Modes of Failure in Venous Thromboembolism Prophylaxis.

Venous thromboembolism (VTE) is associated with potentially preventable in-hospital morbidity and mortality. Although evidence-based guidelines are widely available, their application in clinical practice varies markedly. VTE prophylaxis involves a multistep dynamic process that can fail at various points during hospital stay. Our aim was to identify defects in VTE prophylaxis. Upon admission, our patients undergo VTE risk stratification and orders for prophylaxis are entered. All patients that fulfill the criteria for the Patient Safety Indicator (PSI)-12, as defined by the Agency for Healthcare Research and Quality, are prospectively entered in a database. From a review of 138 PSI-12 patients, only 21 had correct risk stratification and appropriate chemoprophylaxis during their hospital stay; 70 had been incorrectly stratified, with 28 of these patients receiving incorrect prophylaxis due to incorrect stratification, thus delaying the correct administration of chemoprophylaxis for >24 h. Inadequate application of mechanical prophylaxis was noted in 114 patients. VTE prophylaxis relies on correct risk stratification, ordering appropriate pharmacomechanical measures and, finally, the delivery of this treatment throughout the hospital stay. A large percentage of patients who had a thromboembolic complication received inadequate prophylaxis. This study identifies potential areas for intervention to improve VTE prophylaxis.

The implementation of a pulmonary embolism response team in the management of intermediate- or high-risk pulmonary embolism.

BACKGROUND: Massive and submassive pulmonary embolism (PE) can be life-threatening. Treatment options include anticoagulation, fibrinolysis, catheter-directed or open surgical thrombus removal, and extracorporeal membrane oxygenation. With increasing patient complexity and advanced therapeutic options, the approach to optimal care for patients with intermediate- to high-risk PE is not clearly established. Multidisciplinary, rapid response teams can optimize risk stratification and expedite management. A PE response team (PERT) composed of specialists from cardiology, vascular surgery, emergency medicine, pulmonary and critical care, interventional radiology, cardiac surgery, hospital medicine, and pharmacy was created at our institution. The team is tasked with evaluating and treating patients with massive and submassive PE by use of a risk stratification and treatment algorithm. We describe our initial experience with this approach. METHODS: The records of patients treated by the PERT since inception in October 2015 through May 2017 were reviewed (intervention group). The diagnoses codes of the PERT patients were retrieved from the Vizient database. A retrospective control cohort group was created using these specific diagnoses and a matching set of demographics (age, sex), Medicare Severity Diagnosis Related Group, admission severity of illness, and admission risk of mortality. Statistical analysis was performed using the Fisher exact test, the Pearson χ2 statistic, Student t-test, and Cochran-Cox approximation. P < .05 was considered significant. RESULTS: During the time interval, 77 patients with massive or submassive PE were treated by PERT activation; 992 patients included in the control group were treated at the discretion of an attending physician without use of the algorithm from October 2013 to 2016. Both groups had similar demographics, similar distribution of risk of mortality and severity of illness, and similar average Medicare Severity Diagnosis Related Group weighting. There was no statistically significant difference in the mortality rate between the two groups. The PERT group had significantly lower intensive care unit stay and overall length of stay. No difference was seen in direct cost between the two groups despite higher use of interventional treatment modalities in the PERT group. CONCLUSIONS: In our institution, assembly of a dedicated team to treat patients with massive or submassive PE according to a clinical algorithm resulted in expedited treatment and reduced variation of care. Intensive care unit stay and overall length of stay were reduced by this approach, with no impact on direct cost despite the use of advanced modalities of treatment. We believe that this paradigm can be of potential value in other disease entities, particularly when multiple disciplines are involved.

Comparison of perioperative outcomes in endovascular versus open repair for juxtarenal and pararenal aortic aneurysms: A propensity-matched analysis.

Objective Endoluminal aortic aneurysm repair is suitable within certain anatomic specifications. This study aims to compare 30-day outcomes of endovascular versus open repairs for juxtarenal and pararenal aortic aneurysms (JAA/PAAs). Methods The ACS-NSQIP database was queried from 2012 to 2015 for JAA/PAA repairs. Procedures characterized as emergent were included in the study; however, failed prior repairs and ruptured aneurysms were excluded. The preoperative and perioperative patient characteristics, operative techniques, and outcome variables were compared between the open aortic repair and the endovascular aortic repair groups. Propensity scoring was performed to clinically match open aortic repair and endovascular aortic repair groups on preoperative risk and select perioperative factors that differed significantly in the unmatched groups. Outcome comparisons were then performed between matched groups. Results A total of 1005 (789 JAAs and 216 PAAs) aneurysm repairs were included in the study. Of these, there were 395 endovascular aortic repairs and 610 open aortic repairs. Propensity scoring created a matched group of 263 endovascular aortic repair and 263 open aortic repair patients. There was no statistically significant difference in 30-day mortality rates between matched endovascular aortic repair and open aortic repair patients (2.7% vs. 5.7%). The endovascular aortic repair group had a shorter ICU length of stay and overall hospital stay. The 30-day morbidity significantly favored endovascular aortic repair over open aortic repair (16% vs. 35%, p < 0.001). The main drivers of morbidity for endovascular aortic repair versus open aortic repair included return to the OR (6.8% vs. 15%, p < 0.001), rate of cardiac or respiratory failure (7.6% vs. 21%, p = 0.001), rate of renal insufficiency or failure (3.8% vs. 9.9%, p = 0.009), and rate of pneumonia (1.5% vs. 6.8%, p = 0.004). Conclusions There is no difference in mortality rates between endovascular aortic repair versus open aortic repair when repairing JAAs/PAAs. There is a significant difference in overall morbidity, and ICU and hospital length of stay favoring endovascular aortic repair over open aortic repair. This supports the expanded applicability and efficacy of endovascular repair for complex aneurysms.

Type IIIb Endoleak Associated With an Infected Thoracoabdominal Endograft.

We present a 63-year-old male patient who presented with vague abdominal pain after an endoluminal thoracoabdominal aneurysm repair. He was found to have an infected endograft and an associated type IIIb endoleak. We believe that the infection contributed to the fabric degradation along the endograft and resulted in an expanding endoleak. Graft explantation was not performed because of the patient's multiple comorbidities, and the endoleak was treated with an additional stent graft and suppressive antibiotics. Endograft infection may lead to endograft degradation and associated leak. Therefore, an infectious etiology, although rare, should be considered when evaluating a delayed type IIIb endoleak.

The use of HeRo catheter in catheter-dependent dialysis patients with superior vena cava occlusion.

OBJECTIVES: Hemodialysis (HD) patients with superior vena cava (SVC) occlusion have limited access options. Femoral access is commonly employed but is associated with high complication rates. Hemodialysis Reliable Outflow (HeRO) catheters can be used in tunneled catheter-dependent (TCD) patients who have exhausted other access options. The HeRO graft bypasses occlusion and traverses stenosis with outflow directly into the central venous circulation. At our institution we have used the inside-out central venous access technique (IOCVA) to traverse an occluded vena cava for HeRO graft placement. We review our experience with this technique. METHODS: A retrospective chart review was conducted of patients with HeRO graft placement at our institution. All were dependent on a tunneled femoral dialysis catheter due to central venous occlusion (CVO). The IOCVA technique was used in each case. This technique was used as last resort for patients who had no other dialysis access option. Demographics, patency rates, complications, and mortality were recorded. RESULTS: A total of 11 HeRO grafts were placed in 11 patients from January 2012 to June 2013, with 100% technical success rate. Three grafts were ligated due to steal syndrome. Two grafts were lost due to thrombosis. Five of 11 patients experienced a 30-day complication. Three patients died within the follow-up period; however, none were directly related to the graft placement. Follow up range was 65-573 days; 5 of 11 grafts were used for dialysis at the end of the follow-up period. The 12-month patency rate was 30%. CONCLUSIONS: HeRO grafts are one option for dialysis patients with CVO. There is, however, a high incidence of steal syndrome and other complications. These grafts should be offered as a final potential alternative to catheter dependence.

Cost analysis of vascular readmissions after common vascular procedures.

OBJECTIVE: This study analyzed readmissions and their associated hospital costs after common vascular surgeries at a single institution. METHODS: Patients undergoing open or endovascular abdominal aortic aneurysm repair, aortoiliac revascularization, or infrainguinal revascularization, from 2010 through 2012, were retrospectively evaluated. We compared 30- and 90-day readmission rates and costs by procedure group, and we tabulated reasons for readmission and procedures performed during readmission. We used both American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data and patient records; as NSQIP only captures 30-day data, we retrospectively reviewed patient charts to extend the evaluation to 90 days. Analyses were performed using parametric or nonparametric methods as appropriate. RESULTS: Two hundred nineteen cases were analyzed; the overall rate of index admission survivors experiencing at least one readmission within 30 days was 17% and within 90 days, 27%. Median readmission costs were $10,700, which added 39% to the median index costs of $27,700. Over half of readmissions (55%) included an operation. The most common cause for readmission was related to wound complications, comprising approximately 30% of the entire readmission cohort. Independent drivers of readmission costs were the need for additional surgical procedures, the use of intensive care unit services, and the number of days spent in the hospital above the median. Total 90-day costs were statistically equivalent between open and endovascular procedures when including readmissions. CONCLUSIONS: We found that vascular surgery readmissions occur at a rate of 17% at 30 days and 27% at 90 days. When including the costs of readmission for a wide variety of common vascular cases, there is no significant difference in total costs between endovascular and open procedures at 90 days.

Hybrid diffuse optical techniques for continuous hemodynamic measurement in gastrocnemius during plantar flexion exercise.

Occlusion calibrations and gating techniques have been recently applied by our laboratory for continuous and absolute diffuse optical measurements of forearm muscle hemodynamics during handgrip exercises. The translation of these techniques from the forearm to the lower limb is the goal of this study as various diseases preferentially affect muscles in the lower extremity. This study adapted a hybrid near-infrared spectroscopy and diffuse correlation spectroscopy system with a gating algorithm to continuously quantify hemodynamic responses of medial gastrocnemius during plantar flexion exercises in 10 healthy subjects. The outcomes from optical measurement include oxy-, deoxy-, and total hemoglobin concentrations, blood oxygen saturation, and relative changes in blood flow (rBF) and oxygen consumption rate (rV̇O2). We calibrated rBF and rV̇O2 profiles with absolute baseline values of BF and V̇O2 obtained by venous and arterial occlusions, respectively. Results from this investigation were comparable to values from similar studies. Additionally, significant correlation was observed between resting local muscle BF measured by the optical technique and whole limb BF measured concurrently by a strain gauge venous plethysmography. The extensive hemodynamic and metabolic profiles during exercise will allow for future comparison studies to investigate the diagnostic value of hybrid technologies in muscles affected by disease.

An ex vivo approach to complex renal artery aneurysm repair.

Ex vivo repair technique for a complex renal artery aneurysm may have several advantages. Smaller incision size and use of minimally invasive techniques may decrease incisional morbidity and improve recovery time, especially in patients with a high body mass index. Improved visualization afforded by back-table methods may also be valuable when repair of aneurysms involving multiple branches is necessary. We report of a successful case of laparoscopic nephrectomy, followed by back-table aneurysmorrhaphy and autotransplant, in a patient with a renal artery aneurysm.

Ninety-day readmission risks, rates, and costs after common vascular surgeries.

OBJECTIVES: There are relatively sparse data regarding readmission after vascular surgery. The goal of our study is to analyze readmission rates and hospital cost for several common open and endovascular surgical procedures. METHODS: We accessed our local ACS NSQIP clinical database and hospital cost accounting for vascular surgery cases and their 30- and 90-day readmissions from January 1, 2010, to November 30, 2011. Direct hospital costs (DHC$) were analyzed during the index admission and for all readmissions. Risk factors were compared in the readmitted versus non-readmitted groups using parametric or non-parametric tests as appropriate. Significance was set at P < .05. RESULTS: We identified 170 patients who were readmitted. The 30-day all-cause readmission rate was 9.1% and at 90 days almost doubled to 17.9%. When readmissions occurred, on average they added DHC$ (000's) 12.4 ± 12.3, comprising an additional 61.1% beyond index admission DHC$. Preoperative risk factors associated with 90-day readmission included chronic obstructive pulmonary disease (COPD) (P = .027), open wound/infection (P = .005), and functional dependence (P = .027). Readmissions had longer index operative duration (P = .031) and more often received transfusions within 72 hours of the index case (P = .031). Wound infections were associated with a 90-day readmission (P = .012), as was treated DVT (P = .032) and cerebrovascular or cardiovascular events (P = .013). CONCLUSIONS: Ninety-day readmissions after common vascular surgeries occurred at about twice our 30-day rate. The use of endovascular procedures is associated with significant readmission cost. COPD, open wounds with infection, functional dependence, lengthy procedures, and transfusion are associated with 90-day readmission after vascular surgery.

Analysis of 30-day readmission after aortoiliac and infrainguinal revascularization using the American College of Surgeons National Surgical Quality Improvement Program data set.

OBJECTIVE: This study analyzed 30-day hospital readmissions after aortoiliac (AI) and infrainguinal (II) revascularization to further characterize readmissions and to identify modifiable targets for reducing readmission rates. METHODS: We performed a retrospective analysis of the large, multicenter, prospectively collected American College of Surgeons National Surgical Quality Improvement Program data set from 2011. Readmissions were categorized as planned or unplanned and related or unrelated to the index procedure. The primary end point was unplanned readmissions for open and endovascular AI and II procedures. Multivariable logistic regression was performed to determine independent demographic and preoperative clinical and intraoperative risk factors for unplanned readmissions related to the procedure. RESULTS: A total of 8414 patients were discharged after AI or II revascularization with a 30-day readmission rate of 16.5%. Ninety percent of all readmissions were unplanned and 54% were unplanned and related to the index procedure. Reasons for unplanned readmissions related to the procedure were infection (43.1%), diabetic/ischemic wound complications (16.5%), graft complications (13.6%), cardiac events (3.6%), neurologic events (2.9%), and deep venous thrombosis/pulmonary embolism (2.4%). Procedures were performed in the minority of all readmissions (7.7%) and included vascular intervention (28.7%), amputation (24%), débridement (14%), and incision and drainage (10%). The rate of related readmission for open revascularizations (10.9%) was double the rate for endovascular revascularizations (4.7%). Multivariate analysis identified several independent risk factors associated with unplanned readmissions related to the procedure: open procedure (odds ratio [OR], 1.53; P = .43), operative time of more than 260 minutes (OR, 1.66; P < .002), blood transfusion (OR, 1.24; P = .021), body mass index 30 to 35 (OR, 1.56; P < .001), and preoperative open wound/infection (OR, 1.23; P = .12). Interestingly, length of hospital stay and age were not independent predictors of unplanned readmissions related to the procedure. CONCLUSIONS: AI and II revascularization procedures result in readmission of 16.5% of patients. The most frequent reason for readmission was surgical site infection. Interventions focused on wound care management and avoidance of infectious complications could help reduce readmission rates.

Meta-analysis of the correlation between chronic cerebrospinal venous insufficiency and multiple sclerosis.

PURPOSE: To determine whether a correlation exists between chronic cerebrospinal venous insufficiency (CCSVI) and multiple sclerosis (MS). MATERIALS AND METHODS: A meta-analysis of the current literature was performed to evaluate the frequency of CCSVI, diagnosed by echo color Doppler criteria, in patients with MS and in normal controls. RESULTS: In all, 19 studies were identified from January 2005 through February 2013; however, 3 studies were excluded due to duplicate data and 3 additional studies because 0 patients fulfilled CCSVI criteria in both MS and control groups. In order to improve homogeneity, 4 outlier studies were also removed from the analysis. Analysis of the remaining 9 studies demonstrated a significant correlation between CCSVI and MS (odds ratio 1.885, P < .0001) with no significant heterogeneity of the studies (I (2) = 18, P = .279). CONCLUSIONS: The meta-analysis demonstrated a correlation between CCSVI and MS. However, there was no evidence that CCSVI has a causative role in MS.

Intraoperative blood transfusion of one or two units of packed red blood cells is associated with a fivefold risk of stroke in patients undergoing elective carotid endarterectomy.

OBJECTIVE: Transfused blood can disrupt the coagulation cascade. We postulated that packed red blood cell (PRBC) transfusion may be associated with thromboembolic phenomena. We used propensity matching to examine the relationship between intraoperative PRBC transfusion and stroke during carotid endarterectomy (CEA). METHODS: We selected CEA procedures from the American College of Surgeons National Surgical Quality Improvement Program database from 2005-2009. We excluded bilateral, redo, and emergent procedures. We used multivariate logistic regression to identify independent risk factors for stroke. We then calculated a transfusion propensity score to match patients who received one or two units of transfused PRBC intraoperatively with patients of similar risk profiles who had not been transfused. RESULTS: Our criteria resulted in 12,786 elective CEA patients. Of these, 82 (0.6%) received a one- to two-unit intraoperative transfusion. Thirty-day stroke rates were 1.4% (179/12,704) in the nontransfused group and 6.1% (5/82) in the transfused group (Fisher exact test, P = .007). In forward stepwise multivariable regression of risk factors, only hemiplegia, stroke history, and transient ischemic attacks were predictive of 30-day stroke. We used these same variables to calculate transfusion propensity. We matched 80 transfused patients with 160 controls, thus, creating two groups with very similar risk profiles differing only by their transfusion status. In the matched groups, there was a fivefold increase in the risk of stroke in transfused patients (Fisher exact test, P = .043) CONCLUSIONS: Intraoperative transfusion of one to two units of PRBCs is associated with a fivefold increase in stroke risk. This holds true after consideration of stroke risk variables and operative duration as a surrogate for technical difficulty. The increased risk may be related to several effects of transfused blood on the coagulation inflammation cascade.

Deep venous thrombosis after repair of nonruptured abdominal aneurysm.

OBJECTIVE: To examine venous thromboembolism (VTE) rates, timing, and risk factors after nonruptured open or endoluminal abdominal aortic aneurysm (AAA) repair. METHODS: We queried The American College of Surgeons National Surgery Quality Improvement Program dataset from 2005 to 2009 for open or endoluminal AAA repairs using Current Procedural Terminology and International Classification of Diseases, 9th Edition, codes. Operations performed emergently or for ruptured AAA were excluded. VTE was defined as either deep venous thrombosis or pulmonary embolism requiring treatment within 30 days of operation. VTE was classified as occurring in-hospital or postdischarge. Univariate and multivariable analyses of VTE were performed relative to preoperative and operative risks, including type of repair. RESULTS: Query of the dataset yielded 12,469 patients: 8502 endoluminal (68.2%) and 3967 (31.8%) open repairs. Mean patient age was 73.2 ± 8.7 (standard deviation) years, and 19.8% of patients were women. The 30-day VTE rate was 1.1% (n = 135). Of VTE cases, 30% (40/135) were diagnosed after discharge from the surgical hospitalization. The postdischarge VTE rate was 0.3% after both open and endoluminal repairs. The in-hospital VTE rate was higher in the open group (1.6% vs 0.4%; P < .001), as was median length of stay (7 days vs 2 days; P < .001). Independent preoperative predictors of in-hospital VTE were dyspnea, serum albumin (protective), and history of peripheral vascular disease. With preoperative risk adjustment, in-hospital VTE risk increased with duration of operation and number of units of blood transfused. Open repairs were associated with higher risk for VTE than endoluminal repairs (odds ratio, 1.91; 95% confidence interval, 1.10-3.33; P = .022). VTE was associated with increased 30-day mortality from 1.9% (232/12,102) in patients without VTE to 4.4% (6/135) in patients with VTE (χP = .035). CONCLUSIONS: VTE after AAA repair was infrequent but was associated with higher mortality, and one-third of VTEs were diagnosed after discharge. Open AAA repair increased risk for in-hospital VTE compared with endoluminal repair. Patients with the identified risk factors may benefit from pharmacologic thromboprophylaxis after AAA repair. Pharmacologic thromboprophylaxis may be unnecessary after endoluminal repair.

Timing and perioperative risk factors for in-hospital and post-discharge venous thromboembolism after colorectal cancer resection.

INTRODUCTION: We postulated that the risk of venous thromboembolic disease (VTE) may persist after discharge and tested this hypothesis in patients undergoing colorectal resection for cancer. METHODS: The American College of Surgeons National Surgery Quality Improvement Program database was queried for patients undergoing colorectal resections for cancer from 2005 to 2009. The outcome analyzed was a 30-day deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Multivariable forward stepwise regression was used to identify independent predictors of VTE. RESULTS: The database contained 21 943 colorectal cancer resections. The 30-day DVT rate was 1.4% (306 of 21 943), 29% (89 of 306) were diagnosed post-discharge. The 30-day PE rate was 0.8% (180 of 21 943), 33% (60 of 180) was diagnosed post-discharge, the combined DVT/PE rate was 2.0% (446 of 21 943). The median time to diagnosis of VTE was 9 days (interquartile range 4-16) after surgery. Post-discharge VTE rates in patients with length of stay (LOS) less than 1 week (0.6%) were similar to patients with LOS greater than 1 week (0.7%, Fisher exact P not significant). Independent risk factors for post-discharge VTE were preoperative steroid use for chronic condition (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.51-5.57, P = .001) and preoperative systemic inflammatory response syndrome (OR 2.26, 95% CI 1.24-4.10, P = .008). CONCLUSIONS: Diagnosis of almost one third of postoperative VTE in this patient population occurred after discharge. The duration of the prothrombotic stimulus of surgery is not well defined, and patients with malignancy are at high risk of VTE; thromboprophylaxis after discharge should be considered for these patients.

The femoral-based endowedge technique to increase juxtarenal seal and correct graft tilt.

The endowedge technique refers to the use of balloons to align the scallops of the Gore Excluder endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz) to the renal artery to increase juxtarenal seal during endovascular repair of aneurysms with challenging anatomy. With the availability of a reconstrainable deployment system, this now can be performed without the use of brachial access. In addition, the femoral approach facilitates the use of the balloon as a fulcrum to correct unfavorable graft tilt.

Association of blood transfusion and venous thromboembolism after colorectal cancer resection.

INTRODUCTION: Red blood cell (RBC) transfusion is a common event in the perioperative course of patients undergoing surgery. Transfused blood can disrupt the balance of coagulation factors and modulates the inflammatory cascade. Since inflammation and coagulation are tightly coupled, we postulated that RBC transfusion may be associated with the development of venous thromboembolic phenomena. We queried the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database to examine the relationship between intraoperative blood transfusion and development of venous thromboembolism (VTE) in patients undergoing colorectal resection for cancer. MATERIALS AND METHODS: We analyzed the data from 2005 to 2009 for patients undergoing colorectal resections for cancer based on the primary procedure CPT-4 code and operative ICD-9 diagnosis code. The primary outcome was 30-day deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Intraoperative transfusion of RBC's was categorized as: none, 1-2 units, 3-5 units and 6 units or more. DVT/PE occurrences were analyzed by multivariable forward stepwise regression (p for entry<.05, for exit>.10) to identify independent predictors of DVT. RESULTS: The database contained 21943 colorectal cancer resections. The DVT rate was 1.4% (306/21943) and the PE rate was 0.8% (180/21943). Patients were diagnosed with both only 40 times and the combined DVT or PE rate (VTE) was 2.0% (446/21943). After adjusting for age, gender, race, ASA (American Society of Anesthesiologists) class, emergency procedure, operative duration and complexity of the procedure (based on Relative Value Units, RVU's), along with six clinical risk factors, intraoperative blood transfusion was a significant risk factor for the development of VTE and the risk increased with increasing number of units transfused. Preoperative hematocrit did not enter the multivariable model as an independent predictor of VTE, nor did open versus laparoscopic resection or wound class. CONCLUSION: In this study of 21943 patients undergoing colorectal resection for cancer, blood transfusion is associated with increased risk of VTE. Malignancy and surgery are known prothrombotic stimuli, the subset of patients receiving intraoperative RBC transfusion are even more at risk for VTE, emphasizing the need for sensible use of transfusions and rigorous thromboprophylaxis regimens.

Thrombin injection for the treatment of mycotic gluteal aneurysm.

Gluteal aneurysms are rare entity, whose surgical or endovascular management is traditionally challenging. Infectious source being increasingly more common as the underlying etiology. We herein describe successful implementation of direct thrombin injection as another therapeutic option for these patients.

Incidence and risk factors for 30-day postdischarge mortality in patients with vascular disease undergoing major lower extremity amputation.

BACKGROUND: Our goal was to analyze the incidence and risk factors for 30-day postdischarge mortality in patients with vascular disease undergoing major lower extremity amputation. METHODS: We queried the American College of Surgeons National Surgery Quality Improvement Program data set from the years 2005 to 2009 for amputations with vascular disease diagnosis codes. We analyzed in-hospital mortality and postdischarge mortality by year of the study and relative to length of hospital stay. Patients with American Society of Anesthesiologists physical status classification level 5, do-not-resuscitate status, disseminated cancer, and emergent operations were excluded to highlight risk among patients more likely to survive. We compared risk factors for each mortality group using separate multivariate logistic regressions. RESULTS: Our query resulted in 6,188 patients with mean age of 67 ± 14 years; of these, 39.1% were female. Thirty-day mortality was 7.6%; 4.2% in-hospital mortality and 3.4% postdischarge mortality. After postoperative day 14, the majority of deaths were after discharge and the daily death risk was almost constant until postoperative day 30 at around 2.1 per 1000 survivors. The postdischarge death rates were consistent across the 5 years of the study (χ(2): p = 0.59), despite the fact that median hospital length of stay decreased from 12 to 9 days (Kruskal-Wallis: p < 0.001). Preoperative risk factors for postdischarge death included age, functional status, lower serum albumin, serum creatinine level of >1.2 mg/dL, dialysis, serum bilirubin level of >1.0 mg/dL, black race (protective), systemic inflammatory response syndrome, steroid use for chronic condition, impaired sensorium, alcohol abuse, recent weight loss, and dyspnea. CONCLUSIONS: Patients with vascular disease undergoing major amputation are at high risk for postdischarge mortality. This risk is not associated with recent decrease in hospital stay. Systemic comorbid risk factors were identified, thus highlighting the need for adequate medical management of these patients in the 30 days after the operation. Coordination of postdischarge care to ensure management of systemic illness could potentially improve outcomes.

Internal carotid pseudoaneurysm associated with tortuosity after tonsillectomy: a case report.

We present a patient who was found to have an internal carotid pseudoaneurysm 3 years after tonsillectomy and chemoradiation for tonsillar cancer. Ha also had severe tortuosity of both internal carotid arteries. The lesion was in an anatomically challenging location, but an endoluminal approach was not feasible because of the extreme tortuosity. He underwent open repair with resection of the pseudoaneurysm and direct anastomosis with good results.

Endoluminal versus open repair of descending thoracic aortic rupture: a review of the National Trauma Databank.

OBJECTIVES: Open repair for blunt thoracic aortic injury is associated with significant mortality. Interest in less invasive methods of repair has developed and results of several clinical studies have shown successful emergency repair with endovascular stent grafting. The purpose of this report was to compare endoluminal versus open repair of traumatic thoracic aortic injury in the National Trauma Databank. METHODS: We queried the databank from 2002 to 2006. We selected patients who had one of their International Classification of Disease-9 Diagnoses as 901.0, 'injury to the thoracic aorta', whose mechanism of injury was motor vehicle accident, fall or other transport, whose discharge disposition was known, and who received an endovascular or open repair. RESULTS: The search resulted in 997 patients, one of whom had both procedures listed and was excluded from the analysis, 72% were males. A total of 875 underwent open repair and 121 had endoluminal repair. Both groups were similar in terms of age, demographics, associated injuries and hemodynamic status on presentation. Neither method of repair conferred significant advantage of survival, length of stay or ventilator days. Furthermore, there was no significant difference of pulmonary, renal, cardiac, infectious and neurologic complications between the two methods. CONCLUSION: Our findings suggest that in a large unselected population, endoluminal repair for aortic thoracic injury is not associated with decreased mortality or overall morbidity. Long-term data for endoluminal repair and its durability are lacking, especially in young patients. It may be premature to adopt endoluminal repair as the method of choice for all of these patients.