Transcarotid Artery Revascularization Learning Curves Differ between Surgeon Experience Level.

BACKGROUND: There has been ensuing interest in adopting transcarotid artery revascularization (TCAR), because of its low perioperative stroke and complication rates. In our study, we aimed to identify the case number at which there is improvement in TCAR technical proficiency. We also assessed how surgeon experience influenced outcomes. METHODS: The primary outcome was technical proficiency, measured by skin-to-skin, fluoroscopy, and flow reversal times. Secondary outcomes included hospital length of stay and perioperative complication rate. Data was collected from a deidentified database, which included all patients that had a TCAR between 2017 and 2023 at 1 of 4 hospitals. Cases were grouped by the experience of the surgeon who performed the case (≤10 and > 10 years). Linear mixed models were used to analyze primary outcomes after being log-transformed, due to their skewed distributions. The estimated level of the outcome was compared at the first, fifth, 10th and 15th surgery between surgeon groups, and the significance level was adjusted using the Bonferroni correction. RESULTS: There were 160 cases performed by 13 surgeons included in the study. Patients with hostile necks (23.9% vs. 9.7%, P = 0.015) and contralateral occlusions (7.5% vs. 0%, P = 0.007) were operated on more frequently by surgeons with ≤10 years of experience. There was no difference in secondary outcomes between groups. While primary outcomes between groups were not significant when comparing median values, linear mixed models demonstrated a significant improvement among the group of surgeons with less experience after the 15th case relative to their senior partners. At this point, they were operating with 30% less skin-to-skin time (P = 0.002, 95% confidence interval (CI) 13%-44%) and 51% less fluoroscopy time (P = 0.005, 95% CI 20%-70%) compared to surgeons with >10 years of experience. There was no significant difference between groups with respect to flow reversal times. CONCLUSIONS: There was significant improvement experienced by the junior attendings relative to their senior partners after the 15th case. This was not influenced by patient characteristics nor the type of anesthesia used.

Sex Disparities in Arteriovenous Fistula Maturation Outcomes.

BACKGROUND: The end-stage kidney disease life-plan aims to individualize hemodialysis (HD) access selection in patients requiring renal replacement therapy. Paucity of data on risk factors for poor arteriovenous fistula (AVF) outcomes limits the ability of physicians to guide their patients on this decision. This is especially true for female patients, who are known to have worse AVF outcomes when compared to male patients. The goal of this study was to identify risk factors associated with poor AVF maturation outcomes in female patients that will help guide individualized access selection. METHODS: A retrospective review of 1,077 patients that had AVF creation between 2014 and 2021 at an academic medical center was performed. Maturation outcomes were compared between 596 male and 481 female patients. Separate multivariate logistic regression models were created for the male and female cohorts to identify factors associated with unassisted maturation. AVF was considered mature if it was successfully used for HD for 4-week sessions without need for further interventions. Unassisted fistula was defined as an AVF that matured without any interventions. RESULTS: The male patients were more likely to receive more distal HD access; 378 (63%) male versus 244 (51%) female patients had radiocephalic AVF, P < 0.001. Maturation outcomes were significantly worse in female patients; 387 (80%) AVFs matured in females and 519 (87%) in male patients, P < 0.001. Similarly, the rate of unassisted maturation was 26% (125) in female patients versus 39% (233) in male patients, P < 0.001. Mean preoperative vein diameters were similar in both groups; 2.8 ± 1.1 mm in male versus 2.7 ± 0.97 mm in female patients, P = 0.17. Multivariate logistic regression analysis of the female patients revealed that Black race (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.4-0.9, P = 0.045), radiocephalic AVF (OR: 0.6, 95% CI: 0.4-0.9, P = 0.045), and preoperative vein diameter <2.5 mm (OR: 1.4, 95% CI: 10.33-0.901.1-1.7, P = 0.014) were independent predictors of poor unassisted maturation in this cohort. In male patients, preoperative vein diameter <2.5 mm (OR: 1.4, 95% CI: 1.2-1.7, P < 0.001) and need for HD prior to AVF creation (OR: 0.6, 95% CI: 0.3-0.9, P = 0.018) were independent predictors of poor unassisted maturation. CONCLUSIONS: Black women with marginal forearm veins may have worse maturation outcomes, and upper arm HD access should be considered when advising patients on their end-stage kidney disease life-plan.

Early Follow-Up after Arteriovenous Fistula Creation is Associated with Improved Access-Related Outcomes.

BACKGROUND: Up to 60% of arteriovenous fistulas (AVF) require intervention to assist maturation, which prolongs the time until it can be used for hemodialysis (HD). Current guidelines recommend early postoperative AVF examination to detect and address immaturity to decrease time to maturation. This study evaluates how the timing of postoperative follow-up to assess AVF maturity affects patients' outcomes. METHODS: All patients who underwent AVF creation between 2017 and 2021 in an academic medical center were retrospectively reviewed, excluding patients lost to follow-up or not on HD. Outcomes were compared between patients that had delayed follow-up to assess AVF maturity, >8 weeks post surgery, versus early follow-up, <8 weeks post-surgery. AVF evaluation for maturity consisted of physical examination and duplex ultrasound. Primary endpoints were time to first cannulation (interval from AVF creation to first successful cannulation) and time to catheter-free dialysis (interval from AVF creation to central venous catheter removal). RESULTS: A total of 400 patients were identified: 111 in the delayed follow-up group and 289 in the early follow-up group. The median time to follow-up was 78 days (interquartile range [IQR], 66-125) in the delayed follow-up group versus 39 days (IQR, 36-47) in the early follow-up group, (P < 0.0001). The maturation rate was 87% in the delayed follow-up group versus 81% in the early follow-up group, (P = 0.1) and both groups had similar rates of interventions to assist maturation (66% vs. 57%, P = 0.2). The early follow-up group had a significantly shorter median time to first cannulation (50 vs. 88 days; P < 0.0001) and shorter time to catheter-free HD (75 vs. 118 days; P <0.0001). At 4 months after AVF creation, the incidence of first cannulation was 74% in the early follow-up group versus 63% in the delayed follow-up group (P = 0.001). Similarly, the incidence of catheter-free dialysis was 65% in the early follow-up group versus 50% in the delayed follow-up group at 4 months postoperatively, (P = 0.036). CONCLUSIONS: Early postoperative follow-up for evaluation of fistula maturation is associated with reduced time to first successful cannulation of AVF for HD and reduced time to catheter-free dialysis.

Predictors of poor outcomes after lower extremity revascularization for acute limb ischemia.

OBJECTIVES: Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality. METHODS: A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed. RESULTS: The mean patient age was 69 ± 17 years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10 years) as independent predictors of perioperative mortality. CONCLUSIONS: Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.

Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization.

OBJECTIVE: Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR. METHODS: We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded. RESULTS: During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients. CONCLUSIONS: Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.

The effect of nutrition on stroke risk: A systematic review.

Background: An estimated 33% reduction in cardiovascular events can be achieved when incorporating whole grains, fruits, vegetables, poultry, nuts, and vegetable oils in the diet along with reduced consumption of refined carbohydrates, processed meats, and sugar sweetened beverages. We performed a systematic review to analyze the impact of nutritional intervention on stroke risk, as there is no current consensus concerning dietary recommendation for primary and secondary stroke prevention. Methods: A literature search of the PubMed database from January 2010 to June 2020 was performed using combinations of the following search terms: carotid disease, carotid artery disease, carotid stenosis, carotid intima-media thickness (CIMT), diet, nutrition, micronutrition, embolic stroke, and stroke. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 checklist. Results: 28 studies met our inclusion criteria. Multiple studies showed an inverse relationship between consumption of vegetables and fruits and stroke risk. Vitamin B12 or a combination of B Vitamins was the most common supplement studied in stroke prevention. Only one RCT showed the use of B12 (500 micrograms/day) correlated with lower CIMT at follow up in healthy vegetarians. Discussion: The key findings from this systematic review indicate that adopting a diet rich in fruits and vegetables earlier in life may lower stroke risk compared with meats and fat intake. B vitamins also appear to confer some protection against stroke. However, not enough data exists to support the use of multivitamins, calcium, soy products and other supplements for primary or secondary stroke prevention.

The Role of Duplex Ultrasound in Assessing AVF Maturation.

BACKGROUND: Arteriovenous fistulas (AVFs) are favored for hemodialysis (HD) access. However, in many instances, AVFs fail to mature. We examined the utility of postoperative color duplex ultrasound (CDU) in assessing AVF maturation and determining the need for balloon-assisted maturation (BAM). METHODS: A total of 633 patients underwent AVF creation at a single institution from 2015 to 2018. A total of 339 patients (54%) underwent CDU at a median of 8 weeks postoperatively. We collected the following parameters: vein diameter, volume flow (VF), peak systolic velocities in arterial inflow and venous outflow, and presence of stealing branches. A peak systolic velocity ratio (SVR) of ≥2 correlated with ≥50% stenosis in venous outflow, and SVR ≥3 correlated with ≥50% stenosis at the anastomosis. AVFs were considered mature when they were successfully cannulated on dialysis. A generalized linear mixed model (GLMM) was created to compare duplex criteria associated with successful use of AVF (maturation) to those AVFs that required further intervention or failed to mature. Fistulography images, the current gold standard, were compared with findings from CDU studies to determine validity of the duplex ultrasound. RESULTS: Of the 339 AVFs with postoperative CDU, 31.3% matured without interventions, 38.3% required BAM, 9.7% thrombosed, and the remaining patients were not yet on HD. Based on GLMM analysis, the probability of AVF maturation increases if CDU demonstrated one of the following: the vein diameter is ≥ 6 (odds ratio [OR] = 38.7), no evidence of stenosis in the venous outflow tract (OR = 35.6), no stealing branches (OR = 21.6) and VF ≥ 675 (OR = 5.0). Fistulography was performed in 195 patents. Sensitivity and specificity for each are as follows: vein diameter (84.3%, 28.6%), stenosis (59.3%, 78.8%), and stealing branches (20.7%, 92.7%). CONCLUSIONS: Postoperative CDU should be considered routine to correct anatomical findings that might limit AVF maturation and identify the need for further interventions.

Maturation Rates of Arteriovenous Fistulas Using Small Veins in the Era of Endovascular Interventions.

BACKGROUND: Traditional practice suggests the abandonment of veins smaller than 3 mm in diameter for arteriovenous fistula (AVF) creation because of a low rate of maturation. This study aims to show that with balloon-assisted maturation (BAM), undersized veins can be used to create functional AVFs with a high rate of success. METHODS: All patients who underwent AVF creation between 2014 and 2018 at a tertiary academic medical center were retrospectively reviewed. The patients without preoperative vein mapping, those who failed to follow-up, and the patients who were not on dialysis were excluded. A fistula was considered to be mature if it was successfully cannulated for dialysis. A total of 596 patients were identified for analysis. The cohort was divided into the small-vein group (SVG, <2.5 mm) and large-vein group (LVG, ≥2.5 mm) based on preoperative vein size. Categorical variables were analyzed with the chi-squared test for their association with maturation status. Continuous variables were analyzed with the Wilcoxon rank sum test. A P-value less than 0.05 was considered significant. RESULTS: In the study cohort, 61.9% of the patients were male, with an average age of 62.8 ± 13.7 years, and an average preoperative vein size of 2.9 ± 1.1 mm. With similar demographic distribution, the participants in the SVG (n = 216) had significantly smaller preoperative vein size of 1.9 ± 0.4 mm than the patients in the LVG (n = 380), 3.5 ± 0.8 mm (P = 0.001). There were significantly more radio-cephalic AVFs created in the SVG (77.8% versus 48.7%, P < 0.0001). The overall maturation rate was 83.1% (n = 495), 219 fistulas (36.7%) matured primarily and 276 (46.3%) required interventions. Ninety-one percent of the patients required only 1 or 2 BAMs to achieve maturation. The SVG achieved a maturation rate of 75.9% as compared with 87.1% in the LVG (P = 0.002). A significantly higher number of patients in the SVG required BAM for maturation as compared with the LVG (67.7% versus 49.9%, P = 0.0002); however, there was no difference in the average number of BAMs required for fistula maturation between the groups (1.5 ± 0.8 for the SVG vs. 1.4 ± 0.7 for the LVG). In multivariable logistic regression analysis, vein size ≥2.5 mm (odds ratio (OR) = 2.11, confidence interval (CI): 1.36-3.27, P = 0.0009) and male sex (OR = 2.30, CI: 1.49-3.57, P = 0.0002) were independent predictors of maturation. CONCLUSIONS: Small veins can be used for AVF creation with lower but still favorable maturation rates using BAM interventions, especially in male patients. This practice can increase the creation of autogenous dialysis access and potentially reduce complications related to prosthetic dialysis access.

Anatomically Coiled Internal Carotid Artery Resulting in Severe Dysphagia and Burning Mouth Syndrome.

This is a report of a 65-year-old female presenting with symptoms of dysphagia due to a coiled left internal carotid artery, treated with resection and primary repair. Dysphagia lusoria is more commonly caused by aortic arch anomalies, aberrant subclavian or common carotid arteries. Internal carotid tortuosity as a cause of severe dysphagia and burning mouth syndrome is highly unusual. A literature review examines the etiology, natural history, and treatment options.

Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.

Maximizing proximal seal zone in fenestrated endografting: Evolution in the approach to graft configuration.

OBJECTIVE: Fenestrated endografting for juxtarenal and pararenal abdominal aortic aneurysms affords the ability to seal stent grafts in normal aorta at and above the renal arteries. The Zenith fenestrated graft (ZFEN; Cook Medical, Bloomington, Ind) is custom-made to surgeon specifications, subject to certain manufacturing limitations. The most common configuration in the pivotal trial and in commercial use after approval has been as a scallop for the superior mesenteric artery (SMA) and two small fenestrations for the renal arteries (configuration A). An alternative configuration to maximize the seal zone length, consisting of a large fenestration for the SMA and two small fenestrations for the renal arteries (configuration B) has been routinely adopted at our institutions to potentially prevent type IA endoleak. METHODS: The present retrospective cohort study examined 100 consecutive ZFEN grafts designed for patients at two university centers from 2012 through 2019. The proximal seal length, measured from the top of the graft to the beginning of the aneurysm, was determined from the preoperative computed tomography angiograms. Alternative configurations were evaluated to determine whether they would have provided a longer proximal seal length. RESULTS: The two most common configurations were B (n = 45) and A (n = 38). For the cases in which A had been chosen but B could have been built, 5.8 ± 1.9 mm of seal zone length was lost. For the cases in which B was chosen but A could have been built, 5.8 ± 2.8 mm of seal zone length was gained. Owing, in part, to the increased proximal seal length with configuration B, this configuration has been used more frequently in the past 4 years of the present study compared with the first four (53% vs 25%; P = .004). Of 95 patients who had completed surgery and follow-up, type IA endoleaks were observed in 12 (13%) on completion angiography, all of which had resolved on follow-up imaging without intervention. No SMA was compromised by misalignment of the large fenestration in configuration B. CONCLUSIONS: A significantly longer proximal seal length can be obtained using a ZFEN with a large fenestration for the SMA and two small fenestrations for the renal arteries. Whenever possible, surgeons should consider this configuration to maximize the proximal seal length and potentially reduce the risk of proximal endoleak. An additional advantage of this approach is that stenting of the SMA to prevent shuttering will be unnecessary or impossible, making the procedure more technically facile.

Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Is Routine Postoperative Anticoagulation Necessary in All Patients after First Rib Resection for Paget-Schroetter Syndrome?

BACKGROUND: Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. METHODS: Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. RESULTS: Mean patient age was 28.4 (12-64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. CONCLUSIONS: This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.

Infections of Prosthetic Grafts and Patches Used for Infrainguinal Arterial Reconstructions.

BACKGROUND: Prosthetic grafts are often used as alternative conduits in patients with peripheral vascular disease who do not have an adequate autologous vein for bypass. Prosthetic grafts, unfortunately, carry an increased risk of infection and are associated with increased morbidity and mortality. The goal of this study was to identify potential risk factors and subsequent outcomes associated with lower extremity prosthetic graft infections. METHODS: Two hundred seventy-two lower extremity prosthetic bypasses and patches were performed at an academic medical center between 2014 and 2016. A retrospective review of patients' demographics, comorbidities, indication for surgery, type of procedures performed, and procedural characteristics was conducted. Outcomes, including limb loss and mortality, were analyzed. RESULTS: Forty-three (15.8%) patients with graft infections were identified during a median follow-up of 668 days (interquartile range [IQR] = 588). The median time to graft infection was 43 days (IQR = 85) with Staphylococcus being the most common bacteria cultured. Infections were associated with a 30.2% rate of limb loss and a 34.9% rate of mortality. The risk of infection was 2.4 times greater among those with a history of redo surgery (95% confidence interval [CI] of the hazard ratio [HR]: 1.3, 4.3) and 2.1 times greater in women (95% CI: 1.1, 3.8), by multivariable statistics. A 1 g/dL increase in albumin level was associated with a 33.5% decrease in hazard of infection (HR: 0.67, 95% CI: 0.46, 0.96) in the multivariable model. The estimated cumulative incidence of infection for female patients with hypertension and mean albumin of 3.36 undergoing redo surgery was 19.4% at 30 days after surgery (95% CI: 10.6, 35.6) and 39.9% at 1 year (95% CI: 26.8, 59.3). CONCLUSIONS: Female gender, redo surgery, and malnutrition are associated with increased risk of prosthetic graft infections leading to a high rate of limb loss and mortality. Endovascular interventions and bypasses with vein conduits should be considered in these patients.

Improving the Power of the American Society of Anesthesiology Classification System to Risk Stratify Vascular Surgery Patients Based on National Surgical Quality Improvement Project-Defined Functional Status.

BACKGROUND: Recently published reports have shown that the American Society of Anesthesiology (ASA) classification system has limited applicability in vascular surgery patients. Most patients undergoing vascular procedures are designated as ASA class III, limiting discrimination in preoperative risk assessment. The 2006 National Surgical Quality Improvement Project (NSQIP), containing over 170,000 surgical cases, demonstrated that functional status is an important predictor of mortality. We propose that dividing ASA class III into 2 subgroups, based on NSQIP-defined functional status, improves the predictive value of the ASA scheme. METHODS: The 2006 NSQIP database was queried for ASA class III patients undergoing vascular surgery procedures. Patients were divided into groups IIIA and IIIB based on independent or dependent (partial or complete) functional status, respectively. Difference in 30-day survival between subgroups was evaluated using Kaplan-Meier and logistic regression analyses. Differences in postoperative morbidity and length of stay were compared using the unpaired t-test. RESULTS: ASA class III patients having undergone vascular surgery procedures numbered 11,555 (68%). Of those 9,913 (85.7%) patients were independent (IIIA), and 1,642 (14.3%) were dependent (IIIB). Mean 30-day mortality was 1.3% in subgroup IIIA, and 6.5% in IIIB (logrank P < 0.001, χ2, 137.8). Mean lengths of stay between subgroups IIIA and IIIB were 5.4 and 13.2 days (P < 0.001). The risk of NSQIP-defined postoperative complications was 0.16 in IIIA and 0.32 in IIIB (P < 0.001). CONCLUSIONS: A 5-fold difference in mortality was observed between patients who were functionally independent and dependent. A significant increase in length of stay and incidence of postoperative complications was also observed in subgroup IIIB. Subdividing ASA class III vascular surgery patients markedly improves the value of the ASA classification system. Given the "high-risk" nature of patients with vascular disease, the addition of functional status to the preoperative assessment will assist in predicting outcomes in this patient population.

Creation of spliced vein conduit using microvascular anastomotic coupler.

The single-segment great saphenous vein continues to be a conduit of choice for lower extremity arterial bypass. In patients without an adequate continuous segment of great saphenous vein, a spliced vein graft may be used as an alternative. Creating a spliced vein conduit can be technically challenging and time consuming. We present a technique of creating a spliced vein conduit by using a microvascular anastomotic coupler.

Management of Difficult Access during Endovascular Aneurysm Repair.

BACKGROUND: To describe a large single-institutional experience in managing challenging access situations during endovascular aneurysm repair (EVAR). METHODS: Data from all patients undergoing EVAR at a tertiary academic medical center between 2009 and 2013 were collected retrospectively, including demographics, size of iliac arteries, type of device used, approach to managing difficult access (DA), and outcomes. The median follow-up was 38 months. DA was defined as iliac arteries with a diameter of less than 7 mm bilaterally. Fenestrated and snorkel repairs were excluded. RESULTS: Of 400 EVARs performed during the study period, 191 (48%) were done in patients with DA. Of the DA patients, 35 (18.3%) underwent 42 adjuncts before the introduction of the main body device: including 15 dilators, 11 balloon angioplasties, 9 aortouniiliac devices, 3 SoloPath sheaths, 1 retroperitoneal cutdown, and 3 iliac stents. In another 29 patients, iliac stents were used to correct stenoses or kinks in the limbs after EVAR devices were deployed. The average diameter of the iliac artery used to deliver main body component was 4.6 mm in the group of patients requiring adjuncts and 5.4 mm in the remainder of the patients with small iliac arteries (P = 0.008). The median size of the main body device was 28 mm. Two cases were aborted due to inability to deliver the device. Other complications included 7 (3.6%) iliac ruptures, 3 (1.6%) instances of limb ischemia, and 5 (2.6%) patients needed early reoperation (within 30 days). Two patients (1%) had type I endoleaks at the conclusion of EVAR. During follow-up, 12 (6.3%) patients required EVAR revisions. Seven patients (3.6%) had limb thrombosis which occurred only in patients who did not have adjective procedures during the initial EVAR. Limb thrombosis and rate of revisions in patients with DA were not significantly different from the rates observed in non-DA patients. Perioperative mortality after elective repairs was 1.6% in DA patients and 0% in non-DA patients (P = 0.12). CONCLUSIONS: EVAR can be successfully performed in patients with bilateral small iliac arteries. Adjunctive procedures might increase the technical success rate of EVAR in these patients and should definitely be considered in patients with iliac arteries less than 5 mm in diameter. Next generation and "low-profile" devices might minimize the need for adjunctive procedures and facilitate EVAR in these patients.

Trends in Endovascular Aortic Aneurysm Repair Length of Stay over a Decade at a Tertiary Academic Institution.

BACKGROUND: Length of stay (LOS) is used as a quality metric to reduce cost and improve value of delivery of care. We sought to analyze trends in endovascular aortic aneurysm repair (EVAR) LOS at a tertiary academic institution over the last decade. METHODS: A retrospective review of prospectively collected data was performed. Infrarenal EVARs from 2001 to 2013 were divided into 3 groups: group I (2001-2004), EVARs were performed as part of clinical trials; group II (2005-2008), EVARs were referred to a tertiary referral center with the most experience with EVAR; group III (2009-2013), EVARs were referred to academic institutions in the presence of severe patient comorbidities. Trends in LOS and correlation with severity of illness (SOI) as based on All Patient Refined Diagnosis Related Groups and admission and/or disposition status were analyzed. LOS index (LOSI) at our institution was then compared with University HealthSystem Consortium (UHC) Hospitals over the past 3 years. RESULTS: A total of 1,265 EVARs were performed during this time period: 325 in group I, 547 in group II, and 393 in group III. The median LOS was 4 days (inter quartile range [IQR], 2-6) vs. 3 days (IQR, 2-5) ± 0.28 vs. 4 days (IQR, 3-7), respectively (P < 0.01). Although moderate SOI was fairly constant over time (P = 0.66), major and/or extreme SOI constituted a greater proportion of patients in group I, was reduced in group II, and was again increased in group III, P < 0.01. The complication rate paralleled this pattern (group I, 15.2%; group II, 8.6%; group III, 10.4%; P = 0.02). The percentage of patients discharged to nursing home and/or rehab was 5.7% in group I, 8.2% in group II, 11.5% in group III (P = 0.03). Cases that were performed urgently and/or emergently increased over time: 11.6% in group I, 14.9% in group II, 21.6% in group III (P = 0.01). The risk-adjusted LOSI at our institution was significantly greater (1.25) when compared with UHC hospitals (0.75). CONCLUSIONS: Our study suggests a relationship between time period of EVAR, SOI, complications, admission status, and LOS. Attention to these trends could be used to decrease LOS in an increasingly complex patient population.

Quality of care among patients undergoing lower extremity revascularization.

BACKGROUND: Compliance with guidelines for treating patients with peripheral artery disease (PAD) lags compliance for treating patients with coronary artery disease. We assessed the gap between guidelines and practice for patients with PAD who underwent lower extremity revascularization (LER) at our institution from 2007 to 2010. METHODS: Quality of care (QoC) was calculated by measuring provider performance on four indicators (antiplatelet therapy, dyslipidemia management, control of hypertension, and diabetes) derived from the ACCF/AHA PAD guidelines. The QoC score was calculated at the time of admission and at time of discharge for each patient, and reflects the proportion of indicated treatments received. RESULTS: Patients (n = 734, mean age 70±11, female 51%) were followed for a mean of 2.0±1.4 years (range 0-5.7) following LER. The indication for LER was claudication (24.8%), rest pain (16.7%), and tissue loss (58.4%). The percentage of patients with a perfect QoC score increased significantly during hospital admission (11% to 21%, p < 0.001). Significant multivariate predictors of perfect QoC score included race/ethnicity, Charlson score, severity of LE ischemia, and observation period (admission, discharge). Multivariate analysis demonstrated that age>75 years, heart failure, chronic kidney disease, rest pain, and tissue loss-but not compliance with four guideline-based therapies-were associated with decreased freedom from the composite endpoint of major amputation, repeat revascularization, and death. CONCLUSIONS: Although adherence to guidelines improved over time, we found a significant gap between guidelines and practice for this cohort of patients at increased risk for adverse cardiovascular events.

Proximalization of arterial inflow with adjunctive arterial pressure measurements for management of hemodialysis access-induced distal ischemia.

Hemodialysis access-induced distal ischemia (HAIDI) is an uncommon, yet potentially devastating, complication of hemodialysis access surgery. Management of HAIDI depends on the access' volume flow and may involve banding, proximalization of arterial inflow, revision using distal inflow, distal revascularization interval ligation, or access ligation. Various adjunctive techniques have been used to confirm improved distal arterial flow intraoperatively. Here, we present a case of a patient with grade 3 HAIDI treated with proximalization of arterial inflow technique with the adjunctive use of intra-arterial pressure gradient measurements.