Sharvil Sheth, MD

@farkomd @XavierBerardMD Low threshold to ligate and divide left renal vein to improve exposure and ensure speedy anastomosis. Very important intraop decision- Either divide the gonadal/adrenal to mobilize the left renal vein or divide the renal vein, can’t do both or left kidney will be in trouble.

A room with a view👇 Suprarenal X clamp Renal vein preserved. Teaching point: When you clamp above the renals, time matters. Protect what you can (renal vein), work efficiently, & make your anastomosis count. Good exposure buys you renal function. Bad exposure buys you dialysis

@farkomd Is it still on the wire? If yes then try to send a snare on that same wire and pull it out through the sheath

It’s always something. New device or the capture of a displaced nosecone in a total arch?

@drcostantino1 Needs angio with runoff. Likely common femoral to personal bypass. Sounds like rest pain without wounds so peroneal without direct foot runoff may be suffice to relieve symptoms

Open to any and all ideas. Offered admit with drip, palliative care, attempt at recan. 3 months severe pain.

@farkomd Agree 💯 no stent

@farkomd avoid putting sheath in tortuous splenic artery. Soft wire and catheter. Sheath in celiac for support.

Procedural agram. Left radial approach. Severe tortuosity. There is no need to even contemplate a stent graft for this splenic artery aneurysm

The average age of a vascular surgeon in the US is over 55 years. There are not enough new surgeons to replace the coming tsunami of retirements and exits from the workforce. Surveys by the SVS have confirmed a measurable drift from clinical responsibilities as surgeons age. In my opinion, the current system is running on residual momentum from times gone by. Increasing medical school enrollment and downstream training positions is a long term fix. There are currently no major initiatives to increase the future output of vascular surgeons in time to span the coming gap. Access is a problem in rural areas but also beginning to surface in suburban metro areas. It will only get worse in the short term. I think most of us know what needs to be done. It will take a lot of convincing of those who control the purse to get the ship turned around.

@docpark Ligate the smaller one.

For in situ vein bypass what to do when the vein splits into two slightly smaller veins - what do you do? #vascsurg

@theblanketdog @AWBeckMD Yes we had one case of high flow Pancreatico duodenal artery aneurysm where our coils failed and aneurysm started filling again once celiac re-occluded. These are very interesting entities related to occluded celiac artery. Our case has MALS. journals.sagepub.com/doi/10.1177/15…

@AWBeckMD Did you do anything about the celiac? Are you afraid this will recur?

40yo otherwise healthy male with intermittent abdominal pain.

Philadelphia's 3rd Annual Vascular Resident and Fellow Case Conference! Great job to our general surgery residents representing St. Luke's Vascular! Dr. Hankspiker, Dr. Stewart, and Dr. Alder #vascular #vascularsurgery

@StlukesVascular Special thanks to @PennVascular for organizing this fantastic regional conference for our trainees.

@thesurgerylife @_backtable Any concern that repeated IJ access with 12fr could promote future IJ stenosis / occlusion as some of this patients end up with repeat declots every few months

IMO most efficient way to do graft/fistula thrombectomy. I go IJ approach then 12F sheath and CAT 12 typically 1-2 passes and the fistula/graft is all open, single stick, no hands under fluoro, cleaner thrombectomy.. Anyone else doing this approach? #IR, #vascular ? @_backtable

@mattsmeds Venaseal entire vein

Symptomatic venous insufficiency (sore/tired/aching legs) and GSV reflux only below knee. Failed compression. What do you do?

@yuejianing Sorry I meant proximal below right renal and SMA

@yuejianing Retroperitoneal, rifampin soaked Dacron with presewn left renal bypass limb, proximal anastomosis just below left renal and SMA . You can have your GI do an endoscopy to look for AEF.

an AAA endograft infection w/ hostile neck involved. Which approach will you use? Transperitoneal retropancreatic, or transperitoneal medial visceral rotation?

@farkomd @WLGore Do you do rapid pacing during deployment ?

Was Aorta/PA fistula. Repaired with TEVAR. 10 cm CTAG from @WLGore which was perfect fit, and the ctag was able to be conformed nicely to the curve. #AortaEd

@farkomd Looks like a Medtronic EVAR- ipsi via right access, contra limb in to the left hypo and Did you laser fen the left ext iliac limb ? Couldn’t see the prior tevar on CTA cuts. Both Hypos should be preserved if possible. Nice Creative solution!

Prior open repair with what appeared to be a tube graft. That required a limb to the L leg. All done somewhere else. Distal anastomotic aneurysm with single stented renal. This is final ENDO repair. Used only groin access. What was done? #AortaEd

@farkomd Is this some kind of distal aortic Pseudo after open repair? Plug the left internal iliac. AUI to the left. Plug the right common. Left to right fem fem cross over.

Non operative case. Only choice is ENDO. What’s your plan? #AortaEd

Dr. Singh with a JVS publication 💪💪💪💪 #killingit #mystlukes #vascularfellows jvascsurg.org/article/S0741-…

@farkomd Amazing learning experience for fellow to see how an experienced attending surgeon achieves such a perfect exposure of challenging anatomy allowing them to suture effortlessly. They will truly understand this when they perform their first open aorta in practice.

Repair of arteriotomy of the aorta. Vessel loops around celiac and SMA. #AortaEd fellow witb good technique with reloading of needle as he pushes it through the aorta

@gertfrahmjensen @farkomd Nice one! Thanks for sharing will keep in mind. I agree that carotid carotid bypass has its own issues in elderly folks.

@farkomd @sheth_md x.com/usc_vascular/s…

The aneurysm meets criteria for repair. Is zone 2 enough? Or is zone 0 required? Options to all arch devices, what’s your plan and why? #AortaEd