NAIS reconstruction from lower extremity veins is a successful option in patients with extensive aortic prosthetic infection and other complex aortic problems.

The prevalence of unsuspected renal artery stenosis among patients with peripheral vascular disease has been reported to be as high as 40%, but the prevalence of asymptomatic celiac and superior mesenteric artery stenoses in these patients is not known. The biplane aortograms of 205 male patients who were military veterans and had aneurysms or occlusive disease were independently reviewed, and medical records were studied to determine associated coronary disease, risk factors, and patient outcome. Fifty-six patients (27%) had a 50% or greater stenosis in the celiac or superior mesenteric artery, and seven patients (3.4%) had significant stenoses in both mesenteric arteries. Patients with celiac or superior mesenteric artery stenoses were older (p = 0.002) and had a higher prevalence of hypertension (p = 0.029) than those without significant mesenteric stenoses. Fifty of the 205 patients had significant renal artery stenoses, and 20 had advanced (greater than 75% diameter loss) renal stenoses. Ten of the 20 patients (50%) with advanced renal stenoses had a concomitant celiac artery stenosis, compared to 40 of the 185 patients (22%) who did not have advanced renal stenoses (p = 0.011). In the present study asymptomatic celiac or superior mesenteric artery stenoses were common among male veterans evaluated for peripheral vascular disease, but the prevalence of significant stenoses in both the celiac and superior mesenteric arteries was low. The prevalence of significant celiac stenosis was higher in patients with advanced (greater than 75%) renal artery stenoses who might be considered for prophylactic renal revascularization. Lateral aortography with evaluation of the celiac artery is always appropriate in these patients.

To evaluate the usefulness of CT scanning before carotid endarterectomy, a prospective study was performed on 469 consecutive patients considered for carotid endarterectomy during a 5-year period. All patients underwent carotid duplex scanning and CT scanning before carotid arteriography. Two hundred thirty-seven patients (51%) had transient ischemic attacks, 109 (23%) had a prior stroke, and 122 (26%) were asymptomatic. Results of the CT scan were abnormal in 68 (62%) of the 109 patients with stroke. Fifty-one of the 360 patients (14%) without a clinical history of stroke had an abnormal CT scan outcome. Of patients with a stroke documented by CT scanning, 27 had lacunar infarcts, and 92 had cortical infarcts; these findings did not change surgical management in any patient. CT scanning did not reveal any unsuspected infarcts or tumors. Two hundred thirty carotid endarterectomies were performed on 206 patients. Forty-seven patients (23%) in the operative group had abnormal CT scan findings, but the scan did not influence operative decisions or timing in any case. Seventy-two patients (27%) in the nonoperative group had abnormal CT scan results, but CT scan findings did not exclude any patient from arteriography or surgery. Three perioperative strokes (1.3%) occurred. CT scan findings did not correlate with postoperative neurologic complications. Cost of CT scanning was one-half million dollars in our study alone. Routine CT scanning is unnecessary before carotid endarterectomy and is not cost-effective.

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Background Rural access to surgical care has reached crisis level. Practicing in rural America offers unique challenges with limited resources and specialists. Most training programs do not provide enough exposure to the endoscopic or the surgical subspecialty skills to prepare a resident for an isolated rural environment. As awareness has increased, many programs have modified curriculum to address this need. The Advisory Council on Rural Surgery (ACRS) of the American College of Surgeons set out to delineate important components of rural training programs and measure to what degree the existing heterogeneous programs contain these components. Study Design The ACRS identified 4 essential components of rural surgical training based on literature and expert opinion. These components included rotations in a rural setting, broad exposure to surgical specialties, endoscopy experience, and lack of competing specialty learners. A list of Accreditation Council for Graduate Medical Education programs from a prior publication was updated with the 2019 Fellowship and Residency Electronic Interactive Database self-identified “rural track” programs, reviewed, and categorized. Results We identified 39 programs that self-identified as having a rural emphasis. Depending on the extent of which 4 essential components were included, programs were categorized as either “Broad” (12 programs), “Basic” (20 programs), or “Indeterminate” (7 programs). Conclusion The ACRS described the optimal components of a rural surgical training program and identified which components are present in those surgical residencies which self-identified as having a rural focus. This information is valuable to students planning a future in rural surgery and benefits programs hoping to enhance their curriculum to meet this critical need.

Because of the spleen's extensive collateral circulation, the risk of splenic infarction after splenorenal arterial bypass (SRB) has been considered negligible. We report four patients in whom splenic infarctions developed after SRB. Splenic infarction developed in one patient at the time of SKB, and symptoms of splenic abscess (fever, abdominal pain, and leukocytosis) that proved to be splenic infarctions at laparotomy developed in three patients 2 to 16 days after the operation. Factors possibly contributing to splenic infarction could be determined for three patients. These included interruption of collateral vessels, intraoperative hypotension and disseminated intravascular coagulation, and distal splenic artery ligation. Normal Doppler flow was detected in the splenic parenehyma during test occlusions of the splenic artery before SRB in three patients. Our experience suggests that existing collateral circulation may not always sustain splenic viability after SKB, and some patients may not be suitable candidates for this operation. Factors such as adequacy of inflow, splenic artery length, and risk of perioperative hypotension should be considered.

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