Endovascular aneurysm repair (EVAR) is a minimally invasive treatment for abdominal aortic aneurysms (AAAs). Common complications include endoleaks, which are continued blood flow into the aneurysm sac external to the graft. Type I endoleaks occur proximally or distally, resulting from inadequate seals between the graft and artery. Type III endoleaks stem from defects between components in modular grafts or fabric tears. Re-intervention is indicated for type I and III endoleaks due to pressurization of the aneurysm sac resulting in a high risk of rupture. A 68 year-old man presented with an infrarenal AAA and underwent EVAR. He developed a late type I endoleak requiring reintervention with a stent graft cuff, and later presented with a recurrent type I endoleak and type IIIb endoleak. The AAA increased in size to 18 cm with contained rupture, requiring emergent endograft explantation and repair with a bifurcated Dacron graft. His postoperative course was uncomplicated.

Phlegmasia alba dolens is a rare sequela of acute extensive venothrombus of the iliofemoral segments. Rarely, phlegmasia alba dolens can also result from clotted inferior vena cava filter. A 39-year-old with protein S deficiency, and prior inferior vena cava filter placement after remote trauma presented to the emergency department with progressive bilateral lower extremity pain and swelling. Venous duplex revealed extensive bilateral deep vein thromboses from the external iliac veins to popliteal veins, as well as thrombophlebitis of the left great saphenous vein. Venography confirmed patency of the suprarenal vena cava with abrupt occlusion of the infrarenal segment at the level of the inferior vena cava filter. The filter was removed followed by endovascular thrombectomy and adjunctive venoplasty. The patient progressed well and discharged on therapeutic anticoagulation. This case illustrates that a staged endovascular approach may be utilized for acute on chronic caval thrombosis and filter removal.

A patent foramen ovale (PFO) is present in 27-35% of the population. Right to left cardiac shunts predispose patients to arterial emboli in the presence of venous thromboembolisms. Paradoxical embolus should be suspected in patients with deep venous thrombosis (DVT) and arterial emboli. A 45-year-old man with hypercoagulability and history of DVT presented with a week-long history of chest pain, shortness of breath, and left arm numbness. Imaging showed a saddle pulmonary embolus (PE) and emboli involving the aortic arch, left common carotid, and left subclavian artery. The patient proceeded with an endovascular thrombectomy of the pulmonary artery, followed by open thrombectomy. Echocardiogram confirmed a right to left intra-cardiac shunt consistent with a PFO. Paradoxical emboli are rare manifestations of venous thromboemboli in patients with right to left intra-cardiac shunts. Patients should be evaluated for these to help prevent further manifestations.

In 2019, the Vascular Surgery Board of the American Board of Surgery administered the first national Continuous Certification Assessment in vascular surgery. This program was designed to replace the 10-year, high-stakes recertification examination with an online, open book format. To determine the efficacy and value of this new process, we performed a complete psychometric analysis of the examination results and reviewed the postassessment examinee survey. To construct the examination, recent relevant scientific articles were selected by modified Delphi method, and clinically based questions focused on these references were constructed by the Vascular Surgery Board. Participants were given 2 weeks to complete the 40-question online program. Examinees had two opportunities to achieve an 80% passing score. A postassessment survey was delivered to all participants. A total of 258 participants took the 2019 Vascular Surgery Continuous Certification Assessment, of which 236 (91%) were male. Only 10 (4%) maintained a current general surgery certification. Twenty-three (9%) participants were recertifying in vascular surgery after a lapse. Only one candidate failed the examination after two attempts (99.6% pass rate), whereas 53% (137 candidates) passed on the first attempt. Of those, 81 (59%) voluntarily took the second set of questions. There was no association between age, practice type, or number of failures on the vascular surgery qualifying or certifying examination and a first-attempt failure. The average score was 78% on the first attempt and 96% after the second attempt. Total test reliability per assessment was high (α = .68). The postassessment survey had a 95% (245/258) response rate. The majority (93%) of respondents thought the examination difficulty level was “about right” and reported that they looked up an average of 48.5% of the questions before answering. Respondents overwhelmingly agreed or strongly agreed that the examination was a fair assessment of knowledge (85%), was relevant to their practice (86%), and was a valuable use of their time (73%). Participants also agreed that they completed the assessment easily with regard to technical functionality (90%), and they would recommend taking the assessment to a colleague (77%). Vascular surgeons overwhelmingly found this new continuous assessment model to be valuable, relevant to their practice, and of appropriate difficulty. These responses will be used as a baseline comparison for diplomate perceptions regarding the new continuous certification program going forward.

The American Board of Surgery (ABS) has more than 80 years of both direct and indirect involvement in US surgical education, with its primary role being certification of graduates of Accreditation Council for Graduate Medical Education–approved surgical training programs. The ABS’s impact on education has been at multiple levels, including the development of the content and administration of qualifying and certifying examinations; original education research based on the Board’s unique data sets; and surgical training and education-related initiatives in partnership with multiple regulatory bodies and surgical societies. Within these efforts, by incremental steps, the specialty of vascular surgery attained recognition as a primary specialty of the ABS, and the Vascular Surgery Board of the ABS was established 20 years ago, in 1998. The 2 decades that followed have witnessed significant transformations in the evaluation and treatment of vascular disease, the paradigms for training vascular and endovascular surgeons, and the Vascular Surgery Board has partnered with stakeholder organizations to continually ensure quality education for the evolving vascular surgical workforce. Looking forward, while surgical education remains outside of its primary mission, the ABS and Vascular Surgery Board will continue as key stakeholders and leaders in the complex network of professional societies and training institutions that will guide the evolution of vascular surgery training.

Traditionally, traumatic knee dislocations have been categorized as either high energy, resulting from mechanisms consistent with motor vehicular collisions, or low energy, typical in sports or fall injuries. Ultra low energy, however, describes knee dislocations in patients whose injuries occurred as the result daily living activities. At the University of Mississippi Center (UMMC), a Level I trauma center, we present a case series of five morbidly obese patients treated for popliteal artery injury as a result of injuries sustained during daily activities. Patient 1, a 47-year-old woman with a body mass index (BMI) of 38, fell down a flight of stairs. An alternate facility evaluated her as having an open left posterior knee dislocation with popliteal artery injury. Upon her transfer to UMMC, her leg was warm with the presence of distal arterial doppler signals. The grossly dislocated knee was reduced in the emergency room. After computed tomographic angiography (CTA) revealed a total occlusion of the popliteal artery, she underwent repair using reversed saphenous vein graft approximately eight hours after injury and four hours after arrival at UMMC. External fixation was performed next. Postoperatively, the vein graft occluded and multiple attempts at revascularization were unsuccessful, requiring amputation on postoperative day 8. The remainder of the postoperative course was uncomplicated, and shewas discharged to a physical rehabilitation facility five days later. Patient 2, a 46-year-old woman with a BMI of 48, fell while walking to the bathroom, suffering the same left knee and artery injury. Upon arrival, seven hours after injury, her leg was cold and without distal arterial doppler signals. The knee, grossly dislocated, was immediately reduced but the leg remained pulseless and cool. In the operating room, reconstruction of the popliteal artery with reverse saphenous vein graft was performed. An external fixator was placed after the repair. The postoperative course was complicated by cardiac arrest on postoperative day 6 secondary to aspiration. The graft was patent at the time of death. Patient 3, a 21-year-old woman with a BMI of 52, suffered a right posterior knee dislocation while playing soccer. She was brought from the scene to UMMC and presented with a posterior knee dislocation that was reduced immediately. Distal arterial doppler signals were present despite the lack of a palpable pulse. Arteriography demonstrated a complete occlusion of the popliteal artery. She underwent vascular repair with a reverse saphenous vein graft. The time between injury and repair was five hours. An external fixator was placed after arterial repair. With no postoperative complications, she was discharged home eight days after the operation. Patient 4, a 57-year-old female with a BMI of 45, suffered a left posterior knee dislocation after a fall while emptying trash. The initial hospital reduced the dislocation and obtained a CTA. Upon arrival to UMMC, there was a distal arterial doppler signal. She underwent vascular repair with a reverse saphenous vein graft approximately 19 hours after injury. The knee was stabilized with an external fixator after arterial repair. Postoperation was uncomplicated, and she was discharged to a physical rehabilitation facility 21 days after surgery. Patient 5, a 36-year-old male with a BMI of 46, suffered a posterior knee dislocation after tripping over a watermelon. The knee was reduced at another Presented (by JDS) as a poster at the Southeastern Surgical Congress, Atlanta, GA, February 2009. Address correspondence and reprint requests to Justin L. Hunter, Department of General Surgery, University of South Alabama Division of Acute Care Surgery & Burns, 2451 Fillingim Street, Suite 10-I, Mobile, AL 36617-2293. E-mail: jlhunter@health. southalabama.edu.

Aortopulmonary and aortobronchial fistulas are rare and serious events related to aortic aneurysm, dissection, and pseudoaneurysm. They are often a result of concomitant infection and mandate immediate intervention with endovascular, surgical, and antibiotic treatment. We present a case of an infected aortic pseudoaneurysm with resultant fistulization between the aorta and lung tissue. A 41-year-old female presented with several months of episodic massive hemoptysis requiring blood transfusions and multiple hospitalizations. Bronchoscopy localized the bleeding to the left upper lobe. Past medical history is significant for hypertension, fibrosing mediastinitis, colectomy, and descending thoracic aortic aneurysm repair with homograft. Upon transfer to our hospital, she was stable and had a small amount of hemoptysis. CT angiogram of the chest demonstrated a calcified descending aortic homograft with a small pseudoaneurysm at the proximal anastomosis. The pseudoaneurysm appeared contiguous with a consolidated portion of the apical anterior segment of the left upper lobe. We selected a hybrid management approach consisting of endovascular exclusion of the fistula and tissue transfer interposition between the aorta and the lung. Endovascular coverage of the proximal anastomotic site would exclude the orifice of the left subclavian artery. Therefore, we performed a subclavian-carotid bypass immediately followed by placement of two Gore Tag Endovascular Stents (Gore Tag Thoracic Endoprosthesis, Flagstaff, AZ), extending from the arch of the aorta to a landing site just proximal to the celiac artery. Completion angiogram revealed wellseated endografts with no endoleak and excellent flow through the innominate artery and subclavian carotid bypass. We delayed the tissue transfer to allow sufficient time for any small endoleaks to seal. Ten days later, she underwent the second stage of the operation. A redo laparotomy was performed, and the omentum was harvested as a pedicled flap based off the right gastroepiploic artery. It was passed substernally into the thorax. A redo left thoracotomy was performed. The lung was found to be adherent to the aortic homograft, and dissection demonstrated a 2 to 3 mm anastomotic dehiscence with a fistula to the surface of the lung (Fig. 1 A). There was no bleeding and further dissection of the lung off the aorta revealed an attenuated wall of the homograft with exposed aortic endograft (Fig. 1 B). There was no clear evidence of mycotic aneurysm or active infection. The fistula site and the area of exposed endograft were covered with the omentum, and the exposed lung surface was repaired with chromic sutures (Fig. 2). Complete exclusion of the aortopulmonary fistula was achieved. The patient recovered well from both operations and at three months, follow-up has had no further hemoptysis or signs of infection. Cultures grew Staphylococcus epidermidis on broth and are thought to be a contaminant. The patient was placed on lifelong suppressive antibiotics, given the potential colonization of the endograft by exposure to the pulmonary parenchyma. Aortopulmonary fistula is a rare and serious occurrence necessitating immediate intervention. Frequently, in a complication of aortic aneurysm or dissection, it almost always involves a communication between the aorta and the pulmonary artery. The most common cause is erosion of a false aneurysm of the descending thoracic aorta into the pulmonary artery, but it can also be related to pneumonia or a mycotic aortic aneurysm.1 In addition, these fistulas have been reported to occur after aortic surgery and acute and chronic dissection. Less frequently reported than aortopulmonary fistulas are aortobronchial fistulas. The major causes overlap with those of aortopulmonary fistula: thoracic aortic aneurysm with lung infection, pressure necrosis, atherosclerosis, trauma, and previous vascular surgery. Address correspondence and reprint requests to Danielle J. Brown, B.S., M.S., School of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail: djbrown@umc.edu.

A 74-year-old man was referred to our clinic for evaluation of a suspected thoracic aortic aneurysm. A computed tomography angiogram showed no significant aortic pathology, but a single left renal artery was noted to originate from the posterior aspect of the distal thoracic aorta at the level of the 12th thoracic vertebra, approximately 4 cm cephalad to the celiac axis (Cover). The renal artery coursed through the diaphragmatic crura to the hilum of the left kidney (A and B). The celiac, superior mesenteric, and right renal arteries originated from the normal position on the aorta (C). The patient provided consent for the use of his clinical information for research or case report. The renal arteries are the most variable branches of the abdominal aorta in regard to site of origin and number. A study of >10,000 kidneys found that 72% had single renal arteries, most of which originated from the aorta between the lower third of the first lumbar vertebra and the cranial third of the second lumbar vertebra.1Rushton F.W. Roy W.A. Mitchell M.E. Infrarenal origin of the superior mesenteric artery: implications in endovascular repair of abdominal aortic aneurysm.Vasc Endovascular Surg. 2010; 44: 680-682Crossref PubMed Scopus (3) Google Scholar Accessory renal arteries are occasionally seen up to the level of the diaphragm. Supraceliac renal arteries have been previously described, but a single renal artery arising from the aorta proximal to the level of the superior mesenteric artery is distinctly unusual.1Rushton F.W. Roy W.A. Mitchell M.E. Infrarenal origin of the superior mesenteric artery: implications in endovascular repair of abdominal aortic aneurysm.Vasc Endovascular Surg. 2010; 44: 680-682Crossref PubMed Scopus (3) Google Scholar, 2Garti I. Meiraz D. Ectopic origin of main renal artery.Urology. 1980; 15: 627-629Abstract Full Text PDF PubMed Scopus (21) Google Scholar High take-offs of the renal arteries can be explained by the embryologic development of the kidneys. The kidneys ascend during development, and as this occurs, their blood supply shifts to progressively higher levels. Three mesonephric arteries develop on each side near the first and second lumbar segments and become the suprarenal arteries. The lowest artery usually becomes the definitive renal artery, retaining a suprarenal branch.3Gruenwald P. The normal changes in the position of the embryonic kidney.Anat Rec. 1943; 85: 163-176Crossref Scopus (14) Google Scholar If one of the upper mesonephric arteries persists, a high ectopic main renal artery results.1Rushton F.W. Roy W.A. Mitchell M.E. Infrarenal origin of the superior mesenteric artery: implications in endovascular repair of abdominal aortic aneurysm.Vasc Endovascular Surg. 2010; 44: 680-682Crossref PubMed Scopus (3) Google Scholar Persistence of multiple mesonephric arteries results in the development of supernumerary renal arteries. Knowledge of the presence and location of ectopic or multiple renal arteries is of particular importance when planning endovascular and open aortic procedures. Download .docx (.34 MB) Help with docx files Cover

BACKGROUND: Unexpected clinical deterioration (failure events) in surgical patients on standard nursing units (WARDs) could have a significant impact on eventual survival. We sought to investigate failure events requiring intensive care (surgical ICU [SICU]) transfer of surgical patients on WARDs in a single-center academic setting. STUDY DESIGN: Surgical patients admitted to WARDs over a 12-month period, who developed failure events, were retrospectively reviewed. Time to deterioration since WARD arrival, clinical factors, notification chain, and outcomes were identified. A physician review panel determined the preventability of failure events. RESULTS: Ninety-eight patients experienced 111 failure events requiring SICU transfer. Most patients (85%) were emergency admissions. Of 111 events, 90% had been previously discharged from an SICU or a postanesthesia care unit (PACU). Recognition of failure was by nursing (54%) and on routine physician rounds (34%). Rapid response or code blue alone was less common (12%). A second physician notification was needed in 29%, with delays due to failure to identify severity of illness. Most commonly, respiratory events prompted notification (77 of 111, 69%). Overall mortality was 26 of 98 (27%). Median time to failure was 2 days and was associated with early transfer from the SICU or PACU. Rapid response or code blue activation was associated with higher mortality than physician notification. CONCLUSIONS: Patients most at risk for WARD failures were those with acute surgical emergencies or recently discharged from the SICU or PACU. Respiratory complications were the most common cause of WARD failure events. Many early failures may have been due to premature transfer from the SICU or PACU. Failure events on WARDs can have lethal consequences. Awareness, monitoring, and communication are important components of preventative measures.

Wound size impacts the threshold between scarless regeneration and reparative healing in the fetus with increased inflammation showed in fetal scar formation. We hypothesized that increased fetal wound size increases pro-inflammatory and fibrotic genes with resultant inflammation and fibroplasia and that transition to scar formation could be reversed by overexpression of interleukin-10 (IL-10). To test this hypothesis, 2-mm and 8-mm dermal wounds were created in mid-gestation fetal sheep. A subset of 8-mm wounds were injected with a lentiviral vector containing the IL-10 transgene (n=4) or vehicle (n=4). Wounds were harvested at 3 or 30 days for histology, immunohistochemistry, analysis of gene expression by microarray, and validation with real-time polymerase chain reaction. In contrast to the scarless 2-mm wounds, 8-mm wounds showed scar formation with a differential gene expression profile, increased inflammatory cytokines, decreased CD45+ cells, and subsequent inflammation. Lentiviral-mediated overexpression of the IL-10 gene resulted in conversion to a regenerative phenotype with decreased inflammatory cytokines and regeneration of dermal architecture. In conclusion, increased fetal wounds size leads to a unique gene expression profile that promotes inflammation and leads to scar formation and furthermore, these results show the significance of attenuated inflammation and IL-10 in the transition from fibroplasia to fetal regenerative healing.

Objective: Retrievable inferior vena cava (IVC) filters are appealing because they are designed for either retrieval or long-term use. However, the long-term safety of indwelling retrievable compared with permanent filters is largely unknown. This study was undertaken to compare complication rates and types associated with indwelling retrievable and permanent filters.Methods: A retrospective review identified 1234 IVC filters (449 retrievable, 785 permanent) placed in 1225 patients from 2005 to 2010. Patients with retrievable filters removed electively were excluded, yielding 383 patients in whom retrievable filters were left in place. These patients with indwelling retrievable filters were compared with those with permanent filters with respect to demographics, comorbidities, survival, and complication rate and type. Differences in patient characteristics were tested with chi(2), Fisher exact, and Wilcox rank-sum tests. Logistic regression was used to identify predictors of complications. Because there were differences in the characteristics of the patients with indwelling retrievable filters and permanent filters, an additional propensity score analysis was performed yielding 319 patients in each group.Results: Patients with indwelling retrievable filters were younger than those with permanent filters (mean age, 62 vs 75 years; P<.0001). Patients with indwelling retrievable filters had significantly more complications than those with permanent filters (9% vs 3.0%; P<.0001) after mean follow-up of 20 months (range, 0-86 months). Filter complications were categorized as thrombotic, device related, or systemic. While the most common complication type with both indwelling retrievable and permanent filters was thrombotic (4.4% vs 2.2%; P = NS), device related complications were significantly more common with indwelling retrievable filters compared with permanent filters (3% vs 0.5%; P<.006). Propensity score analysis demonstrated that even in the matched groups, indwelling retrievable filters were associated with significantly more complications than permanent filters (9.1% vs 3.5%; P=.0035).Conclusions: Indwelling retrievable IVC filters were associated with significantly higher complication rates than permanent filters. Both thrombotic and device-related complications were more common with retrievable filters. Long-term use of retrievable filters should be avoided, especially considering the younger population in whom they are placed.

The approach of the Department of Surgery at the University of Mississippi to the education of medical students is considerably different from that of earlier eras. An overview of the current strategies for medical student education adopted by the Department in recent years and the philosophies behind them is presented.

To examine the associations of peripheral atherosclerosis, assessed by the ABI at baseline with the extent of AAC and with CAC measured by MDCT at follow-up examination in the Jackson Heart Study cohort. Four categories of ABI: <0.90, 0.90–0.99, 1.00–1.39; >1.40. Presence of CAC/AAC was defined as scoring above the 75th percentile among participants with non-zero CT calcium scores. We conducted multivariable log-binomial models for this analysis examining the relationship between ABI and the presence of CAC or AAC using normal ABI (1.0 ≤ ABI ≤ 1.39) as the reference group. We estimated prevalence ratios adjusted for age, smoking, HTN, DM, BMI, LDL, HDL, CRP, systolic and diastolic blood pressure, and use of lipid-lowering medication. There were 2,398 patients in this analysis (women: 65 %, average age 55 years). AAC scores were not significantly different between sex. CAC scores were significantly higher in males than females regardless of ABI groups. The prevalence of significant AAC was 1.7 times higher for ABI < 0.90 (PR = 1.70; 95 % CI = 1.26–2.28; p = 0.0004) and 1.57 times higher for ABI 0.90–0.99 (PR = 1.57; 95 % CI = 1.20–2.03; p = 0.0008) than the normal ABI; AAC prevalence did not differ between subjects with ABI > 1.40 compared to those with normal ABI. The prevalence of the significant CAC was higher for ABI < 0.90 (PR = 1.55; 95 % CI = 1.12–2.14; p value = 0.0081) and ABI 0.90–0.99 (PR = 1.60; 95 % CI = 1.05–2.46; p = 0.0402) compared to normal ABI; CAC prevalence did not differ between subjects with ABI > 1.40 compared to those with normal ABI. Lower ABI was significantly associated with the extent of AAC and CAC in this cohort. ABI can provide clinicians with an inexpensive additional tool to assess vascular health and cardiovascular risk without exposing the patient to ionizing radiation.

The impairment in diabetic wound healing represents a significant clinical problem. Chronic inflammation is thought to play a central role in the pathogenesis of this impairment. We have previously shown that treatment of diabetic murine wounds with mesenchymal stem cells (MSCs) can improve healing, but the mechanisms are not completely defined. MicroRNA-146a (miR-146a) has been implicated in regulation of the immune and inflammatory responses. We hypothesized that abnormal miRNA-146a expression may contribute to the chronic inflammation. To test this hypothesis, we examined the expression of miRNA-146a and its target genes in diabetic and nondiabetic mice at baseline and after injury. MiR-146a expression was significantly downregulated in diabetic mouse wounds. Decreased miR-146a levels also closely correlated with increased gene expression of its proinflammatory target genes. Furthermore, the correction of the diabetic wound-healing impairment with MSC treatment was associated with a significant increase in the miR-146a expression level and decreased gene expression of its proinflammatory target genes. These results provide the first evidence that decreased expression of miR-146a in diabetic wounds in response to injury may, in part, be responsible for the abnormal inflammatory response seen in diabetic wounds and may contribute to wound-healing impairment.

Ectopic liver is defined as liver parenchyma situated outside the liver proper with no connection to native hepatic tissue. This rare developmental anomaly is most commonly described as an attachment to the gallbladder with an incidence <0.3%, but it has been reported in other locations within the abdomen and thorax.(2-4) Most cases are found incidentally in asymptomatic patients, but ectopic liver has been known to cause visceral or vascular obstruction.(4,5) Herein we present a unique case of ectopic liver attached by a thin stalk seemingly floating in the suprahepatic inferior vena cava. (J Vasc Surg 2012;55:1759-61.)