Categories
amputation aortoiliac occlusive disease (AIOD) BKA bypass Commentary complications limb salvage Lymphatic techniques tibial revascularization training Uncategorized Wounds

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
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Uncategorized

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.

Categories
AIOD aortoiliac occlusive disease (AIOD) complications EndoRE graft infection limb salvage remote endarterectromy techniques Uncategorized

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:

EndoRE in graft infection.002

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.

EndoRE in graft infection.009

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.

EndoRE in graft infection.003

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).

EndoRE in graft infection.006

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.

EndoRE in graft infection.007

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

EndoRE in graft infection.008

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:

 

preop CTA_4

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

 

Categories
iliocaval venous May Thurner's Syndrome postural orthostatic tachycardia synrome POTS Uncategorized Venous venous intervention

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

preop-mri_3

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.

preop-mri_1

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.

preangio

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

preop IVUS.png

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).

post-intervention-angio

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

post IVUS.png

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.

followup duplex.jpg

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.

img_3793

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.

 

 

Categories
innovation Uncategorized

Park Clamp

park-clamp_1

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

Categories
CTA imaging Uncategorized Venous venous aneurysm venous intervention

3D VR Images from CT Data Very Useful in Open Surgical Planning: Popliteal Venous Aneurysm

ct-3dvr-planning

Patient is a middle aged man with history of DVT and PE who in preoperative workup for another operation was found to have a popliteal venous aneurysm affecting his right leg. Unlike the recently posted case (link) which was fusiform, this aneurysm was saccular (CT above, duplex below). Popliteal venous aneurysms have a high risk of pulmonary embolism because: they tend to form clot in areas of sluggish flow and once loaded with clot, will eject it when compressed during knee flexion.

preop-duplex

When I perform open vascular surgery, I tend to get a CTA not just because it is minimally invasive and convenient, but because it gives important information for operative planning. The volume rendering function, which takes the 3 dimensional data set from a spiral CT scan, and creates voxels (3 dimensional pixels) of density information and creates stunning images such as the one featured on the current September 2016 issue of the Journal of Vascular Surgery. But these are not just pretty pictures.

In fact, I use these images to plan open surgery, even to the location of incisions. Vital structures are seen in 3D and injuries are avoided. Take for example the CT Venogram on the panel below. By adjusting the window level, you have first the venographic information showing the saccular popliteal venous aneurysm on the left panel, you can also see where it is in reference to the muscles in the popliteal fossa. The greater saphenous vein and varicose veins below are well seen.

ct-3dvr-planning

By adjusting the level, subcutaneous structures are better seen including the small saphenous vein which could be harvested to create a patch or a panel graft from a posterior approach. A final adjustment of the window level on the right shows the skin, and I can now plan the curvilinear incision.

By changing the orientation, I can also recreate the surgeon’s eye view of the leg in the prone position (below).

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And you can see how well it matches up to the actual operation shown below:

Intraop Photo.png

This was treated with plication of the saccular aneurysm and unlike the fusiform aneurysm, I did not sew over a mandrill (a large 24F foley) inserted through a transverse venotomy, but rather ran a Blalock type stitch under and over a clamp.

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The several weeks postoperatively showed no further trace of the saccular aneurysm.

postop-duplex

The volume rendering software grew out of the 3D gaming industry. The voxel data that paints flesh and bone on skeletons and costumes and weapons is far more complex than what is applied for the 3DVR packages that are available. The images shown for this post comes from TeraRecon/Aquarius, but they are also available as open source software from Osirix, Vitrea, and various software packages sold with CT scanners. While those that are tied to the scanners are often tied to dedicated workstations -limiting you to going to Radiology and taking over their workstation, many will work in the cloud for both the DICOM data and for virtual desktop access through mobile. Contrast is not necessary if the patient has kidney dysfunction -the vessels can be manually centerlined -ie. a line can be dropped in the center of the artery to illustrate its course when viewing the VR images.

I will plan the surgery while in the clinic with the patient, actually tracing out the incisions and dissections necessary to achieve success. It is a wonderful teaching tool for trainees. But most critically, it helps me imagine the operation and its successful completion.

Categories
Uncategorized venous aneurysm

The Clot Gun: Popliteal Venous Aneurysms Are Not Varicose Veins

IMG_9819

The basics of this air rocket pictured above is the projectile, attached by tube to a large bladder which when compressed by external force, ejects the projectile upwards. These are the same features of a popliteal venous aneurysm. First, the large chamber predisposes to stasis and thrombus formation. This thrombus will form on the flaccid walls which are areas where stasis occurs. During activity, it likely dislodge but catch at the outflow, obstructing it. Pressure builds up in the calf veins below, and flexing the knee and pressing the venous aneurysm ejects the thrombus towards the heart and lungs. Clot Gun.

CTV_1

The patient is a young woman who was an active college athlete. She had her first pulmonary embolism occur during practice several years prior to presentation. A duplex noted residual thrombus in her right popliteal vein. Over the next several years, she had two more episodes of pulmonary embolism whenever her anticoagulation was stopped. No thrombophilia was detected on workup. She was referred to the Clinic and Dr. Jerry Bartholomew in the Department of Cardiovascular Medicine noted in her records a mention of a dilated popliteal vein. On examination, she had no historical or physical examination findings to suggest a predisposition to pulmonary embolism. A duplex was ordered.

preop duplex popliteal venous aneurysm.png

The duplex showed a 2.8cm popliteal venous aneurysm of the right leg. No acute DVT was seen but swirling rouleaux could be seen on the B-mode video. A CT venogram was ordered.

CTA summative

No other defect was detected. Operation was planned. Mapping showed no suitable superficial venous conduit, and venorrhaphy was planned. The patient was kept anticoagulated to the day of operation.

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A curvilinear incision (lazy S) was made across the popliteal fossa and careful dissection revealed the aneurysm. It was soft and the vein was normal below in the calf. Above it, there was a tight fibrous band that was contricting it -a popliteal venous entrapment. I released this band. Using a 24 French Foley catheter inserted through a transverse venotomy on the popliteal vein below, the aneurysm was plicated to approximately 1cm diameter, and the catheter removed and the venotomy repaired.

IMG_9703

The nerves were restored to their original position and the wound closed in layers. She recovered well and returned to followup about a month later. Duplex showed a patent vein and she had no symptoms of dyspnea.

pop venous aneurysm post18

The plan is to have her come off of her anticoagulation after a visit with Dr.Bartholomew. Reviewing the literature, my confreres at Mayo published their 15 year experience with popliteal venous aneurysms and found that 5 of their 8 patients presented with pulmonary embolism, and that most of their complications occurred with bypass repair while aneurysmorrhaphy fared well (reference). Because of their rarity, about 200 cases in the literature, it may be assumed that many are not found until complications occur or never found because pulmonary embolism, the most common complication, results in death. Also, it would be easy for unknowing physicians to assume that popliteal venous aneurysm falls under the umbrella of varicose vein which this is not. They should be treated when found, and in most cases, such as this, venorrhaphy is preferred.

 

Reference

Johnstone JK et al. Surgical treatment of popliteal venous aneurysms. Ann Vasc Surg 2015;29:1084-1089.

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Uncategorized

My Innovations Coach Featured in Inc.com article

“Why Cleveland Clinic Believes It Can (at Least) Triple a $1.5 Million Investment in This Startup”

http://www.inc.com/ilan-mochari/cleveland-clinic-startup-tatara-vascular.html

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Journal Club Uncategorized

February Journal Club -Venous Disease

February 16, 2016 630pm at Foundation House.

Presenters:

Dr. Mohammed Abbasi – joi150040 -Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A Randomized Clinical Trial. JAMA 2015;313:1627-1635.

Dr. Keith Glover –PIIS1078588413005947 -Percutaneous Manual Aspiration Thrombectomy Followed by Stenting for Iliac Vein Compression Syndrome with Secondary Acute Isolated Iliofemoral Deep Vein Thrombosis: A Prospective Study of Single-session Endovascular Protocol. Eur J Vasc Endovasc Surg 2014;47:68-74.

 

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Uncategorized

Off the shelf f-EVAR

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Thoracoabdominal stent grafts off the shelf: link

Congratulations to Dr. Gustavo Oderich who has implanted the Gore off the shelf TAAA device at Mayo.