Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair.

BACKGROUND: The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement. METHODS: A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS. RESULTS: A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7 years old. Patients undergoing SA were older with a mean age of 73.4 years versus 64.7 years for patients undergoing GA (P < 0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75 years old: 52.9% vs. 33.3%, P < 0.001; renal comorbidities: 20.6% vs. 10.6%, P = 0.03, and current smokers: 26.7% vs. 9.6%, P < 0.001). Length of stay (LOS) was decreased in the SA group (4.29 days vs. 9.70 days, P < 0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P = 0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P = 0.01), reintervention (19.2% vs. 26.8%, P = 0.02), and return to the operating room (6.8% vs. 12.7%, P = 0.02). Of the 19 patients that had SA + CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P = 0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA + CSFD patients versus SA + CSFD patients. Age >75 (P = 0.002), intraoperative complications (P < 0.001), and perioperative complications (P = 0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis. CONCLUSIONS: Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.

Review of Malpractice Litigation in the Diagnosis and Treatment of Venous & Lymphatic Disease.

BACKGROUND: Malpractice claims involving nonthrombotic venous and lymphatic diseases and interventions have not been reported previously. We investigated common reasons for litigation, medical specialties involved, patient injuries, and case outcomes in malpractice litigation involving venous and lymphatic disease. METHODS: Litigation cases entered into the Westlaw database from June 8th, 1984 to February 15th, 2018 were analyzed. Search terms included relevant words and phrases related to nonthrombotic venous, thoracic outlet syndrome, and lymphatic disease and treatment. Data on physician specialty, malpractice claims, and patient injuries jury outcomes, amount awarded to the plaintiff, and jury fees were collected and compared for each category. RESULTS: A total of 144 cases were identified. 41 cases involved varicose veins, 11 spider veins, 35 thoracic outlet syndrome (TOS), 17 other venous diseases, and 40 lymphatic diseases. Physician defendants were frequently vascular surgeons (23%) and general surgeons (15%). The majority of litigation claims involved "post-procedure complication" (77%), "lack of informed consent" (25%), "failure to diagnose & treat" (15%), and "intraoperative complications" (13%). The most common injuries were skin damage (27.8%), nerve damage (25%), and lymphedema (24%). Patient death occurred in 6% of cases. Out of venous malpractice cases with post-procedure complications, stab phlebectomy (27%) was the most common intervention followed by foam sclerotherapy (21%), rib resection (21%), laser spider vein removal (5%), and endovenous laser ablation therapy (EVLT)(3%). Of varicose vein cases, 15% included deep vein thrombosis or pulmonary embolism as post-procedure complications. In TOS rib resections, 65% of cases referenced nerve damage and 12% involved arterial injury. For lymphatic disease cases, general surgeons were frequently identified defendants (25%). Lymphedema (93%) and lymphangitis (7%) occurred as post-procedure complications after breast, gynecologic, orthopedic, and radiation procedures. A majority of complications occurred after breast cases (40%). Verdicts overall ruled in favor of the defendant in 71% (102/144) of cases and the plaintiff in 20% (29/144) of cases. Out of cases ruled in favor of the plaintiff, 31% were lymphatics, 24% varicose veins, and 24% TOS cases. Only 8% (12/144) of cases were settled and one outcome was unknown. The mean award was $820,193 (standard deviation SD $1,226,008, Range $12,853 - $6,500,000). CONCLUSIONS: The majority of venous and lymphatic litigation cases involve claims of post-procedure complications. Venous complications occurred after open and endovascular treatment of varicose veins, spider vein treatment, and surgical management of TOS. Lymphedema occurred after breast, oncology, and orthopedic procedures. These cases reflect opportunities for intervention to help potentially prevent litigation.

Advancements in Access for End-Stage Renal Disease and the Creation of Endovascular Fistulas.

The prevalence of end-stage renal disease has increased significantly since the 1980s, and the demand for successful, safe, and durable hemodialysis access is rising. Autogenous arteriovenous fistulas continue to be the gold standard modality for hemodialysis access. Biologic and synthetic grafts are used with comparable outcomes but are not without their own complications. Newer developments in hemodialysis access utilize endovascular technology, including dual catheter-based systems and thermal resistance devices, which are pushing the boundaries of fistula creation optimistically forward.

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

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

Acute thrombotic manifestations of coronavirus disease 2019 infection: Experience at a large New York City health care system.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel coronavirus that has typically resulted in upper respiratory symptoms. However, we have encountered acute arterial and venous thrombotic events after COVID-19 infection. Managing acute thrombotic events from the novel virus has presented unprecedented challenges during the COVID-19 pandemic. In our study, we have highlighted the unique treatment required for these patients and discussed the role of anticoagulation for patients diagnosed with COVID-19. METHODS: The data from 21 patients with laboratory-confirmed COVID-19 disease and acute venous or arterial thrombosis were collected. The demographics, comorbidities, home medications, laboratory markers, and outcomes were analyzed. The primary postoperative outcome of interest was mortality, and the secondary outcomes were primary patency and morbidity. To assess for significance, a univariate analysis was performed using the Pearson χ2 and Fisher exact tests for categorical variables and the Student t test for continuous variables. RESULTS: A total of 21 patients with acute thrombotic events met our inclusion and exclusion criteria. Most cases were acute arterial events (76.2%), with the remainder venous cases (23.8%). The average age for all patients was 64.6 years, and 52.4% were male. The most prevalent comorbidity in the group was hypertension (81.0%). Several markers were markedly abnormal in both arterial and venous cases, including an elevated neutrophil/lymphocyte ratio (8.8) and D-dimer level (4.9 µg/mL). Operative intervention included percutaneous angiography in 25.00% of patients and open surgical embolectomy in 23.8%. Most of the patients who had undergone arterial intervention had developed a postoperative complication (53.9%) compared with a 0% complication rate after venous interventions. Acute kidney injury on admission was a factor in 75.0% of those who died vs 18.2% in the survivors (P = .04). CONCLUSIONS: We have described our experience in the epicenter of the pandemic of 21 patients who had experienced major thrombotic events from infection with COVID-19. The findings from our cohort have highlighted the need for increased awareness of the vascular manifestations of COVID-19 and the important role of anticoagulation for these patients. More data are urgently needed to optimize treatment and prevent further vascular complications of COVID-19 infections.

Endotheliitis in Coronavirus Disease 2019-Positive Patients After Extremity Amputation for Acute Thrombotic Events.

BACKGROUND: Both arterial and venous thrombotic events of the extremities occur in coronavirus disease 2019 (COVID-19) infection, but the etiology of these events remains unclear. This study sought to evaluate pathology specimens of COVID-19-positive patients postamputation, who were found to have Rutherford 3 acute limb ischemia requiring amputation. METHODS: A retrospective review was performed of all vascular surgery emergency room and inpatient consultations in patients who presented to the Mount Sinai Health System from March 26, 2020, to May 10, 2020. Pathology specimens were examined using hematoxylin and eosin stain. The specimens were assessed for the following: inflammatory cells associated with endothelium/apoptotic bodies, mononuclear cells, small vessel congestion, and lymphocytic endotheliitis. Of the specimens evaluated, 2 patients with a known history of peripheral vascular disease were excluded. RESULTS: Inflammatory cells associated with endothelium/apoptotic bodies were seen in all 4 patients and in 4 of 5 specimens. Mononuclear cells were found in 2 of 4 patients. Small vessel congestion was seen in all patients. Lymphocytic endotheliitis was seen in 1 of 4 patients. CONCLUSIONS: This study shows endotheliitis in amputation specimens of four patients with COVID-19 disease and Rutherford Class 3 acute limb ischemia. The findings in these patients is more likely an infectious angiitis because of COVID-19.

Large-bore Aspiration Thrombectomy for Acute Venous Thromboembolism.

Pulmonary embolism can occur following dislodgement of deep venous thrombosis into the pulmonary artery circulation, which results in obstruction of the pulmonary artery system and can be fatal. The consequences of pulmonary embolism include hypotension, right heart strain, and hypoxia. In the long term, pulmonary embolism may lead to Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Patients who develop hypotensive massive and submassive pulmonary embolism can be treated with large-bore aspiration thrombectomy. In the acute setting, this improves short-term outcomes by decreasing the ICU stay. It can also reduce the risk of CTEPH. Options for large-bore aspiration thrombectomy include the FlowTriever™ system (Inari Medical, Irvine, CA) and the Lightning 12 vascular thrombectomy system (Penumbra Inc., Alameda, CA). This review discusses the pathophysiology of pulmonary embolism, management, and options for large-bore aspiration thrombectomy.

Transcarotid Artery Revascularization and Advances in Vascular Surgery for Carotid Artery Disease.

Carotid artery atherosclerotic disease impacts over 2 million Americans annually. Since the advent of the carotid endarterectomy by Debakey in 1953, the surgical management of carotid artery stenosis has prevented cerebrovascular accidents. The technology utilized to manage carotid artery stenosis continued to evolve with the utilization of carotid artery stenting in 1989 and more recently transcarotid artery revascularization (TCAR). This review discusses the modern management of carotid artery stenosis with an emphasis on transcarotid artery revascularization (TCAR) and reversal of flow for reversal of flow for embolic protection.

Intravascular Lithotripsy in the Treatment of Lower Extremity Peripheral Arterial Disease.

Endovascular intervention has become first-line treatment for the majority of atherosclerotic lesions associated with peripheral artery disease. Traditionally, treatment modalities have included various types of balloon angioplasty and stenting. However, recent technological advancements have introduced the concept of endovascular lithotripsy as a novel alternative to angioplasty and stenting. This new addition to the armamentarium of surgeons and interventionalists has the potential to alter the treatment paradigm for patients with complex peripheral artery disease.

Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Characteristics and Outcomes of Abdominal and Pelvic Trauma Patients With Psychiatric Illness.

BACKGROUND: The association between psychiatric illness and outcomes in trauma patients in general has only recently been investigated. The aim of this study was to describe the unique characteristics, risk factors, and outcomes of patients with comorbid psychiatric illness and penetrating abdominal and pelvic injuries. MATERIALS AND METHODS: This was a retrospective review of trauma patients with open injuries to the abdomen and pelvis identified in the 2010-2015 the American College of Surgeons Trauma Quality Improvement Program database. Baseline variables extracted included demographics, comorbidities, including a discrete "psychiatric illness" variable that preexisted in the database, and injury information. Outcome variables collected included in-hospital mortality, length of stay and intensive care unit stay, and complications. Categorical variables were analyzed using chi-square and Fisher's exact test. Logistic regression was used to assess independent predictors for mortality with odds ratios (ORs) and 95% confidence intervals (CIs) constructed about group differences. RESULTS: There were 22,053 patients identified, 6.1% of whom were diagnosed with a psychiatric comorbidity. Patients with psychiatric illnesses were more likely to be aged ≥65 y (5.4% versus 3.2%, P < 0.0001), female (25.4% versus 12.4%, P < 0.0001), and have other comorbidities. Their injuries were more likely to be self-inflicted (34.9% versus 4.9%) and of a cut or piercing mechanism (33.7% versus 24.1%). Psychiatric comorbidity was an independent predictor of intensive care unit admission (OR 1.32, 95% CI 1.14-1.53) and was independently associated with decreased odds of mortality (OR 0.42, 95% CI 0.32-0.55) despite increased complication rates. CONCLUSIONS: The presence of a psychiatric comorbidity may be independently associated with trauma patients' complications and outcomes. Patients with psychiatric comorbidities have a unique set of risk factors and health needs that must be recognized and addressed by multidisciplinary care teams.

Managing the Diabetic Foot Ulcer: How Best Practices Fit the Real 2018 United States.

Diabetes Mellitus is a serious systemic illness that has an epidemic-like increasing prevalence in the United States, as well as the rest of the world. With the increasing number of people with diabetes comes the higher incidence of diabetes-related complications. One of these known complications, diabetic foot ulcers (DFU), has an estimated lifetime incidence of 15% in diabetics. Having a DFU increases the risk of infection, amputation, and even death, which is why prompt treatment and surveillance of such ulcers is imperative. Multiple organizations and journals have recently published best practices to heal and close DFU. Despite these guidelines, it is estimated that only 50% of all diabetic foot ulcers close within one year in the United States. To further confuse this picture, many trials include postoperative wounds that behave in a very different way than chronic wounds. The management of diabetic ulcers requires an understanding of not only the pathophysiology along with a multi-modal approach involving local wound care, pressure prevention, infection control, and, in some, revascularization, but also how care is delivered in the United States presently. In this review, we hope to elucidate the current knowledge and modalities used in ulcer management and to focus on key areas and best practices to inform the clinician, both in what they should do and what they can do.

Interhospital transfer for intact abdominal aortic aneurysm repair.

OBJECTIVE: Medically complex patients who need abdominal aortic aneurysm (AAA) repair are at increased risk of mortality. We study the effects of interhospital transfer to high-volume hospitals (HVHs) on postoperative complications and mortality after complications in these patients. METHODS: Data for 491,779 patients undergoing intact AAA surgery were extracted using Medicare files. Patient demographics, comorbidities, hospital volume, repair type, and patient transfer status were collected. Primary outcomes were postoperative complications and failure to rescue within 30 days after surgery. Data were analyzed using multivariable and propensity analysis. RESULTS: From 2000 to 2011, the percentage of patients transferred to another hospital for surgery before starting treatment more than doubled from .7% to 1.9% for endovascular aneurysm repair (EVAR; P < .001) and from 1.2% to 3.7% for open repair (P < .001). At baseline, transferred patients had more congestive heart failure (18.7% vs 11.2%; P < .001), coronary (17.4% vs 15.0%; P < .001), pulmonary (38.3% vs 33.6%; P < .001), and renal failure (8.1% vs 4.6%; P < .001) comorbidities. Transferred patients incurred more complications after EVAR (25.1% vs 12.8%; P < .001) or open repair (42.3% vs 35.5%; P < .001). After propensity matching for comorbidities and demographics, there were fewer complication rates (40.4% vs 47.8%; P < .001) and decreased failure to rescue (5.5% vs 6.5%; P = .04) after open repair in patients transferred to HVHs than in patients who remained at the primary, low-volume hospital for surgery. Complication rates after EVAR for nontransferred patients at low-volume hospitals and transferred patients at HVHs were similar (23.9% vs 24.7%; P = .55). After propensity matching, there was no significant difference in failure to rescue (P = .06) after EVAR between patients transferred to HVHs and nontransferred patients who had procedures at low-volume hospitals. CONCLUSIONS: Transfer of medically complex patients to HVHs for open AAA repair improves outcomes in AAA surgery. Complication rates decrease, and survival of transferred patients increases when they undergo open repair at HVHs.

Recent Advancements in Infrapopliteal Revascularization.

Infrapopliteal arterial disease is a challenging problem to treat. A shift toward an endovascular treatment approach over surgical bypass has occurred over recent years. Although current standard percutaneous transluminal balloon and bare metal stents are employed, their durability and outcomes are questionable. A number of endovascular advancements in the treatment of infrapopliteal (IP) arterial disease have recently been made. We review the recent literature for new atherectomy, stent, and balloon technologies.

Failure to rescue trends in elective abdominal aortic aneurysm repair between 1995 and 2011.

OBJECTIVE: Factors affecting mortality after abdominal aortic aneurysm (AAA) repair have been extensively studied, but little is known about the effects of the shift to endovascular aneurysm repair (EVAR) vs open repair on failure to rescue (FTR). This study examines the impact of treatment modalities on FTR for elective AAA surgery during the years 1995 to 2011. METHODS: Data for 491,779 patients undergoing elective AAA surgery were collected from Medicare files. Patient demographics, comorbidities, hospital volume, and repair type were collected. Primary outcome was FTR: the percentage of deaths in patients who had a complication within 30 days of surgery. Data were analyzed by univariate and multivariate analysis. RESULTS: Patients undergoing AAA surgery have become progressively more complex, with 84.96%, 89.33%, 93.76%, and 95.72% presenting with one or more comorbidities in 1995, 2000, 2005, and 2011, respectively. Despite this, overall FTR after AAA surgery was stable from 1995 to 2000 (P = .38) and decreased from 2.68% to 1.58% between 2000 and 2011 (P < .001). In addition, FTR in EVAR decreased from 1.70% to 0.58% from 2000 to 2006 (P = .03) and then stabilized at 0.88% ± 0.9% after 2007 (P = .45). Unlike for EVAR, FTR for open repair remained stable at 3.06% ± 0.17% to 2.74% ± 0.16% from 1995 to 2000 (P = .38) but increased to 4.51% ± 0.21% in 2011 (P < .001). Mortality was highest after transfusion (20.86%), prolonged ventilation (17.37%), and respiratory complications (29.78%) for all AAA surgeries. Of note, high-volume hospitals had lower FTR rates than low-volume hospitals for both open (2.73% vs 5.66%; P < .001) and endovascular (0.7% vs 1.69%; P < .001) repair. Multivariate analysis showed that high annual volume hospital status (odds ratio, 0.6; confidence interval, 0.58-0.63) and endovascular repair (odds ratio, 0.3; confidence interval, 0.28-0.31) were associated with decreased FTR. CONCLUSIONS: The success in AAA surgery of rescuing patients from 30-day mortality after a complication is associated with increased volume of EVAR. This increased success can also be attributed to the improved FTR outcomes and complication rates when surgeries are performed at high-volume hospital centers.

Loss of independence as a metric for racial disparities in lower extremity amputation for diabetes: A National Surgery Quality Improvement Program (NSQIP) analysis.

INTRODUCTION: This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene. METHODS: We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality. RESULTS: 5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age > 65 (P < 0.0001), independent functional status prior to admission (P < 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693). CONCLUSIONS: LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.