Retrieval of Embolized WATCHMAN® Flex Atrial Appendage Occlusion Device.

This case report documents the management of a 66-year old man with atrial fibrillation with recent placement of a WATCHMAN® Flex atrial appendage occlusion device. The patient presented with renal failure, abdominal pain, and difficulty walking 2 months after placement. The WATCHMAN® Flex device was found to have embolized to his abdominal aorta at the level of the renal arteries with associated thrombus. Extensive workup revealed reduced left ventricular cardiac function and decreased renal function, both of which were felt to be potentially reversible with device removal. The patient then underwent retrieval of the device and all associated thrombus via an open retroperitoneal approach. This case demonstrates a potential consequence of implanting devices such as an atrial appendage occlusion device and describes a technique for removal.

The Effect of Chronic and End-Stage Renal Disease on Long-Term Outcomes after Infrainguinal Bypass.

BACKGROUND: Patients undergoing infrainguinal bypass for chronic limb threatening ischemia (CLTI) with renal dysfunction are at an increased risk for perioperative and long-term morbidity and mortality. Our goal was to examine perioperative and 3-year outcomes after lower extremity bypass for CLTI stratified by kidney function. METHODS: A retrospective, single-center analysis of lower extremity bypass for CLTI was performed between 2008 and 2019. Kidney function was categorized as normal (estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2), chronic kidney disease (CKD) (eGFR 15-59 mL/min/1.73 m2), and end-stage renal disease (ESRD) (eGFR <15 mL/min/1.73 m2). Kaplan-Meier and multivariable analysis were performed. RESULTS: There were 221 infrainguinal bypasses performed for CLTI. Patients were classified by renal function as normal (59.7%), CKD (24.4%), and ESRD (15.8%). Average age was 66 years and 65% were male. Overall, 77% had tissue loss with 9%, 45%, 24%, and 22% being Wound, Ischemia, and foot Infection stages 1-4, respectively. The majority (58%) of bypass targets was infrapopliteal and 58% used ipsilateral greater saphenous vein. The 90-day mortality and readmission rates were 2.7% and 49.8%, respectively. ESRD, compared to CKD and normal renal function, respectively, had the highest 90-day mortality (11.4% vs. 1.9% vs. 0.8%, P = 0.002) and 90-day readmission (69% vs. 55% vs. 43%, P = 0.017). On multivariable analysis, ESRD, but not CKD, was associated with higher 90-day mortality (odds ratio (OR) 16.9, 95% confidence interval (CI) 1.83-156.6, P = 0.013) and 90-day readmission (OR 3.02, 95% CI 1.2-7.58, P = 0.019). Kaplan-Meier 3-year analysis showed no difference between groups for primary patency or major amputation; however, ESRD, compared to CKD and normal renal function, respectively, had worse primary-assisted patency (60% vs. 76% vs. 84%, P = 0.03) and survival (72% vs. 96% vs. 94%, P = 0.001). On multivariable analysis, ESRD and CKD were not associated with 3-year primary patency loss/death, but ESRD was associated with higher primary-assisted patency loss (hazard ratio (HR) 2.61, 95% CI 1.23-5.53, P = 0.012). ESRD and CKD were not associated with 3-year major amputation/death. ESRD was associated with higher 3-year mortality (HR 4.95, 95% CI 1.52-16.2, P = 0.008) while CKD was not. CONCLUSIONS: ESRD, but not CKD, was associated with higher perioperative and long-term mortality after lower extremity bypass for CLTI. Although ESRD was associated with lower long-term primary-assisted patency, there were no differences in loss of primary patency or major amputation.

Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia.

BACKGROUND: Patients with chronic limb-threatening ischemia (CLTI) require revascularization to improve limb perfusion and thereby limit the risk of amputation. It is uncertain whether an initial strategy of endovascular therapy or surgical revascularization for CLTI is superior for improving limb outcomes. METHODS: In this international, randomized trial, we enrolled 1830 patients with CLTI and infrainguinal peripheral artery disease in two parallel-cohort trials. Patients who had a single segment of great saphenous vein that could be used for surgery were assigned to cohort 1. Patients who needed an alternative bypass conduit were assigned to cohort 2. The primary outcome was a composite of a major adverse limb event - which was defined as amputation above the ankle or a major limb reintervention (a new bypass graft or graft revision, thrombectomy, or thrombolysis) - or death from any cause. RESULTS: In cohort 1, after a median follow-up of 2.7 years, a primary-outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endovascular group (hazard ratio, 0.68; 95% confidence interval [CI], 0.59 to 0.79; P<0.001). In cohort 2, a primary-outcome event occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years. The incidence of adverse events was similar in the two groups in the two cohorts. CONCLUSIONS: Among patients with CLTI who had an adequate great saphenous vein for surgical revascularization (cohort 1), the incidence of a major adverse limb event or death was significantly lower in the surgical group than in the endovascular group. Among the patients who lacked an adequate saphenous vein conduit (cohort 2), the outcomes in the two groups were similar. (Funded by the National Heart, Lung, and Blood Institute; BEST-CLI ClinicalTrials.gov number, NCT02060630.).

Percutaneous radial artery access for peripheral vascular interventions is a safe alternative for upper extremity access.

OBJECTIVE: Percutaneous radial artery access has been increasingly used for peripheral vascular interventions (PVIs). Our goal was to characterize the practice patterns and perioperative outcomes among patients treated using PVI performed via radial artery access. METHODS: The Vascular Quality Initiative was queried from 2016 to 2020 for PVI performed via upper extremity access. Univariable and multivariable analyses were used to evaluate the periprocedure outcomes of radial artery access cases. A separate sample of brachial artery access cases was used as a comparator. RESULTS: A total of 520 radial artery access cases were identified. The mean age was 69 ± 10 years, and 41.3% were women. Most procedures were performed in the hospital outpatient setting (71.7%). The sheath size was ≤5F for 10%, 6F for 78%, and 7F for 12%. Ultrasound-guided access and protamine were used in 68.3% and 17.3% of cases, respectively. The interventions were aortoiliac (55%), femoropopliteal (55%), and infrapopliteal (9%). Stenting and atherectomy were performed in 55% and 19% of cases, respectively, and more often with 7F sheaths. Access site complications were any hematoma (4.8%), including hematomas resulting in intervention (0.8%), pseudoaneurysms (1%), and access stenosis or occlusion (0.8%). On multivariable analysis, sheath size was not associated with access site complications. Percutaneous brachial artery access (n = 1135) compared with radial access was independently associated with more overall hematomas (odds ratio, 1.73; 95% confidence interval, 1.06-2.81; P = .03). However, access type was not associated with hematomas resulting in intervention (odds ratio, 2.15; 95% confidence interval, 0.69-6.72; P = .19). CONCLUSIONS: PVIs via radial artery access exhibited a low prevalence of postprocedural access site complications and were associated with fewer minor hematoma complications compared with interventions performed using brachial artery access. Radial artery access compared with brachial artery access should be the preferred technique for PVIs.

High Mortality and Venous Thromboembolism Risk Following Major Penetrating Abdominal Venous Injuries.

BACKGROUND: Penetrating injuries to the inferior vena cava and/or iliac veins are a source of hemorrhage but may also predispose patients to venous thromboembolism (VTE). We sought to determine the relationship between iliocaval injury, VTE and mortality. METHODS: The National Trauma Data Bank was queried for penetrating abdominal trauma from 2015-2017. Univariate analyses compared baseline characteristics and outcomes based on presence of iliocaval injury. Multivariable analyses determined the effect of iliocaval injury on VTE and mortality. RESULTS: Of 9,974 patients with penetrating abdominal trauma, 329 had iliocaval injury (3.3%). Iliocaval injury patients were more likely to have a firearm mechanism (83% vs. 43%, P < 0.001), concurrent head (P = 0.036), spinal cord (P < 0.001), and pelvic injuries (P < 0.001), and higher total injury severity score (median 20 vs. 8.0, P < 0.001). They were more likely to undergo 24-hr hemorrhage control surgery (69% vs. 17%, P < 0.001), but less likely to receive VTE chemoprophylaxis during admission (64% vs. 68%, P = 0.04). Of patients undergoing iliocaval surgery, 64% underwent repair, 26% ligation, and 10% unknown. Iliocaval injury patients had higher rates of VTE (12% vs. 2%), 24-hr mortality (23% vs. 2.0%) and in-hospital mortality (33% vs. 3.4%) (P < 0.001 for all). VTE rates were similar following repair (14%) and ligation (17%). Iliocaval injury patients also had higher rates of cardiac complications (10.3% vs. 1.4%), acute kidney injury (8.2% vs. 1.3%), extremity compartment syndrome (4.0 vs. 0.2%), and unplanned return to OR (7.9% vs. 2.5%) (P < 0.001 for all). In multivariable analyses, iliocaval injury was independently associated with risk of VTE (OR 2.12; 95% CI, 1.29-3.48; P = 0.003), and in-hospital mortality (OR = 9.61; 95% CI, 4.96-18.64; P < 0.001). CONCLUSION: Iliocaval injuries occur in <5% of penetrating abdominal trauma but are associated with more severe injury patterns and high mortality rates. Regardless of repair type, survivors should be considered high risk for developing VTE.

Vascular surgery-related violations of the Emergency Medical Treatment and Labor Act.

OBJECTIVE: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law established in 1986 to ensure that patients who present to an emergency department receive medical care regardless of means. Violations are reported to the Centers for Medicare and Medicaid Services and can result in significant financial penalties. Our objective was to assess all available EMTALA violations for vascular-related issues. METHODS: EMTALA violations in the Centers for Medicare and Medicaid Services publicly available hospital violations database from 2011 to 2018 were evaluated for vascular-related issues. Details recorded were case type, hospital type, hospital region, reasons for violation, disposition, and mortality. RESULTS: There were 7001 patients identified with any EMTALA violation and 98 (1.4%) were deemed vascular related. The majority (82.7%) of EMTALA violations occurred at urban/suburban hospitals. Based on the Association of American Medical Colleges United States region, vascular-related EMTALA violations occurred in the Northeast (7.1%), Southern (56.1%), Central (18.4%), and Western (18.4%) United States. Case types included cerebrovascular (28.6%), aortic related (22.4%; which consisted of ruptured aortic aneurysms [8.2%], aortic dissection [11.2%], and other aortic [3.1%]), vascular trauma (15.3%), venous-thromboembolic (15.3%), peripheral arterial disease (9.2%), dialysis access (5.1%), bowel ischemia (3.1%), and other (1%) cases. Patients were transferred to another facility in 41.8% of cases. The most common reasons for violation were specialty refusal or unavailability (30.6%), inappropriate documentation (29.6%), misdiagnosis (18.4%), poor communication (17.3%), inappropriate triage (13.3%), failure to obtain diagnostic laboratory tests or imaging (12.2%), and ancillary or nursing staff issues (7.1%). The overall mortality was 19.4% and 31.6% died during the index emergency department visit. Vascular conditions associated with death were venous thromboembolism (31.6%), ruptured aortic aneurysm (21.1%), aortic dissection (21.1%), other aortic causes (10.5%), vascular trauma (10.5%), and bowel ischemia (5.3%). CONCLUSIONS: Although the frequency of vascular-related EMTALA violations was low, improvements in communication, awareness of vascular disease among staff, specialty staffing, and the development of referral networks and processes are needed to ensure that patients receive adequate care and that institutions are not placed at undue risk.

Inadequate Adherence to Imaging Surveillance and Medical Management in Patients with Duplex Ultrasound-Detected Carotid Artery Stenosis.

BACKGROUND: It is recommended that patients with ≥50% carotid artery stenosis undergo surveillance imaging and atherosclerotic risk reduction medical therapies, regardless of whether revascularization is performed. The objective of this study was to determine rates of adherence to these recommended measures and to identify risk factors for nonadherence. METHODS: A retrospective analysis was performed of all carotid duplex ultrasound (DUS) from 2016 to 2017 at a single institution. Patients with unilateral or bilateral ≥50% carotid stenosis were included. Primary outcomes were rates and timing of surveillance imaging and medication regimen. Patient and study characteristics were compared using univariate and multivariable analyses. A subgroup analysis of patients with a new finding of carotid stenosis was also performed. RESULTS: Carotid stenosis >50% was detected in 340 patients. Overall, 182 patients (54%) had follow-up imaging (median 261 days [IQR 166-366]) and 158 patients (46%) had no imaging follow-up (NIFU). NIFU patients had similar rates of aspirin use (86% vs. 88%, P = 0.6) and tobacco cessation counseling (71% vs. 71%, P = 0.8) but had less statin use (85% vs. 94%, P = 0.01) compared to those with imaging follow-up. Subsequent carotid revascularization was more common in patients with imaging follow-up (18% vs. 3%, P < 0.001). NIFU patients were less likely to have Medicare or commercial insurance (54% vs. 75%, P < 0.001). The indication for DUS in NIFU patients, compared to those in follow up, was less commonly neurologic symptoms (11% vs. 14%), more commonly other clinical findings (35% vs. 16%), and more commonly as work up before nonvascular surgery (25% vs. 4%, P < 0.001), respectively. NIFU rates decreased with increasing degree of carotid stenosis. Prior carotid intervention, prior DUS, or DUS ordered by a vascular surgeon were characteristics associated with imaging follow-up (P < 0.05 for all). In a subgroup of 160 patients with new carotid stenosis, a majority (64%) had NIFU and statin use was lower in these patients (82% vs. 96%, P = 0.007). On multivariable analysis, preop indication was predictive of NIFU (odds ratio [OR] 8.1 [95% confidence interval, CI 2.5-26.4], P < 0.001) whereas protective factors included: 70-80% stenosis (OR 0.33 [95% CI 0.14-0.76], P = 0.01), study ordered by vascular surgeon (OR 0.40 [95% CI 0.19-0.83], P = 0.01), and Medicare/commercial insurance (OR 0.36 [95% CI 0.2-0.66], P = 0.001). CONCLUSIONS: Nearly half of patients found to have ≥50% carotid stenosis on DUS had no imaging follow-up; these patients were less likely to be on recommended statin therapy. The benefits of nonrevascularization-based treatments for carotid disease require adherence to therapy. Forgoing surveillance imaging in patients with hemodynamically significant carotid stenosis should be a shared decision between provider and patient and does not obviate the need for medical therapies.

Higher body mass index is associated with reinterventions and lower maturation rates after upper extremity arteriovenous access creation.

OBJECTIVE: A patient's body mass index (BMI) can affect both perioperative and postoperative outcomes across all surgical specialties. Given that obesity and end-stage renal disease are growing in prevalence, we aimed to evaluate the association between BMI and outcomes of upper extremity arteriovenous (AV) access creation. METHODS: A retrospective single-institution review was conducted for AV access creations from 2014 to 2018. Patient demographics, comorbidities, and AV access details were recorded. BMI groups were defined as normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-39.9 kg/m2), and morbidly obese (>40 kg/m2). Perioperative complications and long-term outcomes including access maturation (defined as access being used for hemodialysis or the surgeon's judgment that access was ready for use in patients not yet on hemodialysis), occlusion, and reintervention were evaluated. RESULTS: A total of 611 upper extremity AV access creations were performed on patients who were normal weight (29.6%), overweight (31.3%), obese (29.6%), and morbidly obese (9.5%). Access type included brachiocephalic (43.2%), brachiobasilic (25.5%), and radiocephalic (14.2%) fistulas and AV grafts (14.2%). Median age was 60.9 years, and 59.6% were male. Univariable analysis showed no difference between BMI groups for perioperative steal, hematoma, home discharge, or 30-day primary patency. Freedom from reintervention at 2 years on Kaplan-Meier analysis differed by BMI (44.5% ± 4.6% normal weight, 29% ± 3.8% overweight, 39.8% ± 4.3% obese, 34.7% ± 8% morbidly obese; P = .041). There was no difference in 2-year freedom from new access creation or survival. AV access maturity within 180 days differed between BMI groups (74.3% normal weight, 66% overweight, 65.7% obese, 46.6% morbidly obese; P < .001). On multivariable analysis, failure to mature within 180 days was associated with overweight (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.14-3.29; P = .002), obese (OR, 2.12; 95% CI, 1.19-3.47; P = .009), and morbidly obese (OR, 3.68; 95% CI, 1.85-7.3; P < .001) relative to normal weight BMI. AV access reintervention was associated with overweight (hazard ratio [HR], 1.83; 95% CI, 1.34-2.5), obese (HR, 1.56; 95% CI, 1.12-2.16), and morbidly obese (HR, 1.69; 95% CI, 1.1-2.58; P = .02) relative to normal weight BMI. BMI was not independently associated with long-term readmission or survival. CONCLUSIONS: Obesity is associated with higher rates of AV access failure to mature and reintervention. Surgeons performing access creation on obese patients must consider this for planning and setting expectations. Weight loss assistance may need to be incorporated into treatment algorithms.

Selective Nonoperative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis.

OBJECTIVES: Although intervention is generally the standard of care for severe (80-99%) asymptomatic carotid stenosis, conservative management may be appropriate for a subset of patients. Our goal was to assess reasons for and outcomes of nonoperative/delayed operative management of asymptomatic severe carotid stenosis. METHODS: Institutional vascular laboratory data from 2010 to 2018 was queried for all patients who underwent a carotid duplex ultrasonography. Patients with severe asymptomatic carotid stenosis (80-99%) were included. Such stenosis was defined by an end diastolic velocity >140 cm/sec on duplex ultrasound in patients without transient ischemic attacks (TIA)/strokes ≤6 months prior to imaging. Nonoperative/delayed operative management was defined as not undergone carotid endarterectomy (CEA) or carotid artery stent (CAS) ≤6 months after imaging. Reasons for nonoperative management or delayed intervention as well as subsequent TIA/stroke and survival were determined. Kaplan-Meier analysis was performed to evaluate survival. RESULTS: Among 211 patients with severe carotid stenosis, 35 (16.6%) were managed nonoperatively or with delayed operation. Mean age in this subset was 72.6 ± 11.4 years and the majority were female (57.1%), had a smoking history (74.3%), and were on statins (91.4%) at the time of index duplex ultrasound. Reasons for no/delayed intervention were classified as severe medical comorbidities (37.1%), advanced age (17.1%), no referral for intervention (14.3%), patient refusal (14.3%), other severe concomitant cerebrovascular disease (11.4%), and active/advanced cancer (5.7%). Over a median follow-up of 35.2 months, no patients experienced TIAs/strokes attributable to carotid stenosis. One patient had a multifocal bilateral stroke after a cardiac arrest and prolonged resuscitation. A subset of patients underwent delayed CEA (8.6%) or CAS (2.9%). Four-year survival after initial imaging was 79%. CONCLUSIONS: Reasons for nonoperative and delayed operative management in our cohort of asymptomatic carotid stenosis were commonly due to comorbidities and advanced age. However, a subset of patients was never referred to vascular surgeons/interventionalists. Adverse neurologic events due to carotid stenosis were not observed during follow-up and patients had relatively high long-term survival.

The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass.

BACKGROUND: The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss. METHODS: The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately. RESULTS: There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6 years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8 kg/m2 vs. 28 kg/m2), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P < 0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P < 0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P < 0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P > 0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P > 0.05). CONCLUSIONS: Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.

Bilateral Popliteal Artery Entrapment Syndrome in a Young Female NCAA Division-I Collegiate Basketball Player: A Case Report.

CASE: Popliteal artery entrapment syndrome (PAES) is rarely on the differential for exertional lower extremity pain in the young athlete. This article illustrates a case of a 20-year-old female National Collegiate Athletic Association (NCAA) Division-I college basketball player who was diagnosed with PAES after conservative treatment of medial tibial stress syndrome and comprehensive evaluation for chronic exertional compartment syndrome. She received bilateral popliteal artery releases through a posterior approach and made an asymptomatic return to Division-I collegiate basketball. CONCLUSION: PAES is a rare potentially limb-threatening disease that must be included on the differential of young athletes who present with exertional lower extremity pain.

Natural History of Non-operative Management in Asymptomatic Patients with 70%-80% Internal Carotid Artery Stenosis by Duplex Criteria.

OBJECTIVE: Treatment of asymptomatic internal carotid artery (ICA) stenosis, particularly for moderate to severe (70%-80%) disease, is controversial. The goal was to assess the clinical course of patients with moderate to severe carotid stenosis. METHODS: A single institution retrospective analysis of patients with asymptomatic ICA stenosis identified on duplex ultrasound as moderate to severe (70%-80%) from 2003 to 2018 were analysed. Duplex criteria for 70%-80% stenosis was a systolic velocity of ≥325 cm/s or an ICA:common carotid artery ratio of ≥4, and an end diastolic velocity of <140 cm/s. Asymptomatic status was defined as no stroke/transient ischaemic attack (TIA) within six months of index duplex. Primary outcomes were progression of stenosis to >80%, ipsilateral stroke/TIA without documented progression, and death. RESULTS: In total, 206 carotid arteries were identified in 182 patients meeting the inclusion criteria. Mean patient age was 71.5 years, 57.7% were male, and 67% were white. There were 19 stenoses removed from analysis except for survival analysis as they initially underwent carotid endarterectomy or carotid artery stent based on surgeon/patient preference. Documented progression occurred in 24.1% of stenoses. There were 5.3% of stenoses associated with an ipsilateral stroke/TIA without documented progression, which occurred at a mean of 26.4 months. Kaplan-Meier analysis demonstrated a 60.3% five year freedom from stenosis progression, 92.5% five year freedom from stroke/TIA without documented progression, and 83.7% five year survival. Risk factors associated with stroke/TIA without documented progression at five years were atrial fibrillation (hazard ratio [HR] 14.87, 95% confidence interval [CI] 2.72-81.16; p = .002) and clopidogrel use at index duplex (HR 6.19, 95% CI 1.33-28.83; p = .020). Risk factors associated with death at five years were end stage renal disease (HR 9.67, 95% CI 2.05-45.6; p = .004), atrial fibrillation (HR 7.55, 95% CI 2.48-23; p < .001), prior head/neck radiation (HR 6.37, 95% CI 1.39-29.31; p = .017), non-obese patients (HR 5.49, 95% CI 1.52-20; p = .009), and non-aspirin use at index duplex (HR 3.05, 95% CI 1.12-8.33; p = .030). CONCLUSION: Patients with asymptomatic moderate to severe carotid stenosis had a low rate of stroke/TIA without documented progression. However, there was a high rate of stenosis progression reinforcing the need to follow these patients closely.

Femoral vein transposition is a durable hemodialysis access for patients who have exhausted upper extremity options.

OBJECTIVE: Access surgeons often encounter patients with end-stage renal disease who have exhausted all upper extremity hemodialysis access options. Although the lower extremity is often the next alternative, prosthetic lower extremity access can be prone to infectious complications and historically has poor patency. We describe our contemporary experience with an autogenous femoral vein transposition (FVT) arteriovenous fistula. METHODS: All FVTs performed at an academic medical center from 2006 to 2018 were analyzed. FVTs were placed after upper extremity access was deemed no longer possible by the treating surgeon. Patient demographics, comorbidities, and access history were described, and perioperative and short-term outcomes, including maturation, were analyzed. RESULTS: Twenty-one patients treated with FVT were identified. The mean age was 55.3 ± 11.1 years; 23.8% were female, and 71.4% were African American. The median body mass index was 27.1 kg/m2 (range, 17-46 kg/m2). Comorbidities included hypertension (100%), diabetes (61.9%), coronary artery disease (57.1%), congestive heart failure (47.6%), and obesity (38.1%). Twenty patients had at least one prior arm access, whereas 13 patients (61.9%) had more than three prior arm accesses. Seventeen patients (81%) had central venous stenosis or occlusion confirmed on preoperative imaging. The mean operative time was 250 minutes (range, 144-406 minutes), and estimated blood loss was 140.5 mL. Preanastomotic tapering was performed in 20 (95.2%) patients. Four (19%) patients returned to the operating room within 30 days. Thirty-day postoperative cardiac and wound complications occurred in 9.5% and 19% of patients, respectively. Distal arterial ischemia requiring revascularization occurred in one (4.8%) patient at 7 months. There were no access-related infections that resulted in fistula ligation. There was no mortality at 30 days. Successful fistula maturation rate at 6 months was 88.9%. At 1 year, primary and secondary patency rates were 65.9%, and 94.7%, respectively. CONCLUSIONS: Although autogenous FVT performed in patients without upper extremity options has a significant wound complication rate, it is associated with an outstanding maturation rate and excellent patency rates at 1 year. This access should be readily considered in hemodialysis patients without upper extremity access options.

Axillary-bifemoral and axillary-unifemoral artery grafts have similar perioperative outcomes and patency.

OBJECTIVE: It has been suggested that more bypass outflow targets for bypass grafts improve patency and outcomes. Our objective was to examine this in a multicenter contemporary series of axillary to femoral artery grafts. METHODS: The Vascular Quality Initiative database was queried for all axillary-unifemoral (AxUF) and axillary-bifemoral (AxBF) bypass grafts performed between 2010 and 2017 for claudication, rest pain, and tissue loss. Patients with acute limb ischemia were excluded. Patients' demographics and comorbidities as well as operative details and outcomes were recorded. Univariable, multivariable, and Kaplan-Meier analyses were used to assess long-term outcomes. RESULTS: There were 412 (32.9%) AxUF grafts and 839 (67.1%) AxBF grafts identified. Overall, the mean age of the patients was 68.3 years, 51.1% were male, and 84.7% were white. Compared with AxBF grafts, AxUF grafts were more often performed for urgent cases; in patients who were younger, male, nonambulatory, and diabetic; and in those with preoperative anticoagulation, critical limb ischemia, prior bypass, aneurysm repair, peripheral vascular intervention, and major amputation (P < .05 for all). There were no significant differences between AxUF and AxBF grafts in perioperative wound complications (4.2% vs 2.9%; P = .23), cardiac complications (7.3% vs 10.4%; P = .08), pulmonary complications (4.1% vs 6%, P = .18), early stenosis/occlusion (0.2% vs 0.8%; P = .22), perioperative mortality (2.9% vs 3.2%; P = .77), and length of stay (6.4 ± 5.6 days vs 6.7 ± 8 days; P = .29). The mean estimated blood loss (268.1 mL vs 348.6 mL; P < .001) and mean operative time (201 minutes vs 224.1 minutes; P < .001) were significantly lower for AxUF grafts. Kaplan-Meier analysis showed that AxUF and AxBF grafts had similar freedom from graft occlusion (62.6% vs 71.8%; P = .074), major adverse limb event-free survival (57.1% vs 66.6%; P = .052), and survival (86% vs 86%; P = .897) at 1 year. Major amputation-free survival was lower for AxUF grafts (63.7% vs 73%; P = .028). Multivariable analysis also showed that the type of graft configuration did not independently predict occlusion/death (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.77-1.46; P = .72), amputation/death (HR, 1.12; 95% CI, 0.83-1.51; P = .45), major adverse limb event/death (HR, 0.97; 95% CI, 0.73-1.3; P = .85), or mortality (HR, 0.91; 95% CI, 0.65-1.26; P = .55). Three-year survival after placement of AxUF and AxBF grafts was similar (75.1% vs 78.2%; P = .414). CONCLUSIONS: AxUF and AxBF grafts have similar perioperative and 1-year outcomes. Graft patency was not significantly different between an AxBF graft and an AxUF graft at 1 year. Overall, patients treated with these reconstructions have many comorbidities and low long-term survival.

Risk assessment of significant upper extremity arteriovenous graft infection in the Vascular Quality Initiative.

OBJECTIVE: Infectious complications of arteriovenous grafts (AVGs) are a major source of morbidity. Our aim was to characterize contemporary risk factors for upper extremity AVG infection. METHODS: The Vascular Quality Initiative (2011-2018) was queried for all patients undergoing upper extremity AVG creation. AVG infection was classified as an infection treated with antibiotics, incision and drainage, or graft removal. Multivariable analyses were used to evaluate risk factors for short- and long-term AVG infection. RESULTS: Of 1758 upper extremity AVGs, 49 (2.8%) developed significant infection within 3 months, resulting in incision and drainage in 24% and graft removal in 76% of cases. None were managed with antibiotics alone in the study sample. Patients with significant AVG infection were more likely to be white, to be insured, to have a history of coronary artery bypass graft and intravenous (IV) drug use, to be undergoing a concomitant vascular procedure, and to be discharged on an anticoagulant. In multivariable analysis, significant AVG infection within 3 months was associated with IV drug use history (odds ratio [OR], 5; 95% confidence interval [CI], 1.75-14.3; P = .003), discharge to a health care facility (OR, 2.66; 95% CI, 1.07-6.63; P = .035), discharge on an anticoagulant (OR, 2.31; 95% CI, 1.13-4.72; P = .021), white race (OR, 2.3; 95% CI, 1.21-4.34; P = .011), and female sex (OR, 2.02; 95% CI, 1.06-3.85; P = .033). Kaplan-Meier analysis showed that freedom from graft site infection at 1 year was 96.4%. Longer term graft infection at 1 year was independently associated with IV drug use history (hazard ratio [HR], 1.98; 95% CI, 1.06-3.68; P = .032), initial discharge to a health care facility (HR, 1.88; 95% CI, 1.19-2.97; P = .007), and white race (HR, 1.64; 95% CI, 1.23-2.19; P = .001). CONCLUSIONS: Although significant AVG infection was uncommon in the Vascular Quality Initiative, the majority were treated with graft removal. In select high-risk patients, extra care should be taken and alternative forms of arteriovenous access may be considered.

Hypoalbuminemia Predicts Increased Readmission and Emergency Department Visits After Lower Extremity Bypass.

INTRODUCTION: Preoperative hypoalbuminemia is associated with poor outcomes across many surgical fields. However, the effects on outcomes after lower extremity bypass (LEB), particularly over the 90-day global surgical period, are unclear. Our goal was to analyze the effect of hypoalbuminemia within 90 days after LE bypass. METHODS: We performed a single-center retrospective review of all infrainguinal LEBs from 2007 to 2017. Patients were categorized into 3 preoperative albumin groups: severe hypoalbuminemia (SH; albumin ≤2.8g/dL), mild-moderate hypoalbuminemia (MH; albumin >2.8-3.5g/dL), and normal albumin (albumin >3.5g/dL). Patient and procedural details were recorded. Outcomes analyzed included wound infection, myocardial infarction (MI), pulmonary complications, early graft occlusion (≤30 days), mortality, and emergency department (ED) presentation and readmissions within 30 and 90 days. Multivariable analysis was performed. RESULTS: We identified 313 patients undergoing LEB-45 (14.4%) with SH, 133 (42.5%) with MH, and 135 (43.1%) with normal albumin. Overall, the mean age was 65.7 years, and 63.3% were male. The SH group more frequently had tissue loss, diabetes, hypertension, end-stage renal disease, preoperative hematocrit <30%, and patients admitted preoperatively (all P < .05). There were no significant differences in wound complications, MI, pulmonary complications, early graft occlusion, 30-day or 90-day mortality, and 30-day ED presentation. Severe hypoalbuminemia compared to MH and normal albumin, respectively, had significantly higher rates of 30-day readmission (40% vs 30.8% vs 17.8%, P = .005), 90-day ED presentation (55.6% vs 33.8% vs 29.6%, P = .006), and 90-day readmission (66.7% vs 48.9% vs 35.6%, P = .001). Multivariable analysis showed that SH was independently associated with 90-day ED presentation (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.23-6.36, P = .014) and 90-day readmission (OR: 2.63, 95% CI: 1.21-5.71, P = .015). CONCLUSION: Our study suggests that patients with SH undergoing LEB had similar perioperative complication rates compared to normal albumin and MH groups, and SH was independently associated with 90-day ED presentation and readmission. Further studies are needed to assess other factors associated with ED visits and readmission.

Most patients experiencing 30-day postoperative stroke after carotid endarterectomy will initially experience disability.

OBJECTIVE: Although modern rates of stroke after carotid endarterectomy (CEA) have been low, the functional outcomes of stroke after CEA are unclear. Our goal was to assess the degree of initial disability in patients without baseline stroke-related impairment who had undergone CEA and experienced an early postoperative stroke. METHODS: The National Surgical Quality Improvement Program CEA-targeted database was queried for CEA cases from 2011 to 2014. Patients who had experienced a postoperative stroke were included, and the modified Rankin scale (mRS) was used to assess the degree of initial disability from stroke (0, none; 1, no significant; 2, slight; 3, moderate; 4, moderately severe; 5, severe disability; 6, dead). The mRS score was categorized as not applicable (NA) in the absence of any stroke. Patients were excluded if they had had a preoperative mRS score >1. The 30-day outcomes among the cohorts with a postoperative mRS score of NA/0 to 1, 2 to 3, and 4 to 5 were compared. Multivariable analysis was used to determine the predictors of higher initial postoperative mRS scores. RESULTS: A total of 8797 patients with CEA and preoperative mRS scores of NA/0 to 1 were identified. Their mean age was 71 ± 8.8 years, and 61% were men. Most were asymptomatic (88%) and had been taking antiplatelet agents (90%) and statins (82%) preoperatively. At 30 days, the postoperative stroke rate was 1.1% and mortality was 0.6%. Of the patients with a postoperative stroke after CEA, 35.4% had had stable initial postoperative mRS scores of NA/0 to 1, and most had had increased initial postoperative disability with mRS scores of 2 to 3 (32.3%) or 4 to 5 (32.3%). The cohorts with greater initial postoperative mRS scores exhibited a longer length of stay (2.2 ± 3.3 vs 5.8 ± 3.9 vs 11.9 ± 18.8 days; P < .001) and greater rates of major adverse cardiac events (2.7% vs 100% vs 100%; P < .001). Multivariable analysis showed that the initial postoperative disability, determined by a greater mRS score, was independently associated with preoperative bleeding disorder/chronic anticoagulation (odds ratio, 1.79; 95% confidence interval, 1.04-3.11; P = .037) and operative time by hour (odds ratio, 1.38; 95% confidence interval, 1.11-1.7; P = .003). CONCLUSIONS: Although the rate of stroke after CEA has been low, almost two thirds of patients who experienced a stroke within 30 days postoperatively developed some degree of initial postoperative disability and one third developed initial moderately severe to severe disability. These findings provide an evidence base for improved informed consent and risk-benefit discussions with patients.

Vascular repair after firearm injury is associated with increased morbidity and mortality.

OBJECTIVE: Firearm injuries have high morbidity and mortality. Presentation of injuries requiring concurrent vascular repair and its outcomes are unclear. Our study's objective was to characterize the injury details and to assess the associated mortality and morbidity after vascular repair. METHODS: The National Inpatient Sample was queried from 1993 to 2014 for all firearm injuries. International Classification of Diseases, Ninth Revision codes were used to identify firearm injuries and those who also underwent a vascular repair. Multivariable analysis was used to assess the effect of a concurrent vascular repair on outcomes. RESULTS: There were 648,662 firearm injuries identified; 63,973 (9.9%) involved a vascular repair. Overall, 88.7% of patients were male, and Medicaid was the most common insurance (40.2%). Intents were assault or legal intervention (60%), unintentional (24.2%), and suicide (8.6%). Patients undergoing vascular repair were younger, more often of black race and male sex, and on Medicaid insurance, with a lower household income and assault/legal intent (P < .005). Patients who underwent vascular repair had a higher frequency of abdomen/pelvis and extremity injuries as well as an elevated New Injury Severity Score (P < .005). Patients with vascular repair were more frequently treated at urban, teaching, and large hospitals (P < .005). Overall mortality rate was 2.2%; patients who underwent vascular repair had a higher mortality compared with those without (5.51% vs 1.98%; P < .001). Patients with vascular repair had higher rates of acute renal failure (3.1% vs 0.8%), venous thromboembolic events (0.5% vs 0.3%), pulmonary-related events (0.6% vs 0.28%), cardiac-related events (0.8% vs 0.2%), sepsis (1.4% vs 0.5%), and any complication (5.7% vs 2%; all P < .0001). Vascular repair was independently associated with mortality (odds ratio [OR], 2.68; 95% confidence interval [CI], 2.43-2.95; P < .0001). Age older than 46 years (OR, 2.01; 95% CI, 1.71-2.35; P < .0001), male sex (OR, 1.15; 95% CI, 1.05-1.25; P = .003), self-pay/no insurance (OR, 1.6; 95% CI, 1.47-1.75; P < .0001), suicide intent (OR, 3.73; 95% CI, 3.36-4.13; P < .0001), unintentional intent (OR, 1.12; 95% CI, 1.03-1.22; P < .0001), head/neck location (OR, 13.9; 95% CI, 12.5-15.6; P < .0001), Northeast region, and New Injury Severity Score >4 were independently associated with in-hospital mortality. Vascular repair was also independently associated with any complication (OR, 2.12; 95% CI, 1.98-2.28; P < .0001). CONCLUSIONS: Firearm injuries with vascular repair were independently associated with higher injury severity score and mortality. A majority of vascular repairs were performed for injury to the abdomen/pelvis and extremity with assault/legal intent, whereas head and neck injury and suicide intent were the least frequent.

National criteria for academic appointment in vascular surgery.

OBJECTIVE: Advancement in academic medicine is multifactorial. Our objectives were to characterize academic appointments in vascular surgery and to investigate what factors, particularly publications, influenced academic appointment. METHODS: Academic vascular surgeons at Accreditation Council for Graduate Medical Education vascular training programs or at primary sites of U.S. allopathic medical schools were included. Those with qualified titles, such as "adjunct" or a "clinical" prefix, were excluded. Sex, education, region, board certification, and affiliation details were recorded. Web of Science was queried for publication details and h-index. The h-index is a "personal impact factor" defined as "x" number of publications cited at least "x" number of times. After surgeons' information was deidentified, univariate and multivariable analyses were completed for academic appointment and appointment as division chief. RESULTS: There were 642 vascular surgeons who met criteria: 297 (46.3%) assistant professors, 150 (23.4%) associate professors, and 195 (30.4%) professors. There were 96 (15%) division chiefs and 10 (1.6%) chairs of surgery, and 83.2% were male. Surgeons worked in the Northeast (33.5%), Southern (32.6%), Central (20.1%), and Western (13.9%) United States. The mean (±standard deviation) number of publications was 13.7 ± 15.4 for assistant professors, 33.9 ± 28.8 for associate professors, and 86.8 ± 63.6 for professors (P < .001). Mean number of first or last author publications was 5.3 ± 6.4 for assistant professors, 12.2 ± 12.7 for associate professors, and 38.7 ± 35.3 for professors (P < .001). Mean h-index was 5.9 ± 5.4 for assistant professors, 12 ± 7.7 for associate professors, and 24.9 ± 12.6 for professors (P < .001). In multivariable analysis, vascular surgery board certification (adjusted odds ratio [OR], 6.08; 95% confidence interval [CI], 1.15-32.2; P = .03), academic appointment at a public medical school (OR, 1.99; 95% CI, 1.18-3.37; P = .01), years since medical school graduation (OR, 1.13; 95% CI, 1.09-1.18; P < .001, per year), and number of publications (OR, 1.05; 95% CI, 1.03-1.06; P < .001, per publication) were independently associated with associate professor. Factors independently associated with professor were years since medical school graduation (OR, 1.18; 95% CI, 1.12-1.24; P < .001, per year) and number of first or last author publications (OR, 1.05; 95% CI, 1.02-1.09; P = .003, per publication). Appointment as division chief was independently associated with h-index (OR, 1.04; 95% CI, 1.01-1.08; P = .016, per point). CONCLUSIONS: Total number of publications was independently associated with associate professor, with number of first or last author publications particularly important for professor. The h-index was not independently associated with academic appointment, but it was for appointment as division chief. This study provides relevant data for promotional guidance in academic vascular surgery.

Snuffbox arteriovenous fistulas have similar outcomes and patency as wrist arteriovenous fistulas.

OBJECTIVE: Radial artery-based wrist arteriovenous fistulas (AVFs) are commonly created as an initial upper extremity arteriovenous access. A more distal access site, such as the anatomic snuffbox AVF, can also be created. Although much has been written about wrist AVFs, outcomes of snuffbox AVFs are unclear. Our goal was to compare perioperative and midterm outcomes between these two types of distal access. METHODS: The Vascular Quality Initiative database was queried for all patients undergoing snuffbox AVFs and wrist AVFs from 2011 to 2017. Unmatched and matched analyses were performed for baseline characteristics and outcomes at 6 months for ischemic steal, wound infection, and arm swelling. Multivariable analysis was performed for unmatched and matched analyses for primary patency, surgical or endovascular repair, and patient survival. Kaplan-Meier matched analysis was performed for primary patency, freedom from surgical or endovascular intervention, and survival. RESULTS: We identified 4525 distal forearm fistulas: 179 (4%) snuffbox AVFs and 4346 (96%) wrist AVFs. The average age was 59 ± 14.7 years, and 72.3% of patients were male. There were no significant differences in baseline demographics or comorbidities of patients with snuffbox AVFs and wrist AVFs except that patients with snuffbox AVFs had fewer tunneled lines at access creation (70.2% vs 65.2%; P = .046) and had a lower American Society of Anesthesiologists class. There were no significant differences in unmatched outcomes at 6 months for ischemic steal (0.8% vs 1.9%; P = .336), wound infection (0% vs 0.2%; P = .649), and arm swelling (0.8% vs 1.3%; P = .592). Matched analysis showed no significant differences in baseline characteristics and outcomes at 6 months for ischemic steal (0% vs 1.8%; P = .146), wound infection (0% vs 0%), and arm swelling (0.9% vs 1.2%; P = .789). Kaplan-Meier matched analysis showed no significant differences between snuffbox AVFs and wrist AVFs at 6 months for primary patency (51% vs 48%; P = .61), freedom from endovascular intervention (84.5% vs 82.5%; P = .98), freedom from surgical intervention (90% vs 86%; P = .08), and survival (92% vs 96%; P = .1). In multivariable analysis of unmatched data, snuffbox AVFs and wrist AVFs had similar primary patency (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.75-1.26; P = .83), likelihood of surgical intervention (HR, 0.61; 95% CI, 0.35-1.05; P = .074) and endovascular intervention (HR, 0.96; 95% CI, 0.65-1.42; P = .83), and survival (HR, 1.47; 95% CI, 0.9-2.4; P = .128). CONCLUSIONS: Snuffbox AVFs have midterm results similar to those of wrist AVFs.