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PTFE bypass to a smaller tibial artery with Taylor vein patch One of the conclusions of the BEST-CLI trial (ref 1) was that of equivalency between alternate bypass conduits and interventions when a single saphenous vein is not available. I recently contacted Dr. Matt Menard to see if there had been subgroup analysis of these bypasses which represents a heterogeneous group of conduits including PTFE, PTFE with vein patch, spliced vein, composite vein, and even possibly allograft. The results from the abstract were intriguing -“83 of 194 patients (42.8%) in the surgical group and in 95 of 199 pa ..read more

https://www.jvscit.org/article/S2468-4287(23)00014-X/fulltext Innovation was a needed to avoid the coagulopathy that comes so frequently at the end of thoracoabdominal aortic aneurysm repair in a low volume but fully resourced environment such as we had in Abu Dhabi. In this demanding disease, there are no shortcuts to success but every little bit of advantage helps ..read more

Choose to Be a Hero There was an OpMed article on Doximity (https://www.doximity.com/newsfeed/1946e8dd-eddc-4eb4-aad6-46fe59c86da5/public) which reports that 69% of 58,000 physicians surveyed said they would provide emergency care. That number is depressingly low at first view but can be answered by asking how many of us are ATLS, ACLS, or BLS certified? A quick search fails to give a result, although various pro CPR groups have on their websites that all caregivers should be trained in BLS. The darker question is how often do fully trained and certified physicians choose to withhold care and ..read more

The patient is a woman in her forties who works hard and smokes cigarettes to find stress relief. The year prior to presentation, she began to get cramps in her calves while she walked the halls of the building she cleaned, and this became unbearable. A consultation at our hospital revealed moderate to severe diffuse atherosclerosis without a dominant lesion but notable small distal aorta and iliac arteries with a 50% stenosis of the left iliac origin. Recommendations were to quit smoking and exercise. She found this difficult to achieve and went to another hospital nearby. There, 6 months pri ..read more

At the VEITH Symposium, which I attended briefly last week, while I foraged for lunch and sought out friends, I wandered into a crab trap (diagram above). Or more specifically, the WL Gore exhibit hall (below). The coffee and bevarages featured all day, and the steak buffet at lunch, draws people in, like the smell of chicken to a crab, and once you have a plate of food, you then are kind of committed to moving forward into the conference room where they have a video feed of aortic symposium and tables to gobble your lunch. Like a hand reaching into a crab trap to retrieve the catch, the rep ..read more

Median arcuate ligament syndrom (MALS), also known as celiac axis compression syndrome (CACS) and its eponym Dunbar Syndrome, is manifest as epigastric abdominal pain and a compendium of symptoms, arising from chronic compression and inflammation resulting from compression of the celiac plexus between the median arcuate ligament and the celiac axis. Graphic showing the pathoanatomy of neurogenic MALS (from ref 1). The repeated trauma to the celiac plexus results in inflammation and nerve injury with transmission of pain and neuropathic sensations. The diaphragm muscle descends from the neck du ..read more

5 Top FAFO’s In Vascular Surgery In no particular order, I list these problematic situations that are outsized in their ability to take a case sideways. Ischemia syndromes in the unconscious. The unconscious tell you nothing about their pain and follow no commands. Therefore, vigilance and a low threshold for operating are what will save the patient if they are salvageable. Objective evidence of flow -examination, handheld pulse Doppler, duplex ultrasound, CT angiogram, exploration and visual inspection, must be obtained. The typical scenarios are dissections of the ascending thoracic aorta ..read more

I had posted the above picture from over 15 years ago during my time in Iowa of my hybrid AUI-Fem-Fem (under unclampable 2, link). This technique came back to me as I was strategizing the upcoming aortic revascularization of a patient with iliac occlusions with the added complexity of an ileal conduit in the right abdomen. He had multiple failed prior iliac stents and failed femorofemoral bypasses -his right CIA and EIA were occluded while the left EIA had become occluded resulting in ischemic rest pain. While the picture alone is sufficient for me, it was brought to my attention by Dr. Joedd ..read more

I recently had lunch with Dr. PJ O’Hara, emeritus professor, and former partner of mine from the Cleveland Clinic. We hadn’t met since 2018 at the VAM in Boston, while I was still in Abu Dhabi. It was a recent case I did that caused me to reach out. I won’t be posting that recent case in detail today -it was a patient who had had multiple aortoiliac interventions for aortic bifurcation disease, but who closed up their stents within a few months of intervention. Rather than subject that patient to another round of interventions, I chose aortoiliac endarterectomy because the prior interventions ..read more