Don’t Burn Bridges

I’m in the middle of my away sub-I at the Mount Sinai hospital in NYC. Frankly I have not been worked this hard since my crush in high school. Get up at 4am, rounds at 5:15, 3-4 cases through the day with barely enough time to shove down lunch, then rounds and conclusion of the days usually around 8-9pm. Even though I barely have time for leisure, I am learning so much and making great progress in becoming a great vascular surgeon. I think training here would be phenomenal.

Every Friday there is protected teaching conference. This past Friday, we went over a presentation on femoral-popliteal arterial diseases. When discussing the treatment options between open vs endo, something Dr. David Finlay said made an impression on me.

“Don’t burn bridges.”

That’s is the prerequisite of endovascular treatment. You give patient a better quality of life by intervening through endo but you shouldn’t burn future back up plans for bypass, or worse, turning a claudicant into critical limb ischemia.

Let’s say a gentleman with intermittent claudication after 3 blocks with calf pain comes to you for advice for failing medical management. You in your good grace decide to do diagnostic angiogram. You see a moderate CFA stenosis and a severe SFA stenosis in the right side. You plasty it but it is no better despite multiple attempts. What do you do?

This scenario touches the concept of preferential flow. When SFA becomes critically stenosed, the flow to lower leg switches to the profunda. Just like when the vena cava is thrombosed and the azygos system takes over. In this patient, the profunda is compensating for the flow to the lower leg. If you get too aggressive with endo and dissect the CFA, the whole system goes down and your backup plan becomes AKA instead of bypass.

A lot of factors affect our decision of how aggressively we intervene for claudicants, such as TASC II grade, medical stabilization, angiographic findings, success of medical management, etc. the most important factor that I believe is how much the claudication is affecting patient’s quality of life. We are not god, but what we can do and our ultimate goal as vascular surgeons is improve patient’s quality of life. Very frequently, the best treatment is let the claudicants be, especially if they tell you a story that doesn’t convince you their life is dramatically altered by their ischemia. I’ll Keep this in mind when I practice.

Listen to the patient, and don’t get aggressive with endo and end up burning a bridge that was elegantly built by patient’s own vascular anatomy.

Timely Aggression – Lesson from Poker

I’ve been playing poker ever since beginning of high school. Started with $10 buy-in tournaments with friends, then $20, $50… Eventually I was playing $1/$2 cash games, then $2/$5, $5/$5 PLO, and eventually capping at $5/$10 home games.

I was able to roll up my bank roll with disciplinary money management, reading away from tables, watching Youtube videos, googling advanced strategies, etc. One key lesson, among many others, is what I call timely aggression. It might take a long time to build up the image that you’re a manic gambler, but once you flop that made-hand, you play it aggressively like you would with your marginal hands and bluffs. People eventually pay you off with their marginal hands, while you hold the nuts. To sum this up in simpler terms – you appear aggressive while doing damage control with your bad hands, and you get similarly aggressive with your big hands.

Now, contrast this timely aggression with the management we choose in vascular surgery. This is appropriately illustrated in a case of endovascular case in a patient with previous open AAA repair with Dacron. The plan was to stent cover a new stenotic segment within the right common iliac portion of the graft. The surgeon met quite a bit of resistance when trying to advance the sheath before stent deployment. He forced it up, but angiogram after adequate positioning showed blowout disruption of the distal anastomotic site on the right, between the Dacron graft and the native subclavian vessel.

This image is pretty similar to the one I saw during M&M.

Instead of acquiring proximal control from contralateral side with balloon and opening up the groin (aka timely aggression), the surgeon decided to deploy a Viabahn stent over this rupture, basically creating a free floating tube with only radial force of Viabahn keeping itself in place. Meanwhile, patient continued to hemorrhage and became hemodynamically unstable, in the end requiring opening laparotomy to control the hemorrhage and repair of the anastomatic rupture.

Another option besides primary repair of the ruptured site is a aorto-uni-iliac stent graft, fem-fem bypass, and ligation of the proximal side of ruptured side.

When the situation calls for it, timely aggression with open vascular surgical procedure is needed. With endovascular approach being increasingly prevalent, the open procedures are a lost art due to decreased utility, training and some might call “laziness”. I firmly believe in the importance of betting my strong hand aggressively in poker, as well as being ready for open procedure and damage control when situation calls for it.

Podcast – Chronic Venous Insufficiency

Please feel free to listen to the unedited version of the podcast episode I created for Surgery 101, sponsored by University of Alberta. It is on chronic venous insufficiency, a topic I believe students do not learn enough about in medical school. My recording starts at 1 minute mark. Enjoy!

Axillo-hepatic-profunda bypass?

Say what?

That was my response when my vascular surgery mentor from med school told me about her plan.

“Yap, I’ve done it before. It’s the only viable option we have left.

The patient is a Caucasian female in her late 50s. She has extensive aorto-iliac occlusive disease, and status post past aorto-bifem bypasses that failed and salvaged with stents and fem-fem. The fem-fem then failed and more stents were placed. She is now presenting with postprandial abdominal pain, weight loss and food fear, a classic triad of chronic mesenteric ischemia, as well as right sided lower extremity rest pain. Her aorta had extensive calcification throughout, including the supraceliac region, and there was no inflow site adequate for an aorto-mesenteric bypass. Fortunately, extra-anatomical bypass was never done for her in the past. Duplex revealed retrograde flow at common hepatic artery and CT revealed a patent hepatic artery despite severe stenosis at other splanchnic vessels. CT with runoff showed a patent right profunda artery with distal collateralization.

So the outline of bypass was something like this:

In the end, the patient gained palpable right lower extremity pulses and audible doppler signal throughout the branches of her SMA.

Some takeaways and pointers from this procedures are listed below:

  • Tunneling via midaxillary line if axillo-fem bypass only; tunneled deep to the pectoralis major and into the abdominal cavity under the costal margin if axillo-mesenteric bypass. In this case, the tunneling was via right midaxillary line but one of the bifurcated limb of graft was swung over the costal margin into the peritoneal cavity.
  • Third part of axillary artery after emerging from pec minor was used for inflow. This part of axillary artery gives simpler exposure (need to split pec minor/major if more proximal part is used).
  • Ringed PTFE graft for simple procedure (no need for vein harvest) and it is protected from kinking compared to GSV.  However, if bowel were infarcted then GSV preferred due to less likelihood of graft infection.
  • Greater omentum was first sutured around the entry point of the graft into the abdomen and then invaginated over the main body of the graft using interrupted Vicryl suture to exclude it from peritoneal cavity.
  • Interposing vein collar/cuff was not used, but it might have been a good idea…
  • The smaller size of graft is preferred (8mm). A larger diameter will result in slower velocity, increasing the buildup of pseudointima.
  • Endarterectomy of visceral arterial ostium not possible due to no clamping site at supraceliac aorta due to calcification. However, this might be an option if clamp site as present (or do a thoraco-hepatic-profunda bypass)
  • Endovascular intervention was out in this case due to prior aorto-bifem (thrombosed proximal CFA) and supraceliac calcification (rendering brachial approach difficult).
  • Axillary inflow might just serve as a bridging procedure to allow temporary clinical stabilization and definitive reconstruction at a later date. However, in this patient it will likely serve as definitive repair.
  • Renal arteries were patent in this patient, so even though aortic plaque usually originates at the infrarenal aorta, this patient just had ostial lesions at the visceral branches and atherosclerosis of supra celiac region, which represent a rarer progression of aortic atherosclerosis.

If one knows what she is doing, one can achieve great things in what seems to first timers as really funky ways.

SVS Annual Meeting – A Carnival of Expert Surgeons and Professors

This is my 5th day in the stunning San Diego for the 2017 annual meeting of Society of Vascular Surgery. I would just like to say that a less than a week of exposure among these brightest minds of vascular surgery beats months of clinical rotation. You name it: cutting edge research symposium and lectures, technique simulation and practice, exhibition of new technologies for the OR, networking with renouned surgeons and professors (Dr. Frank Veith!), and even mock interviews with program directors. I would highly recommend this event to anyone who is interested in any surgical specialties, or just want to explore the still not-so-well-known field of vascular surgery. They are generous with their scholarships, so apply for them and they just might pay for your trip next time.

Take What’s Given to You

I attended the WNY vascular surgery symposium this weekend, and something Dr. Bower, chair of vascular surgery at Mayo Clinic said really resonated with me. He told the young surgeons and trainees in the audience to “take what’s given to you”.

Let me give this a little more context. Dr. Bower was talking about the slick open IVC reconstruction that they perform for primary and secondary thrombosis of IVC, and he was saying that one really has to look hard at feeding branches of these big vessels and control them as much as possible to prevent hemorrhage. I believe this notion can be applied to all surgeries, and to life. Not everyone is made the same way, just look at the variants of the aortic arch. Therefore, if life hands you a lemon, or take one away from you, you should be able to take advantage of the situation and change on the fly.

Image result for ivc reconstruction

Us medical students spend years learning about basic and clinical science. We learn about pathognomonic findings and evidence based guidelines. These information serve to steer us to the right clinical decision. To be able to adapt, however, we need to master these basic knowledge, go through rigorous training, and collect immense amount of experience. Eventually, when life hands you a lemon (you expose the IVC and find aberrant renal vein), you slice it and put it in a Corona (vessel loop, ligate, re-implant, etc).

Don’t blindly stick to any “rules”. Rules are there to guide you, but not define you. Be able to adapt to the situation, and do what’s best in each individual situation. Take what’s given to you, and milk the heck out of it.

Infra-popliteal bypass – longest case by far

Below is a short and sweet version of the longest surgical case thus far in my short and sweet medical career:

Patient is a 47 years old Caucasian male with IDDM, past stroke, past DVT, PVD, and HTN. He has a dry gangrenous ulcer in the plantar aspect of his right first metatarsal, and occlusion of anterior tibial artery. He is scheduled to undergo femoral to peroneal artery bypass with great saphenous vein.

Image result for popliteal to peroneal bypass

Common femoral artery cut down was performed first for pre-op angiogram; this was partially due to the uncertainty of where exactly the occlusion is and patient’s vascular anatomy. We saw completely occlusion of the anterior tibial artery and distal portion of the posterior tibial artery after the takeoff of peroneal artery. The popliteal artery and peroneal artery were patent. Next, the deep compartment of the mid calf was dissected from the medial leg to skeletonize the peroneal artery. We also skeletonized the popliteal artery because we decided convert the procedure to popliteal to peroneal bypass. Afterwards, we proceeded to looko for the GSV in the medial malleolus, but the vein was too small (lower threshold is 3mm in diameter, but ours was much less). Therefore, we retrieved the GSV from up to, following the sephaneous-femoral-junction. Finally, we heparinized, dilated and anastomosed the venous conduit. Due to the difficult, delicate dissection of the deep compartment of the leg, difficulty exposing the GSV, the changing of procedural planning intra-op, and not having the imaging study pre-op made the whole case around 10 hours. Luckily, the goal of re-perfusing the foot as accomplished, with biphasic pulse on doppler post-op.

The take away from this case is for me is the importance of being prepared before diving in. The fascinating part about vascular surgery for me is the options of choosing your strategies for the battle – like a tactician – may it be open, endovascular, medical, or expectant management. The choices branch out further with each category of treatment. However, in this case since we didn’t have a strong plan going in, we were not able to change our plan smoothly on the fly. The result? 10 hours of anesthesia for patient instead of 6. On a good note, there were lots of dissections and anatomy structures that I learned, rather serendipitously I would say though…

Finally, I learned the luxury of having a stool in a marathon case.

Looking for the Zebras

When I started third year of medical school, I was a zebra whisperer. I think it’s the result of studying so much for Step 1, and reading First Aid trying to memorize the rare diseases. Oh, she has slightly low platelet count and elevated creatinine, we must think about TTP. When in fact AKI was enough to explain her clinical presentation. However, this mentality of painstakingly turning over every stone has helped me in one very memorable instance…

A zebra ^_^

A manic patient from the psych floor in her 40s was transferred to my inpatient internal med unit when I was doing medicine rotation. She (fortuitously you may say) fell on my lap as one of 4 patients I am responsible of following. She experienced syncope and was found to have bradycardia thereafter. She also complained of persistent pain in her left foot. Her HR was normalized by atropine and bedrest, but her foot pain was unabated. My team thought she was malingering because the beds in the psych wards were infamously uncomfortable, but I was unconvinced. I performed the Ottawa Foot rule on her and she was positive at two spots and in addition she was unable to bear weight. I asked for a foot Xray and it was granted. To my dismay, it came back negative. Still skeptical, I meticulously looked at the images myself. I was able to locate a cortical discontinuity on head of first metatarsal on the oblique view. I ran it down to the radiologist’s office for a curbside consult (my favorite type of consult), and he blamed this oversight on his wife’s mistake of making decaf that morning. A noncontrast CT revealed nondisplaced fracture on the first, second and third metatarsal head, and ortho came back and put her in a walking boot the next day.

To the exhilaration of my team, they put this encounter in my final evaluation at the end of my clerkship. Frankly, it was just the way she grimaced and flinched in pain that made me go above and beyond to find the cause. You may say what’s most common is a simple sprain or malingering, but I didn’t want to stop there given how she presented to me. I also think in this case being a psych patient did not help her problem. It’s definitely ideal keep the prejudice out of patient care, and base decision on clinical presentation and patient’s well-being. I am getting better at focusing what’s common these days, but still keeping the zebras in a glass cage so it can be viewed when needed.

Radical Approach and Surgical Menopause – What’s Best for the Patient?

I met a patient during GYN surgery rotation, a 33 years old with stage 4 endometriosis. I watched and assisted her trans-abdominal hysterectomy, bilateral salpingoophorectomy, adhesion lysis and intra-op bilateral ureteral stenting. She had chronic pelvic pain and menorrhagia for years that were refractory to many conservative management such as OCP, progesterone depot shot and D+C. Patient experienced prolonged ileus post-op so she has been a hot topic during our discussion in sign-out (not that she needed it).

Sketch of Radical Abdominal Hysterectomy

Several points about her management were discussed. First and foremost, was trans-abdominal approach the best or could it have been done less invasively via robot. The surgeons who performed her case were concerned about the overabundance of adhesion bands and the extensive resection that was needed, so the invasive approach was chosen. However, a consultant physician who specialize in minimal invasive GYN surgery advocated for the robotic approach when we discussed her post-op status in sign-out. I think there is also a third option of doing a robotic assisted exploratory laparoscopy first, and back out when the adhesions, anatomical distortion, etc pose too much of an obstacle. Of course, you have to be absolutely frank with the patient before the procedure, but this would grant us an opportunity for attempt a much less invasive route with less chance of intra- and post-op complications.

The second dilemma was whether oophorectomy was needed for this 33 years young female. We all know the pathogenesis of endometriosis is estrogen driven, but was removal of both ovaries, creating a surgical menopause, and having the patient be on hormone replacement therapy for 10+ years indicated? From what I found, patient was tired of her dysmenorrhea and had no wish for future childbearing, but I did not think she had a full grasp of predicament of menopause at 33 years old and long duration of hormonal therapy when I talked to her before and after the surgery. Besides, the clinical presentation of endometriosis has absolutely no correlation with severity of lesions grossly (especially when we did not find any ovarian cyst), and less radical approach might have resulted in similar clinical outcome.

I believe I can extrapolate the ethical dilemmas encountered in this case and broaden them to all areas of medicine. It is paramount to go over all treatment options with a patient before reaching a decision. It is also necessary to work towards a goal of patient’s best interest. In this case, perhaps more exploration of treatment alternatives would have changed the course, and perhaps a thorough education about the gravity of early surgical menopause and long term hormonal replacement therapy would have changed her mind and management. I also wonder if more extensive discussion and collaboration among the surgeons would have changed the course of treatment for this woman.