The Implications of Acute Anatomic Injury After Percutaneous Renal Intervention.

PURPOSE: Percutaneous renal artery revascularization for hypertension and renal dysfunction remains common. The frequency, cause, and outcomes of anatomic injury associated with renal intervention are poorly delineated. This study aims to determine the frequency of acute anatomic renal injury after renal artery interventions, identify factors associated with anatomic renal injury, and determine whether anatomic renal injury related to renal intervention is associated with late adverse clinical events. METHODS: A retrospective analysis of patients undergoing renal artery interventions for atherosclerotic renal artery disease between 2002 and 2022 was performed. Acute anatomic renal injury encompassed renal artery dissection, renal artery perforation, acute occlusion, renal parenchymal infarction, and renal parenchymal perforation. Freedom from renal-related morbidity (increase in persistent creatinine >20% of baseline, progression to hemodialysis, death from renal-related causes) and patient survival were measured. RESULTS: A total of 968 patients underwent 1309 renal artery interventions: 47% for hypertension, 25% for hypertension associated with chronic renal dysfunction, and 28% for chronic renal dysfunction. An acute anatomic renal injury occurred in 5.9% of the patients. The occurrence of an anatomic injury was associated with a significant decrement in freedom from renal-related morbidity (79±2% vs 55±8%, no-injury vs injury group, mean±standard error of the mean; p=0.003) and markedly decreased survival at 5 year follow-up (78±3% vs 48±8%; p=0.002). No factor was identified that predicted anatomic injury. In those patients with anatomic injury, perforation was associated with decreased survival, while estimated glomerular filtration rate <60, resistive index >0.8, and dissection were associated with a lack of retained renal benefit. CONCLUSION: Acute anatomic renal injury occurs in approximately 6% of patients undergoing percutaneous renal artery intervention and is a negative predictor of survival and is associated with subsequent renal failure, need for dialysis, and death from renal-related causes. CLINICAL IMPACT: Acute anatomic renal injury occurs in approximately 5% of patients undergoing percutaneous renal artery intervention. Modern endovascular interventions allow for the control and remediation of injuries in the majority of cases with an overall low mortality and morbidity. There is a significant early occlusion of renal arteries following the injury within 1 month. In the long term, the occurrence of injury is a negative predictor of survival and is associated with subsequent renal failure, the need for dialysis, and death from renal-related causes.

Management of depth to achieve timely arteriovenous fistula utilization.

OBJECTIVE: Failure to achieve timely arteriovenous fistulae (AVFs) utilization due to excessive depth (>6 mm) remains an ongoing concern for dialysis access. This study evaluates the outcomes of radiocephalic (RCF) and brachiocephalic (BCF) fistula elevation required for access utilization. METHODS: A retrospective review of all patients undergoing first-time autologous access over 10 years was undertaken. RCF and BCF were analyzed, and cases of initial access failure due to depth alone were selected for study. Primary and staged brachio-basilic AVF were excluded. Outcomes of early thrombosis, line placement, maturation (successful progression to hemodialysis [HD), reintervention, and functional dialysis (continuous HD for 3 consecutive months) were examined. RESULTS: From January 2012 to December 2022, 1733 patients (67% female; mean age, 61 ± 14 years) underwent autologous AVF placement. Of these, 298 patients (17%) had depth-related AVF access issues (BCF, 71% and RCF, 29%). Nineteen percent of these AVFs underwent a primary balloon-assisted maturation (BAM), and 2% had side branch coil embolization before consideration for elevation. The average time to intervention for depth was 11 ± 4 weeks after primary creation. During elevation, side branch ligation occurred in 38% of cases, and 15% underwent intraoperative BAM, The pre-elevation depth was 8.2 ± 3.1 mm, and the mean post-elevation depth was 4.7 ± 2.9 mm (P = .002). Early thrombosis (<18 days) occurred in 4% of cases. There was no mortality, and the 30-day major adverse cardiac event rate was 2%, with a 30-day morbidity of 5%, which was driven by wound issues. Six percent of the AVFs underwent follow-up BAM within 3 months. Mean maturation of the AVFs was 74% ± 3% vs 72% ± 3% (P = .58) for the elevation vs no-elevation groups at 24 weeks, respectively. However, there was an increase in tunneled central line placement in pre-emptive fistula patients due to the delay in maturation (elevation, 17% vs no-elevation, 8%; P = .008). There was a mean successful access time of 6 ± 3 weeks after elevation (16 ± 4 weeks after access creation). There was a median of 2.4 secondary interventions per year after elevation compared with a median of 2.7 secondary interventions per year without elevation. Mean access functionality was 68% ± 8% vs 75% ± 8% at 3 years for the elevation vs no-elevation groups, respectively (P = .25). CONCLUSIONS: Elevation of deep BCF and RCF occurs late after placement but can be successfully achieved with low morbidity and satisfactory long-term functionality. It results in an increase in tunneled central line placement in pre-emptive fistula patients. Elevation is a valuable adjunct to AVF maturation and enhances an autologous access policy.

Pedal medial arterial calcification influences the outcomes of isolated infra-malleolar interventions for chronic limb-threatening ischemia.

OBJECTIVE: Inframalleolar disease is present in most diabetic patients presenting with tissue loss. Inframalleolar (pedal) artery disease and pedal medial arterial calcification (pMAC) are associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). This study aimed to examine the impact of pMAC on the outcomes after isolated inframalleolar (pedal artery) interventions. METHODS: A database of lower extremity endovascular intervention for patients with tissue loss between 2007 and 2022 was retrospectively queried. Patients with CLTI were selected, and those undergoing isolated inframalleolar intervention on the dorsalis pedis and medial and lateral tarsal arteries and who had foot x-rays were identified. X-rays were assessed blindly for pMAC and scored on a scale of 0 to 5. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention to treat analysis by the patient was performed. Amputation-free survival (survival without major amputation) was evaluated. RESULTS: A total of 223 patients (51% female; 87% Hispanic; average age, 66 years; 323 vessels) underwent isolated infra-malleolar intervention for tissue loss. All patients had diabetes, 96% had hypertension, 79% had hyperlipidemia, and 63% had chronic renal insufficiency (55% of these were on hemodialysis). Most of the patients had Wound, Ischemia, and foot Infection (WIfI) stage 3 disease and had various stages of pMAC: severe (score = 5) in 48%, moderate (score = 2-4) in 31%, and mild (score = 0-1) in 21% of the patients. Technical success was 94%, with a median of one vessel treated per patient. All failures were in severe pMAC. Overall, major adverse cardiovascular events was 0.9% at 90 days after the procedure. Following the intervention, most patients underwent a planned forefoot amputation (single digit, multiple digits, ray amputation, or trans-metatarsal amputation). WIfI ischemic grade was improved by 51%. Wound healing at 3 months was 69%. Those not healing underwent below-knee amputations. The overall 5-year amputation-free survival rate was 35% ± 9%. The severity of pMAC was associated with decreased AFS. CONCLUSIONS: Increasing severity of pMAC influences the technical and long-term outcomes of infra-malleolar intervention in diabetes. Severe pMAC is associated with amputation and should be considered as a variable in the shared decision-making of diabetic patients with CLTI.

Improving ABSITE scores - A meta-analysis of reported remediation models.

BACKGROUND: The ABSITE is an annual formative assessment of residents' knowledge. This study examines the effects of remediation models on performance in the ABSITE. METHODS: A systemic literature review, qualitative content analysis and a quantitative meta-analysis were performed on studies from 1980 to 2018. Study quality and bias was also assessed. Main outcome measures were extracted to calculate effect sizes using a random effect model. RESULTS: Seventy-one percent of the studies considered to have acceptable quality and 79% were considered to have a low risk of bias. On qualitative content analysis, the interventions grouped into the following themes: mandatory multimodality remediation program, structured reading program, establishing a passing benchmark, problem-based learning, mandatory didactic conference attendance, learning management system and/or social media, and self-directed learning. Remediation models with the most positive effects were mandatory multimodality remediation programs (SMD 0.78, 95% confidence interval [0.27-1.28] p = 0.003) and the use of learning management systems/social media (0.74, [0.32-1.16] p = 0.001). CONCLUSION: Establishment of mandatory multimodality remediation programs and the use of a learning management systems/social media appear to be the most effective measures.

Outcomes of isolated inframalleolar interventions for chronic limb-threatening ischemia in diabetic patients.

BACKGROUND: Inframalleolar disease is present in many diabetic patients presenting with tissue loss. The aim of this study was to examine the patient-centered outcomes after isolated inframalleolar interventions. METHODS: A database of patients undergoing lower extremity endovascular interventions for tissue loss (critical limb-threatening ischemia, Wound, Ischemia, and foot Infection [WIfI] stage 1-3) and a de novo intervention on the index limb between 2007 and 2017 was retrospectively queried. Those patients with isolated inframalleolar interventions on the dorsalis pedis and medial and lateral tarsal arteries were identified. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention-to-treat analysis by patient was performed. Patient-oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (AFS; survival without major amputation), and freedom from major adverse limb events (above-ankle amputation of the index limb or major reintervention [new bypass graft, jump or interposition graft revision]) were evaluated. RESULTS: There were 109 patients (48% male; average age, 65 years; 153 vessels) who underwent isolated inframalleolar interventions for tissue loss. All patients had diabetes, and 53% had chronic renal insufficiency (47% of these were on hemodialysis). The majority of the patients had WIfI stage 3 disease. Technical success was 81%, with a median of one vessel treated per patient. Thirty-four percent of interventions were a direct revascularization of the intended angiosome in the foot. The 30-day major adverse cardiovascular event rate was 0%. The majority of patients underwent some form of planned forefoot surgery (single digit, multiple digits, ray or transmetatarsal amputation). Wound healing at 3 months in those not requiring amputation was 76%. Predictors for wound healing were improved pedal runoff score (<7), absence of infection, direct angiosome revascularization, and absence of end-stage renal disease. Those in whom the primary wounds or the initial amputation site failed to heal ultimately underwent below-knee amputations. The clinical efficacy was 25% ± 7% (mean ± standard error of the mean) at 5 years. The 5-year AFS rate was 33% ± 8%, and the 5-year freedom from major adverse limb events was 27% ± 9%. On Cox proportional multivariate analysis, predictors for AFS were absence of significant coronary disease, postprocedure pedal runoff score <7 (good runoff), WIfI stage <3, and absence of end-stage renal disease. CONCLUSIONS: Inframalleolar intervention can be successfully performed in high-risk limbs with acceptable short-term results. However, long-term AFS remains poor because of the underlying disease process.

Implications of early failure of isolated endovascular tibial interventions.

BACKGROUND: Endovascular tibial interventions for chronic limb-threatening ischemia are frequent, but the implications of early failure (≤30 days) of an isolated tibial intervention are still unclear. The aim of this study was to examine the patient-centered outcomes after early failure of isolated tibial artery intervention. METHODS: A database of patients undergoing lower extremity endovascular interventions between 2007 and 2017 was retrospectively queried. Patients with chronic limb-threatening ischemia (Rutherford classes 4, 5, and 6) were selected, and failures within 30 days were identified. Lack of technical success at the time of the procedure was an exclusion. Intention-to-treat analysis by patient was performed. Patient-oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (MALEs; above-ankle amputation of the index limb or major reintervention [new bypass graft, jump or interposition graft revision]) were evaluated. RESULTS: There were 1779 patients (58% male; average age, 65 years; 2898 vessels) who underwent tibial intervention for chronic limb-threatening ischemia; 284 procedures (16%) were early failures. In the early failure group, 124 cases (44%) were considered immediate (<24 hours), and 160 cases (56%) failed within the first 30 days after intervention. The two modes of failure were hemodynamic failure (47%) and progression of chronic limb-threatening ischemia (53%). Bypass after early failure was successful in patients with adequate vein, target vessel of ≥3 mm, and good inframalleolar runoff. Progression of symptoms was associated with major amputation in patients with Rutherford class 5 and class 6 disease. Presentation with diabetes and end-stage renal disease were identified as independent clinical predictors for early failure. Lesion calcification, reference vessel diameter <3 mm, lesion length >300 mm, and poor inframalleolar runoff were identified as independent anatomic predictors for early failure and increased MALEs. Early failure was predictive of poor long-term clinical efficacy (11% ± 9% vs 39% ± 8% at 5 years, mean ± standard error of the mean, early vs no early failure; P = .01) and amputation-free survival (16% ± 9% vs 47% ± 9% at 5 years, mean ± standard error of the mean, early vs no early failure; P = .02). CONCLUSIONS: Both clinical and anatomic factors can predict early failure of endovascular therapy for isolated tibial disease. Early failure significantly increases 30-day major amputation and 30-day MALEs and is associated with poor long-term patient-centered outcomes.

Short-term contemporary outcomes for staged versus primary lower limb amputation in diabetic foot disease.

BACKGROUND: Major lower extremity amputations remain among the most common procedures performed by vascular surgeons in patients with diabetes and its associated peripheral vascular disease. After major amputation, this population commonly suffers from high readmission rates, increased wound complications, and conversion to more proximal major amputations. These events impact quality in terms of cost, resources, and subjective quality of life. The aim of this study is to compare outcomes between primary lower extremity above-ankle amputations (primary amputation [PA]) and staged ankle guillotine amputations followed by interval formalization to an above-ankle amputation (staged amputation [SA]) for nonsalvageable infected diabetic foot disease. METHODS: A retrospective review of all de novo major lower extremity amputations performed by the vascular surgery service at a single institution between January 2014 and March 2017 was performed. Inclusion criteria were diabetic patients with foot gangrene who underwent a major de novo above- or below-knee amputation. Amputations for trauma, acute limb ischemia, or malignancy were excluded. Per institutional practice, SA was performed for uncontrolled infection and/or infection with uncontrolled diabetes, and PA was performed in the absence of active infection and in stable diabetes. The primary outcome measure was 30-day freedom from conversion to a higher level amputation. Secondary outcome measures were 30-day stump complications, 30-day readmissions, 30-day major adverse cardiovascular events, and 30-day mortality. RESULTS: One hundred sixteen patients met the inclusion criteria. Sixty-eight percent were male, 18% were active smokers, 30% had end-stage renal disease, and 22% had congestive heart failure. Sixty-one patients underwent SA, and 55 patients underwent PA. The two cohorts were well-matched by demographics and comorbidities. Consistent with the institutional practice, 57% of SA patients met two or more systemic inflammatory response syndrome criteria at presentation compared with 24% of PA patients (P = .0003). There were no 30-day mortalities. There was no significant difference in major adverse cardiovascular events between the groups (2% vs 4%; SA vs PA, respectively; P = .6). The average length of stay did not significantly differ between SA and PA (mean of 14 ± 8 days vs 11 ± 11 days; P = .1). SA patients had a lower rate of 30-day readmission (7% vs 27%; P = .005) and 30-day unplanned conversion to higher level amputation (2% vs 13%; P = .026) compared with PA patients. CONCLUSIONS: In the setting of infected diabetic foot disease, a staged lower extremity amputation achieves quality outcomes superior to a one-stage amputation, despite the former cohort's greater illness acuity level. SA should be considered in all diabetic patients presenting with active foot infection.

Upper extremity arterial endovascular interventions for symptomatic vascular access-induced steal syndrome.

BACKGROUND: Critical hand ischemia owing to vascular access-induced steal syndrome (VASS) continues to be a significant problem. The aim of this study was to examine the outcomes of arterial endovascular interventions in the upper extremity of patients presenting with VASS. METHODS: A database of patients presenting with documented VASS between 2006 and 2016 was retrospectively queried. Patients who underwent isolated endovascular intervention in the upper extremity were analyzed. RESULTS: Ninety-eight patients (66% female; average age 65 years) presented with VASS: 28 presented with upper arm atherosclerotic disease above the arteriovenous (AV) anastomosis (above elbow) and the remaining 70 patients with below AV anastomotic atherosclerotic disease at the elbow (below elbow). Sixty-three percent of the entire patient cohort (N = 65) presented with rest pain and the remainder (n = 33 [34%]) with minor digital ulceration. Of those with upper arm disease above the AV anastomosis, one-third of patients had subclavian occlusive disease and two-thirds had brachial artery occlusive disease. Patients with subclavian disease underwent stent placement, and patients with brachial artery disease underwent balloon angioplasty. Technical success was 100% (n = 28). Ninety-one percent of these patients (n = 25) had symptomatic success at 30 days and the remainder (n = 3) required proximalization of the access. Of those with below AV anastomosis at the elbow disease, all had disease in the forearm vessels with 42% (n = 29) having either the ulnar or radial artery occlusion. Balloon angioplasty was performed in one vessel in 55% (n = 38) and in two vessels in 45% (n = 32) of patients. Technical success was 79% (n = 81 of 102 vessels) with 51% of the patients (n = 36) having symptomatic success at 30 days; of those who remained symptomatic, 80% (n = 27) required proximalization of the access and 20% (n = 7) required ligation. The major adverse cardiovascular event rate for the entire patient cohort was 4% (n = 4). The 30-day complications for the entire patient cohort included continued steal (38%; all resolved with secondary procedures), thrombosis (3%; all forearm vessels treated for occlusion), bleeding (0%), infection (0%), and mortality (1%). Primary clinical success defined as the relief of distal ischemic symptoms and the preservation of a functional access site for dialysis showed rates of 42 ± 9% (mean ± standard error of the mean) and 0 ± 0% at 5 years (above and below elbow groups, respectively). CONCLUSIONS: Upper extremity interventions for VASS owing to above elbow disease are associated with a high rate of success, whereas interventions for below elbow disease have a poor clinical success with more patients requiring secondary procedures and low long-term survival for the access site. Male patients presenting with rest pain, larger forearm vessels (approximately 3 mm), short occlusive lesions (<100 mm), two-vessel runoff, and an intact palmer arch are good candidates for below elbow interventions.

Outcomes of upper extremity interventions for chronic critical ischemia.

BACKGROUND: Critical hand ischemia owing to below-the-elbow atherosclerotic occlusive disease is relatively uncommon. The aim of this study was to examine the outcomes in patients presenting with critical ischemia owing to below-the-elbow arterial atherosclerotic disease who underwent nonoperative and operative management. METHODS: A database of patients undergoing operative and nonoperative management for symptomatic below-the-elbow atherosclerotic disease between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (tissue loss and rest pain) were identified. Three management groups were identified: no revascularization (None), endovascular revascularization (Endo), and open revascularization by bypass (Bypass). Patients with acute embolism, active vasculitis, end-stage renal disease, ipsilateral dialysis access complications of steal, and ipsilateral trauma were excluded. RESULTS: One hundred eight patients (56% male; average age, 59 years) presented with symptomatic below-the-elbow disease: 93% presented with digital ulceration and the remainder with rest pain. Eighty-one percent had diabetes and 41% had chronic renal insufficiency (not on dialysis). All underwent catheter-based angiography. Fifty-three patients (49%) had no intervention and subsequently were committed to wound care; 26 of these required no further intervention, 10 had an interval palmar sympathectomy, and 17 underwent either a phalanx or digital amputation. Thirty-four patients (31%) underwent an endovascular intervention with a median of 1.5 vessels (ulnar, radial, or interosseous arteries) intervened on. Technical success was achieved in 29 patients (85%). Of the five technical failures, two went on to bypass, one had a focal endarterectomy and patch angioplasty, and one was treated conservatively. Ten patients in the Endo group required either a phalanx or digital amputation. Twenty-one patients (19%) underwent a saphenous vein bypass (reversed or nonreserved) to the radial in 12 and the ulnar in 11 limbs. In follow-up, 11 patients underwent open or endovascular intervention to maintain patency of the bypass. There were nine phalanx or digital amputations in the Bypass group. No below-the-elbow or above-the-elbow amputations were performed within 30 days. The wound healing rate without amputation was 78% (85 of 108). The predictors of wound healing were technical success of the revascularization, intact palmar arch and presence of digital run-off. The presence of an incomplete arch and poor digital run-off were associated with a phalanx or digital amputation. CONCLUSIONS: Upper extremity interventions for critical ischemia are associated with a high rate of success. Major amputations are rare and the many can be treated nonoperatively. In appropriately selected patients, both endovascular and open interventions have a high rate of success.