Evaluating growth patterns of abdominal aortic aneurysms among women.

OBJECTIVE: Though initially protected from vessel dilation by estrogen, women may experience rapid abdominal aortic aneurysm (AAA) growth post-menopause. The rate of growth has been poorly defined in prior literature. Here, we describe aneurysm growth in a cohort of women found through an AAA screening program. METHODS: Women with AAAs were retrospectively identified. Aortic imaging was reviewed, and measurements of maximum transverse and anterior-posterior diameters were completed. Growth was stratified by the type of aortic pathology (fusiform aneurysm, aortic ectasia, dissection with aneurysmal degeneration, saccular aneurysm) as well as size category (<3 cm, 3.0-3.9 cm, 4.0-4.9 cm, ≥5.0 cm) at diagnosis. RESULTS: A cohort of 488 women was identified; 286 had multiple scans for review. The mean age of the entire cohort was 75 ± 9.9 years. Stratified by type of pathology, the mean age was 76 ± 8.9 years in patients with a fusiform AAA, 74 ± 9.8 years in ectasia, 65 ± 13.7 years in dissection, and 76 ± 5.6 years in saccular aneurysms. The maximum growth was highest in women with fusiform AAAs, followed by dissection, ectasia, and saccular pathology (9.7 mm, 7.0 mm, 3.0 mm, and 2.2 mm, respectively; P < .001). Comparing mean growth by year, the highest mean growth was in fusiform AAAs (3.6 mm vs 1.75 mm in dissection; P < .001). The Shapiro-Wilk test demonstrated that mean growth per year was non-normally distributed with a right skew. Stratified by aortic diameter at the time of diagnosis, mean growth/year increased with increasing size at diagnosis in fusiform AAAs and dissection (0.91 mm for <3 cm, 2.34 mm for 3.0-3.9 cm, 2.49 mm for 4.0-4.9 mm, and 6.16 mm for ≥5.0 cm in patients with fusiform AAAs vs 0.57 mm, 0.94 mm, 1.87 mm, and 2.66 mm, respectively, for patients with dissection). Smoking history was associated with a higher mean growth/year (2.6 mm vs 3.3 mm; P < .001). Conversely, patients with a family history of AAA had a lower mean growth/year (3.2 mm vs 1.5 mm; P < .001). CONCLUSIONS: The rate of aneurysm growth in women varies based on pathology and aneurysm size, and women experience rapid aneurysm growth at sizes greater than 4.5 cm. Current screening guidelines are inadequate, and our results demonstrate that the rate of growth of fusiform aneurysms in women is faster than in men at a smaller size and may warrant more frequent surveillance than current Society for Vascular Surgery recommendations to prevent risk of increased morbidity.

Young female vascular surgeons more likely to enter academia.

OBJECTIVE: In the last decade, there has been a dramatic increase in the number of women entering vascular surgery. Our goal was to evaluate the differences in career paths based on gender and to determine some of the factors that influence career decisions among young vascular surgeons. METHODS: A 17-item web-based survey focusing on current employment status, reasons for choosing academic vs nonacademic positions, and career satisfaction was distributed to 900 members of the Society for Vascular Surgery who completed vascular surgery training in the past 10 years. RESULTS: A total of 199 individuals responded to the survey (22.1%). The cohort included 49 (24.6%) women and 149 (74.9%) men. The majority of the respondents were non-Hispanic white (66.3%). Sixty-four percent of all respondents were younger than 40 years. Overall, 72.9% of women had applied to academic positions after their training compared with 58.8% of men. Women were more likely to apply for and to work in an academic setting (P = .0266 and P = .0198, respectively) and cited mentorship more frequently (P = .0474) as the reason for choosing an academic practice. Women respondents were less likely to have a spouse or children (P = .0269 and P < .001, respectively). More than 87.4% of all respondents were very satisfied or somewhat satisfied with their careers. However, men were more likely to be very satisfied compared with women (P = .0345). CONCLUSIONS: Career satisfaction remains high among young vascular surgeons. In this cohort of vascular surgery graduates, we found that women were more likely to pursue academic positions than men, with mentorship, ability to teach, and complexity of cases commonly cited as reasons for this career choice. However, whether young women stay in academia and what factors affect academic retention will need further evaluation.

Hybrid Approach to Aneurysms of the Pancreaticoduodenal Artery Associated with Occlusion of the Celiac Axis.

Pancreaticoduodenal artery aneurysms are uncommon but often associated with occlusion or absence of the celiac axis. This anatomic alteration makes management decisions challenging. Presented here are 2 cases of incidentally identified aneurysms, treated with a hybrid approach.

The Contemporary Safety and Effectiveness of Lower Extremity Bypass Surgery and Peripheral Endovascular Interventions in the Treatment of Symptomatic Peripheral Arterial Disease.

BACKGROUND: Treatment for symptomatic peripheral artery disease includes lower extremity bypass surgery (LEB) and peripheral endovascular interventions (PVIs); however, limited comparative effectiveness data exist between the 2 therapies. We assessed the safety and effectiveness of LEB and PVI in patients with symptomatic claudication and critical limb ischemia. METHODS AND RESULTS: In a community-based clinical registry at 2 large integrated healthcare delivery systems, we compared 883 patients undergoing PVI and 975 patients undergoing LEB between January 1, 2005 and December 31, 2011. Rates of target lesion revascularization were greater for PVI than for LEB in patients presenting with claudication (12.3±2.7% and 19.0±3.5% at 1 and 3 years versus 5.2±2.4% and 8.3±3.1%, log-rank P<0.001) and critical limb ischemia (19.1±4.8% and 31.6±6.3% at 1 and 3 years versus 10.8±2.5% and 16.0±3.2%, log-rank P<0.001). However, in comparison with PVI, LEB was associated with increased rates of complications up to 30 days following the procedure (37.1% versus 11.9%, P<0.001). There were no differences in amputation rates between the 2 groups. Findings remained consistent in sensitivity analyses by using propensity methods to account for treatment selection. CONCLUSIONS: In patients with symptomatic peripheral artery disease, in comparison with LEB, PVI was associated with fewer 30-day procedural complications, higher revascularization rates at 1 and 3 years, and no difference in subsequent amputations.

Amputation Risk in Patients with Diabetes Mellitus and Peripheral Artery Disease Using Statewide Data.

BACKGROUND: Conflicting data exist regarding changes in amputation rates in patients with ulcers because of diabetes mellitus (DM) and peripheral artery disease (PAD). This study focuses on how population-based amputation rates are changing in the current treatment era. METHODS: Using the California Office of Statewide Health Planning and Development Patient Discharge database, all patients who underwent major nontraumatic lower extremity (LE) amputation in 2005 through 2011 were identified. Age-adjusted population-based amputation risk was determined by year. Gender and age trends in amputation risk were estimated separately for diabetes-related amputations and PAD-related amputations, treating all California residents as the population at risk. RESULTS: From 2005 to 2011, 32,025 qualifying amputations were performed in California. Of these, 11,896 were DM-associated (n = 1,095), PAD-associated (n = 4,335), or associated with both conditions (n = 6,466). PAD-associated amputation rates and combined PAD/DM-associated amputation rates have changed little since 2009 after decreasing substantially over the prior 5 years, but DM-associated amputation rates have continuously increased since 2005. California residents older than the age of 80 years had the most dramatic decrease in PAD-associated amputation rates from 2005 to 2011 (i.e., from 317 to 175 per million Californians). Men with PAD/DM had amputation rate 1.5 times higher than those of patients with PAD alone and 5 times higher than rates of DM patients. In women the difference between patient with PAD and PAD/DM was not seen; however, these rates were 2.5 times higher than patients with DM alone. CONCLUSIONS: Preventable amputations associated with high-risk diseases are no longer decreasing despite continuing advances in care and education. Octogenarians with PAD represent the highest risk group for amputation, but DM-associated amputations have increased since 2005. Further research to understand treatment pathways for patient with LE wounds may shed light on pathways for amputation prevention in the future.

Anatomic runoff score predicts cardiovascular outcomes in patients with lower extremity peripheral artery disease undergoing revascularization.

BACKGROUND: Although the presence, extent, and severity of obstruction in patients with lower extremity peripheral artery disease (LE PAD) affect their functional status, quality of life, and treatment, it is not known if these factors are associated with future cardiovascular events. We empirically created an anatomic runoff score (ARS) to approximate the burden of LE PAD and determined its association with clinical outcomes. METHODS: We evaluated all patients with LE PAD and bilateral angiography undergoing revascularization in a community-based clinical study. Primary clinical outcomes of interest were (1) a composite of all-cause death, myocardial infarction (MI), and stroke and (2) amputation-free survival. Cox proportional hazards models were created to identify predictors of clinical outcomes. RESULTS: We evaluated 908 patients undergoing angiography, and a total of 260 (28.0%) patients reached the composite end point (45 MI, 63 stroke, and 152 death) during the study period. Anatomic runoff score ranged from 0 to 15 (mean 4.7; SD 2.5) with higher scores indicating a higher burden of disease, and an optimal cutpoint analysis classified patients into low ARS (<5) and high ARS (≥5). The unadjusted rates of the primary composite end point and amputation-free survival were nearly 2-fold higher in patients with a high ARS when compared with patients with a low ARS. The most significant predictors of the composite end point (death/MI/stroke) were age (δ 10 years; hazard ratio [HR] 1.53; CI 1.32-1.78; P < .001), diabetes mellitus (HR 1.65; CI 1.26-2.18; P < .001), glomerular filtration rate <30 (HR 2.23; CI 1.44-3.44; P < .001), statin use (HR 0.66; CI 0.48-0.88; P < .001), and ARS (δ 2 points; HR 1.21; CI 1.08-1.35; P < .001). CONCLUSIONS: After adjustment for clinical factors, the LE PAD ARS was an independent predictor of future cardiovascular morbidity and mortality in a broadly representative patient population undergoing revascularization for symptomatic PAD. A clinically useful anatomic scoring system, if validated, may assist clinicians in risk stratification during the course of clinical decision making.

Management of mixed arterial venous lower extremity ulceration: A review.

Mixed arterial venous disease is estimated to affect up to 26% of patients with lower extremity ulcerations. However, its clinical significance and pathophysiology are incompletely understood. Furthermore, there is no consensus on the optimal treatment modality, whether conservative or operative. In this review paper, we describe the current understanding of the pathophysiology of mixed arterial venous lower extremity ulcers. Guidelines for diagnostic tests for patients with mixed arterial venous diseases are discussed. We review some of the newer biological skin substitutes for conservative wound care. Finally, we propose a treatment algorithm based on current available data.

Racial disparities in outcomes of endovascular procedures for peripheral arterial disease: an evaluation of California hospitals, 2005-2009.

BACKGROUND: Racial/ethnic disparities in treatment outcomes of peripheral arterial disease (PAD) are well documented. Compared with non-Hispanic (NH) whites, blacks and Hispanics are more likely to undergo amputation and less likely to undergo bypass surgery for limb salvage. Endovascular procedures are being increasingly performed as first line of therapy for PAD. In this study, we examined the outcomes of endovascular PAD treatments based on race/ethnicity in a contemporary large population-based study. METHODS: We used Patient Discharge Data from California's Office of Statewide Health Planning and Development to identify all patients over the age of 35 who underwent a lower extremity arterial intervention from 2005 to 2009. A look-back period of 5 years was used to exclude all patients with prior lower extremity arterial revascularization procedures or major amputation. Cox proportional hazards regression was used to compare amputation-free survival and time to death within 365 days. Logistic regression was used for comparison of 1-month myocardial infarction, 1-month major amputation, 1-month all-cause mortality, 12-month major amputation, 12-month reintervention, and 12-month all-cause mortality rates among NH white, black, and Hispanic patients. These analyses were adjusted for age, gender, insurance status, severity of PAD, comorbidities, history of coronary artery angioplasty or bypass surgery, or history of carotid endarterectomy. RESULTS: Between 2005 and 2009, a total of 41,507 individuals underwent PAD interventions, 25,635 (61.7%) of whom underwent endovascular procedures. There were 17,433 (68%) NH whites, 4,417 (17.2%) Hispanics, 1,979 (7.7%) blacks, 1,163 (4.5%) Asian/Native Hawaiians, and 643 (2.5%) others in this group. There was a statistically significant difference in the amputation-free survival within 365 days among the NH white, Hispanic, and black groups (P < 0.0001); the hazard ratio for amputation within 365 days was 1.69 in Hispanics (95% confidence interval [CI] 1.51-1.90, P < 0.0001) and 1.68 in blacks (95% CI 1.44-1.96, P < 0.001) compared with NH whites following endovascular procedures after adjusting for age, gender, insurance status, comorbidities, severity of PAD, history of coronary artery angioplasty or bypass surgery, or history of carotid endarterectomy. After adjusting for the aforementioned confounders, the first reintervention within 12 months was also significantly associated with race/ethnicity (P = 0.002). Odds ratio for reintervention was 1.17 in blacks (95% CI 1.06-1.30, P = 0.002) and 1.084 in Hispanics (95% CI 1.00-1.16, P = 0.04) compared with NH whites. CONCLUSIONS: In this contemporary large population-based study, we demonstrated that even among matched cohorts Hispanics and blacks have worse amputation-free survival than NH whites following endovascular therapy. Our study also found that Hispanics and blacks are more likely to undergo lower extremity arterial reinterventions than NH whites. Further research is crucial in understanding if higher reintervention rates in Hispanics and blacks are because of more severe disease and/or poor access to proper follow-up care and optimal medical management.

Risk factors for recanalization of truncal veins following endoluminal ablation.

BACKGROUND: Recanalization of target veins after treatment of superficial venous incompetence has clinical implications and may depend on the type of intervention. The aim of this study was to evaluate patient and procedural factors associated with truncal vein recanalization in a large study cohort using the Vascular Quality Initiative (VQI) Varicose Vein Registry. METHODS: We performed a retrospective review using the VQI Varicose Vein Registry from 2014 to 2018. We evaluated all procedures performed for truncal venous insufficiency. Demographic data and information about treatment modality were collected. Patients were separated into recanalization and nonrecanalization groups based on the status of the treated vein at follow-up ultrasound examination. The vein was only considered recanalized if the VQI noted complete recanalization of the target vein. Univariate and multivariate comparisons were performed as appropriate. RESULTS: A total of 10,604 procedures were performed in 7403 patients. The average age was 55.9 years and 70.3% of the patients were female. Patients with recanalization were more likely to have a history of phlebitis (P < .001) and had a higher mean body mass index (30.5 vs 32., kg/m2 ; P = .006) compared with those without recanalization. There was no difference in the use of compression therapy, anticoagulation, deep venous reflux, number of pregnancies, prior deep vein thrombosis, Venous Clinical Severity Score, and clinical-etiology-anatomy-pathophysiology between patients with and without recanalization. The number of truncal veins treated per procedure was higher in the recanalization group compared with the nonrecanalization group (2.36 vs 1.88; P = .001). After multivariate logistic regression, laser ablation was associated with higher rate of recanalization compared with radiofrequency ablation (P = .017). CONCLUSIONS: This study is the first to use VQI based data to describe risk factors for recanalization following treatment of truncal venous reflux. The use of laser ablation for truncal veins is associated with a higher risk for recanalization compared with radiofrequency ablation. Obesity, prior phlebitis, and number of veins treated were independently associated with increased rate of recanalization.

Gender-related variation in the clinical presentation and outcomes of critical limb ischemia.

Critical limb ischemia (CLI) is a major cause of limb loss and mortality among patients with advanced peripheral artery disease. Our objective was to evaluate the gender-specific differences in patient characteristics and clinical outcomes among patients with CLI. We performed a retrospective analysis of 97 women and 122 men presenting with CLI who underwent angiography from 2006 to 2010. Baseline demographics, procedural details, and lesion characteristics were assessed for each patient. Kaplan-Meier analysis was used to assess long-term patient and lesion-level outcomes. Cox proportional hazard modeling was used to evaluate the relationship between gender and major adverse cardiovascular events (MACE). Compared to men, women were less likely to have a history of coronary artery disease (39% vs 54%, p = 0.02) or diabetes (57% vs 70%, p = 0.05) but had similar baseline medical therapy. At angiography, women were more likely to have significant femoropopliteal (77% vs 67%, p = 0.02) and multi-level infrainguinal disease (63% vs 51%, p = 0.02). Women were also more likely to undergo multi-vessel percutaneous intervention (69% vs 55%, p = 0.05), but had similar rates of limb salvage after percutaneous intervention or surgical bypass (HR 0.94 [95% CI 0.45-1.94], p = 0.9). During follow-up, women had higher rates of subsequent major adverse cardiovascular events (HR 1.63 [95% CI 1.01-2.63], p = 0.04). In conclusion, women with CLI are more likely to present with femoropopliteal and multi-level infrainguinal disease. Despite similar rates of limb salvage, women with CLI have an increased rate of subsequent major adverse cardiovascular events.

The Effect of Hokkaido Red Wines on Vascular Outcomes in Healthy Adult Men: A Pilot Study.

Moderate red wine intake has been associated with lower cardiovascular mortality, due in part to the intake of polyphenols and anthocyanins, whose content can vary from varietal and year of harvest. This study assessed the vascular effects in response to a single intake of 2015 and 2018 Zweigelt red wines from Hokkaido, Japan. Healthy men were randomly assigned to consume 240 mL each of a red wine, or a sparkling white grape juice as a control in a randomized three-arm cross-over design with a 7 day washout between arms. The augmentation index (AI; a measure of arterial stiffness) and AI at 75 beats/min (AI75), reactive hyperemia index, systolic and diastolic blood pressure (SBP and DBP, respectively), and platelet reactivity were assessed at baseline and two and four hours after each beverage intake. Changes from the baseline were analyzed using a linear mixed model. Significant treatment effects (p = 0.02) were observed, with AI 13% lower after the intake of the 2015 or 2018 vintages compared to the control. Intake of the 2018 vintage reduced SBP and DBP (-4.1 mmHg and -5.6 mmHg, respectively; p = 0.02) compared to the 2015 wine and the control drink. The amount of hydroxytyrosol in the 2018 wine was almost twice the amount as in the 2015 wine, which may help explain the variable blood pressure results. Future studies exploring the vascular effects of the same red wine from different vintage years and different phenolic profiles are warranted.

The X-chromosome has a different pattern of gene expression in women compared with men with ischemic stroke.

BACKGROUND AND PURPOSE: Differences in ischemic stroke between men and women have been mainly attributed to hormonal effects. However, sex differences in immune response to ischemia may exist. We hypothesized that differential expression of X-chromosome genes in blood immune cells contribute to differences between men and women with ischemic stroke. METHODS: RNA levels of 683 X-chromosome genes were measured on Affymetrix U133 Plus2.0 microarrays. Blood samples from patients with ischemic stroke were obtained at ≤ 3 hours, 5 hours, and 24 hours (n=61; 183 samples) after onset and compared with control subjects without symptomatic vascular diseases (n=109). Sex difference in X-chromosome gene expression was determined using analysis of covariance (false discovery rate ≤ 0.05, fold change ≥ 1.2). RESULTS: At ≤ 3, 5, and 24 hours after stroke, there were 37, 140, and 61 X-chromosome genes, respectively, that changed in women; and 23, 18, and 31 X-chromosome genes that changed in men. Female-specific genes were associated with post-translational modification, small-molecule biochemistry, and cell-cell signaling. Male-specific genes were associated with cellular movement, development, cell-trafficking, and cell death. Altered sex specific X-chromosome gene expression occurred in 2 genes known to be associated with human stroke, including galactosidase A and IDS, mutations of which result in Fabry disease and Hunter syndrome, respectively. CONCLUSIONS: There are differences in X-chromosome gene expression between men and women with ischemic stroke. Future studies are needed to decipher whether these differences are associated with sexually dimorphic immune response, repair or other mechanisms after stroke, or whether some of them represent risk determinants.

Application of duplex ultrasound imaging in determining in-stent stenosis during surveillance after mesenteric artery revascularization.

OBJECTIVE: Currently, there are no well-established duplex ultrasound (DUS) criteria for the evaluation of the mesenteric arteries after stenting for occlusive disease. Previous studies suggested DUS velocity criteria in the native superior mesenteric artery (SMA) overestimate stenosis in stented arteries, but most studies have not evaluated DUS imaging after SMA stenting longitudinally. This study was undertaken to determine the accuracy of DUS after mesenteric artery revascularization and, in particular, to evaluate the utility of DUS imaging for the detection of in-stent stenosis (ISS) of the SMA. METHODS: A retrospective record review was performed for all patients who underwent SMA stenting for chronic mesenteric ischemia at a single institution from January 2004 to May 2011. RESULTS: Mesenteric artery occlusive disease resulted in 24 patients undergoing mesenteric stenting of the SMA alone (n = 20) or the SMA and celiac artery simultaneously (n = 3). The mean ± standard deviation peak systolic velocity (PSV) in 13 prestent DUS images of the SMA was 464 ± 130 cm/s. Prestenting angiography revealed an average SMA stenosis of 79% ± 14%. After stenting, completion angiography in each case revealed <20% residual stenosis. No significant correlation was identified between SMA PSV and angiographic stenosis before and after stenting (P > .05). Follow-up SMA DUS imaging showed an average PSV of 335 ± 138 cm/s at 0.9 ± 1.5 months, 360 ± 143 cm/s at 4.8 ±2.6 months, and 389 ± 95 cm/s at 14.4 ± 5.1 months. A significant difference existed between the prestent and the first poststent mean SMA PSV (P < .05), but no significant difference existed between each poststenting interval. Eight reinterventions for SMA ISS were performed, with a mean elevated in-stent SMA PSV of 505 ± 74 vs 341 ± 145 cm/s in patients who did not undergo reintervention. Angiography before the eight reinterventions demonstrated an average SMA ISS of 53% ± 25%. In-stent SMA PSV decreased from 505 ± 74 to 398 ± 108 cm/s after the reintervention (P < .05). CONCLUSIONS: Consistent with other reports, our data demonstrate the PSV in successfully stented SMAs remains higher than the PSV threshold of 275 cm/s used for the diagnosis of high-grade native SMA stenosis. In addition, in-stent SMA PSVs did not significantly change over DUS surveillance for patients who did not undergo reintervention. Thus, obtaining a baseline DUS early after mesenteric stenting should be considered to compare future surveillance DUS. An increase above this baseline or an in-stent SMA PSV approaching 500 cm/s should be considered suspicious for ISS, but larger prospective studies will be required to validate these preliminary findings.

Early duplex scanning after infrainguinal endovascular therapy.

OBJECTIVES: Duplex ultrasound scanning (DUS) has benefit for intraoperative and subsequent evaluation of surgical bypasses in the lower extremities. The utility of DUS after endovascular revascularizations is not established. This study was performed to evaluate whether DUS findings after infrainguinal endovascular interventions for critical limb ischemia (CLI) were predictive of need for reintervention or amputation. METHODS: To identify the study cohort, peripheral interventions for CLI (Rutherford grades 4, 5, 6) over a 24-month period (2006-2007) were reviewed. DUS findings were considered indicative of hemodynamic stenosis if the peak systolic velocity (PSV) was ≥ 180 cm/s or the PSV velocity ratio was ≥ 2.0. Demographic, clinical, procedural, and outcomes were examined. SVS and TASC II classifications and reporting standards were used. Arteriograms were reviewed and treated segments were categorized as patent (<30% residual stenosis) or abnormal (≥ 30% residual stenosis). RESULTS: There were 122 infrainguinal interventions for CLI in 113 patients (53% male; mean age 71 years). Risk factors included diabetes: 61%; renal failure: 20%; and smoking (within 1 year): 40%. DUS was performed within 30 days of the index procedure in 90 cases. Fifty patients had an abnormal early duplex and 40 patients had a normal duplex. In patients with a normal duplex ultrasound the amputation rate was 5% vs 20% in the group with an abnormal duplex (P = .04). Primary patency was 56% in the normal duplex group and 46% in the abnormal duplex group (P = .18). Early duplex ultrasound was able to identify a residual stenosis not seen on completion angiography in 56% of cases. CONCLUSIONS: Duplex scanning detects residual stenosis missed with conventional angiography after infrainguinal interventions. An abnormal DUS in the first 30 days after an intervention is associated with an increased risk of amputation. This suggests a possible role for intraprocedural DUS, as well as routine postprocedure DUS, close clinical follow-up, and consideration of reintervention for residual abnormalities in patients treated for CLI.

Predictors of diagnostic success with renal artery duplex ultrasonography.

BACKGROUND: Renal artery duplex ultrasonography (RA-DUS) is commonly used for the evaluation and follow-up of renal artery atherosclerotic disease. In a complete study, renal artery flow is evaluated from the vessel origin to the intraparenchymal branches. The quality of RA-DUS is in part technologist-dependent, but many factors may affect the ability to complete a diagnostic examination. This study evaluated the clinical and technical factors that predict the ability to obtain a complete RA-DUS examination. METHODS: A prospective evaluation of all patients undergoing RA-DUS between July 2008 and February 2009 was performed. Factors such as patient age, gender, body mass index, technologists' years of experience, patient care setting (inpatient vs. outpatient), bedside examination, smoking before the examination, fasting status, and recent abdominal surgery were all recorded. Multivariate logistic regression analysis was performed. A p value of ≤ 0.05 was considered significant. RESULTS: During the study period, 250 patients underwent RA-DUS (mean age: 59.9 ± 17.8 years, 57% [143] female). A total of 87 (35%) examinations were incomplete. This included nondiagnostic examinations which did not exhibit any segment of the renal artery. Factors that were associated with an incomplete examination included technologists' years of experience (OR = 0.92, p = 0.042), bedside examination (OR = 4.17, p = 0.016), and recent abdominal surgery (OR = 3.45, p = 0.047). Body mass index, fasting status, and smoking before the examination did not affect the ability to obtain a complete study. CONCLUSIONS: One-third of the RA-DUS studies were classified as incomplete by the strict criteria used in this prospective study. An experienced ultrasound technologist is more likely to obtain a complete RA-DUS examination. Recent abdominal surgery and bedside examinations were predictive of a limited examination as well. Vascular laboratories should consider these factors when scheduling examinations so as to obtain complete RA-DUS studies, as well as improve the cost-effectiveness of resource utilization.

Challenges of treating mixed arterial-venous disease of lower extremities.

INTRODUCTION: Mixed arterial-venous lower extremity disease (AVLED) poses a unique challenge for clinicians. This review will outline the impact mixed AVLED has on patients and the healthcare system, by reviewing its epidemiology, diagnosis, current treatment, and the challenges encountered implementing therapies. EVIDENCE ACQUISITION: An extensive search of current literature from online sources, journals and book chapters identified the current challenges facing the treatment of mixed arterial venous ulcers of the lower extremities and potential solutions to these challenges. EVIDENCE SYNTHESIS: The challenges that are identified in the search are the time to heal AVLED, patient education and motivation, early detection of AVLED, wound care center development, treatment consensus from multidisciplinary team members, and cost of treatment. CONCLUSIONS: AVLED ulcers are a challenging problem, but over time we have continued and will continue to improve patient care and tackle these difficult challenges as we have throughout the last century. A diagnostic algorithm to address how we approach these patients in terms of conservative care with wound care and compression and treat arterial and venous insufficiency is crucial. In looking to the future, continued standardization of wound care centers will overcome the social and financial challenges faced by patients and continued clinical research will improve targeted therapies and treatment challenges faced by physicians.

Implementation of an aortic screening program in clinical practice: implications for the Screen For Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act.

OBJECTIVE: Screening for abdominal aortic aneurysms (AAA) significantly reduces aneurysm-related death. In January 2007, the Federal government enacted Medicare coverage guideline to screen persons at risk for the presence of an AAA, the Screen for Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act. The purpose of this study is to evaluate the efficacy and costs of a large scale screening effort for identifying AAAs in patients in clinical practice. METHODS: A regional veterans affairs mandate for screening for AAA was implemented in February 2007. Data were extracted through the Northern California Veterans Affairs (VA) Service Network to identify veteran males 65-75 years of age who ever smoked at least 100 cigarettes during their lifetime. An AAA was defined as an aortic diameter 3.0 cm or greater. A Decision Support Systems software (LumiData, Minneapolis, Minn) package tracked true costs of conducting a large AAA screening protocol in the Northern California VA Health Care System. RESULTS: A total of 2918 patients (average age, 71 +/- 6 years) were screened for AAA over a 1-year period from February 2007 to February 2008. An AAA was diagnosed in 5.1% (148/2918) of patients. Two hundred ninety patients out of the 2918 (9.9%) were inappropriately screened. The aneurysm distribution was as follows: 83% (123/148) of the aneurysms were 3.0-4.4 cm, 13% (19/148) were 4.5-5.5 cm, and 4.1% (6/148) were greater than 5.5 cm. Incidental findings of isolated iliac artery aneurysms were found in 0.1% (3/2918) of patients. The cost of AAA screening per patient is $53. CONCLUSION: The results of a large AAA screening effort in clinical practice reflect the results reported in the major clinical trials at a reasonable cost. The identification of large iliac artery aneurysms in the screening has not been previously reported.

Growth hormone-releasing peptide ghrelin inhibits homocysteine-induced endothelial dysfunction in porcine coronary arteries and human endothelial cells.

OBJECTIVE: Ghrelin, a novel growth hormone-releasing peptide, is implicated to play a protective role in cardiovascular tissues. However, it is not clear whether ghrelin protects vascular tissues from injury secondary to risk factors such as homocysteine (Hcy). This study investigated the effect and potential mechanisms of ghrelin on Hcy-induced endothelial dysfunction. METHODS: Porcine coronary artery rings were incubated for 24 hours with ghrelin (100 ng/mL), Hcy (50 microM), or ghrelin plus Hcy. Endothelial vasomotor function was evaluated using the myograph tension model. The response to the thromboxane A(2)analog U46619, bradykinin, and sodium nitroprusside was analyzed. Endothelial nitric oxide synthase (eNOS) expression was determined using real-time polymerase chain reaction and immunohistochemistry staining, and superoxide anion production was documented lucigenin-enhanced chemiluminescence analysis. Human coronary artery endothelial cells (HCAECs) were treated with different concentrations of Hcy, ghrelin, or antighrelin receptor antibody for 24 hours, and eNOS protein levels were determined by Western blot analysis. RESULTS: Maximal contraction with U46619 and endothelium-independent vasorelaxation with sodium nitroprusside were not different among the four groups. However, endothelium-dependent vasorelaxation with bradykinin (10(-6) M) was significantly reduced by 34% with Hcy compared with controls (P < .05). The addition of ghrelin to Hcy had a protective effect, with 61.6% relaxation, which was similar to controls (64.7%). Homocysteine significantly reduced eNOS expression, whereas ghrelin cotreatment effectively restored eNOS expression to the control levels. Superoxide anion levels, which were increased by 100% with Hcy, returned to control levels with ghrelin cotreatment. Ghrelin also effectively blocked the Hcy-induced decrease of eNOS protein levels in HCAECs in a concentration-dependent manner. Antighrelin receptor antibody effectively inhibited the effect of ghrelin. CONCLUSION: Ghrelin has a protective effect in the porcine coronary artery by blocking Hcy-induced endothelial dysfunction, improving eNOS expression, and reducing oxidative stress. Ghrelin also shows a protective effect on HCACEs from the Hcy-induced decrease in eNOS protein levels. The effect of ghrelin is receptor-dependent. Thus, ghrelin administration may have beneficial effects in the treatment of vascular disease in patients with hyperhomocysteinemia.

Prognostic factors and treatment outcome in mesenteric vein thrombosis.

BACKGROUND: Mesenteric vein thrombosis (MVT) can result in intestinal ischemia and is associated with high morbidity and mortality due in part to its frequent delay in diagnosis. The purpose of this study was to evaluate clinical presentation, diagnostic evaluation, and treatment outcome of MVT. METHODS: Hospital records and clinical data of all patients treated for MVT were reviewed during a recent 14-year period. Clinical outcome and factors affecting survival were analyzed. RESULTS: A total of 68 patients were included in the study. Abdominal exploration was performed in 23 patients (34%), and second-look operation was necessary in 18 patients (26%). Three patients (4%) underwent unsuccessful operative mesenteric vein thrombectomy, whereas percutaneous transhepatic mesenteric thrombectomy was performed successfully in 3 patients (4%). The 30-day mortality rate was 20%. Forty-six of the 54 survivors were treated with long-term oral anticoagulation therapy. Actuarial survival at 2, 4, 6, and 10 years was 68%, 57%, 43%, and 22%, respectively. Risk factor analysis showed malignancy (P < .002), age >60 years (P < .005), cirrhosis (P < .02), symptom duration (P < .005), and bowel resection (P < .03) were associated with mortality. Logistic regression analysis showed age >60 years (odds ratio [OR], 3.64; P = .03), malignancy (OR, 3.88; P = .02), and prolonged symptom duration (OR, 5.62; P = .01) were independent predictors of mortality. CONCLUSIONS: MVT is associated with significant mortality. Prompt diagnostic evaluation with computed tomography may reduce potential treatment delay. Underlying malignancy, advanced age, and prolonged symptom duration are predictive of poor outcome.

Do Women Have Worse Amputation-Free Survival Than Men Following Endovascular Procedures for Peripheral Arterial Disease? An Evaluation of the California State-Wide Database.

OBJECTIVES: Female gender has been shown to negatively affect the outcomes of surgical bypass for peripheral arterial disease (PAD). We examined gender-related disparities in outcomes of endovascular PAD procedures in a large population-based study. METHODS: We used discharge data from California hospitals to identify patients who had PAD interventions during 2005 to 2009. Logistic regression was used for 12-month reintervention, and Cox proportional hazard regression was used for amputation-free survival comparisons. RESULTS: A total of 25 635 patients had endovascular procedures (11 389 [44.4%] women). Women were more likely than men (34.5% vs 30.1%, P < .0001) to have critical limb ischemia (CLI). Twelve-month reintervention rate in women was similar to men. Amputation-free survival was better among women than men (hazard ratio 0.84, 95% confidence interval [CI] 0.76-0.93, P = .0006). CONCLUSION: Despite presenting more frequently with CLI, women had better amputation-free survival than men following endovascular procedures. Future research should determine whether findings favor one type of PAD treatment modality over another for women.