Open Surgical Secondary Interventions are More Durable than Endovascular Interventions for Lower Extremity Bypass Stenosis or Occlusion.

Objectives: Lower extremity bypasses often require secondary interventions to maintain patency. Our objectives were to characterize effectiveness of secondary interventions to maintain or restore bypass graft patency, and to compare outcomes of open and endovascular interventions. Methods: We reviewed patients who underwent lower extremity bypass at our institution from 2007 to 2010. We recorded the index bypass and subsequent ipsilateral interventions performed through 2018 or until loss of secondary patency. Patient, procedure, and anatomic data were collected. Endovascular intervention was compared with open/hybrid intervention. For outcome analysis, patency measures were defined relative to the time of the secondary intervention rather than the time of the index bypass. Results: 174 secondary interventions (56 open/hybrid, 118 endovascular; 42 for graft occlusion, and 132 for stenosis) treating 228 lesions in 97 bypasses were available for study. The index bypass was most commonly performed for tissue loss (71.1%), utilized a tibial artery target (57.7%), and used single-segment great saphenous vein (59.8%) rather than alternative vein (32.0%) or prosthetic (8.2%). A higher portion of open/hybrid interventions (51.8%) were done for graft occlusion than endovascular interventions (11.0%, P < .001). Mean follow-up for secondary interventions was 3.5 years. A multivariate Cox proportional hazards model identified female gender, prior MI, anticoagulation, occlusion, and endovascular intervention as predictors of loss of primary patency. Intervention for occlusion predicted poorer primary and secondary patency. Endovascular intervention was associated with poorer primary patency as compared to open intervention and a trend toward poorer secondary patency. Conclusions: Both open and endovascular secondary interventions on lower extremity bypasses are low-risk procedures that offer acceptable patency. Although more commonly performed in the setting of graft occlusion, open surgical interventions show improved durability compared to endovascular interventions. Some patients, including those with occluded grafts, may benefit from more liberal use of open surgical intervention to restore bypass patency.

Cost-effectiveness analysis of immediate access arteriovenous grafts versus standard grafts for hemodialysis.

OBJECTIVE: Immediate-access arteriovenous grafts (IAAVGs), or early cannulation arteriovenous grafts (AVGs), are more expensive than standard grafts (sAVGs) but can be used immediately after placement, reducing the need for a tunneled dialysis catheter (TDC). We hypothesized that a decrease in TDC-related complications would make IAAVGs a cost-effective alternative to sAVGs. METHODS: We constructed a Markov state-transition model in which patients initially received either an IAAVG or an sAVG and a TDC until graft usability; patients were followed through multiple subsequent access procedures for a 60-month time horizon. The model simulated mortality and typical graft- and TDC-related complications, with parameter estimates including probabilities, costs, and utilities derived from previous literature. A key parameter was median time to TDC removal after graft placement, which was studied under both real-world (7 days for IAAVG and 70 days for sAVG) and ideal (no TDC placed with IAAVG and 1 month for sAVG) conditions. Costs were based on current Medicare reimbursement rates and reflect a payer perspective. Both microsimulation (10,000 trials) and probabilistic sensitivity analysis (10,000 samples) were performed. The willingness-to-pay threshold was set at $100,000 per quality-adjusted life-year (QALY). RESULTS: IAAVG placement is a dominant strategy under both real-world ($1201.16 less expensive and 0.03 QALY more effective) and ideal ($1457.97 less expensive and 0.03 QALY more effective) conditions. Under real-world parameters, the result was most sensitive to the time to TDC removal; IAAVGs are cost-effective if a TDC is maintained for ≥23 days after sAVG placement. The mean catheter time was lower with IAAVG (3.9 vs 8.7 months; P < .0001), as was the mean number of access-related infections (0.55 vs 0.74; P < .0001). Median survival in the model was 29 months. Overall mortality was similar between groups (76.3% vs 76.7% at 5 years; P = .33), but access-related mortality trended toward improvement with IAAVG (6.1% vs 6.8% at 5 years; P = .052). CONCLUSIONS: The Markov decision analysis model supported our hypothesis that IAAVGs come with added initial cost but are ultimately cost-saving and more effective. This apparent benefit is due to our prediction that a decreased number of catheter days per patient would lead to a decreased number of access-related infections.

Postoperative outcomes in thoracic outlet decompression for acute versus chronic venous thoracic outlet syndrome.

OBJECTIVE: Venous thoracic outlet syndrome (VTOS) is a rare disorder that occurs in young athletes and working adults. There are multiple published reports demonstrating excellent outcomes with thoracic outlet (TO) decompression surgery when patients present acutely (within 2 weeks of symptom onset). Our objective was to assess outcomes after decompression surgery in patients with acute, subacute, chronic, and secondary VTOS. Additionally, we sought to identify risk factors for persistence of symptoms following operative decompression. METHODS: A retrospective chart review was performed for all patients who underwent operative decompression for VTOS at the University of Pittsburgh Medical Center from 2013 to 2017. We examined baseline characteristics, comorbidities, presenting symptoms, interventions performed, and postoperative clinical outcomes. Patients were characterized as acute, subacute, or chronic based on onset of symptoms and presentation to our surgeons (acute <2 weeks, subacute 2 weeks to 3 months, and chronic >3 months). Our outcomes of interest were return to baseline functional status as defined by resumption of sports activity or occupation and axillosubclavian vein patency. RESULTS: A total of 51 operative decompressions were performed in 48 patients for VTOS. There were 23 operations (45%) performed on patients who presented acutely, 7 (14%) in the subacute group, and 21 (41%) surgeries in patients with chronic symptoms. Of these 51 operations, 4 (7.8%) were deemed unsuccessful-two surgeries were in the acute group, one in the subacute, and one in the chronic group. The 30-day morbidity after 51 first rib resections included no pneumothoraces, no lymphatic leaks, two surgical site hematomas with associated hemothorax in one patient, two surgical site infections, and only two unplanned returns to the operating room for hematoma evacuation and superficial wound infection washout. In terms of preoperative vein patency, those who presented acutely were more likely to have an occluded axillosubclavian vein (P = .029). The Fisher's exact was 0.540, indicating that the proportion of patients returning to baseline functional status were similar when comparing acute presenters with those who present late. A multivariate Cox proportional hazards model was attempted; however, a small sample size greatly limited the power of the study and prohibited identification of risk factors for surgical failure. CONCLUSIONS: Patients with acute and chronic VTOS resumed their preintervention sports activity or vocation after TO decompression in more than 90% of cases with a low incidence of adverse events. Based on our study results, patients with chronic VTOS benefit as much from TO decompression as those with acute VTOS.

Functional popliteal artery entrapment syndrome: A review of diagnostic and management approaches.

Functional popliteal artery entrapment syndrome (FPAES) presents a challenge for clinicians in the field today. The relative rarity of the disease coupled with its affliction primarily in young, athletic individuals makes it a difficult condition to diagnose. Treatment modalities have been limited to surgical intervention, with more novel methods being developed over the last several years. We present a case report and review the diagnostic and management approaches for FPAES, shedding light on proposed future interventions.

Prior Endovascular Intervention Is Not Detrimental to Pedal Bypasses for Ischemic Wounds.

BACKGROUND: Endovascular strategies are often preferred for revascularization of ischemic foot wounds secondary to infrapopliteal disease because of the less invasive technique and faster recovery. Bypass is typically reserved for failures or lesions not amenable to balloon angioplasty. However, the effects of an endovascular-first approach on subsequent bypass grafts are largely unknown. This study evaluates the effects of prior endovascular tibial interventions (PTIs) on successive bypasses to pedal targets. METHODS: Patients who presented with ischemic tissue loss and tibial arterial occlusive disease to University of Pittsburgh Medical Center between 2006 and 2013 and underwent a surgical bypass to pedal arteries were included in this study. A retrospective chart review was conducted to obtain patient demographics, past medical history, extent of disease, prior tibial endovascular interventions, the treatment intervention, subsequent interventions, wound healing status, limb salvage, and patient survival. The primary outcome was primary patency of the pedal bypass graft. RESULTS: From 122 eligible patients, 27 had a PTI, whereas 95 had no prior endovascular tibial intervention (nPTI) in the treatment of ischemic pedal wounds with mean follow-up of 24.5 and 20.5 months, respectively (P = 0.36). The 2 groups were largely similar in terms of demographics, comorbidities, wound size, and degree of ischemia. Runoff scores between the 2 groups were also comparable (5.0 ± 1.6 for PTI and 4.8 ± 1.9 for nPTI, P = 0.59). The plantar artery was a more common target vessel in the PTI group, whereas the posterior tibial artery was targeted more often in the nPTI group (P = 0.04). At 12 months, those with a PTI exhibited a shorter primary patency (34.8% vs. 60.2%, P = 0.04). In a multivariate model, PTI was a significant risk factor for primary patency loss (hazard ratio 2.51, P = 0.004). Primary assisted patency and secondary patency were similar between the 2 groups. Wound healing was improved in those patients who had a prior endovascular intervention with 63.8% healed at 1 year compared with only 34.8% of those without intervention (P = 0.01). Amputation-free survival was similar (P = 0.68), as was survival alone (P = 0.50). CONCLUSIONS: Despite a decrease in primary patency, pedal bypass was not otherwise negatively affected by a PTI. Similar primary assisted patency, secondary patency, wound healing, and survival between the 2 patient populations indicate that an endovascular-first approach is a feasible treatment strategy to achieve similar clinical outcomes in the management of ischemic foot wounds.