Bypasses still work -a guest post from Dr. Max Wohlauer

pre-angio

angio text.png

Max Wohlauer, a recent graduate, is now Assistant Professor of Surgery at the Medical College of Wisconsin in the Division of Vascular Surgery. He sent along a case which is published with his patient’s and department’s permission.

The patient is an 80 year old man with diabetes mellitus, CHF, and pulmonary fibrosis, who presents with right foot toe ulcers. He had an inflow procedure earlier in the year, but it failed to heal the ulcers. An attempt at crossing a CTO of the SFA/POP failed. Angiogram (above), showed a distal anterior tibial artery target.

Preop ABI, TBI’s, toe waveforms, and pulse Dopplers are shown. are as shown.

 

preop TBI.pngpreop-abi

All point to likely limb loss. The TBI is 0 and the ABI is incompressible. Max planned for bypass. The saphenous vein was mapped and shown to be adequate.

preop saph vein mapping.png

Max comments:

  • Compromised runoff on angio. Cutdown on AT and determined it was adequate target at start of case
  • Right fem-AT bypass
  • Re-do groin exposure
  • Translocated non-reversed GSV
  • Subcutaneous tunnel

 

The operation went well. Completion angiography was performed showing a patent bypass and distal anastomosis with good runoff.

completion angiography.png

A followup duplex showed patency of the graft.

postop duplex.png

Postop ABI’s showed excellent results:

Postop TBI.png

Commentary from Park

Bypasses work and are possible even in high risk individuals with good anesthesia and postoperative care. Because open vascular surgical skills are not well distributed while endovascular skills are more widely distributed, there is bias both in the popular mind and even among some catheter based specialists that bypass surgery is a terrible, no good thing. The fact is that a well planned bypass is usually both effective and durable even in high risk patients, but clearly it is not the only option.

Ongoing developments in endovascular technology bring greater possibilities for revasularizing patients. As someone who does both interventions and operations, I have seen spectacular success (and occasional failure) with both approaches, and I admit to having biases. It is human nature to be biased, but it is because of my biases, I support further ongoing study, as the mistake would be to establish monumental truths without supporting evidence. There is an ongoing randomized prospective trial (BEST-CLI) that aims to answer important questions about what approach brings about the best results in critical limb ischemia. It will bring evidence and hopefully, clarity, to this important disease.*

Finally, I am very proud to have participated in Dr. Wohlauer’s training, and look forward to seeing his evidence, experience, and even biases, presented at future meetings.

 

*CCF is a BEST-CLI study site.

If the odds are against the patient, who is for the patient?

IMG_1484

The first patient, a man in his late 70’s, ruptured in the emergency room at around four in the afternoon on a weekday, which was fortuitous, as the hospital was fully staffed, fully armed. The patient had arrived only a bit earlier with the complaint of severe abdominal pain, and soon after getting his CT, arrested. CPR commenced as I arrived by Dr. Timothy Ryan, our chief resident at that time. 

Ruptured CIAA with CPR 1 -_1
a rupture
The patient was wheeled upstairs with ongoing chest compressions. The anesthesia and operating room staff started a bucket brigade of blood -there was enough staff to start a symposium. Within 5 minutes of hitting the operating, I poured betadine on the chest and belly and took a blade and cut open the abdomen. Blood poured out onto our scrubs and to the floor and our shoes. I pushed my hand into the retroperitoneum, gently sweeping aside the torn tissues and blood clot to feel the hill of the aneurysm. I walked over the slope of the aneurysm and tweedled my fingers around the aorta above the aneurysm. The cross clamp rode my fingers into position around the aorta. The patient, so very dead minutes before in the ED, came back as I began to feel a pulse above the clamp. The patient lived through the operation and the night where grim data -pH of 6.8, lactates in the double digits, four figure LFT’s, kidney failure all predicted a bad outcome. And yet he survived, and a few days later, a second operation to washout and close his belly which had been left opened and packed occurred, and he recovered. We still talk about that day now three years out, and while he thanks me, I thank the whole hospital because I don’t remember speaking very much -the right things just happened around me as we worked, the whole hospital and me.

More recently, while I was finishing up two urgent cases, I got a call that the patient with the leaking aneurysm had arrived from across town and was becoming hypotensive.

ruptured AAA -_1
another rupture
Gratefully, one of my partners, Dr. Christopher Smolock, was rounding that Saturday and stepped in to finish up the last of the two cases while I ran down to the patient, a man in his late sixties, who had arrived in our acute aortic syndrome unit.

IMG_7195 (1)
Dr. Christopher Smolock
We conversed, the patient and I, and he understood what laid ahead. We rolled him up to the OR, and while we were prepping and draping, my fellow, Dr. Francisco Vargas, looked to me gravely and said with certitude, “I think he’s dead.

IMG_7197
Dr. Francisco Vargas
Chest compressions commenced and again, knife in hand, I cut him open from sterum to pubis and got the clamp on. It took 15 minutes of CPR to get a pulse back. I was very pessimistic as during the case, ridiculously bad lab data came back like a pH of 6.9, lactate above 10, no urine.

IMG_7234
Graft Repair of Rupture
The blood bank sent down coolers like the kind you take to tailgates, only filled with blood and plasma. The aneurysm had grown like a rotten apple on a stick and the graft we needed to repair it was surprisingly short. He too made it to the ICU, and after a long recovery which included dialysis, a tracheostomy, and a reboot of the brain -the brain takes a while to recover from the anoxia, but his went “bonnnnng” like a waking Mac after days of spinning beach balls, and he started to follow commands. The morning before he transferred to rehab, we talked about what he could have done to prevent the rupture. Not knowing about it, not much, I replied. People traditionally lived to about 20-30 years of age, I said, before dying of disease, violence, or predation. Longevity has meant wear and tear on irreplaceable parts. We agreed it was good to be alive.

Ruptured aortic aneurysms are the sine qua non of vascular surgical practice. As a junior resident back in the antedeluvian 90’s, I remember one of my chiefs, Dr. Eric Toschlog, now a trauma surgeon out East, running a patient upstairs from the ER with a rupture, and before the attending arrived by taxi, had the graft in. When it became my turn, as a fellow working on a patient who had been helicoptered in from the frozen wastes of Minnesota, I remember playing a trick with my mind -that the patient was proportionally the same size as the rabbits I was working with in the research lab, that I was really big and the patient’s aneurysm very small. This works to calm the heart, steady the hand. Nowadays, my mind is blank, and my hands working reflexively.

There has been a series of papers that create scores that allow prediction of odds for survival, and both of these patients, particularly with their prolonged CPR, have greater than 90% predicted mortality on these measures. In this month’s JVS, Broos et al, in the aptly named paper, “A ruptured abdominal aortic aneurysm that requires preoperative cardiopulmonary resuscitation is not necessarily lethal” describe a 38.5% survival rate among their series of patients with rupture who had CPR (ref 1).

Practically speaking, no one I know would use these scores to decide to not operate. While many series show better survival for emergency EVAR compared to open repair, several randomized control trial failed to show better results when these methods were directly compared. A retroperitoneal approach is preferred by some in our group, but having tried both closed chest CPR with the patient in right lateral decubitus position and open cardiac massage -(both died), I prefer supine.

There is no survival if there is no attempt.

Reference

  1. J Vasc Surg 2016;63:49-54.

Never Stop Following Stent Grafts -Type IV endoleak causing slow growth in 12 year old stent graft

Centerline

 

The patient had undergone EVAR for bilateral common iliac artery aneurysm with the original Gore Excluder stent graft a dozen years before with coil embolization and extension to the external iliac on the larger side and femoral to internal iliac artery bypass on the other side. A coagulopathy, one of the clotting factor deficiencies, had made him high risk for bleeding with major open surgery. His aneurysms never shrank but remained stable and without visible endoleak by CT for a long time resulting in ever longer intervals between followup.

2013_1
2013

Between 2009 and 2013, there was subtle enlargement on the embolized side without a type I or type III leak, and the patient was brought back a year and a half later, with further growth of the sac.

1-2015_3
2015

This was a relatively rare type IV endoleak that was causing sac enlargement due to excessive graft porosity of the original Excluder’s graft material. Its treatment is either explantation or relining. We chose to reline the graft with an Excluder aortic cuff at the top and two Excluder iliac limbs.

2015-11-26 13_25_23

This was done percutaneously and in short followup, there has been stabilization and even some reduction in the aneurysm circumference.

CT Scans

 

It was long known that a certain percentage of PTFE grafts “back in the day” would sweat ultrafiltrated plasma. The relative porosity of the grafts allowed for transudation of a protein rich fluid.

Slide2
Tanski W, Fillinger M. J Vasc Surg 2007;45(2):243-249.

 

 

 

 

 

 

 

This results in a hygroma formation. I remember seeing this in AV graft fistulae back in the 90’s -after flow was introduced, the grafts would start sweating! The newer grafts are lower porosity and this is seen very infrequently. Drs. Morasch and Makaroun published a paper in 2006 comparing parallel series of patients who received the original Gore Excluder (OGE), the currently available Excluder Low-Permeability Device (ELPD), and the Zenith device (ZEN). Sac enlargement occurred in equal measure between OGE and ZEN but zero was reported for the ELPD.

Slide3
Haider S et al. J Vasc Surg 2006;44(4):694-700.

The ELPD had higher rates of sac shrinkage than the OGE, and equal rates of sac shrinkage compared to ZEN.

Slide4
Haider S et al. J Vasc Surg 2006;44(4):694-700.

The diagnosis in my patient’s case came about through serial followup through a decade. While I doubt that the aneurysm would have ruptured in the same way as in a Type I, II, or III endoleak, I am sure it would have progressed to developing symptoms from aneurysmal distension or local pelvic compression.

Is it possible to visualize this kind of endoleak at the time it is suspected? I came across a case series from the Netherlands using Gadofosveset trisodium which takes longer to clear than the usual Gd-based MR contrasts and they successfully visualized transudative leaks in 3 serial patients with the original Excluder graft.

Slide2
Cornelissen SA et al. J Vasc Surg 2008;47(4):861-864.

The problem is that Gd-based contrasts have toxicity, especially for patients with poor renal function. The protocol is time consuming. And I suspect that ten years out, a lot of grafts will have positive findings, especially cloth based grafts that are sutured to their supporting stents, without clinical basis for treatment as their sacs size are likely stable on a year to year basis.

That said, as we are well into the second decade of commercially available stent grafts, it is even more important than ever to continue lifelong followup even for what is assumed stable, patent grafts and anatomy.

Broken Aorta, Advancing Technology

CT_1
The ligamentum arteriosum, the remnant of the ductus arteriosus between the aortic arch, tethers the arch causing a tear during sudden deceleration like hitting a steering wheel with your chest

I recently repaired a traumatic aortic dissection and was struck by how far along things had progressed since I was a resident. I remember seeing a Q&A in the mid nineties where Dr. Mattox expounded on the gold standard for diagnosing traumatic aortic injuries which at that time was contrast aortography. This caused many struggles trying to arrange for arteriography in the middle of the night (these accidents usually occur then). The repairs were open and very morbid for severely injured patients, particularly those with closed head injuries and fractures. This all changed in the early 2000’s as I had mentioned in an earlier post (link). The grafts were homemade (figure)

img_1232

and this was literal -the picture is from my kitchen back in the Bronx in 2004. The grafts were cumbersome to deploy and required long 24-28F sheaths that frequently required iliac and aortic exposures.

img_1233

The revolutionary breakthrough was the fact that thoracotomy and partial cardiac bypass could be avoided. Durability was largely assumed as these patients rarely came back for followup.

img_1237

Fastforward to 2015. CTA is done with 64 slice CT scanner with EKG and respiratory gating eliminating the artifacts that caused Dr. Mattox to assert that aortography was the gold standard. Software based image reconstruction can aid treatment planning in ways that greatly exceed the caliper and ruler methods we had in 2004.

CT_4

The grafts are currently into their second generation of development and have small profile and trackability that allows for percutaneous delivery and treatment.

aortogram trauma

The aortogram shows the tear along the inner curve. These lesions typically require coverage either partial or total of the left subclavian artery origin. This patient had a dominant right vertebral artery and I felt he would tolerate even full coverage of the left subclavian.

aortogram trauma close arch

The device, a Gore C-TAG device which has an FDA trauma indication, is clearly better than our homemade device. Deployment does not require pharmacologic or electrical bradycardia or asystole.

aortogram post stent trauma

The idea behind this design is conformability of the smaller stent elements. The aortic injury is even outlined by the stents in the aortogram above. The bird-beaking that was common to the prior generation of graft is not seen in this aortogram.

Where does this need to go next? At 18-24F access requirements need to become 12-18F and for the same reason, the grafts need to be available down to 14-18mm as trauma doesn’t just happen in middle aged men. Aside from that, it is a definite improvement over what we had in 1995 and in 2004.

Mind the Lymphatics: managing a persistent postoperative seroma

figure 1

The patient was referred from an outside institution for the development of a large tender mass in her below knee incision after a femoropopliteal bypass done with PTFE for ischemia after a aorto-bifemoral bypass. The patient reported swelling that grew in the months after the operation to the point that she was unable to walk without pain. On examination, she had a Nerf football sized swelling in her previous below knee incision without erythema. It was quite tender. CTA showed a patent aorto-bifemoral bypass and a femoropopliteal bypass to the below knee popliteal artery. Incidentally noted was the absence or occlusion of the profunda femoral artery. There was bland lymphedema below the knee.

Differential diagnosis included:

  1. Graft Infection
  2. Seroma from PTFE ultrafiltration leak
  3. Seroma from lymph leak.

Graft infections can present like this, but also drive local and systemic inflammation and in the absence of fevers and white counts, was highly unlikely. Occasionally, indolent infections with S. epidermidis will present with fluid collections but typically this is a late presentation. Ultrafiltration leaks from PTFE are fairly rare in my practice but can occur randomly. Most PTFE grafts nowadays come with an external wrap that acts as a seal against microporosity, but on occasion, I have seen protein rich fluid accumulated around PTFE grafts. This typically is not high pressure and accumulates along significant or whole length of graft. I used to treat that with graft excision and replacement, but I have had success with relining the graft with PTFE based stent grafts and externally draining the seroma.

I suspected this to be a seroma from lymphatic leak. The lymphatics are an unusual system of vessels in that they are remnants of an earlier circulatory system that was designed to move and mix nutrients and primitive phagocytic immune cells throughout the external compartment of an organism. They are diaphanous vessels that have smooth muscles that periodically contract like cardiac muscle, propelling fluid and cellular components past valves. Typically, cautery, suturing, and the inflammation of wound healing are sufficient to close lymphatics, but when there is potential space and a large lymphatic trunk that has been divided within it, that space will be filled with fluid, particularly with edema fluid that accumulates post surgically with dependency.

This patient was treated with I&D, but the lymphatic was identified by injection with Isosulfan blue in the subcutaneous space of the foot (between the toes). The dye is avidly taken up by the lymphatics and it can be used to identify the leak, allowing for extirpation and closure.

Isosulfan blue is injected into the subcutaneous spaces between the toes.
Isosulfan blue is injected into the subcutaneous spaces between the toes.

The vital dye will be cleared by the kidney -the pee will be greenish blue for a day or two. This is contraindicated in patients with known sulfa allergies.

The dye is seen in the wound within minutes without any added measures -no pumping or massaging was required. The patient had begun spontaneously draining the night before her operation.
The dye is seen in the wound within minutes without any added measures -no pumping or massaging was required. The patient had begun spontaneously draining the night before her operation.

The dye concentrates in the lymphatics which are easily identified.

IMG_5298

The lymphatics were ablated and a VAC dressing was applied. Two weeks later, there has been significant healing with complete resolution of the seroma.

IMG_5858

Loss of lymphatics at this level does not cause permanent injury but clearance of edema is slowed. Clearly, the avoidance of lymph leaks is the first step in preventing seromata, but when they occur, it is simple enough to identify and treat them using this technique.

They are one way self circulating pipes and therefore treating the afferent termini is all that is necessary.
They are one way self circulating pipes and therefore treating the afferent termini is all that is necessary.

A Dozen Snippets of Advice to Graduating Trainees

IMG_2287.PNG

  1. Pass your boards and get your licenses. Board eligibility has the shelf life of a sack of dog food. After about two or three years, you better throw it out. While your apprenticeship with me and my partners has given you insight into the various styles and techniques of repairing arteries and veins, no hospital or insurance company will let you touch a patient without eligibility or certification. And while you are at it, maintain your certification  with CME’s. Apply for licenses early and diligently. You are like newly hatched baby sea turtles and the ocean is your board certification.
  2. Look the part. Stand up, look people in the eye, smile. Stay well groomed and wear clean clothes. Scrubs are acceptable only on days you are operating in the hospital, but no one should see you at the grocery store in them. Dress professionally, but don’t spend more money than your peers or partners. Clean fingernails a given.
  3. Remember, your first job is not like a first spouse and may not be forever. Exit strategies at a basic that can be negotiated from the start is coverage of a tail policy upon mutual separation. Triggers for retention salary (never bonus which is taxed differently) can be negotiated. For example, you take a rural job away from people you might want to marry –you may put in your contract that every year after a certain number you aren’t married, you get a raise. Same with partners who are said to be near retirement –people live longer and want to work longer, and you might find that promised increase in volume and salary does not come to fruition. Contracts can be structured for retention salary increases in those instances. Hard to recruit areas need to recognize that and be willing to increase your salary based on volume that would otherwise go to another partner if they could recruit them.
  4. While it can be viewed as a business transaction, you are setting out to take care of people in a community. Cultural competence is a huge advantage if you are not a native. Understanding the reluctance of an 80 year old Iowa farmer to get surgery in the fall because of the harvest may give you insights to head off argument –their fine sons or daughters may come home and help organize the harvest. Part of the process of getting to know the community is establishing some roots –I don’t mean marrying the mayor’s daughter or having three kids out of wedlock. It means joining clubs, churches, community organizations. It means attending the local fairs and buying from local stores even when Amazon would be a lot more convenient.
  5. Towns can be measured by metrics. How hard is it to get to New York from where you are. Is it in fact New York? How hard is it to get to your town from where your loved ones are? What is the swankiest brand of car sold in that town. Is sushi made by Japanese, is dim sum by Chinese, the pho by Vietnamese? Is there Korean food? Is there a Whole Foods? Is there a functioning public transportation system? Can you get fresh fish? How many pro sports teams are there? Is there a college nearby that you have heard of? How fast is the internet? Is there cell coverage? Do they drink the tap water? Is there a meth/heroin/oxycontin problem? Is the highest paid person in the state the football coach?
  6. Learn the limits of your hospital, your ICU, your floors, your consultants, your office staff, and yourself in equal measure of importance. Be patient and stick to simple straightforward low risk cases if possible and have partners co-scrub more challenging cases. Find and know the regional referral center if you are in a community hospital and don’t feel shy about referring patients beyond the capabilities of everything in the first sentence. Your results will be under a microscope, but the most important watcher is you.
  7. Take care of yourself. Exercise, eat right, and take up a leisure time activity that won’t result in lawsuits or court ordered DNA tests. Golf is great. Vacationing is okay, but spending every moment of time out of town sends the wrong message. Budget and start saving for retirement because you won’t be doing this forever. Pay down debts and don’t take on unnecessary debts. You don’t need a Porsche or a McMansion. If you have kids, stick to public schools and live modestly unless your spouse has a lot of money, then you’re a trophy spouse!
  8. Low hanging fruit of publicity –eating meals in the doctor’s lounge, chatting with staff in the OR lounge, attending staff functions, joining the local medical society. The ten minutes of conversation over a stale sandwich or rubbery, overcooked chicken works. Make sure to have business cards handy or your contact set up to share easily by text or email. Pro tip: having pens printed with your name and practice and number –the equipment and drug reps can’t give you swag but you can give them swag to give out. Give grand rounds or CME talks. Bring in your former faculty as guest speakers. Get an article in the local paper –it will end up on the web site, but mostly older people, ie your patients, will read actual papers. Social media and the internet –unless you are deeply committed to keeping a live presence there with frequent posts and comments, don’t bother. There are too many practice websites and doctors blogs that get refreshed every 3-5 years that they are a liability. You need to blog weekly or FB, Tweet, and Instagram post daily to get a following. That said, done right, you can control your image far better than the hive mind will. The people reading the internet won’t be your vascular patients, but it will be their kids who will search you out on the internet. The other tactic is to never, ever be on the internet.
  9. Humans, from the time of the Australopithecines and maybe before, are organized through direct personal relations in groups numbering up to ten or twenty. You will be in control of an OR or an office, and you have to learn how to do this well to be effective, and it will depend on forming good working relationships. This is not easy and mistakes will be made, but ultimately your success will depend on how well you orchestrate your team. Buying pizza for the team is a good way to get pizza for yourself, but will also earn the gratitude of your people.
  10. No amount of preparation on your part will make up for problems outside of your control. When managing these by “taking ownership,” usually by starting committees and study groups, takes up increasing part of your day and happen without compensation or acknowledgement, it is time to move.
  11. Surround yourself with smart competent people. No referral stream is worth the trouble of associating with stupid, incompetent people, because ultimately, you will become one of them. That said, graduating at PGY 5-7, maybe more, means that you are likely the most trained, most up to date individual in the medical community and to the degree you have to live and work there, you have to give something of yourself to take care of patients. If that means admitting a complex patient with an unrecognized exacerbation of a connective tissue disorder because they were referred to your clinic with foot pain, it may be simpler to simply admit the patient to your service and start the care and workup rather than trying to do an outpatient turf. Sending this patient to the emergency room or dismissing the patient with instructions to set up a specialist appointment washes your hands, but you are not taking care of this person are you?
  12. You are being paid to be smart and competent at vascular surgery like LeBron James was brought back to Cleveland to revive it economically and redeem its souls from perdition. Act accordingly.

A Troublesome Accessory Renal Artery Complicating a Complicated Patient

Preop Figure

The patient is an 65 year old man with a growing right common iliac artery aneurysm of 3.7cm, a small AAA, and severe COPD (not oxygen dependent, FEV 1.5L) . He had a prior left nephrectomy for cancer as well as a bladder resection and prostatectomy with an ileal conduit (Indiana pouch or neobladder), with complex abdominal wall closure complicated by infection of Marlex in the past, and prior operations for small bowel obstruction. He is morbidly obese. His kidney function was stable with a Cr 1.5dL/mL, calculated GFR or 44mL/min. His nuclear cardiac stress test (pharmacologic) was normal.

A magnified view of the accessory renal artery is shows below with the arrow

mag preop CT

He needed to have his right CIAA treated but the issues were what to do with his accessory renal artery. Vascular surgery is all about making the right decisions with fall back plans. As with most complicated patients, the options are numerous.

  1. Direct transabdominal open repair
  2. Open retroperitoneal repair –Left sided approach.
  3. Open retroperitoneal repair –Right sided approach
  4. Open debranching right accessory renal artery and EVAR
  5. Parallel graft to right accessory renal artery and EVAR
  6. Coil embolization right accessory renal artery, anticipate worst case postop GFR 20ml/min
  7. Medical management

I informally polled my partners and found an absence of consensus except for rejecting #1, 2, and 7. The first two options were not optimal because of his prior operation and because of the location of his disease. The third option had its proponents, but I felt that the kidney and pouch were in jeopardy from dissection in that area. The open debranching had its appeal for others, but for the same reasons that I rejected #3, I rejected #4 –potential harm to the kidney. #5 may be an option, but in my experience, I have seen too many patients referred for failure of parallel grafts to feel secure about offering it.  #6 would be reasonable if the patient could avoid dialysis. With a calculated CGF of 44ml/min, losing half the remaining kidney would barely leave him off dialysis. By appearances though, the smart money was on losing less than 50% but more than 20%. A 30% loss would result in a GFR of 30mL/min or a Cr of 2.1 which made dialysis not likely. In my experience, the kidney does have some collateralization as evidenced by backbleeding of accessory renals with an infrarenal clamp so it may be that he might lose only 10-15%. I discussed all of these options and medical management with the patient who agreed to proceed with option 5 under my recommendation. My plan was to assess the flow from the accessory renal and proceed if it was small, with plan B being a parallel graft, plan C debranching.

nephrogram

In the OR, the right accessory renal artery was selectively catheterized and a nephrogram revealed that it supplied less than 20% of the kidney. The above diagram shows the extent of the total kidney and the area perfused by the accessory renal artery. I proceeded with coil embolization of it and the right hypogastric artery and EVAR of the AAA/R.CIAA.

post CT

In followup, the patient had a Cr of 1.7mg/dL, representing about 15% loss of kidney function. As the case was done percutaneously, he only had 1cm incision in both groins, and was pleased with his result. No endoleak was seen (CT above).

The telling lesson about this case is that at the time of initial consultation, my first instinct was to prepare the patient for open repair via a right retroperitoneal approach with debranching of the right accessory renal artery as a fallback position. Open surgery is my fallback as it was the foundation of my training. But experience has also taught me that patients with multiple comorbidities often struggle to recover from big operations even if one particular problem is not prohibitively severe. Finally, having smart partners to bounce ideas off of is a not only a luxury but a critical asset.