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

Limb salvage and reconstruction following a zebra attack

Animal bites are fairly rare events but can cause devastating traumatic injuries to the victim. In addition to the soft tissue, vascular, and orthopedic trauma inflicted by these occurrences, bite injuries also have the potential to introduce an inoculum of microbes, which may progress to an infection if not treated properly and expeditiously.We present the case of a healthy male who sustained multiple bite wounds from a domestic zebra to his left upper extremity. This attack caused severe damage, including devascularization of the arm at the brachial artery, disruption of the distal biceps and brachialis, stripping of the forearm nerves, and shearing of the overlying soft tissue. The patient was taken emergently to the operating room for revascularization of the extremity utilizing a vein bypass graft. The soft tissue injuries were addressed with numerous irrigation and debridement procedures, during which coverage of the vein bypass graft was obtained using a variety of techniques, including skin flaps, musculocutaneous advancements, and the application of an acellular dermal matrix (AlloDerm) and a collagen-glycosaminoglycan matrix (Integra).Wound cultures obtained intra-operatively during the irrigation and debridement procedures were notable for the growth of multiple microbes, including Rhodococcus spp., which have been documented to cause infection in immunocompromised patients. The patient in this case was treated with a prolonged course of antibiotics, and wound cultures negative for microbial growth were eventually obtained prior to final closure of his wound. The patient then underwent successful biceps reconstruction with a pedicled latissimus dorsi muscle transfer. This case documents the extraordinary multidisciplinary approach provided in the salvage, management, and eventual reconstruction of a mangled left upper extremity that had sustained devastating traumatic injuries resulting from a rather unusual source. Keywords: Zebra, Bite, Rhodococcus, Salvage, Reconstructio

Snoring and carotid artery disease: A new risk factor emerges

OBJECTIVES/HYPOTHESIS: Previous studies have identified a relationship between snoring, carotid intima media thickening, and the presence of atherosclerosis. This study examines the correlation between snoring and carotid artery disease through use of duplex ultrasound identifying greater than 50% internal carotid artery stenosis. STUDY DESIGN: Prospective cohort study. METHODS: Patients presenting to three academic vascular laboratories for carotid duplex examination completed the following surveys: demographic information, assessment of risk factors for carotid stenosis, assessment of history of obstructive sleep apnea, or continuous positive airway pressure use and Snoring Outcomes Survey. Patients were categorized into 2 groups based on the presence or absence of carotid disease. Data were analyzed by univariate contingency tables and logistic regression analysis. RESULTS: Five hundred one patients completed the survey, of whom 243/501 (49%) had evidence of carotid occlusive disease. On univariate analysis, smoking, hypertension, heart disease, hypercholesterolemia, diabetes, and stroke all correlated with greater than 50% carotid stenosis. Multivariate analysis indicated that snorers were significantly more likely to have carotid disease. Three hundred twenty-seven participants were thought to have primary snoring. On univariate analysis, snorers were found to be significantly more likely to have carotid disease. After adjustment for covariates, snoring was not significant for carotid disease. However, multivariate analysis showed snorers to be significantly more likely to have bilateral carotid disease. CONCLUSIONS: This study shows a potential relationship between snoring and bilateral carotid artery stenosis greater than 50%; snorers have risk of carotid stenosis twice that of nonsnorers. Further investigation is warranted to better elucidate this relationship. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:265-268, 2019

Snoring and carotid artery disease: A new risk factor emerges

OBJECTIVES/HYPOTHESIS: Previous studies have identified a relationship between snoring, carotid intima media thickening, and the presence of atherosclerosis. This study examines the correlation between snoring and carotid artery disease through use of duplex ultrasound identifying greater than 50% internal carotid artery stenosis. STUDY DESIGN: Prospective cohort study. METHODS: Patients presenting to three academic vascular laboratories for carotid duplex examination completed the following surveys: demographic information, assessment of risk factors for carotid stenosis, assessment of history of obstructive sleep apnea, or continuous positive airway pressure use and Snoring Outcomes Survey. Patients were categorized into 2 groups based on the presence or absence of carotid disease. Data were analyzed by univariate contingency tables and logistic regression analysis. RESULTS: Five hundred one patients completed the survey, of whom 243/501 (49%) had evidence of carotid occlusive disease. On univariate analysis, smoking, hypertension, heart disease, hypercholesterolemia, diabetes, and stroke all correlated with greater than 50% carotid stenosis. Multivariate analysis indicated that snorers were significantly more likely to have carotid disease. Three hundred twenty-seven participants were thought to have primary snoring. On univariate analysis, snorers were found to be significantly more likely to have carotid disease. After adjustment for covariates, snoring was not significant for carotid disease. However, multivariate analysis showed snorers to be significantly more likely to have bilateral carotid disease. CONCLUSIONS: This study shows a potential relationship between snoring and bilateral carotid artery stenosis greater than 50%; snorers have risk of carotid stenosis twice that of nonsnorers. Further investigation is warranted to better elucidate this relationship. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:265-268, 2019