Incidence and risk factors of chronic postoperative pain in same-day surgery: A prospective cohort study.

BACKGROUND: The amount of same-day surgery has increased markedly worldwide in recent decades, but there remains limited evidence on chronic postsurgical pain in this setting. METHODS: We assessed pain 90 days after ambulatory surgery in an international, multicentre prospective cohort study of patients ≥45 years old with comorbidities or ≥65 years old. Pain was assessed using the Brief Pain Inventory. Chronic postsurgical pain was defined as a change ≥1 in self-rated average pain at the surgical site between baseline and 90 days, and moderate to severe chronic postsurgical pain as a score ≥4 in self-rated average pain at the surgical site at 90 days. Risk factors for chronic postsurgical pain were identified using multivariable logistic regression. RESULTS: Between November 2021 and January 2023, a total of 2054 participants were included, and chronic postsurgical pain occurred in 12% of participants, of whom 93.1% had new chronic pain at the surgical site (i.e., participants without pain prior to surgery). Moderate to severe chronic postsurgical pain occurred in 9% of overall participants. Factors associated with chronic postsurgical pain were: active smoking (OR 1.82; 95% CI 1.20 to 2.76), orthopaedic surgery (OR 4.7; 95% CI 2.24 to 9.7), plastic surgery (OR 4.3; 95% CI 1.97 to 9.2), breast surgery (OR 2.74; 95% CI 1.29 to 5.8), vascular surgery (OR 2.71; 95% CI 1.09 to 6.7), and ethnicity (i.e., Hispanic/Latino ethnicity OR 3.41; 95% CI 1.68 to 6.9 and First Nations/Native persons OR 4.0; 95% CI 1.05 to 15.4). CONCLUSIONS: Persistent postsurgical pain after same-day surgery is common, usually moderate to severe in nature, and occurs mostly in patients without chronic pain prior to surgery.

A Canadian multicenter experience describing outcomes after endovascular abdominal aortic aneurysm repair stent graft explantation.

BACKGROUND: Most studies describing the outcomes after endovascular abdominal aortic aneurysm repair (EVAR) explantation have been from single, high-volume, centers. We performed a multicenter cross-Canadian study of outcomes after EVAR stent graft explantation. Our objectives were to describe the outcomes after late open conversion and EVAR graft explantation at various Canadian centers and the techniques and outcomes stratified by the indication for explant. METHODS: The Canadian Vascular Surgery Research Group performed a retrospective multicenter study of all cases of EVAR graft explantation at participating centers from 2003 to 2018. Data were collected using a standardized, secure, online platform (RedCap [Research Electronic Data Capture]). Univariate statistical analysis was used to compare the techniques and outcomes stratified the indication for graft explantation. RESULTS: Patient data from 111 EVAR explants collected from 13 participating centers were analyzed. The mean age at explantation was 74 years, the average aneurysm size was 7.5 cm, and 28% had had at least one instructions for use violation at EVAR. The average time between EVAR and explantation was 42.5 months. The most common indication for explantation was endoleak (n = 66; type Ia, 46; type Ib, 2; type II, 9; type III, 2; type V, 7), followed by infection in 20 patients; rupture in 18 patients (due to type Ia endoleak in 10 patients, type Ib in 1, type II in 1, type III in 2, and type V in 1), and graft thrombosis in 7 patients. The overall 30-day mortality was 11%, and 45% of the patients had experienced at least one major perioperative complication. Mortality was significantly greater for patients with rupture (33.3%) and those with infection (15%) compared with patients undergoing elective explantation for endoleak (4.5%; P = .003). The average center volume during the previous 15 years was 8 cases with a wide range (2-19 cases). A trend was seen toward greater mortality for patients treated at centers with fewer than eight cases compared with those with eight or more cases (19% vs 9%). However, the difference did not reach statistical significance (P = .23). Overall, 41% of patients had undergone at least one attempt at endovascular salvage before explantation, with the highest proportion among patients who had undergone EVAR explantation for endoleak (51%). Only 22% of patients with rupture had undergone an attempt at endovascular salvage before explantation. CONCLUSIONS: The performance of EVAR graft explantation has increasing in Canada. Patients who had undergone elective explantation for endoleak had lower mortality than those treated for either infection or rupture. Thus, patients with an indication for explanation should be offered surgery before symptoms or rupture has occurred. A trend was seen toward greater mortality for patients treated at centers with lower volumes.

YouTube as a source of patient information for abdominal aortic aneurysms.

OBJECTIVE: Patients are increasingly referring to the Internet after a diagnosis of vascular disease. This study was performed to quantitatively define the accuracy and reliability of information on YouTube regarding abdominal aortic aneurysms (AAA). METHODS: A systematic search of YouTube was conducted using multiple AAA-specific keywords. The default YouTube search setting of "relevance" was used to replicate an average search attempt, and the first 50 results from each keyword search were reviewed and analyzed by two independent reviewers. Descriptive characteristics, Journal of the American Medical Association Score, modified DISCERN score, Video Power Index, and a novel scoring system for the management of AAAs, the AAA-Specific Score (AAASS), were used to record data. Inter-rater agreement was analyzed using intraclass correlation coefficient estimates and the Kruskal-Wallis test was used for intergroup comparisons. RESULTS: Fifty-one videos were included for analysis. The mean Journal of the American Medical Association Score, DISCERN, and AAASS values among videos were 1.74/4.00 (standard deviation [SD], 0.84), 2.37/5.00 (SD, 0.97), and 6.63/20.00 (SD, 3.23), respectively. Of all the included videos, 78% were educational in nature, 14% were patient testimonials, and 8% were news programs. Based on the AAASS, the majority of analyzed videos fell into the poor category (41%), followed next by the very poor (31%), moderately useful (25%), very useful (2%), and exceptional (0%) categories. Videos by nonphysicians were significantly more popular (P < .05) than vascular surgeon sources. CONCLUSIONS: Although variable in source and content, the completeness and reliability of information offered on YouTube for AAA diagnosis and treatment is poor. Patients watching YouTube for information on their AAA diagnosis are receiving an incomplete and perhaps misleading picture of available diagnostic and treatment options. Given that vascular surgeons are likely to be affected by unrealistic treatment expectations from patients accessing online materials regarding AAA, it is important to acknowledge the nature of content on these platforms.

Fibrin and Thrombin Sealants in Vascular and Cardiac Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: In vascular and cardiac surgery, the ability to maintain haemostasis and seal haemorrhagic tissues is key. Fibrin and thrombin based sealants were introduced as a means to prevent or halt bleeding during surgery. Whether fibrin and thrombin sealants affect surgical outcomes is poorly established. A systematic review and meta-analysis was performed to examine the impact of fibrin or thrombin sealants on patient outcomes in vascular and cardiac surgery. DATA SOURCES: Cochrane CENTRAL, Embase, and MEDLINE, as well as trial registries, conference abstracts, and reference lists of included articles were searched from inception to December 2019. REVIEW METHODS: Studies comparing the use of fibrin or thrombin sealant with either an active (other haemostatic methods) or standard surgical haemostatic control in vascular and cardiac surgery were searched for. The Cochrane risk of bias tool and the ROBINS-I tool (Risk Of Bias In Non-randomised Studies - of Interventions) were used to assess the risk of bias of the included randomised and non-randomised studies; quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Two reviewers screened studies, assessed risk of bias, and extracted data independently and in duplicate. Data from included trials were pooled using a random effects model. RESULTS: Twenty-one studies (n = 7 622 patients) were included: 13 randomised controlled trials (RCTs), five retrospective, and three prospective cohort studies. Meta-analysis of the RCTs showed a statistically significant decrease in the volume of blood lost (mean difference 120.7 mL, in favour of sealant use [95% confidence interval {CI} -150.6 - -90.7; p < .001], moderate quality). Time to haemostasis was also shown to be reduced in patients receiving sealant (mean difference -2.5 minutes [95% CI -4.0 - -1.1; p < .001], low quality). Post-operative blood transfusions, re-operation due to bleeding, and 30 day mortality were not significantly different for either RCTs or observational data. CONCLUSION: The use of fibrin and thrombin sealants confers a statistically significant but clinically small reduction in blood loss and time to haemostasis; it does not reduce blood transfusion. These Results may support selective rather than routine use of fibrin and thrombin sealants in vascular and cardiac surgery.

A Systematic Review of Economic Evaluations in Vascular Surgery.

BACKGROUND: With increasing healthcare costs and the emergence of new technologies in vascular surgery, economic evaluations play a critical role in informing decision-making that optimizes patient outcomes while minimizing per capita costs. The objective of this systematic review is to describe all English published economic evaluations in vascular surgery and to identify any significant gaps in the literature. METHODS: We conducted a comprehensive English literature review of EMBASE, MEDLINE, The Cochrane Library, Ovid Health Star, and Business Source Complete from inception until December 1, 2018. Two independent reviewers screened articles for eligibility using predetermined inclusion criteria and subsequently extracted data. Articles were included if they compared 2 or more vascular surgery interventions using either a partial economic evaluation (cost analysis) or full economic evaluation (cost-utility, cost-benefit, and/or cost-effectiveness analysis). Data extracted included publishing journal, date of publication, country of origin of authors, type of economic evaluation, and domain of vascular surgery. RESULTS: A total of 234 papers were included in the analysis. The majority of the papers included only a cost analysis (183, 78%), and there were only 51 papers that conducted a full economic analysis (22%). The 51 papers conducted a total of 69 economic analyses. This consisted of 32 cost-effectiveness analyses, 29 cost-utility analyses, and 8 cost-benefit analyses. The most common domains studied were aneurysmal disease (89, 38%) and peripheral vascular disease (50, 21%). Economic evaluations were commonly published in the Journal of Vascular Surgery (83, 35%) and Annals of Vascular Surgery (32, 14%), with most study authors located in the United States (127, 54%). There was a trend of economic evaluations being published more frequently in recent years. CONCLUSIONS: The majority of vascular surgery economic evaluations used only a cost analysis, rather than a full economic evaluation, which may not be ideal in pursuing interventions that simultaneously optimize cost and patient outcomes. The literature is lacking in full economic evaluations-a trend persistent in other surgical specialties-and there is a need for full economic evaluations to be conducted in the field of vascular surgery.

The economic burden of inpatient diabetic foot ulcers in Toronto, Canada.

OBJECTIVE: Diabetic foot ulcer, which often leads to lower limb amputation, is a devastating complication of diabetes that is a major burden on patients and the healthcare system. The main objective of this study is to determine the economic burden of diabetic foot ulcer-related care. METHODS: We conducted a multicenter study of all diabetic foot ulcer patients admitted to general internal medicine wards at seven hospitals in the Greater Toronto Area, Canada from 2010 to 2015, using the GEMINI database. We compared the mean costs of care per patient for diabetic foot ulcer-related admissions, admissions for other diabetes-related complications, and admissions for the top five most costly general internal medicine conditions, using the Ontario Case Costing Initiative. Regression models were used to determine adjusted estimates of cost per patient. Propensity-score matched analyses were performed as sensitivity analyses. RESULTS: Our study cohort comprised of 557 diabetic foot ulcer patients; 2939 non-diabetic foot ulcer diabetes patients; and 23,656 patients with the top 5 most costly general internal medicine conditions. Diabetic foot ulcer admissions incurred the highest mean cost per patient ($22,754) when compared to admissions with non-diabetic foot ulcer diabetes ($8,350) and the top five most costly conditions ($10,169). Using adjusted linear regression, diabetic foot ulcer admissions demonstrated a 49.6% greater mean cost of care than non-diabetic foot ulcer-related diabetes admissions (95% CI 1.14-1.58), and a 25.6% greater mean cost than the top five most costly conditions (95% CI 1.17-1.34). Propensity-scored matched analyses confirmed these results. CONCLUSION: Diabetic foot ulcer patients incur significantly higher costs of care when compared to admissions with non-diabetic foot ulcer-related diabetes patients, and the top five most costly general internal medicine conditions.

Factors relating to the publication rate of abstracts presented from 2012 to 2015 at the Society for Vascular Surgery Annual Meeting.

OBJECTIVE: The Society for Vascular Surgery's Annual Meeting acts as a means of disseminating research findings among vascular surgeons through the presentation of research abstracts. Following presentation at the meeting, research is often compiled into a full-text manuscript and submitted to a peer-reviewed journal. However, not all abstracts accepted to the Vascular Annual Meeting (VAM) eventually have a corresponding full-text publication. The objectives of this study were to establish the publication rate of abstracts presented between 2012 and 2015 to the VAM and to identify factors correlating with publication status. METHODS: Abstracts presented at the VAM were available through the Journal of Vascular Surgery. Data extracted from eligible abstracts included level of evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence scheme, type of study (prognostic, therapeutic/harm, diagnostic), sample size, and status of outcome (positive, negative, or descriptive findings). Publication status of the abstracts was determined through a comprehensive literature review of PubMed (MEDLINE), Ovid (MEDLINE), and Embase. A multivariable logistic regression was conducted to determine factors correlating with publication status. RESULTS: The publication rate during the study period was 43.0% with a median time to publication of 9 months, with 412 of the 958 abstracts having a corresponding full-text publication in 48 journals with weighted mean impact factor of 3.40. Eleven journals collectively published 372 (90.3%) of the articles, with the Journal of Vascular Surgery publishing 280 (68.0%) of the manuscripts. Our logistic regression model demonstrated that factors positively affecting publication status were a positive status of outcome (odds ratio, 2.59; 95% confidence interval, 1.56-4.28) and a logarithmic increase in the sample size of the study (odds ratio, 1.35; 95% confidence interval, 1.13-1.60). In addition, studies with a corresponding full-text publication had a greater median sample size (250) compared with those without one (143; P < .001). CONCLUSIONS: From 2012 to 2015, 43.0% of VAM abstracts had a corresponding full-text publication, with greater sample size and a positive status of outcome positively correlating with likelihood of publication. Studies with negative findings made up a small proportion of conference abstracts (9.6%) and were the least likely to be published. Given the relatively small size of the specialty of vascular surgery, it may be particularly important to be mindful of publication bias. It may be worthwhile to give additional consideration to acceptance of abstracts or publication of studies with negative results that meaningfully contribute to the literature.

Optimization of rifampin coating on covered Dacron endovascular stent grafts for infected aortic aneurysms.

OBJECTIVE: In the treatment of an infected aorta, open repair and replacement with a rifampin-impregnated Dacron vascular graft decrease the risk of prosthetic graft infections, with several protocols available in the literature. We hypothesize that the same holds true for endovascular aneurysm repair, and after studying and optimizing rifampin solution concentration and incubation period to maximize the coating process of rifampin on Dacron endovascular stent grafts (ESGs), we propose a rapid real-time perioperative protocol. METHODS: Several prepared rifampin solutions, including a negative control solution, were used to coat multiple triplicate sets of Dacron endovascular aortic stent grafts at different but set incubation periods. Rifampin elution from the grafts was studied by spectroscopic analysis. Once an optimized solution concentration and incubation time were determined, the elution of rifampin over time from the graft and the graft's surface characteristics were studied by ultraviolet-visible spectroscopy and atomic force microscopy. RESULTS: All coated ESGs with any concentration of prepared rifampin solution, regardless of incubation time, immediately demonstrated a visible bright orange discoloration and subsequently after elution procedures returned to the original noncolored state. At the 25-minute incubation time (standard flush), there was no statistical difference in the amount of rifampin coated to the ESGs with 10-mg/mL, 30-mg/mL, and 60-mg/mL solutions (0.06 ± 0.01, 0.07 ± 0.05, and 0.044 ± 0.01, respectively; P > .05). This was also true for a 10-minute incubation time (express flush) of 10-mg/mL and 60-mg/mL rifampin solution concentrations (0.04 ± 0.007 and 0.066 ± 0.014, respectively; P = .22). The elution-over-time of coated rifampin ESG, although not statistically significant, did seem to plateau and to reach a steady state by 50 hours and was confirmed by surface characteristics using atomic force microscopy. CONCLUSIONS: Having studied two variables of rifampin coating techniques to Dacron ESGs, the authors propose a rapid real-time perioperative coating protocol by using a 10-mg/mL rifampin solution for a 10-minute incubation period. As rifampin loosely binds to Dacron ESGs by weak intermolecular forces, a rifampin-coated ESG would need to be inserted in a timely fashion to treat the diseased aorta and to deliver its antibiotic affect. A rapid perioperative coating protocol followed by immediate deployment makes our proposed technique especially useful in an urgent and unstable clinical scenario.

Steroids in cardiac surgery trial: a substudy of surgical site infections.

PURPOSE: Postoperative infection, particularly in cardiac surgery, results in significant morbidity, mortality, and healthcare cost. Identification of novel predictors of postoperative infection can target high-risk populations for prophylactic intervention. METHODS: Steroids in cardiac surgery (SIRS) was a multi-centre randomized-controlled trial assessing intraoperative administration of methylprednisone during cardiac surgery, which enrolled 7,507 patients across 80 centres in 18 countries. It demonstrated that administration of steroids had no effect on mortality or major morbidity after cardiac surgery. Our primary objective was to identify risk factors for postoperative surgical site infections using SIRS participants as a cohort. We excluded patients who did not undergo surgery, died intraoperatively, or died within 48 hr of the operation. Patients were assessed for development of "surgical site infection" over the first 30 days postoperatively. Using theoretical and previously identified risk factors, we used forward stepwise entry to create a binary logistic regression model. RESULTS: Follow-up at 30 days was complete for all patients; 7,406 were included in the cohort. Surgical site infection occurred in 180 (4.8%) and 184 (5.0%) of patients in the placebo and steroid arms respectively. Significant risk factors (P < 0.05 level) included: diabetes managed with insulin (adjusted odds ratio [aOR]: 1.55; 95% confidence interval [CI] 1.13 to 2.12), oral hypoglycemics (aOR 1.60; 95% CI 1.18 to 2.16), or diet (aOR 1.81; 95% CI 1.16 to 2.83), female sex (aOR 1.34; 95% CI 1.05 to 1.71), renal failure with (aOR 2.03; 95% CI 1.06 to 3.91), and without (aOR 1.50; 95% CI 1.04 to 2.14) dialysis, > 96 min cardiopulmonary bypass (CPB) time (aOR 1.84; 95% CI 1.44 to 2.35), body mass index (BMI) < 22.3 (aOR 0.44; 95% CI 0.28 to 0.71) or > 30 (aOR 1.49; 95% CI 1.17 to 1.89), peak intensive care unit blood glucose (aOR 1.02 per mmol·L-1; 95% CI 1.00 to 1.04), and coronary artery bypass grafting (CABG) operation type (aOR 2.59; 95% CI 1.87 to 3.59). CONCLUSIONS: Patients undergoing CABG, requiring longer CPB, with higher BMI, or with diabetes, are at elevated risk of surgical site infection. Strategies to mitigate this risk warrant further investigation.

RéSUMé: OBJECTIF: L'infection postopératoire, en particulier en chirurgie cardiaque, entraîne une morbidité, une mortalité et des coûts en soins de santé significatifs. L'identification de nouveaux éléments prédictifs de l'infection postopératoire permettrait de cibler les populations à risque élevé pour offrir une intervention prophylactique. MéTHODES: L'étude des corticostéroïdes en chirurgie cardiaque (SIRS) était un essai multicentrique, randomisé et contrôlé évaluant l'administration de méthylprednisolone en peropératoire au cours de la chirurgie cardiaque; l'étude avait inclus 7 507 patients dans 80 centres répartis dans 18 pays. Elle a démontré que l'administration de stéroïdes n'avait aucun effet sur la mortalité ou morbidité majeure après la chirurgie cardiaque. Notre objectif principal était d'identifier les facteurs de risque d'infections postopératoires du site chirurgical en utilisant une cohorte constituée des participants à l'étude SIRS. Nous avons exclu les patients n'ayant pas subi de chirurgie, décédés en cours d'intervention ou dans les 48 heures suivant l'intervention. Les patients ont été évalués en fonction de l'apparition d'une « infection du site chirurgical ¼ au cours des 30 premiers jours postopératoires. Utilisant des facteurs de risque théoriques et précédemment identifiés, nous avons utilisé une introduction par étape ascendante pour créer un modèle de régression logistique binaire. RéSULTATS: Le suivi à 30 jours a été complet pour tous les patients; 7 406 patients ont été inclus dans la cohorte. Une infection du site chirurgical est survenue chez 180 (4,8 %) et 184 (5,0 %) des patients dans, respectivement, le groupe placebo et le groupe corticostéroïdes. Les facteurs de risque significatifs (pour P < 0,05) étaient notamment : un diabète géré avec de l'insuline (rapport de cotes ajusté [aOR] : 1,55; intervalle de confiance [IC] à 95 % : 1,13 à 2,12), les hypoglycémiants par voie orale (aOR : 1,60; IC à 95 % 1,18 à 2,16) ou un régime alimentaire (aOR : 1,81; IC à 95 % : 1,16 à 2,83), le sexe fémnin (aOR : 1,34; IC à 95 % : 1,05 à 1,71), une insuffisance rénale avec (aOR : 2,03; IC à 95 % : 1,06 à 3,91) et sans (aOR : 1,50; IC à 95 % : 1,04 à 2,14) dialyse, une durée de circulation extracorporelle (CEC) > 96 minutes (aOR : 1,84; IC à 95 % : 1,44 à 2,35), un indice de masse corporelle (IMC) < 22,3 (aOR : 0,44; IC à 95 % : 0,28 à 0,71) ou > 30 (aOR : 1,49; IC à 95 % : 1,17 à 1,89), un pic d'hyperglycémie en unité de soins intensifs (aOR : 1,02 par mmol·L−1; IC à 95 % : 1,00 à 1,04) et une intervention de type pontage coronarien (aOR : 2,59; IC à 95 % : 1,87 à 3,59). CONCLUSIONS: Les patients subissant des pontages coronariens, nécessitant une CEC prolongée, avec un IMC plus élevé ou un diabète sont à plus grand risque d'infection du site chirurgical. Des stratégies de limitation de ce risque justifient des investigations complémentaires.

Myocardial Injury After Noncardiac Surgery (MINS) in Vascular Surgical Patients: A Prospective Observational Cohort Study.

OBJECTIVE: To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients. BACKGROUND: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described. METHODS: This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring. RESULTS: The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%-22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%-20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%-3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46-25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1-29.1) and without an ischemic feature (12.2%; 95% CI, 5.3-25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6-82.4). CONCLUSIONS: Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.

Level of clinical evidence presented at the Society for Vascular Surgery Annual Meeting during a 5-year period (2012-2016).

OBJECTIVE: During the past decades, there has been an increasing emphasis on the use of high-quality evidence to inform clinical decision-making. The purpose of our study was to assess trends in the level of evidence (LOE) of abstracts presented at the Vascular Annual Meeting from 2012 to 2016. METHODS: All Vascular Annual Meeting abstracts for 2012 to 2016 were obtained through the Journal of Vascular Surgery. Two reviewers independently screened abstracts for eligibility. Research with a nonclinical focus was excluded from the study. Data extracted from eligible abstracts included study type (therapeutic, prognostic, diagnostic), study size, country of academic institution of primary author, presentation type, and whether the sample was recruited or from a database. Abstracts were assigned an LOE using the 2011 Oxford Centre for Evidence-Based Medicine classification scheme based on study design (eg, case series, randomized controlled trial). A χ2 test and analysis of variance test were conducted to assess nonrandom changes in LOE during the study period. RESULTS: Of the 1403 abstracts screened, 1147 were included. Inter-rater agreement was high (κ value for abstract screening was 0.93; κ value for data extraction was 0.89). Therapeutic studies were the most common study type (58%), followed by prognostic studies (37%), then diagnostic studies (5%). The majority of abstracts (75.0%) were submitted from North American institutions. Overall, 0.35% of the presentations were level I evidence, 3.1% level II, 52.8% level III, 38.0% level IV, and 5.7% level V. The average LOE per year fluctuated between 3.54 and 3.32, with a mean LOE of 3.45. The proportion of high-quality evidence (level I and level II) increased in the years 2015 and 2016, representing 78% of all level I and level II abstracts presented in the 5-year period. A χ2 test between LOE and year yielded a P value of .0084, indicating significant nonrandom change in LOE between 2012 and 2016. The majority of high LOE research was presented in poster sessions (37.5%), plenary sessions (27.5%), and international forum sessions/talks (25%) at the meeting. CONCLUSIONS: Overall, average LOE remained relatively consistent between 2012 and 2016, with most abstracts classified as level III or level IV. There was a gradual, albeit minor, increase in the proportion of level I and level II evidence in 2015 and 2016, potentially indicating the increasing commitment to producing and disseminating high-level research in vascular surgery. Furthermore, a lack of a classification tool specific to vascular surgery research occasionally presented a challenge in assigning LOE, perhaps indicating a need for such a tool in this specialty.

Distal Placement of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Restore Hemodynamic Stability in a Patient With Proximal Aortic Rupture.

PURPOSE: To report unconventional use of the resuscitative endovascular balloon occlusion of the aorta (REBOA) technique to restore hemodynamic stability in a patient who was hemorrhaging from aortic injury proximal to the target zone of occlusion. CASE REPORT: A 72-year-old woman underwent urgent thoracic stent-graft repair of a ruptured 8×8-cm mycotic pseudoaneurysm. Two months later, follow-up imaging revealed that the proximal aortic stent seal zone had degenerated, so a percutaneous procedure was performed 2 months later to preemptively reinforce the segment of stented aorta. Shortly after obtaining femoral access, the patient's condition abruptly deteriorated with profound hypotension, presumably a result of an access complication. REBOA was established in the supraceliac aorta, which sustained the mean arterial pressure while the anesthesiologist resuscitated the patient. Unexpectedly, angiography showed a rupture of the descending thoracic aorta immediately proximal to the upper stent-graft. Balloon inflation distal to the rupture site was maintained while the patient's hypotension was treated. Another stent-graft was quickly placed over the area of concern, overlapping proximal to the prior grafts. Once the aortic perforation was sealed, the patient stabilized hemodynamically. Inotropic support was weaned, and the REBOA occlusion catheter was deflated. Final angiograms of the arch and thoracic aorta confirmed no extravasation; angiograms of the infrarenal aorta and iliac arteries showed no evidence of injury. CONCLUSION: This case illustrates that applying REBOA distal to the injury site in certain clinical scenarios may sufficiently increase peripheral resistance to compensate temporarily for cardiovascular collapse secondary to aortic injury.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts.

BACKGROUND: The aim of this study is to describe our institutional experience using iliac branch grafts (IBGs) in aortoiliac aneurysm repair. METHODS: From October 2009 to April 2016, 41 consecutive patients (all men), mean age 71.7 years (range 55-87), underwent IBG implantation. Abdominal aortic aneurysm with common iliac artery involvement (n = 21) or bilateral common iliac artery aneurysms (n = 20) were indications. Computed tomography was used to evaluate patency and postoperative endoleaks within 1 month of implantation and after 1 year. RESULTS: A total of 42 IBGs were deployed in 41 patients successfully. One hundred percent of grafts implanted were patent at 1 month and at annual follow-up. There was 1 mortality at 30 days, due to acute renal failure. Sixteen type II and 1 type Ib endoleaks were found, for which 3 reinterventions were performed and the remainder treated conservatively. Five patients had complications which required reintervention. CONCLUSIONS: IBG placement has excellent short-term outcomes and potential to limit buttock claudication in the treatment of abdominal aortic aneurysms involving the iliac arteries.

Economic burden of illness associated with diabetic foot ulcers in Canada.

BACKGROUND: The primary objective was to estimate the national burden of illness in Canada for diabetic foot ulcer (DFU) for 2011. Secondary objectives included estimating the national incidence and prevalence of DFU, and the 3-year average cost for DFU incident cases. METHODS: Analyses were conducted using four national databases for the period April 1, 2006 to March 31, 2011, with cases being identified by ICD-10 CA codes. Resource utilization and costs, expressed in 2011 Canadian dollars, were estimated for DFU-related hospitalizations, emergency care (ER), same day surgeries, home care, long term care, physician visits and caregiver time losses. RESULTS: In Canada in the year 2011, DFU was associated with 16,883 hospital admissions (327,140 days), 31,095 ER or clinic visits, 41,367 rehabilitation clinic visits, and 26,493 interventions, including 6,036 amputations and 5,796 surgical debridements. This acute institution care represented $320.5 M, and with an additional $125.4 M for home care and $63.1 M for long term care, the annual cost associated with DFU-related care was $547.0 M, or $21,371 annual cost per prevalent case. In 2011, the national prevalence of DFU was 25,597 cases (75.1 per 100,000 population), consisting of 16,161 men (63.1%) and 9,436 women (36.9%), and an estimated 14,449 incident cases. For an incident case of DFU, the average 3-year cumulative cost was $52,360. CONCLUSION: The annual burden for DFU cases that have at least one admission or ER/clinic visit over a 5 year period is higher than previously reported.

Hybrid repair of symptomatic aberrant right subclavian artery and Kommerell's diverticulum.

INTRODUCTION: An aberrant right subclavian artery (ARSA) with or without an associated Kommerell's diverticulum (KOD) is a rare vascular anomaly. Patients with an ARSA may present with a variety of symptoms, including rupture. Options for repair include open, endovascular, and a hybrid approach, with no clear consensus on which is best because of the rarity of the anomaly. We present 2 cases that underwent hybrid repair and a systematic review of the literature. METHODS: A systematic review of the literature was performed from 2000-2012 searching for patients with ARSA with or without KOD who underwent endovascular repair. Twenty-four articles were identified, including a few case reports and small case series, for a total of 31 patients. A chart review was also performed on 2 patients at our institution who underwent a hybrid repair for symptomatic ARSA. RESULTS: We report the presenting history, management, and follow-up of 2 symptomatic patients with ARSA with associated KOD. Both patients underwent a hybrid approach for repair, with no reported complications. After postoperative imaging and clinical follow-up, both patients remained in good general condition without signs of vascular complications. Our systematic literature review identified 31 reported cases of patients with ARSA who underwent endovascular repair (10 patients without an associated KOD and 21 patients with a KOD). The patients ranged in age from 21-82 years of age (average: 56 years). Of these patients, 17 (55%) were women. The presenting symptoms varied, and some patients had multiple symptoms noted on presentation, including dysphagia, dyspnea, or asymptomatic patients. In those patients with an associated KOD, the average size of the diverticulum was 3.3 cm (range: 2.3-7 cm). A number of operative strategies were used in the reported cases, depending on the presence of absence of an associated KOD. The average reported duration of hospital stay was 5.4 days (range: 1-60 days). Seven patients had postoperative complications (22%). There were 3 mortalities reported (10%). Only 1 of these could be directly related to the surgical procedure. Reported decrease in aneurysm size was between 25-50%, although this was not reported for most patients. Four of 31 patients (13%) had an endoleak (1 type I endoleak, 2 type II endoleaks, and 1 type IV endoleak). The range of reported follow-up varied between 6 weeks and 92 months, with 9 patients having no follow-up reported. CONCLUSION: Hybrid approach to repair of an ARSA with associated KOD appears to be feasible, safe, and effective. Despite the poor quality and heterogeneity of the evidence available in the literature for this rare condition, we believe that this could be the preferred treatment option for an ARSA either with or without KOD.

Mortality and major postoperative complications within 1 year after vascular surgery: a prospective cohort study.

INTRODUCTION: Patients undergoing vascular procedures are prone to developing postoperative complications affecting their short­term mortality. Prospective reports describing the incidence of long­term complications after vascular surgery are lacking. OBJECTIVES: We aimed to describe the incidence of complications 1 year after vascular surgery and to evaluate an association between myocardial injury after noncardiac surgery (MINS) and 1­year mortality. PATIENTS AND METHODS: This is a substudy of a large prospective cohort study Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION). Recruitment took place in 28 centers across 14 countries from August 2007 to November 2013. We enrolled patients aged 45 years or older undergoing vascular surgery, receiving general or regional anesthesia, and hospitalized for at least 1 night postoperatively. Plasma cardiac troponin T concentration was measured before the surgery and on the first, second, and third postoperative day. The patients or their relatives were contacted 1 year after the procedure to assess the incidence of major postoperative complications. RESULTS: We enrolled 2641 patients who underwent vascular surgery, 2534 (95.9%) of whom completed 1­year follow­up. Their mean (SD) age was 68.2 (9.8) years, and the cohort was predominantly male (77.5%). The most frequent 1­year complications were myocardial infarction (224/2534, 8.8%), amputation (187/2534, 7.4%), and congestive heart failure (67/2534, 2.6%). The 1­year mortality rate was 8.8% (223/2534). MINS occurred in 633 patients (24%) and was associated with an increased 1­year mortality (hazard ratio, 2.82; 95% CI, 2.14-3.72; P <0.001). CONCLUSIONS: The incidence of major postoperative complications after vascular surgery is high. The occurrence of MINS is associated with a nearly 3­fold increase in 1­year mortality.

Risk Factors for Hospital Readmission Following Noncardiac Surgery: International Cohort Study.

Objective: To determine timing and risk factors associated with readmission within 30 days of discharge following noncardiac surgery. Background: Hospital readmission after noncardiac surgery is costly. Data on the drivers of readmission have largely been derived from single-center studies focused on a single surgical procedure with uncertainty regarding generalizability. Methods: We undertook an international (28 centers, 14 countries) prospective cohort study of a representative sample of adults ≥45 years of age who underwent noncardiac surgery. Risk factors for readmission were assessed using Cox regression (ClinicalTrials.gov, NCT00512109). Results: Of 36,657 eligible participants, 2744 (7.5%; 95% confidence interval [CI], 7.2-7.8) were readmitted within 30 days of discharge. Rates of readmission were highest in the first 7 days after discharge and declined over the follow-up period. Multivariable analyses demonstrated that 9 baseline characteristics (eg, cancer treatment in past 6 months; adjusted hazard ratio [HR], 1.44; 95% CI, 1.30-1.59), 5 baseline laboratory and physical measures (eg, estimated glomerular filtration rate or on dialysis; HR, 1.47; 95% CI, 1.24-1.75), 7 surgery types (eg, general surgery; HR, 1.86; 95% CI, 1.61-2.16), 5 index hospitalization events (eg, stroke; HR, 2.21; 95% CI, 1.24-3.94), and 3 other factors (eg, discharge to nursing home; HR, 1.61; 95% CI, 1.33-1.95) were associated with readmission. Conclusions: Readmission following noncardiac surgery is common (1 in 13 patients). We identified perioperative risk factors associated with 30-day readmission that can help frontline clinicians identify which patients are at the highest risk of readmission and target them for preventive measures.

Mortality and reintervention following elective abdominal aortic aneurysm repair.

BACKGROUND: The objective of this study is to provide an up-to-date meta-analysis on the short- and long-term mortality rates of elective repair of abdominal aortic aneurysms (AAAs) via the open and endovascular approaches. METHODS: MEDLINE, EMBASE, and Cochrane Central Register of Controlled trials, conference proceeding from major vascular meetings were searched for randomized trials comparing open vs elective endovascular aneurysm repair (EVAR) of AAAs. A random-effects model was used for analysis. Risk ratio (RR) and 95% confidence intervals (CIs) of open vs EVAR were calculated for short- and long-term mortality and reintervention rates. RESULTS: The analysis encompassed four randomized controlled trials with a total of 2783 patients. The open repair group resulted in significantly increased 30-day postoperative all-cause mortality compared with EVAR repair group (3.2% vs 1.2%; RR, 2.81; 95% CI, 1.60-4.94); however, there is no statistical difference in the long-term all-cause mortality between both groups (RR, 0.97; 95% CI, 0.86-1.10). Interestingly, fewer patients underwent reintervention procedures in the open repair group compared with those who had EVAR repair (9.3% vs 18.9%; RR, 0.49; 95% CI, 0.40-0.60), but this finding is doubtful due to the large heterogeneity. Lastly, no statistical difference in long-term mortality rates attributable to cardiovascular disease (CVD), aneurysm related, or stroke were found between the two types of repair. CONCLUSIONS: Results of this meta-analysis demonstrate that the 30-day all-cause mortality rate is higher with open than with EVAR repair; however, there is no statistical difference in the long-term all-cause and cause-specific mortality between both groups. The reintervention rate attributable to procedural complication was higher in the EVAR group. Because of the equivalency of long-term outcomes and the short-term benefits of EVAR, an endovascular-first approach to AAAs can be supported by the meta-analysis.

Acute aortic intraluminal thrombus with embolisation and lower-limb ischaemia following intravenous iron sucrose infusion reaction.

A woman in her 50s developed iron deficiency anaemia. Her medical history included hypertension, asthma and remote postpartum pulmonary embolism. There was a strong family history of atherosclerosis. After receiving intravenous iron sucrose (500 mg), she developed vomiting and large-volume diarrhoea, followed by diaphoresis, back pain, haemoconcentration (haematocrit increase, 0.242 to 0.326), leucocytosis and platelet count decline. Myocardial infarction was ruled out and the truncal pain subsided. However, 2 days postdischarge, she was diagnosed with aortic intraluminal thrombus (ILT) with embolisation into the lower extremities. The limbs were salvaged by emergency embolectomies and fasciotomies. Acute aortic ILT is a rare disorder that has not been previously reported as a complication of parenteral iron therapy. We postulate that acute intravascular volume losses (vomiting and diarrhoea) with resulting haemoconcentration and catecholamine-associated platelet activation and consumption, in a patient with subclinical aortic atherosclerosis, triggered acute aortic ILT presenting as lower-limb ischaemia.

The Association of Cannabis Use Disorder with Acute Limb Ischemia and Critical Limb Ischemia.

OBJECTIVES: Heavy cannabis use has been associated with the development of acute myocardial infarction and stroke. The objective of this study was to determine if heavy, chronic cannabis use is associated with the development of acute limb ischemia (ALI) or critical limb ischemia (CLI). METHODS: We conducted a retrospective cohort study within the National Inpatient Sample (2006-2015). Patients without cannabis use disorder (CUD) were matched to patients with CUD in a 2:1 ratio using propensity scores. Our primary outcomes were incidence of ALI and CLI. Secondary outcomes included incidence of acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), frequency of open or endovascular interventions, length of stay, and total costs. Sensitivity analyses were performed with alternative models, including in the entire unmatched cohort with regression models utilizing survey weights to account for sampling methodology. RESULTS: We identified a cohort of 46,297 857 unmatched patients. Patients with CUD in the unmatched cohort were younger, with less cardiovascular risk factors, but higher rates of smoking and substance abuse. The matched cohort included 824,856 patients with CUD and 1,610,497 controls. Those with CUD had a higher incidence of ALI (OR 1.20 95% CI: 1.04-1.38 P=.016). Following multiple sensitivity analyses, there was no robust association between CLI and CUD. We observed no robust association of CUD with AMI, CMI, procedures performed, frequency of amputation, costs, or total length of stay. CONCLUSIONS: Cannabis use disorder was associated with a significantly higher incidence of admission for acute limb ischemia. CUD was not associated with an increased risk of critical limb ischemia following sensitivity analysis. Given CUD is often seen in younger, less co-morbid patients it provides an important target for intervention in this population.