Age does not predict need for reintervention in patients with critical limb ischemia.

OBJECTIVE: Conventional wisdom holds that patients with a need for intervention for femoropopliteal occlusive disease at a younger age have more aggressive disease, although there is a paucity of support in the literature. The purpose of this study was to evaluate this assumption. METHODS: A retrospective cohort of patients undergoing endovascular or open revascularization for femoropopliteal occlusive disease for critical limb ischemia during a 4-year period was assembled. Demographic information, comorbidities, disease characteristics, and time to last follow-up, repeat intervention, amputation, or death was recorded. The patients were stratified by age into a young (≤55 years) group, middle (56-77 years) group, and elderly (≥78 years) group. Univariate and multivariate statistical methods were used to evaluate the primary outcome. RESULTS: The study included 124 patients with a mean age of 64.4 ± 0.8 years. Progression to reintervention or amputation occurred in 50% of the patients during the follow-up period, with 18% dying before having an outcome. Kaplan-Meier analysis showed a trend toward significance (P = .06) in time to reintervention, amputation, or death among the three groups, with time to event of 253, 1083, and 504 days for the young, middle, and elderly groups, respectively. However, differences based on age were not significant (P = .57) in Cox regression analysis. CONCLUSIONS: There does not appear to be an association between time to reintervention and patient age.

Coil embolization of persistent false lumen after type A dissection repair.

A 44-year-old man with a type A dissection repair 5 years earlier presented with progressive enlargement of the residual arch and thoracic aorta. Flow into the false lumen from the distal aortic suture line was evident on contrast-enhanced computed tomography. Through a redo hemisternotomy, the false lumen was accessed directly. An Amplatzer plug was deployed within the narrowed neck of the false lumen proximal to the enlarged false lumen within descending aorta. Interlocking coils were deployed proximal to the Amplatzer plug, resulting in thrombosis of the false lumen.

Role of statin therapy and angiotensin blockade in patients with asymptomatic moderate carotid artery stenosis.

BACKGROUND: The purpose of this study was to evaluate the 10-year outcome of patients presenting with asymptomatic moderate carotid artery stenosis, and to determine which factors correlate with progression of disease to stroke or revascularization. METHODS: A retrospective review of all new patients presenting with asymptomatic moderate carotid artery stenosis from July 1998 to December 2001 was undertaken. Patients were consecutively identified and included by using duplex ultrasonography to identify moderate carotid disease. Variables were recorded for all patient encounters through June 2010. The primary end point was occurrence of ipsilateral cerebrovascular stroke or revascularization event (SORE). Statin therapy and angiotensin blockade (STAB) were categorized as follows: STAB(0)-medical treatment with neither statin therapy nor angiotensin blockade, STAB(1)-treatment with only one of the two, STAB(2)-treatment with both. An amortized cost model analyzed the cost of SORE-free survival. RESULTS: Over a 42-month period, 468 carotids in 366 patients with an average age of 69.0 ± 8.7 years were evaluated. Over a mean follow-up of 6.6 ± 2.7 years, SORE occurred in 150 (32.1%) carotid arteries. Hyperlipidemia was predictive of SORE (hazard ratio [HR]: 1.543, 95% confidence interval [CI]: 1.053-2.262, P = 0.03). Medical therapies protective against SORE were beta-blockade (HR: 0.612, 95% CI: 0.435-0.861, P < 0.05), STAB(1) (HR: 0.487, 95% CI: 0.336-0.706, P < 0.01), and STAB(2) (HR: 0.149, 95% CI: 0.089-0.248, P < 0.01). At 10 years, SORE-free survival in STAB(2) was 82.7% ± 4.6%, STAB(1) was 56.3% ± 5.0%, and STAB(0) was 29.3% ± 5.4% (P < 0.01). The cost per SORE-free year in STAB(2) was $1,695.40 ± $275.60, STAB(1) was $3,916.80 ± $605.44, and STAB(0) was $4,126.40 ± $427.23 (P < 0.01). CONCLUSION: These data demonstrate the clinical and financial advantage of using both statin therapy and angiotensin pathway blockage in patients with asymptomatic moderate carotid artery stenosis.

Impact of operative indication and surgical complexity on outcomes after thoracic endovascular aortic repair at National Surgical Quality Improvement Program Centers.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) devices are increasingly being utilized to treat aortic pathologies outside of the original Food & Drug Administration (FDA) approval for nonruptured descending thoracic aorta aneurysms (DTAs). The objective of this study was to evaluate the outcomes of patients undergoing TEVAR, elucidating the role of surgical and pathologic variables on morbidity and mortality. METHODS: National Surgical Quality Improvement Program (NSQIP) data were reviewed for all patients undergoing endovascular thoracic aorta repair from 2005 to 2007. The patients' operative indication and surgical complexity were used to divide them into study and control populations. Comorbid profiles were assessed utilizing a modified Charlson Comorbidity Index (CCI). Thirty-day occurrences of mortality and serious adverse events (SAEs) were used as study endpoints. Univariate and multivariate models were created using demographic and clinical variables to assess for significant differences in endpoints (P ≤ .05). RESULTS: A total of 440 patients undergoing TEVAR were identified. When evaluating patients based on operative indication, the ruptured population had increased mortality and SAE rates compared to the nonruptured DTA population (22.6% vs 6.2%;P < .01 and 35.5% vs 9.1%;P < .01, respectively). Further analysis by surgical complexity revealed increased mortality and SAE rates when comparing the brachiocephalic aortic debranching population to the noncovered left subclavian artery population (23.1% vs 6.5%; P = .02 and 30.8% vs 9.1%; P < .01, respectively). Multivariate analysis demonstrated that operative indication was not a correlate of mortality or SAEs (odds ratio [OR], 0.95; P = .92 and OR, 1.42; P = .39, respectively); however, brachiocephalic aortic debranching exhibited a deleterious effect on mortality (OR, 8.75; P < .01) and SAE rate (OR, 6.67; P = .01). CONCLUSION: The operative indication for a TEVAR procedure was not found to be a predictor of poor patient outcome. Surgical complexity, specifically the need for brachiocephalic aortic debranching and aortoiliac conduit, was shown to influence the occurrence of SAEs in a multivariate model. Comparative data, such as these, illustrate real-world outcomes of patients undergoing TEVAR outside of the original FDA-approved indications. This information is of paramount importance to various stakeholders, including third-party payers, the device industry, regulatory agencies, surgeons, and their patients.

Examining the myth of the "July Phenomenon" in surgical patients.

BACKGROUND: The objective of this study is to evaluate morbidity and mortality rates in surgical patients at the beginning of the academic year. METHODS: The National Surgical Quality Improvement Program database was utilized to gather data on the 10 most common inpatient operative procedures from 2005-2007. Study end points included mortality, serious adverse events (SAE), and all morbidities. Statistical analysis of outcomes was conducted examining the total population, and then stratified by operation to assess for significant differences in end points (P < .05). RESULTS: A total of 89,473 patients were identified. During the first academic quarter, the mortality rate was no different in the study group than the control group (2.0% vs 2.2%, P = .793). Overall SAE and morbidity rates were similar between populations (11.5% vs 11.4%, P = .697 and 18.3% vs 17.8%, P = .076, respectively). When stratified by operation, "artery bypass graft" (3.7% vs 2.9%, P = .039) and "repair bowel opening" (1.1% vs 0.6%, P = .033) subsets had increases in mortality rate. Multivariate analysis confirmed the deleterious effect of first quarter admission in only the "artery bypass graft" subset (OR = 1.35, CI 1 = .023-1.774). CONCLUSION: By in large, these data refute the "July Phenomenon." Multivariate analysis revealed patient disease to have a greater impact than timing of operation in the "repair bowel opening" subset. The "artery bypass graft" population was affected by timing of operation and the very small effect on mortality (<1%) may reflect new surgery residents being unfamiliar with the management of complex cardiovascular disease.

A contemporary rural trauma center experience in blunt traumatic aortic injury.

INTRODUCTION: Traumatic aortic injury (TAI) is a rare yet highly lethal injury associated with blunt force deceleration injury. The adoption of thoracic endovascular aortic repair (TEVAR) has become a safer option than traditional open repair. The purpose of this study is to review a rural trauma center experience with TAI. METHODS: A retrospective analysis was performed, reviewing all patients who presented with TAI between 2000 and 2009. Clinical, anatomical, and procedural variables of all cases were systematically reviewed. Clinical endpoints included mortality, and aortic-related mortality, and hospital length of stay. The study population was stratified by those that underwent surgical repair (SR) and those managed medically (MM). RESULTS: Fifty-six patients presented with blunt TAI; 35 patients (62.5%) were surgically repaired (22 open, 13 TEVAR), while 21 (37.5%) were MM. The only difference in comorbidities was a higher rate of coronary artery disease in MM. Mean hospital arrival time (SR, 188.6 ± 30.3 minutes, MM, 253 ± 65.3 minutes), aortic injury grade (SR, 2.7 ± 0.1; MM, 2.3 ± 0.2), and injury severity score were not significantly different between the groups. Head Abbreviated Injury Score (AIS) was worse in the MM group, while chest AIS was worse in the SR group (P < .05). There were nine (42.9%) deaths in the MM group, while there were only two (5.7%) in the SR group (P < .001). There was no significant difference in aortic-related mortality. Mean follow-up time was not statistically different. CONCLUSION: These data provide a group of stable patients to examine the management of TAI in the endovascular era. The low aortic-related mortality in the MM group demonstrates that there is time for a thorough evaluation in patients sustaining TAI who arrive without hemodynamic instability.

The impact of socioeconomic factors on outcome and hospital costs associated with femoropopliteal revascularization.

INTRODUCTION: Within the context of healthcare system reform, the cost efficacy of lower extremity revascularization remains a timely topic. The impact of an individual patient's socioeconomic status represents an under-studied aspect of vascular care, especially with respect to longitudinal costs and outcomes. The purpose of this study is to examine the relationship between socioeconomic status and clinical outcomes as well as inpatient hospital costs. METHODS: A retrospective femoropopliteal revascularization database, which included socioeconomic factors (household income, education level, and payor status), in addition to standard demographic, clinical, anatomical, and procedural variables were analyzed over a 3-year period. Patients were stratified by income level (low income [LI] <200% federal poverty level [$42,400 for a household of 4], and higher income [HI] >200% federal poverty level) and revascularization technique (open vs endovascular) and analyzed for the endpoints of primary assisted patency, amortized cost-per-day of patency, and limb salvage. Data were analyzed with univariate and multivariate techniques. RESULTS: A total of 187 cases were identified with complete data for analysis, 146 in the LI and 41 in the HI cohorts. LI patients differed from HI patients by mean age (66.2 +/- 1.0 vs 61.8 +/- 1.5 years, P = .04), high school graduate rate (51.4% vs 85.4%, P < .001), presence of tissue loss (30.1% vs 14.6%, P = .05), female gender (43.7% vs 22.0%, P = .01) and preoperative statin use (45.8% vs 75.6%, P < .001). There were no differences with respect to other comorbidities including smoking status, presence of diabetes, renal insufficiency, anatomic factors or treatment modality (open vs endovascular). Ninety-seven patients underwent endovascular revascularization. The following outcomes were noted in the endovascular subset of LI and HI patients respectively: primary assisted patency (66% vs 71%, P = NS) and 12-month cost-per-day of patency ($166.30 +/- 77.40 vs $22.45 +/- 12.45, P = .05). Ninety-eight patients underwent open revascularization, with the following outcomes in LI and HI patients respectively: primary assisted patency (78% vs 86%, P = NS) and 12-month cost-per-day of patency ($319.43 +/- 225.44 vs $40.47 +/- 4.63, P = .07). Of the 77 patients with critical limb ischemia, 19 underwent eventual amputation. Multivariate analysis demonstrated that income above 100% of the federal poverty line was protective against limb loss (odds ratio 0.06, 95% confidence interval 0.01-0.51, P < .001). CONCLUSION: Income level correlates with advanced presentation, advanced age, and lack of statin use. Although primary assisted patency rate is not affected by income status, an increased cost-per-day of patency and inferior limb salvage is found in lower income patients.

Preoperative statin therapy is associated with improved outcomes and resource utilization in patients undergoing aortic aneurysm repair.

INTRODUCTION: This study hypothesized that preoperative statin therapy would have a protective effect on patients undergoing elective abdominal aortic aneurysm (AAA) repair and that the risk-reduction effect of these agents would result in a reduction in subsequent total hospital costs. METHODS: All patients who underwent an elective endovascular AAA repair (EVAR) or open AAA repair (OAR) between 2004 and 2007 were retrospectively reviewed. Clinical end points included postoperative days, length of hospital stay, postoperative complications (myocardial infarction, stroke, renal failure, hemorrhage, pneumonia, urinary tract infection, wound infection), and 30-day mortality. The financial end point was total hospital cost associated with the procedure. RESULTS: We identified 401 patients, consisting of 173 EVAR patients (43%) and 228 OAR (57%). Despite a higher Society for Vascular Surgery risk score, the EVAR statin cohort had significantly reduced postoperative days (1.9 +/- 0.2 vs 2.3 +/- 0.3, P < .05) and hospital length of stay (2.3 +/- 0.3 vs 2.8 +/- 0.4, P < .05) compared with the nonstatin EVAR cohort. Postoperative complications (4.4% vs 14.7%, P < .05) and the mortality rate (0.0% vs 5.9%, P < .05) were significantly decreased in the OAR statin cohort compared with the nonstatin OAR cohort and trended to be decreased in the EVAR statin group. Statin therapy translated into a lower total cost per patient of $3,205 for EVAR and $3,792 for OAR (P < .05). CONCLUSION: With respect to both clinical outcome measures and subsequent resource utilization, statin therapy is associated with a beneficial effect in patients undergoing elective AAA repair. These data suggest that preoperative statin therapy should be an integral part of the risk optimization for patients undergoing AAA repair.

The association of periprocedural hypertension and adverse outcomes in patients undergoing catheter-directed thrombolysis.

BACKGROUND: Peripheral thrombolysis is an indispensible tool in the treatment of occlusive peripheral vascular disease (PVD). However, the use of intravascular thrombolytic agents carries a significant risk of morbidity and mortality. The aim of this study is to review a contemporary series of patients treated with catheter-directed thrombolytics in the treatment of occlusive PVD. METHODS: A retrospective analysis was performed reviewing all patients who underwent catheter-directed thrombolytic therapy for PVD with recombinant tissue plasminogen activator (rt-PA) between 2005 and 2008. Data included clinical and demographic variables potentially associated with endpoints of technical success, hemorrhagic complications, and death. Data were analyzed with univariate and multivariate measures. Significance was assigned with p <0.05. RESULTS: Over the 36-month study, 125 thrombolytic procedures were performed. Indication for treatment was occlusive thrombus in native artery (49 cases, 37.6%), vein (13 cases, 10.4%), or arterial bypass graft (63 cases, 49.6%). Twenty three cases (14.3%) used ultrasound-assisted catheter technology. Mean patient age was 57.9 +/- 1.1 years. Technical success was achieved in 82% of cases. Mean rt-PA dose was 47.3 +/- 1.4 mg (13.5 +/- 4.5 mg with ultrasound assisted catheter technology). Hemorrhagic complications occurred in 22.4% of patients with a 5.6% stroke rate. Intracranial hemorrhage (ICH) correlated with poor hypertensive control (systolic blood pressure >160 mmHg; OR, 13.67; CI, 1.59-117.68; p = 0.006) and advanced age (>80 years; OR, 9.04; CI, 1.40-58.57, p = 0.049). Hemorrhagic complications (including minor access site hematomas) correlated with poor hypertensive control (systolic blood pressure >180 mmHg; OR, 3.48; CI, 1.22-9.94; p = 0.021) and in patients with congestive heart failure (OR, 3.26; CI, 1.09-9.76; p = 0.036). Overall mortality occurred in 7 patients (5.6%), 4 as a result of hemorrhagic complications. Correlates of mortality were patients with diabetes mellitus (OR, 8.85; CI, 1.62-48.26; p = 0.003), end stage renal disease (OR, 15.33; CI, 2.07-113.39; p < .001) and congestive heart failure (OR, 6.06; CI, 1.22-30.13; p = .014). Serum fibrinogen levels, pre-procedural hypertension, and rt-PA dosage did not correlate with hemorrhagic complication or death. CONCLUSION: Peripheral thrombolysis with catheter-based technologies has a high incidence of technical success. However, the procedure continues to carry a significant complication rate. This study emphasizes the importance of periprocedural hypertensive control and identifies subgroups of patients at risk of untoward complications. On the basis of these data, the authors advocate stricter blood pressure parameters in patients undergoing peripheral thrombolysis.

The use of intravascular ultrasound imaging to improve use of inferior vena cava filters in a high-risk bariatric population.

OBJECTIVE: Pulmonary embolism is the leading cause of death after gastric bypass procedures for obesity, approximating 0.5% to 4%. All bariatric patients, but especially the super-obese, which have a body mass index (BMI) >50 kg/m(2), are at significant risk for postoperative venous thromboembolism (VTE). Visualization and weight limitations of fluoroscopy tables exclude most bariatric and all super-obese patients from inferior vena cava (IVC) filter placement using fluoroscopy. Intravascular ultrasound (IVUS)-guided IVC filter placement is the only modality that allows these high-risk patients to have an IVC filter placed. METHODS: Hospital and outpatient records of the 494 patients who underwent gastric bypass procedures from January 1, 2004, to May 31, 2006, were reviewed. All patients who had concurrent IVC filter placement with the use of IVUS guidance were selected. Comorbidities, outcomes, and complications were recorded. RESULTS: We identified 27 patients with mean BMI of 70 +/- 3 kg/m(2); of these, 25 were super-obese (BMI >50 kg/m(2)). Procedures included five laparoscopic and 22 open gastric bypass operations. All patients underwent concurrent IVC filter placement using IVUS guidance. In addition to super-obesity, indications for IVC filter placement included history of VTE (n = 4), known hypercoagulable state (n = 2), and profound immobility (n = 21). Mean follow up was 293 +/- 40 days. Technical success rate was 96.3%. There were no catheter site complications. In one surviving patient, a nonfatal pulmonary embolism was detected by computed tomography 2 months postoperatively. Two patients died, and autopsy excluded VTE as the cause of death in both. CONCLUSION: This study suggests efficacy of IVUS-guided IVC filter placement in preventing mortality from pulmonary embolism in high-risk bariatric patients, including the super-obese. IVUS-guided IVC filter placement can be safely performed with an excellent success rate in all bariatric patients, including the super-obese, who otherwise would not be candidates for IVC filter placement due to the limitations imposed by their large body habitus.

Mid-term results with laser atherectomy in the treatment of infrainguinal occlusive disease.

BACKGROUND: Laser atherectomy offers a potential intervention for multivessel infrainguinal disease in patients with poor revascularization options. Despite promising early results reported in the literature, the proper patient population who might benefit from laser atherectomy has yet to be determined. METHODS: From July 2004 to June 2006, patients undergoing laser atherectomy were retrospectively reviewed and assessed for comorbidities, operative and follow-up variables potentially associated with the end points of nondefinitive therapy, and limb salvage. RESULTS: During the study period, 40 patients (21 women, 19 men) underwent laser atherectomy, and the average follow-up was 461 +/- 49 days (range, 17 to 1050 days). Their average age was 68 +/- 2 years (range, 43 to 93 years). The indication for laser atherectomy was critical limb ischemia in 26 (65%) and lower limb claudication in 11 (35%). A total of 47 lesions were treated in the following arterial segments: 34 femoropopliteal and 13 infrapopliteal. Femoropopliteal distribution by the Trans-Atlantic Society Classification (TASC) was A in 3, B in 17, C in 10, D in 4, and infrapopliteal lesions distribution was A in 1, B in 3, C in 4, and D in 5. Adjunctive angioplasty was used in 75% of cases. The overall technical success rate (<50% residual stenosis) was 88%. Laser atherectomy-based treatment was the definitive therapy for 23 patients (58%), and the overall 12-month primary patency was 44%. The limb salvage rate at 12 months in 26 patients with critical limb ischemia was 55%. Renal failure was a risk factor for amputation (P < .001) and failed primary patency (P < .05), type 2 diabetes mellitus was a risk factor for amputation (P < .05), and poor tibial runoff was associated with failed primary patency and amputation (P < .05). Outcome was associated with the number of patent infrapopliteal runoff vessels. CONCLUSION: These data demonstrate that laser atherectomy can be used with high initial technical success rate. Chronic renal failure and diabetes are risk factors for a negative outcome. Poor results in patients with diabetes and renal failure necessitate careful case selection in this subgroup, in which laser atherectomy is less likely to provide a definitive revascularization result or limb salvage.

Isolated internal iliac artery aneurysm resection and reconstruction: operative planning and technical considerations.

Isolated iliac artery aneurysms are rare but dangerous aneurysms associated with a high incidence of rupture (between 14 and 70%). Rupture is frequently associated with an exceedingly high mortality primarily because of the elusive nature of the presenting symptoms and the resulting major delays in treatment. Accordingly these aneurysms are best managed aggressively. Although emerging endovascular techniques show promise surgical resection and reconstruction remains the gold standard for definitive management and has withstood the test of time with excellent durable and unparalleled results. That said, from an operative perspective these aneurysms are technically demanding and remain one of the more formidable technical challenges in vascular surgery. To highlight the key elements involved in a successful repair we present a right internal iliac artery aneurysm with an associated contralateral common iliac artery occlusion, review the necessary preoperative planning and the available surgical treatment options, and detail the technical steps leading to a successful reconstruction. Careful operative planning is critical. Inadequate preoperative studies, inadequate preoperative decision making, and a poorly formulated operative strategy can lead to catastrophic results. Some of the most feared complications include pelvic venous injury with resulting massive hemorrhage and postoperative pelvic ischemia (with resulting rectal and/or spinal cord ischemia) which occurs as a result of inadequate contralateral collateral pelvic blood flow when the internal iliac artery is not reimplanted. Accordingly the preoperative workup must include a careful analysis of the adequacy of the contralateral pelvic blood flow to supply collateral flow in the event that the internal iliac is not reimplanted. In the presence of compromised contralateral internal iliac perfusion, resection and reconstruction or an alternative form of pelvic revascularization is mandatory. Excellent and unencumbered exposure is mandatory for a safe and successful repair. The retroperitoneal approach as illustrated in this case is strongly recommended. Although it is challenging excellent results can be achieved by resection of the aneurysm and reconstruction.