The reading of papers can be just that -a passive run through received wisdom, or a critical exercise that can mean life or death when it comes to the medical literature. Dr. Mastracci last year did a wonderful thing by offering a few papers on how to judge the evidence. What the critical reader does is akin to what a pawn broker does when a purchase is considered. There are objective criteria, qualitative criteria, and the gut feeling of value. Do not discount the last, but apply the first because not all that shines is gold.
The graphic is a painting I did several years ago meant to be a market sign for a vascular surgeon in some faraway place. I get no proceeds from their sale, but if I do, they will be turned over to a vascular related charity or foundation.
When conduit is limited, or PTFE or cadaver vein is being considered, in the setting of occluded SFA stents, I have found that it is possible and perhaps preferable to attempt removal of these stents using remote endarterectomy.
The CTA, particularly with 3D reconstruction, is helpful in planning these cases.
The additional material needed is fluoroscopy and endovascular skills. Directing a subintimal Glidewire helps free the stent and aid passage of the Moll ring dissector.
Adding cold saline seems to help shrink the stents. A plaque free distal end point allow the stents to be removed with a gentle tug.
I put these patients on coumadin anticoagulation. Surveillance is needed for recurrent stenoses -typically these occur randomly as focal TASC A stenoses, and likely represent remnant medial tissues that have caused intimal hyperplasia. This may be particularly amenable to treatment with drug eluting balloons. Failure as thrombosis typically is limited to the treated vessel without the embolism seen when PTFE grafts fail. Failure tends to occur in smokers. Inability to pass the dissector is usually seen in patients with heavy calcification -diabetics, renal failure, and I would avoid attempting remote endarterectomy in these patients. When the dissectors fail to pass, cutting down and directly endarterectomizing the vessel and resuming remote endarterectomy is feasible. The common femoral artery is repaired with a patch. I try to avoid having to place a distal stent and when a tapered end point, as in a successful carotid endarterectomy, is achieved, usually unnecessary.
Parts of this was presented at Midwest Vascular in 2008.
1. Beef Jerky, organic, traditional flavor
2. Tall Blonde Roast, two fingers of half and half
3. Honest, hard work
4. 12 inch Subway Club, with mozzarella, toasted, lettuce, tomato, olives, onions, sweet onion relish, and Sriracha, liter of water
5. Hygiene and grooming
6. An updated list with good news
7. Articulate, thoughtful, organized speech
9. Good Halloween candy
10. Dark chocolate from DGC office
Here is a link to the current issue of Cardiac Consult where I have a case report of a difficult EVAR. In it also is a feature on our vice chair, Dr. Timur Sarac, and his bioabsorbable stent, and Dr. Eric Roselli of the Cardiovascular Surgery on stent grafting of ascending thoracic aortic dissections, for which he received special recognition at todays State of the Clinic address by Dr. Cosgrove.