All posts by orjunkie

Endograft Explant and Open AAA Repair

It was a day I saved since two week prior, and I am sure my seniors did the same. It was a big case, an endograft explant and open AAA repair for a type 1a endoleak due to caudad migration of AneuRx graft. It was a day to look forward. In addition, the patient was a pleasant gentleman, which added more warmth to our excitement.

Intra-operatively, we made a midline laparotomy,  dissected down to the peritoneum, moved the omentum and transverse colon up, small bowel to the right in a bowel bag, set up the Omni retractor set up. For the AAA dissection, retroperitoneum was dissected  towards the L renal vein while staying to the right of SMA, and distally the iliac arteries/limbs of graft were vessel looped. We then gave a small amount of heparin and went to work.  Initially, clamp was placed below the left renal artery and above the right renal due to severe downward and left angulation of the aneurysm. Conveniently, his right kidney was small and likely diminished in function.  Aorta was then transected with bevel at posterior wall and the AneuRx endograft was taken out along with struts. We moved the clamp infra-renal, and completed the proximal anastomosis. Afterwards, we moved the clamp to the graft and finished the anastomoses to both distal endograft iliac limbs. Hemostasis took sometime, but we eventually closed the retroperitoneum, put the bowels back and closed the abdomen.

The preparation for surgery and post-op care were just as important as the intra-operative techniques. Bowel prep, medical adjustment and consultation, and patient instructions before the surgery day were extensive. Post-op, he was intimately followed by the SICU team as well as the vascular surgery team, and each aspect of his organ system management were analyzed and communicated thoroughly. To our amazement, despite having multiple co-morbidities such as COPD, CAD, DM, etc he made a complete recovery and was transferred to floor on POD#4 and discharged home soon after.

One paper states removal of endograft using a proctoscope, as it’s easy to resheath

Some of the takeaways and learning points are listed below:

– During explantation of prior endograft, don’t pull out graft too hard, as this can tear the neck and makes it fragile to sew. There is tissue ingrowth and retroperitoneal inflammation.
– After clamping with Fogarty hydrogrip (with padding), check the sac for pulsatility. If there is then it’s not adequately controlled and will bleed.
– Endoleak remains the most common reason for elective explant.
– Late AAA endograft explant: indication and outcomes (Northwestern) – Indications included 9 device failures, 6 endograft infections, and a single type II endoleak with sac enlargement. 75% requiring supraceliac control. Reconstructions depended on clinical manifestations and included 10 in situ prosthetic repairs, 4 extra-anatomic bypasses, and 2 in situ cryopreserved human allograft repairs. 13% mortality rate. Mean hospitalization for survivors was 18 days (range, 6-78 days), and 7 (50%) of the patients were discharged directly home.
– If removal is due to infection, then should attempt to remove all barbs and not leave anything in situ. Proctoscope might help resheath.
– Partial explant (Cleveland Clinic) – 22 patients had a partial late EVAR explantation. Of these 22 patients, there were four patients with proximal components remaining, 17 patients with distal components remaining, and one patient with both proximal and distal components left. Nine of the 22 (41%) had postoperative and follow-up CT imaging, of which none of these patients had migration of their remaining graft components. The average length of follow-up in these nine patients was 25.9 months. Four of the 22 patients (18%) died secondary to postoperative infection, shock, and organ failure after explant.

Patient was extubated POD1, off of all pressors POD2, transferred to floor POD5 and discharged soon after. This has been one of those stories that makes you want to go into a particular specialty, and it was a pleasure caring for this patient, seeing him from pre-op all the way to stablization and discharge.

Start of Integrated Vascular Residency and Chronic Venous Insufficiency in Patient with DVT

I have already done a week of PGY1 year at, let’s just say a certain institution in the NE region. Things have been busy, a little hectic, and definitely what I signed up for. Everyday I learn many new things, and realize how much I don’t know about actual patient care. Things will get smooth and efficient; I am sure.

I have encountered several patients with C6 stage chronic venous insufficiency, with chronic or prior history of DVT, and there are many debates about whether GSV ablation can be safely carried out in these patients. Let me present to you the evidence I’ve found:

SFJ as Mickey mouse as seen on ultrasound
  • Deep vein reflux from previous DVT may improve in some cases after elimination of the superficial reflux, but it does not disappear. The latter is more prevalent in the presence of axial reflux, such as when there is reflux in continuity from the common femoral vein to popliteal or more distal, no just isolated to the SFJ or SPJ.
  • Superficial venous ablation with concurrent chronic DVT is not as forbidden anymore! Traditional advice has been against saphenous vein ablation in the presence of deep venous obstruction, as it was feared that obstructive disease may be made functionally more severe by removing the saphenous vein that might serve as collaterals.
  • When testing venous outflow function in patients with previous deep vein thrombosis, Labropoulos et al. demonstrated that only 9.6% of limbs had their venous outflow reduced by occlusion of the superficial veins. The deep collaterals seem to be more important than the superficial venous system in bypassing the obstruction.
  • Raju et al.,when comparing patients with and without deep obstruction who underwent saphenectomy, found similar outcomes in the two groups with no clinical deterioration in those with obstruction.
  • Risk of DVT following saphenous ablation does not seem to be increased in patients with previous thrombotic events as shown by Puggioni et al. Therefore, the saphenous vein plays an insignificant role as a collateral pathway in patients with deep venous obstruction and can be safely treated to correct underlying hemodynamic pathology.
  • When evaluating the superficial veins in patients with deep vein obstruction it is necessary to demonstrate significant reflux in the superficial veins prior to intervening, as superficial veins can be dilated in order to compensate for the deep vein obstruction. In such patients the diameter change should not be compared with the studies on patients with primary superficial vein reflux. Therefore, superficial veins with large diameter should not be removed unless there is significant reflux that may contribute to the patients’ signs and symptoms.
  • In patients with advanced CVI (C4-6) and superficial reflux, interrogation of the deep venous system for proximal obstruction, even in the absence of previous DVT, is warranted (get MRV or CTV). Treatment of both superficial and proximal deep vein stenosis should be offered, with excellent outcome.
  • Marston et al. found that as many as 30% of patients with chronic venous insufficiency have iliac vein obstruction on CT scan. The presence of such combined disease (superficial reflux and iliac vein obstruction) may warrant treatment of both levels of disease, as it is impossible to identify the pivotal diseased segment that contributes to the clinical presentation. These can be done in a staged or combined fashion.
  • Neglen et al. reported combined saphenous ablation and iliac vein stenting in 99 limbs with significantly improved hemodynamic parameters, improved clinical symptoms (pain and swelling) and significant improvement in all quality-of-life categories after treatment. This was achieved with good 4-year patency (>90%) and low complication rate.
  • Raju’s group which showed that correcting the obstructive element alone of combined obstructive and deep reflux disease can improve clinical symptoms without deterioration in reflux measures.

All in all, treating superficial vein reflux in presence of chronic, non-occluded DVT or prior history of DVT should not be considered as taboo. Of course, it might offer little help in patients with propensity to clot, terrible post-thrombotic syndrome, active venous ulcers that require intensive wound care, etc. At least GSV ablation won’t hurt them. Who knows, venous research has shown us little about how to improve these patients, but definitely shown us enough about safety of GSV ablation.

Your Inner GPS

I like to listen to podcasts when I cannot physically open up a book or don’t want to stare at screens anymore. Tonight, during a long ride of the A train in NYC, I listened to the Behind the Knife podcast episode with Dr. Freischlag. I became instantly amazed with her emotional intelligence, humility and aptitude for being a great mentor. She specifically addressed that not everything in life works out in your favor, and her input aspired me to write about the content below, which I named “Your Inner GPS”.

At this point, many of you know how to get back on track when a mistake has been made or when life throws you some dirt. For god’s sake, we are almost doctors, and we are more than capable of realigning our great ships, right? However, what you might not be good at is what to do when something goes wrong – completely wrong – and when you are forced to make a pit stop on your way to “greatness”. How well do you deal with things when you’ve worked so hard but are forced to change course, or worse, abandon? What about when you’re more than qualified, and you’re denied for a reason that shouldn’t be a reason at all? I’m sure many of you type As and overachievers also got completely chewed up by life from time to time, just like me. Of course, we get better and better at handling these bumps on the road, as we encounter more of them, like hypertensive arteriosclerosis. Let me assure you, none of us are perfect at handling lemons handed by life. We are young, and there’s still much to learn about how to best hit life’s curveballs.

Don’t despair. Take a step back, pause for a moment, think about the problem, come up with options, plan, and execute. We surgeons and doctors and teachers and parents and etc already got here with this method. This is our inner GPS, yet many of us still panic, complain, and ruin our along with our closed ones’ mood when we get into sticky situations laid down by life.

You have to be completely okay with not getting everything you ask for completely and all the time. In fact, you should rejoice (to a healthy degree) when you get something, especially when you worked so hard for it. There is no flow chart or algorithm in life that get you to exactly where you want to be.  Timing and serendipity are elements in addition to hard work that can make life so easy when present, and so miserable if without. Be prepared to fail and be lost for a bit. Enjoy, if you can, the process of learning from a rare mistake that you make, and be a better version of yourself. This self-searching process and reorientation would refine and sometimes define you.

Also, it should be okay for you to get rejected. It should teach you something every time, but the awkwardness and embarrassment that come with it should simply bounce off you. If they don’t, don’t worry, with few more rejections you will get there. Hey, I got here. Just think about this – under the circumstance that you are excellent, you’ve worked hard, and you’re true to yourself, you are simply filtering out your choices through rejections. Not everyone would like you even if you’re all of the above, but you will definitely have options, and eventually a great match.

Amidst all of these turmoils life gives you, try to stay the course and look at the big picture. There’s an expression that says you should look at the windshield, not the rear view mirror. I say look at both. Focus on the windshield and where you want to go and what you wanna achieve next, but also pay attention to the rear view mirror so you learn from the mistakes and never make them twice. You would be surprised the amount of takeaways and life lessons you can acquire from either direction.

Hold steady, and don’t let life ruin your party. Wherever you end up, be happy and never stop learning. There will always be someone ahead who you look up to, and someone behind who looks up to you. Don’t despair and certainly don’t lose purpose. Trust your inner GPS.

China Vascular Surgery Elective

I am now in my last week of my 3 week vascular surgery rotation I set up in the First Affiliated Hospital of Zhengzhou University, in Zhengzhou, China. The experience has been eye-opening.
First assisting in CEA, learning about stent grafts and deploying them, and giving presentations in Mandarin are nothing but small gains I made during this trip. The more profound takeaways were the complexity of healthcare in China and the different training path surgeons in China take.

The Chinese citizen pays much more out of pocket for medical expenses, and crowds the big hospitals even for small problems such as a cough. There’s minimal insurance from the government and private companies, so patients pay 70% of the medical cost including the patch of CEA. Whenever there’s a medical problem, no matter how minimal, people rush to the biggest and most well-known hospital in their region because there are few family docs and the quality of care provided in smaller hospitals are inadequate. The result becomes that big hospitals like the one I rotated in end up having 25 people in a single elevator.

One can actually operate independently at age of 23 in China, after a licensing exam. That is because medical school and college are combined into a 5 year program. However, nowadays no decent hospitals would hire you to be an attending right out of medical school, so surgical trainees go on and do 2 years of masters degree and likely 2 years of doctorate degree in order to get a job at a respectable program. However, the surgeons in China are broken into specialties early on during the latter half of medical school, and their technical skills are much superior than their counterparts in the U.S. Their textbook and literature knowledge are lagging, in my opinion.

These are two fundamental differences in my surgical rotation that struck me. There are lots more interesting contrasts in healthcare and surgical care vs. the U.S. I encourage you all to take a global view on surgery. The scope-broadening and networking are simply phenomenal.

 

 

Advice about clerkship

I had the pleasure of talking to some MS2 who are interested in surgery recently regarding the most optimal way to set up the their third year clerkship. The general ideas are below:

  1. Try to take surgery clerkship in the latter half of the year if you can. It helps if you have a decent understanding of medicine going in.
  2. OBGYN rotation gives you an introduction of how to act in the OR. Good idea to do it before surgery.
  3. When studying for the surgery shelf exam, study medicine! 95% of the questions are medicine.
  4. Get to know a mentor early on, so you can jump on a research project and ask for rec letter later.
  5. Research doesn’t have to be in the surgery specialty that you’re interested. First authorship is first authorship.
Giving advice to MS2

Comment on “Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults” by Yen-Yi Juo et al. JAMA Surg. 2017

Question raised by the paper – MI incidence in high risk vascular surgery didn’t decrease despite advanced cardiac care pre-op (2.7% 30 day MI in 2009; 3.1% in 2014).
My comment on this paper – This study only analyzed high risk procedure includes open AAA and infrainguinal bypass. Endovascular intervention was not included so SHOULD NOT BE MENTIONED ANYWHERE IN THE ARTICLE.
This study has poor generalizability. It is retrospective study on a very unspecific database. NSQIP database lacks specifics on location of cross-clamping in aortic cases and detailed perioperative medical management. Study population is predominantly white, and criteria for MI was not specified and only included up to 30 days.
With the advancement of endovascular intervention, more AAA and TAAA are treated with simple or complex EVAR (branched or fenestrated). The more emergency procedure in open AAA cohort reflects the makeup of open procedure for AAAs, as more and more elective cases of AAA are done endovascular. Open aortic procedure are also becoming increasingly complex, as the simple AAAs with adequate infrarenal aneurysm neck size, length, morphology are treated predominantly by EVAR. The leftover ones with aneurysm neck angulation and large diameter, juxtarenal/pararenal AAA, etc comprise the open AAA intervention. Thus, one can extrapolate that the open AAA procedures are becoming higher risk with expected poorer outcomes. It is no surprise that there is significantly higher actual incidence of post-op MI in open AAA repair [3.0%] vs [1.9%] in infrainguinal bypass, which is more of an elective procedure with subacute patient presentation. Therefore, pre-op cardiac workup and optimization are paramount. However, one cannot associate endovascular intervention with poorer outcome. EVAR, if anything, has made repair of AAA and TAAA into a low risk procedure, without the need for general anesthesia or cross clamp, and made even the rupture of AAA a controllable incident. It has made the cases of AAA/TAAA that require open approach more morbid procedure, but broad perspective that include all AAA/TAAA treated open and endovascularly would likely reflect an improvement in long term outcome of these patients.

Back to Basics

Happy 2018 everybody! Hope not many of your flights are getting delayed too much.

Also, you are not going to believe what I am going to blog about this time. I have just completed a rotation in neurology. If you follow this blog, you know that I am pretty gung-ho about vascular surgery. I guess I tend to find inspirations at unexpected places.

I wasn’t used to it at first. Coming in at 7am, pre-rounding on patients for 3+ hours, table rounding with attending for another 1-2 hours, and finally formally rounding on patients who are now taking afternoon naps. This schedule is different from surgery, to say the least. The amount of sitting probably gave me a badonkadonk.

However, nothing is all bad. Neurology rotation was 3-4 weeks of getting back to basic science and pathophysiology. I spent tremendous amount of time looking at new concepts and relearning old ones (pathogenesis of thrombus formation, atherosclerosis, embolism, etc).

Why is it easier to perform endarterectomy on arterial lesion caused by thrombosis versus Takayasu’s (the latter is associated with transmural inflammation so hard to find a plane)?  Why does intracranial vasospasm primarily give posterior headache (Posterior circulation has more sympathetic input)? How come temporal arteritis rarely affect intracranial vessels ( they have extremely thin walls with much less elastic fibers in the media and adventitia and absent vasa vasorum compared to their extracranial counter parts)? Those are few out of the many new basic science concepts I was able to learn and make clinically relevant during my time on neurology. Not only did I gain new knowledge, rotating in a medical subspecially like neurology taught me to always keep an eye out on the basic pathogenesis of every clinical disease. Indeed, medicine helps surgeon (or in my case, surgeon-in-training) quite a bit; much more than I thought.

I was once told by a mentor that to be a good surgeon, you need to know 2 things – pathophysiology and anatomy. It’s nice to brush up on the pathophys, an area that is easily forgotten if you spend a tad too long wandering in the other territories of medicine.

Anatomy = Technology?

Hey all, it’s been a long time. I am currently half way through the interview trail for 5+0 vascular surgery residency. It’s been busy, sometimes hectic, but definitely eye-opening and fulfilling experience. Visiting top-notch institutions, poking the brains of well-trained and well-researched surgeons, learning about the forefront clinical trials are all part of the interviewing experience that make the $100+ per night hotel stay and 20 hour per week at the airport worthwhile.
To keep this blog topic anonymous, let’s just say when I interviewed at a certain top 10 hospital, I had a pre-interview dinner with Dr. A. Dr. A is a sage who has been practicing vascular surgery all of his life, and who generously extended me the advice of making sure the “anatomy matches technology”.
When he spoke of this philosophical concept, his goal was to tell me to learn all of the options available in vascular surgery, choose what is most appropriate, and draw up plan B, C, D, etc since you have all of the options up your sleeve. This is a great advice, and frankly the most fascinating aspect of vascular surgery in my opinion. Having many ways of treating the same lesion is both interesting and cognitively challenging.
Let me give you an example of the philosophy of “anatomy = technology” in real life vascular surgery that made this concept really resonate with me. There is a new technique of treating carotid lesion that have developed in the past few years called TCAR (trans-carotid artery revascularization). To make a long description short, it utilizes flow reversal from common carotid artery to femoral vein to prevent distal embolization, while allowing a small incision above the clavicle for proximal control and to be the site of angioplasty/stenting, obviating the need to traverse through a hostile aortic arch in trans-femoral approach. Research (ROADSTER trials) has shown that the composite rate of stroke, death and MI rate 30 days after TCAR is smaller than traditional carotid endarterectomy. The vascular surgery world is pretty much split on whether TCAR should be more widely used, as it is currently only indicated for distal internal carotid lesion, high risk patient, redo/irradiated neck, etc as it is for transfemoral carotid stenting. You might ask yourself, what is not to like about TCAR, something that can save patients surgical wound, multiple days of hospital stay, and potentially fewer perioperative stroke?
I urge you to look at new device and technique development with open-mindedness but an objective attitude. This is a classic case of the necessity of making sure that “anatomy matches technology”. Sure, having TCAR allows patient with risky neck or high risk aortic arch to benefit from a small supraclavicular incision. Nevertheless, the traditional carotid endarterectomy is actually a very low risk procedure especially in the hand of a well-trained, experienced vascular surgeon. Some cite the stroke rate of less than 0.2%! For these surgeons, learning a new technique, and most importantly subjecting patient to a procedure that would cost them thousands of more dollars and one that still lacks long term data is much worse. For those of us who are more enthusiastic about TCAR (because it is after all another option in the repertoire), perhaps the right thing to do for now is to learn it well, but still discuss with the patient the possibility of referring to a surgeon with good endarterectomy outcome, if it is not us.
Being cool and cutting-edge is one thing, but individualizing to each patient and doing what’s best for the patient is the rule.

Outcome Research – Less Boring and More Power Than You Think

First and foremost, big shout out to the Eastern Vascular Society for hosting and organizing a thoroughly educational and enjoyable conference at Savannah, Georgia. I am writing this article during my second day here, staying at the gorgeous Westin resort. This conference is not as big as the SVS annual meeting, but it is more intimate and definitely just as informative. The few mosquito bites here and there are no biggie (I am blood type B).

The Westin Savannah Harbor Golf Resort & Spa (top), and the view of downtown from across the Savannah River (bottom).

Day one was all about dialysis; topics included access, maintenance, trouble shooting, and various decision making along the way. I would like to use the topic of dialysis access to show you the power of outcome research.

Many of you reading my blog are students, and I am sure some of you find outcome research in medicine boring, and frequently don’t seem like they apply to daily practice. I will show you that this is not the case, and it is in fact important to carry out more well designed studies and trials so we can create a “bank” of statistically powerful data so we can fall back on them when necessary.

When talking about whether hemodialysis is the best option for patients who are near the end of the road, Dr. Clifford Sales from Westfield NJ cited the data that in octagenarian with ESRD going on dialysis, the mean survival is around 1 year. This has tremendous implication on decision for creating dialysis access. Many of you know, the comparison between AV fistula vs. AV graft can be put simply that AVF is more durable and has less complications such as thrombosis and infection, but takes longer to cannulate and mature (4-6 weeks), whereas AVG can be cannulated much sooner (in 24 hours in some) but has less patency with prolonged use and more complications along the way. It is still advocated to create a native AVF in patients, but what do you think is the best choice of hemodialysis access for octagenarian with the mortality outcome data I presented to you earlier?

Answer is AVG becomes a much more attractive option, perhaps the preferred option. Why? It can be used quickly compared to AVF, so it brings the patient back to a relatively better quality of life when he/she is most likely at the end of the road. With survival of around one year, many complications associated with AVG would not surface, as it is not used long enough to induce thrombosis, infection, seroma, etc. This outcome data is amenable to change, as medicine progresses and octagenarian lives longer, even with ESRD (further highlighting the importance of constantly making progresses and updating on clinical research). In addition, patient with ischemic heart disease and ESRD have poor survival on hemodialysis, so delaying surgery for dialysis access and managing them conservatively are preferred.

You see the importance of clinical research on outcome of patient receiving treatment modalities such as different hemodialysis access, with different patient characteristics and co-morbidities. This has significant applicability on our decisions as surgeons, and definitely guides treatment. This is but a small example of many important clinical trial and followup studies that are going on currently. I urge all of you to learn your basics on the journey of becoming a great surgeon and doctor, but keep updated on the current research on your interested field.

 

 

Extent III TAAA Sandwich Technique – Apprenticeship from Dr. McKinsey

I just had a week of sub-I at Mount Sinai West, where Dr. James Mickinsey practices. For those of you who don’t know, he is internationally known for treating complex aortic cases, and the primary reason I was so excited to extend my stay one more day in this hospital that I have to travel 40 minutes each way. Below is a description for a sandwich technique for an extent III TAAA case I scrubbed.

Patient is a 84 YO AAM who has been followed by Dr. MicKinsey for an extent III TAAA that was >5.5 cm and had ulcerative plaques. The method of repair was going to be so called “Sandwich technique”, where chimney graft for visceral arteries will be sandwiched by two aortic stent grafts (schematics shown below). This technique was designed to bypass the expensive, time consuming step of personally designing fenestrated/branched TEVAR graft for each patient with TAAA that needs visceral artery coverage, and allows off-the-shelf selection of stent grafts.

Schematic drawing of the repair. Top picture shows deployment of first thoracic stent graft and cannulation of celiac and SMA from bilateral brachial cutdown. Middle drawing shows the finished product after sandwiching the balloon expandable stents in celiac and SMA by another aortic stent graft at the distal end of the first one. Bottom drawing shows the cross section design of the aortic and chimney stents, as well as gutters.

RIght CFA, with less iliac tortuosity was accessed and dilated up to 22F for deployment of the first thoracic stent graft, and left CFA accessed with 5F sheath for aortogram. Usually, axillary arteries would be accessed with cutdowns to cannulate the visceral arteries and deploy the chimney stents. Due to a history of hemi-facial and hemi-torsal burn with prior skin grafts covering the left chest and axillary region, cutting down on the axillary would lead to future skin breakdown, so we performed bilateral brachial artery cutdowns instead. One setback for the brachial cutdown is that since the patient’s arms would be abducted and extended, rotating the C-arm to get lateral fluoro views would be difficult. We solved this problem by abducting patient’s arm minimally, giving just enough space for adequate rotation of the C-arm. This might not be possible for obese patients.

Bilateral CFA were accessed first. Aortogram was taken to assess the TAAA, access vessels and visceral branches. Right CFA with less tortuous iliac artery was chosen to be the route of deployment of the first thoracic stent. Bilateral brachial cutdowns were done (an attending at each side with Dr. McKinsey monitoring outside, a common set up of lineup in a complex aortic case here as I’ve heard). The celiac axis and SMA were cannulated from above, balloon expandable chimney stents were inserted and deployed at the same time, with the proximal ends above the upper border of thoracic stent graft. The second aortic stent graft was deployed, sandwiching the chimneys, and the whole system was dilated with CODA balloon, but carefully avoiding the origins of celiac and SMA. Completion angio showed no endoleak. Whether or not to cover the renals then deploying a third aortic stent graft for a second sandwich were discussed, but due to the elderly status of the patient and the extent of coverage possibly leading to spinal cord ischemia, we decided to call it a day.

What a wonderful case that shows how far vascular surgery has come. From open surgery 20 years ago to endovascular cases nowadays, the field of vascular surgery has truly evolved with respective to time and technological innovation. Dr. Frank Veith (surgeon who performed the first EVAR in the U.S.) said in his presidential address during SVS annual meeting a while ago that vascular surgery needs to evolve like Darwinism. Dr. McKinsey’s practice is not only fascinating and unparalleled, but also definitely a representation of Dr. Veith’s vision.