Challenge Accepted

I am very pleased to introduce another case-based issue of Endovascular Today—the third since 2017. Each year, the cases have been truly thought-provoking and the discussions illuminating. The current issue continues that trend, with another suite of interesting cases with great discussions. This got me wondering: why is the case-based format so enduring? There is probably no knowing for sure, but I believe it is because case-based discussions reflect how we actually work—one patient at a time, constantly making risk assessments based upon limited data, and applying our past experiences and acquired knowledge to the unique person before us. I wish my clinical practice ran like a randomized controlled trial with sharply defined inclusion and exclusion criteria, tightly proscribed treatment options, and great follow-up, but it doesn’t. It’s a bit more nuanced and variable than that—much like the contents of this issue.

This year, 29 physicians have accepted the challenge of evaluating complex cases presented by 11 esteemed moderators. These challenging cases span several fields including presentations of stroke, type B aortic dissection, abdominal aortic aneurysm (AAA), carotid stenosis, iatrogenic trauma, uterine fibroids, deep vein thrombosis (DVT), superficial femoral artery (SFA) occlusion, critical limb ischemia (CLI), and superficial venous disease. The panelists’ responses demonstrate the breadth of available treatment options to address these conditions and offer insight into why each approach would be undertaken. Our goal is to provide readers with an opportunity to evaluate their own clinical decision-making and expand critical thinking when faced with perplexing patient cases.

We open with a stroke case from Michael Chen, MD, and André Beer Furlan, MD, presented to Michael T.Froehler, MD; Ashutosh P. Jadhav, MD; and Sandra Narayanan, MD, that involves navigating a basilar artery occlusion. Bruce H. Gray, DO, gathers J. Michael Bacharach, MD; Eugene M. Langan III, MD; and John Perl II, MD, to evaluate treatment algorithms for carotid stenosis before coronary artery bypass grafting. Joseph Lombardi, MD, then provides Adam Beck, MD; G. Chad Hughes, MD; and Darren Schneider, MD, with a patient experiencing type B aortic dissection and renal failure potentially related to a previous type A dissection repair.

Ross Milner, MD, asks Brant W. Ullery, MD; Jeffrey Jim, MD; and Ravi Veeraswamy, MD, to weigh the factors for a patient’s complex AAA and whether elective repair is the best treatment option. William S. Rilling, MD, questions Scott Resnick, MD; Eric J. Hohenwalter, MD; and Kristofer Schramm, MD, about their approach to an iatrogenic trauma case related to a central line complication.

Then, panelists Mary Costantino, MD; Anne Roberts, MD; and Keith M. Sterling, MD, tackle a case from moderator, Theresa Caridi, MD, on the potential use of uterine artery embolization, while taking into account the patient’s symptoms, imaging results, and personal preferences. Christine E. Ghatan, MD, queries a panel including John Moriarty, MD; Sara K. Plett, MD; and Laurencia Villalba, MD, on which methods of intervention and anticoagulation should be employed for filter-associated DVT in a nonagenarian patient. John A. Phillips, MD, leads a discussion with Michael Jolly, MD; Kumar Madassery, MD; and Aditya Sharma, MBBS, about the difficulties in treating long chronic total occlusions in the SFA.

Lawrence A. Garcia, MD, then walks through a case with George L. Adams, MD; Miguel Montero-Baker, MD; and Srini Tummala, MD, that highlights the decision-making that takes place at each stage of care when treating below-the-knee CLI and what device options are appropriate in the current climate. Finally, Julianne Stoughton, MD, asks panelists Ellen D. Dillavou, MD, and Misaki Kiguchi, MD, how they would advance through a multifaceted case of recurrent superficial venous disease.

This issue cannot happen without the enthusiasm and hard work of the contributors; they get most of the credit (I only accept the blame). The rest of the credit goes to the Endovascular Today editorial staff, an incredibly professional and knowledgeable group that I suspect loves this stuff as much as we do. So, enjoy this issue and never forget that, in the end, this is all about our patients.

John A. Kaufman, MD
Guest Chief Medical Editor