Vascular Surgery in the Pacific Theaters of World War II: The Persistence of Ligation Amid Unique Military Medical Conditions.

: Although multiple sources chronicle the practice of vascular surgery in the North African, Mediterranean, and European theaters of World War II, that of the Pacific campaign remains undescribed. Relying on primary source documents from the war, this article provides the first discussion of the management of vascular injuries in the island-hopping battles of the Pacific. It explains how the particular military, logistic, and geographic conditions of this theater influenced medical and surgical care, prompting a continued emphasis on ligation when surgeons in Europe had already transitioned to repairing arteries.

Increased warm ischemia time during vessel harvest decreases the primary patency of cryopreserved conduits in patients undergoing lower extremity bypass.

OBJECTIVE: Autologous vein is the preferred conduit for lower extremity bypass. However, it is often unavailable because of prior harvest or inadequate for bypass owing to insufficient caliber. Cryopreserved cadaveric vessels can be used as conduits for lower extremity revascularization when autogenous vein is not available and the use of prosthetic grafts is not appropriate. Many studies have shown that donor characteristics influence clinical outcomes in solid organ transplantation, but little is known regarding their impact in vascular surgery. The purpose of this study was to examine the effects donor variables have on patients undergoing lower extremity bypass with cryopreserved vessels. METHODS: The tissue processing organization was queried for donor blood type, warm ischemia times (WITs), and serial numbers of cryopreserved vessels implanted at a single center from 2010 to 2016. The serial numbers were then matched with their respective patients using the institutional Clinical Data Repository and patient data were obtained from the Clinical Data Repository and chart review. Primary outcomes were primary patency of the bypass conduits and limb salvage. Time to loss of patency was evaluated using Kaplan-Meier methods and a Cox proportional hazards model determined risk-adjusted predictors of patency and limb salvage. RESULTS: Sixty patients underwent lower extremity bypass with 65 cryopreserved vessels (23 superficial femoral arteries, 41 saphenous veins, 1 femoral vein). Thirty-eight procedures were reoperations. There were 21 inflow, 44 outflow, and 44 infrainguinal procedures. Preexisting comorbidities did not differ significantly between those who lost patency and those who did not. The mean WIT among the entire cohort was 892.3 ± 389.1 minutes (range, 158.0-1434.0 minutes). The median follow-up was 394 days. Kaplan-Meier analysis demonstrated an overall 1-year primary patency rate of 51%. Primary patency at 1 year was 67% and 41% for inflow and outflow procedures, respectively, and did not differ significantly between the two groups (P = .15). Donor-to-recipient ABO incompatibility was not associated with loss of primary patency. The 1-year amputation-free survival was 74%. Primary patency significantly decreased with each hourly increase in WIT on risk-adjusted analysis (hazard ratio, 1.1; P = .02). CONCLUSIONS: Higher cryopreserved vessel WIT was associated with increased risk-adjusted loss of primary patency in this cohort. At 1 year, the overall primary patency was 51% and amputation-free survival was 74%. Vascular surgeons should be aware that WIT may affect outcomes for lower extremity bypass.

Lower extremity bypass and endovascular intervention for critical limb ischemia fail to meet Society for Vascular Surgery's objective performance goals for limb-related outcomes in a contemporary national cohort.

OBJECTIVE: In 2009, the Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) to define the therapeutic benchmarks in critical limb ischemia (CLI) based on outcomes from randomized trials of lower extremity bypass (LEB). Current performance relative to these benchmarks in both LEB and infrainguinal endovascular intervention (IEI) remains unknown. The objective of this study was to determine whether LEB and IEI performed for CLI in a contemporary national cohort met OPG 30-day safety thresholds. METHODS: SVS OPG criteria were applied to 11,043 revascularizations for CLI performed from 2011 to 2015 in the National Surgical Quality Improvement Program (NSQIP) vascular targeted modules. Primary 30-day safety OPGs including major adverse cardiovascular events (MACEs), major adverse limb events (MALEs), and amputation were calculated for the NSQIP LEB (n = 3833) and IEI (n = 3526) cohorts as well as for subgroups at "high anatomic risk" (infrapopliteal revascularization) and "high clinical risk" (age >80 years and tissue loss). These were compared with SVS OPG benchmarks using χ2 comparisons. RESULTS: Compared with the SVS OPG cohort, both the NSQIP LEB and IEI cohorts had fewer patients at high anatomic risk (LEB, 51%; IEI, 27%; SVS OPG, 60%; both P < .0001). The LEB cohort had fewer patients with high clinical risk than the SVS OPG cohort (LEB, 11%; SVS OPG, 16%; P < .0001). The 30-day MALE was significantly higher in the NSQIP LEB (9.0% [8.7%-9.2%]) and IEI (9.7% [9.4%-10.0%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-9.0%]; both P ≤ .007), including significantly higher rates of amputation. MACE was significantly lower in the NSQIP LEB (4.2% [4.1%-4.3%]) and IEI (3.1% [3.0%-3.2%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-8.1%]; both P ≤ .013). Among patients at high anatomic risk, 30-day MALE was significantly higher after LEB (9.5% [9.1%-9.8%]) and IEI (11.1% [10.4-11.8%]) compared with the SVS OPG cohort (6.1% [4.2%-8.6%]; P ≤ .002). Among patients with high clinical risk, IEI was associated with lower MACE compared with the SVS OPG cohort, with similar limb-related outcomes. CONCLUSIONS: In contemporary real-world practice, LEB and IEI for CLI failed to meet SVS OPG limb-related 30-day safety benchmarks for the entire CLI cohort as well as for the patients at high anatomic risk. Additional investigation using SVS OPGs as consistent end points is required to determine why limb-related outcomes after revascularization for CLI remain suboptimal. LEB and IEI surpassed OPG benchmarks for 30-day cardiovascular morbidity and mortality. OPGs for cardiovascular morbidity in patients undergoing revascularization for CLI deserve re-evaluation using contemporary data.

Estimating risk of adverse cardiac event after vascular surgery using currently available online calculators.

BACKGROUND: The decision to proceed with vascular surgical interventions requires evaluation of cardiac risk. Recently, several online risk calculators were created to predict outcomes and to lead to a more informed conversation between surgeons and patients. The objective of this study was to compare and further validate these online calculators with actual adverse cardiac outcomes at a single institution. METHODS: All patients from January 2011 through December 2015 undergoing carotid endarterectomy (CEA), infrainguinal lower extremity bypass, open abdominal aortic aneurysm (AAA) repair, and endovascular aneurysm repair (EVAR) on the vascular surgical service were included using the Society for Vascular Surgery Vascular Quality Initiative database at our health system. Additional information was collected through retrospective chart review. Each patient was entered through three online risk calculators: (1) the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) estimates the risk of cardiac arrest and myocardial infarction (MI); (2) the Revised Cardiac Risk Index (RCRI) estimates risk of MI, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block; and (3) the Vascular Study Group of New England (VSGNE) Cardiac Risk Index estimates risk of postoperative MI only. Observed adverse cardiac events (ACEs) were compared with expected values for each calculator using a χ2 goodness-of-fit test. Institutional Review Board exemption was obtained. RESULTS: A total of 856 cases were included: 350 CEAs, 210 infrainguinal bypasses, 77 open AAA repairs, and 219 EVARs. For CEA, no risk calculator showed statistically significant variation from the observed values (NSQIP, P = .45; RCRI, P = .17; VSGNE, P = .24). For infrainguinal bypass, NSQIP slightly underpredicted adverse events (P = .054), RCRI strongly underpredicted (P = .002), and VSGNE showed no difference (P = .42). For open AAA repair, NSQIP (P = .51) and VSGNE (P = .98) were adequate predictors, but RCRI strongly underpredicted the adverse events (P ≤ .0001). Finally, EVAR cardiac outcomes showed greater adverse events than predicted by all three calculators (NSQIP, P = .02; RCRI, P = .0002; and VSGNE, P = .025). Pooled data for the entire group documented that the VSGNE proved an accurate tool for prediction (P = .34), whereas ACEs were underpredicted by NSQIP (P = .0055) and RCRI (P ≤ .001). CONCLUSIONS: Although online cardiac risk calculators of adverse surgical events are easy to use and to reference in broad surgical decision-making, there is significant variability in their predictability at the procedure and institutional level. Our data suggest that ACEs often occur at a higher rate than expected on the basis of calculated risks profiles, thus creating a platform for future discussion about preoperative evaluation and postoperative care decision-making models.

Preoperative dementia is associated with increased cost and complications after vascular surgery.

OBJECTIVE: Dementia represents a major risk factor for medical complications and has been linked to higher rates of complication after surgery. Given the systemic nature of vascular disease, medical comorbidities significantly increase cost and complications after vascular surgery. We hypothesize that the presence of dementia is an independent predictor of increased postoperative complications and higher health care costs after vascular surgery. METHODS: The Vascular Quality Initiative database was queried for all patients undergoing vascular surgery at a single academic medical center from 2012 to 2017. All modules were included (open abdominal aortic aneurysm, suprainguinal bypass, lower extremity bypass, amputation, carotid endarterectomy, endovascular aortic aneurysm repair, thoracic endovascular aortic aneurysm repair, and peripheral endovascular intervention). An institutional clinical data repository was queried to identify patients with International Classification of Diseases, Ninth Revision diagnosis codes for dementia as well as total hospital cost and long-term survival using Social Security records from the Virginia Department of Health. Hierarchical logistic and linear regression models were fit to assess risk-adjusted predictors of any complication and inflation-adjusted cost. Kaplan-Meier and Cox proportional hazards models were used for survival analysis. RESULTS: A total of 2318 patients underwent vascular surgery and were captured by the Vascular Quality Initiative during the past 5 years, with 88 (3.8%) having a diagnosis of dementia. Patients with dementia were older and had higher rates of medical comorbidities, and the most common procedure was major amputation. In addition, dementia patients had a significantly higher rate of any complication (52% vs 16%; P < .0001) and increased 90-day mortality (14% vs 4.8%; P = .0002). Furthermore, dementia was associated with significant resource utilization, including preoperative length of stay (LOS), postoperative LOS, intensive care unit LOS, and inflation-adjusted total hospital cost (all P < .0001). Hierarchical modeling demonstrated that dementia was the strongest preoperative predictor for any complication (odds ratio, 8.64; P < .0001) and had the largest risk-adjusted impact on total hospital cost ($22,069; P < .0001). Finally, survival analysis demonstrated that dementia is independently associated with reduced survival after vascular surgery (hazard ratio, 1.37; P = .018). CONCLUSIONS: This study demonstrated that dementia is one of the strongest predictors of any complication and increased hospital cost after vascular surgery. Given the high risk of clinical and financial maladies, patients with dementia should be carefully considered and counseled before undergoing vascular surgery.

Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention.

OBJECTIVE: Lower extremity bypass (LEB) has traditionally been the "gold standard" in the treatment of critical limb ischemia (CLI). Infrainguinal endovascular intervention (IEI) has become more commonly performed than LEB, but comparative outcomes are limited. We sought to compare rates of major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) after LEB and IEI in a propensity score-matched, national cohort of patients with CLI. METHODS: The National Surgical Quality Improvement Program (NSQIP) vascular targeted files (2011-2014) for LEB and IEI were merged. CLI patients were identified by ischemic rest pain or tissue loss. Patients were matched on a 1:1 basis for propensity to undergo LEB or IEI. Primary outcomes were 30-day MALEs and MACEs. Within the propensity-matched cohort, multivariate logistic regression was used to identify independent predictors of MALEs and MACEs. RESULTS: A total of 13,294 LEBs and IEIs were identified, with 8066 cases performed for CLI. Propensity matching identified 3848 cases (1924 per group). There were no differences in preoperative variables between the propensity-matched LEB and IEI groups (all P > .05). At 30 days, rates of MALEs were significantly lower in the LEB group (9.2% LEB vs IEI 12.2%; P = .003). On multivariate logistic regression, bypass with single-segment saphenous vein vs IEI (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.54-0.92; P = .01), bypass with alternative conduit (prosthetic, spliced vein, or composite) vs IEI (OR, 0.7; 95% CI, 0.56-0.98; P = .04), antiplatelet therapy (OR, 0.8; 95% CI, 0.58-1.00; P = .049), and statin therapy (OR, 0.8; 95% CI, 0.62-0.99; P = .04) were protective against MALEs, whereas infrageniculate intervention (OR, 1.4; 95% CI, 1.09-1.72; P = .01) and a history of prior bypass of the same arterial segment (OR, 1.8; 95% CI, 1.41-2.41; P <. 0001) were predictive. Rates of 30-day MACEs were not significantly different (4.9% LEB vs 3.7% IEI; P = .07) between the groups. Independent predictors of MACEs included age (OR, 1.02; 95% CI, 1.01-1.04; P = .01), steroid use (OR, 1.8; 95% CI, 1.08-2.99; P = .03), congestive heart failure (OR, 1.7; 95% CI, 1.00-1.96; P = .02), beta blocker use (OR, 1.6; 95% CI, 1.09-1.43; P = .01), dialysis (OR, 2.3; 95% CI, 1.55-3.45; P < .0001), totally dependent functional status (OR, 3.1; 95% CI, 1.25-7.58; P = .02), and suboptimal conduit for LEB compared with IEI (OR, 1.6; 95% CI, 1.08-2.36; P = .02). CONCLUSIONS: Within this large, propensity-matched, national cohort, LEB predicted lower risk-adjusted 30-day MALE rate compared with IEI. Furthermore, there was no difference in 30-day MACE rate between the groups despite higher inherent risk with open surgical procedures. Therefore, this study supports the effectiveness and primacy of LEB for revascularization in CLI.

Surgeon, not institution, case volume is associated with limb outcomes after lower extremity bypass for critical limb ischemia in the Vascular Quality Initiative.

OBJECTIVE: Studies from large administrative databases have demonstrated associations between institutional case volume and outcomes after lower extremity bypass (LEB). We hypothesized that increased institutional and surgeon volume would be associated with improved outcomes after LEB. Using a national, prospectively collected clinical database, the objective of this study was to determine the effects of both surgeon and institutional volume on outcomes after LEB. METHODS: The Vascular Quality Initiative (VQI) was queried to identify all LEBs for critical limb ischemia or claudication between 2004 and 2014. Average annual case volume was calculated by dividing an institution's or surgeon's total LEB volume by the number of years they reported to the VQI. Institutional and surgeon volumes were analyzed as continuous variables to determine the impact of volume on major adverse cardiac events (MACEs), major adverse limb events (MALEs), graft patency, and amputation-free survival. Hierarchical regression models were used with cases clustered by surgeon and center. Time-dependent outcomes were evaluated with multivariable shared frailty Cox proportional hazards models. RESULTS: From 2004 to 2014, there were 14,678 LEB operations performed at 114 institutions by 587 surgeons. Average annual institutional volume ranged from 1.0 to 137.5 LEBs per year, with a median of 26.9 (interquartile range, 14-45.3). Average annual surgeon volume ranged from 1 to 52 LEBs per year with a median of 5.7 (interquartile range, 2.5-9.3). Institutional LEB volume was not associated with MACEs or MALEs or with loss of patency. However, average annual surgeon volume was independently associated with reduced MALEs and improved primary patency. Institutional and surgeon volume did not predict MACEs. CONCLUSIONS: In contradistinction to previous studies, there was no relationship in this study between institutional LEB volume and outcomes after LEB. However, greater average annual surgeon volume was associated with improved primary patency and decreased risk of MALEs. Open LEB remains a safe and effective procedure for limb salvage. Limb-related outcomes in critical limb ischemia and claudication will be optimized if surgeons maintain adequate volume of LEB.

Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day. RESULTS: Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05). CONCLUSIONS: Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.

Vascular Graft Infection: Incidence and Potential Risk Factors.

PURPOSE: The purpose of this study was to identify factors that increase the risk of vascular graft infections (VGI) in patients following abdominal or lower extremity revascularization surgery. DESIGN: Retrospective, descriptive study. METHODS: We reviewed the electronic health records of 223 patients who had undergone abdominal or lower extremity revascularization procedures from July 2012 to November 2014, looking for factors associated with VGI. We reviewed 28 preoperative, intraoperative, and post-operative factors. Descriptive statistics (mean, range, and standard deviation) were used to describe the sample; χ was used to determine correlations between the risk factors and subsequent VGIs. The level of significance was determined at P = .05, with a confidence level of 95%. RESULTS: We identified 33 cases of VGIs for the 223 charts reviewed, yielding an incidence rate of 15%. Seventeen of the 33 patients with VGI (51.5%) were male. The average age of patients who experienced VGI was 60.9 years (standard deviation, 12.2 years, range, 29-81 years). Preoperative factors that were shown to show statistical significance for the development of VGI were sequential procedures (P = .003), diabetes mellitus (P = .002), hemoglobin A1c more than 7.0 (P = .0002), blood glucose more than 180 mg/dL (P = .0006), and lack of mobility (0.0097). Intraoperative factors associated with VGI were hemostatic agents applied to the surgical field intraoperatively (P = .003) and perioperative hypoxemia (P = .027). Postoperative factors associated with VGI were discharge from the hospital to skilled nursing facility or acute rehabilitation facility (P = .005) and unscheduled clinic visits (P = .008). CONCLUSION: We measured a 15% incidence of VGI and identified multiple pre-, intra-, and postoperative associated factors. Vigilance is required to prevent VGI and knowledge of specific risk factors is important.

Vascular Surgery in World War II: The Shift to Repairing Arteries.

Vascular surgery in World War II has long been defined by DeBakey and Simeone's classic 1946 article describing arterial repair as exceedingly rare. They argued ligation was and should be the standard surgical response to arterial trauma in war. We returned to and analyzed the original records of World War II military medical units housed in the National Archives and other repositories in addition to consulting published accounts to determine the American practice of vascular surgery in World War II. This research demonstrates a clear shift from ligation to arterial repair occurring among American military surgeons in the last 6 months of the war in the European Theater of Operations. These conclusions not only highlight the role of war as a catalyst for surgical change but also point to the dangers of inaccurate history in stymieing such advances.

Vascular Quality Initiative and National Surgical Quality Improvement Program registries capture different populations and outcomes in open infrainguinal bypass.

OBJECTIVE: Both the Vascular Quality Initiative (VQI) and the National Surgical Quality Improvement Program Procedure Targeted (NSQIP-PT) databases aim to track outcomes and to improve quality in vascular surgery. However, both registries are subject to significant selection bias. The objective of this study was to compare the populations and outcomes of a single procedure in VQI and NSQIP-PT and to identify areas of similarity and discrepancy. METHODS: Deidentified regional data were provided by VQI, and the public use files were provided by NSQIP. Patient characteristics and outcomes were compared between data sets with parametric and nonparametric statistical tests as appropriate. For variables with different definitions between VQI and NSQIP-PT, a standardized definition was created to permit comparison across databases. To account for differences in populations of patients between the data sets, VQI and NSQIP-PT records were propensity matched, allowing a comparison of outcomes between databases adjusted for case mix. RESULTS: VQI contained 1358 records from 2011 to 2015, whereas NSQIP-PT contained 5273 complete records from 2011 to 2013. Patients in VQI are younger than those in NSQIP (65 [15] vs 68 [16] years; P < .001) and were less likely to have congestive heart failure (1.7% vs 3.1%; P = .005), to be on dialysis (4.0% vs 6.1%; P = .003), or to be receiving preoperative aspirin (62% vs 79%; P < .001) or statin therapy (63% vs 68%; P < .001). Significant discrepancies were noted in preoperative angina symptoms, prior myocardial infarction, and prior percutaneous coronary intervention, with 0, 1, and 0 NSQIP patients, respectively, having these risk factors compared with 9.4%, 0.7%, and 19.5% of the VQI cohort. Approximately 20% of patients in VQI underwent surgery for acute limb ischemia, which is not a recognized indication in NSQIP-PT. Overall 30-day mortality was equivalent (2.0% vs 1.8%; P = .6), as was composite myocardial infarction/stroke (3.9% vs 3.2%; P = .2). Major amputation (3.3% vs 1.6%; P = .002), return to operating room (16.1% vs 11.5%; P < .001), and wound infection rates (12.8% vs 1.4%; P < .001) were higher in NSQIP relative to VQI. Bleeding rates were higher in VQI (36.5% vs 17.2%; P < .001). Significant differences persisted in the propensity-matched groups. CONCLUSIONS: This is the first study to compare patient characteristics and outcome reported in the VQI and NSQIP-PT registries. These data documented statistically significant differences in demographics and comorbidities as well as in outcomes between databases. Physicians, payers, and the public should consider differences between these databases when reporting on outcomes and quality. Results from these two registries should not be directly compared.

Staged hybrid repair of extensive thoracoabdominal aortic aneurysms secondary to chronic aortic dissection.

OBJECTIVE: Many patients with aortic dissection develop Crawford extent I or II thoracoabdominal aortic aneurysms (TAAA). Because open repair is associated with a high morbidity and mortality, hybrid approaches to TAAA repair are emerging. In this study, we evaluated the midterm outcomes and aortic remodeling of a hybrid technique that combines proximal thoracic endovascular aneurysm repair (TEVAR), followed by staged distal open thoracoabdominal repair for patients with Crawford extent I or II TAAAs secondary to chronic aortic dissection. METHODS: We identified 19 patients with Crawford extent I (n = 1) or extent II (n = 18) TAAAs secondary to chronic aortic dissection who underwent a staged hybrid repair from 2007 to 2014 at our institution. Nine patients had previous open ascending aortic surgery for type I aortic dissection. Stage 1 TEVAR was performed via percutaneous (n = 8), femoral cutdown (n = 8), or iliac exposure (n = 3). The left subclavian artery was covered in nine patients and revascularized in eight patients using carotid-subclavian bypass (n = 7) or laser fenestration (n = 1). Stage 2 open repair was performed a median of 18 weeks later with partial cardiopulmonary bypass via left femoral arterial and venous cannulation for visceral and lower body perfusion. The open thoracoabdominal graft was anastomosed proximally in an end to end fashion with the endograft. We then assessed surgical morbidity and mortality, midterm survival, and freedom from reintervention. Aortic remodeling was measured and change in maximum aortic and false lumen diameter at last follow-up (median, 3 years) from baseline was assessed. RESULTS: There were no deaths, strokes, or chronic renal failure in this cohort. After stage 1 TEVAR, three patients required repeat intervention for endoleak (type Ia, n = 1; type Ib, n = 1; type II, n = 1) before open repair. After stage 2 open repair, there was a single delayed permanent paralysis 2 weeks after discharge. At a median 3-year follow-up (range, 6 months-6.2 years), there were no deaths, neurologic events, endoleaks, or TAAA reinterventions. Complete false lumen thrombosis occurred in 100% of the patients, with maximum false lumen diameter decreasing from 34.3 ± 15.3 mm to 13.2 ± 12.0 mm (P < .01) and total aortic diameter decreasing from 60.2 ± 9.0 mm to 49.4 ± 9.6 mm (P < .01). CONCLUSIONS: Staged hybrid TAAA repair, using a combination of proximal TEVAR with open distal repair, can be performed using established endovascular skills and technology coupled with traditional open aortic surgical techniques, with low surgical morbidity and mortality. In the midterm, staged hybrid TAAA repair was associated favorable survival, aortic remodeling, and freedom from reintervention.

The natural history of penetrating ulcers of the iliac arteries.

OBJECTIVE: The natural history of penetrating ulcers of the iliac arteries (PUIA) has not been previously described. The potential for degeneration into pseudoanerysm and rupture are feared complications. It is hypothesized that PUIA, similar to their thoracic aortic counterparts, signal impending vascular catastrophe. METHODS: A search of computed tomography (CT) angiography reports for the words, "penetrating ulcer" was performed. Patients with PUIA who underwent CT imaging from October 2010 to August 2011 were identified. Their clinical course was followed through December 2014. If patients with PUIA had additional vascular pathology that necessitated intervention, it was performed. A prospective and retrospective review of the imaging was performed when possible. Associated iliac diameter and ulcer dimensions were measured for patients with repeat imaging (n = 22). Demographic characteristics were compared for patients who were identified as having penetrating ulcers of the abdominal aorta. Mann-Whitney U, Fisher exact, and Pearson correlation coefficient tests were performed for statistical analysis. RESULTS: The calculated incidence of PUIA for patients who underwent CT imaging was 0.3%. The age at the time of diagnosis was 70.7 ± 10.0 years and the cohort included 28 male patients (82.3%). Median clinical and imaging follow-up was 42.0 (range, 1-82) months and 40.5 (range, 1-77) months. Most patients had a history of hypertension (82.4%), hyperlipidemia (76.5%), and tobacco use (70.6%). Twenty-one patients (61.8%) had concomitant aneurysms not necessarily associated with the PUIA. Although no PUIA rupture occurred, the population was sick because seven patients (20.6%) were deceased at the study end. Only one individual presented with symptoms that could possibly be attributed to their PUIA. Repeat imaging was performed for 22 patients (64.7%). The calculated median iliac artery diameter growth rate through the PUIA was 0.1 (range, 0-4.1) mm/y. CONCLUSIONS: PUIA are generally slow-growing and are found incidentally. Most patients with PUIA were in their eighth decade with a history of hypertension and tobacco use. Patients with PUIA frequently have concurrent aortic aneurysm disease that requires intervention. The mortality for this population was high, but was not caused by rupture of a PUIA. Diameter changes noted in the PUIA during follow-up did not suggest ulcer treatment would improve survival.

The History of Incidentally Discovered Penetrating Aortic Ulcers of the Abdominal Aorta.

BACKGROUND: The management of incidentally discovered penetrating ulcers of the abdominal aorta (PUAA) is not well described. METHODS: A search of computed tomography (CT) angiography imaging reports for the words "penetrating ulcer" was performed from October 2010 to August 2011. Patients with a PUAA were identified, and their clinical course was followed through December 2014 (n = 53). No specific intervention for the ulcers was sought unless additional aortic pathology necessitated intervention. Prospective and retrospective review of imaging was performed by dedicated vascular radiologists. Aortic diameters and ulcer dimensions were measured for patients with repeat imaging. Mann-Whitney U, Fisher's exact, and Pearson correlation coefficient tests were performed for statistical analysis. RESULTS: The calculated incidence of PUAA for patients undergoing CT imaging was 0.48%. Age at diagnosis was 71.6 ± 10.5 years in a population that included 35 (66.0%) males. Repeat imaging was performed for 29 (54.7%) patients. Median clinical and imaging follow-up was 36 (1-127) months and 34 (1-89) months. A history of hypertension (92.5%), hyperlipidemia (77.4%), and tobacco use (81.8%) was common. Twenty-seven (50.9%) had concomitant aneurysms not necessarily associated with PUAA. No aortic aneurysm or PUAA rupture occurred, but the population was sick with 19 patients (35.8%) deceased at the end of the study. Median aortic diameter growth rate through the PUAA was 0.5 (0-11.4) mm/year. No difference in mortality or aortic pathology was detected in patients with aortic growth rates >1 mm/year compared with <1 mm/year (P = 0.21 and P = 0.71, respectively). CONCLUSIONS: Patients with PUAA in general are elderly with multiple comorbidities. A large percentage of patients have concurrent, separate, aortic pathology, most frequently aortic aneurysms. Small changes in the appearance of the PUAA were frequent but did not equate with abdominal aortic catastrophe. Long-term mortality for this population was high, but the ulcer growth during follow-up did not suggest PUAA treatment would improve survival.

Targets to prevent prolonged length of stay after endovascular aortic repair.

OBJECTIVE: Endovascular aneurysm repair (EVAR) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly, even within institutions. The present study reviewed the morbidity, mortality, and the financial effect of increased LOS to establish modifiable factors associated with prolonged hospital LOS, with the goal of improving quality. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary, elective EVAR at a single institution between January 1, 2011, and May 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤2 days and >2 days. RESULTS: Complete 30-day variable and cost data were available for 138 patients with an average follow-up of 12 months; of these, 46 (33%) had a LOS >2 days. Variables determined to be statistically significant predictors of prolonged LOS included aneurysm diameter (P = .03), American Society of Anesthesiologists Physical Status Classification score (P < .001), thromboembolectomy (P = .01), and increased postoperative cardiac (P < .001) and renal (P = .01) complications. Specifically, modifiable risk factors that contributed to increased LOS included performance of a concomitant procedure (P < .001), increased volume of iodinated contrast (P = .05), increased volume of intraoperative crystalloid (P = .05), placement in an intensive care unit (P < .001), return to the operating room (P < .001), and the use of vasoactive medications (P < .001). Hospital charges ($102,000 ± $41,000 vs $180,000 ± $73,000; P = .01) and costs ($27,000 ± $10,000 vs $45,000 ± $19,000 P = .01) were significantly higher in patients with prolonged LOS; however, there was no difference in physician charges ($8000 ± $5700 vs $12,000 ± $12,000; P = .09). Increased LOS after EVAR was associated with an increase in mortality at 1 month (0% vs 4% P = .05) and 12 months (3% vs 13% P = .03). CONCLUSIONS: This study highlights several modifiable risk factors leading to increased LOS after EVAR, including performance of concomitant procedures, admission to the intensive care unit, and postoperative renal and cardiac complications. Further, increased LOS was associated with increased charges, costs, morbidity, and mortality after EVAR. This study highlights specific areas of focus for decreasing LOS after EVAR and, in turn, improving quality in vascular surgery.

Cost analysis of endovascular versus open repair in the treatment of thoracic aortic aneurysms.

OBJECTIVE: For descending thoracic aortic aneurysms (TAAs), it is generally considered that thoracic endovascular aortic repairs (TEVARs) reduce operative morbidity and mortality compared with open surgical repair. However, long-term differences in survival of patients have not been demonstrated, and an increased need for aortic reintervention has been observed. Many assume that TEVAR becomes less cost-effective through time because of higher rates of reintervention and surveillance imaging. This study investigated midterm outcomes and hospital costs of TEVAR compared with open TAA repair. METHODS: This was a retrospective, single-institution review of elective TAA repairs between 2005 and 2012. Patient demographics, operative outcomes, reintervention rates, and hospital costs were assessed. The literature was also reviewed to determine commonly observed complication and reintervention rates for TEVAR and open repair. Monte Carlo simulation was used to model and to forecast hospital costs for TEVAR and open TAA repair up to 3 years after intervention. RESULTS: Our cohort consisted of 131 TEVARs and 27 open repairs. TEVAR patients were significantly older (67.2 vs 58.7 years old; P = .02) and trended toward a more severe comorbidity profile. Operative mortality for TEVAR and open repair was 5.3% and 3.7%, respectively (P = 1.0). There was a trend toward more complications in the TEVAR group, although not statistically significant (all P > .05). In-hospital costs were significantly greater in the TEVAR group ($52,008 vs $37,172; P = .001). However, cost modeling by use of reported complication and reintervention rates from the literature overlaid with our cost data produced a higher cost for the open group in-hospital ($55,109 vs $48,006) and at 3 years ($58,426 vs $52,825). Interestingly, TEVAR hospital costs, not reintervention rates, were the most significant driver of cost in the TEVAR group. CONCLUSIONS: Our institutional data showed a trend toward lower mortality and complication rates with open TAA repair, with significantly lower costs within this cohort compared with TEVAR. These findings were likely, at least in part, to be due to the milder comorbidity profile of these patients. In contrast, cost modeling by Monte Carlo simulation demonstrated lower costs with TEVAR compared with open repair at all time points up to 3 years after intervention. Our institutional data show that with appropriate selection of patients, open repair can be performed safely with low complication rates comparable to those of TEVAR. The cost model argues that despite the costs associated with more frequent surveillance imaging and reinterventions, TEVAR remains the more cost-effective option even years after TAA repair.

Staged hybrid approach using proximal thoracic endovascular aneurysm repair and distal open repair for the treatment of extensive thoracoabdominal aortic aneurysms.

OBJECTIVE: Repair of patients with extent I and II thoracoabdominal aortic aneurysms (TAAAs) is associated with significant morbidity and mortality, whereas repair of more distal extent III and IV TAAAs has a lower risk of paraplegia and death. Therefore, we describe an approach using thoracic endovascular aneurysm repair (TEVAR) as the index operation to convert extent I and II TAAAs to extent III and IV TAAAs amenable to subsequent open aortic repair to minimize patient risk. METHODS: Between July 2007 and March 2012, 10 staged hybrid operations were performed to treat one extent I and nine extent II TAAAs. Aortic aneurysm pathology included five chronic type B dissections, three acute type B dissections, and two penetrating aortic ulcers. Initially, the proximal descending thoracic aorta was repaired with TEVAR for coverage of the most proximal fenestration or penetrating ulcer, with seven elective and three emergent repairs. Interval open distal aortic replacement was performed in a short-term planned setting or for progressive dilation of the distal aortic segment. In the open repair, the proximal end of the graft was sewn directly to the distal end of the TEVAR and outer wall of the aorta. RESULTS: Average patient age was 48 years, and 60% were men. Risk factors included hypertension (80%), current tobacco use (50%), and Marfan syndrome (30%). Complications after TEVAR included type IA (n=1) and type II (n=3) endoleaks, pleural effusions (n=3), and acute kidney injury (n=1). Three patients required endovascular reinterventions. In patients with dissection, persistent filling of the false lumen was common and associated with distal thoracic aortic dilation. Complications of open repair included acute kidney injury in two patients, but no cardiac, pulmonary, or neurologic morbidity. Median time between TEVAR and open repair was 14 weeks. Most importantly, no deaths or neurologic deficits occurred after either procedure during a median follow-up of 35 weeks. CONCLUSIONS: A staged hybrid approach to extensive TAAAs combining proximal TEVAR, followed by interval open distal TAAA repair, is safe and appears to be an effective alternative to traditional open repair. This approach may decrease the significant morbidity associated with single-stage open extent I and II TAAA repairs and may be applicable to multiple TAAA etiologies.

Results of external iliac artery reconstruction in avid cyclists.

OBJECTIVE: We report the midterm results of external iliac artery reconstruction in 25 high-performance cyclists. METHODS: Cyclists undergoing arterial reconstruction for symptomatic external iliac arteriopathy at a single institution between October 2004 and August 2010 were identified. With Institutional Review Board approval, data were collected from medical record review and telephone interview. Results were analyzed with χ(2) or independent t-test. RESULTS: Twenty-five patients (31 limbs) underwent operation, which included arterial reconstruction with or without inguinal ligament release. The average patient age at operation was 43.8 ± 5.0 for graft and 35.1 ± 1.9 for patch (P = .08). The average time from competitive cycling until operation was 18.2 ± 5.8 years for graft and 20.0 ± 2.5 for patch repairs (NS). Patients included 14 males and 11 females. There were 23 unilateral and four bilateral arterial reconstructions, including 26 patch angioplasties for localized disease and five interposition grafts for extensive disease; three patients underwent contralateral reconstruction as a separate procedure. Concomitant ipsilateral inguinal ligament release was performed in 25 patients (28 limbs), with contralateral release done in 12 patients (12 limbs). Three patients with isolated ligament release required subsequent arterial intervention. Follow-up averaged 32 months (range, 2-74). Primary patency for all reconstructions was 100%; the four reoperations (five limbs; one bilateral) were for symptom recurrence, two postgraft and two postangioplasty. Three reoperations were for recurrent intimal hyperplasia, one for disease distal to the anastomosis, and one for concomitant atherosclerotic disease. Based on available data, postexercise ankle-brachial indices were improved in 18 of 23 limbs. Seventeen patients completed questions regarding satisfaction: 10 were satisfied or very satisfied (zero graft, 10 patch; P = .25), while four were unsatisfied (three graft, two patch; P = .017, including one patient with both a patch and graft repair). All 20 patients for whom follow-up data were available are still cycling, 10 competitively. Two of the four reoperated patients were unsatisfied; all four are still cycling, one competitively. CONCLUSIONS: External iliac arteriopathy is a disease of prolonged, sustained, and repetitive trauma. Patch angioplasty yields a low rate of reoperation, more satisfied patients, return to competitive activity, and improvement in postexercise ankle-brachial indices. Interposition grafting is associated with slightly older patients, more extensive disease, and less satisfying results. Intimal hyperplasia is the most frequent complication necessitating reoperation. Both the decision to pursue arterial reconstruction and patient expectations must be tempered by the pattern of disease and the potential for unsatisfactory results.

Greater saphenous vein evaluation from computed tomography angiography as a potential alternative to conventional ultrasonography.

OBJECTIVE: Autologous greater saphenous vein (GSV) graft is frequently used as a conduit during arterial bypass. Preoperative vein mapping has been traditionally used to assess conduit adequacy and define GSV anatomy, thereby decreasing operative time and reducing wound complications. The purpose of this study was to determine whether GSV mapping using computed tomography angiography (CTA) closely correlated with that of traditional duplex ultrasonography (US). METHODS: From August 2009 through June 2011, 88 limbs from 51 patients underwent CTA of the lower extremities for the purpose of defining arterial anatomy with concurrent US for preoperative vein mapping. GSV diameters were measured by two blinded reviewers on CTA (both antero-posterior [AP] and lateral dimensions) and compared with US-based measurements at levels of the proximal thigh, mid-thigh, knee, mid-calf, and ankle. CTA and US measurements were compared at each anatomic level using linear regression. Statistical analysis was performed using SPSS software. Charge reduction was calculated based on technical and professional fees for each imaging study. RESULTS: GSV diameter sequentially decreased from the proximal thigh to the mid-calf and then increased to the ankle as measured by CTA and US. CTA-based measurements of the GSV significantly correlated with US GSV diameters (R = 0.927 [lateral dimension], 0.922 [AP dimension]; P < .005). The strongest degree of correlation occurred in measurements at the proximal thigh, followed by the mid-thigh, mid-calf, knee, and ankle. GSV measurement by CTA was over 90% sensitive and accurate for detecting appropriate GSV diameter for bypass (diameter >2.0 mm). Eliminating preoperative US vein mapping for the study patients at our institution would have resulted in charge reductions of $49,316 over the study period. CONCLUSIONS: Indirect venography by CTA correlates well with US for GSV mapping in the lower extremity and offers significant reduction in imaging-related preoperative charges. CTA is sensitive and accurate for detecting GSVs that are appropriate for bypass. Furthermore, CTA allows AP and lateral evaluation of the GSV throughout its anatomic course. As CTA is often performed prior to arterial bypass, indirect evaluation of the GSV using preoperative CTA should be considered a promising alternative to the use of US.

Transcatheter arterial revascularization outcomes at vascular and general surgery teaching hospitals and nonteaching hospitals are comparable.

BACKGROUND: Outcomes following transcatheter interventions at vascular and general surgery teaching hospitals (STH) are unknown. We examine whether surgery training programs influence clinically relevant outcomes after commonly performed endovascular procedures. METHODS: Using an all-payer inpatient care database from 2008, we selected adults who underwent either endovascular carotid stenting, endografting of descending thoracic aortic aneurysm, endovascular abdominal aortic aneurysm repair, or peripheral arterial revascularization. Patients were stratified by procedures completed at Surgery Teaching (Participate in Accreditation Council for Graduate Medical Education [ACGME]-accredited vascular and general surgery programs), STH, or nonteaching hospitals (NTH). Hierarchical regression models assessed adverse outcomes and in-hospital mortality among groups. RESULTS: Of the 175,698 records, 44% of the patients were treated at STH, while 56% underwent procedures at NTH. The adjusted odds ratio of any complication or mortality at STH and NTH were similar. Transfers, weekend admissions, and nonelective cases were higher at STH (P < .001, respectively). Paradoxically, STH treated fewer patients with more than three comorbidities compared with NTH (STH: 47% vs NTH: 53%; P < .001). Surgical teaching status did not lower the adjusted odds of mortality for any procedure. Moreover, the occurrence of any complication (adjusted odds ratios, 0.9; 95% confidence interval, .82-1.14; P = .69) and mortality (adjusted odds ratios, 0.9; 95% confidence interval, .74-1.22; P = .67) were equivalent between vascular and general STH. CONCLUSIONS: Following commonly performed transcatheter vascular procedures, and despite more transfers, weekend admissions, and nonelective procedures completed at STH, complications, and mortality were comparable across centers.