Ariel - Volume 11 Number 4

Executive Editor Ellen Feldman Leonardo S. Nasca, Jr. Business Managers Barbara L. Davies Martin B. Getzow News Editor Hugh A. Gelabert Features Editor Aaron D. Bleznak CAHS Editor Joan M. Greco Editorial Page Editor Samuel Markind Photography Editor Todd L. Demmy Sports Editor Paul F. Mansfiel

Cystic adventitial disease of the popliteal artery: features on 3T cardiovascular magnetic resonance

Cystic adventitial disease (CAD) of the popliteal artery is a rare vascular disease of unknown etiology in which a mucin-containing cyst develops in the adventitial layer of the artery. We report the case of a 26-year-old male with CAD of the right popliteal artery diagnosed non-invasively with 3 Tesla cardiovascular magnetic resonance and confirmed on post-operative histopathology

Endovenous ablation of incompetent perforating veins is effective treatment for recalcitrant venous ulcers

ObjectivesEndovenous closure of incompetent saphenous veins has been reported to facilitate venous ulcer healing; however, there is little information about the effectiveness of perforator ablation (PA) in healing recalcitrant venous ulcers. We report our experience with PA with venous ulcers unresponsive to prolonged compression therapy.MethodsPatients with nonhealing venous ulcers of >3 months' duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Patients who had either no saphenous incompetence or persistent ulcers after saphenous ablation underwent PA of incompetent perforating veins >3 mm that demonstrated reflux; initial treatment was performed on the perforator vein adjacent to the ulcer with additional incompetent veins treated if ulcer healing failed.ResultsSeventy-five ulcers with 86 associated incompetent perforating veins were treated with PA in 45 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (61%), calf (37%), and lateral ankle (2%). Initial success of PA, assessed by postprocedure duplex ultrasound, was 58%; repeat ablation was 90% successful and 71% had eventual successful perforator closure. No complications (skin necrosis, infection, or nerve injury) occurred. Failure of ulcer healing with successful perforator closure occurred in 10% and was due to intercurrent illness, patient noncompliance, and patient death due to unrelated causes. Of patients who healed their ulcers, the healing occurred at a mean of 138 days; an average PA of 1.5 incompetent veins per ulcer was required for healing. Ninety percent of ulcers healed when at least one perforator was closed; no ulcer healed without at least one perforator being closed.ConclusionsThis experience demonstrates both the feasibility and effectiveness of PA for a selected group of patients with venous ulcers who fail conventional therapy with compression

Cigarette smoking increases the development of intimal hyperplasia after vascular injury

Purpose: Our purpose was to determine whether exposure to cigarette smoke increases the development of intimal hyperplasia (IH) after vascular injury.Methods: Sixteen adult male Sprague-Dawley rats underwent standardized balloon catheter injury of the left common carotid artery. For 4 weeks before and 4 weeks after injury, animals in the experimental group (n=8) were exposed to cigarette smoke with an automated vacuum pump device. Animals in the control group (n=8) were restrained in the smoking device for an identical amount of time and underwent arterial injury at 4 weeks but were not exposed to cigarette smoke. Carotid arteries were perfusion-fixed in vivo, prepared as histologic cross sections, and stained for elastin. IH was measured by planimetry and is reported both as the absolute area of IH and as the ratio (IH/IEL) of the absolute area of IH to the normalized area enclosed by the internal elastic lamina (expressed as a percent).Results: The absolute area of IH was 2.09±0.34 for the experimental group compared with 0.94±0.25 for the control group; mean IH/IEL was 43.7%±7.1% for the experimental group versus 17.7%±4.7% for the control group (p<0.05, two-tailed unpaired t test).Conclusions: Inhalation of cigarette smoke increases the development of intimal hyperplasia in a rat model of balloon catheter arterial injury

Ariel - Volume 11 Number 1

Executive Editors Ellen Feldman Leonardo S. Nasca, Jr. Business Managers Barbara L. Davies Martin B. Getzow News Editor Aaron D. Bleznak Features Editor Dave Van Wagoner CAHS Editor Joan M. Greco Editorial Page Editor Samuel Markind Photography Editor Leonardo S. Nasca, Jr. Sports Editor Paul F. Mansfiel

A multi-institutional experience in adventitial cystic disease

AbstractBackgroundAdventitial cystic disease (ACD) is an unusual arteriopathy; case reports and small series constitute the available literature regarding treatment. We sought to examine the presentation, contemporary management, and long-term outcomes using a multi-institutional database.MethodsUsing a standardized database, 14 institutions retrospectively collected demographics, comorbidities, presentation/symptoms, imaging, treatment, and follow-up data on consecutive patients treated for ACD during a 10-year period, using Society for Vascular Surgery reporting standards for limb ischemia. Univariate and multivariate analyses were performed comparing treatment methods and factors associated with recurrent intervention. Life-table analysis was performed to estimate the freedom from reintervention in comparing the various treatment modalities.ResultsForty-seven patients (32 men, 15 women; mean age, 43 years) were identified with ACD involving the popliteal artery (n = 41), radial artery (n = 3), superficial/common femoral artery (n = 2), and common femoral vein (n = 1). Lower extremity claudication was seen in 93% of ACD of the leg arteries, whereas patients with upper extremity ACD had hand or arm pain. Preoperative diagnosis was made in 88% of patients, primarily using cross-sectional imaging of the lower extremity; mean lower extremity ankle-brachial index was 0.71 in the affected limb. Forty-one patients with lower extremity ACD underwent operative repair (resection with interposition graft, 21 patients; cyst resection, 13 patients; cyst resection with bypass graft, 5 patients; cyst resection with patch, 2 patients). Two patients with upper extremity ACD underwent cyst drainage without resection or arterial reconstruction. Complications, including graft infection, thrombosis, hematoma, and wound dehiscence, occurred in 12% of patients. Mean lower extremity ankle-brachial index at 3 months postoperatively improved to 1.07 (P < .001), with an overall mean follow-up of 20 months (range, 0.33-9 years). Eight patients (18%) with lower extremity arterial ACD required reintervention (redo cyst resection, one; thrombectomy, three; redo bypass, one; balloon angioplasty, three) after a mean of 70 days with symptom relief in 88%. Lower extremity patients who underwent cyst resection and interposition or bypass graft were less likely to require reintervention (P = .04). One patient with lower extremity ACD required an above-knee amputation for extensive tissue loss.ConclusionsThis multi-institutional, contemporary experience of ACD examines the treatment and outcomes of ACD. The majority of patients can be identified preoperatively; surgical repair, consisting of cyst excision with arterial reconstruction or bypass alone, provides the best long-term symptomatic relief and reduced need for intervention to maintain patency

International Multi-Institutional Experience with Presentation and Management of Aortic Arch Laterality in Aberrant Subclavian Artery and Kommerell's Diverticulum

Background: Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch. Methods: Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions. Results: 288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change. Conclusions: In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality

Adolescent athletes can get back in the game after surgery for thoracic outlet syndrome

ObjectiveWe compared the functional outcomes among adolescent athletes with venous thoracic outlet syndrome (VTOS) and neurogenic TOS (NTOS) after thoracic outlet decompression.MethodsWe performed a single-institution retrospective review of a prospective database of adolescent athletes (aged 13-19&nbsp;years) from June 1, 1996 to December 31, 2021 who had undergone operative decompression for TOS. The demographic data, preoperative symptoms, operative details, and postoperative outcomes were compared. The primary outcome was the postoperative return to sport. The secondary outcomes included symptom resolution and assessment of the somatic pain scale, QuickDASH, and Derkash scores. The Fisher exact test and t test were used to evaluate the categorical and continuous variables, respectively. A logistic regression model was constructed to adjust for the influence of preoperative factors and return to sport.ResultsA total of 60 patients (40.0% with VTOS and 60.0% with NTOS) were included. The average age of the VTOS patients was 17.2&nbsp;years vs 16.6&nbsp;years for the NTOS patients (P&nbsp;= .265). The NTOS patients were more likely to be female (88.9% vs 62.5%; P&nbsp;= .024). The NTOS patients had more frequently presented with pain (97.2% vs 70.8%; P&nbsp;= .005), paresthesia (94.4% vs 29.1%; P&nbsp;= .021), and weakness (67.7% vs 12.5%; P&nbsp;= .004) but had less often reported swelling (25.0% vs 95.8%; P&nbsp;&lt; .001). At presentation, the NTOS patients had also reported a longer symptom duration (17.7&nbsp;months vs 3.1&nbsp;months; P&nbsp;&lt; .001). Transaxillary first rib resection with subtotal scalenectomy was performed for 100% of the VTOS patients and 94.4% of the NTOS patients undergoing cervical rib resection (2.8%) or scalenectomy alone (2.8%). Additionally, 11.1% of the NTOS patients had undergone combined first rib resection and cervical rib resection. For the VTOS patients, postoperative venography showed patent subclavian veins in 27.8%. In addition, 44.4% had required venoplasty, 16.8% had required thrombolysis, and 11% were chronically occluded. No significant differences were found in blood loss, operative time, or length of stay between the groups. No surgical complications occurred. The average follow-up was 6.3&nbsp;months. Significant differences were found between the VTOS and NTOS groups for the pre- and postoperative somatic pain scale, QuickDASH, and Derkash scores. Complete symptom resolution had occurred in 83.3% of the VTOS and 75% of the NTOS patients (P&nbsp;= .074). No statistically significant difference in the return to sport was observed between the two groups (VTOS, 94.4%; vs NTOS, 73.9%; P&nbsp;= .123). Of the NTOS patients, 10.0% had had other concomitant injuries and 5.0% had had medical conditions that had precluded their return to sport. Logistic regression found no significant relationship between the preoperative somatic pain scale score, QuickDASH score, or duration of symptoms and the return to sport.ConclusionsAdolescent athletes with VTOS and NTOS can have good functional outcomes, and most will be able to return to sport after surgery. Greater initial symptom severity and concomitant injuries were observed in adolescents with NTOS. Of those who had not returned to sport postoperatively, three of seven had had unrelated health issues that had prevented their return to sport

The impact of competitive level of high school and collegiate athletes on outcomes of thoracic outlet syndrome

ObjectiveThoracic outlet syndrome (TOS) has life-changing impacts on young athletes. As the level of competition increases between the high school (HS) and collegiate (CO) stage of athletics, the impact of TOS may differ. Our objective is to compare surgical outcomes of TOS in HS and CO athletes.MethodsThis was a retrospective review of HS and CO athletes within a prospective surgical TOS database. The primary outcome was postoperative return to sport. Secondary outcomes were resolution of symptoms assessed with somatic pain scale (SPS), QuickDASH, and Derkash scores. Categorical and continuous variables were compared using χ2 and analysis of variance, respectively. Significance was defined as P&nbsp;&lt; .05.ResultsThirty-two HS and 52 CO athletes were identified. Females comprised 82.9% HS and 61.5% CO athletes (P&nbsp;= .08). Primary diagnoses were similar between groups (venous TOS: HS 50.0% vs CO 42.3%; neurogenic TOS: 43.9% vs 57.7%; pectoralis minor syndrome: 6.3% vs 0.0%) (P&nbsp;= .12). Pectoralis minor syndrome was a secondary diagnosis in 3.1% and 3.8% of HS and CO athletes, respectively (P&nbsp;= 1.00). The most common sports were those with overhead motion, specifically baseball/softball (39.3%), volleyball (12.4%), and water polo (10.1%), and did not differ between groups (P&nbsp;= .145). Distribution of TOS operations were similar in HS and CO (First rib resection: 94.3% vs 98.1%; scalenectomy: 0.0% vs 1.9%, pectoralis minor tenotomy: 6.3% vs 0.0%) (P&nbsp;= .15). Operating room time was 90.0 vs 105.3&nbsp;minutes for HS and CO athletes, respectively (P&nbsp;= .14). Mean length of stay was 2.0 vs 1.9&nbsp;days for HS and CO athletes (P&nbsp;= .91). Mean follow-up was 6.9&nbsp;months for HS athletes and 10.5&nbsp;months for CO athletes (P&nbsp;= .39). The majority of patients experienced symptom resolution (HS 80.0% vs CO 77.8%; P&nbsp;= 1.00), as well as improvement in SPS, QuickDASH, and Derkash scores. Return to sport was similar between HS and CO athletes (72.4% vs 73.3%; P&nbsp;= .93). Medical disability was reported in 100% HS athletes and 58.3% CO athletes who did not return to sport (P&nbsp;= .035).ConclusionsDespite increased level of competition, HS and CO athletes demonstrate similar rates of symptom resolution and return to competition. Of those that did not return to their sport, HS athletes reported higher rates of medical disability as a reason for not returning to sport compared with CO athletes