Anticoagulation Therapy is Associated with Increased Access-related Wound Infections after Hemodialysis Access Creation.

BACKGROUND: The effect of anticoagulation therapy (AC) on hemodialysis access patency and related complications is not well defined. Patients on long-term or chronic AC due to their underlying comorbid conditions may be particularly susceptible to access-related bleeding and complications from repetitive cannulation. Our goal is to assess the effect of anticoagulation therapy on outcomes after access creation. METHODS: The Vascular Quality Initiative (VQI) database was queried for patients undergoing arteriovenous fistula (AVF) or graft (AVG) placement, from 2011 to 2019. Only patients with data on post-procedural AC status were included. Anticoagulation use was defined as patients on warfarin, dabigatran, or rivaroxaban after access creation at postoperative follow up. Demographic and procedural details were analyzed. Wound infection and patency rates at six months were assessed. Binomial logistic regression analysis was performed to assess the association of anticoagulation use with these outcomes. RESULTS: A total of 27,757 patients underwent access creation, with the majority undergoing AVF creation (78.8%). The average age was 61.4 years and 55.3% were male. 12.9% of patients were on postoperative AC. The wound infection rate was 2.3- 3.8% in the no AC and AC cohorts, respectively (P < 0.001). At six months follow-up, patency was 85.7- 84.3% in the no AC and AC cohorts, respectively (P = 0.044). Expectedly, grafts had lower patency rates compared to AVF; those within the no AC cohort had a patency of 83.0% compared to 81.2 % in those on AC (P = 0.106). On multivariable analysis, anticoagulation use was associated with a higher risk of wound infections (odds ratio [OR] 1.513, 95% confidence interval [CI] 1.160-1.973, P = 0.002). AC use did not significantly affect access patency. CONCLUSION: Anticoagulation therapy was associated with a higher rate of wound infections but did not affect short-term access patency within six-months. These patients warrant close surveillance of their access for signs of infection. Furthermore, long-term implications of anticoagulation needs further evaluation.

Ambulatory Status following Major Lower Extremity Amputation.

BACKGROUND: The ability to ambulate following major lower extremity amputation, either below (BKA) or above knee (AKA), is a major concern for all prospective patients. This study analyzed ambulatory rates and risk factors for nonambulation in patients undergoing a major lower extremity amputation. METHODS: A retrospective review of 811 patients who underwent BKA or AKA at our institution between January 2009 and December 2014 was conducted. Demographic information and co-morbid conditions, including the patients' functional status prior to surgery, at 6 months, and at latest follow up were recorded. Following exclusion criteria, 538 patients were included. Patients who were either independent or used an assistive device were considered ambulatory, while those who were completely wheelchair-dependent or bed-bound were considered nonambulatory. RESULTS: Pre-operatively, 83.1% of BKA patients were ambulatory, significantly more so than those undergoing AKA (44.9%, P < 0.0001). At 6-month follow-up these percentages dropped to 58.0% and 25.2%, respectively, for all patients. For patients who were ambulatory pre-operatively, 182/246 (73.9%) of BKA and 32/51 (62.7%) of AKA remained so post-amputation. Of those patients with both 6-month and greater than 1-year follow-up, there was no change in ambulatory status between the 2 time periods. On multivariable logistic regression, age greater than 70 years and female sex were associated with nonambulation post-operatively (P = 0.001, P = 0.015, respectively). None of the co-morbid conditions recorded (diabetes, renal insufficiency, end-stage renal disease, peripheral vascular disease, or body mass index > 35) was found to have a statistically significant correlation with post-operative ambulation using multivariable analysis. CONCLUSIONS: The majority of ambulatory patients undergoing a major amputation were able to remain ambulatory. Patients who failed to ambulate 6 months after their amputation, failed to resume ambulating. Age greater than 70 and female sex were found to have a statistically significant association with becoming nonambulatory following surgery.

A Propensity-Matched Analysis of Endovascular Intervention versus Open Nonautologous Bypass as Initial Therapy in Patients with Chronic Limb-Threatening Ischemia.

OBJECTIVES: Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention. METHODS: We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models. RESULTS: A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P < 0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization. CONCLUSIONS: An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.

Malpractice Litigation for Compartment Syndrome.

BACKGROUND: The aim of this study was to analyze litigation involving compartment syndrome to identify the causes and outcomes of such malpractice suits. A better understanding of such litigation may provide insight into areas where clinicians may make improvements in the delivery of care. METHODS: Jury verdict reviews from the Westlaw database from January 1, 2010 to January 1, 2018 were reviewed. The search term "compartment syndrome" was used to identify cases and extract data on the specialty of the physician defendant, the demographics of the plaintiff, the allegation, and the verdict. RESULTS: A total of 124 individual cases involving the diagnosis of compartment syndrome were identified. Medical centers or the hospital was included as a defendant in 51.6% of cases. The most frequent physician defendants were orthopedic surgeons (45.96%) and emergency medicine physicians (20.16%), followed by cardiothoracic/vascular surgeons (16.93%). Failure to diagnose was the most frequently cited claim (71.8% of cases). Most plaintiffs were men, with a mean age of 36.7 years, suffering injuries for an average of 5 years before their verdict. Traumatic compartment syndrome of the lower extremity causing nerve damage was the most common complication attributed to failure to diagnose, leading to litigation. Forty cases (32.25%) were found for the plaintiff or settled, with an average award of $1,553,993.66. CONCLUSIONS: Our study offers a brief overview of the most common defendants, plaintiffs, and injuries involved in legal disputes involving compartment syndrome. Orthopedic surgeons were most commonly named; however, vascular surgeons may also be involved in these cases because of the large number of cases with associated arterial involvement. A significant percentage of cases were plaintiff verdicts or settled cases. Failure to diagnosis or delay in treatment was the most common causes of malpractice litigation. Compartment syndrome is a clinical diagnosis and requires a high level of suspicion for a timely diagnosis. Lack of objective criteria for diagnosis increases the chances of medical errors and makes it an area vulnerable to litigation.

Factors Associated with Ipsilateral Limb Ischemia in Patients Undergoing Femoral Cannulation Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an important life-saving modality for patients with cardiopulmonary failure. Vascular complications, including clinically significant limb ischemia, may occur as a result of femoral artery cannulation for venoarterial (VA) ECMO. This study examines our institutional experience with femoral VA ECMO and the development of ipsilateral limb ischemia. METHODS: We performed a retrospective review of all consecutive patients undergoing femoral VA ECMO between 2011 and 2016. The primary endpoint was clinical evidence of limb-threatening ischemia. Multivariate logistic regression analysis was used to identify predictors for limb ischemia after cannulation. RESULTS: Between March 2011 and September 2016, 154 patients underwent femoral cannulation for VA ECMO. Overall in-hospital mortality was 59.7%. Clinically significant ipsilateral limb ischemia occurred in 34 (22%) patients; 7 required four-compartment fasciotomy, and 3 of these patients required amputation. On univariate analysis, a history of pulmonary disease, peripheral arterial disease, and stroke or transient ischemic attack was significantly associated with clinical limb ischemia. On multivariate analysis, younger age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93-0.99), diabetes (OR, 2.77; 95% CI, 1.08-7.12), pulmonary disease (OR, 3.86; 95% CI, 1.38-10.78), and peripheral arterial disease (OR, 13.68; CI, 2.75-68.01) were associated with limb ischemia. Lack of prophylactic distal perfusion catheter and arterial cannula size were not independently associated with limb ischemia. CONCLUSIONS: Femoral ECMO cannulation can be associated with significant limb ischemia necessitating surgical intervention. Younger patients, as well as those with a history of diabetes, pulmonary disease, and peripheral arterial disease, may be at increased risk for this complication.

Why Do Vascular Surgeons Get Sued? Analysis of Claims and Outcomes in Malpractice Litigation.

BACKGROUND: The objective of the study was to analyze causes and outcomes of malpractice claims against vascular surgeons in the United States. METHODS: Cases entered into the Westlaw database from January 1, 1999 to December 31, 2014 were reviewed. Search terms "vascular" and "surgeon" were used. Data were compiled on the allegation, subject matter, and outcome of each case. Additional data including demographics of the defendant were obtained from the U.S. News Health reports on practicing physicians. RESULTS: Of a total of 785 cases identified from the Westlaw database using the search terms "vascular" and "surgeon", 485 (61.8%) were identified where a vascular surgeon was the defendant or expert witness. Of these, 135 (27.8%) had a vascular surgeon identified as a defendant. Among these 135 cases, 88 (65.2%) were found for the defendant with 31 (23%) and 15 (11.1%) being found for the plaintiff or settled, respectively. Of the 31 cases found for the plaintiff, the median award was $750,000 and mean award was $1,830,000. Mean time from incident to verdict was 4.8 years. The most common procedures which led to litigation were open or endovascular peripheral revascularization (PR) (14.8%), carotid interventions (CIs) (11.85%), aortic interventions (AI) (11.1%), vascular trauma (9.63%), dialysis access (8.15%), and venous surgery (5.93%). The most common allegation was "failure to diagnose and treat" (48.9%), followed by complication of open surgery (31.85%) and negligent procedure (25.19%). The most common injuries reported were death (31.85%), major amputation (23.7%), neurovascular injury (14.8%), and bleeding (5.9%). CONCLUSIONS: Analysis of vascular surgery malpractice litigation in the Westlaw database revealed details regarding the subject matter and outcomes of these cases. Through this closed claims analysis, the most common procedures leading to litigation were found to be PR, CI, and AI and not thoracic outlet syndrome procedures as commonly believed. Furthermore, the most common allegations were a "failure to diagnose and treat" and "open surgical complication". Analysis of the salient features and outcomes in these cases can provide a framework for heightened awareness of issues which lead to malpractice claims and can ultimately improve patient care and safety.

Fifty years of hemodialysis access literature: The fifty most cited publications in the medical literature.

Objectives The modern era of hemodialysis access surgery began with the publication in 1966 by Brescia et al. describing the use of a surgically created arteriovenous fistula. Since then, the number of patients on chronic hemodialysis and the number of publications dealing with hemodialysis access have steadily increased. We have chronicled the increase in publications in the medical literature dealing with hemodialysis access by evaluating the characteristics of the 50 most cited articles. Methods We queried the Science Citation Index from the years 1960-2014. Articles were selected based on a subject search and were ranked according to the number of times they were cited in the medical literature. Results The 50 most frequently cited articles were selected for further analysis and the number of annual publications was tracked. The landmark publication by Dr Brescia et al. was unequivocally the most cited article dealing with hemodialysis access (1109 citations). The subject matter of the papers included AV fistula and graft (9), hemodialysis catheter (9), complications and outcomes (24), and other topics (8). Most articles were published in nephrology journals (33), with fewer in surgery (7), medicine (7), and radiology (3) journals. Of the 17 journals represented, Kidney International was the clear leader, publishing 18 articles. There has been an exponential rise in the frequency of publications regarding dialysis access with 42 of 50 analyzed papers being authored after 1990. Conclusion As the number of patients on hemodialysis has increased dramatically over the past five decades, there has been a commensurate increase in the overall number of publications related to hemodialysis access.

Incidence and characteristics of venous thromboembolic disease during pregnancy and the postnatal period: a contemporary series.

BACKGROUND: To evaluate the incidence and characteristics of venous thromboembolic events (VTE) associated with pregnancy in a contemporary patient series. METHODS: We performed a retrospective review of 33,311 deliveries between June 2003 and June 2008. Patients with objective documentation of a VTE during pregnancy or the 3-month postnatal period were identified from hospital discharge International Classification of Disease Codes edition 9 codes. Diagnosis of deep venous thrombosis (DVT) was largely made by a Duplex ultrasound, whereas pulmonary embolism (PE) was diagnosed by a computerized tomographic angiography (CTA). RESULTS: Of 33,311 deliveries during the study period, 74 patients (0.22%) had a VTE. There were 40 incidents of DVT (0.12%) and 37 of PE (0.11%). DVT involved the iliac veins (6), the femoral or popliteal veins (16), the infrapopliteal veins (17), and the axillary vein (1). Most (57.5%) of the DVTs involved the left lower extremity. Thirty-eight (51.6%) of the VTEs occurred in the postnatal period, and of those 33 (87%) occurred within 1 week of delivery. Most of the postnatal VTEs (68%) were seen in patients who underwent a cesarean section. Among patients with VTE during pregnancy, there were 28% in the first trimester, 25% in the second, and 47% in the third. Events were distributed among maternal age groups as follows: 26% aged 13-24, 50% aged 25-34, and 24% aged 35-54. Of the 35 patients tested for a hypercoagulable disorder, 12 were found to have a positive test result. Five (6.8%) of these 74 patients had a prior history of VTE, with two having a hypercoagulable disorder. In addition, 45 of the 74 patients were on oral contraceptive therapy or received hormonal stimulation therapy before pregnancy. Patients with a VTE during pregnancy were treated with low molecular weight or unfractionated heparin. Most postnatal patients were treated with subcutaneous low molecular weight heparin and coumadin. Six inferior vena cava filters were placed in patients with bleeding complications as a result of anticoagulation. There were no deaths during the study period. CONCLUSIONS: Comparing our results with historic controls (DVT: 0.04-0.14% and PE: 0.003-0.04%), the incidence of DVT in pregnancy has not changed significantly. We note, however, that the incidence of pulmonary embolus in our series is higher than previously reported. CTA has been used for the diagnosis of PE since the past decade. The increase in the rate of PE in the current series may be because of the higher sensitivity of CTA when compared with previous diagnostic modalities.

Experience with a modified composite sequential bypass technique for limb-threatening ischemia.

BACKGROUND: Composite sequential femoro-popliteal-distal bypass is a valuable option for treatment of critical limb ischemia when autogenous vein is limited and an isolated popliteal or distal arterial segment exists. We report a modified technique for composite sequential bypass and the results with its use over a 14-year period. METHODS: Twenty-five modified composite sequential bypass procedures were performed on 24 patients to treat gangrene, ischemic ulceration, and severe rest pain. Vein grafts were anastomosed from blind popliteal or blind distal arterial segments above-knee (7) or below-knee (18) to a distal outflow vessel including the below-knee popliteal (1), posterior tibial (5), anterior tibial (7), or peroneal (12) artery. Polytetrafluoroethylene bypass grafts were then placed from a suitable inflow artery to the proximal hood of the vein graft. RESULTS: Cumulative primary patency rates were 80% at 3 years, and 65% at 5 years. The limb-salvage rate was 85% at 4 years. Occlusion of the prosthetic segment with a patent distal vein segment was recognized in two patients who presented with less severe recurrent ischemia. Limb-salvage in these patients was achieved by a secondary prosthetic graft to the patent vein graft. CONCLUSION: Our modified configuration of the prosthetic-vein anastomosis for composite sequential bypass is an alternative to the conventional procedure and may help preserve vein graft patency should the polytetrafluoroethylene graft thrombose.

Refractory in-stent restenosis following carotid artery stenting: a case report and review of operative management.

In-stent restenosis following carotid artery stenting is a challenging problem that vascular surgeons will likely encounter with increasing frequency. The following describes a patient who developed progressive in-stent restenosis 3 years after carotid artery stenting, which was treated with operative therapy after failed balloon angioplasty. A review of the literature describing surgical approaches to the treatment of in-stent restenosis was also performed.

Incidence and significance of nonaneurysmal-related computed tomography scan findings in patients undergoing endovascular aortic aneurysm repair.

OBJECTIVE: This study examined the frequency and nature of incidental findings seen on computed tomography (CT) scans during preoperative and postoperative follow-up in patients undergoing endovascular aortic aneurysm repair (EVAR). METHODS: Between January 1, 2000, and March 1, 2006, 176 consecutive patients who underwent EVAR at our institution were retrospectively reviewed. Patients were included in the study if all preoperative and postoperative surveillance CT scans were performed at our institution. Eighty-two patients, 26 women (32%) and 56 men (68%), met this criterion. Their mean age was 76 years (range, 51-103 years). Official CT scan reports were reviewed. Findings were considered primary incidental if they were noted on preoperative CT scans and secondary incidental if they appeared on surveillance CT scans but not on the preoperative study. Primary and secondary incidental findings were considered either benign (eg, gallstones, diverticulosis) or clinically significant if they warranted further workup (eg, suspicious masses or changes suggestive of malignancy, internal or diaphragmatic hernias, and diverticulitis). The median follow-up was 29 months (range, 3-60 months). Each incidental finding was counted only once, on the first scan in which it appeared. RESULTS: Of the 82 patients, 73 (89%) had at least one primary incidental finding, and 14 (19%) of these were clinically significant. Secondary incidental findings, many of which were clinically significant, continued to appear throughout the follow-up period. The most common clinically significant primary incidental finding was the presence of a lung mass (n = 4). The most common clinically significant secondary incidental findings were lung mass (n = 6), liver mass (n = 6), and pancreas mass (n = 3). There was a significant difference in the proportion of men to women in the group with clinically significant incidental findings vs the group without clinically significant incidental findings (P = .03959). Differences between the groups with respect to age or aneurysm size were not significant. CONCLUSION: CT scans yielded surprisingly large numbers of both primary and secondary incidental findings, many of which were clinically significant. Primary incidental findings were more common than secondary incidental findings; however, clinically significant findings were found at a consistent rate throughout the study period.

Strategies for Hemodialysis Access: A Vascular Surgeon's Perspective.

Problems related to hemodialysis access are a significant cause of morbidity and mortality in patients with end-stage renal disease. Physicians of all specialties who are involved in the placement and maintenance of vascular access for hemodialysis must have a long-term strategy for sequential placement of autogenous fistulas, transpositions, and prosthetic grafts to preserve access sites and to avoid long-term use of tunneled dialysis catheters. The Fistula First and KDOQI initiatives have provided strategies and algorithms for access placement in patients with chronic kidney disease. Preservation of veins should begin before dialysis access is necessary to achieve the goal of creating a primary arteriovenous (AV) fistula or transposition suitable for cannulation when dialysis is initiated. Prosthetic and biologic grafts offer reasonable alternatives when autogenous access is not feasible. Newer graft materials and conduits are under evaluation to improve long-term outcomes. Use of tunneled dialysis catheters should be discouraged and they should be considered a last resort for long-term access. We present a strategy from the perspective of a vascular surgeon for the sequential placement of AV fistulas, venous transpositions, and AV grafts in these challenging patients. We also discuss specific concerns regarding hemodialysis access in difficult patient populations such as the elderly patient and the morbidly obese patient.

Evidence for vascular macrophage migration inhibitory factor in destabilization of human atherosclerotic plaques.

OBJECTIVE: Macrophage migration inhibitory factor (MIF) is a pro-inflammatory cytokine and has been shown to play a role in pathogenesis of atherosclerosis. The aim of this study is to investigate the potential role of MIF in the destabilization of atherosclerotic plaques by stimulation of vascular MMP-1 expression. METHODS: MIF and matrix metalloproteinase protein-1 (MMP-1) expression in human atherosclerotic plaques were determined by immunohistochemistry. The functional activity of MIF was examined by its ability to induce MMP-1 expression in vascular smooth muscle cells (VSMCs) in vitro. RESULTS: Two-color immunohistochemistry demonstrated that MIF was strongly upregulated in vulnerable, but not in fibrous plaques. Upregulation of vascular MIF was associated with macrophage accumulation (p<0.01), strong expression of vascular MMP-1 (p<0.001), and collagenolysis in vulnerable atheromatous plaques, but not in the fibrous lesions. Co-expression of MIF and MMP-1 in vulnerable atheromatous plaques appeared to contribute to the weakening of fibrous caps and plaque disruption. The role of MIF in vascular MMP-1 expression was demonstrated by the ability of MIF to directly stimulate VSMCs to express MMP-1 mRNA and protein, and to increase MMP-1 activity in a dose- and time-dependent manner, which was blocked by a neutralizing MIF antibody (p<0.001). CONCLUSIONS: MIF and MMP-1 are markedly upregulated in vulnerable atheromatous plaques and are associated with the weakening of the fibrous cap. The ability of MIF to induce MMP-1 expression and collagenolytic activity in VSMCs suggests that MIF may play a role in the destabilization of human atherosclerotic plaques.

Macrophage migration inhibitory factor induces MMP-9 expression: implications for destabilization of human atherosclerotic plaques.

Macrophage migration inhibitory factor (MIF) has been shown to participate in both experimental and human atherogenesis. Expression of MMP-9 has been shown to play a role in the instability of atherosclerotic plaque. Thus, we hypothesize that MIF may participate in the destabilization of atherosclerotic plaques by stimulating MMP-9 expression. This hypothesis was investigated by examining the expression of MIF and MMP-9 in human atherosclerotic plaques using two-color immunostaining and by determining the potential role of MIF in the induction of MMP-9 expression in vascular smooth muscle cells (VSMC) and macrophages in vitro. Two-color immunohistochemistry demonstrated that MIF was strongly upregulated by macrophages and VSMCs. This was associated with marked increase in MMP-9 expression in vulnerable atheromatous plaques, but not in the fibrous lesions. Upregulation of MIF and MMP-9 in vulnerable atheromatous plaques was associated with the weakening of fibrous caps. The role of MIF in MMP-9 expression was demonstrated by the ability of MIF to directly induce MMP-9 mRNA and protein expression in macrophages and in VSMCs in a dose and time-dependent manner, which was blocked by a neutralizing MIF antibody. In conclusion, MIF and MMP-9 are markedly upregulated in vulnerable atheromatous plaques. The ability of MIF to induce MMP-9 expression in VSMCs and macrophages suggests that MIF may play a role in the destabilization of human atherosclerotic plaques.

Alternative graft materials for hemodialysis access.

Since the initial description of the arteriovenous (AV) fistula, autogenous access has been the procedure of choice for chronic hemodialysis. Recently established National Kidney Foundation Dialysis Outcome and Quality Initiative guidelines have validated the superiority of arteriovenous fistulas over AV grafts but have also addressed the fact that a significant percentage of the growing dialysis population does not have veins suitable for primary AV fistulas. Recent advances in forearm, upper arm, and femoral venous transpositions have facilitated the performance of increased numbers of autogenous access procedures. Nevertheless, substantial numbers of patients on chronic hemodialysis require prosthetic AV grafts. Since early reports describing hemodialysis access using expanded polytetrafluoroethylene, surgical results with prosthetic graft materials have remained suboptimal. Modifications in polytetrafluoroethylene grafts and the recent development of alternative graft materials for hemodialysis access have yielded encouraging early results in efforts to improve patency of AV grafts. We will review currently available graft materials and recent developments in an ongoing effort to improve the results with prosthetic and biologic hemodialysis access conduits.

Pseudoaneurysm of the subclavian-vertebral artery junction--case report and review of the literature.

Pseudoaneurysm of the subclavian-vertebral artery junction (SVJ) is a rare complication of internal jugular vein catheter placement. Because of its retroclavicular location, arterial injury at the SVJ poses a significant therapeutic challenge. A case report and review of the literature are presented.

Standardizing vascular surgery residency: merger of two programs to create one model.

The practice of vascular surgery has been transformed in the last decade. It is now necessary to change the way we train vascular surgeons, to keep pace with this rapidly evolving specialty.

Experience with covered stents for the management of hemodialysis polytetrafluoroethylene graft seromas.

Prosthetic graft seromas is a rare complication that has been traditionally managed with open methods using partial graft replacement and open drainage. We report the first two cases of hemodialysis graft seromas successfully treated with a covered stent. Both patients underwent arteriovenous graft placement from the brachial artery to the axillary vein using a standard wall, tapered 4 to 7 mm polytetrafluoroethylene graft, but developed a seroma at the arterial end of the graft. Unsuccessful attempts were made to treat these seromas with percutaneous and open drainage. In both patients, an 8 mm x 50 mm Wallgraft (Boston Scientific, Natick, Mass) was retrogradely deployed "bareback" at the arterial end of the graft allowing for complete resolution of the graft seromas.

Use of a local fasciocutaneous flap for treatment of exposed vascular grafts to the dorsalis pedis artery.

Exposed or infected peripheral vascular grafts pose a significant challenge to the vascular surgeon. Although graft removal and extraanatomic bypass is feasible in selected circumstances, this procedure is generally not applicable for bypass to the pedal vessels. Preservation of patent grafts is almost always required for limb salvage. We present a case report of an exposed vein graft to the dorsalis pedis artery. We conclude that a local fasciocutaneous flap is an excellent treatment option, and describe the procedure in detail.