Reported pain at work is a risk factor for vascular surgery trainee burnout.

BACKGROUND: Work-related pain is a known risk factor for vascular surgeon burnout. It risks early attrition from our workforce and is a recognized threat to the specialty. Our study aimed to understand whether work-related pain similarly contributed to vascular surgery trainee well-being. METHODS: A confidential, voluntary survey was administered after the 2022 Vascular Surgery In-Service Examination to trainees in all Accreditation Council for Graduate Medical Education-accredited vascular surgery programs. Burnout was measured by a modified, abbreviated Maslach Burnout Inventory; pain after a full day of work was measured using a 10-point Likert scale and then dichotomized as "no to mild pain" (0-2) vs "moderate to severe pain" (3-9). Univariable analyses and multivariable regression assessed associations of pain with well-being indicators (eg, burnout, thoughts of attrition, and thoughts of career change). Pain management strategies were included as additional covariables in our study. RESULTS: We included 527 trainees who completed the survey (82.2% response rate); 38% reported moderate to severe pain after a full day of work, of whom 73.6% reported using ergonomic adjustments and 67.0% used over-the-counter medications. Significantly more women reported moderate to severe pain than men (44.3% vs 34.5%; P < .01). After adjusting for gender, training level, race/ethnicity, mistreatment, and dissatisfaction with operative autonomy, moderate-to-severe pain (odds ratio, 2.52; 95% confidence interval, 1.48-4.26) and using physiotherapy as pain management (odds ratio, 3.06; 95% confidence interval, 1.02-9.14) were risk factors for burnout. Moderate to severe pain was not a risk factor for thoughts of attrition or career change after adjustment. CONCLUSIONS: Physical pain is prevalent among vascular surgery trainees and represents a risk factor for trainee burnout. Programs should consider mitigating this occupational hazard by offering ergonomic education and adjuncts, such as posture awareness and microbreaks during surgery, early and throughout training.

Results of the North American Complex Abdominal Aortic Debranching (NACAAD) Registry.

BACKGROUND: Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting. METHODS: Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed. RESULTS: A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%-21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality (P<0.01), whereas mortality was 3% in a score ≤9. Early complications occurred in 140 (73%) patients and included respiratory complications in 45 patients (22%) and spinal cord ischemia in 22 (11%), of whom 10 (45%) fully recovered. At 5 years, survival was 61±5%, primary graft patency was 90±2%, and secondary patency was 93±2%. The most significant predictor of late mortality was renal insufficiency (P<0.0001). CONCLUSIONS: Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers' experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms.

Thoracic aortic diseases, including disease of the descending thoracic aorta (DTA), are significant causes of death in the United States. Open repair of the DTA is a physiologically impactful operation with relatively high rates of mortality, paraplegia, and renal failure. Thoracic endovascular aortic repair (TEVAR) has revolutionized treatment of the DTA and has largely supplanted open repair because of lower morbidity and mortality. These Society for Vascular Surgery Practice Guidelines are applicable to the use of TEVAR for descending thoracic aortic aneurysm (TAA) as well as for other rarer pathologic processes of the DTA. Management of aortic dissections and traumatic injuries will be discussed in separate Society for Vascular Surgery documents. In general, there is a lack of high-quality evidence across all TAA diseases, highlighting the need for better comparative effectiveness research. Yet, large single-center experiences, administrative databases, and meta-analyses have consistently reported beneficial effects of TEVAR over open repair, especially in the setting of rupture. Many of the strongest recommendations from this guideline focus on imaging before, during, or after TEVAR and include the following: In patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging, usually computed tomography angiography (CTA) because of its speed and ease of use for preoperative planning. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). If TEVAR is being considered, we recommend fine-cut (≤0.25 mm) CTA of the entire aorta as well as of the iliac and femoral arteries. CTA of the head and neck is also needed to determine the anatomy of the vertebral arteries. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). We recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). We recommend contrast-enhanced computed tomography scanning at 1 month and 12 months after TEVAR and then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is detected at 1 month. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). Finally, based on our review, in patients who could undergo either technique (within the criteria of the device's instructions for use), we recommend TEVAR as the preferred approach to treat elective DTA aneurysms, given its reduced morbidity and length of stay as well as short-term mortality. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). Given the benefits of TEVAR, treatment using a minimally invasive approach is largely based on anatomic eligibility rather than on patient-specific factors, as is the case in open TAA repair. Thus, for isolated lesions of the DTA, TEVAR should be the primary method of repair in both the elective and emergent setting based on improved short-term and midterm mortality as well as decreased morbidity.

Surveillance Recommendations after Thoracic Endovascular Aortic Repair Should Be Based on Initial Indication for Repair.

BACKGROUND: Current surveillance recommendations after thoracic endovascular aortic repair (TEVAR) include contrast-enhanced computed tomography (CT) scans at 1-, 2-, 6-, and 12-month intervals, with annual scans thereafter. Patient compliance with such schedules remains inconsistent for all etiologies of aortic disease. It remains unclear which boundaries prevent compliance and whether compliance is associated with improved aorta-specific outcomes. METHODS: A retrospective analysis was performed of a multicenter health-care system's electronic medical records to include all patients who underwent TEVAR from July 1, 2011 to April 1, 2016. Patients were assigned a compliance score of 0 through 4 based on the number of images received at the recommended time intervals. Whether patients underwent any postoperative imaging within 1 year of discharge was also recorded. Patients who died within 12 months of discharge were excluded. Aorta-specific complications included postoperative sac expansion, rupture, or need for additional aortic intervention. RESULTS: A total of 262 patients were included; of whom, 203 (77.5%) received at least one postoperative contrast-enhanced CT scan. Race, insurance status, and distance to hospital were not associated with 12-month compliance or compliance score (all P > 0.05). Regarding 12-month compliance, 76.2% of aneurysm patients, 81.6% of dissection patients, 72.2% of transection patients, and 72.2% of penetrating aortic ulcer patients underwent at least 1 CT scan within the first year (all P > 0.05). There were no differences in compliance score based on indication for repair. The overall aorta-related complication rate was 34.7%. TEVAR for dissection was associated with increased long-term aorta-specific complications (49.5%, P < 0.05 when compared with other indications). CONCLUSIONS: In this large, multihospital analysis of TEVAR outcomes, there was no difference in compliance among patients undergoing TEVAR for major indications, but patients with dissection who required TEVAR had a significant difference in aorta-specific complication rates. TEVAR for dissection should be subject to stricter surveillance guidelines than TEVAR for other indications.

Controversies and evidence for cardiovascular disease in the diverse Hispanic population.

OBJECTIVE: Hispanics account for approximately 17% of the U.S. POPULATION: They are one of the fastest growing racial/ethnic groups, second only to Asians. This heterogeneous population has diverse socioeconomic conditions, making the prevention, diagnosis, and management of vascular disease difficult. This paper discusses the cultural, racial, and social aspects of the Hispanic community in the United States and assesses how they affect vascular disease within this population. Furthermore, it explores risk factors, medical and surgical treatments, and outcomes of vascular disease in the Hispanic population; generational evolution of these conditions; and the phenomenon called the Hispanic paradox. METHODS: A systematic search of the literature was performed to identify all English-language publications from 1991 to 2014 using PubMed, which draws from the National Institutes of Health and U.S. National Library of Medicine, with the words "cardiovascular disease," "prevalence," "vascular," and "Hispanic." An additional search was performed using "cardiovascular disease and Mexico," "cardiovascular disease and Cuba," "cardiovascular disease and Puerto Rico," and "cardiovascular disease and Latin America" as well as for complications, management, outcomes, surgery, vascular disease, and Hispanic paradox. The resulting publications were queried for generational data (spanning multiple well-defined age groups) regarding cardiovascular disease, and cross-references were obtained from their bibliographies. Results are segmented by country of origin. RESULTS: Compared with non-Hispanic whites, Hispanics face higher risks of cardiovascular diseases because of a high prevalence of high blood pressure, obesity, diabetes mellitus, and ischemic stroke. However, the incidence of peripheral arterial disease and carotid disease appears to be significantly lower than in whites. The Hispanic paradox (lower mortality in spite of higher cardiovascular risk factors) may relate to challenges in ascribing life expectancy and cause of death in this diverse population. Low socioeconomic status and high prevalence of concomitant diseases negatively influence the outcomes of all patients, independent of being Hispanic. CONCLUSIONS: Understanding the cultural diversity in Hispanics is important in terms of targeting preventive measures to modify cardiovascular risk factors, which affect development and outcomes of vascular disease. The available literature regarding vascular disease in the Hispanic population is limited, and further longitudinal study is warranted to improve health care delivery and outcomes in this group.

Mynx Vascular Closure Device in Arterial Endovascular Procedures.

BACKGROUND: Vascular closure devices have been used to achieve hemostasis of percutaneous access sites following endovascular procedures, with reported decreased time for arterial control as well as decreased time to ambulation. We sought to determine rates and risk factors of postoperative bleeding complications and failures using these devices from a single institution experienced in the use of vascular closure devices. METHODS: All patients undergoing arterial endovascular procedures with percutaneous access between March 2010 and October 2015 at a single institution were identified and analyzed (n = 894). Patients undergoing endovascular aneurysm repair, open access, venous procedures, or upper extremity access were excluded. Comparison groups were formed between those using the Mynxgrip® (Mynx), Angio-Seal™, Perclose® vascular closure devices and manual pressure (MP). Patient demographics, intraoperative data, and postoperative complications were compared. RESULTS: A total of 615 (69%) patients received Mynx, 165 other vascular closure devices (VCD) ([14%] Perclose, 44 [4%] Angio-Seal), and 114 (13%) MP. MP patients were more likely to be diagnostic angiogram with smaller sheaths, while VCD patients were more likely to be interventions with larger sheaths. Univariate analysis identified age, atrial fibrillation, intervention (as opposed to diagnostic), and sheath size >5F associated with postoperative bleeding (P < 0.05), and in backward, logistic regression analysis, sheath size, age, and renal failure were independent predictors of the same. CONCLUSIONS: Use of vascular closure devices has a low rate of bleeding complication, device failure, and need for operative repair. Bleeding is associated with increased age, interventional procedure, and end-stage renal disease. Mynx, Perclose, and Angio-Seal have similar rates of complications. Use of these devices are a safe option for groin vessel closure.

Contemporary Characteristics and Outcomes of Young Patients (Under 50 Years) Undergoing Open Carotid Artery Surgery.

BACKGROUND: Stroke is the second leading cause of death worldwide, with 10% of neurologic events occurring in adults aged 18-49 years. The incidence in this age group has risen over the last 2 decades (while falling in the aged), despite improved diagnostic capacity and greater ability to treat it medically and surgically. We are unaware of any modern data regarding the risk factors and outcomes after carotid artery surgery in this demographic. We sought to evaluate the contemporary characteristics and outcomes of young adults undergoing carotid surgery. METHODS: Retrospective analysis of patients aged 18-49 years who underwent carotid surgery from 2005 to 2015. We collected demographics, indications, and outcomes, comparing them to previously published series. RESULTS: Sixteen patients were with the mean age of 46 (41-49) years, and 44% were male. Most were Caucasian (88%) and smokers (94%), consuming 1.3 packs/day with a mean pack-year history of 32 years (10-100). Average body mass index was 29. The majority (81%) were symptomatic prior to surgery (69% of these were strokes). Complications after surgery were hyperperfusion (1) and one deep vein thrombosis. Compared to young patients treated from 1973 to 1990s, we found significantly more female patients (P < 0.001) and more strokes (P < 0.04) leading to the procedure, while smoking remained the most prevalent risk factor. CONCLUSIONS: Carotid artery surgery in young patients continues to be associated with symptomatic stenosis and smoking; however, compared to 2-4 decades ago it may be more common in young females, and following a stroke. This may be from an increased prevalence of female smoking and improved neuroimaging.

Nicotine Dependence and Willingness to Quit Smoking in Vascular Surgery Patients.

BACKGROUND: Smoking rates have declined; however, it remains the primary modifiable risk factor for vascular disease. While vascular surgeons often advise patients to quit, few provide assistance. We sought to understand patients' interest in quitting and determine factors that influence this willingness to quit. METHODS: Anonymous surveys were given to vascular surgery clinic patients in a single institution over a 5-month period. Demographic information, smoking status, cessation attempts, and barriers to quitting were obtained. Nicotine dependence was determined using the Fagerstrom Test, and willingness to quit was assessed using a contemplation ladder. Patient's willingness to quit was evaluated in relation to symptomatic status, previous/planned operation, and nicotine dependence levels. RESULTS: A total of 490 patients (92%) completed the survey with 109 (22%) current smokers, 195 (40%) former smokers, and 186 (38%) never smokers. Never smokers were more likely to be female and employed while smokers were more likely to be disabled. Although 51% of smokers displayed moderate/high nicotine dependence, 54% demonstrated willingness to consider quitting within 6 months. The primary barrier to cessation identified was previous failed attempt(s) to quit in 44%. Most (90%) had previously attempted quitting, 63% attempted 3 or more times, and the most common technique used was "quitting cold turkey". Fifty-nine percent of patients reported physicians' had offered assistance in cessation, but only 2% had been in a cessation program. There was no correlation between willingness to consider quitting and symptomatic status, previous/planned operation, or nicotine dependence. Smokers of less than 10 cigarettes/day had a lower nicotine dependence level (P = 0.0001) and higher willingness to consider quitting (P = 0.0015), as did those who had fewer failed prior attempts to quit and who did not believe it was too late to quit. CONCLUSIONS: Most of our vascular patients self-report as nonsmokers. Over half of those who smoke demonstrate willingness to consider quitting within 6 months, which is not dependent on nicotine dependence, previous/planned operation, or symptomatic status. Those who smoke less than 10 cigarettes per day, have fewer past failed attempts to quit, and believe that it is not too late to quit are more likely to consider quitting. Vascular surgeons should be more aware of previous quit attempts and patterns of smoking and be proactive in assisting patients in cessation attempts.

Risk of Acute Kidney Injury after Percutaneous Pharmacomechanical Thrombectomy Using AngioJet in Venous and Arterial Thrombosis.

BACKGROUND: Percutaneous mechanical thrombectomy is commonly used to treat acute thrombotic syndromes. AngioJet (AJ) forcibly sprays fibrinolytics to fragment and aspirate thrombus. It is known to cause hemolysis and gross hematuria, yet potential consequences to renal function after AJ remain unstudied. We sought to determine the risk of acute kidney injury (AKI) after AJ when compared with other lysis techniques. METHODS AND RESULTS: We retrospectively reviewed patients treated with thrombolysis over 5 years. We identified those treated with AJ or catheter-directed thrombolysis (CDT). Demographics, indications, procedures, and laboratory values within 3 days were recorded. AKI was defined as an increase >25% above the baseline creatinine within 72 hr of the procedure. IN total, 102 patients (52 AJ, 50 CDT) had no statistical difference in mean age (50 and 51), indication (arterial thrombosis 65% and 88%), or baseline creatinine (0.9 and 1.0 mg/dL), respectively. AKI occurred in 15 (29%) patients treated with AJ versus 4 (8%) of CDT (P = 0.007). Similar numbers of AJ and CDT patients underwent additional open surgical procedures (21% and 30%, respectively, P = not significant). Multivariable analysis demonstrated that the odds of AKI were only increased by AJ (odds ratio [OR] 8.2, 95% confidence interval [CI] 1.98-34.17, P = 0.004), open surgery (OR 5.4, 95% CI 1.43-20.17, P = 0.013), or a >10% drop in hematocrit (OR 4.0, 95% CI 1.15-14.25, P = 0.03). CONCLUSIONS: In our observational study, AJ is an independent risk factor for AKI. Concomitant open surgery and drop in hematocrit also raise the odds of AKI. Renal injury after AJ is under-reported in the literature, and may be related to hemolysis from the device.

Management of noninfected prosthetic aortic bypass failures using femoral vein.

OBJECTIVE: The use of femoral-popliteal vein as a conduit to treat infected aortoiliac pathologies has been described extensively and is referred to as the neoaortoiliac system procedure. We examined our center's outcomes after using deep vein as a conduit for the salvage of failed aortofemoral prosthetic bypasses in patients without infection. METHODS: Procedures using femoral vein as conduit at the University of Arkansas for Medical Sciences between January 2005 and July 2013 were retrospectively reviewed (n = 110). Patients were excluded if the reconstruction was for infectious etiologies (n = 71) or for nonaortofemoral reconstructions (n = 31). Operative variables, complications, and patency rates were collected. RESULTS: Femoral vein was used to revascularize failed aortobifemoral bypasses in eight patients. Indications included rest pain (n = 7) and short-distance claudication (n = 1). Reconstructions identified two patients each with aortobifemoral bypass or aortofemoral bypass, and one patient each with aortofemoral bypass with femorofemoral bypass, aorotoiliac bypass, iliofemoral bypass with femorofemoral bypass, or ilioprofunda bypass. Mean follow up was 27.5 months. There were no major postoperative complications. Symptoms secondary to deep vein harvest (swelling/dermatitis) developed in three of eight patients. The average ankle-brachial index improved from 0.33 to 0.73 (P = .003), with a limb salvage rate of 100%. Kaplan-Meier analysis found primary patency was 70% at 1 year and 53% at 5 years, which improved to 100% and 75%, respectively, with secondary measures. CONCLUSIONS: Despite a need for secondary interventions and venous hypertension syndromes, deep vein offers good patency and excellent limb salvage after failed prosthetic aortoiliac bypasses.

Successful treatment of a mycotic multifocal thoracoabdominal aortic aneurysm as a late sequelae of intravesical bacillus Calmette-Guerin therapy: case report and literature review.

Bacillus Calmette-Guerin (BCG) is a live, attenuated strain of Mycobacterium bovis commonly used for the treatment of superficial bladder carcinoma. Intravesical BCG is well tolerated despite side effects that range from hematuria to sepsis syndrome. A very rare complication is vascular infection developing a mycotic BCG aneurysm, especially in the thoracoabdominal aorta (TAAA). These are challenging to diagnose because of their scarcity, nontraditional culture media, slow growth, and are often lethal. We report the first successful repair of a symptomatic, multifocal TAAA secondary to M bovis manifesting 17 months after intravesical BCG therapy and review the literature.

Outcomes after arterial endovascular procedures performed in patients with an elevated international normalized ratio.

BACKGROUND: Patients treated with anticoagulants frequently require urgent vascular procedures and elevated prothrombin time/international normalized ratio (INR) is traditionally thought to increase access site bleeding complications after sheath removal. We aimed to determine the safety of percutaneous arterial procedures on patients with a high INR in the era of modern ultrasound-guided access and closure device use. METHODS: Patients undergoing arterial endovascular procedures at a single institution between October 2010 and November 2012 were reviewed (n = 1,333). We retrospectively analyzed all patients with an INR > 1.5. Venous procedures, lysis checks, and cases with no documented INR within 24 hr were excluded. Sixty-five patients with 91 punctures were identified. A comparison group was then generated from the last 91 patients intervened on with INR < 1.6. Demographics, intraoperative data, and postoperative complications were compared. RESULTS: The demographics were similar. More Coumadin use and higher INR were found in the study group (71/91 and 0/91, P = 0.001; 2.3 and 1.1 sec, P = 0.001, respectively), but there was more antiplatelet use in the control group (68/91 and 51/91, P = 0.01). Intraoperatively, the sheath sizes, protamine use, closure device use, ultrasound guidance, brachial access, and procedure types were not statistically different. Sheath sizes ranged from 4 to 22F in the study group and 4 to 20F in the control group. Paradoxically, heparin was administered more frequently in the study group (64/91 and 50/91, P = 0.046). Bleeding complications occurred more commonly in the study group (3/91 and 1/91, P = 0.62), but this failed to reach significance and the overall complication rate in both groups was low. CONCLUSIONS: Endovascular procedures may be performed safely with a low risk of bleeding complications in patients with an elevated INR. Ultrasound guidance and closure device use may allow these cases to be performed safely, but a larger series may be needed to confirm this.

Contemporary outcomes with percutaneous vascular interventions for peripheral critical limb ischemia in those with and without poly-vascular disease.

Given the very ill nature of patients with critical limb ischemia (CLI), the use of percutaneous vascular interventions (PVIs) for limb salvage may or may not be efficacious; in particular, for those with polyvascular arterial disease. Herein, we reviewed large, multi-institutional outcomes of PVI in polyvascular and peripheral arterial disease (PAD) patients with CLI. An 18-hospital consortium collected prospective data on patients undergoing endovascular interventions for PAD with 6-month follow-up from January 2008 to December 2011. The patient cohort included 4459 patients with CLI; of those, 3141 patients had polyvascular (coronary artery disease, cerebrovascular disease and PAD) disease, whereas 1318 patients suffered from only PAD. All patients were elderly and with significant comorbidities. The mean ankle-brachial index (ABI) was 0.44 and was not different between those with and without polyvascular disease. Polyvascular patients had more femoropopliteal and infra-inguinal interventions and less aortoiliac interventions than PAD patients. Pre- and post-procedural cardioprotective medication use was less in the PAD patients as compared with polyvascular patients. Vascular complications requiring surgery were higher in PAD patients whereas other access complications were similar between groups. At 6-month follow-up, death was more common in the polyvascular group (6.7% vs 4.1%, p<0.001) as was repeat PVI, but no difference was found in the amputation rate. Considering the group as a whole at the 6-month follow-up, predictors of amputation/death included age (HR=1.01; 95% CI=1.002-1.02), anemia (HR=2.6; 95% CI=2.1-3.2), diabetes mellitus (HR=1.6; 95% CI=1.3-1.9), congestive heart failure (HR=1.6; 95% CI=1.4-1.9), and end-stage renal failure (HR=1.9; 95% CI=1.5-2.3), while female sex was protective (HR=0.7; 95% CI=0.6-0.8). In conclusion, from examination of this large, multicenter, multi-specialist practice registry, patients with polyvascular disease had higher 6-month mortality than PAD patients, but this was not a factor in 6-month limb amputation outcomes. This study also underscores that PAD patients still lag in cardioprotective medication use as compared with polyvascular patients.

Rifampin soaking dacron-based endografts for implantation in infected aortic aneurysms--new application of a time-tested principle.

Infections involving the aorta are associated with high rates of morbidity and mortality, and their management is complex. Saturating Dacron grafts in rifampin (60 mg/mL) inhibits the growth of organisms commonly found to be involved in both primary aortic infections and aortoenteric fistulas. Open repair and replacement of the aorta with rifampin-soaked Dacron grafts is frequently used in clinical practice and is considered a viable option for open repair with a low recurrence of infection; however, the morbidity and mortality of the procedure is significant. More recently, patients who are high risk for open surgery have been managed with endografts to treat infected aortas and aortoenteric fistulas with limited success, a high recurrence rate, and elevated mortality. We describe a technique to expose Dacron endografts with rifampin delivered via injection port or into the sheath before deployment in selected patients with aortic infections. We used this novel technique in 2 patients who were high risk for open repair: 1 with a bleeding aortoenteric fistula and 1 with mycotic abdominal aortic aneurysm. The first patient tolerated 1.5 years without surgical correction of the duodenal defect after placement of a rifampin-treated endograft. This allowed her to recover and ultimately undergo definitive repair under elective circumstances. Our second patient remains without evidence of recurrence 1 year after implantation for a mycotic abdominal aortic aneurysm. Following the principles of rifampin use in open vascular repairs, treating Dacron endografts with rifampin may add similar antimicrobial resistance when used to treat selected aortic infections.

Urine podocyte mRNAs, proteinuria, and progression in human glomerular diseases.

Model systems demonstrate that progression to ESRD is driven by progressive podocyte depletion (the podocyte depletion hypothesis) and can be noninvasively monitored through measurement of urine pellet podocyte mRNAs. To test these concepts in humans, we analyzed urine pellet mRNAs from 358 adult and pediatric kidney clinic patients and 291 controls (n=1143 samples). Compared with controls, urine podocyte mRNAs increased 79-fold (P<0.001) in patients with biopsy-proven glomerular disease and a 50% decrease in kidney function or progression to ESRD. An independent cohort of patients with Alport syndrome had a 23-fold increase in urinary podocyte mRNAs (P<0.001 compared with controls). Urinary podocyte mRNAs increased during active disease but returned to baseline on disease remission. Furthermore, urine podocyte mRNAs increased in all categories of glomerular disease evaluated, but levels ranged from high to normal, consistent with individual patient variability in the risk for progression. In contrast, urine podocyte mRNAs did not increase in polycystic kidney disease. The association between proteinuria and podocyturia varied markedly by glomerular disease type: a high correlation in minimal-change disease and a low correlation in membranous nephropathy. These data support the podocyte depletion hypothesis as the mechanism driving progression in all human glomerular diseases, suggest that urine pellet podocyte mRNAs could be useful for monitoring risk for progression and response to treatment, and provide novel insights into glomerular disease pathophysiology.

Endovascular aortic aneurysm repair with carbon dioxide-guided angiography in patients with renal insufficiency.

OBJECTIVE: Renal dysfunction following endovascular abdominal aortic aneurysm repair (EVAR) remains a significant source of morbidity and mortality. We studied the use of carbon dioxide (CO(2)) as a non-nephrotoxic contrast agent for EVAR. METHODS: Recorded data from 114 consecutive patients who underwent EVAR with CO(2) as the contrast agent over 44 months were retrospectively analyzed. CO(2) was used exclusively in 72 patients and in an additional 42 patients iodinated contrast (IC) was given (mean, 37 mL). Renal and hypogastric artery localization and completion angiography were done with CO(2) in all patients, including additional arterial embolization in 16 cases. Preoperative National Kidney Foundation glomerular filtration rate (GFR) classification was normal in 16 patients, mildly decreased in 52, moderate to severely decreased in 44, and two patients were on dialysis. RESULTS: All graft deployments were successful with no surgical conversions. CO(2) angiography identified 20 endoleaks (two type 1, 16 type 2, and two type 4) and three unintentionally covered arteries. Additional use of IC in 42 patients did not modify the procedure in any case. When compared with a cohort of patients who underwent EVAR using exclusively IC, the operative time was shorter with CO(2) (177 vs 194 minutes; P = .01); fluoroscopy time was less (21 vs 28 minutes; P = .002), and volume of IC was lower (37 vs 106 mL; P < .001). Postoperatively, there were two deaths, two instances of renal failure requiring dialysis, and no complications related to CO(2) use. Among patients with moderate to severely decreased GFR, those undergoing EVAR with IC had a 12.7% greater decrease in GFR compared with the CO(2) EVAR group (P = .004). At 1, 6, and 12-month follow-up, computed tomography angiography showed well-positioned endografts with the expected patent renal and hypogastric arteries in all patients and no difference in endoleak detection compared with the IC EVAR group. During follow-up, eight transluminal interventions and one open conversion were required, and no aneurysm-related deaths occurred. CONCLUSIONS: CO(2)-guided EVAR is technically feasible and safe; it eliminates or reduces the need for IC use, may expedite the procedure, and avoids deterioration in renal function in patients with pre-existing renal insufficiency. A prospective trial comparing CO(2) with IC during EVAR is warranted.