Erica Mitchell

Approval of the primary certificate in vascular surgery eliminated the requirement for certification in general surgery before vascular surgery certification. New training paradigms for training in vascular surgery have emerged driven by the desire to offer greater flexibility of training and to shorten the length of training. Many of these changes are based upon "expert opinion," promise, and "logic" without objective evaluation of the residents or the training programs themselves. To be on the forefront of surgical education, vascular surgery will need to adopt methods of curriculum development firmly grounded in educational principles and use modern assessment tools for the evaluation of competence and performance. This report presents the evolution and challenges to the current vascular surgical training model and then argues for a more rigorous and scientific approach to training in vascular surgery. It presents an analysis of potential avenues for placing education and training in vascular surgery on the forefront of modern surgical education.

Because of the speed and efficiency of laparoscopic adrenalectomy, alternative surgical procedures for adrenal adenomas are uncommon. The present report outlines the case of a young patient with an adrenal adenoma causing Conn syndrome who was a poor candidate for surgical treatment. Computed tomography (CT)-guided radiofrequency ablation of the adenoma was performed with a paraspinal approach and injection of dextrose 5% in water. After successful ablation of the 1.8-cm x 1.2-cm mass according to imaging criteria, the patient's symptoms largely resolved.

Arteriovenous malformations remain a difficult clinical problem. There is very little understanding of the underlying pathogenesis of these lesions, and therapy frequently involves considerable risks with suboptimal outcomes. Recently, a comprehensive description of the angiosomes of the head and neck was completed in the authors' unit. It was noticed that the location of several clinically observed arteriovenous malformations in the head and neck seemed to correspond to the anatomic location of the choke anastomotic zones linking the angiosomes. Therefore, selective clinical angiograms were compared with those from the authors' previously performed fresh cadaver injection studies, in which they defined the angiosomes of the head and neck. In each patient, the location of the arteriovenous malformation corresponded directly to the choke vessel anastomotic zone linking two or more adjacent angiosomes. Clinical and pathologic ramifications of this observation are discussed.

To retrospectively review the outcomes after placement and retrieval of retrievable inferior vena cava (IVC) filters at two academic medical centers. All patients who underwent retrievable filter placement between May 2001 and December 2005 were included. Hospital records at both institutions were reviewed, and relevant data were collected concerning the placement and retrieval of all removable filters. A total of 197 patients underwent placement of a retrievable IVC filter. Of those, 143 patients (72.5%) had Günther Tulip filters (GTFs) placed, and 54 patients (27.5%) had Recovery filters placed. A total of 94 patients underwent attempted filter retrieval, accounting for just less than half of all retrievable filters placed during the study period (47.7%). Retrievals were successful in 80 patients (85.1%). Half the retrieval failures (n = 7) were the result of thrombus within the filter, and technical difficulties (eg, filter embedded in IVC wall, tilted filter) were the cause of retrieval failure in the other half. There was no significant difference in retrieval failure rates between the GTF and Recovery filter (16.4% vs 9.5%, respectively). GTFs were removed after a median implantation time of 11 days (range, 1-139 d), whereas Recovery filters were removed after a median implantation time of 28 days (range, 6-117 d). Placement and retrieval of nonpermanent IVC filters can be performed safely with a high technical success rate. In patients at high risk for venous thromboembolism and contraindication to anticoagulation, retrievable filters may be used aggressively to prevent the potentially devastating outcome of pulmonary embolism.

To describe a contemporary series of open abdominal aortic aneurysm (AAA) repairs in patients not anatomically suitable for endovascular AAA repair. A prospectively maintained database including consecutive nonruptured open aneurysm repairs from March 1, 2000, through July 31, 2007, was reviewed. Patient demographic characteristics and perioperative outcomes were evaluated and stratified based on proximal aortic cross-clamp placement. A total of 185 patients with AAA underwent 103 infrarenal and 82 suprarenal cross-clamp repairs. Overall, the complication rate was 37.0% with infrarenal and 61.0% with suprarenal cross-clamps (P = .001). The 30-day mortality was 2.9% with infrarenal and 6.1% with suprarenal cross-clamps (P = .18). Postoperative renal insufficiency (29.3% vs 7.8%; P < .001) and pulmonary complications (25.6% vs 12.6%; P = .03) were more frequent with suprarenal cross-clamps. Suprarenal cross-clamps were associated with greater intraoperative blood loss (2586 mL vs 1638 mL; P = .006), operative duration (391 min vs 355 min; P = .005), use of adjunctive renal and/or visceral grafts (43.9% vs 1.9%; P < .001), duration of intensive care unit stay (4.5 days vs 3.0 days; P = .006), and hospital length of stay (9 days vs 7 days; P = .04). Of patients who received a suprarenal cross-clamp, 25.6% required temporary nursing home placement vs 17.5% with an infrarenal cross-clamp (P = .14). Until fenestrated and branched endografts are available, open AAA repairs will become increasingly complex. Suprarenal cross-clamping is associated with increased rates of complications but similar mortality rates and need for nursing home placement. With the disappearance of straightforward open aneurysm repair, trainees in vascular surgery will have to learn AAA repair almost exclusively by operating on patients with complex AAAs. Fewer surgeons will perform these repairs, and fewer fellows will be able to complete the operation independently immediately after training.