failed revascularization, there was a trend towards faster rates of ingress and shorter time to maximum intensity. However, for patients who had successful outcomes defined as at least 6 months amputation-free and not requiring reintervention, the most significant difference was the increase in maximum fluorescence signal (51% vs 7%, Fig 2). ICGA can be used as a functional study to look at skin perfusion dynamics to better predict end points of revascularization procedures and predict potential failures of therapy, despite successful angiographic results. There is a need to better identify objective, visual data to evaluate tissue perfusion in real-time. Initial results of ICGA are promising because the measured dynamics appear to correlate clinically. ICGA provides a rapid, safe, and easy method for evaluating revascularization procedures.Fig 2Average increase in maximum fluorescence.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: To test the hypothesis that ever smokers would suffer more recurrences and worse overall and disease-free survival than never smokers following colon cancer resection.Summary Background Data: Smoking is associated with an increased risk of developing colon polyps, specifically aggressive polyps, as well as an increased risk of colon cancer.Large database studies have shown an increased risk of colon cancer mortality among smokers, but it is not clear whether this risk is related to differences in the biology/ aggressiveness of the disease or differences in clinical response to treatment.Methods: The medical records of 2540 patients with resected stage I-III colon cancers treated at a single institution were reviewed.Demographics, tumor and surgical variables, and follow-up information were recorded.Univariate and multivariate analyses were performed to examine predictors of overall and disease-free survival as well as time to recurrence of colon cancer.Results: Tumor variables and chemotherapy administration were similar among smokers and nonsmokers.Overall survival was significantly higher for never smokers compared to ever smokers (5 year OS 79.8% nonsmokers versus 72.3% ever smokers, p ,0.0001; HR 1.51, 95% CI 1.30 -1.74).Disease free survival was significantly higher for nonsmokers compared to smokers.Time to cancer recurrence was also significantly influenced by smoking status.Smoking status remained a poor prognostic factor in multivariate models for overall and disease-free survival as well as time to recurrence.Conclusions: This study confirms that ever smokers have worse colon cancer outcomes than never smokers.Surgeons should refer all smokers with colon polyps or cancers for smoking cessation programs.

Hydration waters impact protein dynamics. Dissecting the interplay between hydration waters and dynamics requires a protein that manifests a broad range of dynamics. Proteins in reverse micelles (RMs) have promise as tools to achieve this objective because the water content can be manipulated. Hemoglobin is an appropriate tool with which to probe hydration effects. We describe both a protocol for hemoglobin encapsulation in reverse micelles and a facile method using PEG and cosolvents to manipulate water content. Hydration properties are probed using the water-sensitive fluorescence from Hb bound pyranine and covalently attached Badan. Protein dynamics are probed through ligand recombination traces derived from photodissociated carbonmonoxy hemoglobin on a log scale that exposes the potential role of both α and β solvent fluctuations in modulating protein dynamics. The results open the possibility of probing hydration level phenomena in this system using a combination of NMR and optical probes.

Introduction: Pneumoperitoneum seen on postoperative imaging presents a diagnostic dilemma. It can be a normal finding secondary to air that was introduced at surgery, which typically resolves in a matter of days. On the other hand, it could also represent a sign of a perforated viscus or an anastomotic leak, which might require reoperation. Distinguishing one from the other is critical to successful management. This study examines clinical and radiological findings in order to determine objective criteria to facilitate the distinction between benign and pathological postoperative pneumoperitoneum. Methods: A retrospective analysis of medical records from a large urban teaching hospital was performed. Imaging studies reporting “pneumoperitoneum”, “free air”, and “free intraperitoneal air”, from 2008-2011 were selected for review. The cases were divided into two groups: patients who ultimately were returned to the operating room and had findings requiring operative intervention and those who were managed expectantly. Demographic, physical findings and laboratory studies were recorded. Results: 52 patients were found to have postoperative pneumoperitoneum after abdominal surgery. Nine (17.3%) underwent re-exploration because of presumed intra-abdominal complication and the remainder of patients was managed by observation alone. At re-operation, all 9 patients were found to have pathologic conditions requiring intervention. Thirty-seven patients had an open surgery initially and 15 had a minimally invasive abdominal procedure. The patients in each group were similar with regard to age, gender, vital signs, pain score, physical findings, or open vs. laparoscopic procedure. However, patients requiring re-operation were found to have pneumoperitoneum 7.7 days after initial surgery compared to postoperative 4.3 days for those that could be managed expectantly (P = 0.003). Also, patients requiring re-operation had an average WBC of 17.4 compared to 9.7 for those managed conservatively. This suggests that postoperative pneumoperitoneum after postoperative day 5 with a WBC greater than 10.5 was 80 % sensitive for patients requiring re-operation. Conclusions: This study suggests that patients with postoperative free air still present a diagnostic and therapeutic challenge. However, free air several days following surgery with an elevated WBC may provide an indication that this finding should be of greater concern. Such patients have a greater likelihood of requiring reoperation for the treatment of a postoperative complication.

Background: Trp-188 plays a role in regulating the activity of nitric-oxide synthase (NOS). Results: W188H mutation stabilizes a 420-nm intermediate by distorting the heme macrocycle. Conclusion: The 420-nm intermediate is a hydroxide-bound ferric heme species with a tetrahydrobiopterin radical center. Significance: The data provide the first evidence for a critical intermediate in NOS. Nitric-oxide synthase (NOS) catalyzes nitric oxide (NO) synthesis via a two-step process: l-arginine (l-Arg) → N-hydroxy-l-arginine → citrulline + NO. In the active site the heme is coordinated by a thiolate ligand, which accepts a H-bond from a nearby tryptophan residue, Trp-188. Mutation of Trp-188 to histidine in murine inducible NOS was shown to retard NO synthesis and allow for transient accumulation of a new intermediate with a Soret maximum at 420 nm during the l-Arg hydroxylation reaction (Tejero, J., Biswas, A., Wang, Z. Q., Page, R. C., Haque, M. M., Hemann, C., Zweier, J. L., Misra, S., and Stuehr, D. J. (2008) J. Biol. Chem. 283, 33498–33507). However, crystallographic data showed that the mutation did not perturb the overall structure of the enzyme. To understand how the proximal mutation affects the oxygen chemistry, we carried out biophysical studies of the W188H mutant. Our stopped-flow data showed that the 420-nm intermediate was not only populated during the l-Arg reaction but also during the N-hydroxy-l-arginine reaction. Spectroscopic data and structural analysis demonstrated that the 420-nm intermediate is a hydroxide-bound ferric heme species that is stabilized by an out-of-plane distortion of the heme macrocycle and a cation radical centered on the tetrahydrobiopterin cofactor. The current data add important new insights into the previously proposed catalytic mechanism of NOS (Li, D., Kabir, M., Stuehr, D. J., Rousseau, D. L., and Yeh, S. R. (2007) J. Am. Chem. Soc. 129, 6943–6951).

The nitric oxide (NO) produced by inducible nitric oxide synthase (iNOS) up-regulates the expression of heme oxygenase (HO), which in turn produces carbon monoxide (CO) that down-regulates iNOS activity by reducing its expression level or by inhibiting its activity by converting it to an inactive P420 form (iNOS(P420)). Accordingly, CO has been considered as a potentially important attenuator of inflammation. Despite its importance, the nature of the proximal heme ligand of the iNOS(P420) species remains elusive. Here we show that the 221 cm(-1) mode of the photoproduct of iNOS(P420) does not exhibit any H(2)O-D(2)O solvent isotope shift such as that found in the iron-histidine stretching mode of myoglobin, indicating that the proximal ligand of iNOS(P420) is not a histidine. The nu(Fe-CO) and nu(C-O) data reveal that the proximal heme ligand of iNOS(P420) is consistent with a protonated thiol instead of a thiolate anion. Furthermore, the optical absorption properties of iNOS(P420) are similar to those of a neutral thiol-heme model complex but not myoglobin. Together the data support the scenario that iNOS(P420) is inactivated by protonation of the native proximal thiolate ligand to a neutral thiol, instead of by ligand switching to a histidine, as prior studies have suggested.