Definition and Perception of Autonomy in Vascular Surgery Training.

BACKGROUND: There is a lack of data evaluating operative autonomy within vascular surgery. This study aims to determine where discrepancies exist in the definition of autonomy between trainees and attending faculty. METHODS: An Institutional Review Board-approved, anonymous survey was e-mailed to vascular trainees and attending faculty at all Accreditation Council for Graduate Medical Education-approved vascular surgery training programs in the United States. Data were compared using chi-square statistical analysis. RESULTS: One-hundred forty-nine responses from vascular surgery trainees (n = 89) and faculty (n = 60) were obtained. The most highly ranked preoperative skill by trainees was Case Planning, at all post-graduate year-levels. Although a majority of trainees believe this skill is expected of them, only 36.1% of attendings responded that they expect all trainee levels to perform this task. Draping/positioning was ranked as the second most important intraoperative task for all post-graduate year-levels by attendings; however, only 32.8% of attendings expect trainees to perform this. Exposure of Critical Structures was ranked as the most important intraoperative task by both trainees and attendings at the Chief and Fellow level. However, responses by both trainees and attendings showed that this is expected <70% of the time. When asked about double-scrubbing independently of other tasks, most trainees assessed double-scrubbing as inherently important to autonomy at all levels of training and within all regions. Only 44.3% of attendings responded that they expect all trainees to double-scrub. Additionally, most trainees in all regions responded that they spend <25% of cases double-scrubbed. CONCLUSIONS: These responses show a discrepancy between the skills that both trainees and attendings deem important to autonomy versus what is being expected of trainees in reality.

Percutaneous, Antegrade Access of the Superficial Femoral Artery can be Safely Used in Procedures for the Treatment of Lower Extremity Limb Ischemia.

BACKGROUND: Recent studies have shown that antegrade access for treatment of infrainguinal peripheral vascular disease is associated with decreased radiation exposure and contrast use without a significant increase in access complication, although data are limited on antegrade superficial femoral artery (SFA) access for larger sheath sizes. We aim to describe a single institution's contemporary experience with percutaneous antegrade SFA access. METHODS: A retrospective review of percutaneous, infrainguinal endovascular interventions for arterial occlusive disease at a major academic institution was conducted between 2018 and 2020. Antegrade, percutaneous, SFA access cases were included. Information on demographics, indication, sheath size, arteries treated, type of intervention, concurrent pedal access, closure devices, and complications was collected and analyzed. RESULTS: A total of 45 patients with an average body mass index of 25.25 were identified. Indications for intervention included tissue loss (64.4%), rest pain (6.7%), claudication (13.3%), and acute limb ischemia (11.1%). Of which, 80.0% of patients had multilevel interventions. Angioplasty was performed in 68.8% of patients, stenting in 8.3%, atherectomy in 15.6%, and thrombectomy in 7.3%. Nearly a quarter of cases involved concurrent pedal access. Maximum sheath size was 4F for 4.4% of patients, 5F for 28.9%, 6F for 46.7%, 7F for 11.1%, and 8F for 8.9%. The closure device was utilized in 75.6% of cases, with no closure device failures. In the entire cohort, there were no demonstrated access site complications. CONCLUSIONS: This study demonstrates percutaneous, antegrade SFA access for complex endovascular interventions for infrainguinal occlusive disease can be effectively utilized, even with larger sheath size. Moreover, routine use of closure devices is safe, improving patient comfort and expediting time to ambulation.

Thoracic Endovascular Aortic Repair for Iatrogenic Injury of the Thoracic Aorta.

PURPOSE: Address iatrogenic injury to the descending thoracic aorta by breached spinal screws through a novel approach of concomitant spinal screw removal and thoracic endovascular repair (TEVAR) placement. CASE REPORT: A 36-year-old female with idiopathic scoliosis underwent T4 to L3 bilateral pedicle instrumentation with spinal fusion and correction of scoliosis deformity. Ten months post-operative, she continued to complain of mid-thoracic pain; computed tomography (CT) angiography revealed protrusion of the left T5 and T6 transpedicular screws into her descending thoracic aorta by 3 and 5 mm, respectively. She was taken to the odds ratio (OR) in a combination case with vascular and neurosurgery. Positioned in the right lateral decubitus position, TEVAR was successfully deployed while neurosurgery concurrently removed the invading spinal screws via posterior spinal exposure. Neurosurgery then completely revised the spinal hardware during the same operation. The patient progressed well throughout the remainder of her hospital stay and was discharged on postoperative day 4. Two-year angiography demonstrated a well-placed TEVAR with no extravasation or aortic abnormality. CONCLUSIONS: In the setting of iatrogenic aortic injury due to pedicle screws, concomitant TEVAR and spinal screw removal is a safe and feasible treatment option that allows for spinal reconstruction to occur without multiple trips to the operating room.

Staging Endovascular Thoracic and Thoracoabdominal Aortic Aneurysm Repairs and the Risk of Post-operative Spinal Cord Ischemia.

OBJECTIVE: Staged aortic aneurysm repair is one method used to decrease the risk of spinal cord ischemia (SCI) following endovascular aortic intervention. Sequential sacrifice of arteries perfusing the spine may allow for improved spinal perfusion through the development of collateral networks over time. To evaluate the impact of staging endovascular aortic aneurysm repairs on SCI, we conducted a conservative analysis of Vascular Quality Initiative (VQI) data. METHODS: De-identified VQI data were queried for cases of endovascular thoracic and thoracoabdominal aneurysm repairs from year 2014 to 2019. Cases were selected based on inclusion criteria: aneurysmal disease, no ruptures, no prior aortic surgeries, no retreatments, and only cases with complete data on aortic zones and SCI. Chi-square, Student's t-tests, and Mann-Whitney U tests were used for univariable analyses, as appropriate. Logistic regression analyses were used to identify independent predictors of outcome. RESULTS: There were 116 staged aortic repairs (SARs) (8.2%) performed out of a total of 1421 endovascular aortic repairs that fit study criteria. The overall rate of SCI within the study cohort was 3.4% (n = 48). The distribution of SARs and SCI events according to aortic zone coverage are displayed in Table 1. Patients who underwent staged endovascular aortic repairs had higher rates of SCI, pre-op spinal drain placement, non-African-American race, COPD, smoking history, positive stress tests, aspirin and statin use, increased estimated blood loss, physician-modified endografts, number of aortic zones covered, lower pre-op hemoglobin levels, larger aneurysm sac size, fusiform aneurysms, and longer total procedure times, Table 2. After adjusting for factors associated with SCI, a priori, and factors with a P < 0.1 univariable analysis, SAR was not associated with SCI (odds ratio [OR] = 1.86, 95% confidence interval [CI] = 0.77-4.50, P = 0.17). Of the six factors associated with SCI on univariable analysis, only procedure time ≥6 hours (OR = 2.49, 95% CI = 1.09-5.70, P = 0.031) and the number of aortic zones covered (OR = 1.15, 95% CI = 1.00-1.32, P = 0.047) were predictive of SCI. Staged repairs had a lower proportion of permanent SCI (38%, 3 of 8 cases) compared with repairs that were not staged (68%, 27 of 40 cases), with a relative risk reduction of 44% for those who developed SCI, P = 0.21. CONCLUSIONS: In a large national data set, SARs were performed for patients with more extensive aortic disease. SARs were only performed in about 8% of cases and the rate of SCI remained low. After adjusting for baseline comorbidities, extent of aortic disease, and other factors that may potentiate SCI, staged aortic aneurysm repair had a similar risk of SCI compared with non-staged repairs. However, there was a trend toward decreased permanent SCI risk in the SAR group.

Superior sagittal sinus-to-internal jugular vein bypass shunt with covered stent construct for intractable intracranial hypertension resulting from iatrogenic supratorcular sinus occlusion: technical note.

BACKGROUND: Acute occlusion of the posterior sagittal sinus may lead to dramatic increase in intracranial pressure (ICP), refractory to standard treatment. Hybrid vascular bypass of cranial venous outflow into the internal jugular vein (IJV) has seldom been described for this in recent neurosurgical literature. OBJECTIVE: To describe creation of a novel vascular bypass shunt from the superior sagittal sinus (SSS) to internal jugular vein (IJV) utilizing a covered stent-Dacron graft construct for control of refractory ICP. METHODS: We illustrate a patient with refractory ICP increases after acute sinus ligation that was performed to halt torrential bleeding from intraoperative injury. A temporary shunt was created that successfully controlled ICP. From the promising results of the temporary shunt, we utilized a prosthetic hybrid bypass graft to function as a shunt from the sagittal sinus to IJV. Yet the associated anticoagulation led to complications and a poor outcome. RESULTS: Rapid and sustained ICP reduction can be expected after sagittal sinus-to-jugular bypass shunt placement in acute sinus occlusion. Details of the surgical technique are described. Heparin anticoagulation, while imperative, is also associated with worrisome complications. CONCLUSION: Acute occlusion of posterior third of sagittal sinus carries a very malignant clinical course. Intractable intracranial hypertension from acute sinus occlusion may be effectively treated with a SSS-IJV bypass shunt. A covered stent construct provides an effective vascular bypass conduit. However, the anticoagulation risk can lead to fatal outcomes. The neurosurgeon must always strive for primary repair of an injured sinus.

Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair.

BACKGROUND: As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI. RESULTS: A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level. CONCLUSIONS: TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.

Occlusion of the Celiac Artery during Endovascular Thoracoabdominal Aortic Aneurysm Repair Is associated with Increased Perioperative Morbidity and Mortality.

BACKGROUND: Some studies suggest that celiac artery coverage during elective endovascular thoracoabdominal aortic aneurysm (TAAA) repair is safe given sufficient collateralization of visceral organ perfusion from the superior mesenteric artery. However, there is concern that celiac artery coverage may lead to increased risk of foregut or spinal cord ischemia with an attendant increased risk of mortality. We sought to investigate rates of bowel ischemia, spinal cord ischemia, and 30-day mortality associated with celiac artery coverage during TEVAR and complex EVAR. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was queried for TEVAR and complex EVAR cases from 2012 to 2018. Inclusion criteria included TAAA pathology and endograft extension to aortic zone 6. Patients with aortic rupture, trauma, prior thoracic aortic surgery, known preoperative occlusion of the left subclavian superior mesenteric, or celiac arteries were excluded. Cases with intraoperative celiac artery occlusion (CAO) were compared retrospectively to cases with celiac artery preservation (CAP). Primary outcomes included 30-day mortality and a composite end point of 30-day mortality, spinal cord ischemia (transient or permanent lower extremity neurologic deficit), and bowel ischemia (colonoscopic evidence of ischemia, bloody stools in a patient who dies prior to colonoscopy or laparotomy, or other documented clinical diagnosis). Univariable comparisons were performed using chi-squared tests and Student's t-tests, as appropriate. Multivariable logistic regression analyses were employed to identify independent predictors of outcome. RESULTS: There were 628 cases identified for inclusion in the study. Patients undergoing CAO (n = 44) were more likely to be female or to have higher rates of preoperative spinal drain use, American Society of Anesthesiologists score ≥3, low preop hemoglobin, and/or symptomatic presentation, but fewer mean number of aortic zones covered. CAO was associated with higher 30-day mortality (5 of 44, 11%) compared to CAP (23 of 584, 4%), P = 0.039. The composite end point occurred at a significantly greater proportion for those who had CAO (10 of 44, 23%) compared to CAP (53 of 584, 9%, P = 0.008), driven by higher rates of 30-day mortality and bowel ischemia (9% vs. 2%, P = 0.026). By multivariate analysis, CAO was predictive of 30-day mortality (odds ratio [OR] = 3.9, 95% confidence interval [CI] = 1.1-13.8, P = 0.04) and the composite endpoint (OR = 3.0, 95% CI = 1.1-8.5, P = 0.03). Increasing procedure time was also associated with 30-day mortality (OR = 1.4, 95% CI = 1.1-1.7, P < 0.001) and the composite end point (OR = 1.4, 95% CI = 1.1-1.6, P < 0.001). CONCLUSIONS: For those treated for TAAAs, CAO was independently predictive of increased 30-day mortality and a composite end point of perioperative mortality, spinal cord ischemia, and bowel ischemia. When treating patients with extensive aortic aneurysmal disease, physicians should attempt to preserve the celiac artery, by revascularization or avoiding ostium coverage, whenever feasible.

Management of Aortoiliac Aneurysms with Atypical Renal Artery Anatomy.

BACKGROUND: Renal artery anomalies occur at a rate of 1-2% and present a challenge to vascular surgeons performing aortic surgery. We describe adjuncts used to manage such anatomic variants. METHODS: A single surgeon registry of all abdominal aortic aneurysms repaired in an academic center was retrospectively reviewed. Patients with prior renal transplants, congenital pelvic kidneys, or horseshoe kidneys were included. Open repair was reserved for patients with no endovascular or hybrid repair options. RESULTS: Over an 8-year period, 18 patients were identified (renal transplant n = 9, horseshoe kidney n = 3, congenital pelvic kidney n = 6). All transplant patients were treated with endovascular repair. Four required cross-femoral bypasses, 1 for retrograde allograft perfusion after aorto-uni-iliac (AUI) procedure to the contralateral external iliac artery and 3 for contralateral limb perfusion after endograft extension into iliac artery ipsilateral to allograft. Three transplant patients required carotid access due to severe iliofemoral occlusive disease or allograft origin off the internal iliac artery. Two horseshoe kidney patients underwent open repair with direct reimplantation of accessory renal arteries, whereas 1 underwent endovascular repair with exclusion of an isthmus branch. Of the congenital single/pelvic kidney cohort, 2 underwent open repair with renal reimplantation, 2 underwent endovascular aneurysm repair, 1 was treated with AUI and cross-femoral bypass, and one was treated with a staged iliorenal bypass and subsequent fenestrated endovascular repair. Intravascular ultrasound was used to minimize contrast use in patients with chronic renal insufficiency (Cr > 1.5 mg/dL, n = 6). Over a mean follow-up of 31 months (range, 1-110), there were no aortic deaths or reintervention, no decline in renal function (measured by serum creatinine and glomerular filtration rate), and 100% patency of the preserved renal arteries. CONCLUSIONS: Atypical renal anatomy should not preclude repair of aortic aneurysms. Repair of such aneurysms is safe and achieves good long-term outcomes with the use of the described techniques.

Revascularization of radial artery for ischemic hand with history of hand reimplantation.

Limb reimplantation is widely described, but there are sparse reports of limb ischemia complications. We present the case of a patient with hand reimplantation who developed limb-threatening ischemia 20 years later. The patient is a 37-year-old man with a history of traumatic wrist amputation and reimplantation who presented with fingertip ulcerations. Testing demonstrated ischemic digit pressures and no flow in the palmar arch. The initial angiogram demonstrated radial artery occlusion. Balloon angioplasty had initial success; however, the loss of primary patency prompted repeat angiography with the use of intravascular ultrasound and laser atherectomy. His symptoms and wounds resolved, with normalized digit pressures. His radial artery remains patent after 2 years.

Contemporary rates of inferior vena cava filter thrombosis and risk factors.

OBJECTIVE: Inferior vena cava (IVC) thrombosis is an uncommon complication associated with IVC filters (IVCFs), with studies reporting rates ranging from 1% to 31%. Few observational studies have described the risk factors associated with IVCF thrombosis, despite the significant clinical sequelae such as post-thrombotic syndrome, venous claudication, and venous ulceration. To better describe IVCF thrombosis and the risk factors, data were queried from Vascular Quality Initiative (VQI) participating centers. METHODS: IVCF data were obtained from the international VQI database from 2013 to 2019. The patients included in the present analysis had 2 years of follow-up data available. The baseline demographics, medical comorbidities, medication, and procedural, anatomic, and postoperative variables were assessed using Kaplan-Meier survival curves with log-rank tests, Student's t tests, or Mann-Whitney U tests for IVCF thrombosis at 2 years. Cox regression analyses were used to identify independent predictors of IVCF thrombosis. A subgroup analysis of those who had presented with venous thromboembolism (VTE) was also performed. RESULTS: A total of 62 U.S. and Canadian VQI-participating centers included 12,874 cases of IVCF placement. Of the 5780 cases with 2 years of follow-up available, 78 (1.3%) had developed IVCF thrombosis. Those who had experienced IVCF thrombosis had had significantly lower rates of diabetes, coronary artery disease, preoperative antiplatelet medications, preoperative statin use, and lower rates of discharge and follow-up antiplatelet medications. On univariable analysis, the cases of IVCF thrombosis also had higher rates of pulmonary embolism and VTE on admission, internal jugular venous access (vs femoral vein access), temporary IVCF use, follow-up anticoagulation, follow-up IVCF complication, follow-up access site thrombosis, and rates of new or propagated deep vein thrombosis at follow-up, and longer postoperative hospital stays. Multivariable analysis demonstrated that the independent predictors of IVCF thrombosis included new or propagated deep vein thrombosis at follow-up (hazard ratio [HR], 16.3; 95% confident interval [CI], 9.8-27.3; P < .001), no antiplatelet therapy at follow-up (HR, 4.8; 95% CI, 1.9-12.5; P = .001), internal jugular venous access (HR, 2.2; 95% CI, 1.4-3.5; P = .001), the presence of VTE on admission (HR, 2.7; 95% CI, 1.4-5.1; P = .002), and temporary IVCF placement (HR, 2.5; 95% CI, 1.1-5.6; P = .031). In an analysis of the subgroup of patients with VTE on admission, similar predictive factors were identified in a multivariable model. Massive pulmonary embolism was also predictive of IVCF thrombosis in this subgroup. CONCLUSIONS: The rate of IVCF thrombosis remained low in a contemporary international database. The results from the present study of >5000 patients with IVCFs suggest that antiplatelet therapy should be administered after IVCF placement to decreased the risk of IVCF thrombosis.

Outcomes of venous bypass combined with thoracic outlet decompression for treatment of upper extremity central venous occlusion.

BACKGROUND: Upper extremity central venous stenosis results from a variety of environmental and anatomic conditions, including venous thoracic outlet syndrome, the presence of device leads or catheters, and the turbulence created by the presence of arteriovenous fistulas or grafts. In cases of total occlusion, especially at the bony costoclavicular junction, options for endovascular treatment and open venous reconstruction are limited and bypass grafting may be needed. We describe our experience with venous bypass combined with thoracic outlet decompression in a cohort of symptomatic patients with subclavian vein occlusion. METHODS: A prospectively collected database of patients was queried for patients treated for central venous obstructive disease with venous bypass in the setting of both symptomatic venous thoracic outlet syndrome and ipsilateral arteriovenous access from July 2012 to December 2017. All but one patient presented with arm swelling and had either failed to respond to or were unsuitable for endovenous therapy. One patient desired elective removal of a venous stent because of pain and anxiety. Operative procedures were performed at the discretion of the operating surgeon. RESULTS: Fourteen patients (eight men; average age, 42 years) underwent open thoracic outlet decompression with first rib resection (n = 11) or claviculectomy (n = 4). Indication for treatment was dialysis-associated venous outlet obstruction in five, effort thrombosis (Paget-Schroetter syndrome) in seven, presence of a venous implantable cardioverter-defibrillator lead in one, and patent but painful venous stent in situ with significant anxiety. Nine patients required first interspace sternotomy for exposure of the proximal subclavian vein. One patient with acute Paget-Schroetter syndrome had been treated with preoperative thrombolysis without resolution; all others were chronically occluded. Bypass conduit was jugular vein in one, bovine carotid artery graft in two, paneled great saphenous vein in two, femoral vein in eight, and polytetrafluoroethylene in one. Mean operative time was 187 (±45) minutes, with mean estimated blood loss of 379 (±209) mL. There were two early graft thromboses that were revised with jugular venous turndown and femoral vein bypass, respectively. All patients experienced immediate symptom relief. Morbidity included two graft thromboses, two instances of wound dehiscence, two operative site hematomas, non-ST elevation myocardial infarction, vein harvest site infection, polytetrafluoroethylene graft infection, and phrenic nerve injury. At a mean follow-up of 357 (±303) days, primary assisted patency and secondary patency for the entire cohort were 71.4% and 85.7%, respectively, with 100% primary assisted patency among those with femoral vein conduit. At last follow-up, 13 of the 14 living patients (93%) remained symptom free. CONCLUSIONS: In our experience, venous bypass combined with thoracic outlet decompression achieves symptomatic relief in approximately 90% of patients with symptomatic upper extremity central venous occlusion, with morbidity limited to the perioperative period.

Sciatica Caused by Venous Varix Compression of the Sciatic Nerve.

BACKGROUND: The authors report the case of a 76-year-old woman presenting with leg pain, numbness, and weakness mimicking a lumbosacral radiculopathy. CASE DESCRIPTION: Initial lumbar spine magnetic resonance imaging demonstrated mild root compression, but lumbar decompression afforded only transient symptomatic relief. Postoperative magnetic resonance imaging of the lumbosacral plexus and sciatic nerve revealed a gluteal venous varix compressing the sciatic nerve just distal to the piriformis muscle. Neurolysis and surgical resection of the offending varix resulted in resolution of her symptoms. CONCLUSIONS: Variceal compression is a rare cause of extraspinal origin of lower extremity radicular pain. It should be considered if there is lack of correlation between radiologic findings and the clinical picture or if there is a failure of response to treatment of the assumed spinal cause.

Mycotic pseudoaneurysm of a superficial femoral artery stent.

Mycotic pseudoaneurysms are relatively infrequent entities, and the best means of management of them remain to be elucidated due to their small number and medical complexities surrounding them. We present here an interesting case of a mycotic pseudoaneurysm of the superficial femoral artery along with our management of the case and a brief review of the available literature. The particular presentation of this patient will hopefully reinforce the use of prolonged antibiotic therapy for mycotic disease and judicious reexamination of patients whose clinical picture does not immediately fit the framework of our most common diagnoses.