Perspectives in Vascular Surgery and Endovascular Therapy

The increased operating cost of running a practice, decreasing reimbursement, and general pessimism is leading to increasing number of physicians choosing employment by hospitals and large physician groups. Although over 50% of members of the Society for Vascular Surgery are currently in a practice of less than 3 surgeons and over half of all private practitioners are employed by physician groups, the landscape is shifting quickly. Younger physicians finishing training are increasingly opting for employment. Hospitals are also anxious to hire vascular surgeons to maintain or increase market share of chronic disease management and preempt hiring difficulties with future shortages of vascular surgeons. New vascular surgeons have to carefully weigh the pros and cons of employment before making a decision.

Mycotic aneurysms resulting from intravesical bacillus Calmette-Guérin (BCG) treatment are exceptionally rare. We report on the case of a 73-year-old man who underwent intravesical therapy of BCG for bladder carcinoma and developed a right neck mass. A carotid pseudoaneurysm within a fibrotic mass was noted on surgical exploration. Radical resection was performed followed by a polytetrafluoroethylene interposition graft. Final pathology revealed necrotizing granulomas and multinucleated giant cells concerning for tuberculoma. Intravesicular BCG immunotherapy is an accepted treatment for patients with urothelial carcinoma. Carotid aneurysms are exceptionally rare in this setting and should prompt evaluation for systemic tuberculoid dissemination.

A relationship between decreased carotid arterial flow and apoplectic manifestations was already suspected by the ancient Greeks. Early attempts at carotid surgery, however, were limited to emergency arterial ligation in patients with neck trauma. Attempts to suture arterial stumps together to restore blood flow paved the way for Carrel’s revolutionary idea of reconstructing the resected or injured arterial segment with an interposition vein graft. DeBakey and Eastcott were the first to perform carotid endarterectomy in North America and the United Kingdom, respectively. In 1959, DeBakey proposed a cooperative study to assess the effectiveness of carotid endarterectomy in the treatment and prevention of ischemic cerebrovascular disease. The study was officially designated the Joint Study of Extracranial Arterial Occlusion and represented the first trial in the United States in which large numbers of patients were randomly allocated to surgical or nonsurgical therapy.

Unilateral paresis of cranial nerves IX to XI is defined as Vernet’s syndrome. We retrospectively assessed cranial nerve symptoms from the clinical records of 143 carotid endarterectomy patients. A flexible nasolaryngoscope was used to examine vocal fold movements in 73 patients. If vocal fold paresis (VFP) was confirmed, the patient also underwent magnifying laryngoscopy (for correct diagnosis of injury to the glossopharyngeal and vagus nerves). It was found from clinical records that 8 patients (6%) were confirmed to have cranial nerve symptoms corresponding to Vernet’s syndrome; 7 patients (9 %) had VFP on nasolaryngoscopy. In 2 patients, magnifying laryngoscopy confirmed ipsilateral VFP, pharyngeal paresis, pharyngeal wall hypesthesia, and ipsilateral pharyngeal wall swelling. These 2 patients also had symptoms of injury to the accessory nerve. Damage to cranial nerves IX to XI probably occurred in the parapharyngeal space, based on the existence of posterior pharyngeal wall edema or swelling after carotid endarterectomy.

Introduction. Vascular injuries to hepatic arterial blood flow present a challenge in reconstruction. The location and extent of the injury dictate intraoperative decision making, with repair being performed expeditiously to preserve hepatic function. Formal arterial repair either primarily or with interposition or transposition grafts is indicated in the majority of patients. Special consideration should be made in patients with underlying liver disease and those undergoing biliary reconstructions. This latter group of patients is at high risk of complications following the injury secondary to bile duct ischemia. Methods. A case of proper hepatic artery (PHA) transection repaired with gastroduodenal artery (GDA) transposition is presented with a relevant review of limited literature available on the subject. Results. During an elective pancreaticoduodenectomy the PHA was inadvertently transected just distal to the origin of the GDA. As the GDA had not been transected at this stage of the operation, it was available for transposition. This was performed, restoring arterial blood flow to the liver and the bile duct. The patient did well postoperatively with no evidence of biliary or pancreatic leak or hepatic dysfunction at both discharge and follow-up clinic visit. Conclusion. Injuries to hepatic artery injury are uncommon in experienced hands. This case report is only the second instance of such injury requiring reconstruction in 434 cases of single operator experience pancreaticoduodenectomies. We present arterial transposition of GDA as a feasible method to ensure adequate arterial supply to the hepatobiliary system.