Venous Stasis Ulceration due to Massive Splenomegaly Causing Iliac Vein Compression From Secondary Myelofibrosis

Venous stasis ulcers are nonhealing lesions due to venous hypertension secondary to valvular dysfunction or deep venous outflow obstruction. We describe a case of a 71-year-old male with a history of polycythemia vera, secondary myelofibrosis, and massive splenomegaly up to 38 cm who presented with chronic, perimalleolar venous stasis ulcers and pain on the left lower extremity. CT showed significant compression of the left common iliac vein due to mass effect from the spleen. He was managed medically while being evaluated for partial splenic artery embolization but expired due to other chronic conditions before any intervention could be performed. Partial splenic artery embolization may be considered as a treatment option for patients with symptomatic iliac vein compression due to massive splenomegaly secondary to myelofibrosis, as long as extramedullary hematopoiesis is not compromised.

Virtual reality can reduce anxiety during office-based great saphenous vein radiofrequency ablation

OBJECTIVE

Office-based treatment of venous pathology is common and frequently involves the use of anxiolytic medication to reduce anxiety. Virtual reality (VR) has been shown to effectively reduce pain and anxiety in a variety of settings. The objective of the present study was to determine whether VR could be smoothly integrated into office-based vascular procedures and to ascertain whether VR could reduce procedural pain or anxiety.

METHODS

A total of 40 patients undergoing an office-based endovenous radiofrequency ablation were included in the present study. Of the 40 patients, 20 were randomized to the VR group and 20 to the control group. The patients in the VR group were equipped with a Samsung GearVR headset and headphones (Samsung, Suwon, South Korea) running AppliedVR software (AppliedVR Inc, Los Angeles, Calif), which ran throughout the duration of the procedure. All 40 patients underwent unilateral great saphenous vein radiofrequency ablation. After the procedure, the patients were surveyed regarding their preprocedure anxiety and their pain and anxiety during the procedure using the Wong-Baker scale.

RESULTS

All procedures were successfully completed, and all patients were generally satisfied with their treatment. The average procedure time was not significantly different. No statistically significant differences were present in preprocedure anxiety or procedural pain between the two groups. The anxiety level during the procedure, however, was 4.09 of 10 in the control group vs 2.95 of 10 in the VR group, statistically significant difference using a paired t test. Furthermore, the anxiety level for the control group had increased during the procedure but that of the VR group had decreased. Finally, 85% of the patients in the VR group would recommend using VR to someone undergoing a similar procedure.

CONCLUSIONS

VR can be safely and efficiently integrated into office-based vascular procedures. VR was generally well liked and recommended by those who used it. Most importantly, our findings suggest that VR can decrease procedural anxiety. Further research should examine whether this might obviate the need for anxiolytic medication.

Endovascular Treatment of Claudication due to Isolated Internal Iliac Artery Occlusive Disease

Aortoiliac occlusive disease is a common cause of lower extremity claudication. Patients are typically found to have diminished femoral pulses and abnormal noninvasive vascular studies of the lower extremities. Isolated lesions of the internal iliac arteries are much less commonly treated but can cause similar claudication symptoms in the buttocks, hips, or thighs. Occlusive disease in the internal iliac artery is more challenging to diagnose because the lower extremity pulses and vascular studies can be normal. This may falsely steer the diagnosis away from a vascular etiology. We present a case of disabling buttock claudication in a patient with normal pulses and isolated ipsilateral internal iliac artery stenosis. This was treated successfully with drug-eluting balloon angioplasty. We review the literature for similar cases of isolated internal iliac artery occlusive disease and summarize the disease characteristics and treatment modalities.

Sartorius Muscle Flaps for Vascular Groin Wound Complications

Sartorius myoplasty (SM) has been used as an adjunct for soft tissue coverage in vascular groin wound complications. However, the reliability of SM as a primary muscle flap has been questioned. The purpose of this study is to determine the reliability of SM performed by vascular surgeons in the management of vascular groin wound complications. A retrospective review was performed on all patients who underwent SM from 1997 to 2012. The three indications for SM were prophylactic, infection, and noninfectious wound complication. Failure of SM was defined as operative reintervention for bleeding, persistent wound drainage, or infection. A total of 99 patients underwent 103 SM procedures. The patients were 43 per cent male and 57 per cent female; the mean age was 69 years. The indication for SM was infectious in 62 cases (60%), prophylactic in 21 cases (20%), and noninfectious in the remaining 20 cases. Failure of SM occurred in 11 cases (11%). Of these, salvage bypass and/or salvage muscle flap was required in eight cases (73%). When salvage bypass was required, extra-anatomic obturator bypass was performed in 80 per cent of cases. Salvage wound coverage included rectus abdominus flap (60%), rotational flap (20%), and skin grafting (20%).Seventy-three per cent of failures came from the infectious wound group. The most common reason for SM failure was hemorrhage (45%). In 82 per cent of the cases, the sartorius muscle was still viable at reoperation and was used for continued muscle coverage. SM performed by the vascular surgeon provides reliable soft tissue coverage for vascular groin wound complications and should be used as the primary muscle flap in the majority of patients. In cases of SM failure, the vascular surgeon should consider other more extensive muscle flap options.

Sartorius Muscle Flaps for Vascular Groin Wound Complications

Sartorius myoplasty (SM) has been used as an adjunct for soft tissue coverage in vascular groin wound complications. However, the reliability of SM as a primary muscle flap has been questioned. The purpose of this study is to determine the reliability of SM performed by vascular surgeons in the management of vascular groin wound complications. A retrospective review was performed on all patients who underwent SM from 1997 to 2012. The three indications for SM were prophylactic, infection, and noninfectious wound complication. Failure of SM was defined as operative reintervention for bleeding, persistent wound drainage, or infection. A total of 99 patients underwent 103 SM procedures. The patients were 43 per cent male and 57 per cent female; the mean age was 69 years. The indication for SM was infectious in 62 cases (60%), prophylactic in 21 cases (20%), and noninfectious in the remaining 20 cases. Failure of SM occurred in 11 cases (11%). Of these, salvage bypass and/or salvage muscle flap was required in eight cases (73%). When salvage bypass was required, extra-anatomic obturator bypass was performed in 80 per cent of cases. Salvage wound coverage included rectus abdominus flap (60%), rotational flap (20%), and skin grafting (20%). Seventy-three per cent of failures came from the infectious wound group. The most common reason for SM failure was hemorrhage (45%). In 82 per cent of the cases, the sartorius muscle was still viable at reoperation and was used for continued muscle coverage. SM performed by the vascular surgeon provides reliable soft tissue coverage for vascular groin wound complications and should be used as the primary muscle flap in the majority of patients. In cases of SM failure, the vascular surgeon should consider other more extensive muscle flap options.

Treatment options for late type III endoleaks after endovascular aneurysm repair

Late type III endoleaks result from complete or partial separation of endograft device components. Component separation repressurizes the aortic sac and may result in aortic rupture. We report 4 cases of late type III endoleaks after initial successful endovascular aneurysm repair for abdominal aortic aneurysm. Our cases include 3 aortic cuff separations and 1 iliac limb separation. The average time before graft separation was 3.25 years with an average aneurysm size at re-presentation of 8.2 cm. Management of these complex cases will be discussed, the literature reviewed, and recommendations for treatment offered.

Venous thromboembolism secondary to uterine fibroids: a case of phlegmasia cerulea dolens and review of the literature

Uterine fibroids are usually benign soft tissue tumors, however, when they become large, they can cause external venous compression. We present a case of a 45-year-old woman who presented with phlegmasia cerulea dolens from a large uterine fibroid. She was successfully treated with hysterectomy, venous thrombectomy, and fasciotomy. We review the literature for previous reports of venous thromboembolism resulting from uterine fibroids. The patient characteristics, thrombotic complications, and treatment modalities are reviewed.

Effects of systemic tadalafil on skin flap survival in rats

OBJECTIVE

Phosphodiesterase-5 inhibitors, used to increase penile blood flow in erectile dysfunction patients, have recently been postulated to increase blood flow and flap survival in cutaneous flaps based on random blood supply. This study aims to investigate the phosphodiesterase-5 inhibitor tadalafil, administered orally, on random flap survival.

METHODS

Modified McFarlane flaps measuring 8 cm × 2.5 cm were raised on the backs of 37 male Sprague-Dawley rats. Rats received were divided into a control group, a low-dose group (10 mg/kg tadalafil), and a high-dose group (20 mg/kg tadalafil). Treatment doses were administered once preoperatively and every 24 hours postoperatively for a total of 7 doses. On postoperative day 7 and 14, the area of flap survival was calculated and compared.

RESULTS

All rats survived and thrived throughout the experimental period. Control group rats showed an average flap survival of 77% ± 11% at 7 days and 77% ± 9% at 14 days. Low-dose-group rats showed an average flap survival of 82% ± 10% at 7 days (P=0.21), and 81% ± 12% at 14 days (P=0.41). High-dose group rats showed an average flap survival of 81% ± 11% at 7 days (P = 0.45) and 80% ± 12% at 14 days (P = 0.53). Statistical analysis was performed using the Mann-Whitney test.

CONCLUSIONS

Our results indicate a trend toward increased random-pattern flap survival with both high- and low-dose oral tadalafil in a rat model. Because this trend did not achieve statistical significance, further studies are warranted.

Self-evaluation effects of interpersonal versus intergroup social comparison

Two studies tested the prediction that the outcome of social comparison will differ depending on whether interpersonal or intergroup comparison processes have been engaged. Results of an experiment in which college student participants were assigned to membership in a minority or majority social category confirmed the predicted three-way interaction effect of in-group salience, target group membership, and upward-downward comparison on self-assessments of academic ability. Majority group members exhibited contrast effects in their self-ratings following exposure to a videotape of an in-group member displaying either very high or very low academic competence. Self-evaluations of minority group members revealed assimilation effects in response to in-group comparisons and contrast effects in response to out-group comparisons. In a second, follow-up experiment, this in-group assimilation effect was found to be dependent on intergroup contrast.

Self-evaluation effects of interpersonal versus intergroup social comparison

Two studies tested the prediction that the outcome of social comparison will differ depending on whether interpersonal or intergroup comparison processes have been engaged. Results of an experiment in which college student participants were assigned to membership in a minority or majority social category confirmed the predicted three-way interaction effect of in-group salience, target group membership, and upward-downward comparison on self-assessments of academic ability. Majority group members exhibited contrast effects in their self-ratings following exposure to a videotape of an in-group member displaying either very high or very low academic competence. Self-evaluations of minority group members revealed assimilation effects in response to in-group comparisons and contrast effects in response to out-group comparisons. In a second, follow-up experiment, this in-group assimilation effect was found to be dependent on intergroup contrast.

Effects of group identity on resource use in a simulated commons dilemma

In a review of research on in-group categorization and group identity, Brewer (1979) proposed that cooperative solutions to social dilemmas, such as Hardin 's (1968) "tragedy of the commons ", may be achieved by exploiting the positive consequences arising from a common social-group identity. Three laboratory experiments were conducted to assess the effects of making salient either a superordinate (collective) or subordinate (differentiating) group identity in heterogeneous groups. In the first two experiments, naturally occurring social categories were used as a basis for group differentiation. In the third, the level of social-group identity was manipulated by varying the common fate of the group members. It was predicted that individual restraint would be most likely when a superordinate group identity was made salient and under conditions in which feedback indicated that the common resource was being depleted. Results from all three experiments provide support for this general hypothesis, indicating that cooperative responding is enhanced even when the basis for superordinate group identity is minimal.

Effects of group identity on resource use in a simulated commons dilemma

In a review of research on in-group categorization and group identity, Brewer (1979) proposed that cooperative solutions to social dilemmas, such as Hardin 's (1968) "tragedy of the commons ", may be achieved by exploiting the positive consequences arising from a common social-group identity. Three laboratory experiments were conducted to assess the effects of making salient either a superordinate (collective) or subordinate (differentiating) group identity in heterogeneous groups. In the first two experiments, naturally occurring social categories were used as a basis for group differentiation. In the third, the level of social-group identity was manipulated by varying the common fate of the group members. It was predicted that individual restraint would be most likely when a superordinate group identity was made salient and under conditions in which feedback indicated that the common resource was being depleted. Results from all three experiments provide support for this general hypothesis, indicating that cooperative responding is enhanced even when the basis for superordinate group identity is minimal.