Understanding and addressing varying perceptions of autonomy.

Recently, there has been a major shift in the concept of resident autonomy in the operating room. As a result, surgical residents' independence has decreased during their training years. This change has been secondary to multiple factors, including fragmented attending resident interactions, hospital demands for productivity, operating room efficiency, and the public's perception of resident participation in surgery. Multiple gender, personality, and racial biases have also influenced the autonomy of surgical residents. In this paper, we have analyzed the impact of all these factors on the current state of resident autonomy after reviewing relevant literature. We have proposed a strategy to increase resident autonomy via increased resident and faculty interactions, case planning, and encouraged recruitment of diverse vascular surgery trainees and faculty.

Women are Not at Higher Risk for Reintervention or Major Amputation after Lower Extremity Atherectomy for Peripheral Artery Disease.

BACKGROUND: Our objective was to compare short-term and long-term differences in reintervention-free and major amputation-free survival between female and male patients undergoing lower extremity atherectomy for peripheral artery disease. METHODS: We analyzed lower extremity atherectomy procedures performed on 294 patients between January 2014 and September 2019. Reintervention was defined as either open bypass or endovascular procedure to the same region following the index operation. Kaplan-Meier (KM) survival analysis was performed to compare reintervention-free and major amputation-free survival between sexes. Multivariate logistic regression analyses were performed to determine the adjusted odds of reintervention and major amputation based on sex. We conducted subgroup analyses by anatomic region (femoropopliteal vs. tibial), indication (claudication vs. chronic limb-threatening ischemia (CLTI)), and balloon type (drug-coated balloon (DCB) versus plain balloon angioplasty (POBA)) across sexes. RESULTS: Of the 294 patients, 125 (42.5%) were female. Compared to men, women receiving atherectomy were more likely to be Black (28.0% vs. 16.6%; P = 0.018), a nonsmoker (44.8% vs. 21.3%; P < 0.001), and present with CLTI (55.2% vs. 43.2%; P = 0.042). There were no differences in atherectomy region, lesion type, or balloon type between sexes. KM analysis showed similar 4-year reintervention-free survival (68.8% vs. 75.1%; P = 0.88) and major amputation-free survival (97.6% vs. 97.6%; P = 0.41) between sexes. Women and men had similar reintervention-free survival when grouped by femoropopliteal (67.9% vs. 70.8%; P = 0.69) or tibial (76.2% vs. 83.9%; P = 0.68) atherectomy region. Indication (claudication versus CLTI) did not affect reintervention-free survival in either women (64.5% vs. 69.6%; P = 0.28) or men (68.5% vs. 76.7%; P = 0.84). KM curves for DCB versus POBA were also similar between sexes and showed an early benefit in reintervention rate favoring DCB, which dissipated in both women (65.4% vs. 72.7%; P = 0.61) and men (75.5% vs. 78.4%; P = 0.18) by 3 years. CONCLUSIONS: Compared to men, women demonstrate commensurate benefit from atherectomy for lower extremity revascularization. There were no differences seen in long-term reintervention or major amputation between sexes.

Double-barrel iliocaval reconstruction using closed-cell dedicated venous stents.

OBJECTIVE: Double-barrel iliocaval reconstruction is performed by deploying two stents simultaneously in a side-by-side, or "double-barrel," configuration in the inferior vena cava (IVC) with extension into the bilateral common iliac veins. The aim of this study was to examine the outcomes of double-barrel reconstruction using closed-cell dedicated venous stents for the treatment of iliocaval deep venous thrombosis and iliac vein compression syndrome. METHODS: All endovascular procedural reports comprising vascular surgery and interventional radiology operators from a single urban academic hospital between May 1, 2019, and April 30, 2021, were retrospectively searched. A cohort of 22 consecutive patients who underwent double-barrel iliocaval stenting with closed-cell dedicated venous stents for chronic or acute-on-chronic iliocaval venous disease without prior endovascular iliocaval repair was identified. Baseline characteristics, procedural data, and patient outcomes were determined via a manual review of preprocedure clinical notes, diagnostic imaging studies, procedure notes and images, and follow-up clinical notes. RESULTS: The median (range) age was 59 (27-81) years, and the cohort consisted of 59.1% female. The most common presenting symptoms of venous disease were lower extremity swelling (90.9%) and pain (50.0%). CEAP clinical classification was C3 in 86.4% of patients, whereas the remainder had C4 disease. Most patients (72.7%) had post-thrombotic syndrome, 22.7% had a nonthrombotic iliac vein lesion, and one patient (4.5%) had the congenital absence of the infrarenal IVC. A total of 40.9% of patients had a pre-existing IVC filter at the time of treatment. Six of the 22 patients underwent concurrent pharmacomechanical thrombectomy during the index iliocaval reconstruction and stenting procedure. The number of stents placed ranged from 2 to 5. With a mean follow-up period of 7.1 months, ranging from 12 days to 16.7 months, the freedom from reintervention rate was 90.9%. Twenty of 22 patients achieved subjective improvement or resolution of symptoms. The major adverse event rate was 9.1%, as two patients had access site complications requiring intervention. CONCLUSIONS: Double-barrel iliocaval reconstruction with closed-cell dedicated venous stents for the treatment of post-thrombotic syndrome or iliac vein compression syndrome is technically feasible and clinically effective with a low reintervention rate.

Follow-up after acute thrombotic events following COVID-19 infection.

OBJECTIVE: COVID-19 infection results in a hypercoagulable state predisposing patients to thrombotic events. We report the 3- and 6-month follow-up of 27 patients who experienced acute arterial thrombotic events in the setting of COVID-19 infection. METHODS: Data were prospectively collected and maintained for all vascular surgery consultations in the Mount Sinai Health System from patients who presented between March 16 and May 5, 2020. RESULTS: Twenty-seven patients experienced arterial thrombotic events. The average length of stay was 13.3 ± 15.4 days. Fourteen patients were treated with open surgical intervention, six were treated with endovascular intervention, and seven were treated with anticoagulation only. At 3-month follow-up, 11 patients (40.7%) were deceased. Nine patients who expired did so during the initial hospital stay. The 3-month cumulative primary patency rate for all interventions was 72.2%, and the 3-month primary patency rates for open surgical and endovascular interventions were 66.7 and 83.3, respectively. There were 9 (33.3%) readmissions within 3 months. Six-month follow-up was available in 25 (92.6%) patients. At 6-month follow-up, 12 (48.0%) patients were deceased, and the cumulative primary patency rate was 61.9%. The 6-month primary patency rates of open surgical and endovascular interventions were 66.7% and 55.6%, respectively. The limb-salvage rate at both 3 and 6 months was 89.2%. CONCLUSIONS: Patients with COVID-19 infections who experienced thrombotic events saw high complication and mortality rates with relatively low patency rates.

Neutrophil-to-Lymphocyte Ratio Associated With Adverse Events After Endovascular Aneurysm Repair (EVAR).

BACKGROUND: The blood neutrophil-to-lymphocyte ratio (NLR) is a surrogate biomarker of systemic inflammation with important prognostic significance in multiple disease processes, including cardiovascular diseases. It is inexpensive, widely available, and may be related to the outcomes of patients after surgery. We aimed to investigate the possible association of NLR with the outcomes of patients following endovascular aneurysm repair (EVAR). METHODS: This single-center, retrospective study of a prospectively maintained database evaluated 777 patients with a diagnosed abdominal aortic aneurysm (AAA) who underwent EVAR and were longitudinally followed between 2001 and 2017. NLR was defined as the ratio of absolute neutrophil count to absolute lymphocyte count. The mortality and reinterventions were used to evaluate outcomes using the appropriate univariate models, and the effect of clinical variables on NLR was further investigated using multivariate modelling. RESULTS: The median NLR for all patients was 3 IQR [2.2 - 4.6]. A cut-off point of 3.6 was uncovered in a training set of 388 patients using the maximally ranked statistic method. Patients with NLR < 3.6 had significantly improved mortality rates (P< 0.0001) in the training set, and results were internally validated in a testing set of 389 patients (P = 0.042). Multivariate analysis revealed that high NLR (HR 1.4 95% CI [1.0 - 2.0]; P< 0.05) remained an independent predictor of mortality in a multivariate analysis controlling for characteristics such as comorbidities, age, and maximal aortic diameter. 5-year mortality and 30-day, 1-year and 5-year reinterventions were all higher in the high NLR group. CONCLUSION: High NLR was significantly associated with higher rates of death at 5 years as well as higher rates of reinterventions at 30 days, 1 year and 5 years. We also suggest that an internally validated cut-off point of NLR >3.6 may be clinically important to help segregate patients into high and low NLR categories. It remains unclear whether NLR is directly linked to adverse events post-EVAR or whether it is a surrogate for an inflammatory state that predisposes patients to higher risk of death or reinterventions.

Trends, factors, and disparities associated with length of stay after lower extremity bypass for tissue loss.

OBJECTIVE: The objective of this study was to determine predictors of increased length of stay (LOS) in patients who underwent lower extremity bypass for tissue loss. METHODS: Using 2011 to 2016 National Surgical Quality Improvement Program vascular targeted databases, we compared demographics, comorbidities, procedural characteristics, and 30-day outcomes of patients who had expected LOS vs extended LOS (>75th percentile, 9 days) after nonemergent lower extremity bypass for tissue loss. We also compared factors associated with short LOS (<25th percentile, 4 days) and extended LOS (>75th percentile, 9 days) vs the interquartile range of LOS (4-9 days). Yearly trends and independent predictors were determined by linear and logistic regression. This study was exempt from Institutional Review Board approval. RESULTS: In 4964 analyzed patients, there were no significant yearly trends or changes in LOS in the recent 5 years (P > .05). Overall 30-day mortality, major amputation, and reintervention rates were 1.6%, 4.5%, and 4.8%, respectively, also with no significant yearly trends (all P > .05). On univariate analysis, nonwhite race, dependent functional status, transfers, dialysis, congestive heart failure, hypertension, beta blockers, distal bypass targets, and extended operative time were associated with extended LOS (P < .05). Extended LOS was also associated with higher rates of 30-day major adverse limb and cardiac events, additional procedures related to wound care, deep venous thrombosis, complications (pulmonary, renal, septic, bleeding, and wound), and discharge to facility but lower 30-day readmission rates. After adjustment for covariates, the independent factors for extended LOS included dialysis, beta blockers, prolonged operative time, reintervention, major amputation, additional procedures related to wound care, deep venous thrombosis, complications (pulmonary, renal, septic, bleeding, and wound), and discharge to facility (P < .05). On the other hand, multivariable analysis showed that patients with expected LOS were significantly more likely to have been of white race or readmitted postoperatively (P < .05). CONCLUSIONS: From 2011 to 2016, there were no significant changes in LOS. Efforts to decrease LOS without increasing readmission rates while focusing on some of the identified factors, including preventable postoperative complications and pre-existing socioeconomic factors, may improve the overall vascular care of these challenging patients.

Persistent symptoms after endovenous thermal ablation may suggest proximal venous outflow obstruction.

OBJECTIVE: Proximal venous outflow obstruction (PVOO) in the iliac veins and superficial venous disease are inter-related in ways not fully understood. We observed among our patients undergoing vein stent placement for PVOO a significant number having had prior endovenous thermal ablations (EVTA) in their history. This study was undertaken to better characterize these patients and develop an algorithm in their management. METHODS: In a combined retrospective and prospective data registry of 682 patients who underwent vein stent placement for chronic PVOO at a single institution from March 2013 to November 2017, 100 limbs of 99 patients (14.5% of all patients) had a history of EVTA or other superficial venous procedures before their vein stenting. Limbs with dilated truncal veins on ultrasound examination or limbs that underwent poststent EVTA or superficial venous procedures were excluded. The mean age of these 99 patients was 60.2 years (range, 28-88 years; standard deviation, 13.855). Fifty-one percent of the patients were male. The most common presenting symptom of the patient cohort was edema (n = 59), followed by venous-related skin changes (n = 22). RESULTS: Bilateral stents were performed in 58%, with a mean number of 2.06 stents per patient. EVTA was the primary superficial vein procedure in 97%. Bilateral EVTA were performed in 53% and unilateral EVTA in 47%. The mean time between the first EVTA to vein stenting was 1202.7 days. Patients were followed at 30 days, 90 days, 6 months, 1 year, and >1 year. The outcome for each patient at each postoperative visit was compared with preoperative parameters (subject's assessment, physical examination, and provider assessment) and was scored as follows: -1 (worse than preoperative), 0 (no change), +1 (mildly improved), +2 (significantly improved), or +3 (completely recovered). The mean outcome score at 30 days was 1.63 (84 patients), 2.05 at 90 days (62 patients), 2.09 at 6 months (74 patients), 1.93 at 1 year (54 patients), and 1.97 at >1 year (39 patients). CONCLUSIONS: Approximately 15% of patients undergoing vein stent placement for chronic PVOO have an antecedent history of superficial venous disease and EVTA. PVOO should be considered and the patient evaluated accordingly if symptoms persisted or recurred after EVTA. Vein stent placement among these patients with PVOO will result in further symptomatic relief, but complete symptomatic relief is not observed in everyone. The algorithm for the management of these patients warrants further investigation.

Mechanochemical ablation as an alternative to venous ulcer healing compared with thermal ablation.

OBJECTIVE: We aimed to compare mechanochemical ablation (MOCA) and thermal ablation (radiofrequency ablation and endovenous laser therapy) for venous ulcer healing in patients with clinical class 6 chronic venous insufficiency. METHODS: Electronic medical records were reviewed of patients with venous ulcers who underwent truncal or perforator ablation between February 2012 and November 2015. These records contained history of venous disease and ulcer history, procedures, complications, follow-up, method of wound care, and current status of the ulcer. The patients were grouped according to the method of ablation for comparison. RESULTS: In 66 patients, 82 venous segments were treated, 29 with thermal methods and 53 with MOCA; 16% of patients had prior venous intervention. Before ablation, three patients in the thermal group had a history of deep venous thrombosis compared with seven in the MOCA group. On average, patients treated with MOCA were older (thermal ablation, 57.2 years; MOCA, 67.9 years; P = .0003). Ulcer duration before intervention ranged from 9.2 months for thermal ablation to 11.2 months for MOCA (P = NS). In total, 74% of patients treated with MOCA healed their ulcers compared with 35% of those treated with thermal ablation (P = .01). A healed ulcer was defined as elimination of ulcer depth and superficial skin coverage. The mean time to heal was 4.4 months in the thermal ablation group compared with 2.3 months with MOCA (P = .01). The mean length of follow-up was 12.8 months after thermal ablation and 7.9 months after MOCA (P = .02). Both age (P = .03) and treatment modality (P = .03) independently had an impact on ulcer healing on multiple logistic regression analysis. All but two patients were treated with an Unna boot after venous ablation. Complications included readmission of two patients with nonaccess-related infections, one nonocclusive deep venous thrombosis, and one late death unrelated to the procedure second to pneumonia in the setting of advanced colon cancer. There were three recurrent ulcers at 1 week, 2 months, and 7 months after MOCA that rehealed with Unna boot therapy and continued compression. CONCLUSIONS: MOCA is safe and effective in treating chronic venous ulcers and appears to provide comparable results to methods that rely on thermal ablation. Younger age and use of MOCA favored wound healing. MOCA was an independent predictor of ulcer healing. Randomized studies are necessary to further support our findings.

Defining Types and Determining Risk Factors for Vascular Surgery Readmissions.

BACKGROUND: Vascular surgery patients typically have numerous comorbidities, which puts them at higher risk for postoperative readmissions. This study aims to investigate the risk factors for and appropriately categorize the various types of vascular surgery readmissions. METHODS: Nine hundred seventy-two patients were retrospectively reviewed. Readmissions were classified into 3 separate groups: readmissions that occurred between 0 and 30 days (30-day readmissions), 31-90 days (3-month readmissions), and 91-365 days (1-year readmissions). Each readmission was then assigned to 1 of the 4 categories based on whether they were related to the index procedure and whether they were planned. Univariate tests were performed for demographic variables based on their type of readmission, and logistic regressions were then performed to identify predictors of each unplanned, related readmissions. RESULTS: The overall 30-day readmission rate was 21.9% (n = 213). The unplanned, related readmission cohort (n = 83) had the highest readmission rate of 8.5%. The related, planned readmission rate was 5.9% (n = 58), while the unrelated, unplanned readmission rate was 5.6% (n = 55). In contrast, the overall 1-year readmission rate was 40.0% (n = 389), with the largest category being unplanned, unrelated readmissions at 19.7% (n = 191). The unplanned, related readmission rate was 8.7% (n = 85), whereas the planned, related readmission rate was 5.7% (n = 55). Compared with other types of readmissions, unplanned, related readmissions tended to affect patients who were younger, had poor glycemic control, and had higher body mass indexes (BMIs). Multivariate predictors of unplanned, related readmissions were poor glycemic control at 3 months (odds ratio [OR]: 2.16, P = 0.03), and BMI at 30 days (OR: 1.06, P = 0.04) and 1 year (OR: 1.05, P = 0.04). CONCLUSIONS: Readmissions have varying risk factors depending on their category; targeting glycemic control and obesity may reduce unplanned, related readmissions.

Trends in vena cava filter insertions and "prophylactic" use.

BACKGROUND: Prophylactic vena cava filter (VCF) use in patients without venous thromboembolism is common practice despite ongoing controversy. Thorough analysis of the evolution of this practice is lacking. We describe trends in VCF use and identify events associated with changes in practice. METHODS: Using the National Inpatient Sample, we conducted a retrospective observational study of U.S. adult hospitalizations from 2000 to 2014. Trends in prophylactic VCF insertion were analyzed both across the entire study population and within subgroups according to trauma status and type of concurrent surgery. Annual percentage change (APC) was calculated, and trends were analyzed using Poisson regression. RESULTS: Among 461,904,314 adult inpatients (median [interquartile range] age, 58.1 [38.5-74.3] years; 39.6% male), the incidence of VCF insertion increased rapidly at first (from 0.19% to 0.35%; APC, 11.2%; 95% confidence interval [CI], 10.3%-12.2%; P < .001), then at a slower rate after the publication of the Prévention du Risque d'Embolie Pulmonaire par Interruption Cave 2 (PREPIC2) trial in 2005 (from 0.35% to 0.42%; APC, 4.4%; 95% CI, 2.8%-6.0%; P < .001), and it began decreasing after the 2010 Food and Drug Administration (FDA) safety alert (from 0.42% to 0.32%; APC, -5.5%; 95% CI, -6.5% to -4.6%; P < .001). The percentage of total VCFs that had a prophylactic indication increased quickly before publication of the PREPIC2 trial (APC, 19.5%; 95% CI, 17.9%-21.0%; P < .001), increased at a slower rate after publication in 2005 (APC, 4.4%; 95% CI, 2.6%-6.2%; P < .001), and dropped after the FDA safety alert, stabilizing at 18.5% for the last 3 years (APC, -0.3%; 95% CI, -2.2% to 1.7%; P = .8). Subgroups most associated with prophylactic VCF insertion were operative trauma (odds ratio [OR], 10.9; 95% CI, 10.2-11.7), orthopedic surgery (OR, 4.7; 95% CI, 4.3-5.2), and neurosurgical procedures (OR, 3.9; 95% CI, 3.6-4.2). All groups except orthopedic surgery experienced a deceleration in prophylactic VCF growth after the publication of PREPIC2. Meanwhile, the FDA safety alert was associated with a decrease in prophylactic VCF insertions for all groups except other major surgery. CONCLUSIONS: Whereas publication of the PREPIC2 trial led to a deceleration in prophylactic VCF insertion growth, the FDA alert had a bigger impact, leading to declining rates of prophylactic VCF use. Further investigations of prophylactic insertion of VCF in trauma, orthopedic, and neurosurgical patients are needed to determine whether current levels of use are justified.

Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention.

BACKGROUND: Although many studies have demonstrated racial disparities after major vascular surgery, few have identified the reasons for these disparities, and those that did often lacked clinical granularity. Therefore, our aim was to evaluate differences in initial vascular intervention between black and white patients. METHODS: We identified black and white patients' initial carotid, abdominal aortic aneurysm (AAA), and infrainguinal peripheral artery disease (PAD) interventions in the Vascular Quality Initiative (VQI) registry from 2009 to 2014. We excluded nonblack or nonwhite patients as well as those with Hispanic ethnicity, asymptomatic PAD, or a history of prior ipsilateral interventions. We compared baseline characteristics and disease severity at time of intervention on a national and regional level. RESULTS: We identified 76,372 patients (9% black), including 35,265 carotid (5% black), 17,346 AAA (5% black), and 23,761 PAD interventions (18% black). For all operations, black patients were younger, more likely female, and had more insulin-dependent diabetes, hypertension, congestive heart failure, renal dysfunction, and dialysis dependence. Black patients were less likely to be on a statin before AAA (62% vs 69%; P < .001) or PAD intervention (61% vs 67%; P < .001) and also less likely to be discharged on an antiplatelet and statin regimen after these procedures (AAA, 60% vs 64% [P = .01]; PAD, 64% vs 67% [P < .001]). Black patients presented with more severe disease, including higher proportions of symptomatic carotid disease (36% vs 31%; P < .001), symptomatic or ruptured AAA (27% vs 16%; P < .001), and chronic limb-threatening ischemia (73% vs 62%; P < .001). Black patients more often presented with concurrent iliac artery aneurysms at the time of AAA repair (elective open AAA repair, 46% vs 26% [P < .001]; elective endovascular aneurysm repair, 38% vs 23% [P < .001]). CONCLUSIONS: Black patients present with more advanced disease at the time of initial major vascular operation. Efforts to control risk factors, identify and treat arterial disease in a timely fashion, and optimize medical management among black patients may provide opportunity to improve current disparities.

Regional variation in outcomes for lower extremity vascular disease in the Vascular Quality Initiative.

BACKGROUND: Increased focus has been placed on perioperative and long-term outcomes in the treatment of peripheral artery disease (PAD), both for purposes of quality improvement and for assessment of performance at a surgeon and institutional level. This study evaluates regional variation in outcomes after treatment for PAD within the Vascular Quality Initiative (VQI). By describing the variation in practice patterns and outcomes across regions, we hope that each regionally based quality group can select which areas are most important for them to focus on as they will have access to their regional data to compare. METHODS: We identified all patients in the VQI who had infrainguinal bypass or endovascular intervention from 2009 to 2014. We compared variation in perioperative and 1-year outcomes stratified by symptom status and revascularization type among the 16 regional groups of the VQI. We analyzed variation in perioperative end points using χ2 analysis, and 1-year end points were analyzed using Kaplan-Meier and life-table analysis. RESULTS: We identified 15,338 bypass procedures for symptomatic PAD: 27% for claudication, 59% for chronic limb-threatening ischemia (CLI; 61% of these for tissue loss), and 14% for acute limb ischemia. We identified 33,925 endovascular procedures for symptomatic PAD: 42% for claudication, 48% for CLI (73% of these for tissue loss), and 10% for acute limb ischemia. Thirty-day mortality varied significantly after endovascular intervention for CLI (0.5%-3%; P < .001) but not for claudication (0.0%-0.5%, P = .77) or for bypass for claudication (0.0%-2.6%; P = .37) or CLI (0.0%-5.0%; P = .08). After bypass, rates of >2 units transfused red blood cells (claudication, 0.0%-13% [P < .001]; CLI, 6.9%-27% [P < .001]) varied significantly. In-hospital major amputation was variable after bypass for CLI (0.0%-4.3%; P = .004) but not for claudication (0.0%-0.6%; P = .98), as was postoperative myocardial infarction (claudication, 0.0%-4% [P = .36]; CLI, 0.8%-6% [P = .001]). One-year survival varied significantly for endovascular interventions for claudication (92%-100%; P < .001), bypass for CLI (85%-94% [P < .001]), and endovascular interventions for CLI (77%-96%; P < .001) but not after bypass for claudication (95%-100%; P = .57). CONCLUSIONS: In this real-world comparison among VQI regions, we found significant variation in perioperative and 1-year end points for patients with PAD undergoing bypass or endovascular intervention. This study highlights opportunities for quality improvement efforts to reduce variation and to improve outcomes.

The Protective Effects of Diabetes Mellitus on Post-EVAR AAA Growth and Reinterventions.

BACKGROUND: This study aims to investigate the effect of diabetes on post-endovascular aneurysm repairs (EVARs) of abdominal aortic aneurysms (AAAs). METHODS: A total of 1,479 consecutive patients who underwent AAA EVAR were reviewed. The cohorts were divided based on their diabetes status and compared. Preoperative demographic and comorbidity data were analyzed using the t-test and chi-squared test, whereas post-EVAR outcomes were analyzed using Probit multivariate model, followed by Kaplan-Meier survival curve and Cox regression. RESULTS: Of our 1,479 patients, 993 met inclusion criteria. One hundred eighty-three were diabetics (18.4%) compared with 810 nondiabetics (81.6%). Coronary artery disease (CAD; diabetics: 70.49%, nondiabetics: 60.76%, P = 0.014) and hypertension (HTN; diabetics: 90.16%, nondiabetics: 79.46%, P = 0.0008) were the only comorbidities analyzed, including follow-up length, which had any significant differences between the diabetic and nondiabetic groups. Probit multivariate analysis using a combined cohort follow-up mean of 51 months showed a significant decrease in aneurysm sac enlargement in diabetic patients (diabetics: 13.11%, nondiabetics: 19.43%, model estimate: 0.3058; 95% confidence interval [CI]: 0.0486-0.5629, Pr > ChiSq = 0.0198) and trended toward significantly fewer reinterventions (diabetics: 23.50%, nondiabetics: 28.41%, model estimate: 0.1990; 95% CI: -0.0262 to 0.4243, Pr > ChiSq = 0.0833). In the Cox regressions, diabetes had a significant protective factor on reinterventions (hazard ratio [HR]: 0.697, Pr > ChiSq = 0.0151), and was trending toward significance for aneurysm sac enlargement (HR: 0.750, Pr > ChiSq = 0.1961). There was no significant difference across diabetic status in any other outcomes, including mortality and endoleak occurrence. CONCLUSIONS: Although a higher proportion of diabetic patients present with HTN and CAD, they have decreased long-term rates of aneurysm sac enlargement after EVAR. As a result, this cohort trends toward a lower need for reintervention after EVAR.

Preoperative inflammatory status as a predictor of primary patency after femoropopliteal stent implantation.

OBJECTIVE: The purpose of this study was to evaluate the impact of preoperative inflammatory status, as determined by complete blood count test parameters, on 12- and 24-month patency of femoropopliteal stenting for peripheral arterial disease. METHODS: We retrospectively analyzed baseline clinical and angiographic data among 138 patients (median age, 73 years; 46% female) from 2005 to 2014 at our institution with preoperative complete blood count test values and information of patency for at least 12 months after first-time femoropopliteal stenting. Patients were stratified into tertiles on the basis of preoperative blood counts to evaluate associations with in-stent restenosis (ISR) leading to loss of primary patency, defined by a Doppler velocity ratio ≥2.5:1, computed tomography angiography demonstrating ≥50% luminal narrowing within the stent, or reintervention. RESULTS: Univariate analysis determined that the 81 patients (59%) who experienced ISR within 12 months had significantly higher preoperative white blood cell (WBC), platelet, neutrophil, and lymphocyte counts than the 57 patients (41%) whose stents remained patent for longer than 12 months (8.7 vs 6.7 [P < .001], 246 vs 184 [P < .001], 5.7 vs 4.7 [P = .001], and 1.8 vs 1.2 [P = .004], respectively). Compared with patients in the lower WBC tertile (n = 45) who had a median patency of 19.4 months, those in the upper WBC tertile (n = 44) had a median patency of only 7.0 months and a 3.3-fold increased risk for ISR after adjusting for age, sex, lesion type, TransAtlantic Inter-Society Consensus II score, tibial vessel runoff, antiplatelet therapy, presence of diabetes, critical limb ischemia, adjunct procedures, hyperlipidemia, and end-stage renal disease in multivariate analysis (P < .001). Compared with patients in the lower platelet tertile (n = 45) who had a median patency of 16.9 months, those in the upper platelet tertile (n = 47) had a median patency of 7.1 months and a 2.7-fold increased adjusted risk (P = .001). Compared with patients in the lower neutrophil tertile (n = 33) who had a median patency of 14.3 months, those in the upper neutrophil tertile (n = 33) had a median patency of 6.2 months and a 3.2-fold increased adjusted risk (P = .001). After adjusting for covariates, patients divided into tertiles by lymphocyte counts exhibited no significant differences for ISR. CONCLUSIONS: Routine preoperative tests that determine baseline inflammatory status may provide strong clinical utility in assessing potential risk stratification of patients for ISR after femoropopliteal stenting. Circulating WBCs, platelets, and neutrophils may be important inflammatory mediators of ISR.

Successful off-label use of the GORE EXCLUDER Iliac Branch Endoprosthesis to preserve gluteal perfusion during staged endovascular repair of bilateral isolated hypogastric aneurysms.

Endovascular repair of iliac artery aneurysms has emerged as an alternative to traditional open surgical repair. Although there is little consensus on indications to preserve hypogastric blood flow during aneurysm repair, it is well understood that complications from bilateral hypogastric occlusion may be significant. The GORE EXCLUDER Iliac Branch Endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz) received United States Food and Drug Administration approval in March 2016 for treatment of common iliac artery and aortoiliac aneurysms. This case report discusses an off-label use of GORE EXCLUDER Iliac Branch Endoprosthesis to maintain pelvic perfusion during treatment of bilateral internal iliac artery aneurysms without surrounding aortoiliac pathology.

Vascular surgeon-hospitalist comanagement improves in-hospital mortality at the expense of increased in-hospital cost.

OBJECTIVE: We have shown that vascular surgeon- hospitalist co management resulted in improved in-hospital mortality rates. We now aim to assess the impact of the hospitalist co management service (HCS) on healthcare cost. METHODS: A total of 1558 patients were divided into three cohorts and compared: 516 in 2012, 525 in 2013, and 517 in 2014. The HCS began in January 2013. Data were standardized for six vascular surgeons that were present 2012-2014. New attendings were excluded. Ten hospitalists participated. Case mix index (CMI), contribution margin, total hospital charges (THCs), length of stay (LOS), actual direct costs (ADCs), and actual variable indirect costs (AVICs) were compared. Analysis of variance with post-hoc tests, t-tests, and linear regressions were performed. RESULTS: THC rose by a mean difference of $14,578.31 between 2012 and 2014 (P < .001) with a significant difference found between all groups during the study period (P = .0004). ADC increased more than AVIC; however, both significantly increased over time (P = .0002 and P = .014, respectively). A mean $3326.63 increase in ADC was observed from 2012 to 2014 (P < .0001). AVIC only increased by an average $392.86 during the study period (P = .01). This increased cost was observed in the context of a higher CMI and longer LOS. CMI increased from 2.25 in 2012 to 2.53 in 2014 (P = .006). LOS increased by a mean 1.02 days between 2012 and 2014 (P = .016), and significantly during the study period overall (P = .018). After adjusting for CMI, LOS increases by only 0.61 days between 2012 and 2014 (P = .07). In a final regression model, THC is independently predicted by comanagement, CMI, and LOS. After adjusting for CMI and LOS, the increase in THC because of comanagement (2012 vs 2014) accounts for only $4073.08 of the total increase (P < .001). During this time, 30-day readmission rates decreased by ∼7% (P = .005), while related 30-day readmission rates decreased by ∼2% (P = .32). Physician contribution margin remained unchanged over the 3-year period (P = .76). The most prevalent diagnosis-related group was consistent across all years. Variation in the principal diagnosis code was observed with the prevalence of circulatory disorders because of type II diabetes replacing atherosclerosis with gangrene as the most prevalent diagnosis in 2013 and 2014 compared with 2012. CONCLUSIONS: In-hospital cost is significantly higher since the start of the HCS. This surge may relate to increased CMI, LOS, and improved coding. This increase in cost may be justified as we have observed sustained reduction in in-hospital mortality and slightly improved readmission rates.

Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative.

OBJECTIVE: Prior studies on the cause and effect of surgical variation have been limited by utilization of administrative data. The Vascular Quality Initiative (VQI), a robust national clinical registry, provides anatomic and perioperative details allowing a more robust analysis of variation in surgical practice. METHODS: The VQI was used to identify all patients undergoing infrainguinal open bypass or endovascular intervention from 2009 to 2014. Asymptomatic patients were excluded. The 16 regional groups of the VQI were used to compare variation in patient selection, operative indication, technical approach, and process measures. χ2 analysis was used to assess for differences across regions where appropriate. RESULTS: A total of 52,373 interventions were included (31%). Of the 16,145 bypasses, 5% were performed for asymptomatic disease, 26% for claudication, 56% for chronic limb-threatening ischemia (CLI) (61% of these for tissue loss), and 13% for acute limb-threatening ischemia. Of the 35,338 endovascular procedures, 4% were for asymptomatic disease, 40% for claudication, 46% for CLI (73% tissue loss), and 12% for acute limb-threatening ischemia. Potentially unwarranted variation included proportion of prosthetic conduit for infrapopliteal bypass in claudication (13%-41%, median, 29%; P < .001), isolated tibial endovascular intervention for claudication (0.0%-5.0%, median, 3.0%; P < .001), discharge on antiplatelet and statin (bypass: 62%-84%; P < .001; endovascular: 63%-89%; P < .001), and ultrasound guidance for percutaneous access (claudication: range, 7%-60%; P < .001; CLI: 5%-65%; P < .001). Notable areas needing further research with significant variation include proportion of CLI vs claudication treated by bypass (38%-71%; P < .001) and endovascular intervention (28%-63%; P < .001), and use of closure devices in percutaneous access (claudication; 26%-76%; P < .001; CLI: 30%-78%; P < .001). CONCLUSIONS: Significant variation exists both in areas where evidence exists for best practice and, therefore, potentially unwarranted variation, and in areas of clinical ambiguity. Quality improvement efforts should be focused on reducing unwarranted variation. Further research should be directed at identifying best practice where no established guidelines and high variation exists.

The Impact of Surgical Care Improvement Project Measures on In-Hospital Outcomes following Elective Vascular Procedures.

BACKGROUND: As part of the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations including the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention implemented several perioperative guidelines regarding antibiotic, venous thromboembolism (VTE), and beta-blocker prophylaxis for surgical patients. We evaluated the effect of SCIP on in-hospital surgical site infections (SSI), graft infections, VTE, myocardial infarctions (MIs), cardiac complications, mortality, and length of stay following elective major vascular surgery. METHODS: Using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and procedure codes, we identified elective open abdominal aneurysm repair (OAR), endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), major lower extremity amputation, and lower extremity bypass (LEB) procedures in the National Inpatient Sample from 2000 to 2012. Logistic regression and generalized linear models controlling for covariates were used to compare postoperative in-hospital outcomes before and after SCIP implementation (pre-SCIP era 2000-2005 versus post-SCIP era 2009-2012). RESULTS: In the post-SCIP era, the rate of in-hospital SSI following OAR increased from 1.0% to 1.6% (P < 0.05). Nonetheless, there were improvements in in-hospital SSI (in EVAR and CEA), graft infections (in OAR, EVAR, and LEB for tissue loss), VTE (in CEA), MI (in EVAR and LEB for tissue loss), cardiac complication (in all procedures except OAR), mortality (in EVAR, CEA, major lower extremity amputation, and LEB for tissue loss), and length of stay (in all procedures except OAR) (all P < 0.05). However after adjusting for covariates, SCIP was only associated with reducing SSI in CEA and major lower extremity amputation, graft infections in OAR and LEB for tissue loss, VTE in LEB for claudication or rest pain, mortality in OAR, and length of stay in all procedures except EVAR and CEA. CONCLUSIONS: Implementation of SCIP measures was associated with slight improvements in a few in-hospital outcomes following vascular procedures. Additional measures that are more specific to the clinical and technical challenges of treating vascular disease may be more effective for improving the management of vascular patents.

Contemporary management of isolated chronic infrarenal abdominal aortic dissections.

OBJECTIVE: The purpose of this study was to report the presentation, treatment, and follow-up of isolated infrarenal aortic dissections. METHODS: A review of 37 patients with isolated infrarenal aortic dissections was performed. Computed tomography scans with intravenous administration of contrast material were examined for all patients; catheter-based angiography, magnetic resonance angiography, and duplex ultrasound were used selectively. In dissections associated with the development of abdominal aortic aneurysm (AAA), the aneurysm growth rate was determined by measuring the change in maximum aneurysm diameter over time and dividing that by the duration of observation. RESULTS: The majority of infrarenal abdominal aortic dissection patients were male (67.6%). Hypertension (77.1%) and hyperlipidemia (77.1%) were the most common comorbidities among these patients. Aortic atherosclerosis was present in the majority of patients (60.0%); 67.6% of dissections were discovered incidentally and were asymptomatic. The mean dissection length was 5.84 ± 4.23 cm. Concomitant AAAs were present in 48.6% of cases with an average maximum diameter of 4.38 ± 1.41 cm. The aneurysm growth rate was 1.2 mm/y. Aneurysms were significantly larger in men than in women (4.87 ± 1.31 vs 3.12 ± 0.67 cm; P = .001). Endovascular intervention was performed on 14 (37.8%) patients, open surgery was performed on 1 (2.7%) patient, and surveillance with conservative medical treatment was used for 22 (59.5%) patients. Ten patients were treated successfully with endovascular repair for progressive aneurysm expansion. At the time of intervention, the mean AAA diameter was 5.04 ± 1.39 cm. The mean growth rate for aneurysms that were intervened on was 2.3 mm/y. The mean diameter of AAAs that were not intervened on was 3.56 ± 1.04 cm. Type II endoleaks were observed in three (30%) patients who underwent endovascular repair. None of these were associated with aneurysm growth and none required reintervention. The mortality rate for endovascular intervention was 0%. The only open surgical repair performed was on a patient with a ruptured AAA, which the patient did not survive. Angioplasty with stent or stent graft placement was performed in four patients for the treatment of symptomatic arterial insufficiency resulting from aortic dissection. No patients experienced restenosis, and no reinterventions were performed. CONCLUSIONS: Isolated infrarenal aortic dissection is an uncommon vascular disease that is related to hypertension, hyperlipidemia, and atherosclerosis and may be associated with infrarenal AAA formation. The presence of dissection does not appear to increase the risk of complication or mortality for repair of concomitant aneurysm or for treatment of stenosis.