Successful treatment of endotension and aneurysm sac enlargement with endovascular stent graft reinforcement

Abdominal aortic aneurysm (AAA) enlarges after successful endovascular repair because of endoleak, which is persistent blood flow within the aneurysm sac. In the absence of detectable endoleak, AAA may still expand, in part because of endotension, which is persistent pressurization within the excluded aneurysm. We report three patients who underwent successful endovascular AAA repair using the Excluder device (W. L. Gore & Associates, Flagstaff, Ariz). Although their postoperative surveillance showed an initial aneurysm regression, delayed aneurysm enlargement developed in all three, apparently due to endotension. Endovascular treatment was performed in which endograft reinforcement with a combination of aortic cuff and iliac endograft extenders were inserted in the previously implanted stent grafts. The endograft reinforcement procedure successfully resulted in aneurysm sac regression in all three patients. Our study underscores the significance of increased graft permeability as a mechanism of endotension and delayed aneurysm enlargement after successful endovascular AAA repair. In addition, our cases illustrate the feasibility and efficacy of an endovascular treatment strategy when endotension and aneurysm sac enlargement develops after endovascular AAA repair

Impact of metabolic syndrome on the outcomes of superficial femoral artery interventions

BackgroundMetabolic syndrome (MetSyn) is an epidemic in the United States and is associated with early onset of atherosclerosis, increased thrombotic events, and increased complications after cardiovascular intervention. MetSyn is found in ∼50% of patients with peripheral vascular disease. However, its impact on peripheral interventions is unknown. The aim of this study is to determine the outcomes of superficial femoral artery (SFA) interventions in patients with and without MetSyn.MethodsA database of patients undergoing endovascular treatment of SFA disease between 1999 and 2009 was retrospectively queried. MetSyn was defined as the presence of ≥3 of the following criteria: blood pressure ≥130 mm Hg/≥85 mm Hg; triglycerides ≥150 mg/dL; high-density lipoprotein ≤50 mg/dL for women and ≤40 mg/dL for men; fasting blood glucose ≥110 mg/dL; or body mass index ≥30 kg/m2. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables.ResultsA total of 1018 limbs in 738 patients (64% male, average age 67 years) underwent endovascular treatment for symptomatic SFA disease with 45% of patients meeting the criteria for MetSyn. MetSyn patients were more likely to be female (P = .001), to present with critical ischemia (rest pain/tissue loss: 55% MetSyn vs 45% non-MetSyn; P = .001), have poorer ambulatory status (P = .001), and have more advanced SFA lesions (TransAtlantic Inter-Society Consensus II C/D: 51% vs 11%; P = .001) and worse tibial runoff (P = .001). MetSyn patients required more complex interventions (P = .0001). There was no difference in mortality and major adverse cardiac events, but systemic complications (4% vs 1%; P = .001) and major adverse limb events (12% vs 7%; P = .0009) were significantly higher in the MetSyn group. Immediate postprocedural hemodynamic improvement, resolved or improved symptoms, and restoration of impaired ambulation were equivalent in both groups. Early failure (<6 months) was more common in those with MetSyn. At 5 years, primary, assisted primary, and secondary patencies were not affected by the presence of MetSyn. The presence of MetSyn was associated with a decrease in clinical efficacy, decreased freedom from recurrent symptoms, and decreased freedom from major amputation at 5 years.ConclusionsMetSyn is present in nearly half of the patients presenting with SFA disease. These patients present with more advanced disease and have poorer symptomatic and functional outcomes compared with those patients without MetSyn

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10&nbsp;years; 78.2% included were male with a median age of 37&nbsp;years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Whatâs the clinical significance of adding diffusion and perfusion MRI in the differentiation of glioblastoma multiforme and solitary brain metastasis?

Objective: To evaluate the additional diagnostic value of diffusion and perfusion MRI in the differentiation of glioblastoma multiforme (GBM) and solitary brain metastasis. Patients and methods: This retrospective study included 24 patients with histologically proven brain tumors who underwent conventional MRI with analysis of diffusion (DWI) and perfusion (PWI) MRI findings of each tumor. The Apparent Diffusion Coefficient (ADC) values were calculated in the minimum (ADC-MIN), mean (ADC-MEAN), and maximum (ADC-MAX) in all the tumors and the peritumoral regions. The PWI data was expressed as maximum regional cerebral blood volume (rCBV) of the tumors and peritumoral regions. Results: After adding diffusion and perfusion to conventional MRI findings, we found that the accuracy of differentiation between glioblastoma multiforme (GBM) and solitary metastasis increased from 70% to 90%.There is a significant difference in DWI signal intensity between GBM and metastatic tumors (P < 0.05). The ADC values of GBM were lower than that of metastatic tumors. On perfusion MRI, the maximum rCBV of the peritumoral region (rCBVP) of GBM was higher than that of brain metastases (P < 0.001). Conclusion: The addition of diffusion and perfusion to the MRI protocol increases the accuracy of differentiation between GBM and solitary brain metastasis and should be considered routinely. Keywords: Diffusion MRI, Perfusion MRI, GBM, Solitary brain metastase

Traumatic carotid artery dissection caused by bungee jumping

Bungee jumping is a popular recreational activity in which participant experiences transient freefall while connected to a bungee cord. The rapid freefall and the resultant rebound force created by the bungee cord can result in a variety of bodily injuries. We report herein a case of traumatic carotid artery dissection caused by bungee jumping. The symptoms related to carotid artery dissection were successfully treated with anticoagulation. The etiology of carotid dissection related to bungee jumping is discussed. Physicians should be cognizant of this potential injury due to the force created by the freefall and rebound motion associated in this recreational sport