Pediatric Vascular Surgical Practice Patterns.

BACKGROUND: Vascular surgeons infrequently care for pediatric patients. As such, variability in operative management and available hospital resources at free-standing children's hospitals (CHs) may exist. The study aims were (1) to determine vascular surgeon comfort level with pediatric vascular surgery and (2) to determine variations in pediatric vascular surgery practice patterns. METHODS: A survey composed of clinical vignettes emailed to all members of Vascular and Endovascular Surgery Society was designed to assess operative management of pediatric vascular conditions and hospital resources. Comparisons of surgeon satisfaction between free-standing CHs and a CH within an adult general hospital were made using Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made using a McNemar's test. P-values less than or equal to 0.05 indicated statistical significance. RESULTS: Response rate was 18% (93/525) with 96% (89/93) indicating completion of a 2 year vascular fellowship. Surgeon satisfaction with operative equipment (P = 0.002), support staff (P < 0.001), and vascular laboratory availability (P = 0.01) was significantly lower at CHs. Eighty-seven percent of surgeons operated on fewer than 2 children over the preceding 3 months. For the different clinical vignettes, there was a wide variation in practice patterns with a range of 50-89% of the surgeons performing fewer than 5 cases over the preceding 10 years. There was a significant decrease in surgeon's comfort level with elective pediatric vascular operations compared to the operative management of pediatric vascular trauma (P = 0.0025). CONCLUSIONS: Most vascular surgeons do not feel comfortable in the operative management of pediatric vascular disease, and optimal resource availability within pediatric CHs may be lacking. Centralized care of this patient population may be warranted.

Use of Mock Oral Examinations in Vascular Surgery Training Programs: A Nationwide Survey.

BACKGROUND: Mock oral examinations (MOEs) are valuable tools for knowledge assessment and preparation for the surgical certifying examinations. Use of MOE is not standardized. We sought to determine the current use in vascular residencies/fellowships. METHODS: Program directors (PD) of all U.S. vascular training programs were sent anonymous online surveys in July of 2015 evaluating importance of MOEs, current use, barriers to implementation, and preparedness of trainees to sit for the certifying board examination (CE). Comparisons were performed between programs that use MOEs and those that do not. RESULTS: Fifty-four percent (59/108) of program directors completed the survey. The majority believed MOEs are important for vascular residents and fellows (86% versus 81%); however, only 51% (30/59) use them. The most common reason for using MOE was to provide feedback about readiness for the CE (90%). Of programs not giving MOE, 69% expected their trainees to get oral examinations at national conferences. The most common barriers to implementation/continuation of MOEs were availability of faculty (48%) or time (31%). Irrespective of whether they used MOE or not, 29% believed vascular fellows were better prepared for the CE than vascular residents. CONCLUSIONS: MOEs are regarded as a valuable tool to prepare trainees for the CE. However, it is not a commonly adopted practice, due to variables such as institutional/faculty availability. A third of program directors believed that vascular fellows were more prepared to pass the CE than vascular residents which may warrant further investigation into how programs can more rigorously prepare vascular residents for the vascular CEs.

Perioperative Outcomes From the Prospective Multicenter Least Invasive Fast-Track EVAR (LIFE) Registry.

PURPOSE: To determine the feasibility, perioperative resource utilization, and safety of a fast-track endovascular aneurysm repair (EVAR) protocol in well-selected patients. METHODS: Between October 2014 and May 2016, the LIFE (Least Invasive Fast-track EVAR) registry ( ClinicalTrials.gov identifier NCT02224794) enrolled 250 patients (mean age 73±8 years; 208 men) in a fast-track EVAR protocol comprised of bilateral percutaneous access using the 14-F Ovation stent-graft, no general anesthesia, no intensive care unit (ICU) admission, and next-day discharge. The primary endpoint was major adverse events (MAE) through 30 days. The target performance goal for the MAE endpoint was 10.4%. RESULTS: Vascular access, stent-graft delivery, and stent-graft deployment success were 100%. A total of 216 (86%) patients completed all elements of the fast-track EVAR protocol. Completion of individual elements was 98% for general anesthesia avoidance, 97% for bilateral percutaneous access, 96% for ICU avoidance, and 92% for next-day discharge. Perioperative outcomes included mean procedure time of 88 minutes, median blood loss of 50 mL, early oral nutrition (median 6 hours), early mobilization (median 8 hours), and short hospitalization (median 26 hours). Fast-track EVAR completers had shorter procedure time (p<0.001), less blood loss (p=0.04), faster return to oral nutrition (p<0.001) and ambulation (p<0.01), and shorter hospital stay (p<0.001). With 241 (96%) of the 250 patients returning for the 30-day follow-up, the MAE incidence was 0.4% (90% CI 0.1% to 1.8%), significantly less than the 10.4% performance goal (p<0.001). No aneurysm rupture, conversion to surgery, or aneurysm-related secondary procedure was reported. There were no type III endoleaks and 1 (0.4%) type I endoleak. Iliac limb occlusion was identified in 2 (0.8%) patients. The 30-day hospital readmission rate was 1.6% overall. CONCLUSION: A fast-track EVAR protocol was feasible in well-selected patients and resulted in efficient perioperative resource utilization with excellent safety and effectiveness.

Mynx Vascular Closure Device in Arterial Endovascular Procedures.

BACKGROUND: Vascular closure devices have been used to achieve hemostasis of percutaneous access sites following endovascular procedures, with reported decreased time for arterial control as well as decreased time to ambulation. We sought to determine rates and risk factors of postoperative bleeding complications and failures using these devices from a single institution experienced in the use of vascular closure devices. METHODS: All patients undergoing arterial endovascular procedures with percutaneous access between March 2010 and October 2015 at a single institution were identified and analyzed (n = 894). Patients undergoing endovascular aneurysm repair, open access, venous procedures, or upper extremity access were excluded. Comparison groups were formed between those using the Mynxgrip® (Mynx), Angio-Seal™, Perclose® vascular closure devices and manual pressure (MP). Patient demographics, intraoperative data, and postoperative complications were compared. RESULTS: A total of 615 (69%) patients received Mynx, 165 other vascular closure devices (VCD) ([14%] Perclose, 44 [4%] Angio-Seal), and 114 (13%) MP. MP patients were more likely to be diagnostic angiogram with smaller sheaths, while VCD patients were more likely to be interventions with larger sheaths. Univariate analysis identified age, atrial fibrillation, intervention (as opposed to diagnostic), and sheath size >5F associated with postoperative bleeding (P < 0.05), and in backward, logistic regression analysis, sheath size, age, and renal failure were independent predictors of the same. CONCLUSIONS: Use of vascular closure devices has a low rate of bleeding complication, device failure, and need for operative repair. Bleeding is associated with increased age, interventional procedure, and end-stage renal disease. Mynx, Perclose, and Angio-Seal have similar rates of complications. Use of these devices are a safe option for groin vessel closure.

Effects of Mentorship on Graduating Vascular Surgery Trainees.

BACKGROUND: Mentorship within surgery, particularly vascular surgery, has not been extensively evaluated. This study sought to examine mentorship experiences in graduating vascular trainees (VTs). METHODS: An anonymous electronic survey examining current mentor relationships, ideal characteristics, academic productivity, and operative comfort level was emailed to all US graduating 2015 (n = 141) and 2016 (n = 144) VTs during their last year of training. A parallel survey was emailed to program/associate program directors (PDs) of all US vascular training programs (n = 169). RESULTS: Surveys were completed by 65 (38%) PDs and 62 (22%) VTs. Forty-three (69%) VTs identified a mentor with no difference in frequency of having a mentor noted among gender, type of training (fellowship/residency), or geographical region. The majority (41/43, 95%) recognized a vascular surgeon as their mentor; the mentor was assigned to 10 of 43 (23%) trainees and was their PD to 9 of 43 (21%). Ideal mentor characteristics, identified by VTs using 4-point Likert scales, were approachability, supportiveness, and accessibility (3.94, 3.76, and 3.74, respectively), while those of a good mentee were enthusiasm, ethical work, and commitment (3.79, 3.69, and 3.45, respectively). Trainees scored accessibility, approachability, compassion, and same gender significantly higher than PDs as characteristics of ideal mentors (P < 0.05). The majority of PDs thought mentorship increased access to research opportunities, professional networking, and job opportunities, but not operative skill (90%, 95%, 65%, and 18%, respectively). There was no difference between trainees with mentors and those without in terms of reported academic productivity or operative comfort level. Vascular fellows reported higher comfort than residents in open abdominal aortic aneurysm repair (3.32 vs. 2.73, P = 0.006), juxtarenal aneurysm repair (2.8 vs. 2.1, P = 0.02), and aorto-mesenteric bypass (2.57 vs. 1.93, P = 0.03), and neither group was comfortable performing carotid stenting or fenestrated endovascular aneurysm repairs. CONCLUSIONS: There is no difference in academic productivity or case comfort level between surgical trainees with mentors and those without. Possible benefits identified by PDs and trainees include professional networking and increased research and job opportunities. Mentors should be approachable, accessible, supportive, and ethical, while mentees should be enthusiastic, ethical, committed, and approachable. Vascular fellows feel more comfortable with open vascular operations than residents, and nether group feels comfortable with complex endovascular cases. More research is warranted.

Contemporary Characteristics and Outcomes of Young Patients (Under 50 Years) Undergoing Open Carotid Artery Surgery.

BACKGROUND: Stroke is the second leading cause of death worldwide, with 10% of neurologic events occurring in adults aged 18-49 years. The incidence in this age group has risen over the last 2 decades (while falling in the aged), despite improved diagnostic capacity and greater ability to treat it medically and surgically. We are unaware of any modern data regarding the risk factors and outcomes after carotid artery surgery in this demographic. We sought to evaluate the contemporary characteristics and outcomes of young adults undergoing carotid surgery. METHODS: Retrospective analysis of patients aged 18-49 years who underwent carotid surgery from 2005 to 2015. We collected demographics, indications, and outcomes, comparing them to previously published series. RESULTS: Sixteen patients were with the mean age of 46 (41-49) years, and 44% were male. Most were Caucasian (88%) and smokers (94%), consuming 1.3 packs/day with a mean pack-year history of 32 years (10-100). Average body mass index was 29. The majority (81%) were symptomatic prior to surgery (69% of these were strokes). Complications after surgery were hyperperfusion (1) and one deep vein thrombosis. Compared to young patients treated from 1973 to 1990s, we found significantly more female patients (P < 0.001) and more strokes (P < 0.04) leading to the procedure, while smoking remained the most prevalent risk factor. CONCLUSIONS: Carotid artery surgery in young patients continues to be associated with symptomatic stenosis and smoking; however, compared to 2-4 decades ago it may be more common in young females, and following a stroke. This may be from an increased prevalence of female smoking and improved neuroimaging.

Nicotine Dependence and Willingness to Quit Smoking in Vascular Surgery Patients.

BACKGROUND: Smoking rates have declined; however, it remains the primary modifiable risk factor for vascular disease. While vascular surgeons often advise patients to quit, few provide assistance. We sought to understand patients' interest in quitting and determine factors that influence this willingness to quit. METHODS: Anonymous surveys were given to vascular surgery clinic patients in a single institution over a 5-month period. Demographic information, smoking status, cessation attempts, and barriers to quitting were obtained. Nicotine dependence was determined using the Fagerstrom Test, and willingness to quit was assessed using a contemplation ladder. Patient's willingness to quit was evaluated in relation to symptomatic status, previous/planned operation, and nicotine dependence levels. RESULTS: A total of 490 patients (92%) completed the survey with 109 (22%) current smokers, 195 (40%) former smokers, and 186 (38%) never smokers. Never smokers were more likely to be female and employed while smokers were more likely to be disabled. Although 51% of smokers displayed moderate/high nicotine dependence, 54% demonstrated willingness to consider quitting within 6 months. The primary barrier to cessation identified was previous failed attempt(s) to quit in 44%. Most (90%) had previously attempted quitting, 63% attempted 3 or more times, and the most common technique used was "quitting cold turkey". Fifty-nine percent of patients reported physicians' had offered assistance in cessation, but only 2% had been in a cessation program. There was no correlation between willingness to consider quitting and symptomatic status, previous/planned operation, or nicotine dependence. Smokers of less than 10 cigarettes/day had a lower nicotine dependence level (P = 0.0001) and higher willingness to consider quitting (P = 0.0015), as did those who had fewer failed prior attempts to quit and who did not believe it was too late to quit. CONCLUSIONS: Most of our vascular patients self-report as nonsmokers. Over half of those who smoke demonstrate willingness to consider quitting within 6 months, which is not dependent on nicotine dependence, previous/planned operation, or symptomatic status. Those who smoke less than 10 cigarettes per day, have fewer past failed attempts to quit, and believe that it is not too late to quit are more likely to consider quitting. Vascular surgeons should be more aware of previous quit attempts and patterns of smoking and be proactive in assisting patients in cessation attempts.

Risk of Acute Kidney Injury after Percutaneous Pharmacomechanical Thrombectomy Using AngioJet in Venous and Arterial Thrombosis.

BACKGROUND: Percutaneous mechanical thrombectomy is commonly used to treat acute thrombotic syndromes. AngioJet (AJ) forcibly sprays fibrinolytics to fragment and aspirate thrombus. It is known to cause hemolysis and gross hematuria, yet potential consequences to renal function after AJ remain unstudied. We sought to determine the risk of acute kidney injury (AKI) after AJ when compared with other lysis techniques. METHODS AND RESULTS: We retrospectively reviewed patients treated with thrombolysis over 5 years. We identified those treated with AJ or catheter-directed thrombolysis (CDT). Demographics, indications, procedures, and laboratory values within 3 days were recorded. AKI was defined as an increase >25% above the baseline creatinine within 72 hr of the procedure. IN total, 102 patients (52 AJ, 50 CDT) had no statistical difference in mean age (50 and 51), indication (arterial thrombosis 65% and 88%), or baseline creatinine (0.9 and 1.0 mg/dL), respectively. AKI occurred in 15 (29%) patients treated with AJ versus 4 (8%) of CDT (P = 0.007). Similar numbers of AJ and CDT patients underwent additional open surgical procedures (21% and 30%, respectively, P = not significant). Multivariable analysis demonstrated that the odds of AKI were only increased by AJ (odds ratio [OR] 8.2, 95% confidence interval [CI] 1.98-34.17, P = 0.004), open surgery (OR 5.4, 95% CI 1.43-20.17, P = 0.013), or a >10% drop in hematocrit (OR 4.0, 95% CI 1.15-14.25, P = 0.03). CONCLUSIONS: In our observational study, AJ is an independent risk factor for AKI. Concomitant open surgery and drop in hematocrit also raise the odds of AKI. Renal injury after AJ is under-reported in the literature, and may be related to hemolysis from the device.

Management of noninfected prosthetic aortic bypass failures using femoral vein.

OBJECTIVE: The use of femoral-popliteal vein as a conduit to treat infected aortoiliac pathologies has been described extensively and is referred to as the neoaortoiliac system procedure. We examined our center's outcomes after using deep vein as a conduit for the salvage of failed aortofemoral prosthetic bypasses in patients without infection. METHODS: Procedures using femoral vein as conduit at the University of Arkansas for Medical Sciences between January 2005 and July 2013 were retrospectively reviewed (n = 110). Patients were excluded if the reconstruction was for infectious etiologies (n = 71) or for nonaortofemoral reconstructions (n = 31). Operative variables, complications, and patency rates were collected. RESULTS: Femoral vein was used to revascularize failed aortobifemoral bypasses in eight patients. Indications included rest pain (n = 7) and short-distance claudication (n = 1). Reconstructions identified two patients each with aortobifemoral bypass or aortofemoral bypass, and one patient each with aortofemoral bypass with femorofemoral bypass, aorotoiliac bypass, iliofemoral bypass with femorofemoral bypass, or ilioprofunda bypass. Mean follow up was 27.5 months. There were no major postoperative complications. Symptoms secondary to deep vein harvest (swelling/dermatitis) developed in three of eight patients. The average ankle-brachial index improved from 0.33 to 0.73 (P = .003), with a limb salvage rate of 100%. Kaplan-Meier analysis found primary patency was 70% at 1 year and 53% at 5 years, which improved to 100% and 75%, respectively, with secondary measures. CONCLUSIONS: Despite a need for secondary interventions and venous hypertension syndromes, deep vein offers good patency and excellent limb salvage after failed prosthetic aortoiliac bypasses.

Outcomes after retroflexed gracilis muscle flap for vascular infections in the groin.

OBJECTIVE: Multiple catheterizations and procedures on the femoral arteries can increase the risk of infection and eventual destruction of the overlying skin and subcutaneous tissue. Without adequate tissue coverage, vascular structures are exposed and, thus, vulnerable to disruption. This can lead to loss of limb and/or life and carries a significant mortality. We hypothesized that gracilis muscle flap (GMF) was a reliable adjunct in providing healthy tissue coverage for a complex surgical problem. METHODS: Retrospective review of charts was performed on all patients who had undergone GMF for groin infections at a tertiary care medical center. RESULTS: From 1997 to 2012, GMF was performed in 68 limbs (64 patients) by vascular surgeons for infectious etiology to cover the common femoral artery. At the time the GMF was placed, the femoral artery had synthetic graft/patch in 14 limbs, whereas 54 limbs had procedures with autologous conduit. Complete healing was achieved in 58 (85%) limbs. Treatment was deemed not successful in 10 limbs where patients continued to have persistent infection. Six out of 10 limbs had anastomosis disruption requiring emergent ligation of the common femoral artery. Nine patients died during the perioperative period (30-day). There were a total of 13 amputations in 12 patients. Limb salvage was achieved in 55 limbs (81%). Univariate analysis suggested that patients that had revascularization procedures with synthetic graft had a higher complication rate compared with autologous/vein reconstruction (24% vs 5%; P = .021). This group also has a higher rate of persistent infection compared with the autologous group (24% vs 2%; P = .006). Patients older than 75 years at the time of GMF had a higher incidence of GMF-related complications (57% vs 5%; P = .04). Multivariate analysis confirmed that presence of prosthesis led to higher incidence treatment failures and muscle flap complications at the surgical site (odds ratio, 6.6; P = .04; and odds ratio, 13.3; P = .03, respectively). CONCLUSIONS: GMF is technically simple to perform and provides durable soft tissue coverage with a high rate of healing for complex groin wounds even in the presence of synthetic conduit.

Outcomes after arterial endovascular procedures performed in patients with an elevated international normalized ratio.

BACKGROUND: Patients treated with anticoagulants frequently require urgent vascular procedures and elevated prothrombin time/international normalized ratio (INR) is traditionally thought to increase access site bleeding complications after sheath removal. We aimed to determine the safety of percutaneous arterial procedures on patients with a high INR in the era of modern ultrasound-guided access and closure device use. METHODS: Patients undergoing arterial endovascular procedures at a single institution between October 2010 and November 2012 were reviewed (n = 1,333). We retrospectively analyzed all patients with an INR > 1.5. Venous procedures, lysis checks, and cases with no documented INR within 24 hr were excluded. Sixty-five patients with 91 punctures were identified. A comparison group was then generated from the last 91 patients intervened on with INR < 1.6. Demographics, intraoperative data, and postoperative complications were compared. RESULTS: The demographics were similar. More Coumadin use and higher INR were found in the study group (71/91 and 0/91, P = 0.001; 2.3 and 1.1 sec, P = 0.001, respectively), but there was more antiplatelet use in the control group (68/91 and 51/91, P = 0.01). Intraoperatively, the sheath sizes, protamine use, closure device use, ultrasound guidance, brachial access, and procedure types were not statistically different. Sheath sizes ranged from 4 to 22F in the study group and 4 to 20F in the control group. Paradoxically, heparin was administered more frequently in the study group (64/91 and 50/91, P = 0.046). Bleeding complications occurred more commonly in the study group (3/91 and 1/91, P = 0.62), but this failed to reach significance and the overall complication rate in both groups was low. CONCLUSIONS: Endovascular procedures may be performed safely with a low risk of bleeding complications in patients with an elevated INR. Ultrasound guidance and closure device use may allow these cases to be performed safely, but a larger series may be needed to confirm this.

Preservation of pelvic perfusion in endovascular aneurysm repair.

Endovascular aneurysm repair requires a suitable anatomy for placement of covered stent grafts, which includes a non-aneurysmal distal landing zone within the common iliac arteries. Patients with iliac artery aneurysms, thus, are often not candidates for this minimally invasive repair, as extension of the graft to an appropriate site would cover the internal iliac artery and result in significant symptoms related to poor pelvic perfusion. We present two cases of common iliac artery aneurysms treated by modified endovascular techniques with good results. Select patients with iliac artery aneurysms may be candidates for endovascular repair. These patients should be referred to centers familiar with these techniques.

Definitive test to diagnose median arcuate ligament syndrome: injection of vasodilator during angiography.

The diagnosis of median arcuate ligament (MAL) syndrome and its correlation with symptoms has been controversial since the disease entity was described. The authors describe a technique that will identify patients who will benefit from intervention. Eight patients with isolated celiac artery compression from MAL were identified by the authors. Their technique involved selective cannulation of the superior mesenteric artery (SMA) and injection of a vasodilator during angiography. Symptom reproduction and loss of collateral filling of the celiac territory represented a positive test: 4 of the 8 patients had a positive test and underwent successful surgical treatment of the condition; 3 of them remained asymptomatic at follow-up; 1 patient continues to have mild abdominal discomfort. Of the 4 patients with a negative test, 2 were found to have other conditions causing their symptoms. Vasodilator injection into the SMA is a useful diagnostic test to identify patients with symptomatic MAL syndrome.

Comparison of perioperative costs with fast-track vs standard endovascular aneurysm repair.

BACKGROUND: Perioperative health care utilization and costs in patients undergoing elective fast-track vs standard endovascular aneurysm repair (EVAR) remain unclear. METHODS: The fast-track EVAR group included patients treated with a 14 Fr stent graft, bilateral percutaneous access, no general anesthesia or intensive care monitoring, and next-day hospital discharge. The standard EVAR group was identified from Medicare administrative claims using a matching algorithm to adjust for imbalances in patient characteristics. Hospital outcomes included operating room time, intensive care monitoring, hospital stay, secondary interventions, and major adverse events (MAEs). Perioperative outcomes occurring from hospital discharge to 30 days postdischarge included MAE, secondary interventions, and unrelated readmissions. RESULTS: Among 1000 matched patients (250 fast-track; 750 standard), hospital outcomes favored the fast-track EVAR group, including shorter operating room time (2.30 vs 2.83 hrs, P<0.001), shorter hospital stay (1.16 vs 1.69 d, P<0.001), less need for intensive care monitoring (4.4% vs 48.0%, P<0.001), and lower secondary intervention rate (0% vs 2.4%, P=0.01). Postdischarge outcomes also favored fast-track EVAR with a lower rate of MAE (0% vs 7.2%, P<0.001) and all-cause readmission (1.6% vs 6.8%, P=0.001). The total cost to the health care system during the perioperative period was $26,730 with fast-track EVAR vs $30,730 with standard EVAR. Total perioperative health care costs were $4000 (95% CI: $3130-$4830) lower with fast-track EVAR vs standard EVAR, with $2980 in savings to hospitals and $1030 savings to health care payers. CONCLUSION: A fast-track EVAR protocol using a 14 Fr stent graft resulted in shorter procedure time, lower intensive care utilization, faster discharge, lower incidence of MAE, lower readmission rates, and lower perioperative costs compared to standard EVAR.

The effects of Toradol on postoperative intimal hyperplasia in a rat carotid endarterectomy model: laboratory research.

Carotid endarterectomy (CEA) and more recently carotid artery stenting are the treatments of choice for atherosclerotic disease of the extracranial carotid arteries; however, early restenosis caused by neointimal hyperplasia confounds surgical therapy. Oxidative stress has been implicated in the progression of intimal hyperplasia. The authors hypothesized that ketorolac tromethamine (Toradol), a nonsteroidal antiinflammatory drug that is a potent cyclooxygenase inhibitor, would decrease oxidative stress and thereby reduce intimal hyperplasia in a rat CEA model. Twenty-nine male Sprague-Dawley rats underwent CEA and were divided into 3 treatment groups as follows: (1) control (placebo), (2) 7.5 mg/kg Toradol, and (3) 10 mg/kg Toradol. Toradol treatment began 2 days before CEA and continued for 2 weeks. Two weeks after endarterectomy, carotid arteries were fixed, harvested, and examined for platelet activity (platelet reactive units), oxidative stress (malondialdehyde and glutathione), and intimal hyperplasia (measured as percentage of luminal stenosis). Platelet activity, malondialdehyde and glutathione, and intimal hyperplasia were all significantly lowered in both 7.5- and 10-mg/kg doses of Toradol versus control. Toradol given daily beginning 2 days before CEA and ending 2 weeks after the procedure was effective at significantly reducing platelet activity, oxidative stress, and intimal hyperplasia development in the rat without any increase in bleeding. Although the mechanism of action of this reduction is not completely understood, one possible explanation may be through the inhibition of reactive oxygen species production.

Techniques for managing complications of arterial closure devices.

According to data reported by the American Heart Association, more than 5 million diagnostic and therapeutic catheterizations are performed each year in the United States. The number of catheterizations has tripled since 1979. It has been estimated that complications related to the access site result in more than 75,000 surgical procedures annually. Thus, improved management of the access site itself is essential to achieve the greater goals of improved care and reduced cost. Manual compression directly over the site of arterial puncture usually results in adequate hemostasis but has several significant drawbacks. Manual compression is uncomfortable for the patient, is fatiguing and time-consuming for staff, and necessitates several hours of costly in-hospital observation. In addition, it may be ineffective in achieving hemostasis, especially in the setting of systemic anticoagulation or following the use of large-bore devices. Based on the perceived need for an improved method of managing the arterial access site following catheterization, various vascular sealing devices have been developed. There are at least 8 (and the number is increasing) hemostatic vascular closure devices that are currently approved by the FDA for access site closure after femoral arterial catheterization. The chief advantage attributed to vascular sealing devices is accelerated access site hemostasis, even in the setting of anticoagulation, leading to earlier ambulation and hospital discharge following arterial catheterization. The most important drawbacks related to vascular sealing devices include the cost of the devices and the possibility of increased access site complications. Despite the paucity of properly designed studies supporting their use, it is estimated that over one million vascular sealing devices are used annually in the United States, a number that has increased dramatically in the past 5 years.In this review, we present a brief description of the design and function of the most widely used devices, describe the most common mechanisms of failure, and recommend strategies for management of access site complications including hemorrhage, arterial obstruction, and infection.

Pravastatin and clopidogrel combined inhibit intimal hyperplasia in a rat carotid endarterectomy model.

Intimal hyperplasia, resulting from a complex cascade of events involving platelets, leukocytes, and smooth muscle cells, may be inhibited by the HMG-CoA reductase inhibitor pravastatin, which demonstrates inhibition of platelet activity and leukocyte adhesion and may be associated with inhibition of vascular smooth muscle cell proliferation and migration. Clopidogrel, an adenosine diphosphate (ADP) receptor inhibitor, was shown to decrease platelet activity and aggregation but not intimal hyperplasia (IH). We postulated that the combination of both pravastatin and clopidogrel would significantly decrease IH in a rat carotid endarterectomy model. Male Sprague-Dawley rats (n = 18) divided by treatment regimen underwent treatment for 2 weeks both before and after an open carotid endarterectomy. Serum collected at the time of harvest was measured for C-reactive protein (CRP), platelet activity, and total serum cholesterol; carotid arteries were removed and processed for IH determination. Control rats (n = 7) received oral vehicle daily before and following endarterectomy. Pravastatin-alone rats (n = 6) received oral pravastatin (10 mg/kg/day) before and after endarterectomy. Pravastatin plus clopidogrel rats (n = 5) received oral pravastatin (10 mg/kg/day) plus a preendarterectomy bolus of oral clopidogrel (4.3 mg/kg) before endarterectomy and resumed pravastatin (10 mg/kg/day) plus oral clopidogrel (1 mg/kg/day) postendarterectomy. Pravastatin alone and pravastatin plus clopidogrel significantly decreased CRP compared to controls (120.2 +/-11.2 and 134.1 +/- 9.9 vs 191.1 +/- 9.2 microg/mL, respectively p = 0.003 and p =0.0024). CRP levels were not different between pravastatin alone and pravastatin plus clopidogrel (p = 0.35). Platelet activity was significantly decreased by pravastatin alone and pravastatin plus clopidogrel in comparison to controls (7.3 +/- 2.2 and 6.6 +/- 2.8 vs 19.2 +/- 6.1 platelet reactive units (PRU), respectively p = 0.048 and p = 0.045). No significant difference was noted in platelet activity between pravastatin alone and pravastatin plus clopidogrel (p = 0.89). Pravastatin plus clopidogrel significantly reduced serum cholesterol compared to control and pravastatin alone (84.0 +/- 6.6 vs 110.4 +/- 7.4 and 117.0 +/- 8.8 mg/dL, respectively p = 0.03 and p = 0.01). Pravastatin alone did not decrease serum cholesterol compared to controls (p = 0.54). IH was not reduced by pravastatin alone compared to controls (p = 0.61) but was significantly decreased by pravastatin plus clopidogrel in comparison to control and pravastatin alone (3.0 +/- 1.1 vs 46.3 +/- 13.7 and 37.4 +/- 14.6% luminal stenosis, respectively p = 0.01 and p = 0.05). Pravastatin plus clopidogrel significantly decreased CRP, platelet activity, total serum cholesterol, and IH while pravastatin alone decreased only CRP and platelet activity. Intimal hyperplasia reduction may therefore be dependent on other contributors, possibly growth factors, cytokines, and oxidative stress. The combination of pravastatin plus clopidogrel may have synergistic or even additional inhibitory effects on IH. Pravastatin plus clopidogrel was effective in decreasing IH in a rat carotid endarterectomy model and may prove a useful therapy for IH reduction in the clinical setting.

Delayed management of Grade III blunt aortic injury: Series from a Level I trauma center.

BACKGROUND: Blunt aortic injuries (BAIs) are traditionally treated as surgical emergencies, with the majority of repairs performed in an urgent fashion within 24 hours, irrespective of the grade of aortic injury. These patients are often underresuscitated and often have multiple other trauma issues that need to be addressed. This study reviews a single center's experience comparing urgent (<24 hours) thoracic endovascular aneurysm repair (TEVAR) versus delayed (>24 hours) TEVAR for Grade III BAI. METHODS: All patients undergoing TEVAR for BAI at a single institution between March 2004 and March 2014 were reviewed (n = 43). Patients with Grade I, II, or IV aortic injuries as well as those who were repaired with an open procedure or who lacked preoperative imaging were excluded from the analysis. Demographics, intraoperative data, postoperative survival, and complications were compared. RESULTS: During this period, there were 43 patients with blunt thoracic aortic injury. There were 29 patients with Grade III or higher aortic injuries. Of these 29 patients, 1 declined surgery, 2 were repaired with an open procedure, 10 underwent urgent TEVAR, and 16 had initial observation. Of these 16, 13 underwent TEVAR in a delayed fashion (median, 9 days; range, 2-91 days), and 3 died of non-aortic-related pathology. Comparing the immediate repair group versus the delayed repair group, there were no significant demographic differences. Trauma classification scores were similar, although patients in the delayed group had a higher number of nonaortic injuries. The 30-day survival was similar between the two groups (9 of 10 vs. 12 of 16), with no mortalities caused by aortic pathology in either group. CONCLUSION: Watchful waiting may be permissible in patients with Grade III BAI with other associated multisystem trauma. This allows for a repair in a more controlled environment. LEVEL OF EVIDENCE: Therapeutic study, level V.

Percutaneous isolated limb perfusion with thrombolytics for severe limb ischemia.

Patients with severe tibioperoneal disease are poor candidates for a distal bypass. Absence of a distal target, lack of conduit, or multiple medical problems can make these patients a prohibitive risk for revascularization. Acute on chronic ischemia in this group poses a greater challenge. Thrombolytic therapy for acute ischemia can be prolonged and carries a significant risk of bleeding if continued beyond 24 hours. However, if the ischemic limbs can be isolated from the systemic circulation, a higher dose of the lytic agent can be given with lower risk. These are the initial results of a series of 10 patients who underwent percutaneous isolated limb perfusion with a high dose of thrombolytics for severe ischemia. Ten patients (lower extremity 8 and upper extremity 2) presented with severe limb-threatening ischemia. Mean ankle/brachial index (ABI) was 0.15 for the lower extremity, and there were no recordable digital pressures in patients with upper extremity ischemia. No distal target was visible on the initial arteriogram. These patients were then taken to the operating room, and under anesthesia, catheters were placed in an antegrade fashion via femoral approach in the popliteal artery and vein percutaneously. For upper extremity, the catheters were placed in the brachial artery and vein. A proximal tourniquet was then applied. This isolated the limb from the systemic circulation. Heparinized saline was infused through the arterial catheter while the venous catheter was left open. A closed loop or an isolated limb perfusion was confirmed when effluent became clear coming out of the venous port. A high dose of thrombolytic agent (urokinase 500,000 to 1,000,000 U) was infused into the isolated limb via the arterial catheter and drained out of the venous catheter. After 45 minutes, arterial flow was reestablished. In 4 patients, Reopro((R)) was used in addition to thrombolytics. Postprocedure angiograms showed minimal changes, but patients exhibited marked clinical improvement. The ABI changed from 0.15 to 0.5 in the lower extremity and near-normal digital pressures in upper extremity ischemia. Limb salvage and symptomatic relief at 6 months was 90%. All patients except one were kept on anticoagulation postoperatively. No bleeding complications were observed from the procedure. Percutaneous isolated limb perfusion brought symptomatic relief to patients presenting with acute on chronic limb ischemia. This can be an alternate option for patients facing amputation with no revascularization options.