Heterotopic ossification in right popliteal fossa causing arterial insufficiency.

Heterotopic ossification (HO) is the abnormal formation of extra-skeletal bone in soft tissue, which can occur after trauma or surgery. HO in joints can cause pain, hinder mobility, and compress surrounding nerves and blood vessels. We present an unusual case of arterial insufficiency caused by HO in the right popliteal fossa.

Type IV Hypersensitivity Reaction after Cyanoacrylate Venous Closure.

BACKGROUND: Nonthermal endovenous closure techniques are routinely utilized to treat superficial axial venous reflux. Cyanoacrylate closure is a safe and effective modality implemented for truncal closure. However, an adverse reaction of type IV hypersensitivity (T4H), unique to cyanoacrylate, is a known risk. This study aims to evaluate the real-world incidence of T4H and examine risk factors that may predispose its development. METHODS: A retrospective review between 2012- and 2022 was performed at four tertiary US institutions to examine patients who underwent cyanoacrylate vein closure of their saphenous veins. Patient demographics, comorbidities, CEAP (Clinical [C], Etiological [E], Anatomical [A], and Pathophysiological [P]) classification, and periprocedural outcomes were included. The primary endpoint was development of T4H post procedure. Logistic regression analysis for risk factors predictive of T4H was performed. Variables with a P-value of <0.05 were deemed significant. RESULTS: 595 patients underwent 881 cyanoacrylate venous closures. Mean age was 66.2 ± 14.9, and 66% of patients were female. There were 92 (10.4%) T4H events in 79 (13%) patients. Oral steroids were administered to 23% for persistent and/or severe symptoms. There were no systemic allergic reactions to cyanoacrylate. Multivariate analysis revealed younger age (P = 0.015), active smoking status (P = 0.033), and CEAP 3 (P < 0.001) and 4 (P = 0.005) classifications as independent risk factors associated with development of T4H. CONCLUSIONS: This real-world multicenter study shows the overall incidence of T4H to be 10%. CEAP 3 and 4 patients of younger age and smokers predicted a higher risk of T4H to cyanoacrylate.

Race, sex, and socioeconomic disparities affect the clinical stage of patients presenting for treatment of superficial venous disease.

OBJECTIVE: Superficial venous disease has a U.S. prevalence of nearly 30%, with advanced disease contributing to a significant healthcare burden. Although the risk factors for venous disease are well known, the correlation between race, sex, socioeconomic status, and disease severity on presentation is not well established. The area deprivation index (ADI) is a validated metric with respect to regional geography, social determinants of health, and degree of socioeconomic disadvantage. In the present study, we aimed to identify the disparities and the effect that the ADI, in addition to race and sex, has among patients associated with an advanced venous disease presentation. METHODS: A retrospective review between 2012 and 2022 was performed at four tertiary U.S. institutions to identify patients who underwent endovenous closure of their saphenous veins. Patient demographics, state ADI, comorbidities, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, and periprocedural outcomes were included. Pearson's correlation was performed between the CEAP classification and ADI. Poisson regression analysis was performed to identify factors predicting for an increasing CEAP classification at presentation. Variables with P < .05 were deemed significant. RESULTS: A total of 2346 patients underwent endovenous saphenous vein closure during the study period, of whom 7 were excluded because of a lack of follow-up data. The mean age was 60.4 ± 14.9 years, 65.9% were women, and 55.4% were White. Of the 2339 patients, 73.3% presented with an advanced CEAP class (≥3). The mean state ADI for the entire cohort was 4.9 ± 3.1. The percent change in the CEAP classification is an increase of 2% and 1% for every level increase in the state ADI for unadjusted (incidence rate ratio [IRR] = 1.02; P < .001) and adjusted (IRR = 1.01; P < .001) models, respectively. Black race has a 12% increased risk of a higher CEAP class on presentation compared with White race (IRR = 1.12; P = .005). Female sex had a 16% lower risk of a higher CEAP presentation compared with male sex (IRR = 0.84; P < .01). CONCLUSIONS: Low socioeconomic status, Black race, and male sex are predictive of an advanced CEAP classification on initial presentation. These findings highlight the opportunity for improved mechanisms for identification of venous disease and at-risk patients before advanced disease progression in known disadvantaged patient populations.

Cause-Specific Mortality as a Sequalae of Perioperative Stroke Following Cardiac and Vascular Surgery.

BACKGROUND: There is a paucity of data regarding cause-specific mortality following a perioperative stroke. In this study, we aim to establish the risk of cause-specific mortality associated with perioperative stroke following cardiac and vascular procedures at 30 days, 90 days, and 1-year postoperative. It is hoped that this fund of knowledge will enhance perioperative risk stratification and medical management for patients who have suffered a perioperative stroke. METHODS: This is a retrospective cohort study evaluating 277,654 cardiac and vascular surgical patients dually documented within the Inpatient Discharge Claims Database and the Pennsylvania Department of Health Death Statistics database. A univariate assessment followed by a multivariate logistic regression analysis was used to determine the odds of cerebrovascular, cardiovascular, pulmonary, malignancy, infectious, and dementia causes of mortality following perioperative stroke. RESULTS: Perioperative stroke significantly increased the odds of overall mortality (P<0.0001) as well as cause-specific mortality in all categories (P<0.05) except dementia (P=0.8907) at all-time endpoints. Cerebrovascular-related mortality was most impacted by perioperative stroke [adjusted odds ratio: 34.5 (29.1, 40.9), P<0.0001 at 30 d]. CONCLUSIONS: Perioperative stroke in the cardiac and vascular surgical population is associated with increased odds of overall, cerebrovascular, cardiovascular, pulmonary, malignancy, and infectious causes of mortality at 30 days, 90 days, and 1-year postoperatively when compared with patients who did not experience a perioperative stroke.

Utilization and Outcomes of Radial Artery Access for Lower Extremity Endovascular Intervention.

INTRODUCTION: Radial artery access has become popular for cardiac interventions, but its role in lower extremity interventions is not well defined. We aimed to describe current utilization and outcomes of transradial access for lower extremity interventions. METHODS: Peripheral vascular intervention (PVI) from 2016-2020 where transradial access was employed in the Vascular Quality Initiative (VQI) registry were studied. Cases before 2016 were excluded as documentation of transradial access was not possible in earlier years. PVIs involving radial artery access were evaluated with regard to access guidance, access-site complications, target vessels treated and the technical success of these interventions. RESULTS: Of 167,098 PVIs, 1,096 (0.66%) involved radial access. Utilization varied significantly by region (P < 0.01). The left radial artery was used in 66.9% of cases. Ultrasound-guided access was documented in 72.7% of cases. There were no significant differences in age, body mass index, or sex between the transradial group and other PVIs. In 450 procedures, a second access site was utilized, most commonly a retrograde femoral access (60.0%) or retrograde pedal access (16.7%). The largest sheath was 6-Fr in 78.0%. Interventions documenting radial-only access more commonly treated the aortoiliac segment (49.4% vs. 29.5%, P < 0.001) and less commonly treated the tibial segments (7.1% vs. 32.1%, P < 0.001). Technical success was 94.0%, with inability to cross the lesion (3.1%) and residual stenosis after treatment (2.2%) being most common. There were access-site complications in 2.9%, with hematoma (2.4%) being most common. DISCUSSION: Radial access is associated with high technical success rates and low access-site complication rates. Advances in device profile and shaft length may overcome shortcomings of transradial access and lead to further utilization of this access site.

Open Surgical Secondary Interventions are More Durable than Endovascular Interventions for Lower Extremity Bypass Stenosis or Occlusion.

Objectives: Lower extremity bypasses often require secondary interventions to maintain patency. Our objectives were to characterize effectiveness of secondary interventions to maintain or restore bypass graft patency, and to compare outcomes of open and endovascular interventions. Methods: We reviewed patients who underwent lower extremity bypass at our institution from 2007 to 2010. We recorded the index bypass and subsequent ipsilateral interventions performed through 2018 or until loss of secondary patency. Patient, procedure, and anatomic data were collected. Endovascular intervention was compared with open/hybrid intervention. For outcome analysis, patency measures were defined relative to the time of the secondary intervention rather than the time of the index bypass. Results: 174 secondary interventions (56 open/hybrid, 118 endovascular; 42 for graft occlusion, and 132 for stenosis) treating 228 lesions in 97 bypasses were available for study. The index bypass was most commonly performed for tissue loss (71.1%), utilized a tibial artery target (57.7%), and used single-segment great saphenous vein (59.8%) rather than alternative vein (32.0%) or prosthetic (8.2%). A higher portion of open/hybrid interventions (51.8%) were done for graft occlusion than endovascular interventions (11.0%, P < .001). Mean follow-up for secondary interventions was 3.5 years. A multivariate Cox proportional hazards model identified female gender, prior MI, anticoagulation, occlusion, and endovascular intervention as predictors of loss of primary patency. Intervention for occlusion predicted poorer primary and secondary patency. Endovascular intervention was associated with poorer primary patency as compared to open intervention and a trend toward poorer secondary patency. Conclusions: Both open and endovascular secondary interventions on lower extremity bypasses are low-risk procedures that offer acceptable patency. Although more commonly performed in the setting of graft occlusion, open surgical interventions show improved durability compared to endovascular interventions. Some patients, including those with occluded grafts, may benefit from more liberal use of open surgical intervention to restore bypass patency.

Poor runoff and distal coverage below the knee are associated with poor long-term outcomes following endovascular popliteal aneurysm repair.

OBJECTIVE: Reports of good short-term outcomes for endovascular repair of popliteal artery aneurysms have led to an increased use of the technique. However, data are lacking on long-term limb-related outcomes and factors associated with the failure of endovascular repair. METHODS: All patients who underwent endovascular popliteal aneurysm repair (EPAR) at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event-free survival (MALE-FS) and graft loss/occlusion were analyzed with multivariable cox regression analysis and Kaplan-Meier curves. RESULTS: We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158 months). The average age was 73 ± 9.3 years. Thirty-two patients (29.1%) were symptomatic (claudication, rest pain, tissue loss, or rupture). The stent grafts crossed the knee joint in 91.4% of cases. In all, 36.8% of procedures used one stent graft, 41.0% used two stent grafts, and 22.2% of procedures used more than two stent grafts. The median arterial length covered was 100 mm, with an average length of stent overlap of 25 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had a three-vessel runoff, 20.2% had a two-vessel runoff, and 17% has a one-vessel runoff. The Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. The 1- and 3-year primary patency rates were 88.2% and 72.6%, and the 1- and 3-year major adverse limb event-free survival (MALE-FS) rates were 82% and 57.4%. The 1- and 3-year survival rates were 92.9% and 76.2%, respectively. On multivariable Cox regression, aneurysm size, one-vessel runoff, and coverage below the knee were associated with a lower 3-year MALE-FS. Coverage below the knee was also associated with a lower 3-year MALE-FS. Other anatomic or technical details were not associated with limb-related events or patency. CONCLUSIONS: This study is the largest single center analysis to describe the predictors of poor outcomes after EPAR. EPAR is a safe and effective way to treat popliteal artery aneurysms. Factors associated with poor MALE-FS after EPAR include single-vessel tibial runoff and coverage below the knee.

A prospective safety and effectiveness study using endovenous laser ablation with a 400-µm optical fiber for the treatment of pathologic perforator veins in patients with advanced venous disease (SeCure trial).

BACKGROUND: Treatment of pathologic perforator veins (PPVs) can shorten time to healing and reduce recurrence of ulcers in patients with advanced venous disease. Because of limited clinical evidence and device options, widespread adoption of PPV treatment is controversial. The objective of this study was to evaluate the safety and efficacy of endovenous laser therapy using a 400-µm optical fiber to treat PPVs. METHODS: This study was a single-arm, prospective, seven-center, nonblinded clinical study examining patients with advanced skin changes or healed or active ulceration (Clinical, Etiology, Anatomy, and Pathophysiology clinical class C4b, C5, and C6). Patients received treatment with a 1470-nm laser. Procedural technical success and 10-day primary closure were evaluated. All device-related adverse events were reported. Follow-up of patients was continued for 12 months after initial ablation. RESULTS: The primary PPV closure (at 10-day visit) rate was 76.9% (95% confidence interval, 70.3%-82.4%). Successful primary closure rates of 75.7%, 70.3%, 62.1%, 68.8%, and 71.3% of PPVs were achieved at 1 month, 3 months, 6 months, 9 months, and 12 months, respectively. Statistically significant improvements (P < .05) were seen in patients' quality of life at 1 month, 3 months, 6 months, 9 months, and 12 months compared with screening. The percentage of patients with ulcers (22.9% at screening, 14.1% at 1 month, 13.7% at 3 months, 10.1% at 6 months, 12.3% at 9 months, and 11.1% at 12 months) displayed improvement during the course of the study. Tibial deep venous thrombosis and procedural pain were the only device-related adverse events observed. CONCLUSIONS: Endovenous laser therapy for PPV using the 400-µm optical fiber with the 1470-nm laser yielded safe and effective outcomes with no major adverse sequelae.

Treatment of superficial and perforator reflux and deep venous stenosis improves healing of chronic venous leg ulcers.

OBJECTIVE: To evaluate the impact of three treatment modalities, superficial truncal vein ablation, perforator vein ablation, and deep venous stenting on venous leg ulcer (VLU) healing, as well as their cumulative effect on ulcer healing, in an attempt to establish the best algorithm for the treatment of chronic and recalcitrant VLUs. METHODS: Multicenter retrospective cohort study using a standardized database to evaluate patients with chronic venous ulcers treated between January 2013 and December 2017. RESULTS: Eight-hundred thirty-two consecutive patients with VLU were identified at 11 centers in the United States. All patients were initially managed with wound care and compression for at least 2 months. Compression and wound care management alone, used in 187 patients, led to ulcer healing in 75% of patients by 36 months. Ulcer recurrence in patients managed without surgery at 6, 12, and 24 months was 3%, 5% and 15%, respectively. Five hundred twenty-eight patients underwent ablation of incompetent superficial veins, and 344 of those also underwent incompetent perforator ablation. Patients who underwent truncal vein ablation alone had an ulcer healing rate of 51% at 36 months. Patients who received both superficial and perforator ablation were significantly younger, and had a 17% improvement in healing at 36 months (68% vs 51%, respectively), but there was no impact of combined superficial and perforator ablations on ulcer recurrence rates. One hundred thirty-four patients had stenosis of one of more lower extremity deep veins and 95 (71%) underwent endovenous stenting. Ulcer healing and recurrence rates for those who underwent stent placement alone was 77% and 27%, respectively, at 36 months. Patients who underwent deep venous stenting and ablation of both incompetent truncal and perforator veins had an ulcer healing rate of 87% at 36 months and ulcer recurrence of 26% at 24 months. CONCLUSIONS: This study demonstrates that correction of superficial truncal vein reflux, as well as deep vein stenosis, both contribute to healing of VLU. Patients who fail to heal their VLU after superficial and perforator ablation should have the iliocaval system imaged to identify hemodynamically significant stenoses or occlusions amenable to stenting, which facilitates venous ulcer healing even in patients with large ulcers.

Single- versus multiple-stage catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis does not have an impact on iliac vein stent length or patency rates.

BACKGROUND: Incomplete venous thrombolysis and residual nonstented iliac vein disease are known predictors of recurrent deep venous thrombosis (DVT). Controversy exists as to whether the number of thrombolysis sessions affects total stent treatment length or stent patency. The goal of this study was to evaluate the outcomes of patients who underwent single vs multiple catheter-directed lysis sessions with regard to stent extent and patency. METHODS: Consecutive patients who underwent thrombolysis and stenting for acute iliofemoral DVT between 2007 and 2018 were identified and divided into two groups on the basis of the number of treatments performed (one vs multiple sessions). Operative notes and venograms were reviewed to determine the number of lytic sessions performed and stent information, including size, location, total number, and length treated. End points included total stent length, 30-day and long-term patency, and post-thrombotic syndrome (Villalta score ≥5). The χ2 comparisons, logistic regression, and survival analysis were used to determine outcomes. RESULTS: There were 79 patients who underwent lysis and stenting (6 bilateral interventions; mean age, 45.9 ± 17 years; 48 female). Ten patients (12 limbs) underwent single-stage treatment with pharmacomechanical thrombolysis, and the remaining 69 (73 limbs) had two to four operating room sessions combining pharmacomechanical and catheter-directed thrombolysis. Patients who underwent a single-stage procedure were older and more likely to have a malignant disease. These patients received less tissue plasminogen activator compared with the multiple-stage group (17.2 ± 2.2 mg vs 27.6 ± 11.6 mg; P = .008). Average stent length was 8.8 ± 5.2 cm for the single-stage group vs 9.2 ± 4.6 cm for the multiple-stage group (P = .764). Patients who underwent a single-stage procedure had no difference in average length of stay from that of patients who underwent multiple sessions (8.5 days vs 5.9 days; P = .269). The overall 30-day rethrombosis rate was 7.3%. Two-year patency was 72.2% and 74.7% for the single and multiple stages, respectively (P = .909). The major predictors for loss of primary patency were previous DVT (hazard ratio [HR], 5.99; P = .020) and incomplete lysis (HR, 5.39; P = .014) but not number of procedures (HR, 0.957; P = .966). The overall post-thrombotic syndrome rate was 28.4% at 5 years and was also not associated with the number of treatment sessions. CONCLUSIONS: Single- vs multiple-stage thrombolysis for DVT is not associated with a difference in extent of stent coverage. Patency rates remain high for iliac stenting irrespective of the number of lytic sessions, provided lysis is complete and the diseased segments are appropriately stented.

Lemierre's Syndrome: An Atypical Presentation.

Septic thrombophlebitis is a rare diagnosis in this era of widespread antibiotic usage. The clinical diagnosis requires astute clinical suspicion and evaluation. We describe an asplenic 63-year-old woman who presented to the emergency department with a 24-hour history of a tender, swollen, right neck and upper chest wall. She denied any recent illnesses, but two years before, she was hospitalized and treated for Streptococcus pneumoniae meningitis and endocarditis. An enhanced computed tomography scan demonstrated inflammatory changes around a thrombosed right internal jugular vein, which extended to the brachiocephalic/superior vena cava junction. A retropharyngeal effusion was present, but no pulmonary or oropharyngeal abscess was identified. Lemierre's syndrome, although rare, must be recognized promptly to reduce morbidity and mortality associated with this condition.

Standardized care protocol and modifications to electronic medical records to facilitate venous ulcer healing.

BACKGROUND: Venous ulcers are painful, recurrent, and difficult to heal. Electronic medical records (EMRs) are often not optimized to track wounds. Specialized wound care programs may not interface with office-based records, creating a need to standardize the process of venous ulcer measurement and dressing documentation within existing systems. This work describes the creation of an EMR protocol to track venous ulcer size, to standardize dressings, to address related health issues, and to improve education of the patient. We hypothesized that the institution of an EMR protocol to track clinical features of venous ulcer patients, including wound size and health status, would facilitate wound healing. METHODS: We performed a retrospective review of a prospective database from September 2014 to May 2017. Modifications to the EMR included the formation of a venous ulcer patient list, a dressing tracker, calculation of total ulcer area, graphing of ulcer size over time, and images of the wound area. Patient education materials were created through the EMR and loaded into an automatic end-visit printout that emphasized smoking cessation, weight loss, and consultation with specialty services as necessary. Quarterly meetings with the supervising physician were established to review each patient's wound progress and to target areas of improvement. RESULTS: During the study period, 204 patients with chronic C5 and C6 disease were observed. Before the start of the project, the healing rate was 53.3%. Wound healing rates improved from 59.5% (quarter 1) to 77.94% (quarter 8). In the quarter before the project started, there were no patients who had quit or cut down on smoking or smokeless tobacco, no patients who were referred for weight loss consultation, and nine who were already patients of bariatric surgery. During the study period, 29% of patients quit smoking, 19% decreased smoking, and 20% cut down smokeless tobacco use. There were 54 patients who underwent advanced arterial evaluation; 175 patients underwent sclerotherapy and 137 patients had endovenous thermal ablation to treat axial reflux in the affected limb. The EMR modification project took 13 months to craft and to implement, with approximately 8 hours of meeting time from the surgical team. CONCLUSIONS: A comprehensive care model for venous ulcer patients through EMR modification improved overall patient care, increased communication between providers, and facilitated ulcer healing. EMR modification can be introduced with an acceptable time investment on the part of both the provider and the institutional information technology team.

Outcomes of peritoneal dialysis catheter configurations and pelvic fixation.

BACKGROUND: Laparoscopic peritoneal dialysis catheter placement has expanded indications, although a relative paucity of data exists about the best configuration for improving outcomes. The purpose of this study is to investigate the role of different catheter configurations and pelvic fixation on catheter and patient outcomes. METHODS: Retrospective chart review of patients undergoing peritoneal dialysis catheter implantation between January 1, 2013, and December 31, 2016. All procedures were conducted laparoscopically at a single center. Statistical analyses were conducted using Stata/SE 14.2. RESULTS: Buried catheter configuration was a statistically significant predictor of peritonitis compared to unburied configuration (P = 0.008). Buried catheter was exteriorized at 100 days (SD 107.8). A longer length of time to exteriorization significantly correlated with peritonitis, need for revision, and need for revision pelvic fixation (P < 0.05). Additionally, initial pelvic fixation was a significant predictor of revision (HR 3.94). CONCLUSIONS: Peritoneal dialysis catheter placement via a laparoscopic approach can be successfully performed in a diverse patient mix with positive results. However, buried catheter configuration and prophylactic pelvic fixation should be carefully employed in select patients.

Peroneal bypass versus endovascular peroneal intervention for critical limb ischemia.

OBJECTIVE: The peroneal artery is a well-established target for bypass in patients with critical limb ischemia (CLI). The objective of this study was to evaluate the outcomes of peroneal artery revascularization in terms of wound healing and limb salvage in patients with CLI. METHODS: Patients presenting between 2006 and 2013 with CLI (Rutherford 4-6) and isolated peroneal runoff were included in the study. They were divided into patients who underwent bypass to the peroneal artery and those who underwent endovascular peroneal artery intervention. Demographics, comorbidities, and follow-up data were recorded. Wounds were classified by Wound, Ischemia, foot Infection (WIfI) score. The primary outcome was wound healing; secondary outcomes included mortality, major amputation, and patency. RESULTS: There were 200 limbs with peroneal bypass and 138 limbs with endovascular peroneal intervention included, with mean follow-up of 24.0 ± 26.3 and 14.5 ± 19.1 months, respectively (P = .0001). The two groups were comparable in comorbidities, with the exception of the endovascular group's having more patients with cardiac and renal disease and diabetes mellitus but fewer patients with smoking history. Based on WIfI criteria, ischemia scores were worse in bypass patients, but wound and foot infection scores were worse in endovascular patients. Perioperatively, bypass patients had higher rates of myocardial infarction (4.5% vs 0%; P = .012) and incisional complications (13.0% vs 4.4%; P = .008). At 12 months, the bypass group compared with the endovascular group had better primary patency (47.9% vs 23.4%; P = .002) and primary assisted patency (63.6% vs 42.2%; P = .003) and a trend toward better secondary patency (74.2% vs 63.5%; P = .11). There were no differences in the rate of wound healing (52.6% vs 37.7% at 1 year; P = .09) or freedom from major amputation (81.5% vs 74.7% at 1 year; P = .37). In a multivariate analysis, neuropathy was associated with improved wound healing, whereas WIfI wound score, cancer, chronic renal insufficiency, and smoking were associated with decreased wound healing. Treatment modality was not a significant predictor (P = .15). CONCLUSIONS: Endovascular peroneal artery intervention results in poorer primary and primary assisted patency rates than surgical bypass to the peroneal artery but provides similar wound healing and limb salvage rates with a lower rate of complications. In appropriately selected patients, endovascular intervention to treat the peroneal artery is a low-risk intervention that may be sufficient to heal ischemic foot wounds.

Heel Wounds Predict Mortality but Not Amputation after Infrapopliteal Revascularization.

BACKGROUND: Ischemic heel ulcerations are generally thought to carry a poor prognosis for limb salvage. We hypothesized that patients undergoing infrapopliteal revascularization for heel wounds, either bypass or endovascular intervention, would have lower wound healing rates and amputation-free survival (AFS) than patients with forefoot wounds. METHODS: A retrospective chart review was performed on patients who presented between 2006 and 2013 to our institution with ischemic foot wounds and infrapopliteal arterial disease and underwent either pedal bypass or endovascular tibial artery intervention. Data were collected on patient demographics, comorbidities, wound characteristics, procedural details, and postoperative outcomes then analyzed by initial wound classification. The primary outcome was major amputation or death. RESULTS: Three hundred ninety-eight limbs underwent treatment for foot wounds; accurate wound data were available in 380 cases. There were 101 bypasses and 279 endovascular interventions, with mean follow-up of 24.6 and 19.9 months, respectively (P = 0.02). Heel wounds comprised 12.1% of the total with the remainder being forefoot wounds; there was no difference in treatment modality by wound type (P = 0.94). Of 46 heel wounds, 5 (10.9%) had clinical or radiographic evidence of calcaneal osteomyelitis. Patients with heel wounds were more likely to have diabetes mellitus (DM) (P = 0.03) and renal insufficiency (P = 0.004). 43.1% of wounds healed within 1 year, with no difference by wound location (P = 0.30). Major amputation rate at 1 year was 17.8%, with no difference by wound location (P = 0.81) or treatment type (P = 0.33). One- and 3-year AFS was 66.2% and 44.0% for forefoot wounds and 45.7% and 17.6% for heel wounds, respectively (P = 0.001). In a multivariate analysis, heel wounds and endovascular intervention were both predictors of death; however, there was significant interaction such that endovascular intervention was associated with higher mortality in patients with forefoot wounds (hazard ratio 2.25, P < 0.001) but not those with heel wounds (hazard ratio 0.67, P = 0.31). CONCLUSIONS: Patients presenting with heel ulceration who undergo infrapopliteal revascularization are prone to higher mortality despite equivalent rates of amputation and wound healing and regardless of treatment modality. These patients may benefit from an endovascular-first strategy.

Prior Endovascular Intervention Is Not Detrimental to Pedal Bypasses for Ischemic Wounds.

BACKGROUND: Endovascular strategies are often preferred for revascularization of ischemic foot wounds secondary to infrapopliteal disease because of the less invasive technique and faster recovery. Bypass is typically reserved for failures or lesions not amenable to balloon angioplasty. However, the effects of an endovascular-first approach on subsequent bypass grafts are largely unknown. This study evaluates the effects of prior endovascular tibial interventions (PTIs) on successive bypasses to pedal targets. METHODS: Patients who presented with ischemic tissue loss and tibial arterial occlusive disease to University of Pittsburgh Medical Center between 2006 and 2013 and underwent a surgical bypass to pedal arteries were included in this study. A retrospective chart review was conducted to obtain patient demographics, past medical history, extent of disease, prior tibial endovascular interventions, the treatment intervention, subsequent interventions, wound healing status, limb salvage, and patient survival. The primary outcome was primary patency of the pedal bypass graft. RESULTS: From 122 eligible patients, 27 had a PTI, whereas 95 had no prior endovascular tibial intervention (nPTI) in the treatment of ischemic pedal wounds with mean follow-up of 24.5 and 20.5 months, respectively (P = 0.36). The 2 groups were largely similar in terms of demographics, comorbidities, wound size, and degree of ischemia. Runoff scores between the 2 groups were also comparable (5.0 ± 1.6 for PTI and 4.8 ± 1.9 for nPTI, P = 0.59). The plantar artery was a more common target vessel in the PTI group, whereas the posterior tibial artery was targeted more often in the nPTI group (P = 0.04). At 12 months, those with a PTI exhibited a shorter primary patency (34.8% vs. 60.2%, P = 0.04). In a multivariate model, PTI was a significant risk factor for primary patency loss (hazard ratio 2.51, P = 0.004). Primary assisted patency and secondary patency were similar between the 2 groups. Wound healing was improved in those patients who had a prior endovascular intervention with 63.8% healed at 1 year compared with only 34.8% of those without intervention (P = 0.01). Amputation-free survival was similar (P = 0.68), as was survival alone (P = 0.50). CONCLUSIONS: Despite a decrease in primary patency, pedal bypass was not otherwise negatively affected by a PTI. Similar primary assisted patency, secondary patency, wound healing, and survival between the 2 patient populations indicate that an endovascular-first approach is a feasible treatment strategy to achieve similar clinical outcomes in the management of ischemic foot wounds.

Bypass versus endovascular intervention for healing ischemic foot wounds secondary to tibial arterial disease.

OBJECTIVE: Pedal (inframalleolar) bypass is a long-standing therapy for tibial arterial disease in patients with ischemic tissue loss. Endovascular tibial intervention is an appealing alternative with lower risks of perioperative mortality or complications. Our objective was to compare the effectiveness of these two treatment modalities with respect to patency and limb-related clinical outcomes. METHODS: We performed a retrospective chart review of patients presenting between 2006 and 2013 with ischemic foot wounds and infrapopliteal arterial disease who underwent a revascularization procedure (either open surgical bypass to an inframalleolar target or endovascular tibial intervention). Data were collected on baseline demographics and comorbidities, procedural details, and postprocedure outcomes. The primary outcome was successful healing of the index wound, with mortality, major amputation, and patency assessed as secondary outcomes. RESULTS: We identified 417 patients who met our eligibility criteria; 105 underwent surgical bypass and 312 underwent endovascular intervention, with mean follow-up of 25.0 and 20.2 months, respectively (P = .08). The endovascular patients were older at baseline (P = .009), with higher rates of hyperlipidemia (P = .02), prior cerebrovascular accidents (P = .04), and smoking history (P = .04). Within 30 days postoperatively, there was no difference in mortality (P = .31), but bypass patients had longer hospital length of stay (P < .0001), higher rate of discharge to nursing facility (P < .001), and higher rates of myocardial infarctions (P = .03) and wound complications (P < .001). At 6 months, the rate of wound healing was 22.4% in the bypass group compared with 29.0% in the endovascular group (P = .02). At 1 year, survival was higher after bypass (86.2% vs 70.4%; P < .0001), but freedom from major amputation was similar (84.9% vs 82.8%; P = .42). Primary patency (53.1% vs 38.2%; P = .002) and primary assisted patency (76.6% vs 51.7%; P < .0001) were higher in the bypass group, but there was no difference in secondary patency (77.3% vs 73.8%; P = .13). CONCLUSIONS: Endovascular tibial intervention is associated with poorer primary patency but similar secondary patency and wound healing rates compared with the "gold standard" of surgical bypass to a pedal target. In patients with tibial arterial disease, endovascular intervention should be considered a lower risk alternative to pedal bypass that provides similar clinical outcomes.

High mortality rates after both open surgical and endovascular thoracic aortic interventions in patients with end-stage renal disease.

BACKGROUND: Morbidity and mortality have improved with the evolution of endovascular techniques (thoracic endovascular aortic repair [TEVAR]) for thoracic aortic disease, but results after aortic intervention in patients with end-stage renal disease (ESRD) remain unclear. The objective of this study was to evaluate outcomes of open and endovascular descending thoracic aortic repair in dialysis-dependent patients. METHODS: We identified 352 patients with ESRD on dialysis undergoing open repair (n = 136) or TEVAR (n = 216) of the thoracic aorta from 2005 to 2008 using the United States Renal Data System database. Acute presentation was defined as ruptured aneurysm, dissection, or traumatic injury; all other interventions were considered elective. End points were 30-day mortality, overall survival, rates of perioperative complications, and procedural trends over time. Between-group comparisons and survival analysis used standard statistical methods. Logistic regression and Cox regression were performed using multivariate analysis. RESULTS: TEVAR subjects were older than those undergoing open repair (68.2 ± 11.5 vs 60.8 ± 13.2 years; P < .001); no other demographics differed. There were 303 patients who had thoracic or thoracoabdominal aneurysms; 47 (13.4%) were ruptured on presentation. There were 44 patients (12.5%) who had aortic dissection and 5 (1.4%) with aortic trauma. Overall 30-day mortality was 21.3% (n = 75), and it was greater for open repair (n = 41 [30.1%]) than for TEVAR (n = 34 [15.7%]; P = .002). Elective 30-day mortality for open repair (n = 27 [29.3%]) was also greater than for TEVAR (n = 24 [14.3%]; P = .005). Those with acute presentation trended toward higher mortality for open repair (n = 14 [31.8%] vs n = 10 [15.7%]; P = .17). Respiratory failure was higher for open repair (n = 69 [50.7%] vs n = 56 [25.9%]; P < .001); postoperative stroke was higher with TEVAR (n = 21 [9.7%] vs n < 10 [<7%]; P = .02). Estimated 1-year survival was 50% and did not differ between groups (44% for open repair, 53% for TEVAR). In multivariate analysis, TEVAR decreased odds of 30-day mortality compared with open repair (odds ratio, 0.41; 95% confidence interval, 0.24-0.71) but failed to demonstrate long-term survival advantage. CONCLUSIONS: In ESRD patients, TEVAR provides short-term mortality benefits compared with open repair, but long-term mortality remains high regardless of treatment modality. Elective intervention for thoracic aortic disease in this population remains high risk and should be approached with caution.

Effects of Gender Differences on Short-term Outcomes in Patients with Type B Aortic Dissection.

BACKGROUND: Gender-related differences in type B aortic dissection (TBAD) presentation and outcomes are not well understood. The objective of this study is to assess the impact of gender on short-term outcomes in patients with TBAD. METHODS: Patients with TBAD were identified from the National Inpatient Sample datasets from 2009 to 2012 according to previously published methods. The primary outcomes of interest were in-hospital mortality and major complications (renal, cardiac, pulmonary, paraplegia, and stroke related) between men and women. An inverse propensity-weighted regression was used to balance comorbid and clinical presentation differences. Subgroup analyses were performed on those undergoing endovascular (thoracic endovascular aortic repair [TEVAR]) and open repair, and for elderly patients over the age of 70. RESULTS: We identified 9855 patients with TBAD; women were fewer (43.6%, n = 4293) and presented at a later age (69.8 ± 15.5 vs. 62.8 ± 15.6, P < 0.001). Women had more comorbidities (median Elixhauser 4 [interquartile range, IQR 2-5] vs. 3 [IQR 2-5], P < 0.001) and were more often managed nonoperatively (87.4% vs. 81.8%, P < 0.001) compared with men. For those undergoing intervention, 58% (n = 903) had open repair and TEVAR rates were higher in women compared with men (45.6% vs. 40.0%, P < 0.001). Unadjusted mortality rates did not differ significantly by gender (male: 11.6% vs. female: 10.7%). In an adjusted propensity-weighted regression, gender did not significantly affect in-hospital mortality or stroke rates, but women were less likely to have acute renal failure during their hospitalization and more likely to experience cardiac events when undergoing open repair. Elderly women were also less likely to experience acute renal failure but had higher odds of cardiac events regardless of intervention compared with elderly men. CONCLUSIONS: In comparison with men, women with TBAD presented at a later age, were more likely to undergo TEVAR, sustain a perioperative cardiac event with open surgery, and were less likely to experience acute renal complications overall. Elderly women were additionally more likely to sustain a cardiac event regardless of operative status. Future studies should attempt to identify anatomic and epidemiologic reasons for these differences.

Evidence summary of combined saphenous ablation and treatment of varicosities versus staged phlebectomy.

OBJECTIVE: The objective of this review was to create an evidence summary of the available literature comparing saphenous vein ablation and concomitant phlebectomy vs ablation with staged phlebectomy. METHODS: A review of the literature for ambulatory patients treated for venous insufficiency with saphenous ablation and phlebectomy was conducted. A literature search was performed using MEDLINE, Cochrane Library, Google Scholar, and PubMed with the keywords phlebectomy, endovenous ablation, staged procedures, vein stripping, superficial venous disease, and powered phlebectomy. All studies that described a single approach, systematic reviews, case series (N < 20), and nonclinical studies were excluded. RESULTS: Eight clinical comparative studies of combined saphenous ablation and phlebectomy vs staged procedures were found: three randomized prospective studies, two prospective comparisons, and three retrospective reviews. CONCLUSIONS: Combined treatment of saphenous incompetence and symptomatic varicosities results in better short-term and better to equivalent long-term patient outcomes.