Perioperative complications following open or endovascular revascularization for chronic limb-threatening ischemia in the BEST-CLI Trial.

OBJECTIVE: Anticipated perioperative morbidity is an important factor for choosing a revascularization method for chronic limb-threatening ischemia (CLTI). Our goal was to assess systemic perioperative complications of patients treated with surgical and endovascular revascularization in the Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial. METHODS: BEST-CLI was a prospective randomized trial comparing open (OPEN) and endovascular (ENDO) revascularization strategies for patients with CLTI. Two parallel cohorts were studied: Cohort 1 included patients with adequate single-segment great saphenous vein (SSGSV), whereas Cohort 2 included those without SSGSV. Data were queried for major adverse cardiovascular events (MACE-composite myocardial infarction, stroke, death), non-serious (non-SAEs) and serious adverse events (SAEs) (criteria-death/life-threatening/requiring hospitalization or prolongation of hospitalization/significant disability/incapacitation/affecting subject safety in trial) 30 days after the procedure. Per protocol analysis was used (intervention received without crossover), and risk-adjusted analysis was performed. RESULTS: There were 1367 patients (662 OPEN, 705 ENDO) in Cohort 1 and 379 patients (188 OPEN, 191 ENDO) in Cohort 2. Thirty-day mortality in Cohort 1 was 1.5% (OPEN 1.8%; ENDO 1.3%) and in Cohort 2 was 1.3% (2.7% OPEN; 0% ENDO). MACE in Cohort 1 was 4.7% for OPEN vs 3.13% for ENDO (P = .14), and in Cohort 2, was 4.28% for OPEN and 1.05% for ENDO (P = .15). On risk-adjusted analysis, there was no difference in 30-day MACE for OPEN vs ENDO for Cohort 1 (hazard ratio [HR] 1.5; 95% confidence interval [CI], 0.85-2.64; P = .16) or Cohort 2 (HR, 2.17; 95% CI, 0.48-9.88; P = .31). The incidence of acute renal failure was similar across interventions; in Cohort 1 it was 3.6% for OPEN vs 2.1% for ENDO (HR, 1.6; 95% CI, 0.85-3.12; P = .14), and in Cohort 2, it was 4.2% OPEN vs 1.6% ENDO (HR, 2.86; 95% CI, 0.75-10.8; P = .12). The occurrence of venous thromboembolism was low overall and was similar between groups in Cohort 1 (OPEN 0.9%; ENDO 0.4%) and Cohort 2 (OPEN 0.5%; ENDO 0%). Rates of any non-SAEs in Cohort 1 were 23.4% in OPEN and 17.9% in ENDO (P = .013); in Cohort 2, they were 21.8% for OPEN and 19.9% for ENDO (P = .7). Rates for any SAEs in Cohort 1 were 35.3% for OPEN and 31.6% for ENDO (P = .15); in Cohort 2, they were 25.5% for OPEN and 23.6% for ENDO (P = .72). The most common types of non-SAEs and SAEs were infection, procedural complications, and cardiovascular events. CONCLUSIONS: In BEST-CLI, patients with CLTI who were deemed suitable candidates for open lower extremity bypass surgery had similar peri-procedural complications following either OPEN or ENDO revascularization: In such patients, concern about risk of peri-procedure complications should not be a deterrent in deciding revascularization strategy. Rather, other factors, including effectiveness in restoring perfusion and patient preference, are more relevant.

Comparison of Genes Associated with Thoracic and Abdominal Aortic Aneurysms.

Aneurysms impacting the ascending thoracic aorta and the abdominal aorta affect patient populations with distinct clinical characteristics. Through a literature review, this paper compares the genetic associations of ascending thoracic aortic aneurysm (ATAA) with abdominal aortic aneurysms (AAA). Genes related to atherosclerosis, lipid metabolism, and tumor development are associated specifically with sporadic AAA, while genes controlling extracellular matrix (ECM) structure, ECM remodeling, and tumor growth factor ß function are associated with both AAA and ATAA. Contractile element genes uniquely predispose to ATAA. Aside from known syndromic connective tissue disease and poly-aneurysmal syndromes (Marfan disease, Loeys-Dietz syndrome, and Ehlers-Danlos syndrome), there is only limited genetic overlap between AAA and ATAA. The rapid advances in genotyping and bioinformatics will elucidate further the various pathways associated with the development of aneurysms affecting various parts of the aorta.

The association between diabetes mellitus and its management with outcomes following endovascular repair for descending thoracic aortic aneurysm.

OBJECTIVE: Prior literature is conflicted regarding the effect of diabetes mellitus (DM) on outcomes after endovascular repair of aortic aneurysms. In this study, we aimed to examine the association between DM and outcomes after thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysm (TAA). METHODS: We identified patients who underwent TEVAR for TAA of the descending thoracic aorta in the Vascular Quality Initiative between 2014 and 2022. We created two cohorts, DM and nonDM, based on the patient's preoperative DM status, and secondarily substratified patients with DM by management strategy: dietary management, noninsulin medications, and insulin therapy cohorts. Outcomes included perioperative and 5-year mortality, in-hospital complications, indications for repair, and 1-year sac dynamics, which were analyzed with multivariable cox regression, multivariable logistic regression, and χ2 tests, respectively. RESULTS: We identified 2637 patients, of which 473 (18%) had DM preoperatively. Among patients with DM, 25% were diet controlled, 54% noninsulin medications, and 21% insulin therapy. Within patients who underwent TEVAR for TAA, the proportions of ruptured presentation were higher in the dietary-managed (11.1%) and insulin-managed (14.3%) cohorts relative to noninsulin therapy (6.6%) and those without DM (6.9%). After multivariable regression analysis, we found that DM was associated with similar perioperative mortality (odds ratio, 1.14; 95% confidence interval [CI], 0.70-1.81) and 5-year mortality compared with patients without DM (hazard ratio, 1.15; 95% CI, 0.91-1.48). Furthermore, all in-hospital complications were comparable between patients with DM and patients without DM. Compared with patients without DM, dietary management of DM was significantly associated with higher adjusted perioperative mortality (OR, 2.16; 95% CI, 1.03-4.19) and higher 5-year mortality (hazad ratio, 1.50; 95% CI, 1.03-2.20), although this was not the case for other DM subgroups. All cohorts displayed similar 1-year sac dynamics, with sac regression occurring in 47% of patients without DM vs 46% of patients with DM (P = .27). CONCLUSIONS: Preoperatively, patients with DM who underwent TEVAR had a higher proportion of ruptured presentation when treated with diet or insulin medications than when treated with noninsulin medications. After TEVAR for descending TAA, DM was associated with a similar risk of perioperative and 5-year mortality as nonDM. In contrast, dietary therapy for DM was associated with significantly higher perioperative mortality and 5-year mortality.

Positron Emission Tomography Imaging of Vessel Wall Matrix Metalloproteinase Activity in Abdominal Aortic Aneurysm.

BACKGROUND: Matrix metalloproteinases (MMPs) play a key role in the pathogenesis of abdominal aortic aneurysm (AAA). Imaging aortic MMP activity, especially using positron emission tomography to access high sensitivity, quantitative data, could potentially improve AAA risk stratification. Here, we describe the design, synthesis, characterization, and evaluation in murine AAA and human aortic tissue of a first-in-class MMP-targeted positron emission tomography radioligand, 64Cu-RYM2. METHODS: The broad spectrum MMP inhibitor, RYM2 was synthetized, and its potency as an MMP inhibitor was evaluated by a competitive inhibition assay. Toxicology studies were performed. Tracer biodistribution was evaluated in a murine model of AAA induced by angiotensin II infusion in Apolipoprotein E-deficient mice. 64Cu-RYM2 binding to normal and aneurysmal human aortic tissues was assessed by autoradiography. RESULTS: RYM2 functioned as an MMP inhibitor with nanomolar affinities. Toxicology studies showed no adverse reaction in mice. Upon radiolabeling with Cu-64, the resulting tracer was stable in murine and human blood in vitro. Biodistribution and metabolite analysis in mice showed rapid renal clearance and acceptable in vivo stability. In vivo positron emission tomography/computed tomography in a murine model of AAA showed a specific aortic signal, which correlated with ex vivo measured MMP activity and Cd68 gene expression. 64Cu-RYM2 specifically bound to normal and aneurysmal human aortic tissues in correlation with MMP activity. CONCLUSIONS: 64Cu-RYM2 is a first-in-class MMP-targeted positron emission tomography tracer with favorable stability, biodistribution, performance in preclinical AAA, and importantly, specific binding to human tissues. These data set the stage for 64Cu-RYM2-based translational imaging studies of vessel wall MMP activity, and indirectly, inflammation, in AAA.

Correlation between reflux time and venous clinical severity score in patients undergoing saphenous vein ablation: A prospective study.

OBJECTIVES: It is unclear whether reflux time independently correlates with severity of symptoms in patients with great saphenous vein reflux. METHODS: Eighty patients (mean age 64+/-12.7 years, 56% female) undergoing great saphenous vein (GSV) ablation for symptomatic reflux were assessed prospectively. Fifty-seven underwent ablation with radiofrequency, 23 with cyanoacrylate adhesive. Venous clinical severity score (VCSS) was assessed at, or prior to the time of ablation. The highest reflux time in the GSV was selected. RESULTS: VCSS values ranged from 2 to 20 (median 7). Mean reflux time was 5.3 s (+/-3.3). The Spearman rank correlation yielded a value of rs = -0.123, p (2-tailed) = .279, which was not significant. The patients with concomitant deep vein reflux had higher VCSS (p < .05). Analysis of patients with only superficial vein reflux (n = 45) also demonstrated a poor correlation between VCSS and reflux time (rs = -0.051, p (2-tailed) = .741). CONCLUSION: This prospective study did not demonstrate a correlation between reflux time and VCSS.

Correlation between great saphenous length of treatment zone and diameter with improvement in symptoms after ablation.

OBJECTIVE: The aim of the present study was to examine the relationship between the great saphenous vein (GSV) length of segment ablated and diameter with symptom improvement. METHODS: Data from a multicenter, randomized, controlled prospective study of 242 patients undergoing radiofrequency ablation (RFA) or cyanoacrylate closure (CAC) of the GSV were analyzed. The venous clinical severity score (VCSS) was measured at baseline and at 1, 3, 6, 12, 24, and 36 months after ablation. The GSV diameter was evaluated for a correlation with VCSS at each time point. Using the median treatment length of 34 cm, the patients were divided into group I (treatment length ≥34 cm) vs group II (<34 cm) for analysis. The pretreatment VCSS and VCSS improvement (ΔVCSS) after treatment were evaluated with respect to the length of the ablated GSV segment. The postablation VCSS was compared between the pretreatment GSV diameters of <5.5 mm vs ≥5.5 mm. RESULTS: The mean GSV length ablated by RFA was 35.3 ± 14 cm vs 32.6 ± 11 cm with CAC (P = NS). No significant difference was found in the VCSS (at baseline or follow-up) between RFA and CAC. The pooled data for all participants (n = 242) demonstrated a correlation between the treated GSV length and pretreatment VCSS and the ΔVCSS at 36 months (R = 0.23; P < .001). Greater VCSS improvement was seen in group I (≥34 cm ablated) than in group II (<34 cm ablated) at ≤36 months of follow-up (P = .003). At baseline, group I had had higher VCSSs (6.21 ± 2.75 vs 4.88 ± 2.33; P < .00001) and CEAP (clinical, etiologic, anatomic, pathophysiologic) and reflux scores. Of the 242 patients, 101 had had a GSV diameter <5.5 mm and 141 had had a GSV diameter of ≥5.5 mm. No significant differences were noted in the VCSSs, either at baseline or at follow-up, between the two groups. Within the study population, a poor correlation was found between the GSV diameter and baseline VCSS (R = -0.004; P = .95) and between the GSV diameter and ΔVCSS for ≤36 months (R = 0.04; P = .55). CONCLUSIONS: Longer segments of GSV reflux appeared to correlate with symptom severity. We found a small to moderate correlation between the length of GSV segment ablated and symptom improvement. This might reflect the greater severity of symptoms at baseline in patients with longer segments with reflux. We found a poor correlation between the proximal GSV diameter and symptom improvement after ablation.

Trends and outcomes of thoracic endovascular aortic repair with open concomitant cervical debranching.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has become the most common surgical procedure for treatment of descending thoracic aortic pathology. Cervical debranching in the form of carotid-subclavian bypass or transposition (CSBT) and carotid-carotid bypass (CCB) has enabled the use of TEVAR for the treatment of more complex anatomy involving the arch. The present study examined the effects of concomitant cervical bypass on the perioperative outcomes of TEVAR. METHODS: The American College of Surgeons National Surgical Quality Improvement Program files (2005-2017) were reviewed. Using the Current Procedural Terminology codes, all patients who had undergone TEVAR were identified and were divided into three groups: TEVAR, TEVAR with one bypass (CSBT or CCB), and TEVAR with two bypasses (CSBT and CCB). The patient characteristics and perioperative outcomes of the three groups were compared. Multivariable analysis was performed to determine the factors associated with mortality. RESULTS: A total of 3281 patients had undergone TEVAR and 10% had also undergone one or more debranching procedure (one bypass, 9%; two bypasses, 1%). The frequency of debranching had increased from 3.4% to 10.9% (P = .01) during the study period. Significant differences were found among the three groups in age, sex, smoking history, urgency of surgery, and anesthesia technique. The patients who had undergone TEVAR with cervical debranching had had significantly greater morbidity, longer operating times, and longer hospital stays compared with those who had undergone TEVAR alone. The mortality of TEVAR with two bypasses (22.6%) was significantly greater than that of TEVAR alone (7.5%) and TEVAR with one bypass (6.8%; P < .01). The total morbidity (30.9% vs 35.1% vs 67.7%; P < .001) and stroke rate (3% vs 7.5% vs 12.9%; P < .0001) increased with the increasing number of bypasses. A subgroup analysis of patients who had undergone TEVAR with one bypass showed no significant differences in mortality between TEVAR plus CSBT (6.6%) vs TEVAR plus CCB (8.8%; P = .63). Multivariable analysis showed that TEVAR with two bypasses was associated with significantly increased mortality compared with TEVAR alone (odds ratio [OR], 4.33; 95% confidence interval [CI], 1.75-10.73) and TEVAR with one bypass (OR, 3.44; 95% CI, 1.24-9.51). Older age (OR, 1.74; 95% CI, 1.42-2.13), dependent functional status (OR, 1.48; 1.00-2.19), dialysis (OR, 2.61; 95% CI, 1.57-4.33), and emergent status (OR, 3.66; 95% CI, 2.73-4.90) were also associated with mortality. CONCLUSIONS: TEVAR with concomitant cervical debranching has been increasingly used to treat complex aortic pathology but is associated with significantly worse outcomes than TEVAR alone. As advanced endovascular technology to treat the aortic arch emerges, the outcomes of open surgical debranching in the present study constitute an important benchmark for comparison.

Safety of compression therapy for venous ulcer disease in the setting of congestive heart failure.

OBJECTIVES: Compression therapy is the mainstay of treatment for patients with venous ulcer disease. There exists a lack of certainty as to the safety of compression therapy in patients with congestive heart failure. METHODS: A retrospective review of 95 patients with the diagnosis of congestive heart failure (systolic, diastolic, or combined), who underwent compression therapy at the wound care center of a large teaching hospital between January 2013 and June 2019, was performed. Patient outcomes including mortality, weight gain, admission for heart failure decompensation, and requirement for diuretic dose increase were compared to the general congestive heart failure population as well as to the registry data. RESULTS: In the compression cohort, with a mean compression period of 310 days, seven patients (7.3%) were admitted for congestive heart failure exacerbation and six (6.3%) underwent diuretic dosage increase. Two patients (2.1%) died during the compression period. These endpoints were not significantly higher than within the general congestive heart failure population. CONCLUSIONS: Compression therapy appears safe amongst patients with stable congestive heart failure.

A Pilot Study of a Standardized Smoking Cessation Intervention for Patients with Vascular Disease.

BACKGROUND: The goal of this study is to evaluate the efficacy of a smoking cessation intervention performed by a vascular surgery provider compared with current smoking cessation practices. METHODS: Patients with peripheral arterial and aneurysmal disease who presented to the vascular surgery service at a tertiary care center over a 9-month period were randomized to either control or intervention group. Both control and intervention groups received 2 weeks of free nicotine patches and referral to an outpatient smoking-cessation program. The intervention group additionally received a brief presentation by a vascular surgeon regarding the benefits of smoking cessation, with a focus on vascular complications. At enrollment and at follow-up, patients underwent carbon monoxide breath testing and completed a survey. The primary outcome was smoking cessation or reduction among control and intervention groups in patients who underwent medical management, endovascular procedures, or open surgical procedures. Fisher's exact test was used to assess the primary outcome among groups. RESULTS: Fifty-nine patients were enrolled in the trial initially, but 55 had 1-month follow-up (control n = 28, intervention n = 27) and 52 had long-term follow-up (control n = 28, intervention n = 24). By long-term follow-up, 40 patients (77%) had reduced smoking by at least 50% and 16 patients (31%) had quit completely. At long-term follow-up, 88% of patients in the intervention group and 68% of patients in the control group reduced smoking (P = 0.1). CONCLUSIONS: A large proportion of vascular patients who received 2 weeks of nicotine replacement with or without the addition of brief smoking cessation counseling delivered by a vascular surgery provider were able to reduce smoking and maintain reduction after 6 months. Delivery of a brief standardized smoking cessation counseling session by a vascular surgery provider is safe and feasible. Additional randomized controlled trials with large enrollment periods and long follow-up are needed to determine the efficacy of this intervention in comparison to standard care.

Trends and outcomes in endovascular and open surgical treatment of visceral aneurysms.

OBJECTIVE: Visceral artery aneurysms (VAAs) are rare but often repaired because of dire consequences of rupture. This is a population-based evaluation of chronologic trends in management, risk factors, and outcomes of endovascular and open therapy. METHODS: The 2003 to 2013 Agency for Healthcare Research and Quality (AHRQ) National Inpatient Sample (NIS) database was reviewed. Cases with primary diagnosis of VAA and undergoing endovascular or open repair were identified. Patients with renal artery or abdominal or thoracoabdominal aortic disease were excluded. Case numbers of respective techniques were charted over time. Baseline characteristics and in-hospital outcomes were compared for endovascular and open groups using χ2 test, Fisher exact test, or t-test. Predictors of mortality and complications were evaluated with multivariate logistic regression. RESULTS: There were 9260 interventions for VAAs from 2003 to 2013, including 5166 endovascular and 4094 open. Endovascular repairs increased from 5.3 to 24.7 per 10 million U.S. population (P < .001), surpassing open repairs in 2008, which decreased from 14.3 to 9.2 per 10 million (P < .001). Endovascular patients were more likely to have been treated at urban teaching hospitals (77.1% vs 61.8%; P < .0001); to have higher proportions of renal failure (7.6% vs 4.9%; P = .02), liver disease (11.3% vs 6.6%; P < .001), alcohol abuse (13.1% vs 3.6%; P < .001), chronic blood loss anemia (4.5% vs 1.6%; P < .001), metastatic cancer (2.7% vs 0.8%; P = .003), solid tumor without metastases (3.6% vs 2.0%; P < .037), and weight loss (9.8% vs 5.2%; P < .001); and less likely to have had elective admission (28.9% vs 59.8%; P < .0001). In-hospital mortality (4.1% vs 4.5%; P = .618) and overall complication rates (37.8% vs 38.8%; P = .688) were similar between groups; however, pulmonary complications were decreased for endovascular patients (10.6% vs 19.7%; P < .001). Endovascular patients had shorter hospital stays (6.5 vs 8.7 days; P < .001). Multivariate adjustment for mortality predictors, including coagulopathy (odds ratio [OR], 4.34; confidence interval [CI], 2.56-7.35; P < .001), liver disease (OR, 2.25; CI, 1.25-4.07; P = .01), fluid and electrolyte disorders (OR, 2.84; CI, 1.73-4.66; P < .001), and solid tumor without metastases (OR, 2.81; CI, 1.10-7.18; P = .03), showed that open treatment was associated with increased mortality (OR, 1.70; CI, 1.03-2.81; P = .04). Analysis of overall complications revealed that open treatment was again associated with increased complications (OR, 1.78; CI, 1.43-2.21; P < .001). CONCLUSIONS: Endovascular VAA repairs are increasing. Despite patients' having worse comorbidities and more nonelective admissions, endovascular therapy appears to be associated with decreased mortality and complications and shorter hospital stays.

Distal embolization during lower extremity endovascular interventions.

OBJECTIVE: Distal embolization (DE) during peripheral arterial endovascular interventions is a well-known complication that is poorly studied. The goal of this study was to determine the incidence, risk factors, and effect of DE on the outcomes of lower extremity endovascular interventions (LEIs). METHODS: All LEIs between 2010 and 2014 in the Vascular Study Group of New England (VSGNE) database were reviewed. Patient characteristics were analyzed to determine predictors of DE. LEIs involving the superficial femoral artery (SFA) were reviewed to assess the effect of type of treatment on DE. The outcomes examined were loss of patency, limb loss, and mortality after LEI involving the SFA. A multivariable regression was used to determine predictors of DE. RESULTS: There were 10,875 procedures. The incidence of DE was 17.3 per 1000 procedures, and 68% required treatment (57% endovascular, 11% open surgery). DE was more common in patients treated for critical limb ischemia compared with claudication (relative risk [RR], 2.06; 95% confidence interval [CI], 1.24-3.45; P = .006) and for emergency interventions compared with elective (RR, 2.98; 95% CI, 1.22-7.30; P = .017). DE increased with the number of arteries treated (P < .0001) and with the length of occlusion (P < .0001). The SFA was the most commonly treated artery (4751 [43.7%]). In comparison with atherectomy and balloon angioplasty, stenting alone (RR, 0.36; 95% CI, 0.17-0.73; P = .005), balloon angioplasty alone (RR, 0.23; 95% CI, 0.13-0.41; P < .0001), and combined stenting and balloon angioplasty (RR, 0.29; 95% CI, 0.17-0.49; P < .0001) were associated with a significantly lower risk of DE. DE was not significantly associated with loss of patency, major amputation, or mortality. CONCLUSIONS: The incidence of DE during LEIs is 1% to 2% in the VSGNE database, and most patients are treated with additional endovascular interventions. The incidence increases in patients with critical limb ischemia and with the use of atherectomy.

Explantation of infected aortic aneurysm and endograft with ascending aorta to mesenteric bypass for mesenteric ischemia.

A 65-year-old man presented with an infected perivisceral aortic aneurysm after previous treatment of an abdominal aortic aneurysm with an endograft. On presentation, he was septic and had occlusion of the celiac, superior mesenteric, inferior mesenteric, and bilateral renal arteries. He underwent a three-stage procedure: first, axillobifemoral bypass; then resection of the thoracoabdominal aorta; and finally bypass from the ascending aorta to the celiac and superior mesenteric arteries with a rifampin-soaked Gelsoft graft (Vascutek, Renfrewshire, Scotland). The abdominal pain resolved, and the patient remains symptom free 10 months postoperatively. This rare surgical revascularization technique offered a nontraditional solution to a difficult surgical issue.

Compression therapy for venous disease.

For centuries, compression therapy has been utilized to treat venous disease. To date it remains the mainstay of therapy, particularly in more severe forms such as venous ulceration. In addition to mechanisms of benefit, we discuss the evidence behind compression therapy, particularly hosiery, in various forms of venous disease of the lower extremities. We review compression data for stand-alone therapy, post-intervention, as DVT prevention, post-thrombotic syndrome and venous ulcer disease. We also review the data comparing compression modalities as well as the use of compression in mixed arteriovenous disease.

Percutaneous endovascular aneurysm repair in morbidly obese patients.

OBJECTIVE: Endovascular aneurysm repair (EVAR) with percutaneous femoral access (PEVAR) has several potential advantages. Morbidly obese (MO) patients present unique anatomical challenges and have not been specifically studied. This study examines the trends in the use of PEVAR and its surgical outcomes compared with open femoral cutdown (CEVAR) in MO patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Program files for the years 2005 to 2013 were reviewed. The study included all MO patients (body mass index [BMI] ≥40 kg/m2) undergoing EVAR. Patients were categorized as having CEVAR if they had any one of 11 selected Current Procedural Terminology (American Medical Association, Chicago, Ill) codes describing an open femoral procedure. The PEVAR group included any remaining patients who had only codes for EVAR and endovascular procedures. Linear correlation was used to evaluate temporal trends in the use of PEVAR among MO patients. Baseline comorbidities and surgical outcomes were compared between the PEVAR and CEVAR groups using χ2 tests or t-tests. RESULTS: There were 833 MO patients (470 CEVAR and 363 PEVAR) constituting 3.0% of all patients undergoing EVAR. The use of PEVAR in MO patients significantly increased from 27.3% of total EVARs in the years 2005 to 2006 to 48.6% in 2013 (P = .039). The two groups had similar baseline characteristics, including age, BMI, comorbidities, and emergency procedures, except for history of severe chronic obstructive pulmonary disease (29.6% CEVAR vs 22.6% PEVAR; P = .024). PEVAR patients had shorter duration of anesthesia (244 vs 260 minutes; P = .048) and shorter total operation time (158 vs 174 minutes; P = .002). PEVAR patients had significantly decreased wound complications (5.5% vs 9.4%; P = .039). There was a trend towards PEVAR patients being more likely to be discharged home than to a facility (93.6% vs 87.8%; P = .060). There was no difference in any other complication or mortality. A subgroup analysis of 109 superobese patients with BMI ≥50 kg/mg2 (59 CEVAR and 50 PEVAR) demonstrated no significant differences in outcomes between groups. CONCLUSIONS: PEVAR is increasingly used in MO patients and decreases operating time and rates of wound infection compared with CEVAR. The advantages of PEVAR seem to be lost in the superobese patients.

Venous ulcer: late complication of a traumatic arteriovenous fistula.

Arteriovenous fistula (AVF) formation after penetrating trauma is a well-described phenomenon. However, diagnosis of traumatic AVF is frequently delayed as patients often do not have hard signs of vascular injury at the initial presentation. Late complications of traumatic AVF include arterial and venous dilatation, distal ischemia, venous congestion, and congestive heart failure. This case report describes a traumatic femoral AVF causing distal venous ulceration 3 years after the injury. The AVF was treated with open repair. In the operating room, the Nicoladoni-Branham sign was elicited. The ulcer healed at 1 month and has not recurred at 1-year follow-up.