Endovascular reconstruction in inferior vena cava atresia in a patient with sickle cell trait

Atresia of the inferior vena cava (IVC) is a rare anomaly associated with increased risk of deep venous thrombosis and lower extremity venous stasis. A significant number of patients with caval atresia remain asymptomatic however, due to compensatory lower extremity collateral venous networks. Over time, these venous tributaries may become insufficient and lead to venous hypertension and subsequent ulcer formation. The following case report describes a 54-year-old male with sickle cell trait who presented with IVC atresia and successfully underwent a technically challenging endovascular reconstruction.Given the scarcity of the condition, there is no established treatment paradigm in patients with atresia of the IVC. Additionally, given the variety of clinical presentation, it is important to tailor treatment to the individual. Our patient's medical history, clinical course, and physical exam findings raised suspicion of a condition affecting the central venous system, confirmed by a CT angiogram with dedicated venous phase. Given his clinical picture as well as our prior experience with central venous pathology, an endovascular reconstruction was offered. Now more than 18 months after surgery, the patient is living well and has not presented any new thrombotic events.Although not all patients with atresia of the inferior vena cava require surgical intervention, we propose that an endovascular approach is a successful strategy that leads to prompt recovery and a favorable outcome

Endovascular Aortoiliac Revascularization in a Patient with Spinal Cord Injury and Hip Contracture

Treatment of chronic peripheral ischemic wounds in patients with spinal cord injury (SCI) can be technically challenging, especially if they have significant hip contracture. This article describes the endovascular aortoiliac revascularization of a paraplegic patient with hip contracture and a hostile abdomen. It also reviews the particularity of the peripheral arterial system in SCI patients

Phalloplasty in Transgender Men with and without Urethral Lengthening

Our goal in trans man phalloplasty is to decrease the patient’s level of gender incongruence, obviate the use of an external prosthesis, be able to orgasm, and give the patient the ability to urinate standing (if desired), while also attempting to decrease urinary complications. The decision to undergo urethral lengthening is considered early in this surgical process. However, urethral complications are among the most common problems we see in phalloplasty, and surgical techniques have evolved to decrease these complications. We have developed an advanced two-stage mucosa-only prelaminated neourethra phalloplasty technique to address these issues. Our surgical technique is detailed in addition to providing patient demographics, co-morbidities, flap complications, and urinary sequelae. We also discuss the perineal urethroplasty in patients opting for no urethral lengthening in phalloplasty. All options should be given and risks considered in trans men undergoing soft tissue phalloplasty, and these will be discussed in detail

Inferior Vena Cava Filter Long Term Complications and Retrieval Techniques: A Case Series and Literature Review

Introduction and Importance Long-term mechanical complications after inferior vena cava (IVC) filter placement include embedded or tilted filters, erosion of the vena cava, filter thrombosis. In the setting of caval thrombosis, patients may subsequently develop venous hypertension and post-thrombotic syndrome (PTS). Here we present three unique cases of IVC filter complications and surgical management. Case Presentation A 30-year-old female presented with acute abdominal pain, revealing a duodenal perforation caused by an IVC filter eroding into her duodenum. A 42-year-old female with an IVC filter in place for 20 years due to a prior pulmonary embolism underwent laser-assisted retrieval of the filter due to concerns of caval adherence. A 48-year-old male with a history of DVT, venous stasis ulcer, and an IVC filter presented for filter retrieval. Clinical Findings and Investigations The surgical techniques described in this report include complicated IVC filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis resulting in PTS. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience. Intervention and Outcomes The surgical techniques described in this report include complicated inferior vena cava filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience. Relevance and Impact Endovascular retrieval of long-term complicated IVC filters is challenging, but it can be a safely performed in many patients. However, open surgery may be necessary in selected patients

Study habits centered on completing review questions result in quantitatively higher American Board of Surgery In-Training Exam scores

The American Board of Surgery In-Training Exam (ABSITE) is administered to all general surgery residents annually. Given the recent changes in the format of the examination and in the material being tested, it has become increasingly difficult for residents to prepare for the ABSITE. This is especially true for incoming postgraduate year (PGY) 1 residents because of the respective variability of the surgical clerkship experience. There have been many studies in the past that support the use of weekly assigned readings and examinations to improve ABSITE scores. Other studies have investigated the study habits of residents to determine those that would correlate with higher ABSITE scores. However, there is a lack of information on whether completing review questions plays an integral role in preparing for the ABSITE. We hypothesize that those residents who completed more review questions performed better on the ABSITE. ABSITE scores of current and past general surgery residents at SUNY Downstate Medical Center, a university hospital, were reviewed (2009-2013). These residents were then polled to determine how they prepared for their first in-training examination. Average ABSITE percentile was 46.4. Mean number of review questions completed by residents was 516.7. Regression analysis showed that completion of more review questions was associated with a significantly higher percentile score on the ABSITE (p < 0.0027). Further analysis showed that for every 100 review questions completed by a PGY 1 resident taking the ABSITE for the first time, the ABSITE percentile score should improve by 3.117 ± 0.969. Average reported study time in hours/week was 9.26. Increased study time was also significantly correlated with higher ABSITE percentile scores (p < 0.007). Again, further analysis showed that for every 1h/wk spent studying, ABSITE percentile score should increase by 1.76 ± 0.62. The Kruskal-Wallis H test showed that studying in group vs individual settings had no effect on ABSITE performance (p = 0.20). It was also used to analyze primary study resource, which demonstrated that there was no significant difference in residents' performance based on their primary study source (p = 0.516). Recent changes in the format of the ABSITE to a 2-tiered examination in 2006 and subsequent plan to return to a unified test for all PGY levels has made preparation difficult. With a more focused, question-based approach to studying, residents may see a demonstrable improvement in their scores. Our study supports this hypothesis-showing that residents who complete more review questions had higher ABSITE percentile scores. In the past, it has been demonstrated that strong ABSITE scores are associated with higher written board scores. With the widespread adoption of the Surgical Council on Resident Education curriculum, we postulate that residency programs that rely on this review question-based curriculum will report improved ABSITE percentile scores and written board pass rates

Traumatic Lower Extremity Vascular Injuries and Limb Salvage in a Civilian Urban Trauma Center

Data on management of traumatic lower extreity arterial injuries comes largely from military experience and involves few civilian centers. This study reports on the experience of an urban trauma center and factors associated with limb loss. A retrospective review of lower extremity arterial injuries between 2013 and 2020 at an academic urban level 1 trauma center was completed. Patients with lower extremity revascularization were included in the final data analysis. Demographics, clinical variables, operative details, type of revascularization, as well as 30-day morbidity and postoperative outcomes were analyzed. The primary outcome of interest was 30-day limb loss. Secondary outcomes included postoperative complications and functional outcomes. Seventy-five patients were included in our analysis. Sixty-nine were male (92%), mean age 33 ± 15 years, 50 patients had penetrating trauma (67%), mean injury severity score was 15 ± 9. Thirty-day limb loss was reported in 8 (11%). Factors associated with limb loss included female sex (P = 0.001), high body mass index (P = 0.001), blunt injury (P = 0.001), associated fractures (P = 0.005), significant soft tissue injury (P = 0.007), delayed repair after shunt placement (P = 0.003), bypass revascularization (P = 0.001), initial revascularization failure (P = 0.019), and wound complications (P 30 days. Twenty-three reported ambulation without assistance, 9 neuromotor deficit including 1 patient that had delayed amputation. Patients with blunt trauma and associated fracture and/or extensive soft tissue injury are at risk of limb loss. These injuries are often associated with postoperative wound complications, requiring aggressive soft tissue care that substantially increases ROR and LOS; Expectations for limb salvage in these patients should be tempered when the other associated factors with limb loss mentioned above are also present. When limb salvage is achieved, regaining full limb function remains a challenge