Educational resources for vascular laboratory education in vascular surgery residencies and fellowships: Survey of Vascular Surgery Program Directors.

OBJECTIVE: The Registered Physician in Vascular Interpretation (RPVI) credential is a prerequisite for certification by the Vascular Surgery Board of the American Board of Surgery. Of concern, as more current trainees and recent program graduates take the Physician Vascular Interpretation (PVI) examination, vascular surgery trainee pass rates have decreased. Residents and fellows have a lower PVI examination pass rates than practicing vascular surgeons. The purpose of this study was to assess current vascular laboratory (VL) training for vascular surgery residents and fellows and to identify gaps that residency and fellowship programs might address. METHODS: Program directors (PDs) of Accreditation Council for Graduate Medical Education-accredited vascular surgery programs (107 fellowships, 53 integrated residency programs) were surveyed using a web-based tool. Responses were submitted anonymously. Data collected included information about the program, the PD, accreditation status of the VL, and the curriculum used to meet the PVI prerequisites. Concurrent data (June 2017) on the credentials of all PDs were obtained from the Alliance for Physician Certification and Advancement (APCA). RESULTS: Sixty-one of 117 PDs participated in the survey (52% response rate). Of these, 44 individuals (72% of responders) reported they held the RPVI and/or Registered Vascular Technologist credential. Records from APCA indicated that 51 of 117 PDs of accredited vascular surgery residencies and fellowships (44%) had an RPVI/Registered Vascular Technologist credential. Ninety-four percent reported that their VL was accredited. Practical VL experience for trainees was reported to be 20 hours or less by 62% of respondents. The use of a structured curriculum for practical experience was reported by only 15 programs. Programs with fellowships established for more than 10 years were more likely to have a structured program for didactic instruction (P = .03). Only 23 programs reported a dedicated VL rotation. Didactic instruction provided was 20 hours or less for 75% of the cohort. CONCLUSIONS: In the absence of a standardized VL curriculum, there is variation in the VL instruction provided to trainees. Fellowship programs with longer histories have more structured instruction, but time allocated to VL education is substantially less than the 30 hours of didactic and 40 hours of practical experience recommended by the APCA. Programs and learners may benefit from the development of VL training guidelines and curriculum resources.

Positive Impact of an Aortic Center Designation.

BACKGROUND: In January 2015, we created a multidisciplinary Aortic Center with the collaboration of Vascular Surgery, Cardiac Surgery, Interventional Radiology, Anesthesia and Hospital Administration. We report the initial success of creating a Comprehensive Aortic Center. METHODS: All aortic procedures performed from January 1, 2015 until December 31, 2016 were entered into a prospectively collected database and compared with available data for 2014. Primary outcomes included the number of all aortic related procedures, transfer acceptance rate, transfer time, and proportion of elective/emergent referrals. RESULTS: The Aortic Center included 5 vascular surgeons, 2 cardiac surgeons, and 2 interventional radiologists. Workflow processes were implemented to streamline patient transfers as well as physician and operating room notification. Total aortic volume increased significantly from 162 to 261 patients. This reflected an overall 59% (P = 0.0167) increase in all aorta-related procedures. We had a 65% overall increase in transfer requests with 156% increase in acceptance of referrals and 136% drop in transfer denials (P < 0.0001). Emergent abdominal aortic cases accounted for 17% (n = 45) of our total aortic volume in 2015. The average transfer time from request to arrival decreased from 515 to 352 min, although this change was not statistically significant. We did see a significant increase in the use of air-transfers for aortic patients (P = 0.0041). Factorial analysis showed that time for transfer was affected only by air-transfer use, regardless of the year the patient was transferred. Transfer volume and volume of aortic related procedures remained stable in 2016. CONCLUSIONS: Designation as a comprehensive Aortic Center with implementation of strategic workflow systems and a culture of "no refusal of transfers" resulted in a significant increase in aortic volume for both emergent and elective aortic cases. Case volumes increased for all specialties involved in the center. Improvements in transfer center and emergency medical services communication demonstrated a trend toward more efficient transfer times. These increases and improvements were sustainable for 2 years after this designation.

Configuration affects parallel stent grafting results.

OBJECTIVE: A number of adjunctive "off-the-shelf" procedures have been described to treat complex aortic diseases. Our goal was to evaluate parallel stent graft configurations and to determine an optimal formula for these procedures. METHODS: This is a retrospective review of all patients at a single medical center treated with parallel stent grafts from January 2010 to September 2015. Outcomes were evaluated on the basis of parallel graft orientation, type, and main body device. Primary end points included parallel stent graft compromise and overall endovascular aneurysm repair (EVAR) compromise. RESULTS: There were 78 patients treated with a total of 144 parallel stents for a variety of pathologic processes. There was a significant correlation between main body oversizing and snorkel compromise (P = .0195) and overall procedural complication (P = .0019) but not with endoleak rates. Patients were organized into the following oversizing groups for further analysis: 0% to 10%, 10% to 20%, and >20%. Those oversized into the 0% to 10% group had the highest rate of overall EVAR complication (73%; P = .0003). There were no significant correlations between any one particular configuration and overall procedural complication. There was also no significant correlation between total number of parallel stents employed and overall complication. Composite EVAR configuration had no significant correlation with individual snorkel compromise, endoleak, or overall EVAR or procedural complication. The configuration most prone to individual snorkel compromise and overall EVAR complication was a four-stent configuration with two stents in an antegrade position and two stents in a retrograde position (60% complication rate). The configuration most prone to endoleak was one or two stents in retrograde position (33% endoleak rate), followed by three stents in an all-antegrade position (25%). There was a significant correlation between individual stent configuration and stent compromise (P = .0385), with 31.25% of retrograde stents having any complication. CONCLUSIONS: Parallel stent grafting offers an off-the-shelf option to treat a variety of aortic diseases. There is an increased risk of parallel stent and overall EVAR compromise with <10% main body oversizing. Thirty-day mortality is increased when more than one parallel stent is placed. Antegrade configurations are preferred to any retrograde configuration, with optimal oversizing >20%.

Intraoperative Gutter Leaks That Merit Our Attention.

INTRODUCTION: The natural history and potential morbidity of gutter endoleaks are unclear. We present our experience with intraoperative gutter endoleaks and strategies to determine which of these require intervention. METHODS: This is a retrospective review of all patients treated with parallel stent grafts from January 2010 to September 2015. We reviewed all operative records and intraoperative angiograms as well as all postoperative imaging and secondary interventions. All gutter leaks were classified as low-flow/nonsac-enhancing gutter endoleaks or high-flow/sac-enhancing gutter endoleaks. Adjunctive interventions to manage the gutter leaks were noted, as were all subsequent interventions for gutter leak and endoleak management. RESULTS: Seventy-eight patients had 144 parallel stents placed over a 5-year period with an average of 1.8 stents per patient. Twenty-eight patients (36%) had gutter endoleaks diagnosed intraoperatively. Seventeen patients had adjunctive procedures to reduce gutter leaks prior to leaving the operating room (OR). Patients selected for treatment had gutters filling early during completion angiography and/or contrast enhancement of the aneurysm sac. Twenty-two patients (28%) left the OR with low-flow/delayed/nonsac-enhancing gutter endoleaks. At 30 days, a total of 6 persistent gutter endoleaks were diagnosed on computed tomographic angiography. This gives a 73% rate of resolution for low-flow/nonaneurysm sac-enhancing endoleaks. There were 2 de novo endoleaks not detected at the index procedure diagnosed at 6-month follow-up. Of the 8 total postoperative endoleaks, 5 required additional intervention with a 100% success rate. Multivariate analysis revealed that the only significant predictor of having a postoperative endoleak is leaving the OR with an endoleak. CONCLUSIONS: Intraoperative treatment of gutter endoleaks has an acceptable rate of resolution. It does have a high rate of converting high-flow endoleaks to low-flow endoleaks. Low-flow/nonsac-enhancing gutter endoleaks have a high rate of spontaneous resolution. Intraoperative gutter endoleaks are not predictive of future aneurysm sac growth.

Open abdominal surgical training differences experienced by integrated vascular and general surgery residents.

BACKGROUND: As the integrated vascular residency program reaches almost a decade of maturity, a common area of concern among trainees is the adequacy of open abdominal surgical training. It is our belief that although their overall exposure to open abdominal procedures has decreased, integrated vascular residents have an adequate and focused exposure to open aortic surgery during training. METHODS: National operative case log data supplied by the Accreditation Council for Graduate Medical Education were compiled for both graduating integrated vascular surgery residents (IVSRs) and graduating categorical general surgery residents (GSRs) for the years 2012 to 2014. Mean total and open abdominal case numbers were compared between the IVSRs and GSRs, with more in-depth exploration into open abdominal procedures by organ system. RESULTS: Overall, the mean total 5-year case volume of IVSRs was 1168 compared with 980 for GSRs during the same time frame (P < .0001). IVSRs reported nearly double the number of surgeon-chief cases compared with GSRs (452 vs 239; P < .0001). GSRs reported more than double the number of open abdominal procedures compared with IVSRs (205 vs 83; P < .0001). Sixty-five percent of the open abdominal experience for IVSRs was focused on procedures involving the aorta and its branches, with an average of 54 open aortic cases recorded throughout their training. The largest single contributor to open surgical experience for a GSR was alimentary tract surgery, representing 57% of all open abdominal cases. GSRs completed an average of 116 open alimentary tract surgeries during their training. Open abdominal surgery represented an average of 7.1% of the total vascular case volume for the vascular residents, whereas open abdominal surgery represented 21% of a GSR's total surgical experience. CONCLUSIONS: IVSRs reported almost double the number of total cases during their training, with double chief-level cases. Sixty-five percent of open abdominal surgeries performed by IVSRs involved the aorta or its renovisceral branches. Whereas open abdominal surgery represented 7.1% of an IVSR's surgical training, GSRs had a far broader scope of open abdominal procedures, completing nearly double those of IVSRs. The differences in open abdominal procedures pertain to the differing diseases treated by GSRs and IVSRs.

Comparison of the integrated vascular surgery resident operative experience and the traditional vascular surgery fellowship.

OBJECTIVE: After almost 10 years since its approval, residents in integrated vascular surgery training programs now outnumber traditional vascular fellows. We examined the Accreditation Council for Graduate Medical Education (ACGME) case log data to assess whether there is a difference in operative experience between the graduating integrated residents and vascular fellows. METHODS: We analyzed the total clinical experience of vascular surgery trainees during the academic years between 2012 and 2014 for the 30 graduated integrated vascular surgery residents (VSRs) and the 243 graduated vascular surgery fellows (VSFs). Data were compared on the basis of reported categories defined by the ACGME operation reporting system. VSR case totals were calculated by combining "surgeon chief," "surgeon junior," and "secondary procedures" categories. VSF "surgeon fellow" and "secondary procedures" case totals were combined with all vascular cases done in general surgery residency (using averages of general surgery resident ACGME case log data from the same years) to reflect their total vascular experience. RESULTS: The average total vascular experience reported by VSRs was 1446.0 compared with 1421.8 for VSFs (P = .2086). VSRs performed 694.7 major vascular procedures on average compared with 616.3 major cases for VSFs (P = .0106). Highlighted comparisons include the following: open aortic aneurysm cases, VSRs 20.6 and VSFs 22.2 (P = .320); endovascular aortic aneurysm cases, VSRs 80.0 and VSFs 80.6 (P = .945); cerebrovascular cases, VSRs 78.8 and VSFs 85.0 (P = .1132); and peripheral obstructive cases, VSRs 343.6 and VSFs 293.4 (P = .0032). CONCLUSIONS: Integrated VSRs and traditional VSFs graduate with comparable overall vascular surgery clinical experience. VSRs reported, on average, a significantly higher number of major vascular procedures during their tenure as trainees as well as a significantly increased number of cases in six of the other ACGME categories.

Outcomes of a Clinical Pathway for Borderline Resectable Pancreatic Cancer.

BACKGROUND: Without prospective data establishing a consensus multimodality approach to borderline resectable pancreatic adenocarcinoma, institutional treatment regimens vary. This study investigated the outcomes of the clinical pathway at the author's institution, which consists of neoadjuvant gemcitabine, docetaxel, capecitabine, and stereotactic radiotherapy followed by surgery. METHODS: The study reviewed all cases that met the National Comprehensive Cancer Network (NCCN) diagnostic criteria for borderline resectable pancreatic adenocarcinoma from 1 January 2006, to 31 December 2013. Pancreatectomy rates, margin status, pathologic response, disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS) were retrospectively examined. Standard statistical methods and Kaplan-Meier survival analysis were used for statistical comparisons. RESULTS: Of 121 patients who met criteria, 101 entered the clinical pathway, and 94 (93.1 %) completed neoadjuvant chemotherapy and radiation therapy. Of the 101 patients, 55 (54.5 %) underwent pancreatectomy, with 53 patients (96.4 %) having microscopically negative margins (R0) and 2 patients (3.6 %) having microscopically positive margins (R1). Vascular resection was required for 22 patients (40 %), with rates of 95.5 % for R0 (n = 21) and 4.5 % for R1 (n = 1). A pathologic response to treatment was demonstrated by 45 patients (81.8 %) and a complete response by 10 patients (14.5 %). Pancreatectomy resulted in a median DFS of 23 months (95 % conflidence interval [CI] 14.5-31.5), a median DSS of 43 months (95 % CI, 25.7-60.3), and a median OS of 33 months (95 % CI, 25.0-41.0) versus a median DSS and OS of 14 months (95 % CI, 10.9-17.1) for patients without pancreatectomy (DSS: P = 3.5 × 10(-13); OS: P = 4.7 × 10(-10)). CONCLUSIONS: The study demonstrated high rates for neoajduvant therapy completion (93.1 %) and pancreatectomy (54.5 %). After pancreatectomy, DSS was significantly improved (43 months), with a pathologic response demonstrated by 81.8 % and a complete response by 14.5 % of the patients. The results support further study of this borderline resectable pancreatic adenocarcinoma clinical pathway.

Outcomes after inferior vena cava thrombectomy and reconstruction for advanced renal cell carcinoma with tumor thrombus.

BACKGROUND: This report details the experience of a multidisciplinary surgical team in the management of stage III and stage IV renal cell carcinoma (RCC) with concomitant inferior vena cava (IVC) tumor thrombus. METHODS: A retrospective inquiry of our vascular database from 2003 to 2012 identified 55 surgical cases of stage III (n = 40) and stage IV (n = 15) RCC presenting with IVC tumor thrombus. Tumor characteristics and IVC tumor thrombus were evaluated by clinical staging and postoperative pathology staging. Patient demographics and surgical reconstruction are detailed. Cancer-specific outcomes consisted of oncologic surveillance with computed tomography or magnetic resonance imaging. A Clavien-Dindo classification of early (<30 days) complications and mortality was recorded, including a review of secondary surgical interventions. RESULTS: According to the Novick classification of IVC tumor thrombus, there were 10 supradiaphragmatic (level IV), 20 intrahepatic (level III), and 25 infrahepatic (level II or I) tumor thrombi. Vena cava reconstruction was completed in 54 patients (98%), with one patient deemed unresectable. Vena cava control required cardiac bypass (n = 10), venovenous bypass (n = 4), or infrahepatic IVC control (n = 40). Reconstruction of the IVC was completed with two prosthetic interposition grafts for one stage IV thrombus and one stage III thrombus; two patch repairs were done for stage III thrombus, and there were 50 primary IVC repairs. All other IVC reconstructions were patent at a mean follow-up of 23 months. A single asymptomatic patient with primary IVC repair had estimated 30% IVC narrowing but no other measurable stenosis as detected by postoperative imaging. Three patients required reoperation (two for surgical site bleeding, one for small bowel fistula). Early surgical complications included Clavien-Dindo grades I (n = 3), II (n = 6), IIIa (n = 2), IIIb (n = 3), and V (n = 2). Regional retroperitoneal or distant recurrent RCC occurred in 26 patients (48%); a single patient demonstrating recurrent IVC tumor thrombus at 8 months required secondary IVC thrombectomy. All patients with tumor invasion of the IVC wall developed recurrent RCC, and no patient survived beyond 5 years. Early mortality was 3.6% (n = 2), with 27 patients (49%) dying within 24 months, resulting in an overall mortality for the cohort of 80% (n = 44) as established on routine regular postoperative surveillance. CONCLUSIONS: A multidisciplinary approach for the management of advanced RCC and IVC tumor thrombus helps optimize outcomes. Primary IVC repairs are possible in most patients, and IVC patency is good. Recurrent tumor thrombus rates are low; however, RCC tumor recurrence and mortality are high, especially among patients with advanced cancer with IVC wall invasion.

A single-institution experience: the integrated vascular surgery residency's effect on fellowship and general surgery resident case volume and diversity.

BACKGROUND: To determine whether the formation of an integrated vascular surgery residency (0 + 5) has negatively impacted the case volume and diversity of the vascular surgery fellows (5 + 2) and chief general surgeons at the same institution. METHODS: Operative data from the vascular integrated (0 + 5), independent (5 + 2), and general surgery residencies at a single institution were retrospectively reviewed and analyzed to determine vascular surgery case volumes from 2006-2012. National operative data (Residency Review Committee) were used for comparison of diversity and volume. Standard statistical methods were applied. RESULTS: During this period, the 5 + 2 fellows at our institution performed on average 741 (range, 554-1002) primary cases and 1091 (range, 844-1479) combined primary and secondary cases for the 2-year fellowship. Our integrated residency began in July 2007. Our fellows' primary case volumes remained relatively stable between 2006 and 2011, with a 4% increase in the number of cases, although their total (primary and secondary) case volumes fell 15%; by comparison, the equivalent national 50th percentile rates rose 16% during this time frame. Our institution's general surgery residents performed an average of 116 (range, 56-221) vascular cases individually during their 5-year residency from 2005-2011. From 2006-2011, the total case volume fell only 5%, while the national 50th percentile rate fell 24%. Across all years, however, resident and fellow volumes both continue to be above Accreditation Council for Graduate Medical Education minimum requirements, and the major vascular case volume at our institution in all groups studied remained statistically greater than or equal to the national 50th percentile of cases. Our first integrated resident to graduate finished in June 2012 with 931 total vascular cases and 249 general surgery cases for a total operative experience of 1180 cases during the 5-year residency. Finally, after an 8-year period (2003-2010) in which none of our general surgery residents pursued vascular training, 1 resident in each of the 2011, 2012, and 2013 graduating years has now done so. CONCLUSIONS: At our institution, the introduction of a 0 + 5 vascular residency has correlated with a modest drop (15%) in overall case volume for the 5 + 2 fellows, but the number of primary cases have actually increased slightly and they continue to meet or exceed Accreditation Council for Graduate Medical Education requirements and national 50th percentile rates. General surgery residents' vascular volumes, by contrast, have remained stable, and interest in vascular surgery by residents has increased. Our integrated vascular residents are projected to exceed the fellows' 50th percentile case volume and diversity targets during their residency experience.

Renal cell carcinoma accompanied by venous invasion and inferior vena cava thrombus: classification and operative strategies for the vascular surgeon.

Venous invasion is a common characteristic of renal cell carcinoma, manifesting as tumor thrombus with possible extension into the renal vein and, in extensive cases, the thrombus can reach from the renal vein to the right atrium. Currently, cytoreductive nephrectomy and tumor thrombectomy are the foundations for improving quality of life and survival in the treatment of renal cell carcinoma, and a role has emerged for a vascular specialist to become an integral part of operative planning and therapy.

Important surgical considerations in the management of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus.

UNLABELLED: What's known on the subject? and What does the study add? Historically, the surgical management of renal tumours with intravascular tumour thrombus has been associated with high morbidity and mortality. In addition, few cases are treated, and typically at tertiary care referral centres, hence little is known and published about the ideal surgical management of such complex cases. The present comprehensive review details how a multidisciplinary surgical approach to renal tumours with intravascular tumour thrombus can optimise patient outcomes. Similarly, we have developed a treatment algorithm in this review that can be used in the surgical planning of such cases. OBJECTIVES: To detail the perioperative and technical considerations essential to the surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus, as historically patients with RCC and IVC tumour thrombus have had an adverse clinical outcome. • Recent surgical and perioperative advances have for the most part optimized the clinical outcome of such patients. MATERIALS AND METHODS: A comprehensive review of the scientific literature was conducted using MEDLINE from 1990 to present using as the keywords 'renal cell carcinoma' and 'IVC tumor thrombus'. • In all, 62 manuscripts were reviewed, 58 of which were in English. Of these, 25 peer-reviewed articles were deemed of scientific merit and were assessed in detail as part of this comprehensive review. • These articles consist of medium to large (≥25 patients) peer-reviewed studies containing contemporary data pertaining to the surgical management of RCC and IVC tumour thrombus. • Many of these studies highlight important surgical techniques and considerations in the management of such patients and report on their respective clinical outcomes. RESULTS: Careful preoperative planning is essential to optimising the outcomes within this patient cohort. High quality and detailed preoperative imaging studies help delineate the proximal extension of the IVC tumour thrombus and possible caval wall direct invasion while determining the potential necessity for intraoperative vascular bypass. • The surgical management of RCC and IVC tumour thrombus (particularly for level III or IV) often requires the commitment of a multidisciplinary surgical team to optimise patient surgical outcomes. • Despite significant improvements in surgical techniques and perioperative care, the 5-year overall survival remains only between 32% and 69%, highlighting the adverse prognosis of such locally advanced tumours. • Important prognostic factors within this patient cohort include pathological stage, nuclear grade, tumour histology, lymph node and distant metastatic status, preoperative performance status, Charlson comorbidity index, and nutritional status. CONCLUSIONS: The multidisciplinary surgical care of RCC and IVC tumour thrombus (particularly high level thrombi) is pivotal to optimising the surgical outcome of such patients. • Similarly, important preoperative, perioperative, and postoperative considerations can improve the surgical outcome of patients.

Evolving microbiology and treatment of extracavitary prosthetic graft infections.

The authors report the microbiology and outcomes following an individualized treatment algorithm for extracavitary (EC) prosthetic graft infection, including the use of graft preservation and in situ graft replacement techniques. A retrospective 8-year review of 87 patients treated for EC prosthetic graft infections was carried out. The treatment algorithm included culture-specific antibiotic therapy, surgical site debridement with antibiotic bead placement, selected graft preservation with muscle flap coverage, or graft excision with in situ conduit replacement. Outcomes measured included death, limb loss, and recurrent infection. It was found that present-day management of EC prosthetic graft infections is associated with lower mortality and morbidity despite changes in microbiology and the increased application of graft preservation and in situ grafting treatments.

Efficacy of duplex ultrasound surveillance after infrainguinal vein bypass may be enhanced by identification of characteristics predictive of graft stenosis development.

OBJECTIVE: Controversy regarding the efficacy of duplex ultrasound surveillance after infrainguinal vein bypass led to an analysis of patient and bypass graft characteristics predictive for development of graft stenosis and a decision of secondary intervention. METHODS: Retrospective analysis of a contemporary, consecutive series of 353 clinically successful infrainguinal vein bypasses performed in 329 patients for critical (n = 284; 80%) or noncritical (n = 69; 20%) limb ischemia enrolled in a surveillance program to identify and repair duplex-detected graft stenosis. Variables correlated with graft stenosis and bypass repair included: procedure indication, conduit type (saphenous vs nonsaphenous vein; reversed vs nonreversed orientation), prior bypass graft failure, postoperative ankle-brachial index (ABI) < 0.85, and interpretation of the first duplex surveillance study as "normal" or "abnormal" based on peak systolic velocity (PSV) and velocity ratio (Vr) criteria. RESULTS: Overall, 126 (36%) of the 353 infrainguinal bypasses had 174 secondary interventions (endovascular, 100; surgery, 74) based on duplex surveillance; resulting in 3-year Kaplan-Meier primary (46%), assisted-primary (80%), and secondary (81%) patency rates. Characteristics predictive of duplex-detected stenosis leading to intervention (PSV: 443 +/- 94 cm/s; Vr: 8.6 +/- 9) were: "abnormal" initial duplex testing indicating moderate (PSV: 180-300 cm/s, Vr: 2-3.5) stenosis (P < .0001), non-single segment saphenous vein conduit (P < .01), warfarin drug therapy (P < .01), and redo bypass grafting (P < .001). Procedure indication, postoperative ABI level, statin drug therapy, and vein conduit orientation were not predictive of graft revision. The natural history of 141 (40%) bypasses with an abnormal first duplex scan differed from "normal" grafts by more frequent (51% vs 24%, P < .001) and earlier (7 months vs 11 months) graft revision for severe stenosis and a lower 3-year assisted primary patency (68% vs 87%; P < .001). In 52 (15%) limbs, the bypass graft failed and 20 (6%) limbs required amputation. CONCLUSIONS: The efficacy of duplex surveillance after infrainguinal vein bypass may be enhanced by modifying testing protocols, eg, rigorous surveillance for "higher risk" bypasses, based on the initial duplex scan results and other characteristics (warfarin therapy, non- single segment saphenous vein conduit, redo bypass) predictive for stenosis development.

The relative importance of graft surveillance and warfarin therapy in infrainguinal prosthetic bypass failure.

BACKGROUND: We sought to describe modes of failure and associated limb loss after infrainguinal polytetrafluoroethylene bypass grafting in patients lacking a saphenous venous conduit and to define specific clinical or hemodynamic factors prognostic for bypass failure. METHODS: We identified 121 patients (mean age, 67 years; 90 men and 31 women) with determinable outcomes (minimum follow-up, 2 months; mean, 17 months) after 130 prosthetic infrainguinal bypasses between 1997 and 2005. Ischemic presentation was rest pain in 52%, tissue loss in 34%, and disabling claudication and/or popliteal aneurysm in 14%, with 24% of patients requiring a redo bypass. Distal targets were the above-knee (n = 44), distal popliteal (n = 27), or tibial/pedal (n = 59) arteries. Sixty-six (77%) of the below-knee (BK) target (distal popliteal or tibial) bypasses had distal anastomotic adjuncts (vein cuff or patch). Duplex graft surveillance was performed at 1, 4, and 7 months after surgery and twice yearly thereafter, with recording of midgraft velocities and imaging encompassing inflow and outflow vessels. Arteriography and open/endovascular intervention was performed for stenoses identified by duplex scanning (peak systolic velocity >300 cm/s; velocity ratio >3.5). An attempt was made to salvage occluded grafts by using catheter-directed thrombolysis or open techniques. Eighty-six patients (74% of BK bypasses) were placed on chronic warfarin therapy with a target international normalized ratio range between 2 and 3. Prognostic factors were identified by using univariate statistics and multivariate logistic regression analysis. RESULTS: Three-year primary, assisted, and secondary patency rates were 39%, 43%, and 59%, respectively, for all bypasses, with no difference noted between above-knee and BK grafts (P = .5). At 3 years, freedom from limb loss was 75%, and patient survival was only 70%, with no adverse effect on survival imparted by amputation. Sixty-nine total adverse events occurred as a result of thrombotic occlusion (n = 51), duplex scan-detected stenosis (n = 13), or graft infection (n = 5). Forty-nine percent of all initial graft occlusions eventually led to amputation. Twenty-three grafts (27% of 86 patients) in patients maintained on chronic warfarin were subtherapeutic at the time of occlusion. Use of a distal anastomotic adjunct with BK bypasses reduced graft thrombosis (35% with vs 60% without) but did not impart a significant patency advantage (P = .07). Multivariate analysis revealed low graft flow (midgraft velocity < or =45 cm/s; odds ratio [OR], 6.1; 95% confidence interval [CI], 1.9-19.2), use of warfarin (OR, 8.4; 95% CI, 2.1-34.5), and therapeutic warfarin (OR, 24.6; 95% CI, 5.7-106) to be independently predictive for bypass patency. Graft patency was maintained in 89% of grafts remaining therapeutic on warfarin compared with only 55% of subtherapeutic or nonanticoagulated grafts (P < .001). Low-flow grafts (n = 61) occluded more frequently than higher-flow grafts (46% vs 13%; P < .001). Therapeutic warfarin augmented the patency of low-flow (P < .001) but not high-flow (P = .15) grafts. CONCLUSIONS: Low graft flow was a more common mode of prosthetic bypass failure than development of duplex scan-detected stenotic lesions during follow-up. Early duplex scanning may be more important for characterizing midgraft velocity and related thrombotic potential and selecting patients for chronic anticoagulation. Maintenance of therapeutic warfarin is paramount in optimizing prosthetic bypass patency and limb preservation.

Duplex scan surveillance after carotid angioplasty and stenting: a rational definition of stent stenosis.

OBJECTIVE: A duplex ultrasound (DUS) surveillance algorithm used after carotid endarterectomy (CEA) was applied to patients after carotid stenting and angioplasty (CAS) to determine the incidence of high-grade stent stenosis, its relationship to clinical symptoms, and the outcome of reintervention. METHODS: In 111 patients who underwent 114 CAS procedures for symptomatic (n = 62) or asymptomatic (n = 52) atherosclerotic or recurrent stenosis after CEA involving the internal carotid artery (ICA), DUS surveillance was performed 300 cm/s, diastolic velocity >125 cm/s, internal carotid artery stent/proximal common carotid artery ratio >4) involving the stented arterial segment prompted diagnostic angiography and repair when >75% diameter-reduction stenosis was confirmed. Criteria for >50% CAS stenosis was a PSV >150 cm/s with a PSV stent ratio >2. RESULTS: All 114 carotid stents were patent on initial DUS imaging, including 90 (79%) with PSV <150 cm/s (94 +/- 24 cm/s), 23 (20%) with PSV >150 cm/s (183 +/- 34 cm/s), and one with high-grade, residual stenosis (PSV = 355). During subsequent surveillance, 81 CAS sites (71%) exhibited no change in stenosis severity, nine sites demonstrated stenosis regression to <50% diameter reduction, and five sites developed velocity spectra of a high-grade stenosis. Angiography confirmed >75% diameter reduction in all six CASs with DUS-detected high-grade stenosis, all patients were asymptomatic, and treatment consisted of endovascular (n = 5) or surgical (n = 1) repair. During the mean 33-month follow-up period, three patients experienced ipsilateral, reversible neurologic events at 30, 45, and 120 days after CAS; none was associated with severe stent stenosis. No stent occlusions occurred, and no patient with >50% CAS stenosis on initial or subsequent testing developed a permanent ipsilateral permanent neurologic deficit or stroke-related death. CONCLUSION: DUS surveillance after CAS identified a 5% procedural failure rate due to the development of high-grade in-stent stenosis. Both progression and regression of stent stenosis severity was observed on serial testing, but 70% of CAS sites demonstrated velocity spectra consistent with <50% diameter reduction. The surveillance algorithm used, including reintervention for asymptomatic high-grade CAS stenosis, was associated with stent patency and the absence of disabling stroke.

Selective application of sartorius muscle flaps and aggressive staged surgical debridement can influence long-term outcomes of complex prosthetic graft infections.

BACKGROUND: The complexity of variables associated with vascular surgical site infections (VSSI) often contribute adversely to reinfection, limb salvage, and mortality rates. This report details our experience with the selective use of a sartorius muscle flaps (SMF) as part of an overall treatment strategy focused on staged surgical debridement (SSD) to control prosthetic graft bed infection prior to a graft preservation or revision plan. METHODS: From our vascular registry, we identified 422 VSSI of which 89 (21%) had SMF for 24 aorto-bifemoral (ABF), 19 extra-anatomic bypasses (EAB), 34 infrainguinal bypasses, and 12 combined inflow/outflow reconstructions. All 86 patients had Szilagyi grade III prosthetic (Dacron-36, polytetrafluoroethylene [PTFE]-50) graft infections. The treatment algorithm included: SSD, culture-directed parenteral antibiotics, graft preservation (n = 3), or reconstruction (graft excision/EAB, n = 4; rifampin-bonded PTFE, n = 22; autologous conduit, n = 57) based on microbiology and consideration for SMF for extensive soft tissue defects (n = 43) or non-sterilized graft beds (n = 40). Analysis of microbiology, recurrent infection, vascular reconstruction, limb salvage, and mortality was completed over a mean follow-up of 52 months (range: 12 to 132 months). RESULTS: Thirty-day mortality was 2% with two aortic graft infections dying from sepsis. Survival by life table analysis at 1, 3, and 5 years was 94%, 92%, and 90%, respectively. Wound isolates were most commonly gram positive organisms (n = 58, 65%), with gram negative isolates and mixed infections accounting for 19% and 10%, respectively. A single recurrent groin infection was documented at 30 days. Freedom from recurrent infection (n = 6) at 1 and 5 years was 98% and 92% by life tables. Methicillin-resistant Staphylococcus aureus (MRSA) was involved for 50% of reinfections. No amputations were attributable to uncontrolled VSSI and graft patency was 100% in surveillance monitored patients. CONCLUSION: These results suggest that selective utilization of SMF as part of SSD treatment plan in an attempt to achieve graft bed sterilization can effectively control the complex infectious process allowing for potentially improved outcomes for in situ or preservation graft salvage techniques. Lifelong graft surveillance is recommended.

Optimizing compliance, efficiency, and safety during surveillance of small abdominal aortic aneurysms.

BACKGROUND: Outcome data documenting safety for observation of small abdominal aortic aneurysms (AAA 4.0 to 5.4 cm) are lacking outside of large clinical trials but requires near perfect patient compliance. This study describes a clinical pathway for AAA surveillance using a prospective database utilizing a nurse practitioner oversight to provide efficient use of clinic visits while maintaining a high level of patent participation. METHODS: Over a 7-year period (June 1999 through June 2006), 334 patients were enrolled in an AAA surveillance pathway at our academic veterans hospital. To minimize patient travel, clinic visitation was reserved for an initial examination with patient education and for discussion of intervention options in patients demonstrating AAA growth (>5.4 cm or expansion >1 cm/yr) during follow-up. Biannual ultrasound or CT imaging was scheduled and results discussed (after physician review) via telephone or "same day" direct patient contact. An electronic database was used to update patient information and plan follow-up. RESULTS: Compliance with the AAA surveillance pathway was achieved in 98.5% of patients, with only three patients (0.9%) lost to follow-up and two others (0.6%) choosing early repair at civilian institutions. At a mean interval of 29 months (+/-20 mo), surgical repair was performed in 225 (67%) patients by open (n = 143) or endovascular (n = 82) techniques for AAA growth to >5.4 cm (n = 219) or expansion by >1cm/yr (n = 6). One hundred six patients currently remain in surveillance. A single AAA rupture resulting in death occurred during surveillance (0.3%) and perioperative mortality (<60 days) was 0.9% in patients needing intervention for AAA growth. Cumulative aneurysm-related mortality was 0.9% for patients compliant with the AAA surveillance pathway. CONCLUSIONS: Use of a prospectively-maintained surveillance database managed by a non-physician provider with a reliance on telephone contact resulted in a high degree of patient compliance, reduced unnecessary patient travel, and provided practical clinic use. Limited additional resources were needed to implement our pathway and a similar approach may prove useful for large volume hospital, clinic, or practice systems.

Plaque excision with the Silverhawk catheter: early results in patients with claudication or critical limb ischemia.

OBJECTIVE: This study was conducted to detail the early experience after infrainguinal atherectomy using the Silverhawk plaque excision catheter for the treatment of symptomatic peripheral vascular disease. METHODS: A prospective database was established in August 2004 in which data for operations, outcomes, and follow-up were recorded for patients undergoing percutaneous plaque excision for peripheral arterial occlusive disease. Society for Vascular Surgery (SVS) ischemia scores and femoropopliteal TransAtlantic Inter-Society Consensus (TASC) criteria were assigned. A follow-up protocol included duplex ultrasound surveillance at 1, 3, and 6 months and then yearly thereafter. Standard statistical analyses were performed. RESULTS: During a 17-month period, 66 limbs of 60 patients (37 men [61.7%]) underwent 70 plaque excisions (four repeat procedures). Indications included tissue loss based on SVS ischemia at grades 5 and 6 (25/70), rest pain at grade 4 (22/70), and claudication at grades 2 to 3 (23/70). The mean lesion length was 8.8 +/- 0.7 cm. The technical success rate was 87.1% (61/70). Adjunctive treatment was required in 17 procedures (24.3%), consisting of 14 balloon angioplasties and three stents. Femoropopliteal TASC criteria included 5 TASC A lesions, 14 TASC B lesions, 32 TASC C lesions, and 19 TASC D lesions. Although 17 plaque excisions included a tibial vessel, no patient underwent isolated tibial atherectomy. The mean increase in ankle-brachial index was 0.27 +/- 0.04 and in toe pressure, 20.3 +/- 6.9 mm Hg. Mean duplex ultrasound follow-up was 5.2 months (range, 1 to 17 months). One-year primary, primary assisted, and secondary patency was 61.7%, 64.1%, and 76.4%, respectively. Restenosis or occlusion developed in 12 patients (16.7%) and was detected at a mean of 2.8 +/- 0.7 months. Restenosis or occlusion was significantly more common (P < .05) in patients with TASC C and D lesions compared with patients with TASC A and B lesions. Six (8.3%) of 12 patients underwent reintervention on the basis of duplex ultrasound surveillance results. Four (33.3%) of 12 patients experienced reocclusion during the same hospitalization, and amputation and open revascularization were required in two patients each. CONCLUSIONS: Percutaneous plaque excision is a viable treatment option for lower extremity revascularization. Outcomes are related to ischemia and lesion severity. Patency and limb salvage rates are equivalent to other endovascular modalities.

The application of duplex surveillance after carotid intervention.

Carotid duplex ultrasound testing provides a safe and accurate method to detect and grade the severity of atherosclerotic internal carotid artery stenosis both before and following carotid intervention. Testing after surgical endarterectomy or stent angioplasty allows assessment of the technical success by excluding residual stenosis. The focus of duplex surveillance after carotid intervention is to identify recurrent stenosis, repair site occlusion, and progression of contralateral internal carotid artery disease. Patients who develop a neurologic event or a duplex-detected >75% diameter-reducing internal carotid artery stenosis with a peak systolic velocity >300 cm/s and end-diastolic velocity >125 cm/s should be further evaluated by angiographic imaging and should be considered for reintervention if an appropriate lesion is confirmed. Duplex surveillance allows the vascular surgeon to evaluate patency of the rendered intervention, its stenosis-free durability, and its effectiveness in stroke prevention.