Older patients with cardiovascular disease face a high burden of thromboembolic disease but are often underrepresented in clinical trials. Biological aging increases both thrombotic and bleeding risk. Individualized strategies, such as risk scores, procedural choices, medication selection, and improvements in medication adherence are essential across conditions like acute coronary syndrome, atrial fibrillation, and venous thromboembolism. Direct oral anticoagulants are generally safer than vitamin K antagonists but require dose adjustment in older adults. When bleeding occurs, prompt management and carefully timed anticoagulation resumption are critical. A balanced, patient-centered approach remains key to optimizing outcomes in this complex, high-risk population.

With the rising prevalence of obesity and the increasing utilization of bariatric surgery, general surgeons are increasingly encountering patients presenting with acute postoperative complications. While bariatric procedures are generally safe and effective, they carry a unique profile of surgical and metabolic emergencies due to altered anatomy, nutritional vulnerability, and technical complexity. Given that many patients present to non-bariatric centers, it is essential for general surgeons to be equipped to recognize and manage these emergencies. This narrative review aims to provide a comprehensive, procedure-specific guide for general surgeons on the diagnosis and management of bariatric surgical emergencies. It emphasizes timely recognition, key diagnostic principles, and tailored operative and nonoperative strategies, while also highlighting system-level challenges and disparities affecting outcomes. We reviewed the clinical presentation, pathophysiology, and evidence-based management of major categories of bariatric emergencies, including anastomotic leaks, internal hernias, bowel obstruction, bleeding, marginal ulcers, band-related complications, thrombotic events, and nutritional crises. We also examined the distinct challenges posed by revisional surgery. Consideration was given to disparities in access to care, delayed diagnosis, and the role of structured referral systems and enhanced recovery pathways. General surgeons play a critical frontline role in the management of bariatric emergencies. Familiarity with altered anatomy, procedure-specific risks, and atypical presentations is essential. Early imaging, prompt intervention, and multidisciplinary collaboration can significantly improve outcomes. In parallel, addressing systemic barriers and improving access to specialized care are necessary to ensure equitable and high-quality care for the growing population of bariatric surgery patients.

Accurate identification of cancer-associated thrombosis (CAT) in electronic health records is essential for disease surveillance, trial design, and the development of risk stratification models. Manual chart review is impractical at scale, while ICD-code or similar coding system-based extraction often misses events, fails to distinguish incident from prevalent events, or equates bland and tumor thrombi. Natural language processing (NLP) is a promising solution, offering scalable extraction of structured CAT events directly from clinical text. We systematically reviewed the literature for NLP-based pipelines for CAT identification according to PRISMA guidelines. PubMed, Embase, and Web of Science were queried for English language studies from 2010-2025. NLP methodology, training strategy, and model performance were extracted from relevant studies. Seven studies, implementing NLP approaches ranging from lexicon or rules-based pipelines to transformer models, met inclusion criteria. Most studies developed and evaluated models using text from a single institution, and only one distinguished incident CAT events from prevalent events. Reported metrics varied between studies, though models tended to exhibit higher specificity and negative predictive value than sensitivity and positive predictive value. Overall, current NLP systems for CAT identification have achieved desired results to assist but not supplant manual chart review. Major limitations include small and institution-specific datasets, absence of external validation, and lack of distinction between incident versus prevalent events. Development of generalizable models will require large, multi-institutional datasets as the field moves towards transformer-based models, and standardized evaluation metrics with shared benchmark test sets are needed for an unbiased measure of progress.

Vascular Ehlers-Danlos Syndrome (VEDS) is a rare genetic disorder characterized by arterial fragility and a high risk of spontaneous vascular rupture. Splenic artery rupture is an uncommon but life-threatening manifestation of this condition. We report the case of a 34-year-old male with VEDS who presented with sudden abdominal pain and rapid progression to hemorrhagic shock. Imaging confirmed active bleeding from the distal splenic artery. After multidisciplinary evaluation, endovascular embolization via a left humeral approach was performed using multiple coils. The procedure achieved hemostasis, and the patient showed immediate clinical improvement. He was discharged after 27 days following immunization against encapsulated organisms due to presumed hyposplenism. This case highlights the critical role of endovascular techniques in managing vascular emergencies in VEDS patients, offering a minimally invasive and effective alternative to open surgery, minimizing vascular manipulation in fragile tissues. Splenic artery embolization may be life-saving, but long-term surveillance and preventive strategies are crucial, given the risk of recurrence and complications.

Limited information exists regarding the effectiveness of oxygenated right ventricular assist devices (OxyRVAD) versus standard right ventricular assist device (RVAD) configurations in patients with acute right ventricular failure (aRVF). We analyzed 345 patients (n = 197 OxyRVAD; n = 148 RVAD) with aRVF from a multicenter registry (PLACE study). Propensity scores were estimated using generalized boosted models. Inverse probability of treatment weighting was applied to balance groups. The primary endpoint was 30 day mortality; secondary endpoints included in-hospital mortality, complications, and successful weaning. Subgroup and interaction analyses were conducted to assess effect modification, particularly by baseline PaO2. Oxygenated right ventricular assist device use was not associated with improved 30 day mortality (Hazard Ratio [HR]: 1.09, 95% confidence interval [CI]: 0.72-1.65) but was linked to higher risks of thromboembolism (Odds Ratio [OR]: 1.68, 95% CI: 1.04-2.71), bleeding (OR: 1.53, 95% CI: 1.01-2.39), and renal replacement therapy (OR: 1.61, 95% CI: 1.01-2.61). Subgroup analysis revealed a significant interaction between PaO2 and treatment group (p = 0.019), with a mortality benefit observed in patients with PaO2 of less than 60 mm Hg (HR: 0.67, 95% CI: 0.45-0.99). In non-hypoxemic aRVF patients, OxyRVAD use was associated with increased complications and no survival benefit. These findings support a physiologically stratified approach to temporary RV support and discourage unselected, patient phenotype-oriented OxyRVAD use in the presence of refractory aRVF.

Fontan-associated liver disease (FALD) is a critical long-term complication following Fontan surgery for complex congenital heart disease. The non-physiological Fontan circulation, which relies on elevated central venous pressure (CVP) to drive pulmonary blood flow, inherently leads to chronic hepatic congestion, fibrosis, and potentially hepatocellular carcinoma. We report the anesthetic management of a 25-year-old male with FALD and hepatocellular carcinoma (8.3 cm) undergoing open hepatectomy. Our anesthetic strategy focused on maintaining cardiac contractility, preserving venous return, and reducing pulmonary vascular resistance using inotropic and inodilator support and inhaled nitric oxide. During liver resection, the patient experienced catastrophic hemorrhage (6,875 mL) characterized by diffuse oozing due to high CVP and coagulopathy, leading to hypovolemic shock. Hemodynamics were sustained by ultra-rapid transfusion (up to 200 mL/min) and vasopressor support. Intraoperative coagulation was monitored via thromboelastography (TEG), which revealed severe qualitative and quantitative deficiencies in fibrinogen function that persisted despite fresh frozen plasma transfusion. Targeted administration of 3 g of fibrinogen concentrate and 40 units of platelet concentrate based on TEG findings achieved clinical hemostasis. Despite the massive bleeding and postoperative heart failure, the patient was successfully discharged. In conclusion, this case suggests that for hepatectomy in Fontan patients, a multidisciplinary approach incorporating the Pringle maneuver and TEG-guided precision transfusion can be a vital strategy to prevent circulatory collapse and manage life-threatening hemorrhage.

Popliteal artery aneurysms (PAAs) are the most common peripheral arterial aneurysms, although they remain relatively rare. Symptomatic PAAs generally present with limb ischemia due to distal embolization; however, rupture is extremely uncommon, and the optimal management has not yet been established. A 91-year-old woman presented with acute pain in the right leg and swelling of the popliteal fossa and posterior thigh. Computed tomography revealed a 45.1×44.7-mm right PAA. Emergency intervention was indicated, and open surgical repair via a posterior approach using a prosthetic graft was performed. Intraoperatively, a defect in the aneurysmal wall with active bleeding was identified, confirming rupture. The postoperative course was uneventful, and limb viability and graft patency were maintained for 3 years. Prosthetic graft interposition may be a feasible therapeutic option in carefully selected very elderly patients with ruptured PAA, even in the presence of limited distal runoff.