Predictors of amputation-free survival and wound healing after infrainguinal bypass with alternative conduits.

OBJECTIVE: Inadequate vein quality or prior harvest precludes use of autologous single segment greater saphenous vein (ssGSV) in many patients with chronic limb-threatening ischemia (CLTI). Predictors of patient outcome after infrainguinal bypass with alternative (non-ssGSV) conduits are not well-understood. We explored whether limb presentation, bypass target, and conduit type were associated with amputation-free survival (AFS) after infrainguinal bypass using alternative conduits. METHODS: A single-center retrospective study (2013-2020) was conducted of 139 infrainguinal bypasses performed for CLTI with cryopreserved ssGSV (cryovein) (n = 71), polytetrafluoroethylene (PTFE) (n = 23), or arm/spliced vein grafts (n = 45). Characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, and outcomes were recorded. Multivariable Cox proportional hazards and classification and regression tree analysis modeled predictors of AFS. RESULTS: Within 139 cases, the mean age was 71 years, 59% of patients were male, and 51% of cases were nonelective. More patients undergoing bypass with cryovein were WIfI stage 4 (41%) compared with PTFE (13%) or arm/spliced vein (27%) (P = .04). Across groups, AFS at 2 years was 78% for spliced/arm, 79% for PTFE, and 53% for cryovein (adjusted hazard ratio for cryovein, 2.5; P = .02). Among cases using cryovein, classification and regression tree analysis showed that WIfI stage 3 or 4, age >70 years, and prior failed bypass were predictive of the lowest AFS at 2 years of 36% vs AFS of 58% to 76% among subgroups with less than two of these factors. Although secondary patency at 2 years was worse in the cryovein group (26% vs 68% and 89% in arm/spliced and PTFE groups; P < .01), in patients with tissue loss there was no statistically significant difference in wound healing in the cryovein group (72%) compared with other bypass types (72% vs 87%, respectively; P = .12). CONCLUSIONS: In patients with CLTI lacking suitable ssGSV, bypass with autogenous arm/spliced vein or PTFE has superior AFS compared with cryovein, although data were limited for PTFE conduits for distal targets. Despite poor patency with cryovein, wound healing is achieved in a majority of cases, although it should be used with caution in older patients with high WIfI stage and prior failed bypass, given the low rates of AFS.

Capturing the complexity of open abdominal aortic surgery in the endovascular era.

OBJECTIVE: Volume and quality benchmarks for open abdominal aortic surgery and particularly open aortic aneurysm repair (OAR) in the endovascular era are guided by the Society for Vascular Surgery guidelines, but the Vascular Quality Initiative (VQI) OAR module fails to capture the full spectrum of complex OAR. We hypothesized that VQI-ineligible complex OAR would be the dominant form of open repairs performed at a VQI-participating tertiary center. METHODS: All OAR cases performed at a single tertiary care center from 2007 to 2020 were reviewed. The VQI OAR criteria were applied with exclusions (non-VQI) defined as concomitant renal bypass, clamping above the superior mesenteric artery or celiac artery, repairs performed for trauma, anastomotic aneurysm, isolated iliac aneurysm, or infected aneurysms. Linear regression was used to assess temporal trends. RESULTS: Among a total of 481 open abdominal aortic operations, 355 (74%) were OAR. The average annual OAR volume remained stable over 14 years (25 ± 6; P = .46). Non-VQI OAR comprised 54% of all cases and persisted over time (R2 = 0.047, P = .46). Supraceliac clamping (35%) was often necessary. The proportion of endograft explantation cases significantly increased over time from 4% in 2007 to 20% in 2019 (P = .01). Infectious indications represented 20% (n = 70) of cases. Visceral branch grafts were performed in 16% of all cases. OAR for ruptured aneurysm constituted 10% of cases. Thirty-day mortality was significantly higher in non-VQI vs VQI-eligible OAR cases (10% vs 4%; P = .04). CONCLUSIONS: Complex OAR comprises a majority of OAR cases in a contemporary tertiary referral hospital, yet these cases are not accounted for in the VQI. Creation of a "complex OAR" VQI module would capture these cases in a quality-driven national registry and help to better inform benchmarks for volume and outcomes in aortic surgery.

Emotional Regulation in Surgery: Fostering Well-Being, Performance, and Leadership.

Emotional regulation is increasingly gaining acceptance as a means to improve well-being, performance, and leadership across high-stakes professions, representing innovation in thinking within the field of surgical education. As one part of a broader cognitive skill set that can be trained and honed, emotional regulation has a strong evidence base in high-stress, high-performance fields. Nevertheless, even as Program Directors and surgical educators have become increasingly aware of this data, with emerging evidence in the surgical education literature supporting efficacy, hurdles to sustainable implementation exist. In this white paper, we present evidence supporting the value of emotional regulation training in surgery and share case studies in order to illustrate practical steps for the development, adaptation, and implementation of emotional regulation curricula in three key developmental contexts: basic cognitive skills training, technical skills acquisition and performance, and preparation for independence. We focus on the practical aspects of each case to elucidate the challenges and opportunities of introducing and adopting a curricular innovation into surgical education. We propose an integrated curriculum consisting of all three applied contexts for emotional regulation skills and advocate for the dissemination of such a longitudinal curriculum on a national level.

VITT following Ad26.COV2.S vaccination presenting without radiographically demonstrable thrombosis.

We report a case of vaccine-induced immune thrombotic thrombocytopenia (VITT) in a young man diagnosed 13 days after Ad26.COV2.S COVID-19 (Johnson & Johnson/Janssen) vaccination. He presented to us with 5 days of progressive left leg pain, thrombocytopenia, hypofibrinogenemia, and markedly elevated d-dimers, but without radiographically demonstrable thrombosis. Despite negative imaging, we initiated treatment of presumptive VITT given the striking clinical picture that included the timing of his recent adenovirus-based COVID-19 vaccine, leg symptoms, marked thrombocytopenia, and consumptive coagulopathy. He received intravenous immune globulin, prednisone, and argatroban and was discharged 7 days later much improved. His positive platelet factor 4 enzyme-linked immunosorbent assay antibody test returned after treatment was initiated. To our knowledge, this is the first reported case of VITT following Ad26.COV2.S vaccination presenting without radiographically demonstrable thrombosis. Our patient highlights the importance of knowing vaccine status and initiating treatment as soon as possible in the right clinical setting, even in the absence of radiographic evidence of thrombus. Early VITT recognition and treatment provide an opportunity to prevent serious thrombotic complications.

Contemporary Experience with Paravisceral Aortic Aneurysm (PVAAA) Repair in a Tertiary Center.

OBJECTIVES: To describe contemporary outcomes from a single center capable of both complex open and endovascular aortic repair for paravisceral aortic aneurysms (PVAAA). METHODS: Data on all patients receiving open or endovascular (endo) treatment for aortic aneurysms with proximal extent at or above the renal arteries and distal to the inferior pulmonary ligament (IPL) were reviewed. Coarsened exact matching (CEM) on age, aneurysm type, gender, coronary artery disease (CAD), previous aortic surgery and symptomatic status created balanced cohorts for outcomes comparisons. RESULTS: Between October, 2006 and February, 2018, 194 patients were treated for juxtarenal (40%), pararenal (21%), paravisceral (6%) and Type 4 thoracoabdominal (34%) aortic aneurysms with open (81, 42%) or endo (113, 58%) at a single tertiary center. Endo repairs included renal coverage with a bifurcated graft (2%), unilateral (13%) or bilateral (4%) renal snorkels, Z-fen (15%), multi-branched graft (IDE protocol; 62%) and unique complex configurations (4%). On multivariable analysis, patients selected for open surgery were more likely to be symptomatic, whereas older patients, female patients and those with Type 4 TAAA extent were more often selected for endovascular treatment. Matching based on the significant independent covariates reduced the open and endovascular groups by one-third. Survival at 30 days was 97% for endo and 94% for open repair, 98% for both subgroups when excluding symptomatic cases, and was not different between the matched groups (98% vs 89%; P=0.23). Hospital and ICU stays were longer in open patients (8 vs. 10 days, 2 vs. 4, both P≤0.001). Post-op CVA, MI, lower extremity ischemia, surgical site infections and reoperation were not different between matched groups (all p>0.05), while pulmonary and intestinal complications, as well as grade 1/2 renal dysfunction by RIFLE criteria, were more common after open repair (all P<0.05). Spinal cord ischemia was significantly more frequent in the unmatched Endo group (11% vs. 1%, P=0.02), but this difference was not significant after matching. Composite major aortic complications was no different between treatment groups (unmatched P=0.91, matched P=0.87). Endo treatment resulted in patients more frequently discharged to home (84% vs. 66%, P=0.02). Reintervention after 30 days occurred more frequently in the endo group (P=0.002). Estimated survivals at 1 and 5 years for endo and open are 96% vs. 81% and 69% vs. 81% respectively (Log-rank P=0.57). CONCLUSIONS: Contemporary repair of PVAAA demonstrates safe outcomes with durable survival benefit when patients are well-selected for open or complex endovascular repair. We believe these data have implications for off-label device use in the treatment of PVAAA, and that open repair remains an essential option for younger, good risk patients in experienced centers.

Exploration of Individual and System-Level Well-being Initiatives at an Academic Surgical Residency Program: A Mixed-Methods Study.

Importance: Physician well-being is a critical component of sustainable health care. There are few data on the effects of multilevel well-being programs nor a clear understanding of where and how to target resources. Objective: To inform the design of future well-being interventions by exploring individual and workplace factors associated with surgical trainees' well-being, differences by gender identity, and end-user perceptions of these initiatives. Design, Setting, and Participants: This mixed-methods study among surgical trainees within a single US academic surgical department included a questionnaire in January 2019 (98 participants, including general surgery residents and clinical fellows) and a focus group (9 participants, all clinical residents who recently completed their third postgraduate year [PGY 3]) in July 2019. Participants self-reported gender (man, woman, nonbinary). Exposures: Individual and organizational-level initiatives, including mindfulness-based affective regulation training (via Enhanced Stress Resilience Training), advanced scheduling of time off, wellness half-days, and the creation of a resident-driven well-being committee. Main Outcomes and Measures: Well-being was explored using validated measures of psychosocial risk (emotional exhaustion, depersonalization, perceived stress, depressive symptoms, alcohol use, languishing, anxiety, high psychological demand) and resilience (mindfulness, social support, flourishing) factors. End-user perceptions were assessed through open-ended responses and a formal focus group. Results: Of 98 participants surveyed, 64 responded (response rate, 65%), of whom 35 (55%) were women. Women vs men trainees were significantly more likely to report high depersonalization (odds ratio [OR], 5.50; 95% CI, 1.38-21.85) and less likely to report high mindfulness tendencies (OR, 0.17; 95% CI, 0.05-0.53). Open-ended responses highlighted time and priorities as the greatest barriers to using well-being resources. Focus group findings reflected Job Demand-Resource theory tenets, revealing the value of individual-level interventions to provide coping skills, the benefit of advance scheduling of time off for maintaining personal support resources, the importance of work quality rather than quantity, and the demoralizing effect of inefficient or nonresponsive systems. Conclusions and Relevance: In this study, surgical trainees indicated that multilevel well-being programs would benefit them, but tailoring these initiatives to individual needs and specific workplace elements is critical to maximizing intervention effects.

Transforming Surgical Education through a Resident Robotic Curriculum.

Objective: Here, we describe a systematic approach to design, implement, and assess a robotic surgery curriculum for surgical residents. By describing our process, including identifying and addressing institutional challenges, we illustrate successful development of a robust curriculum. Summary Background Data: As robotic-assisted surgeries increase, educational challenges have emerged and illustrate an alarming impact on medical training. Robotic curricula are frequently grounded in the industry's educational materials resulting in a variety of existing resident curricula that lack cognitive components and critical evaluation. As such, surgical educators struggle to identify the curricular restructuring needs that likely accompany emerging technologies. It is essential to develop a curricular framework for the surgical education community to approach the ongoing and inevitable integration of new technologies. Methods: Our process parallels the widely accepted approach to curricular development in medical education described by Kern et al. Using this 6-step model, we describe derivation of a curriculum that was data driven, features multimodal educational strategies, and provides documentation methods that allow for continued evaluation and assessment at the individual and departmental level. Results: This study highlights the systematic process of design, implementation and assessment of a robotic surgery curriculum for surgical residents. Built on a robust national and local needs assessment, and further strengthened by preemptive identification of institutional challenges, this curricular model includes a structured documentation system that allows for ongoing evaluation, assessment, and monitoring of curricular progress. Conclusions: We illustrate a robustly built curricular structure that can be adopted, adapted, and successfully implemented at other training institutions around the world.

Acute Insulin Resistance and Rapid Alterations in Neuronal Derived Blood Exosome Concentration After Branched Endovascular Aortic Aneurysm Repair.

OBJECTIVE: Hyperglycaemia following branched endovascular repair (BEVAR) of extensive aortic aneurysms is associated with post-operative lower extremity weakness (LEW). Insulin administration to maintain euglycaemia appears to decrease LEW rates. The purpose of this study was to examine changes in insulin receptor content of neuron derived blood exosomes (NDEs) after BEVAR. METHODS: Ten patients with a range of post-operative lower extremity neurological deficits after elective BEVAR were included in the study. Blood samples were collected pre-operatively, immediately after aneurysm repair, and on post-operative day 1. NDE insulin receptor substrate proteins were quantified by enzymevlinked immunosorbent assays. RESULTS: NDE levels of phosopho-serine312-type 1 insulin receptor substrate ([P-Ser312-IRS1], an inhibitor of insulin signalling) increased sevenfold in the immediate post-operative period (from 7.90 ± 0.89 to 58.54 ± 6.77 pg/mL; p < .001), whereas those of pan-tyrosine-phospho insulin receptor substrate ([P-panTyr-IRS1], which facilitates insulin signalling), rose only 50% (from 0.41 ± 0.07 to 0.63 ± 0.10 pg/mL; p = .03). As a result, the mean ratio of P-Ser312-IRS1 to P-panTyr-IRS1, which reflects the level of insulin resistance, increased fivefold immediately post-operatively (from 22.31 ± 3.28 to 106.33 ± 11.83; p < .001) and returned to normal levels by the next day (18.72 ± 1.87). CONCLUSION: BEVAR is associated with an acute state of insulin resistance within neuronal tissue. Further studies in a larger cohort of patients are needed to understand the potential interconnected processes of insulin resistance, hyperglycaemia, and spinal cord ischaemia after extensive endovascular aortic procedures.

Multibranched endovascular aortic aneurysm repair in patients with and without chronic aortic dissections.

OBJECTIVE: The objective of this study was to compare multibranched endovascular aneurysm repair (MBEVAR) of postdissection thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs) with MBEVAR of degenerative TAAAs and PRAAs and to assess the role played by the preoperative correction of potential complicating factors, such as true lumen compression and false lumen origin of vital branches, using adjunctive maneuvers. METHODS: From July 2005 to July 2017, there were 162 patients who underwent elective MBEVAR of TAAAs and PRAAs. Data on demographics, procedural details, and outcomes were collected prospectively. RESULTS: The mean age was 73 ± 8 years, and 119 of 162 (74%) were men; 19 of 162 (12%) had prior aortic dissections. Patients with dissections were younger (65 ± 11 years vs 74 ± 7 years; P = .002) and were less likely to have smoked (13/19 [68%] vs 135/143 [94%]; P = .002) or to have peripheral artery disease (0/19 [0%] vs 35/143 [24%]; P = .01) compared with those without dissections. Patients with prior dissections were more likely to have Crawford type II (10/19 [53%] vs 22/143 [15%]; P = .001) and type III (6/19 [32%] vs 16/143 [11%]; P = .03) TAAAs and were more likely to require at least one pre-MBEVAR adjunctive procedure (14/19 [74%] vs 55/143 [38%]; P = .006) compared with those without dissection. There was no difference in perioperative death, stroke, or paraplegia rates between the two groups. Median follow-up was 2.4 years (interquartile range, 0.8-4.7) and did not differ significantly between the two groups. There were no significant differences in branch vessel occlusion, endoleak rate, or aneurysm-related death between the two groups. CONCLUSIONS: Patients with chronic type B aortic dissection are more likely to have extensive aneurysms and more likely to require adjunctive procedures to provide the appropriate anatomic substrate for MBEVAR, but this does not appear to affect the conduct of MBEVAR or its outcomes.

Late graft failure is rare after endovascular aneurysm repair using the Zenith stent graft in a cohort of high-risk patients.

OBJECTIVE: Device-specific data on the long-term efficacy of endovascular aneurysm repair (EVAR) are limited by the constant evolution of stent graft design. Whereas some modifications, such as barb-mediated fixation, probably enhance durability, others, such as thin-walled fabric, are of less certain benefit. The purpose of this study was to examine 15 years of a single-center experience of EVAR using the Zenith stent graft (Cook Medical, Bloomington, Ind). METHODS: Retrospective analysis was conducted of 325 high-risk patients who underwent elective EVAR with Zenith stent grafts between October 1998 and December 2005 under a physician-sponsored investigational device exemption. Patients' charts and death registries were reviewed to identify late stent graft failures and causes of death. Late stent graft failures were defined as type I or type III endoleaks; enlarging aneurysm sac requiring revision; and limb kinking or occlusion, stent graft infection, renal artery occlusion, or aneurysm rupture occurring >30 days after the index procedure. RESULTS: The mean age at treatment was 75.9 ± 7.4 years, and 300 of 325 (92%) were men. The mean aneurysm diameter was 60 ± 9 mm, and the median main body stent graft diameter was 28 mm (range, 22-32 mm). During a median follow-up time of 5.6 years (interquartile range, 2.6-8.7 years), there were six (2%) aneurysm-related deaths caused by the following: one stent graft infection, one infection of a femoral-femoral bypass graft placed after limb occlusion, one infection of a stent graft placed to treat a type IB endoleak, and three aneurysm ruptures. There were 19 (6%) late stent graft failures occurring at a median time of 4.0 years (range, 39 days-14.6 years) after the procedure. Patients with late stent graft failure were more likely to have had impaired renal function (creatinine concentration ≥2 mg/dL; 21% vs 6%; P = .03) and less likely to have had cardiac disease (42% vs 67%; P = .04) at the time of the index procedure. There was no significant association between late stent graft failure and age, sex, aneurysm size, stent graft diameter, diabetes, smoking, or lung disease. Kaplan-Meier estimated overall survival was 60% at 5 years, 29% at 10 years, and 12% at 15 years. Kaplan-Meier estimated freedom from aneurysm-related mortality was 98% at 5 years, 97% at 10 years, and 97% at 15 years. CONCLUSIONS: Late-occurring stent graft failures and aneurysm-related death are rare after EVAR using the Zenith stent graft, especially in high-risk patients whose comorbidities diminish life expectancy.

Feasibility of Formal Mindfulness-Based Stress-Resilience Training Among Surgery Interns: A Randomized Clinical Trial.

Importance: Among surgical trainees, burnout and distress are prevalent, but mindfulness has been shown to decrease the risk of depression, suicidal ideation, burnout, and overwhelming stress. In other high-stress populations, formal mindfulness training has been shown to improve mental health, yet this approach has not been tried in surgery. Objective: To test the feasibility and acceptability of modified Mindfulness-Based Stress Reduction (MBSR) training during surgical residency. Design, Setting, and Participants: A pilot randomized clinical trial of modified MBSR vs an active control was conducted with 21 surgical interns in a residency training program at a tertiary academic medical center, from April 30, 2016, to December 2017. Interventions: Weekly 2-hour, modified MBSR classes and 20 minutes of suggested daily home practice over an 8-week period. Main Outcomes and Measures: Feasibility was assessed along 6 domains (demand, implementation, practicality, acceptability, adaptation, and integration), using focus groups, interviews, surveys, attendance, daily practice time, and subjective self-report of experience. Results: Of the 21 residents included in the analysis, 13 were men (62%). Mean (SD [range]) age of the intervention group was 29.0 (2.4 [24-31]) years, and the mean (SD [range]) age of the control group was 27.4 (2.1 [27-33]) years. Formal stress-resilience training was feasible through cultivation of stakeholder support. Modified MBSR was acceptable as evidenced by no attrition; high attendance (12 of 96 absences [13%] in the intervention group and 11 of 72 absences [15%] in the control group); no significant difference in days per week practiced between groups; similar mean (SD) daily practice time between groups with significant differences only in week 1 (control, 28.15 [12.55] minutes; intervention, 15.47 [4.06] minutes; P = .02), week 2 (control, 23.89 [12.93] minutes; intervention, 12.61 [6.06] minutes; P = .03), and week 4 (control, 26.26 [13.12] minutes; intervention, 15.36 [6.13] minutes; P = .04); course satisfaction (based on interviews and focus group feedback); and posttraining-perceived credibility (control, 18.00 [4.24]; intervention, 20.00 [6.55]; P = .03). Mindfulness skills were integrated into personal and professional settings and the independent practice of mindfulness skills continued over 12 months of follow-up (mean days [SD] per week formal practice, 3 [1.0]). Conclusions and Relevance: Formal MBSR training is feasible and acceptable to surgical interns at a tertiary academic center. Interns found the concepts and skills useful both personally and professionally and participation had no detrimental effect on their surgical training or patient care. Trial Registration: ClinicalTrials.gov identifier: NCT03141190.

The impact of prior aortic surgery on outcomes after multibranched endovascular aortic aneurysm repair.

OBJECTIVE: The purpose of this study was to evaluate the impact of prior aortic surgery on outcomes after multibranched endovascular aneurysm repair (MBEVAR) of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs). METHODS: From July 2005 to October 2016, there were 153 patients who underwent elective endovascular repair of TAAA and PRAA using multibranched stent grafts. Data on demographics, procedural details, and outcomes were collected prospectively. RESULTS: The mean age was 73 ± 8 years, and 113 of 153 (74%) were men. Mean aneurysm diameter was 67 ± 9 mm. Before MBEVAR, 68 of 153 (44%) patients had undergone a prior aortic surgery; 49 of 68 (72%) had prior open aortic surgery, 15 of 68 (22%) had prior endovascular aortic surgery, and 4 of 68 (6%) had both. There were no significant differences in age, sex, preoperative aneurysm diameter, or medical comorbidities (coronary artery disease, lung disease, diabetes mellitus, or hypertension) in patients with previous aortic surgery compared with those without. Patients with previous aortic surgery had higher fluoroscopy times (131 ± 59 vs 118 ± 54 minutes; P = .18) and procedural times (370 ± 101 vs 345 ± 118 minutes; P = .27) during MBEVAR, but these differences did not reach statistical significance. Patients without previous aortic intervention had higher rates of postoperative paraplegia (9/85 [11%]) vs (0/68 [0%]; P = .005) compared with those with previous aortic surgery. Of 153 patients, 3 (2%) had a postoperative stroke, and this was not different between the two groups. Median follow-up time was 2.5 years (interquartile range, 1.0-4.5 years) and did not differ between those with and those without previous aortic surgery. Kaplan-Meier estimated 5-year freedom from aneurysm-related mortality and overall mortality was 90% and 48%, respectively, and did not differ between the two groups. There was also no difference in branch vessel occlusion between the two groups. CONCLUSIONS: A high proportion of patients undergoing MBEVAR for TAAA or PRAA have already undergone prior open or endovascular aortic procedures, but this does not appear to increase the complication rate or affect midterm clinical outcomes. Patients with prior aortic surgery who undergo MBEVAR have lower rates of paraplegia compared with those without prior surgery, which may be due to effective recruitment of collateral circulation.

Cryopreserved saphenous vein as a last-ditch conduit for limb salvage.

OBJECTIVE: In patients lacking autogenous vein suitable for infrainguinal bypass, cryopreserved saphenous vein (CSV) allograft (CryoLife, Inc, Kennesaw, Ga) may be an acceptable alternative. The purpose of this study was to examine outcomes of CSV conduit for infrainguinal revascularization. METHODS: Between February 2008 and August 2015, 70 patients underwent infrainguinal bypass grafts in 73 limbs using CSV. All patients lacked suitable arm or leg vein. Demographic data and patient outcomes were retrospectively collected using electronic medical records. RESULTS: The mean age of our cohort was 70 ± 14 years, and 36 (51%) were male; 47 (67%) were white, 39 (56%) had coronary artery disease, 27 (39%) had diabetes, 56 (80%) had hypertension, and 50 (71%) were former or current smokers. Median follow-up was 304 days (interquartile range, 130-991 days). Indications for the index operation included rest pain (27%), tissue loss (55%), and prosthetic graft infection (18%); 62 of 73 (85%) bypasses were performed for critical limb ischemia, and 45 of 73 (62%) were redo operations. Distal targets included superficial femoral artery or popliteal (38%), tibial (55%), and pedal (7%). All grafts had a minimum diameter of 3 mm. At 30 days, 55 of 64 grafts (86%) were patent; 9 were lost to early follow-up. The only significant risk factors associated with 30-day failure were ABO mismatch (43% vs 10%; P = .05) and donor blood type B or AB (40% vs 9%; P = .03). Estimated overall 1-year primary patency was 35%. In a multivariate analysis, nonblack race (P = .05), donor B or AB blood type (P = .01), and bypass to a tibial or pedal target (P = .05) were independently associated with loss of primary patency. There were 20 (27%) major amputations, and all grafts in these limbs had occluded at the time of amputation. Of the 33 limbs with ischemic tissue loss that had long-term follow-up, 17 of 33 (52%) went on to graft occlusion, 10 of 33 (30%) had a major amputation, and 24 of 33 (73%) had complete healing of the index wound. CONCLUSIONS: In the setting of a multidisciplinary team with aggressive wound care, CSV may be a reasonable choice for infrainguinal revascularization in patients with ischemic tissue loss who lack autogenous conduit. However, poor midterm to long-term patency suggests that optimal selection of patients is needed to derive meaningful clinical benefit.

Low-profile versus standard-profile multibranched thoracoabdominal aortic stent grafts.

OBJECTIVE: This study compared midterm results using low-profile stent grafts (LPSGs; 18F) and standard-profile stent grafts (SPSGs; 22F-24F) for endovascular pararenal and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: From July 2005 to March 2015, 134 asymptomatic patients underwent endovascular repair of a pararenal or TAAA using multibranched aortic stent grafts. In March 2011, we started using a LPSG with nitinol stents and thin-walled polyester fabric. Prospectively collected data on operative repair, complications, and outcomes were compared between the two groups. RESULTS: LPSGs were used in 37 patients (8 women [21.6%]; mean ± standard deviation age, 72.5 ± 8 years) and SPSGs in 97 patients (25 [26%] women; mean age, 73 ± 8 years). Medical comorbidities, aneurysm size, and aneurysm extent were similar in the LPSG and SPSG groups. Mean follow-up time was longer in the SPSG group (3.1 ± 2 years) than in the LPSG group (1.3 ± 0.9 years; P < .001). Operative time, renal failure, stroke, myocardial infarction, and perioperative death were not significantly different between the two groups (P > .05). Aneurysm-related death, rupture, stent graft migration, type I or III endoleaks, aneurysm enlargement >5 mm, branch vessel occlusion, and reintervention rates were similar between the two groups (P > .05). However, the combined outcome of conduit use or access artery injury occurred at a lower rate in the LPSG group than in the SPSG group (16% vs 36%; P = .03). Women experienced significantly higher rates of conduit use and access artery injury than men after repair with SPSGs (64% vs 26%, respectively; P = .001) but similar rates after repair with the LPSG (25% vs 14%, respectively; P = .45). CONCLUSIONS: LPSGs had similar safety profile and midterm outcomes compared with the SPSGs for treatment of pararenal and TAAA. The substitution of LPSGs for SPSGs lowered the number of patients who required conduit insertion to avoid access artery injury, especially in women, thereby reducing an otherwise striking gender difference.

Standard off-the-shelf versus custom-made multibranched thoracoabdominal aortic stent grafts.

OBJECTIVE: The complex aortic branch anatomy in thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs) presents a challenge for endovascular repair. The multibranched endovascular device has durable midterm results with use of a custom branch stent graft (CSG) configuration. The midterm results with use of the standard branch stent graft (SSG) configuration are unknown, but it has the advantage of off-the-shelf technology. The goal of this study was to compare the midterm outcomes of CSG and SSG multibranched endovascular devices. METHODS: From July 2005 to September 2014, 133 patients underwent elective endovascular repair of TAAA and PRAA in a prospective trial. Beginning in December 2008, SSGs were used in those with suitable anatomy. RESULTS: Fifty patients (mean age, 71 ± 7 years; 11 women [22%]) were treated using SSGs, and 83 patients (mean age, 74 ± 9 years; 22 women [26.5%]) underwent repair using CSGs. The SSG and CSG groups were similar with regard to aneurysm size, aneurysm extent, and medical comorbidities, with the sole exception of lung disease, which was more common in the SSG group. All stent grafts were deployed as intended, with no conversions to open repair. Mean ± standard deviation follow-up (days) was 694 ± 525 for the SSG group and 942 ± 764 for the CSG group (P = .045). There were no significant differences in aneurysm-related death, renal failure requiring dialysis, stroke, endoleak, visceral or renal branch occlusion, lower extremity weakness, or reintervention (P > .05 for each). The volume of contrast material was significantly lower in those with SSGs compared with CSGs (P = .016), but there were no significant differences in operative or fluoroscopy times. Time to treatment (days from consent to surgery) was significantly lower in SSG patients compared with CSG patients (P = .01). CONCLUSIONS: For patients with suitable anatomy, the use of SSGs for TAAA and PRAA repair results in significantly shorter wait times to surgery and is as safe, effective, and durable in the midterm compared with CSGs.

Risk Factors for 30-Day Hospital Readmission in Patients Undergoing Treatment for Peripheral Artery Disease.

Early hospital readmission among vascular surgery patients is a focus of Medicare's new reimbursement structure. We aim to identify factors associated with 30-day readmission after lower extremity interventions to treat peripheral artery disease (PAD). Retrospective analysis of 174 consecutive patients discharged from the vascular surgery service between January 1, 2011, and July 31, 2012, after procedures for lower extremity PAD was performed. Of 174 patients, 37 were readmitted within 30 days of discharge. There were no significant differences in baseline characteristics between the readmitted and the nonreadmitted groups. In a multivariate logistic regression model, urgent operation and advanced chronic kidney disease (CKD) were associated with increased risk of 30-day readmission. The most common reasons for readmission were infection of the surgical site or index limb (18 of 37), followed by unresolved limb symptoms (13 of 37). The 30-day readmission is frequent after lower extremity interventions to treat PAD. Urgent operative intervention and advanced CKD appear to be risk factors for early hospital readmission.

Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts.

OBJECTIVE: We conducted our study to describe the incidence, presentation, management, risk factors, and outcomes of lower extremity weakness (LEW) after elective endovascular aneurysm repair with multibranched thoracoabdominal stent grafts. METHODS: Excluding symptomatic patients and those with aortic dissection, between July 2005 and October 2013, 116 patients with aortic aneurysms were treated in a prospective, single-center trial of multibranched endovascular aneurysm repair. LEW that resolved within 30 days of operation was classified as transient. Persistent LEW was defined as inability to walk or stand 30 days after surgery. Perioperative spinal cord protection measures included bypass as needed to maintain flow to the subclavian and internal iliac arteries, cerebrospinal fluid drainage, and permissive hypertension. RESULTS: Postoperative LEW occurred in 24 of 116 patients (20.6%). In 15 (12.9%), LEW was transient with full recovery. Nine patients (7.7%) had persistent LEW, three with paraparesis and six with paraplegia. Five of 24 patients (21%) awoke from anesthesia with LEW. Symptoms of LEW developed within 72 hours of operation in 14 of 24 (58%). Late-onset LEW (≥72 hours postoperatively) always occurred in the presence of a precipitating hypotensive event (5 of 24; 21%). Univariate analysis showed no association between LEW and Crawford type, staged repair, aneurysm extent, or postoperative endoleak. Baseline glomerular filtration rate <30 mL/min/1.73 m(2) (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.2-14.6; P = .03), fluoroscopy time >190 minutes (OR, 3.6; 95% CI, 1.0-12.7; P = .04), and sustained hypotension (OR, 2.9; 95% CI, 1.1-7.7; P = .04) were identified as independent risk factors for LEW in multivariate analysis. CONCLUSIONS: Most episodes of LEW after multibranched endovascular aneurysm repair are transient and do not occur in the operating room. Adjunctive strategies to maintain spinal perfusion, including cerebrospinal fluid drainage and permissive hypertension, may help prevent permanent LEW.

Visceral branch occlusion following aneurysm repair using multibranched thoracoabdominal stent-grafts.

PURPOSE: To identify risk factors for late-occurring branch occlusion following multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysm. METHOD: Out of 120 patients who underwent multibranched endovascular aneurysm repair between September 2005 and May 2013, 100 (78 men; mean age 72.4 ± 7.4 years) met the criteria for inclusion in the current retrospective analysis. Demographic data were gleaned from a prospectively maintained database. Mean aneurysm diameter was 66.7 ± 11.7 mm. Multiplanar reconstructions of postoperative computed tomographic angiography were used to measure 6 parameters of renal branch morphology. RESULTS: All 100 patients had undergone successful placement of multibranched aortic stent-grafts with a total of 95 celiac branches, 100 superior mesenteric artery (SMA) branches, and 187 renal branches. During a mean follow-up of 25.6 months, there were no stent fractures or stent separations, no SMA occlusions, and only 2 (2.1%) celiac artery occlusions, neither of which required reintervention. In contrast, there were 18 (9.6%) renal branch occlusions in 16 patients, all men (p=0.02). Patients with renal branch occlusions were significantly more likely to have a history of myocardial infarction (p=0.004). The mean renal artery length was significantly greater in the occlusion group compared to the non-occlusion group (47.5 ± 13.6 vs. 39.4 ± 14.2, p=0.03). No other aspect of branch morphology was significantly different between the occlusion and non-occlusion groups. CONCLUSION: Renal branch occlusion was by far the commonest late failure mode after multibranched endovascular aneurysm repair. The current study provides no basis for a change in patient selection or stent-graft design, only a change in the components used to construct renal branches. It is too early to tell the effect this will have.