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Top Ten Things -Tech Gadgets- That Have Grabbed My Attention, 2021

Okay, so I have made this intermittent list of top ten gadgets and gewgaws which I used to to call “Top Ten Things to Get Your Favorite Vascular Surgeon” but even in jest, over the years that I have been publishing this blog, the world has changed. As a watcher of technology, I have always had my eye out for the next great thing, and here is my list. I hope you all have a great Christmas and a wonderful New Year.

  1. Giant Laptops with Complications -old automatic watches with complications are still coveted, and the tech space is no different. Whereas, Apple has always veered to minimalism, there is an exuberance to adding “stuff” in among the Chinese manufacturers and ASUS is no different.

This laptop, the ASUS ZenBook Pro UX581 is a perfect example of innovation by jamming as much possible onto your ADHD-addled field of view. What would I use it for? Who knows, but I want!

2. Timex watches retroversions. Like automakers making updated versions of classic muscle cars, the old standby Timex, has launched watches that that make you want to party like it’s 1979.

The Navi XL Automatic 41mm by Timex is beautiful to look at and of all the knockoff Omega Seamasters out there, it is nice to see a classic American branded offering. Cheaper watches are a smart thing for surgeons in that it’s easy to lose them when you take them off to scrub for a case. While Apple watches are popular, the only square watches I like are Cartier Tanks, and for health data, I wear a Fitbit on my right wrist.

3. Entertainment tablets have made the large family TV obsolete. Add in good audio, and you have that weird future that they promised back in the 1980’s when they swindled your parents to buy a $3000 computer that really couldn’t do anything.

The Lenovo Yoga Tab is an incredible value for what you get which is a bright screen, fast enough processor, long battery life and great sound (JBL speakers with Dolby Atmos processing). It comes in 8, 10, and 13 inch sizes. Coupled with a keyboard and mouse, and an Office or Drive account, and you have a very portable workstation. The only thing missing is the ability to draw as it does not pair with a stylus.

4. E-ink based tablets. If you have ever had a Kindle, you know what an E-Ink based tablet is like. Viewable in direct light, these displays have the advantage of minimizing fatigue in the same way paper does compared to staring at a monitor. These 3rd generation tablets run full Android and can run the Kindle app, as well as advanced note taking and PDF markup software, and have that warm backlighting that comes with the modern Kindles.

The Boox Max Lumi does all of that. Paired with a keyboard, it recreates a basic typewriter well. It also functions as a second screen, allowing you to stare at and markup documents driven by a laptop computer. I want.

5. The modern update to the Psion Series 5mx. The Psion Series 5mx was a pocketable computer that ran a very efficient operating system, powered by two AA cells which lasted up to 40 hours, and had a tiny keyboard that with practice was fine for authoring chart notes that I would then print out to HP printers that that infrared ports (IrDA). This allowed me over a three year period of residency, to collect my personal EMR that I kept on a huge for that time 32mB flash drive. I sold my 5mx, along with a considerable box of hard to find accessories, to a journalist in Mexico who needed to author articles and fax them to his paper in 2007.

The Gemini PDA was made by a group of engineers and programmers who remember that time and updated the Psion Series 5mx form factor, down to the legendary keyboard. Available in Android and a Linux, it is a pocketable microlaptop.

6. Asian stationary, notebooks and pens, are next level. In certain malls in coastal cities in the US, you can find the odd Japanese store that has a section for stationary. The bindings are fantastic and the pens work forever. My favorites are mechanical pencils and fountain pens, which despite the incredible builds, are really affordable.

For example, the Planting Tree Paper Bind Ruled Notebook 5 Piece Set, available from Muji, is available for 2.99 on line and are great looking and durable.

7. Instant Coffee is anathema to serious coffee snobs. I have a friend who keeps a water heater, lab style glassware, digital food scale, and grinder to make a perfect cup of drip brewed coffee for himself -a fifteen minute process. The disposable pod coffees -blurgh. In Abu Dhabi, I got introduced to high end instant coffees at the grocery -the packaging and brands oozed luxury, and the coffee was much better than the instant coffee I grew up with.

Mount Hagen Fairtrade Organic Freeze Dried Coffee is what I found as an alternative to the old instant brands that represented bad instant coffee. This stuff mixes well with cold water as well, and delivers a bright kick of caffeine. It lets me make a to-go cup of coffee, well, instantly.

8. Headlights are always fun, but running in them is challenging because they sit off the center axis and tend to drop down. I have tried many times to incorporate them as cheap operating room headlamps, but failed largely as they are not bright enough. These light band headlamps which popped up in my Facebook were intriguing.

These lights (link) have both the light band which is amazingly bright and a regular flash light on the side, both of which can be turned on by waving your hand by a sensor next to your head. I thought this was the answer to my search for a cheap OR headlamp (the regular ones cost way over 1500USD), but the problem is that anyone looking at you is immediately blinded and their retinas seared. But for running, these forehead based high beams are amazing.

9. If you are surprised at the lack of Apple products, it’s because I typically aren’t in the market for them. They last forever. My 2007 Macbook Pro still runs, survived a major upgrade which included maxing out RAM and swapping the spinning platter hard drive for an SSD, resulting in lightning speed. Unfortunately, they are exhorbitantly expensive and so I find myself hesitating at purchasing a 2500USD laptop, especially one that I can no longer upgrade and maintain as I could the older Apple laptops. The problem is the battery and the SSD. They have finite lives. You can still buy batteries for the 2007 Macbook Pro, and get all day work from several batteries. Apple solves the problem of owners keeping their Apple gear for decades by imposing obsolescence, and recently even slowing down the performance of older machines to get owners to buy new iPhones.

So this makes the purchase of iPad, Macbook Pro, and even the iMac problematic in that they are all closed box systems with limited lifespans. Of the recent Apple products, the best bang for the buck comes from the Mac Mini. The older ones from 2012 can be found in droves, refurbished, and can still be upgraded, but the new ones with the blisteringly fast M1 chip that can run iOS apps is worthy of my consideration. It may be the last Mac that I ever purchase. My 2007 MacBook no longer runs the latest OS version, and I will be turning it into a Chromebook.

10. Typewriters are a fantastic way to write. They don’t let you check social media or email, and encourage that focused state where words just flow. That is the concept behind the Freewrite and its special edition Hemigwrite.

Whatever you type gets stored in you choice of cloud account, including Google, Dropbox, and Evernote. You can work on 3 different files, and as you type, the Wifi connection updates your file in the cloud. The keys are that clickety clack mechanism reminiscent of original keyboards from the 80’s, and the E-Ink screen, now backlit on this beautiful aluminum clad Hemingway edition of the Freewrite, makes it easy on the eyes. The great American novel awaits to come erupting out of your head.

Categories
AIOD aortoiliac occlusive disease (AIOD) Commentary humor opinion PAD

Perfectly Compulsive, Perfectly Smart

Recently, in clinic, my nurse handed me the patient sheet with the comment, “this is for iliac stents.” This caught my attention as “iliac stents” does not make sense as a chief complaint. The patient had been sent with a vascular lab report. It was a duplex scan documenting peak systolic velocities over 300cm/s in the common iliac arteries, appropriately diagnosing 50-99% stenoses. The patient had hip and thigh pain with walking short distances. I could have been excused for just cancelling the visit and booking an angiogram, except that would make me just a technician responding to a request. So I talked to the patient.

The patient was a nice lady over 70 years of age with recent onset of hip and thigh pain with walking 50-100 feet. This was incapacitating her as she was used to living an active and independent lifestyle. Her pulse examination was normal, not an uncommon finding with aortoiliac occlusive disease which manifests as a hemodynamic phenomena best explained as “small pipes.” Except she had never smoked, and had only hypertension and mild hypercholesterolemia. The review of systems was notable for fatigue and arm and shoulder pain. While she had not lost weight, strangely, her jaws hurt when chewing food.

I do not claim any kind of magic skills when it comes to diagnostics, but these other complaints did not fit. And it is not uncommon for someone to have several common conditions. Maybe she had TMJ, shoulder arthritis, early heart failure, and aortoiliac occlusive disease, to fit all of her complaints. Why was I wasting my time diving into nonvascular ephemera when I could be sending her to be scheduled for an aortogram and iliac angioplasty and stent?

I’ve carried with me this notion that all physicians can be mapped on x-y axes with one axis representing degrees of intelligence peaking at perfectly smart. Perfectly smart doctors have seemingly magical skills. While they are not rolling back their eyes while waving their hands over the patient, the handful of perfectly smart physicians I have worked with can quietly listen and digest a case and come up with the diagnosis, no matter how obscure and rare. On the other axis is compulsion, with the perfectly compulsive marching their patients through every test and algorithm to rule out every diagnosis on a exhaustively long differential list.

Intelligence and Compulsion, Written with a Doctor’s Penmanship

Those striving to be perfectly smart hope to bring efficiency to the clinical process -such as for this patient, it would have made sense for efficiency’s sake to move forward with an exercise treadmill ABI test and booking for an aortogram. Those stuck in perfect compulsion never quite reach a diagnosis, even after ordering batteries of tests, but rarely make mistakes, which is the point of perfect compulsion, because if you carpet bomb the diagnostic possibilities, something will hit. They are especially bulletproof to malpractice, particularly when patients choose not to have any more tests out of exhaustion. Their patients are rarely happy having to go through a myriad of tests to paint away the rule-outs while never quite identifying the disease. Those who play around with being perfectly smart get burned by that which are unknown and unfamiliar. They get blindsided. You want to revert to compulsion when you are tired and overloaded. You want to be smart, all the time.

The point of training, which never ends, is you have strive to be both perfectly smart and selectively compulsive, but it’s better to be lucky than good. It was my luck that I recently reviewed temporal arteritis. Every few weeks, I get asked to remove temporal arteries, and choosing not to be just a technician (although admittedly in the workup of TA, we kind of are), I plowed into UpToDate and Pubmed, seeing if there was a way out of doing these procedures -there really is not, except in the requests for temporal artery biopsy in younger patients -go read it yourself. It was here that I refreshed myself on polymyalgia rheumatica, which has as its symptom complex, muscle pain, lethargy, and jaw claudication. Out of duty, and compulsion, I ordered a CTA, because I knew that the patient had risk for atherosclerosis and arteries stiffened by calcium can have elevated velocities without critical stenoses. Out of curiosity, and after a quick call to one of the Clinic’s rheumatologists who order these temporal artery biopsies, I ordered an ESR and CRP.

The CTA came back with calcium at the aortic bifurcation and origins of the common iliac arteries where the outside duplex showed elevated velocities, but only revealed mild disease on the CTA. Both ESR and CRP came back very elevated. I referred the patient to our rheumatologist, and with steroid therapy, all of her symptoms resolved. Without an aortogram or stents.

I sat and thought about this for a while before posting. The patient was quite happy to give her permission. I cannot fault the outside vascular lab for their diagnosis of iliac stenosis because the diagnostic criteria are basically the same as our labs. It has made me think that approaching this case as a revenue opportunity as increasingly happens would not necessarily have been in error if I had performed an aortogram as long as I did not place stents. I can’t imagine the pressures put upon physicians who have put themselves into situations where they are paying for costly angio suites or their own 90th percentile salaries and lifestyles from not over-calling a stenosis and deploying stents, particularly when there is no oversight.

41 percent of my patients with median arcuate ligament syndrome present missing their gallbladders because biliary colic was the diagnosis that was both familiar and vaguely fit the complaints (reference 1). Not much harm can come from taking out a gallbladder, no? We know that a minority of operators harvest a significant share of the Medicare pie when it comes to peripheral interventions (link to terrific OPED, reference 2). Oh, I am sure each of these cases can be “justified.” Pleading justification from limits of knowledge means I proceed to treat what I am familiar and comfortable with -vascular disease, rather than an unfamiliar disease (at least to vascular surgeons) like polymyalgia rheumatica. If I can fail to recognize my ignorance, who can fault the perfectly compulsive? Like a broken clock that can be correct twice a day, someone of poor intelligence but perfect compulsion can be more effective than a greedy hack seeking to be perfectly smart and efficient.

Dunning and Kruger found that those with lower competence overestimate their ability, and those with higher competence underestimate their ability. Medicine is a perfect laboratory of Dunning Kruger. To be effective, you have to be correct and assertive. The problem is you are trained to project that confidence in the early stages of training and career when you are not ready. What patient would seek an unconfident physician? What person truly knows what they don’t know? The hardest step in medicine is both admitting what we don’t know but also applying hard-gained knowledge and experience with audacity. True humility comes from self knowledge and awareness. False modesty is externally directed, but true humility is internally focused. I don’t have a pat answer, but to become perfectly smart, you have to be perfectly compulsive about filling your knowledge and experience base. You have to submit your complications for peer review, you have seek and collaborate with sound partners, and you have to avoid financial traps that bias you to bad behavior. Above all, you have to stay curious.

References

  1. Weber JM, Boules M, Fong K, Abraham B, Bena J, El-Hayek K, Kroh M, Park WM. Median Arcuate Ligament Syndrome Is Not a Vascular Disease. Ann Vasc Surg. 2016 Jan;30:22-7. doi: 10.1016/j.avsg.2015.07.013. Epub 2015 Sep 10. PMID: 26365109.
  2. Sheaffer WW, Davila VJ, Money SR, Soh IY, Breite MD, Stone WM, Meltzer AJ. Practice Patterns of Vascular Surgery’s “1%”. Ann Vasc Surg. 2021 Jan;70:20-26. doi: 10.1016/j.avsg.2020.07.010. Epub 2020 Jul 29. PMID: 32736025.
Categories
bypass complications graft infection mycotic aneurysm open aneurysm surgery peripheral aneurysm pseudoaneurysm skunk works techniques

EIA pulldown transposition: another way to treat infected common femoral pseudoaneurysm

Patient with infected femoral pseudoaneurysm, skin necrosis, about to blow

A surgeon from Nepal posted a case of a ruptured common femoral pseudoaneurysm infected from IV drug abuse on LinkedIn. The comments centered around typical textbook responses which were:

  1. Ligate, debride, obturator bypass
  2. In situ bypass with femoral vein +/- sartorius flap
  3. Rifampin soaked graft or crypreserved allograft
  4. Ligate only

My preferred treatment is #2, in-situ bypass with harvest of adjacent deep femoral vein. I never liked that procedure because in general in these patients, everything bleeds. Then I had a thought -how about if you mobilize the external iliac artery in the pelvis over its entire length and pull it out from under the inguinal ligament to sew to the femoral bifurcation or SFA? That is, when you enter the pelvic retroperitoneum to gain proximal control:

The external iliac artery is usually redundant and elastic in young people

You mobilize the external iliac artery from the iliac bifurcation to the inguinal ligament, detaching the inferior epigastrics as a last step. And then you pull it out from under the inguinal ligament, and anastomose it to the femoral bifurcation or the SFA.

The mobilized external iliac artery is pulled down to reach normal femoral artery. The distance x is the length of CFA that needs replacing

This makes sense because in young people and those with AAA and minimal atherosclerosis, the external iliac artery is both redundant and elastic, making it suitable for a pull down transposition. But then, how do you know as you mobilize the artery in the pelvis that you have enough to pull down?

Pythagoras figured that out two an a half millenia ago. If you measure the straight line distance from iliac bifurcation to the takeoff of the inferior epigastric arteries, you get the straight line external iliac artery distance. The length of the common femoral artery which is the excess EIA length needed, is assigned the value x. Then the height of the stretched artery off the line between the iliac bifurcation and the inguinal ligament will determine how much extra artery you have.

Taking these values, I did some maths.

The solution for h, the height, is highlighted in yellow below. (note, the variable x in my notes is half the length of CFA, l is half the length of EIA, ie. 2x is CFA length).

Creating a spreadsheet for CFA lengths from 2 to 6cm and EIA straight distances of 5-10cm, the ratio of height H to CFA length varies from a minimum of 0.7 to maximum of 1.7 with an average of 1.1. That means the majority of the time, if you get 1.5x the length of CFA height off the pelvis, you should reach.

If you are short, you can detach the profunda and mobilize the SFA, pulling upwards, then reattach the PFA. Though this is entirely a thought experiment, there is no reason why it should not work. As with most things, I predict that it already has been done!

The advantages are using autologous tissues and leveraging the natural anatomy. There is a cost benefit in that OR time is shorter with less time for venous harvest and avoiding grafts, patches, and devices. The patient would avoid ischemia as would happen in the staged repair. The disadvantage is when you are short, but if you mobilize the appropriate amount (height off pelvis at least 1.5x the CFA length) you should be okay. The more curvature and tortuosity seen on 3DVR recontstruction and absence of significant atherosclerosis would predict feasibility.

Categories
AIOD aortoiliac occlusive disease (AIOD) bypass complications cost innovation graft infection techniques

The Story Should Fit: Repair of a Stent Graft Infection with Aortoiliac Endarterectomy and Bovine Pericardial Graft

One of the greatest surgical texts, Cope’s Early Diagnosis of the Acute Abdomen, is something every surgical resident, vascular or general, should read. The mid-century edition which I owned during my residency, has since been updated, but the central message of the book is this: every complaint or pain the patient has comes from a nerve, either peripheral or visceral, and understanding the nature of the pain, you narrow the diagnosis to only a few possibilities. Irritation of the psoas muscle results in a characteristic pain that years of diagnosing appendicitis the old fashioned way -by exam, then operation, makes it easy to recognize, like Marilyn Manson showing up as your substitute teacher (I would have said Alice Cooper, but that completely dates me). When the psoas muscle is irritated, by a hematoma, injury, inflammation, or abscess, the muscle relays intense pain localized to the retroperitoneum. Stretching the muscle worsens the pain, and the patient is often seen with the ipsilateral hip flexed. The genitofemoral nerve which rides on top of the psoas, is triggered and there is pain referred to the groin and proximal anterior thigh. Seeing this, and fitting the story allows for a diagnosis, before imaging. Without this insight, there is no swift vector to treatment and resolution.

Patient with inability to straighten left hip after iliac stent placement

The patient, a middle aged man, had undergone a redo-iliac angioplasty and stent for left iliac in-stent restenosis. He relayed that on the table, he felt immediate left lower quadrant abdominal pain and the desire to flex his left hip. He was restrained, sedated, and the procedure finished -a covered stent had been placed. When he came to my office a month after his initial procedure done elsewhere, he was in wheel chair, unable to straighten his leg. He claimed before coming to see me, he had gone to another hospital, where he had a CT scan and was told nothing was wrong (will have to confirm). He was having subjective fevers at home.

On examination, he sat on the exam table with left hip flexed. His pedal pulses were easily palpable. He had furuncles in his groins which he relayed he had had all of his life. I sent him for CTA and subsequently admitted him for surgery.

left iliopsoas abscess

The CT showed a large collection around the left iliac artery and stents and on the psoas muscle, an abscess. The blood cultures on admission were positive for Staphylococcus lugadensis sensitive to penicillin.

Putting the story together after the fact is much easier than when you are in the moment, but being aware of the location and type of pain should give you a clue. Very likely, he had a brief rupture on the angiosuite table resulting in his sudden pain, drowned out by the sedatives typically given in response to a patient moving when a stent is deployed. Inflating a balloon in an artery typically causes some discomfort -as the vessels are lined with visceral nerve fibers which are quite sensitive but less localizable than say a pin poking on the index finger. If you ever had bloating with gas, that general discomfort localizable to the mid abdomen, that nausea and discomfort is from stretched visceral pain fibers. If you have ever had dull aching pain of distended spider veins, that is visceral pain. It’s there, but you would not be able to pinpoint it exactly. That is not what this patient had when he flexed his hip on the angio suite table. While the covered stent was deploying, he likely briefly ruptured causing both somatic and visceral pain around his left common iliac artery and iliopsoas muscle. Additionally, if the sheath had been entered through an area of a skin abscess, likely the sheath, wires, and gloves were contaminated. Any handling of the balloon expandable stent graft, which I highly discourage, would have contaminated it, resulting in a device infection, which was made more likely due to his diabetes. As the hematoma got infected, it resulted in the worsening symptoms he was having of left lower quadrant abdominal pain, groin pain, thigh pain, and inability to straighten his hip without pain.

I took him to the operating room and drained his abscess, assisted by Dr. Andrew Tang, chief resident headed to CT Surgery fellowship here at the Clinic, and Dr. Jenny Chang, PGY 2 Surgery. I gave Dr. Chang a copy of Cope’s with the admonition to read it soon and pass it on, as most of the current generation claim no knowledge of this important text. While I am not against interventional drainage, it takes time to drain the collection through a tube whereas sticking your hand in, sampling the collection, observing the injury, and breaking up collections and washing out with brown-bubbly -a mix of betadine/peroxide diluted in saline, I believe speeds the recovery from the infection. His drainage was done through a retroperitoneal approach from the left side and notably, his psoas muscle while viable, did not retract to cautery energy, suggesting some degree of rhabdomyolysis. The iliac artery was an indurated, thickened, and hard from the calcium and plaque that was the original problem affecting his distal aorta and iliac arteries (see left arteriogram centerline). I placed a pair of JP drains, removed one that wasn’t draining much on POD #3, and the other about a week after discharge on POD#5. His WBC elevation which was never high promptly resolved. I kept him on oxacillin with consultation from ID, and waited. After 3 weeks, I repeated his CTA.

His right iliac centerline showed patent stent with diffuse plaque and calcium starting in mid infrarenal aorta.

His abscess had significantly resolved and his pain was gone. He was ambulating again.

Before and after abscess drainage

The choices at this point were the following

  1. Continue treatment of patient with supressing antibiotics for life
  2. Resection of left iliac stent graft which is presumed to be infected

If resection chosen, the options for repair that I considered included:

  1. NAIS (ref 1). Neoaortoiliac System graft using femoral vein
  2. Aortoiliac homograft
  3. Rifampin soaked gelatin coated graft (ref 2)
  4. Extra-anatomic bypass with axillofemoral bypass or femorofemoral bypass.
  5. Aortoiliac endarterectomy and repair with bovine pericardial patch and graft

The choice of replacement is becoming clearer in that while rifampin soaked grafts offer immediacy and expedience, all grafts seem to be prone to reinfection at a higher rate than autologous material (ref 3). The NAIS bypass is a great option, but is hampered by the addition of several hours invested in harvest of the femoral veins. While it can be staged with mobilization done one day and harvest another, those added hours add complications. We often forget that the simple metric of procedure time is the most important determinant of complication rate. Any operation going over 2 hours risks wound infection for example simply from ambient colonization of the open wounds from the rain of dead skin from the surgeon’s face, aerosolized fecal flora from flatii (prohibited in my ORs). The microenvironment of the open wound is also room temperature and not 37, having an impact on organ function and hemostasis. The homograft is the original aortic graft -before Arthur Voorhees invented the cloth vascular graft as a resident at Columbia P&S (my medical school alma mater, ref 4), major hospitals had tissue banks of aortic homografts harvested from the recently deceased. Having homografts is now an outsourced function, but does require having proper refrigeration for the cyropreserved grafts and generally can’t be ordered with short notice.

Rifampin soaked grafts work well, especially wrapped in omental flap, in the short and medium term but suffer a reinfection rate that is higher than seen with autologous tissues, and prosthetic grafts without rifampin, such as PTFE for extraanatomic bypass, have the highest rates of reinfection (3), despite being the board answer decades ago.

Endarterectomy allows for use of native tissues for repair. The adventitia around plaque and stents, while thin, can support physiologic pressures, even when they have been occluded for years. And while practice of aortoiliac endarterectomy is a bit of a lost art, it has both a long history stretching back nearly a century and a modern track record with carotid and femoral endarterectomy. It is merely a matter of scale. Pinch and zoom in on a femoral endarterectomy at the bifurcation and you have the same case as with an aortic one.

The question is, is bovine pericardium more autologous than prosthetic? It is a decellularized sheet of collagen from a cow’s pericardium, used in heart valves and vascular patches, but only recently applied as a graft (ref 5-7). I have long used bovine pericardium as a patch with some caution, but the rule of thumb is are there well vascularized tissues around it? A layer of Scarpa’s fascia and fat in a groin wound are not sufficient to protect a bovine patch, but a sartorius flap is. For me, once the infected stent graft is out, knowing if the surrounding tissues bleeds well is an important one.

I chose to do aortoiliac endarterectomy. The patch and graft would be made with bovine pericardium, unless I found the left iliac segment to be devitalized and foul with anaerobic vapors, then, I would close and go NAIS or extra-anatomic. The key point is that choices have to be on the table and constantly rearranged during the conduct of the operation.

The patient was preoperatively vein mapped and had suitable deep femoral vein for bypass conduit, having robust duplicated systems that would impact the patient minimally. The patient was placed in a supine position and via a midline laparotomy, the infrarenal aorta and the common iliac arteries beyond the short iliac stents exposed. I chose this limited exposure as any further into the phlegmon on the left risk injury to ureter and vein. The aorta had a palpable demarcation between plaque and mildly diseased proximal segment, predicted by the CTA to be at the IMA. A longitudinal arteriotomy was created on the right side from mid aorta to mid right iliac, and the left side had a separate arteriotomy to release the stent. The plaque came out in a single specimen (image).

The exposed stent is the left iliac stent holding within a stent graft.

The left iliac artery was destroyed by the infection but the tissues around it bled avidly and were not foul or infected. I avoided excess debridement here as the iliac vein was intimate with the phlegmon. There was a 3cm gap. Again, I thought briefly about taking femoral vein, but proceeded to make a graft from the bovine pericardium. This was sewn around the rod portion of a renal vein retractor from the OMNI set. The finished product resembled Voorhees’ graft. It was sewn into the orifice of the iliac from inside the aorta and end to end to the freshened iliac stump. Unfortunately, the omentum was atropic across the transverse colon, but the tissues around the resected artery and stent graft bled well, indicating good penetration of antibiotic. The retroperitoneum was closed after hemostasis obtained. Dr. Shashank Sharma, our chief resident headed to a vascular surgery fellowship at the renown Houston Methodist next year got to see what is unfortunately a rare occurrence -an aortoiliac endarterectomy, which through me puts him three degrees of separation from Cid Dos Santos (ref 8). Dr. D’Andre Williams, PGY-2 Vascular Surgery Resident, got important lessons on sewing the aorta. She’s part of a fortunate cohort that get exposed to open aortic surgery at our main campus which is unfortunately rare throughout the world.

The pericardium was soaked in rifampin, but probably did not bond to the collagen.

The final graphic shows the operative end result.

The patient recovered well and was discharged within the week with another month of IV antibiotics planned.

Before and After

Conclusion: The operation was started at 8 in the morning and was done by lunch time. For aortic cases, this is a crucial metric, as when the clock winds past the surgeon’s comfort, the patient suffers even more. Adding the femoral vein for a NAIS may have been the textbook thing to do, but we don’t do extra-anatomic bypasses that much either. I don’t believe that adding two more hours for retrieving the femoral vein would have enhanced the procedure, and would have served to add potential areas for complication. Technically, the aorta closes much as with a carotid or femoral endarterectomy, but the adventia is thin and really should be sewn with 5-0 or 6-0 Prolene. The larger needles such as the SH size creates unnecessary bleeding unless sewn with a line of felt which could become infected. Despite the thinness, it will hold pressure if it is not infected. Clamps that bend out of the “airspace” above the laparotomy, such as the Cherry Supraceliac Clamp and Wiley Hypogastric Clamp, prevent limiting the operative space with long clamps such as aortic Fogarty or DeBakey clamps, while being stronger than the Zenker.

A final comment for Staphyloccocus lugudensis. This is the second major vascular graft infection with this organism I encountered this year. The other was an infected aortic stent graft. Lugudensis means from Lyons. I do not know why that is, but it is so far not the nasty player that is S. aureus. I am sure it will share some plasmids, and become resistant one day, but in the earlier case in Abu Dhabi and now this, it is sensitive to penicillin, and came from the skin at the femoral puncture site, and for this we are fortunate. Major vascular infections are one of the few areas that still demand open surgical skills, and we foresake them at great peril. It’s critical to remember all the collective memory of surgery from the past, or we will become mere technicians fixing whatever comes out of the radiologist’s report with whatever knowledge obtained from a Zoom meeting for the latest, greatest device.

Acknowledgement

Gratefully, the patient gave his permission, as with all patient, for use of his case for educational purposes.

References

  1. Chung J, Clagett GP. Neoaortoiliac System (NAIS) procedure for the treatment of the infected aortic graft. Semin Vasc Surg. 2011 Dec;24(4):220-6. doi: 10.1053/j.semvascsurg.2011.10.012. PMID: 22230677.
  2. Oderich GS, Bower TC, Hofer J, Kalra M, Duncan AA, Wilson JW, Cha S, Gloviczki P. In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric erosion or fistula. J Vasc Surg. 2011 Jan;53(1):99-106, 107.e1-7; discussion 106-7. doi: 10.1016/j.jvs.2010.08.018. PMID: 21184932.
  3. Smeds MR, Duncan AA, Harlander-Locke MP, Lawrence PF, Lyden S, Fatima J, Eskandari MK; Vascular Low-Frequency Disease Consortium. Treatment and outcomes of aortic endograft infection. J Vasc Surg. 2016 Feb;63(2):332-40. doi: 10.1016/j.jvs.2015.08.113. PMID: 26804214.
  4. Smith RB 3rd. Arthur B. Voorhees, Jr.: pioneer vascular surgeon. J Vasc Surg. 1993 Sep;18(3):341-8. PMID: 8377227.
  5. Almási-Sperling V, Heger D, Meyer A, Lang W, Rother U. Treatment of aortic and peripheral prosthetic graft infections with bovine pericardium. J Vasc Surg. 2020 Feb;71(2):592-598. doi: 10.1016/j.jvs.2019.04.485. Epub 2019 Jul 18. PMID: 31327614.
  6. Lutz B, Reeps C, Biro G, Knappich C, Zimmermann A, Eckstein HH. Bovine Pericardium as New Technical Option for In Situ Reconstruction of Aortic Graft Infection. Ann Vasc Surg. 2017 May;41:118-126. doi: 10.1016/j.avsg.2016.07.098. Epub 2016 Nov 27. PMID: 27903471.
  7. Belkorissat RA, Sadoul C, Bouziane Z, Saba C, Salomon C, Malikov S, Settembre N. Tubular Reconstruction with Bovine Pericardium Xenografts to Treat Native Aortic Infections. Ann Vasc Surg. 2020 Apr;64:27-32. doi: 10.1016/j.avsg.2019.10.104. Epub 2020 Jan 10. PMID: 31931127.
  8. Barker WF. A history of endarterectomy. Perspectives in Vascular and Endovascular Therapy. 1991;4(1)1-12. doi:10.1177/153100359100400102
Categories
taaa tbad techniques thoracabdominal aortic aneurysm type b aortic dissection visceral malperfusion

Something new in open thoracoabdominal aortic aneurysm repair

Our debranch first technique described by Dr. Niranjan Hiremath and was presented at CX Aortic in Vienna in October. Hoping to collect multicenter experience with this technique.

Categories
techniques thoracabdominal aortic aneurysm type b aortic dissection

Video of TAAA case using debranch-first technique.

www.linkedin.com/posts/w-park-565310a_clevelandclinicabudhabi-activity-6849686801343369216-2cxD

Link to original blog article regarding this case

Link to journal article.

Categories
EndoRE

An Open Letter to LeMaitre Vascular

George W. LeMaitre, Chairman and Chief Executive Officer, LeMaitre Vascular, Inc.

Dear George,

If you go to the LeMaitre Vascular website, there is a link to the story about the company’s founding by your father, Dr. George Lemaitre, which I heard first hand over dinner hosted by him and your mother many years ago. The original LeMaitre Valvulotome has followed me through my career from surgery residency in the 90’s to a recently closed tenure as vascular chief at Cleveland Clinic Abu Dhabi. There is no in-situ bypass that I perform where I am not struck by your father’s story and by the ideals passed by him into the company he founded which had at its core the desire to help vascular surgeons take care of their patients. There are so many other companies, most of them in fact, in this vascular space who are investor-first when it comes to decisions about what diseases, procedures, and specialties to support, but LeMaitre Vascular has always felt different.

For decades, LeMaitre Vascular seemed focused on helping vascular surgeons care for their patients with unique, purpose-designed solutions. Engineering at its finest. It gave life to many ingenious products like Anastoclip, Unballoon, and LeverEdge, that seemed to spring from the minds of working surgeons and physicians directly into their hands, much like the valvulotome. The best ones appealed to the many surgeons who wanted to advantage their patients and their institutions with both lower cost, time efficiency, and equivalent or better outcomes to the usual way things are done. Unfortunately, we live in a universe where the incredibly potent gravitational pull of the investor interests is for high volume, high margin items. This pull greatly exceeds that of the bright yet smaller stars and moons that are common sense, durability, and sustainability. Items that drop out of peel packs, are used once, and thrown into a landfill, have become everything used in healthcare. The sudden absence of EndoRE (remote endarterectomy) on the LeMaitre product page speaks volumes to this. Something that is low volume, durable, subject to repeat use like a set of Vollmar Rings, which are purchase once and used for a long time, must have little appeal to those who author investor reports. It is in such an decision environment that EndoRE the product must have been cancelled from the LeMaitre Vascular web page (link). I wouldn’t think that LeMaitre would give up manufacturing the eponymous valvulotome for low sales figures, but it did give up on remote endarterectomy for that reason.

Let me show you one of the first cases I did after returning to Cleveland. I am now practicing at Fairview and Avon Hospitals, premier flagship hospitals in the Cleveland Clinic fleet, on Cleveland’s west side, and a patient arrived while I was on call with sudden onset of pain in his leg from a lack of blood flow. He had occlusive atherosclerotic plaque extending from his external iliac artery to the above knee popliteal artery causing ischemic rest pain.

Occluded from external iliac origin to the above knee popliteal artery

I contacted LeMaitre Vascular and got in touch with your representative, L. Fisher, who promptly sent the Moll Ring Cutters I needed to perform a remote endarterectomy of the patient’s occlusive external iliac and superficial femoral artery plaque. The technical details of remote endarterectomy are have been covered in my blog (https://vascsurg.me/?s=endore), but in the end, through a 7cm incision in the groin (don’t believe the hype, this is minimally invasive), I restored his arteries to their original open condition. Shown below are the results. It was with great sadness that I heard that the LeMaitre Vascular equipment being sent were the last of the stock available in North America. The patient did very well, with the operation completed well before lunch, and is recovering rapidly from his small wound and big rescue. He gets to walk out of the hospital on two legs, but also with the surety that he avoided a major bypass operation, and avoided the short term gains of stenting from the aorta to the profunda -more peel packs and landfill items and a dubious long term durability. Hey, I even used a XenoSure patch on the common femoral.

The patient’s arteries from external iliac artery in the pelvis to the above knee popliteal artery at the knee are restored to patency
The plaque from the external iliac artery has been removed with a Moll Ring Dissector
This was done in a regular operating room with portable imaging equipment. On the right is the plaque, nearly half a meter extracted from the patient who now has palpable pulses in his foot.

Endarterectomy is foundational to vascular surgery going back to the work of Professors J. Cid Dos Santos and E. Jack Wiley. Through Dr. Kenneth J. Cherry, who trained under Dr. Wiley, and who trained me, I can claim two degrees of separation from the originator of endarterectomy, and this drives my passion for preserving this critical tool in our vascular kit. The basic tools, the endarterectomy rings, are as old as vascular surgery itself. To lose a critical supplier, particularly in a time when the pendulum to open surgery is swinging back, when the best results come from combining traditional surgery and cutting edge endovascular techniques in hybrid procedures such as EndoRE, when the coming healthcare cost-apocalypse will cause everyone to question the value of thousand dollars-plus items dropped from peel packs, is devastating.

I get it that the aSpire stent never panned out, and that disposable dissector/cutters never moved that well, and that you run a business, not a charity. But I do believe that best companies reflect the best values of their people, such as the prompt action and followup of your rep L. Fisher who by getting us the rare supplies, helped in achieving this patient’s excellent results. While I believe there is a business case to be made in preserving and relaunching EndoRE, as endarterectomy has proved to be future proof for nearly a century, I believe more strongly that it is the right thing to do.

Sincerely

W. Michael Park

Categories
Commentary cost innovation ECMO opinion skunk works techniques type b aortic dissection ultrasound vascular lab visceral malperfusion

5 innovations, 4 years and how cost innovation must save healthcare

At CCAD, during my 4 years here as chief of vascular surgery, I had the privilege of working with excellent colleagues in a world class facility in an amazing and generous host nation. Over that time, our operative case volumes grew rapidly (figure below) as we proved our worth.

Our unique situation as both a main campus of Cleveland Clinic and a startup in 2015 with a fraction of the systems already in place at Cleveland made innovation a necessity. When making do became making great, we achieved the world class results as we were tasked to do. I count 5 off the top off my head in vascular, but there are many more that we do every day, contributed by all the team members. It is in the Cleveland Clinic’s DNA, from its origins century ago in the vasty fields of wartime France, this systemic mission to make things better. I think a lot of how our founders worked from necessity near the trenches in operating theaters within tents, sleeping on rough cots, thousands of miles from Cleveland. It is working in a startup hospital here, a stunning facility endowed by the Emirate of Abu Dhabi, that I realized that practical innovations were the lifeblood of hospitals in times past, and that it continues to have meaning when lives are saved. In a world where costs, not ideas, will, or skills, limit the availability of healthcare, cost innovation will play a large role in its salvation.

Innovation #1: Debranching Thoracoabdominal Aortic Aneurysm

The thoracoabdominal aortic aneurysm (TAAA) is the most challenging operation to do either with open or endovascular approaches because of the complications associated with the procedure including bleeding, kidney failure, spinal cord ischemia, and death. You really can only get good by doing a lot of these regularly, as it brings with it precious experience for the OR, ICU, rehab, and floor staff. The patients with TAAA presenting to CCAD do not always have the opportunity to travel to one of the acknowledged aortic centers (with which each of the faculty here have close ties), and we must offer results that match those other centers. To me, the biggest hassle and source of complication with an open TAAA repair is the drying up of bleeding at the end of the case, the result of long visceral clamp times. Long procedure time prolongs the case and exposes the patient to a more turbulent and prolonged recovery and higher risk.

Endovascular repair with branched or fenestrated stent grafts offers one solution in avoiding the thoracoabdominal exposure and long procedure times. Unfortunately, a significant minority of patients do not have the anatomy for endovascular approaches. We have the skills, staffing, and facilities to offer both approaches, but are handicapped by low volume. Review of our volumes show that aortic aneurysm disease is dwarfed by diabetic circulatory problems. So to offer these patients the same results with open aortic surgery as the patients I had at main campus in Cleveland, I had to cheat a bit by rearranging the deck. How so? By turning the highwire act of thoracoabdominal aortic aneurysm surgery and turning into a deliberate walk on a low balance beam. By debranching the visceral branches from the graft one by one, the visceral ischemia time is minimized (video) or largely eliminated.

I discussed this with Dr. Niranjen Hiremath, our aortic trained clinical associate and like all things in medicine, a similar concept was applied by his mentor, Dr. Matalanis in Australia, to the aortic arch. We have performed two of these and both patients survived and are doing well, including the most recent one with a hybrid extant 2 repair. We published the technique after the first case in Journal of Thoracic and Cardiovascular Surgery (figure below, reference 1). I also presented the first case on this blog (link). More gratifying are the reports of adoption of this technique around the world. The patients come out of the operation without the torrent of coagulopathic bleeding seen with the traditional technique.

Innovation #2, The Vascular Lab in Every Patient’s Room

One of the things that happened early in my tenure was realizing how limited the tools available for vascular assessment were for non vascular caregivers. Both the physical examination with pulse palpation and pulse Doppler examination are challenging to master and usually fail to answer the simple question: is there enough perfusion? The absence of a pulse or Doppler signal in the hands of a non-vascular caregiver is an inconstant thing, and various projects have been undertaken that do not specifically address the triage gap that vascular surgery has compared to cardiology for chest pain. Not all chest pains are referred to cardiology. Only those those patients who pass the screening test of EKG and serum troponin levels are referred. My first inclination was to budget for pulse volume recording machines to be located in the ED and ICU’s of the hospital, but it was not a simple solution and would require stretching the limited vascular lab staff. Then it dawned on me that the toe waveforms offered a solution. On the PVR machines, the toe waveforms are captured by transmitting red laser light through the nail of the toe. A receptor captures a waveform (figure below) that is reflects the passage of blood that absorbs that red light.

This is in fact the identical technology in a pulse oximeter which has extra circuitry to calculate an oxygen saturation. I was not interested in the saturation, but rather the waveform. It turns out, for all practical purposes, the waveform given by pulse oximeter units is qualitatively the same as that given by the pulse volume recorder’s digital plethysmograph (figure below).

So now, when I get a phone call from the ED that a patient has no DP or PT pulse, I ask the caller to place a pulse oximeter with a waveform trace on the patient’s second toe (or nearest extant toe). I then ask, is there a waveform? The presence of a waveform, no matter how dampened, means the patient does not face acute ischemia, and can safely wait until the morning, avoiding a drive in the middle of the night (figure below, severely dampened waveforms).

an abnormal DPPG captured with a hospital ICU pulse oximeter

We are validating this with a study that has completed data collection and hope to present this simple test to a broad audience. This is something akin to having a point of care vascular lab study that can answer a simple question: is there blood flow at the level of the toes? The finer points of “how much blood flow” can be answered by formal testing but that keen absence of broad vascular assessment skills among healthcare providers and absence of a simple test like an EKG for MI will feel less sharp, particularly because of the near universal availability of a pulse oximeter with waveform display throughout most hospitals.

Innovation #3: Assessing for Visceral Malperfusion before Surgery for Aortic Dissection

The typical scenario for a sad ending is this: a patient undergoes emergency surgery for an ascending aortic dissection. The operation ends in the middle of the night. The morning labs show a lactate of 10 which had been rising since the end of the operation from a high borderline level of 2. The urine output also dropped to zero. The patient remains intubated and has palpable femoral pulses, but now has a distended abdomen full of bowel gas, and is unable to report pain. The decision is made to get a CTA on top of the ones the patient received preoperatively which nearly guarantees permanent renal failure and need for hemodialysis. The descending aortic portion of the dissection is noted to be causing a malperfusion of the SMA and left renal artery, and there is pneumatosis of the small bowel through transverse colon which are resected after revascularization. The patient recovers with a jejunostopy and lifelong TPN and hemodialysis. This sad scenario is what I thought about when I was asked to assess a patient intraoperatively without a femoral pulses after an aortic dissection for possible visceral malperfusion. The question was if CT with contrast was indicated. Having an RVT credential (I’m old), I frequently do my own scans, and have found under general anesthesia, the abdomen is easy to scan well. The patient is typically prepped from neck to toes for the operation, so sliding in with an abdominal probe was simple. It is possible to get excellent windows on the visceral segment abdominal aorta with long axis and short axis views of the celiac axis, SMA, renal arteries, and iiac and lower extremity arteries (figure below).

At CCAD, the patients also get a TEE, and the arch and descending thoracic aorta is well visualized. That first patient underwent a femorofemoral bypass for the lower extremity malperfusion, and I found that the left renal artery had obstruction, but the right did not. The patient was reassessed at the end of the case and good visceral perfusion was seen at that point. I realized I was onto something, and whenever possible now for ascending aortic dissections, myself or the vascular tech is called to evaluate the visceral and lower extremity arteries at the beginning of the case, avoiding contrast studies. We are submitting the experience as an abstract for the STS conference.

Innovation #4: Retrograde tibial artery distal perfusion cannulas for ECMO

This past year, ECMO has been lifesaving for many patients facing cardiovascular collapse from COVID and other conditions. Once the cannulas go in, a hypoxic patient in heart failure has a chance at recovery. The drama of the moment causes the caregivers to overlook the fact that up to 10 percent of patients without a distal perfusion cannula will develop leg ischemia, and that after 6 hours, irreversible will occur leading in neuromuscular death and limb loss. This has happened for two patients transferred for care this year. The problem is that the skill of placing a antegrade femoral artery distal perfusion cannula in the proximal thigh is not always present, and the ability to judge perfusion is degraded with ECMO flow. While older patients on ECMO may have significant arterial disease, young patients generally do not, and I saw that as an opportunity for simplifying the distal perfusion cannula by placing a 5F micropuncture sheath into the dorsalis pedis artery (figure below).

The distal perfusion cannula is in the dorsalis pedis artery

This provided sufficient flow to avoid limb loss in a series of patients on which we published a technical article (reference 2) and presented. The retrograde access of these supericial vessels is within the technical envelope of most intensivists and cardiologists, those who most frequently place emergency ECMO cannulae. It was gratifying to catch up with one of my first patients who walked in with both legs, having undergone a heart transplant while bridged with ECMO.

Innovation #5: Park Clamp Used in Thoracoscopic and Laparoscopic Surgery

The Park Clamp (link) is a circular compressor that is intended to compress bleeding tissues allowing for suturing within the circle. I invented this while at main campus, and missing it sorely, had two custom made at the prototyping facility at Cleveland Clinic and shipped into CCAD. It is particularly useful in venous bleeding during spinal exposures, redo groins around the profunda, and retroperitoneal tumor resection. Dr. Redha Souilamas, chief of thoracic surgery (image above) found it particularly useful in thoracoscopic pneumonectomies, when staple line bleeding is encountered on the pulmonary artery (image below).

Pulmonary artery staple line bleeding controlled, ready for suturing.

In laparoscopic surgery, it is possible to introduce the compressor via a small incision and this will allow for laparoscopic suturing of a vascular injury in a bloodless field. I was able to resect an IVC tumor thrombus with Dr. Waleed Hassen using this device to achieve hemostasis. The critical feature of the Park Clamp, lacking a manufacturer, is that we made it ourselves in our own hospital.

Conclusion: a modest proposal or how cost innovation will save health care

Inventions and innovations exist in a vacuum unless they are implemented, and this requires the will to accept the possibility of a better way. You should never be satisfied with the status quo if there is harm to be reduced. There has to be buy in from everyone involved or you get the situation I had when I was a PGY-2 in 1995 in the ICU. Being the surgical ICU resident, I was called nearly hourly to change the dressing on a patient with HIV and necrotizing pancreatitis with an open abdomen. There was over a liter an hour of exudate soaking the dressings and pads, making it a nightmare for the nurses. After a third round of this and feeling it would interrupt lunch, I came upon a plan for covering the wound with lap pads, overlaying a chest tube, and sealing everything with an Ioban. With the chest tube to negative pressure via a Pleuravac, the calls to change the patient’s dressing ceased, and the nurses no longer hand to change the bedding hourly -bedding that was soaked with HIV positive exudate. I was very pleased about this until I was stat called to the director’s office. I was given the dressing down of my life -how dare I experiment on his patient and didn’t I think that placing a suction on the transverse colon would result in a fistula? I hung my head in shame and took down the dressing. Of course, readers will know that this preceded the VAC dressing by about a decade, and negative pressure wound therapy is now a multi-billion dollar industry. What it teaches me to this day is that progress only happens when success is actually seen by everyone, but also there has to be buy-in from the stakeholders -the people who bear responsibility for any bad outcomes -fistula and death in the case of this proto-VAC dressing. Without convincing everyone, there is no success, and the invention goes off to die.

The fact is, one time early in my tenure here at CCAD, we ran out of negative pressure pumps, and I placed this chest tube/Pleurevac dressing on a patient with a large groin wound that was leaking high volumes of exudate and lymph. After two days, when a VAC pump became available, the patient’s groin turned out to be clean and granulating and it came to me that the next great leap in innovation is low cost innovation.

Cost Innovation, to name it, is using what is available, sometimes repurposing, or at others, dialing back the clock, to replace costly things that threaten to break a hospital’s finances while maintaining quality. It was only a few generations ago when hospitals were self contained communities. Rather than use peel packs of disposable gowns and drapes, there were tailors, seamstresses, and launderers making and maintaining the same. The Mayo Clinic was making its own insulin after discovering it and gave away the recipe out of concern for ethics -out of believing it is wrong to profit from a life threatening condition. We have the technology and capacity to make low cost endoscopes and reprocess them -possibly undercutting current costs by a factor of a thousand. We slaughter millions of hogs and cows annually, but harvest no heparin from them in the US. Laser CNC cutters, 3D printers, and enthusiastic makers have proliferated and could make every item that we currently open from a peel pack, use once, and discard into landfills -one only has to look at the cottage industry of face shields and hand sanitizers that bloomed last year during the pandemic. Pharmacists are fully capable and trained to manufacture custom pills and compound salves and solutions by the gallons if only if they are allowed to, saving hospitals millions in cost of medications sold in blister packs and tiny tubes and bottles. Stents can be printed in-house, and stent grafts can be custom made (link). Every town or city has tradespeople who can work stainless steel, plastic, and glass, or make and program custom computers -it is a short jump to making medical equipment at scale in your hospital.

Cost innovation is the only way out for the inflationary cost cycle that has throttled healthcare throughout the world. We have become a world where healthcare is delivered out of peel packs and million dollar investments to perform single procedures is considered normal and desirable, almost to the point of thinking people as coming in disposable peel packs. When I watch shows about hospitals a century ago, such as The Knick, I don’t guffaw at the old-timey medical stuff. I see a fervent environment of innovation in purposeful communities of specialized workers within hospital walls. We need to return to such practicality if we are to break out of the plastic peel pack.

References

  1. Hiremath N, Younes H, Aleinati T, Park WM. Open repair of extent-III thoracoabdominal aortic aneurysm using a modified branch-first technique. JTCVS Tech. 2021 Mar 13;7:29-31. doi: 10.1016/j.xjtc.2021.03.014. PMID: 34318197; PMCID: PMC8312144.
  2. Göbölös L, Hogan M, Kakar V, Raposo N, Sänger S, Bhatnagar G, Park WM. Alternative option for limb reperfusion cannula placement for percutaneous femoral veno-arterial ECMO. Perfusion. 2021 Mar 26:2676591211003282. doi: 10.1177/02676591211003282. Epub ahead of print. PMID: 33765883.
Categories
Uncategorized

Describe vascular surgery without saying it in one sentence…

Too much blood, not enough blood.

Categories
Commentary Lifestyle

Top 10 things to get your favorite vascular surgeon, 2021 -pandemic edition

My list of favorite things this year is simpler than in the past, in respect for the difficulties of the past year. Everything is under $300, and I use these every day. Treat your surgeon well and she will give you a nice scar.

1. Lenovo Ideapad Duet. Cloud computing has diminished the need to carry processing power unless you are editing Pixar films or playing super high resolution video games. For composing words on the go, and sketching diagrams for patients, and putting together powerpoints, this Chromebook hits the sweetspot of price, battery life, and quality. It comes with easel stand and attached keyboard with trackpad. An Apple Magic Keyboard for the iPad costs more than the Duet! Battery life is easily all day, and in tablet mode, streaming movies is great. It fits on the stunted traytables on airplanes well because of its petite size. I drew this sketch for planning an arch repair on it. Can’t beat the price at $249 and cheaper with discounts. I got mine as a open box at Best Buy for $200.

Sketch made on a Lenovo Duet

2. Theragun Mini. It is a stereotype that middle aged Asians buy giant massage chairs, which are AMAZING, but if you want something more manageable, the Theragun Mini is the ticket. It is a personal massager designed for deep tissue massage, with a lithium ion battery built in. After a long day of operating, all the aches are pulverized by this machine.

Theragun Mini

3. Masterclass Subscription -During pandemic, diversions like enrolling in an MBA program and Youtube yoga, are the hot ticket, but for someone with a short attention span in need of non-work diversion, these classes are great! Penn and Teller teach magic. Steve Martin teaches comedy. And FBI hostage negotiator Chris Voss teaches high stakes negotiation. All of these highly relevant to a vascular surgeon. Trust me.

4. Moleskine Backpack -I have struggled with overly heavy work bags, but need to carry my computer and some papers and maybe a water bottle, pens, a powerbank, some cables. I find black vinyl laptop bags generally horrible to look at, and too easy to overpack. Expensive leather designer bags carry a similar price as a handbag from Gucci or Louis Vuitton, and would not survive a day without getting scuffed. This backpack from Moleskine, yes the notebook company, is both beautiful to look at but practical as well. It is water resistant and holds everything I need for the day. Has a measured number of compartments and inner panels for pens, cables, and cards, and is well padded for carrying your electronics. Looks great, and would survive medical school.

Moleskine Backpack -not just for notebooks

5. Freewrite Traveler -a writing appliance, a typewriter. The original Freewrite was designed to look like a typewriter, and the spirit of the machine is it takes away all the distractions of the internet for the focus of plain paper. The Traveler is the second machine by the Freewrite people, and offers the same focused writing in a portable package. Not for everyone, this one, but if you like writing, if you must write, this is amazing. It features a Kindle-like e-ink screen, and you type without the ability to edit. Everything you write goes to the cloud of your choice, including Dropbox and Drive, and so you won’t lose it. It has internal space for thousands of pages, and a 4 week battery life. If you hope to write the Great American Novel, this is the gadget for you.

Freewrite Traveler for the Hemigway in you

6. LED UV Blacklight -If you’re of a certain age, Spencer’s Gifts was one of the stops you made at the mall, and you always checked out the blacklight section, with its fluorescent posters and purple lamps that made your white shirt glow. As a surgeon, you want a Wood’s Lamp, but most hospitals do not have one, and most nursing staff have no idea what you are talking about. Good thing is that there are many cheap but powerful LED Blacklight options that emit UV light. This is great to have in the OR for a fluorescein test of gut perfusion (link). Take it camping in the deserts around here and you can see the scorpions at night! Or you can torture yourself by breaking it out at the next hotel you stay at and visualize all the glowing “protein stains.” Under $10, but slightly more for the higher power ones.

portable LED blacklight!

7. Old School iPod -This is as close as you can get to getting a Walkman without dealing with the inconvenience or poor sound quality of cassette tapes. In 2004, these were cutting edge, and Apple to its credit still supports file transfers of purchased (but not streaming) music files. The cool thing about these is that if you can do a carotid endarterectomy, replacing the battery and upgrading the memory are nothing, and there are many videos on line to show you how. These units are cheap to find on eBay, and there is nothing cooler than carrying around 10,000 songs in your pocket, without the need for a network, meaning uninterrupted music in the OR without relying on the network.

An iPod I purchased in 2006, upgraded to 32gB from original 8gB, just replaced battery for third time, still works.

8. Golf Ball Stamps -These stamps are meant to mark golf balls, but they are incredibly useful for graphically marking up a printed list. Each of these symbols represents a status or an action, which lets me look at a list at a glance and remember exactly what needs to happen. At pro shops everywhere.

Meant for golf, repurposed to act as semiotic markers on lists

9. Swiss Army Knife -the first one I got was as a graduation gift from my dad, thought technically not a gift as superstition dictated I purchase it from him for a dollar, it was the same as this one which is currently my fourth, bought at a Boy Scout camp for about $10. I keep one in my checked luggage for use at my destination for opening bottles, uncorking wine, cutting salume and cheeses, tightening screws, and when the occasion arises, performing an appendectomy (need a hotel sewing kit). This one also has tiny forceps and a toothpick.

With this, I can do several life saving operations.

10. Skirt steak -rarely seen any more shrink wrapped at chain groceries, you generally have to ask the fellow behind the counter or know a butcher. This diaphragmatic muscle used to be cheap. Considered offal in many places, this formerly cheap meat ended up being the go to meet for tacos and street cart barbecues in Asia, but don’t sniff at it. As it is not a structural muscle, it is not tough, has great flavor, and while leaner than traditional steak cuts, not devoid of fat like a filet (which is not my favorite) giving it enough buttery fat tones to remind you it is meat. Because it’s harder to find, that means the people who supply it know beef. Here in Abu Dhabi, I ordered this from the CarniStore in Dubai. Dinner is served.