Spontaneous iliac vein rupture resulting in a retroperitoneal hematoma is extremely rare and can present as a life-threatening emergency. There is often a delay in diagnosis with no established treatment recommendations. We report the case of a 39-year-old woman who presented with hypovolemic shock, a large left retroperitoneal hematoma, and left lower extremity phlegmasia in the setting of a previously asymptomatic May-Thurner syndrome. She was successfully treated with a combined open and endovascular approach. We also reviewed the literature on the evolution of diagnosis and treatment of this rare condition and present our recommendations for management.

A 56-year-old man with a family history of aortic aneurysm underwent routine repair in 2003. A postoperative computed tomography scan showed a 6-cm perigraft hygroma. Sudden onset of abdominal pain 12 months later revealed a larger hygroma, with an additional anterior fluid collection suggestive of contained rupture. The bilobed hygroma remained stable until 2010, when he presented with chills and severe abdominal pain. A computed tomography scan demonstrated free rupture of the sister hygroma, with air pockets observed within the sac. Conservative management was elected. Air pockets as well as the hygroma eventually resolved, and the patient remains well.

We evaluated the safety of suprarenal aortic clamping in patients with abdominal aortic aneurysm (AAA) treated by open aortic replacement by retrospectively reviewing all patients who underwent elective AAA replacement at a university hospital from 1993 until 2003. We reviewed 249 patient charts and divided them into three groups according to the clamp location during aortic replacement: group 1, infrarenal clamp group (n = 185); group 2, suprarenal clamp group (n = 52); and group 3, supraceliac clamp group (n = 12). Groups 1 and 2 were compared with respect to risk factors, intraoperative events, and postoperative events. Statistical analysis was done using Wilcoxon's rank-sum test, chi-squared test, and Fisher's exact test. Risk factors were comparable in groups 1 and 2 except for weight, which was higher in group 1. Intraoperative urine output, hypotensive episodes, and use of renal protective drugs were comparable in the two groups. Operation time, blood loss, and use of IV fluids were all significantly higher in group 2, while total aortic clamp time was higher in group 1. Postoperative events were comparable except for postoperative peak creatinine, intensive care unit length of stay, and postoperative length of stay, which were higher in group 2; however, discharge creatinine was comparable without a significant difference. Suprarenal clamping is a safe method of aortic control during open AAA replacement surgery. The selection of clamping site should be individualized according to the intraoperative anatomy. Supraceliac clamping is not necessarily the preferable method of aortic control when the infrarenal location is not suitable for clamping.

Evaluamos la seguridad del clampaje aórtico suprarrenal en los pacientes con aneurisma aórtico abdominal (AAA) tratados mediante sustitución aórtica abierta revisando de forma retrospectiva todos aquellos sometidos a una corrección del AAA programada en un hospital universitario desde el año 1993 hasta el 2003. Revisamos las historias clínicas de 249 pacientes y los dividimos en 3 grupos según la localización del clampaje durante la sustitución aórtica: grupo 1, clampaje infrarrenal (n = 185); grupo 2, clampaje suprarrenal (n = 52); y grupo 3, clampaje supracelíaco (n = 12). Se compararon los grupos 1 y 2 con respecto a los factores de riesgo, los sucesos intraoperatorios, y los sucesos postoperatorios. Se realizó el análisis estadístico utilizando el test de la suma de los rangos de Wilcoxon, el test chi-cuadrado, y el test exacto de Fisher. Los factores de riesgo fueron comparables en los grupos 1 y 2 a excepción del peso, que fue más elevado en el grupo 1. La diuresis intraoperatoria, los episodios de hipotensión, y el uso de protectores renales fueron comparables en ambos grupos. La duración de la cirugía, la pérdida de sangre, y el uso de fluidos endovenosos fueron significativamente más altos en el grupo 2, en cambio el tiempo total de clampaje aórtico fue más alto en el grupo 1. Los sucesos postoperatorios fueron comparables exceptuando los niveles plasmáticos postoperatorios máximos de creatinina, la duración de la estancia en cuidados intensivos, y la estancia hospitalaria, que fueron más elevados en el grupo 2; sin embargo, la concentración de creatinina al alta hospitalaria fue comparable sin que existiese una diferencia significativa. El clampaje suprarrenal es un método seguro de control aórtico durante la cirugía abierta de sustitución de AAA. La selección del lugar del clampaje debe individualizarse en función de la anatomía intraoperatoria. El clampaje supracelíaco no es necesariamente el método preferible de control aórtico cuando la localización infrarrenal no es adecuada para el control aórtico.

Nous avons évalué la sûreté du clampage de l'aorte supra-rénale chez les malades ayant un anévrysme de l'aorte abdominale (AAA) traité par remplacement aortique chirurgical en étudiant rétrospectivement tous les malades ayant eu le remplacement électif d'un AAA dans un hôpital universitaire entre 1993 et 2003. Nous avons étudié 249 dossiers de malades et les avons divisés en trois groupes suivant la localisation du clampage au cours du remplacement aortique : groupe I clampage sous-rénal (n = 185); groupe II clampage supra-rénal (n = 52); et groupe III clampage supra-cœliaque (n = 12). Les groupes I et II ont été comparés en ce qui concerne les facteurs de risque et les événements per et post-opératoires. L'analyse statistique a été faite en utilisant un test de Wilcoxon, un test du χ2 et un test exact de Fisher. Les facteurs de risque étaient comparables dans les groupes I et II sauf le poids, plus élevé dans le groupe I. La diurèse per-opératoire, des épisodes d'hypotension artérielle et l'utilisation de drogues néphro-protectrices étaient comparables dans les deux groupes. La durée de l'intervention, les pertes sanguines et l'utilisation de fluides intra-veineux étaient toutes significativement plus élevées dans le groupe II, alors que la durée totale du clampage aortique était plus importante dans le groupe I. Les événements post-opératoires étaient comparables sauf le pic de créatininémie post-opératoire, la durée de séjour en unité de soins intensifs et la durée de séjour post-opératoire, qui étaient plus importants dans le groupe II. Cependant, la créatininémie lors de la sortie était comparable, sans différence significative. Le clampage supra-rénal est une méthode sûre de contrôle aortique au cours de la chirurgie conventionnelle des AAA. La sélection du site de clampage doit être individualisée suivant l'anatomie per-opératoire. Le clampage supra-cœliaque n'est pas nécessairement la méthode préférable de contrôle aortique lorsqu'un clampage sous-rénal n'est pas possible.

BACKGROUND:Professionalism assessment has become necessary for all postgraduate training programs because it is now required for accreditation. To validate the novel items we generated to assess professionalism, we tested whether residents' ratings of faculty they judged as outstanding in professionalism would be distinguishable from those they judged as not outstanding.METHODS:Educators from core clinical disciplines generated 20 items assessing professionalism behaviors on a 7-point frequency scale anchored by "always" and "never." Thirty-five surgical and pediatric residents completed the form twice, anonymously rating 1 faculty member they judged as outstanding and another they judged as not outstanding.RESULTS:The residents produced 69 faculty ratings with means that differed significantly on all items between the outstanding and not-outstanding faculty. The form was highly unidimensional, with the primary factor's eigenvalue being 11.5 and Cronbach's alpha being 0.97. Groups differed most on items, ie, "listens well," "inspires trust," "answers questions directly," and "demonstrates respect for all."CONCLUSION:The behaviors that best distinguished clinical faculty judged by residents as outstanding professionals were listening, trustworthiness, answering directly, and respect.

PURPOSE:The purpose of this study was to evaluate the role of balloon angioplasty in the treatment of failing infrainguinal vein bypass (IVB) grafts.METHODS:A retrospective chart review of patients undergoing revision of a failing IVB graft by vascular surgeons at a tertiary care center from 1990 to 2001 was performed. Failing bypass grafts were identified by routine duplex scan surveillance and physical examination. The criteria for endovascular intervention varied on the basis of surgeon preferences and time period; factors considered when choosing balloon angioplasty included significant comorbidities that precluded operative intervention, the lack of adequate conduit for surgical revision, or poor accessibility of the stenotic lesion. Data recorded included demographic patient data, type of IVB graft, patency status, further procedures performed, and all complications and mortalities. Cumulative primary and assisted patency rates were calculated by using Kaplan-Meier life-table analysis.RESULTS:A total of 45 balloon angioplasties were performed in 36 patients. There were 36 angioplasties of vein bypass grafts, and additional balloon angioplasties were performed on nine of these patients. Locations of IVB grafts included femoropopliteal (13 patients), femorodistal (13), and popliteal to distal (10). Initial success was achieved in 33 of 36 vein bypass grafts (91.7%). In these bypass grafts, the stenotic lesions were identified and treated at the proximal anastomosis (3 patients), mid-bypass graft (6 patients), and distal anastomosis (27 patients). Autogenous vein was used for all bypass grafts. Cumulative vein bypass graft (life-table analysis) primary patency rates (those free of occlusion or bypass graft threatening stenosis) were 74.2% at 6 months, 62.7% at 12 months, and 58.2% at 24 months. Repeat interventions included surgical thrombectomy with vein patch angioplasty or bypass graft revision, as well as repeat balloon angioplasty with or without thrombolysis. Cumulative assisted vein bypass graft patency rates (those free of occlusion or bypass graft threatening stenosis) were 87.0%, 83.2%, and 78.9% at 6, 12, and 24 months, respectively. Two patients (4%) developed thigh hematomas; no other procedure-related complications were noted, and there were no deaths in the perioperative period.CONCLUSION:Balloon angioplasty of failing infrainguinal vein bypass grafts can be successfully performed with a low rate of complications. Acceptable short-term patency can be achieved. This procedure should be considered as an initial option in failing IVB grafts.

Thromboembolic disease occurs in a heterogeneous group of patients with significant co-morbidities and variable presentations, resulting in high morbidity and mortality rates. To decrease these complications, multiple different endovascular modalities have been developed and used to treat this challenging problem. Physicians are now left with a broad array of endovascular and surgical options. Unfortunately, there are little data that accurately compare these modalities. Therefore, an individual approach to each patient with acute ischemia from thromboembolic disease must be employed. In order to tailor the treatment to the needs of each patient, the physician must be familiar with the techniques, complications, technology, and relative strengths and weaknesses of each treatment modality. This article will first outline the main technical considerations for performing surgical thromboembolectomy. The complications of operative thromboembolectomy will then be discussed followed by the data comparing operative and nonoperative therapy. Finally, clinical scenarios that are best treated by surgical intervention will be described.

The management of acute mesenteric ischemia in the contaminated abdomen may require the use of an autogenous graft to achieve mesenteric revascularization. The authors present a case of an ischemic small bowel perforation in a 62-year-old-woman whose preoperative angiogram demonstrated occlusion of the celiac, superior mesenteric, and inferior mesenteric arteries. Vein mapping of the right greater saphenous vein demonstrated a dual saphenous system whose individual diameters were more than 4 millimeters. Exploratory laparotomy revealed a diffusely ischemic small bowel and liver, as well as abdominal sepsis from the perforated small bowel. Revascularization was accomplished by using saphenous vein in a nonreversed orientation as a bifurcated conduit from the supraceliac aorta to the hepatic and superior mesenteric arteries. Following revascularization, the liver and small bowel immediately regained a normal perfused appearance and the perforated segment of small bowel was resected and reanastomosed. She returned for a follow-up clinic visit 5 months later and was found to have an asymptomatic 6 cm aneurysm involving the proximal mesenteric vein bypass. The aneurysmal aspect of the vein bypass was replaced with a polytetrafluoroethylene interposition graft originating from the supraceliac aorta. On follow-up 3 months later, her aortomesenteric bypass is patent without aneurysmal recurrence, and she is clinically asymptomatic from any symptoms of mesenteric ischemia.

The purpose of this study was to review the long-term outcomes, particularly patient satisfaction, of patients surgically treated for thoracic outlet syndrome (TOS). All patients who had undergone surgery for TOS at the University of Iowa Hospitals and Clinics between 1988 and 1999 were reviewed. A retrospective chart review of 29 patients (36 operations) was performed. In addition, 20 (69%) of the patients were able to be contacted for a phone survey. There was no operative mortality. Specific neurologic complications occurred in 4/36 operations (11%) including one brachial plexus traction palsy, two phrenic nerve palsies, and one long thoracic nerve palsy. All nerve palsies were either mild or temporary. Mean follow-up was 4 years. On phone survey, 80% of the patients were actively employed. Twenty-seven percent reported that they had an excellent result, 58% reported they had a good result, 8% reported that they had a fair result, and 8% had a poor result. If they had it to do over again, 85% of the patients would have the same surgery again for relief of TOS.

A case of trilobar pulmonary mucormycosis in a diabetic patient with severe obstructive pulmonary disease, successfully treated with systemic antifungal therapy and complete video-assisted thoracic surgery (VATS) resection, is presented. The VATS approach permitted accurate diagnosis and definitive therapy using lung-sparing techniques in a minimally invasive manner.

A 6-year-old girl, postnephrectomy for a Wilms tumor, demonstrated a recurrence involving the liver and inferior vena cava by ultrasound. Reoperation for removal of the recurrence required further resection and a bypass using an ascending lumbar collateral as an outflow vessel.

Ten years after placement of a thoracofemoral graft for aortoiliac occlusive disease, a mid graft pseudoaneurysm was identified following new trauma to the left flank. An aortogram confirmed the pseudoaneurysm. An initial attempt at repair with an endovascular stent failed; an open repair was required.

Abdominal aortic aneurysm (AAA) is an inflammatory disorder characterized by localized connective tissue degradation and smooth muscle cell (SMC) apoptosis, leading to aortic dilatation and rupture. Reactive oxygen species are abundantly produced during inflammatory processes and can stimulate connective tissue-degrading proteases and apoptosis of SMCs. We hypothesized that reactive oxygen species are locally increased in AAA and lead to enhanced oxidative stress. In aortas from patients undergoing surgical repair, superoxide levels (measured by lucigenin-enhanced chemiluminescence) were 2.5-fold higher in the AAA segments compared with the adjacent nonaneurysmal aortic (NA) segments (6638+/-2164 versus 2675+/-1027 relative light units for 5 minutes per millimeter squared, respectively; n=7). Formation of thiobarbituric acid-reactive substances and conjugated dienes, 2 indices of lipid peroxidation, were increased 3-fold in AAA compared with NA segments. Immunostaining for nitrotyrosine was significantly greater in AAA tissue. Dihydroethidium staining indicated that increased superoxide in AAA segments was localized to infiltrating inflammatory cells and to SMCs. Expression of the NADPH oxidase subunits p47(phox) and p22(phox) and NAD(P)H oxidase activity were increased in AAA segments compared with NA segments. Thus, oxidative stress is markedly increased in AAA, in part through the activation of NAD(P)H oxidase, and may contribute to the disease pathogenesis.