Top 12 Things to Get Your Favorite Surgeon in 2018

1. Microsoft Surface Book 2. It comes in two flavors, Large (13.5inch) and Supersize (15 inch).

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Surface Book 2 13.5 Inch

Like Apple and their Macbook Pros, Microsoft decided to price it out of the reach of most people. In my opinion, it is worth it because of the versatility of popping off the screen and using as a tablet. Reading a journal articles is unmatched at 13.5 inch size.

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The Surface Book 2 13.5 Inch Detached as a Giant Tablet

The other feature is the 12 plus hours of battery life for both sizes although results may vary. The keyboard part has a second large battery and an NVIDIA graphics processor which makes short order of Fortnite Battle Royale. The storage options come steeply priced, but there is an SD slot -with a half height MicroSD adapter (link)and some fiddling with DiskManagement (link), you can trick the computer to thinking the SD card slot is onboard hard drive, so you can add 200-400gB for dumping pictures, media, and Dropbox onto it.

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Sketched on Tablet Using Sketchbook

Low usage apps can also be installed onto this drive. The pen allows you create nice artwork -something that I have always needed for my blogging.  And it plays nice with Apple -you can run iTunes (yes it sucks), and link iCloud to your calendar, photos, iPhone, and Mac desktop. The sweetspot is the Core i5 with 256gB SSD in the 13.5 inch version for about $1400, but if you can swing it, the Core i7 with a 1tB SSD and 15 inch screen (with listed 17hr battery life) is the way to go, but be prepared for sticker shock

2. Samsung Galaxy Note 8/9 Smartphone. I know, I have been a lifelong Apple user, but I wearied of the closed nature of the Apple ecosystem. Get a Note 8 and you can add as much memory as you need via the MicroSD slot (remember to change settings on your apps to make use of this). The AMOLED screens are gorgeous, the pen (pens are back!) lets you scratch down patients MRNs during phone calls and sign PDFs. Google services are great for a lot of things. Add a folding bluetooth keyboard and you have an ultraportable solution to avoiding the giant corporate laptop. The imminent release of the 9 should give you pause, but given the incremental changes under the hood, buy if you find a deal on the 8. The battery life is sufficient for all day use, plays nice with iTunes music, and takes some of the greatest phone pictures I have ever taken (below).

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3. Bluetooth Keyboards -I know they are incredibly boring and utilitarian, but hear me out. There are two form factors that bear consideration. First, the folding keyboards that in combination with a large screen smartphone, give you 95% of the capabilities of a laptop, letting you travel with bare minimum of items. The EC Techology Folding Blue Tooth Keyboard (link) is smaller, and likely not suitable for people with giant paws, but for me, who used to write long form essays and papers on a Psion Series 5MX, this keyboard works well, particularly because it has the phone/tablet stand built into it.

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Samsung Galaxy Note 8 and EC Technology Folding Bluetooth Keyboard

For several months last year, TSA restricted travel to the US with anything bigger than a smartphone. My workaround then was digging up an old Palm Bluetooth keyboard, but the modern stuff is far better. The EC keyboard is sturdier, rechargeable, usable with multiple devices (the one above links to 3 devices). It isn’t backlit but you can find those that are.

The other kind of Bluetooth keyboard that I love are the ones that incorporate retro keys -there are several that have old typewriter keys and others that have the large IBM keys -these both share the clicky key mechanism that were lost when island type chiclet keyboards became the norm. While I love the Macbook, and tolerate the keys, for long typing, I need a real keyboard, and lately, I am willing to spend on mechanical keys.

Why do I like them? For focused writing, the chunky keys with a loud clickety clack sound is incredibly comforting -it sounds like intense work to spit out words on these keyboards. I recently purchased a Bastron Wireless Mechanical Keyboard (link) which looks and feels like an IBM Thinkpad keyboard circa 1995. It is backlit and has a groove for placing tablets and smartphones, although I use it as the center keyboard of my writing station between my laptop and a large second screen. It is backlit which is a plus. Most of you are familiar with the bluetooth keyboards that are like mechanical typewriter keyboards, but I think aside from the asthetics, they are generally very costly and I don’t feel compelled to get one. This Bastron Keyboard is a keeper at the 35 dollars on Amazon (a clearance price). Some people have a difficult time managing the wonky Bluetooth and therefore it gets a 3-ish rating. Just sit tight and follow the instructions and you will be fine. Mine came with a free Bluetooth mouse. I give it a 4 -taking off a point because it uses AA batteries.

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Bastron Wireless Mechanical Keyboard

4. Smartwatches. Sure, go ahead and get a fancy automatic watch, but be prepared to pay through the nose in maintenance and repair fees as when five to ten years out, you notice the watch not keeping time well.

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The watch is round, the way it should be…

The repair fees may actually come out to the same price as getting a new watch. The newer generation of smartwatches offer so many useful functions that they trump their general fugliness. The Apple Watch and the Samsung Gear 3 both hit the right pricepoint for not crying when the inevitable better and newer versions come out. My Gear 3 offers customizable faces and quick swapouts of bands to match my wardrobe. It tracks my activity and measures my heartbeat, and can record my runs. The battery is good for 3 days and recharges in about an hour wirelessly. Unlike the Apple watch, it is round.
5. A two week vacation in the middle of nowhere. All surgeons want out of a vacation is to be completely away from work and preferably with a stunning view. I suggest the following. A two week cruise with a private balcony and view of the ocean and never getting off the boat for excursions. A cabin/house rental off season -that means going to Vail or Aspen in the summer or Martha’s Vineyard or the Hamptons in the winter. Bring food for the apocalypse -Spam, pasta, rice, canned vegetables, oatmeal, powdered milk, sack of potatoes. The ultimate lonely vacation destinations are British microcolonies -the Falklands, the Hebrides, Prince Edward Island, Bermuda, Pitcairn. Unfortunately, they probably all have internet. Bring a couple bottles of whiskey and a box of cigars. Go shoot something with a local. Or spend two weeks on the transcontinental train across Russia from St. Petersburg to Vladivostok in a premier car.

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Go far away, eg. Maldives

6. Blank sheet journal of high quality. Moleskine makes a nice one, but when I travel, I always drop in on local stationers and arts stores for unusual blank books to write in. The Japanese in their infinite wisdom offer a cheap but high quality bound notebook of blank paper that you can find in Japanese bric-brac stores that are cheap but wonderful.

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From local Japanese Store (Daiso), for 10AED (about 3 dollars US), Personalized

I think that all surgeons need to keep notes on what makes their operations fail or work, and imagine what would make things better, but writing about your passions or scratching travel notes is great brain exercise. The bottom line is that an idea needs to be written down as much as a seed needs to be placed into soil.
7. Large capacity battery for recharging -I carry two of these Anker beasts (link). They will charge my Macbook and Surfacebook, and my smartphones multiple times. I can’t tell you how useful it is to not worry about low charges during travel. I bought mine 3 years ago and they are still going strong. They don’t need to be fancy, just incredibly reliable and able to recharge at the higher amperage required by tablets and computers. My MacBook will typically go from 25% to 100% on one of these power banks -nothing to sniff at when you want to write any where any time. Mine are 20100 mAh, but larger ones are available. They do get heavy and they must be on the carry on luggage.
8. Small bluetooth speaker. Not all operating rooms have good sound systems, but you don’t want to lug a huge speaker either. Most tablets will be sufficient for playing music at volume but without sufficient bass. You can play around with the acoustics by placing your smartphone or tablet in a large metal basin, but you want speakers if you want to hear the bottom half of your music, whether it be Vivaldi or Childish Gambino.

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Harman/Kardon makes a supercompact speaker that also is an excellent speakerphone and in a pinch will recharge your phone (link). It’s is plenty loud and gives a nice balanced sound. If you want more bass, you want something like the Bang and Olufson of bluetooth speakers. Again, there are larger speakers, but I’m focusing on ones that will fit nicely in a laptop bag, and I’m happy with my Harman Kardon’s.
9. Giant E-Ink Tablet. Imagine reading journal articles in original A4 size. While it is possible to do this with a standard tablet, the screen will cause eye fatigue. Printing this out means carrying heavy paper copies that are easily lost.

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Boox Max 2 In Monitor Mode. It’s also an Android 6.0 Tablet

You might remember that Amazon once had a Brobdingnagian Kindle -the Kindle DX, but has focused on ever smaller form factors. I had the DX and reading PDFs on it in normal size was a pleasure. Unfortunately, the DX was an early Kindle and not particularly fast nor high resolution. While it was excellent for its time, it has comparatively a muddy low resolution screen when compared to modern Kindles. So you would think in the effort to go paperless that modern hardware and software would combine with state of the art E-ink to create a great reader. Well, Sony put out the Sony DPT-RP1/B 13” Digital Paper, but based on feedback on Amazon, it is clear that Sony hasn’t shaken off their great handicap which is putting out great looking products with terrible names that fail in crucial fashion either in software or hardware. In this case, the proprietary software cuts the legs off this device. The Chinese on the other hand, have put out what appears to be an excellent 13-inch E-Ink tablet running Android (link), the Boox Max 2  and allowing for direct wired second monitor function. This is the sweet spot, but unfortunately is quite pricey. That said, if you really want to make your surgeon smile, this is the gadget. It has that modern high resolution E-ink screen that is close to paper linked to a touch screen and medium range Android hardware. The reviews say that it works well as a second monitor, but I would use it in combination with my bluetooth keyboard and IAWriter (link) to create a focused writing station.
10. Japanese massage chair. My father got one a couple of years back, and now whenever I visit him, I have to wake him up and shoo him out of this chair to get an intense deep tissue massage. The calf and forearm massage function is a must. When I get my forever house, a dark room with several large screens and this chair will be the core of this home. Put on golf or an animal documentary with Attenborough and you get the best nap of your life!

11. Audible.com Subscription. While commuting or long haul driving, catching up with the latest business managment book or historical non-fiction tome makes the 10 minute red lights in Abu Dhabi a pleasure. While there are free podcasts galore, audiobooks lets you get through the latest materials with minimal fuss. There are often free books with coupon codes from some podcasts. Suggested listening -Norse Mythology by Neil Gaiman, 1453: Holy War for Constantinople and the Clash of Islam and the West by Roger Crowley, How to American: An Immigrant’s Guide to Disappointing Your Parents by Jimmy O. Yang, and Ready Player One by Ernest Cline.

12. Ichiran Ramen Instant Noodles. If you haven’t been, you need to go to Ichiran Ramen in Brooklyn, NY. There you will be seated in a single booth, solo with a small cryptic order slip. You choose the texture of your ramen -basically under or over al dente, the add ons like fish cake, seasoned egg, pork belly, and some sides and ring a bell. The roll up shades peak and a hand, no face, reaches in and gets your order. You wait about 5 minutes, and the shade opens and your ramen is placed in front of you. One slurp and you are transported to a kind of ramen induced rapture. It is that good. The noodles are great -they invested a serious amount of time to create a noodle factory out in Brooklyn, but it is the soup that brings you to your knees. The donkotsu broth is made from pork shoulder and bones and has character, depth, and a lingering finish that burnishes itself into your memories. You can’t eat at a normal table and get the same effect -hence the flavor concentration booths. As you walk out, you can purchase boxes of packaged instant Ichiran Ramen which cost as much as buying one fresh, but lets you enjoy the noodles and broth at home or far away like here in Abu Dhabi. You can buy them on Amazon (link) but it looks to be overstock. 20180727_144208They opened a branch in Manhattan, but my kids say it wasn’t as good as in Brooklyn. I can’t imagine what it must be like at the original store in Japan, but I am planning an entire trip just to eat ramen.

Addendum

This post is meant to be a review of items and satirical in presentation. It is not a demand for gifts or services in kind. Anything sent from anonymous sources will not be acknowledged. Please consider donations to your local charity -in Cleveland, the United Way offers services to the needs of the community. Surgeons are perfectly fine getting these things for themselves.

The Interstitial

https://opmed.doximity.com/new-interest-in-the-interstitium-is-like-people-suddenly-obsessing-about-the-stuffing-in-sofas-308b1336a317

By Woosup Park, MD

A recently published paper caused breathless worldwide headlines about a “new” human organ hiding in plain site — the interstitium. It had me smiling because vascular surgeons, the good ones, recognize it and have been managing it for a long time. The interstitium is described as the space outside the cells. The new interest in it is like people suddenly obsessing about the stuffing in sofas. It is the body’s contained negative space and it is the most important organ because it was the first. It has been there all the while.

The genome and its expression, the organism, carry the past like hoarders. Look at a skin cell, and you see a nucleus and a cell membrane, the hallmark of the eukaryote, and the mitochondria that it took captive in eons past when it was a sea bacteria that was eaten and refused to be digested. The next most important step in evolution was multicellularity and specialization of these cells. The earliest efforts started as clumps of cells, but clumps have a limit — every cell had to have exposure to the outside and eventually these became spheres with a hollow internal space. Here was the first interstitium — the first inside, the first not-outside.

To these first animals, segregating an internal space different from the outer sea had advantages. You can concentrate nutrients inside when the seas outside are plentiful and use these when they are not. Add some structure and you have an endoskeleton — we share this with sponges inside this interstitium. As the organism became larger, this sphere flattened and some became animals with one pore ingesting and ejecting and others with two holes. We fall into a lineage that found transiting food through a cylinder to be advantageous. The nutrients were digested and absorbed from the worm into this internal space. The interstitial waters needed to be mixed as food came not from the outside but from this internal protodigestive tract, to have currents and streams. This was done with the development of tubes lined with smooth muscles that beat, interspaced with one way tricuspid valves. This primitive circulatory system is seen in many of our spiny sea cousins like starfish and sea cucumber, and lives in us as the lymphatics.

The interstitium is the remnants of this primitive sea creature that we carry with us, carrying within this pouch of internal sea. The fluid that fills blisters is a kind of briny sea water. When you see an edematous patient, observe the level of this sea by seeing where the edema ends. See how easy it is to milk out this edema out of a hand or foot, just as it is to squeeze the water out of a sponge. Edema is so common that it is easy to forget that so many diseases cause failure of the lymphatics — the bilge pumps of the body, and that on this tide may come many other things that makes the problem worse. In other instances, it may be just high tide in Venice, right before all the sewage gets washed out into the Adriatic.

The interstitium, as much as it was the progenitor of the circulatory system, is likely the foundational element of the nervous system. The various ion pumps are highly conserved and are useful only when concentration gradients are stable. The bioluminescent jellyfish is testament to this. Without the interstitium, cross membrane voltage potentials cannot be maintained. It is the bioelectric spark that life motion. If a planaria, a flatworm, is to have a soul, it resides in the interstitium. It is the spiritual ether bottled inside us. The ghost in our machine swims our portable primordial sea.

These old parts and compartments are hiding in plain site. The lymphatics beat and spread some of the nutrients from the gut into the venous system in connections up at the base of the neck. Both have been superseded by the portal venous system and the circulatory system but the lymphatics persist because there was no reason to abandon it, but possibly it is critical to our existence. The interstitium must play a critical role in homeostasis in the same way that the older autonomic nervous system plays critical subliminal roles by being both a buffer and a store. Every cell in our body is in contact with this inner sea as much as the first cell was afloat in the primordial one.

The interstitium is the final contact point between each cell and the organism as a whole. Oxygen does not go from alveoli to the skin without transiting the interstitium. Just as we are only beginning to grasp the complexity of genetics and the heredity of epigenetics, we are just noticing the interstitium. Up to now, it is as if we have been studying the outlines and histories of Byzantium, Rome, and Carthage, in isolation without studying the depth, composition, and currents of the Mediterranean.

Exovascularist’s Dilemma: Where Is Our LIMA to LAD

During our daily morning huddles, peopled by cardiologists and cardiac surgeons, one thing impresses me more than anything else. The assembled interventional cardiologists, world class and renown, they who can place a stent in any part of the body, will defer to the unassailable superiority of the LIMA to LAD bypass over any existing intervention. I am always a little sad that the analog for this, the vein bypass in the leg does not get the same love. The open surgical bypass of the leg is the great straw man at international symposia. It is fast becoming a diminishing and curious habit of a fading generation.

The acknowledged superior hemodynamics and patency of the bypass is diminished in the literature by pooling patency loss with other factors such as amputation, heart attacks, and death. Some vascular surgeons dogmatically cling to habits learned in training that favor complications, making themselves their own worst enemies both in the literature and in the marketplace. These bad habits involve long incision length, closure techniques that do not anticipate edema, and wound orientation that makes failure more likely.

Operations require far more support and resources to succeed than do interventions that soon go home. Brilliant operations alone will not heal the patient. It is pathways and postoperative care infrastructure and staff that prevent these secondary complications -the very complications that keep the leg vein bypass from being as respected, if not loved, as the LIMA to LAD.

The postoperative care of these patients devolves to management of leg edema. No medical or nursing school adequately teaches the basic science nor management of edema, which is the most common vascular condition

The incisions are too long in the classic vein bypass. When you create and then close an incision, the inflammation drives the accumulation of fluid in the extracellular space – creating edema. This postoperative edema, poorly managed, results in complications that leave the patient hobbled with time lost to healing wound complications, pain, and excess limb weight. Additionally, vein bypasses usually involve groin exposure and the delicate lymphatics that coalesce there are perturbed or destroyed during exposure. Postop, this damage and the inflammation rapidly overcomes the capacity of a lymphatic system. The traditional vein harvest also involves cutting through deep layers of fat. The fat is typically closed by broad sutures that create areas of fat necrosis -potential fodder for bacteria. The best ways the complications of long and deep incisions is to avoid them altogether. The calculus of the operative moment – “I must see the vein,” must include the vision of a patient losing months to wound therapies to heal a gaping, necrotic, infected wound. I recommend skip incisions or adopting in-situ bypass technique with endovascular management of fistulae. Or corral your cardiac PA to harvest the vein segment in the thigh after mobilizing the vein in the leg with the endoscope.

The incisions are often closed with Nylon sutures and skin clips which can become potential foci of infection. With edema, they create zones of ischemia around them, killing skin and creating entry points for skin flora as the skin expands under an unyielding clip or suture. Placed under a pannus, these sutures or clips fester in an anaerobic environment. Closure should adhere to anatomy. The body relies on connective tissue planes to keep itself together. In the groin, these are Scarpa’s layer and the dermis. They should be closed with absorbable monofilament in a buried interrupted fashion at the dermis with a final running subcuticular layer of 4-0 absorbable monofilament. Steristrips or glue at the skin finishes the job. If you use sutures, particularly at the distal anastomotic site, take care to realize that you have about 12 hours before the skin dies in the best of circumstances, and less with microangiopathy of diabetes and ESRD. Squeezing out the edema before closure with a sterile Esmarch or short counterincisions or even a large one to allow for tension free closure over an anastomosis will prevent wound complications over your graft.

The classic longitudinal groin incisions that cut across the inguinal crease divides a tension point -that crease is like a cord that supports the pannus that is slung over it and when divided and then closed with a stitch, that stitch then bears the weight of that pannus every time the patient sits up or stands. If you are observant, wound necrosis typically starts at the groin crease under a surgical clip or suture. Incisions in the groin should be obqlique and parallel to this crease, or if you can, even inside this crease. When these wounds are closed, the natural lines of tension are in line with the incision rather than orthogonal to it. The natural forces keep the wound shut.

This is only the first step. The next is keeping the wound clean and dry for at least 5 days. At the Mayo Clinic, where I trained, the nurses up on 5 Mary Brigh were trained to blow dry the groin wounds every few hours on cool setting and redressing the wound with dry gauze. You can get something close to it by ensuring the wounds painted with betadine, allowed to air dry, and dressed with dry gauze. If there is a constant leak of fluid, you have a serious problem as there is too much edema in the leg, or the wound isn’t closed, or there is a lymph leak. It needs to be actively dried out or you get a wet, macerated, infected wound like a grenade went off in the groin.

They don’t teach compression wrap techniques in medical or nursing school

The simplest thing to avoid lymph leaks is to not make them. Cutting near lymph nodes is hazardous, and once below Scarpa’s you have to orient your dissection directly over the femoral artery. Stray horizontally and you will undoubtedly cut one of the 4 to 10 invisible lymph channels.

They are invisible but detectable -after you break them, you will see a constant wetness in the wound. Think about injecting a cc or two of Lymphazurin (Isosulfan Blue, for those not allergic to Sulfa) into the intertriginous space on the same foot and you will see the lymph channel in bright blue, or stare carefully at the likely spots for a lymph leak and clip it, burn it, Ligasure or Harmonic scalpel it.

Lymph leak identified from saphenectomy incision (for CABG)

So how did we get to a rather dry discussion about edema? Wound complications are tremendously debilitating and offset any benefit from vein bypass operations. These long incisions become terrible big wounds if not prevented. It takes the concerted effort of a team and particularly nursing in actively managing edema. And at the end, the patient too must be included in this discussion. For the vein bypass of the leg to get the same respect and love as the LIMA to LAD bypass, surgical wound complications must become never events.

Water goes downhill

Hello Abu Dhabi

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Taken from Al Maqam Building during my on boarding classes. The hospital has more structural steel than the Burj Khalifa. Valet and helicopter parking available.
Since my last post, I have relocated to Cleveland Clinic Abu Dhabi in the United Arab Emirates. I am now the Chief of Vascular Surgery at this remarkable campus of the Cleveland Clinic. I have moved my family of 4 with 21 suitcases to a new country and region on the opposite side of the planet from all that is familiar. My mission is to bring the Clinic’s main campus culture and expertise to our other main campus here in Abu Dhabi. The hospital was conceived over a decade ago by H.R.H. Sheikh Zayed bin Sultan Al Nahyan, the father of the U.A.E., and only opened in 2015. Cleveland Clinic Abu Dhabi is the most comprehensive and focused healthcare effort in this country and region, and I am proud and honored to be part of it. It is in my opinion the most modern healthcare facility on this planet. In the Department of Vascular Surgery, we aim to provide the full range of consultative and surgical services available at the Cleveland Clinic’s Ohio campus involving diseases of the arteries, veins, and lymphatics. Our guiding principles will be, same as in Ohio, that of clinical excellence, research, education, and innovation delivered with focus on the patient. On this Eid Al Adha, starting tomorrow, I pray for peace to you and our shared world.

Salvage: A different approach to graft infections in the groin

The principles of salvage are in rescuing valuable undamaged goods in the setting of catastrophe. This guided me when a patient was flown in from an outside institution to our ICU with a saline soaked OR towel in his right groin -he had had an aorto-bifemoral bypass for aorto-iliac occlusive disease a year prior, but had never properly healed his right groin wound which continued to drain despite VAC therapy and wound care. On revealing his groin, this is what I saw:

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A CT scan was sent with the patient but has been lost to time, and it showed a patent aorto-bifemoral bypass send flow around an occluded distal aorta and iliac arteries. The graft did not have a telltale haze around it nor a dark halo of fluid which signaled to me that it was likely well incorporated and only sick in the exposed part. The patient was not septic, but had grown MRSA from the wound which was granulating from the extensive wound care that had been delivered.

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I felt that it would be possible to move his anastomosis point more proximally on the external iliac in a sterile field (figure above), and then close, then endarterectomize the occluded external iliac artery after removing the distal graft, then after vein patching, cover the repair with a sartorius muscle flap. It would salvage the remaining graft and avoid a much larger, more intense operation which was plan B. To prepare for that, I had his deep femoral veins mapped.

The patient was prepped and draped, the groin was excluded by placing a lap pad soaked in peroxide/betadine/saline solution (recipe for “brown bubbly” liter saline, a bottle of peroxide, a bottle of betadine), and covering with an adesive drape. The rest of the abdomen was then draped with a second large adhesive drape. A retroperitoneal (transplant-type) right lower quadrant incision was made (below) and the external iliac artery and graft were exposed. As predicted on CT, the graft was well incorporated.

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The external iliac artery was opened and focally endarterectomized of occlusive plaque (image below). The adventitia had good quality despite the longstanding occlusion.

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The graft was mobilized and transected and anastomosed end to side to this segment of artery (below). Dissecting was made difficult by how well incorporated it was.

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The wound was irrigated (with brown bubbly) and closed, dressed, and sealed over with the adhesive drape. The groin wound was then revealed and the graft pulled out (below).

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Remote endarterectomy using a Vollmer ring was used -in this case I didn’t use fluoroscopy given the short distance to the terminus of the plaque which i had mobilized in the pelvis.

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The plaque came out easily and was not infected appearing. It is shown below ex vivo.

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A segment of saphenous vein was harvested from the patient medially and the arteriotomy was patched. The sartorius muscle was mobilized and applied as a flap over this. The wound was irrigated with brown bubbly and packed open with the intention of VAC application.

The patient healed very rapidly and remains infection free. I had used this approach on several occasions in the past and twice more recently. It truly is salvage as it preserves the uninfected graft while never exposing it to the infection in the process of operating. It avoids having to remove the whole graft which then damages the left side -I have seen other surgeons take this approach elsewhere taking a all-or-nothing approach to graft infection to considerable morbidity to the patient. It avoids having to harvest deep femoral vein -another large operation to which the body responds truculently. The patient recently came by for his 4 year followup, still smoking, but legs preserved.

Followup At 4 Years

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The patient came back in followup -it has been 4 years since his infection was repaired. He was complaining of short distance claudication. His wound healed well and remains closed. CTA shows along with his short segment SFA occlusion which we will treat, a widely patent R. EIA (below).

CTA 4 year followup

The remote endarterectomy of the external iliac artery remains patent. Compare this to the preop CTA which I found and wasn’t available when I posted this case originally:

 

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The chronically occluded EIA can be readily seen. The artery shown in the current CTA is that recanalized artery.

 

POTS+May-Thurner’s Syndrome: Rare Disease Causes Rare Disease?

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The patient is a younger man in his twenties who began having dizzy spells associated with near syncope and tunnel vision. He was previously an athlete and was fit and never had such episodes -he had a resting heart rate typically in the 60’s or lower. Workup for arrhythmias was ultimately positive for POTS -postural orthostatic tachycardia syndrome and he was referred to Dr. Fredrick Jaeger of our Syncope Clinic. Tilt table testing the demonstrated the reported tachycardia over 140bpm while upright rising from 60bpm while supine. A radionuclide hemodynamic study (Syncope Radionuclide Hemodynamic Test) showed 54% of his blood volume pooled in his left lower extremity and lower abdomen with upright posture. Air plethysmography (PHLEBOTEST) showed abnormal refill and fill times in both legs and a duplex of the legs showed deep venous reflux in both legs. MRV revealed narrowing of left common iliac vein by the overlying right common iliac artery (May-Thurner’s Syndrome, MTS), and this was where the patient came to my clinic.

The MRV, shown above and below showed the typical pathoanatomy for MTS, but the patient had no symptoms related to left leg swelling, DVT, or varicosities. He did have a reducible left inguinal hernia which was quite tender.

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After some deliberation, while not promising anything regarding his POTS, I agreed to proceed with treating his pathoanatomy. Discussion with Dr. Jaeger revealed this: normally about 20% of blood volume parks in the legs with standing which is rapidly dissipated with normal calf muscle pump action. In a subset of patients with POTS, there is a 30-40% maldistribution of blood volume into the legs which may or may not drive the autonomic responses leading to POTS. He has never seen a study result showing a 54% distribution.

It made physiologic and anatomic sense to me to proceed with a venogram and intervention, but I confess I was dubious about any affects I might have on the patient’s POTS and I informed him of it. Also, I recommended seeing a general surgeon for his hernia.

Venography showed obstruction of his left common iliac vein as evidenced by the filling of pelvic and lumbar collateral veins.

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Intravascular ultrasound showed the narrowing better and more directly (panel below). The right common iliac artery narrowed the left common iliac vein severely.

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A 22mm Wall Stent was positioned across this and dilated with a 22mm balloon in the IVC and an 18mm balloon in the iliac vein. The resulting venogram showed resolution of the obstruction with collateral veins no longer visualized (below).

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But again, IVUS demonstrated more directly the result (and illustrates the importance of having IVUS available for venous interventions).

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The patient was discharged after procedure on a baby aspirin only. He subsequently underwent laparoscopic inguinal herniorrhaphy and returned to my clinic about a month later. His followup duplex showed a widely patent stent and normal flows in the left iliac venous system.

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Surprisingly -the patient declared that he was cured of his POTS. He said since the stents went in, he has not had any more episodes of near syncope, dizziness, tunnel vision, nor weakness requiring lying down to rest. His wife confirmed that he was a flurry of activity over the holidays that was surprising considering how debilitated he was before. This is astonishing to me.

But it should not be a surprise given this: if the POTS symptoms were the result of autonomic dysregulation, a breakdown of the feedback control loop, there were only several places this could be a problem.

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The pathology, the MTS, explains the POTS in this instance very nicely. Because the problem was in the cardiovascular system part of the diagram which I can fix and not the autonomic nervous system control element, which I can’t fix yet, a solution could be tried. This was not an asymptomatic compression of the iliac vein which we do encounter as an incidental finding. It seems to be POTS caused by MTS, and cured for now by treatment of the MTS.

 

 

Park Clamp

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One of the reasons why I moved my family to Cleveland was to participate in innovation at the Clinic. One of the devices that I have been working on has reached the patent stage and I am free to divulge it. Full link below. Innovation is part of the culture here like oxygen in the air.

Clinic link