Faculty Bibliography

We present a 68-year-old female who developed multiple pseudo-aneurysms (PSAs) following cardiac catheterization via the right groin. During subsequent thrombin injection of PSAs, the patient developed acute occlusion of the popliteal artery. A covered stent was placed to obliterate the PSAs and allow for successful endovascular treatment of the occlusion without hemorrhage from the previous arteriotomy sites. This report demonstrates a safe and successful method to treating high surgical risk patients with recent PSA's and a necessity for thrombolysis.

AIM: We reviewed the number of vascular publications listed in PubMed from 2001 to 2009 for US program directors in vascular surgery and suggest that this can be used as a benchmark. METHODS: PubMed listed 3284 citations published during this time period. The average number of citations in PubMed per program director was 3.68 per year. The top third produced 67% of the publications. Journal of Vascular Surgery publications made up 37%. No statistical differences could be ascertained between the regions of the country and the number of publications. RESULTS: Compared to the first six years, the number of citations decreased during the last three years (13%). During the first period, there were no programs with no publications and seven with no Journal of Vascular Surgery publication. During the last three years, there were seven programs with no publications and 19 programs with no Journal of Vascular Surgery publications. The number of aortic-endovascular citations peaked in 2002 and 2003, while the number of open and basic science citations decreased. Imaging citations peaked in 2003-2005, and carotid-endovascular, vein-endovascular, and thoracic aortic-endovascular citations climbed. CONCLUSIONS: The decrease in the number of citations/program/year raises concern about the level of academic activity in vascular surgery. Overall, the annual distribution of the topic of these citations represents a continued shift from open to endovascular cases and decreasing basic science citations.

BACKGROUND: Balloon-assisted maturation (BAM) of arteriovenous fistula (AVF) is a fairly new procedure used to accelerate the process of maturation. As with any procedure, complications do arise. In this retrospective analysis of 336 office-based BAM procedures, 5 major complications were analyzed. These were categorized as formation of wall hematoma, extravasation or rupture, spasm, thrombosis, and formation of puncture-site hematoma. METHODS: Prospective data were collected from May 14, 2009 to March 3, 2011 on 336 office-based duplex-guided BAM procedures. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex guided. Balloon calibers were chosen based on duplex vein measurements and surgeon preference (approximately 1-2 mm larger than minimal vein diameter). Vascular injuries were classified based on postprocedural duplex assessment. All patients had follow-up duplex scans within a week after BAM. RESULTS: Of the 336 procedures, the most common injury was formation of wall hematoma (136, 40.5%) followed by extravasation or rupture (32, 9.5%), spasm (26, 7.7%), formation of puncture-site hematoma (13, 3.9%), and thrombosis (5, 1.5%). The injuries were further compared based on balloon size, ranging from small balloon group (3-6 mm) to large balloon group (7-12 mm); entry position, retrograde (n=177) versus antegrade (n=159); and type of fistula; radial-cephalic (n=232), brachial-cephalic (n=64), brachial-basilic (n=34), brachial-brachial (n=4), and ulnar-cephalic (n=2). A significant increase in complications was noted in BAM procedures performed in forearm AVF versus upper arm AVF (67% vs 54%, P=0.02) and in the large balloon group versus small balloon group (72% vs 52%, P<0.001). CONCLUSIONS: The data suggest that office-based BAM procedures are safe. Fortunately, major complications are not seen at an alarming rate. While increased complications are seen in BAM procedures performed in the forearm and with larger balloons, except for wall hematoma formation (40.19%), each complication occurs in <10% of the procedures. Further studies to help clarify the nature of these complications and their relationship to fistula maturation are warranted.

We present a case of a high-risk 76-year-old man who was electively admitted for repair of a large infrarenal abdominal aortic aneurysm. After placement of the main body of the bifurcated graft, the contralateral guidewire became entrapped at the level of suprarenal fixation. Multiple endovascular maneuvers were attempted to remove this wire from the femoral approach, but all were unsuccessful. The wire was then transected at the level of the common femoral artery and anchored to the arterial wall with 1 small monofilament suture. A short bare stent was also used to secure this wire to the inner wall of the external iliac artery. However, the proximal end of the wire that extended freely up to the mid-descending aorta was left undisturbed. On postoperative day 2, an attempt at snaring the proximal end of the wire via a brachial approach also failed to displace the trapped wire. At 1-year of follow-up, the patient has been asymptomatic with no obvious sequelae, such as thromboembolism or aortic dissection, and there is no evidence of damage to the aorta or graft on computed tomographic imaging. To our knowledge, this complication has not been previously reported.

There are greater than 120,000 above-knee amputations (AKA) and below-knee amputations (BKA) performed in the USA each year. Traditionally, general anesthesia (GA) was the preferred modality of anesthesia. The use of regional nerve blocks has recently gained popularity, however, without the supporting evidence of any mortality benefits. Our objective was to evaluate whether regional nerve blocks yield significant mortality reduction in major lower-extremity amputations. Retrospective data of both AKA and BKA procedures at the Maimonides Medical Center from 2005 to 2009 were analyzed. Patients received either general sedation, spinal or ultrasound-guided regional nerve blocks as per decision of the attending anesthesiologist. Regional nerve blocks for major lower-extremity amputations consisted of femoral, sciatic, saphenous and popliteal nerve blocks. A retrospective inquiry of 30-day mortality was performed with reference to the Social Security Death Index and hospital records. One hundred and fifty-eight patients were included in the study (82 men and 86 women with mean age of 74.5 years +/- 12.9 SD, range of 33-98 years) of which 46 patients had regional nerve blocks and 112 had GA or spinal blocks. Patients who received both regional blocks and GA/spinal blocks within 30 days were excluded. The overall 30-day mortality was 17.1% (27 patients) consisting of 15.2% for regional nerve analgesia versus 17.9% for GA/spinal blocks (P = 0.867). Age did not affect mortality outcome in either groups of anesthesia modality. Our analysis did not reveal any mortality benefit of utilizing regional nerve block over GA or spinal blocks.

BACKGROUND: Balloon assisted maturation (BAM) is a recent, innovative, yet controversial method for developing autogenous arterio-venous fistulae (AVF), with little supportive data. Few retrospective studies have addressed the efficacy of BAM and cofactors affecting successful maturation. We conducted a retrospective analysis of our vascular access database to compare possible factors associated with a successful BAM, as determined by increase in volume flow of the fistulae. METHODS: Between 2009 and 2010, data was prospectively collected on patients undergoing BAM of their AVF under ultrasound guidance at our institution. 30 of these patients, consisting of 143 BAMs, were retrospectively analyzed. Data collection included: past medical history, age, number of BAM procedures preformed, volume flow measurement (VFM) in mid-fistulae, size of balloon used, and presence of post procedural wall hematoma. VFM was determined with duplex within one month prior to and subsequent to each BAM performed. RESULTS: Of the 30 patients, consisting of 143 BAMs, the average age was 69 years old + 15 (range 38-92) with 20 males and 10 females. The most common risk factors were hypertension (n = 27) and diabetes mellitus (n = 16). The average BAM per patient was 4.8 (range 1-7). Of the 143 BAM procedures, 4 were excluded due to absence of preoperative or postoperative duplex. In 139 BAMs, 74 developed a post procedural hematoma as observed on duplex, and 76 showed an increase in VFM. In all BAMs analyzed, there was no correlation observed between the presence of a hematoma and increase in VFM (P = 0.87). Hematomas occurred most frequently during the second BAM procedure, with 24.3% of all hematomas observed. In 139 BAMs, 8 different balloon sizes were used, 3 mm-10 mm, with the 7mm balloon being the most frequently used (n = 34). No significant difference was noted between increase in VFM in 3 mm to 7 mm balloons. A 8 mm balloon was used in 31 BAMs with 22 developing hematomas. Of the 8mm balloon group, a statistical difference was noted between percent increase in VFM with presence of a hematoma and percent increase in VFM without presence of a hematoma (P = 0.027). CONCLUSIONS: These preliminary data, suggest that a more aggressive approach to BAM, with use of larger balloons to create hematoma formation and minimizing excessive dilatation procedures, may have a significant impact on performing a successful maturation in respects to increase in VFM.